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Syphilis and the role of emergency medicine in infectious disease public health
EDITOPdALS Syphilis and the Role of Emergency Medicine in Infectious Disease Public Health In 1495 the army of Charles VIII of France captured Naples; however, a new infectious disease attacked his troops and soon compelled the evacuation of the city, dispersing these diseased soldiers all over the continent. Over the next 50 years an epidemic of what later would be known as syphilis spread across Europe, killing thousands. At its inception, syphilis was a virulent and lethal infection. In recent years the epidemic has re-emerged despite the fact that syphilis is a more indolent disease and there exist adequate tests for detection, effective therapy, and a modern public health system. Between 1981 and 1989, the incidence of primary and secondary syphilis in the U n i t e d States increased 34%, from 13.7 to 18.4 cases per 100,000 persons, the highest incidence since 1949.1 In this issue of Annals, Ernst and colleagues report the results of an active screening program for asympt o m a t i c syphilis a m o n g emergency d e p a r t m e n t patients w i t h sexually t r a n s m i t t e d disease (STD)-related complaints. In this group these investigators found a prevalence of 6% FTA-ABS-confirmed, VDRL-positive patients. Although remarkable, this high prevalence is not surprising for m a n y reasons. See related article, p 627. The decrease' in incidence rates of syphilis in the United States in the early 1980s was ascribed to changes in sexual behavior among homosexual and bisexual men in response to the HIV epidemic. However, the recent explosion in new syphilis cases has occurred almost exclusively in both male and female heterosexual m i n o r i t y patients. Several reports h a v e l i n k e d the r e c e n t spread of syphilis to use of illegal drugs, especially "crack" cocaine, and the practice of "sex for drugs." Persons with these habits are generally medically 20:6:June1991
underinsured and disenfranchised, the very characteristics of patients who tend to use the ED as their prim a r y m e d i c a l resource. The high prevalence of syphilis noted in this Connecticut ED is consistent with the fact that this state had the greatest increase in cases between 1985 and 1989 (6.8 to 35.7 cases per 100,000). As an increasing number of people use the ED for primary care, what is the role of emergency medicine in the screening and prevention of diseases of great public health importance such as syphilis? Despite the assertions by Ernst and colleagues, the Centers for Disease Control provide only vague r e c o m m e n d a t i o n s that do not specifically address the ED setting. Active hospital surveillance is o n l y s p e c i f i c a l l y r e c o m mended for congenital syphilis in areas that have five or more women w i t h early infectious syphilis per 100,000 population. 2 The CDC states that for patients in general who are at risk for acquisition of STD, laboratory tests should be "available" for STD screening (eg, syphilis and HIV serology), a The CDC further states that patients with diagnosed STD should be " c l o s e l y e v a l u a t e d " for other STDs. 3 Therefore, the extent to which screening should be conducted for patients with presumed STD or STD-related s y m p t o m s in EDs has not been defined by the US Public Health Service. The potential role of EDs to actively participate in infectious disease screening and prevention is becoming clear as i m p o r t a n t studies such as that of Ernst et al are conducted. Previous studies have noted low rates of i m m u n i z a t i o n among ED patients. For example, Polis et al demonstrated that only 8% of pneumococcal vaccine candidates presenting to the ED for u n r e l a t e d complaints had been immunized and that vaccination was feasible in the ED. 4 Although syphilis is a serious concern, even more significant is the poAnnals of Emergency Medicine
tential for prevention and treatment of childhood sepsis and HIV infection with the advent of Haemophilus influenzae type b vaccine and azidothymidine treatment of asymptomatic HIV-infected patients, respectively. However, many questions remain to be answered. Rates of STD are highly population dependent, and there are areas in this country for which screening would be clearly nonproductive; high-prevalence ED populations must be identified. Public hospital EDs represent the likely setting to initiate more comprehensive screening and prevention programs; however, for these hospitals, the tests and vaccinations represent significant direct and generally u n c o m p e n s a t e d costs. These costs must be analyzed along with other factors such as the likelihood, costs, and preventive benefit of follow-up care and earlier treatment of patients, partners, and their offspring. The cost-effectiveness and impact of this approach must also be justified to third-party payers as well as other primary care providers. EDs must be compensated appropriately to maintain these programs where they can be shown to be beneficial. In previous position papers, the American College of Emergency Physicians has already set a precedent indicating that emergency physicians should actively participate in screening and prevention by immunization against childhood diseases s and, with regard to HIV, stating that HIV antib o d y t e s t i n g s h o u l d be " r e c o m mended" to high-risk populations. 6 However, at present, the only immunization history that is consistently obtained in EDs is with regard to tetanus toxoid and only in the setting of a w o u n d . As Ernst et al d e m o n strated, EDs w i t h o u t an e x p l i c i t screening policy appeared to have incomplete screening for syphilis in their high-prevalence population with STD-related complaints. In light of the modern phenomenon of the shifting of primary care to 697/145
EDITORIALS
EDs and the current high rate of underimmunization and increasing incidence of serious communicable diseases such as syphilis and AIDS, emergency medicine should pursue a more prominent role in maintaining public health. How can this be accomplished? First, there must be more careful history taking for immunizations and STD risk of all ED patients. Where shown to be feasible and cost-effective, vaccinations and screening tests should be administered in the ED. In all cases, e m e r g e n c y p h y s i c i a n s should be aware of and use appropriate avenues of referral to private physicians or public clinics. All states require reporting of communicable diseases, yet these laws go unenforced.
