Universal ED Syphilis Screening Outperforms Targeted Approaches, Study Shows

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A universal syphilis screening program implemented in an emergency department (ED) identified more cases of syphilis than programs targeting specific patient populations, such as pregnant women and people already receiving blood draws, according to a new study.¹

The findings were presented at the 2025 Conference on Retroviruses and Opportunistic Infections (CROI), held March 9-12, in San Francisco, CA.

“As syphilis numbers have been rising, we have been realizing that people who are highly or more at risk for syphilis often are not accessing the health care system in the usual places that we’ve traditionally screened them. We’re finding that if they have limited access to health care, they’re often going to the emergency department for their care,” presenting author Kimberly A. Stanford, MD, MPH, associate professor of medicine at the University of Chicago, said during a press conference at the meeting.² "As a result, screening programs in the ED have been getting increasing attention over the last few years."

Stanford and colleagues previously implemented a universal opt-out ED syphilis screening program in 2019 for all ED patients aged under 65 years at a large, urban tertiary care hospital in Chicago. At CROI 2024, Stanford presented retrospectively collected data assessing the program's impact by comparing 2 years before implementation with 2 years after. Results showed that in the 2 years preceding the intervention, 6.2% of ED encounters included syphilis testing. This increased nearly eightfold to 52.4% post-intervention. Additionally, more syphilis cases were identified after the intervention (16 vs 3).³

“There’s been a lot of debate nationally about whether [a universal screening program] makes sense,” Stanford said during the press conference.² “Does it make sense to screen everybody, or should we be targeting certain groups? A lot of HIV screening programs are tied to someone ... already having a blood draw. So, we just ignore the folks that aren’t getting their blood drawn already? Or do we think about who is our at-risk population? Do we target this towards people who are reproductive potential? Do we target this towards people who are already pregnant?”

To assess if a more targeted screening program would be successful, the research team retrospectively reviewed the screened population within the universal program and determined the number of patients who would have been missed if only targeted populations were tested, according to the study abstract.¹

Over a 2-year period, 37 289 ED patients under the age of 65 were screened for syphilis, identifying 624 active cases (1.7%). To assess the effectiveness of targeted screening, the study examined hypothetical models that limited testing to specific groups¹:

• Screening only patients tested for gonorrhea or chlamydia would have identified just 147 cases (23.6% sensitivity).
• Screening only women of reproductive age would have detected 142 cases (22.8% sensitivity).
• Screening only those receiving any blood draw would have captured 516 cases (82.7% sensitivity).
• Screening only those undergoing a complete blood count (CBC) would have identified 472 cases (75.6% sensitivity).

The results indicate that while targeted screening may reduce costs and resource use, it would also miss a large proportion of syphilis cases. Notably, the 2 highest-yield targeted models—screening patients receiving blood draws or CBCs—still failed to identify 17% to 25% of cases.¹

With syphilis rates rising nationally, particularly among populations with limited access to routine healthcare, ED visits may represent a critical opportunity for early detection.

"While implementation of universal ED screening may require additional resources and infrastructure, it may be the most effective strategy to address the syphilis epidemic in high prevalence communities facing major health care disparities," investigators concluded.¹