Are emergency departments the next frontier for sexually transmitted disease screening?

Abstract

THE PAST DECADE has witnessed a revolution in strategies for sexually transmitted disease (STD) control. When outbreaks of syphilis in hard-to-reach populations such as drug users and sex workers revealed the limitations of traditional approaches to case finding, public health was compelled to move beyond STD and family planning clinics, and into the community. A new tenet guiding STD control is to go to the very places where persons at high risk for STD congregate, and to facilities such as prisons and jails that house persons at high risk for STD, even though their primary purpose is entirely nonclinical. The development of noninvasive urine tests for Chlamydia trachomatis, and Neisseria gonorrhoeae, and the availability of single dose, oral antimicrobial therapy for both of these infections has made screening and treatment in these non-clinical venues feasible. STD prevention programs have routinized screening for chlamydial infection and gonorrhea in many jails and prisons, and some have begun to screen for chlamydial infection in schools and community settings.1,2 A substantial amount of experience and data have accumulated to support such screening, although few studies have examined the cost-effectiveness of these approaches. Somewhat surprisingly, the move from traditional, clinical venues to nontraditional, nonclinical venues has largely skipped over emergency departments (EDs). Why is this? Data are now accumulating to suggest that EDs may represent high-yield screening venues, although implementation of ED screening raises unique operational and feasibility issues. The article by Mehta et al in this issue of Sexually Transmitted Diseases contributes more data to the body of evidence indicating that ED screening may identify a substantial number of persons with STD. In their article entitled “Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: A critical population for STD control intervention,” Mehta and colleagues describe chlamydia and gonorrhea testing in an ED population that has a high STD prevalence and risk behaviors associated with the acquisition of STD and HIV.3 Testing for STD in this population was appealing for several reasons. The ED may serve as a point of contact for persons who are uninsured, with little or no access to a regular source of health care, and who are at high risk for STD. In an earlier study in the same ED, 65% of men and 34% of women queried reported that they had no regular source of health care, and approximately half of those men and women had an STD in the past year.4 In a study of persons living in an urban area with high STD incidence, Farley and colleagues found that while few had access to regular sources of health care almost 60% had visited a public or private ED in the past 12 months5; 70% of participants in this study had multiple partners and 30% had unprotected casual sex.5 The Mehta study and others have demonstrated the high prevalence of both STD and HIV infection in urban EDs.3,6–9 The prevalence of infection in recent studies has ranged from 8% to 11% for Chlamydia trachomatis,6–8,10 2% to 9% for gonorrhea,6,7 2% to 8% for syphilis,9,11,12 and 4% to 6% for HIV.9,13 Although ED screening for STD is likely to be high yield, it is unclear whether routine STD testing by ED staff is Correspondence: Julia A Schillinger, MD, MSc, Division of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC, Mailstop E-02, 1600 Clifton Road, NE, Atlanta, GA 30333. E-mail: jus8@cdc.gov Reprint requests: Julia A. Schillinger, Information Services, National Center for HIV, STD, and TB Prevention, CDC, Mailstop E-06, Atlanta, GA 30333. Received for publication October 10, 2000 and accepted October 23, 2000. From the *Surveillance and Special Studies Section and the Epidemiology Research Section, Epidemiology and Surveillance Branch, and the Office of the Director, Division of STD Prevention, National Center for HIV, STD, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia