Jim Kling / 2024 年 10 月 9 日 / Medscape 醫學新聞 / 專題
一項新研究的結果顯示，急診室 (ED) 選擇性退出 (opt-out) 檢測策略 (註) ，導致芝加哥地區梅毒篩檢和診斷數量大幅增加。新診斷的病例通常沒有症狀，凸顯了這種策略在早期發現病例和預防併發症方面的潛力。
這項研究已線上發表在《傳染病開放論壇》。這項結果發布之際，成人梅毒和先天梅毒病例正在增加，美國疾病管制與預防中心估計 2018 年至 2022 年間分別增加了 80% 和 183%。根據作者Kimberly Stanford醫師表示，這可能包括COVID-19 大流行、服務取得機會減少、性傳播感染 (STI) 診所關閉以及引入暴露前預防後對愛滋病毒的擔憂減少。
「我認為，特別是對於梅毒，我們有點放鬆了警惕。它又悄悄地襲擊了我們」，史丹佛說道，他是一名醫學副教授，也是急診 HIV/STI 檢測和急診社會醫學的主任，芝加哥醫學院團隊。
史丹佛表示，新方法係基於愛滋病毒之選擇退出性篩檢，消除了測試的恥辱和潛在偏見。 「這對愛滋病毒來說非常有效，因為它接觸到了一群自己不認為自己處於危險之中的人，而進行篩檢的人也不會認為自己處於危險之中，這確實讓事情變得更容易。梅毒和愛滋病毒之間有很多相似之處，無論是在其影響的人群中，還是在很長一段時間內它們都可能無症狀」，史丹佛說道。
該測試方案要求對年齡在 18 歲至 64 歲之間、沒有 HIV 診斷且在過去 12 個月內沒有 HIV 篩檢史的任何人，並基於臨床判斷對其進行梅毒篩檢。研究人員比較了介入實施前兩年和介入實施後前兩年（2017 年 6 月至 2021 年 5 月）的數據。 總共包含了 299,651 次於急診上之遭遇。
在篩檢介入之前，3.6%的急診室患者進行了梅毒檢測，而在篩檢策略開始後，這一數字上升至24.4%。研究人員在介入前確定了 161 名疑似梅毒感染患者，介入後確定了 624 名患者。在懷孕者中，篩檢率從5.9%躍升至49.9%，推定病例從2例增加到15例。
史丹佛表示，廣泛實施的這種篩檢策略可能會對梅毒發病率產生重大影響。它尤其受到先天性梅毒的影響。 「這確實令人沮喪，因為這是一種非常可以治療和預防的疾病，我認為我們確實有機會接觸到人們，且在這種情況發生之前讓他們得到診斷和治療。自從我們實施該計畫以來，我們看到了越來越多的神經梅毒患者的發生率。我見過患有結腸炎和胰臟炎的人，他們一直到接受大腸鏡檢查，試圖弄清楚發生了什麼，然後最終被診斷為梅毒。我認為，由於這項篩檢計畫，我們現在開始看到其中一些事情得到了更早的診斷，」她說道。
史丹佛承認該測試給急診室人員帶來了額外的負擔。由於先前治療過的感染，可能會出現假陽性，需要再與患者接觸或查閱醫療記錄來進一步確認結果。
擔任該研究計畫官員的卡洛琳·迪爾博士表示，該研究的一個重要限制是測試是在單一地點進行的，可能無法推廣到其他急診室。她還指出，該研究受到了 COVID-19 大流行的影響。迪爾在一封電子郵件回覆中表示：「目前尚不清楚這種大流行疾病如何影響研究結果」。她是國家過敏和傳染病研究所微生物學和傳染病部門腸道和性傳播感染科主任。
「我認為這是在健康系統學術中實施篩檢計畫的一種非常聰明的方法，」被要求發表評論的保羅·亞當森 (Paul Adamson) 醫學博士說。 「事實上，我們（在加州大學洛杉磯分校）也對研究感興趣。我認為這顯示我們可以改善那些難以接觸到的人群之梅毒篩檢，而且這是一種相對簡單的介入措施」，亞當森是加州大學洛杉磯分校大衛格芬醫學院的臨床助理教授。
亞當森同意該測試會給已經在工作上超負荷的急診醫療提供者增加負擔。 「另一方面，我認為急診室之醫療提供者是了解愛滋病毒的流行，也可能在較小程度上亦了解梅毒，但是透過一些教育，我認為這可以相信是一項值得做的活動」，他說道。
「這確實需要 [傳染病] 提供者的支持，坦率地說，他們也過度勞累和負擔過重。我認為人們都同意這是一個值得解決的問題，所以我認為人們會接受它。就我個人而言，我認為應該有一種方法來激勵這種行為，要麼是某種的品質指標，要麼是公共衛生系統向急診部門支付用於鑑別病例的費用」，亞當森說。
亞當森和史丹佛沒有相關利益上的之揭露。
引用此內容：急診室梅毒篩檢促進監測和診斷 – Medscape – 2024 年 10 月 9 日。
註：選擇性退出 (opt-out) ：意即若當事人未表明不願意接受，執行者便會執行某種作為。
ED Syphilis Screening Boosts Surveillance, Diagnoses
Jim Kling / October 09, 2024 / Medscape Medical News / Features
An emergency department (ED) opt-out testing strategy led to big increases in syphilis screening and diagnosis in the Chicago area, according to the results of a new study. Newly diagnosed cases were generally asymptomatic, highlighting the potential of such a strategy to catch cases early and prevent complications.
The study was published online in Open Forum Infectious Diseases. The results come as cases of adult and congenital syphilis are on the rise, with the US Centers for Disease Control and Prevention estimating increases of 80% and 183%, respectively, between 2018 and 2022. That rise may be due to a combination of factors that might include the COVID-19 pandemic, reduced access to services, closure of sexually-transmitted infection clinics, and fewer worries about HIV following the introduction of pre-exposure prophylaxis, according to study author Kimberly Stanford, MD.
“I think with syphilis in particular, we a little bit let our guard down. It kind of snuck up on us again,” said Stanford, who is an associate professor of medicine and director of ED HIV/STI Testing and the ED Social Medicine Team, Biological Sciences Division, The University of Chicago Medicine, Chicago.
The new approach is based on opt-out screening for HIV, which removes both stigma and potential bias of testing, according to Stanford. “That’s worked really well for HIV because it’s gotten to a population of people who wouldn’t have themselves thought they were at risk, and the people doing the screening wouldn’t have thought they were at risk, and it really makes it a lot easier. There are a lot of similarities between syphilis and HIV, both in the populations that it affects and also in the fact that they could both be asymptomatic for a long time,” said Stanford.
The testing protocol called for offering syphilis screening to anyone between the ages of 18 and 64 with no HIV diagnosis and no history of HIV screening in the past 12 months, as well as based on clinical discretion. The researchers compared data from 2 years before the intervention was implemented and the first 2 years afterwards, between June 2017 and May 2021. It included a total of 299,651 ED encounters.
Before the screening intervention, 3.6% of ED encounters led to syphilis tests, and this number rose to 24.4% after the screening strategy began. The researchers identified 161 patients with presumed syphilis infection before the intervention and 624 afterwards. Among those who were pregnant, the screening rate jumped from 5.9% to 49.9% and presumed cases increased from 2 to 15.
Such a screening strategy, widely implemented, could have a big impact on syphilis rates, said Stanford. She is particularly affected by congenital syphilis. “It’s really upsetting because it’s a very treatable and preventable condition, and I think we really have an opportunity here to reach people, to get them diagnosed and treated before it gets to that point. Since we implemented this program, we have been seeing increased rates of neurosyphilis. I’ve seen people with colitis and pancreatitis who went all the way through to the point of getting a colonoscopy, trying to figure out what was going on, and then it ended up being syphilis. I think we’re now starting to see some of those things getting diagnosed a little bit earlier because of this screening program,” she said.
Stanford acknowledged that the test puts an additional burden on ED personnel. False positives can occur due to previously treated infections, requiring contact with patients or access to medical records to confirm a result.
One important limitation of the study was that testing was conducted at a single site and may not be generalizable to other EDs, according to Carolyn Deal, PhD, who served as a program official for the study. She also noted that the study was affected by the COVID-19 pandemic. “It’s not known how the pandemic could have impacted the study results,” Deal said in an email response. She is chief of the Enteric and Sexually Transmitted Infections Branch, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases.
“I thought it was a really clever way to implement a screening program in an academic health system,” said Paul Adamson, MD, who was asked to comment. “In fact, it’s something that we’ve also been interested in researching (at UCLA) as well. I think it showed that we can improve syphilis screening in hard-to-reach populations, and it was a relatively simple intervention,” said Adamson, who is an assistant clinical professor at the David Geffen School of Medicine at UCLA.
Adamson agreed that the test would add a burden to ED providers who are already overworked. “On the other hand, emergency room providers I think understand the epidemic of HIV, and also maybe to a lesser extent syphilis, but with some education could I think be convinced that this is a worthwhile activity to do,” he said.
“It does require buy-in from [infectious disease] providers who, frankly, are also overworked and overburdened. I think people all agree that this is a problem that’s worth solving, so I think people will be on board with it. Personally, I think there should be a way to incentivize this, to have it either be some kind of quality metric, or a public health system payout to emergency departments for identifying cases,” said Adamson.
Adamson and Stanford had no relevant financial disclosures.
Cite this: ED Syphilis Screening Boosts Surveillance, Diagnoses – Medscape – October 09, 2024.