Sep 16, 2024

A Collaborative Syphilis Screening Pilot Project

This article originally appeared in CorrectCare magazine.

By Elizabeth Samson, MA, LMHC, CCHP, and Diane Bartlett, CCHP

According to Centers for Disease Control and Prevention surveillance data, cases of syphilis among the general public increased 74% from 2017 to 2021, and congenital syphilis soared by over 203%. For individuals who are incarcerated and those with a history of incarceration, the risk of syphilis is one and a half times higher than for those who have never been in jail or prison.

Many county jails test for syphilis and other sexually transmitted infections only if a patient presents with symptoms or requests testing. That limited form of testing, known as “passive case detection” or “opt-in testing,” is inadequate in that it fails to identify asymptomatic individuals and misses the opportunity to safeguard the health of incarcerated patients and their future sexual partners, as well as creating potential medical issues for any future children.

Untreated syphilis during pregnancy increases the risk of miscarriage, prematurity, and stillbirth, as well as severe birth defects. According to the CDC, clinical manifestations may include saddle nose due to destruction of cartilage, frontal bossing, tibial thickening, joint swelling, perforation of the hard palate, abnormal tooth development, interstitial keratitis, neurologic deafness, and optic atrophy.

In Palm Beach County, Fla., 2022 county-level surveillance data showed a syphilis rate (all stages) of 25.0 per 100,000 among women – a strikingly high increase from just one year before. To address the rising rate, Wellpath, in collaboration with the Palm Beach County Sheriff’s Office, designed an opt-out testing pilot program to screen all women processed into the Main Detention Center within 48 hours of their intake. The goal: to identify and assist – as early as possible – those who may require treatment and services from the local Department of Public Health.

At the core of the pilot program is the compelling story of one patient, Jane Doe. Her interaction with the criminal justice system unveiled a complex medical history, demonstrating the critical role of proactive health care initiatives in correctional facilities (see sidebar, next page).

Pilot Program Design
Subject matter experts from the CDC and Emory University were instrumental in developing the testing protocol and selecting the location. The Florida Department of Public Health generously provided rapid syphilis testing kits, a qualitative assay for detection of syphilis antibodies that requires two drops of blood using a finger stick.

Over the course of the pilot program, opt-out testing was offered to all women entering the Palm Beach County Main Detention Center during their health and physical exam (H&P). Typically, H&Ps and STI testing occur within seven to 14 days of arrival, but with the sheriff’s department assistance, patients were transferred to the clinic sooner – between days two and three – for their assessments, including the rapid syphilis test. Three cohorts were considered: pregnant women, non-pregnant women, and those with an unknown pregnancy status.

Results
During the 90-day project, a total of 1,417 women were booked. Of these, 1,005 were released prior to screening being offered. Thirteen were not clinically indicated for rapid testing as they reported a history of syphilis. A total of 145 patients were tested. Of those, three had reactive tests, indicating current or past syphilis and the need for further testing.

Of the women booked, 33 had a known pregnancy status; of those, 19 were released before screening. Of the remaining 14 pregnant patients, eight opted out of testing and six received the rapid test. Among those tested, three had reactive tests. Two were released before confirmatory testing could be conducted; for the third, Jane Doe, confirmatory testing indicated the presence of syphilis.

Preliminary data indicates the average length of stay for women was less than 24 hours. As a result, approximately 71% of them were released prior to being screened. Ideally, testing would have taken place closer to intake; however, the constraints of existing staff workloads and the complexity of the intake process made that impossible.

Final Thoughts
The implementation of the Syphilis Opt-Out Testing Pilot at the Palm Beach Main Detention Center demonstrates the pivotal role of promptly identifying and addressing active syphilis infections and emphasizes the broader impact of public health initiatives within vulnerable populations such as incarcerated individuals.

The pilot program serves as a model for other correctional facilities, highlighting the potential to not only improve the health of individuals within the system but also protect the well-being of current and future generations.

Case Study: Meet Jane Doe
Jane Doe, a 33-year-old woman, was arrested and booked into the Palm Beach County Sheriff’s Office. During intake, Ms. Doe disclosed a recent emergency department admission for suspected chest pain. According to hospital records provided to the jail with the patient’s consent, a blood test revealed elevated D-dimer levels, hinting at a potential pulmonary embolism or other dangerous blood clot. Despite that, the patient had signed out of the emergency department against medical advice.

The hospital records also revealed that Ms. Doe had been given a pregnancy test, which confirmed that she was 11 weeks pregnant. She reported recent alcohol, opiate, and cocaine use.

At the jail, appropriate detox protocols were initiated, and she was referred for medical appointments, started on prenatal vitamins, and given a pregnancy diet order. She was housed in an infirmary unit at the jail and seen by a medical provider before transfer to a general population housing unit.

Prior to administering the syphilis rapid test, the nurse coordinator conducted a mandatory risk assessment, which helps ensure that patients with a history of syphilis or active symptoms are not tested, as their results will always be reactive. The assessment form also includes questions about the patient’s medical history and risk factors.

Ms. Doe denied any history of previously being diagnosed with syphilis but reported several risk factors during the 12 months prior to her current arrest, including multiple sex partners, sex for money/drugs, commercial sex, and illicit drug use. The physical symptoms she reported were swollen lymph nodes in the groin and an abscess in her leg from IV drug use. She also reported being homeless.

Ms. Doe’s result was reactive, indicating current or past syphilis. Further testing confirmed that she was positive for syphilis. She also tested positive for chlamydia and gonorrhea. All required documents were completed, and contact was made with Department of Public Health community case workers

Over the course of the 12 days she was in custody, Ms. Doe received the first of three injections of an antibiotic to treat the syphilis, as well as treatment for chlamydia and gonorrhea. She left the facility with a discharge plan and prescription for two more injections.

Prepared with the patient’s contact information and discharge plan provided by the detention center’s Wellpath health care team, the local health department was equipped to follow up with her and support her in securing the last two doses of medication, with continued support from the Florida Department of Public Health and community case workers.

The Opt-Out Testing Pilot not only found and treated an active syphilis infection in Ms. Doe but also played a crucial role in preventing potential long-term effects on her unborn child. By identifying the infection early in the pregnancy, timely and appropriate interventions were started early, minimizing the risk of severe birth defects associated with congenital syphilis.

Elizabeth Samson, MA, LMHC, CCHP, is continuous quality improvement director and Diane Bartlett, CCHP, is clinical innovations coordinator with Wellpath.

The authors would like to express their gratitude to the individuals and organizations that played pivotal roles in the successful completion of this project: Wellpath Corporate, Regional, and on-site leaders and staff; the Palm Beach County Sheriff’s Office; the Florida Department of Public Health; and subject matter experts from the CDC and Emory University.