To the extent that emergency physicians do consistent reporting, the epidemics can be followed and funding to combat these diseases can be justified. Our specialty must promote education in the recognition and treatment of infectious diseases. Prevention and treatment of infectious diseases have resulted in more lives saved than in any other area of medical care. The ED is becoming the m o d e r n b a t t l e g r o u n d for the frontline attack on the m o d e r n epidemics. The potential for emergency medicine to lead the way in promoting infectious disease public health has never been greater.
Dave A Talan, MD, FACEP Departments of Emergency Medicine
and Internal Medicine Olive View/UCLA Medical Center Sylmar, California 1. Rolfs RT, Nakashima AK: Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. lAMA 1990;264:1432-I437. 2. Centers for Disease Control: Guidelines for the prev e n t i o n and control of congenital syphilis. MMWR 1988;37:1-13. 3. Centers for Disease Control: 1989 Sexually transmitted diseases t r e a t m e n t guidelines. MMWR 1989;38 (S-8):1-43. 4. Polis MA, Davey VJ, Collins ED, et al: The emergency department as part of a successful strategy for increasing adult immunization. Ann Emerg Med 1988; 17:1016-1018. 5. American College of Emergency Physicians: Tetanus i m m u n i z a t i o n r e c o m m e n d a t i o n s for persons seven years of age or older. Ann Emerg Med 1986;15:111-I12. 6. American College of Emergency Physicians: AIDS Statement of principles and interim recommendations for,emergency department personnel and prehospital care providers. Ann Emerg Med 1988;17:1249-i251.
Departments of Emergency Medicine in Universities: The Ohio State Experience In the mid 1800s, the growth of sci: ence in Europe and the United States prompted a trend toward academic specialization. The push for specialization in universities was particularly strong at the graduate and professional level, resulting in the crea t i o n of a c a d e m i c d e p a r t m e n t s responsible for all levels of instruction. Today, university departments are the fundamental administrative units that initiate faculty appointments, promotion, and tenure, and exercise control over the distribution of allocated resources. See related article, p 680. In the United States, emergency medicine faculty are organized as autonomous departments in only 20 of the 126 accredited medical schools. The article by Rusnak et al in this issue of the Annals presents a synopsis of the creation and evolution of those departments and suggests some general strategic principles to assist emergency medicine faculty in creating departments in academic medical 146/698
centers (AMCs). I would like to comment on the recent creation of our own department and present some observations. On July 1, 1990, the Board of Trustees at the Ohio State University established an autonomous Department of Emergency Medicine within the College of Medicine. The Board's resolution noted that emergency medicine had been recognized as a separate specialty since 1979 and that emergency medicine represented a distinct body of medical knowledge. With a total enrollment of 940 students, Ohio State is the fourth largest medical school in the country.1 The event marked the culmination of a long, determined effort by our specialty both within and outside our institution. In the early 1970s the medical college established a committee chaired by a surgeon to study the emergency medicine issue at Ohio State. Recogn i z i n g deficiencies in e m e r g e n c y care, the c o m m i t t e e i n v i t e d Drs Ronald Krome and Peter Rosen to the campus. Both individuals were k n o w n to the c o m m i t t e e chair as Annals of Emergency Medicine
able fellow surgeons with interest and expertise in academic emergency care. They r e c o m m e n d e d recruitment of a full-time medical director, establishment of a residency training program, and the development of an emergency medicine faculty to staff the emergency department. Such proposals had the tentative support of the departments of Surgery and Internal Medicine (the chairman of the Department of Internal Medicine had established a prototype mobile coronary care unit within the community). In 1977 I was asked by the dean to take on the emergency medicine assignment. Realizing that the first step required a substantial upgrading of the clinical service, I tried to recruit excellent clinicians to both provide and supervise patient care. Two of us initially provided partial ED coverage. When we gained some control over revenues generated from professional billing, we quickly expanded to a faculty of five providing 24-hour coverage. The Department of Preventive Medicine had previously sheltered a clinical division (Family 20:6 June 1991
underinsured and disenfranchised, the very characteristics of patients who tend to use the ED as their prim a r y m e d i c a l resource. The high prevalence of syphilis noted in this Connecticut ED is consistent with the fact that this state had the greatest increase in cases between 1985 and 1989 (6.8 to 35.7 cases per 100,000). As an increasing number of people use the ED for primary care, what is the role of emergency medicine in the screening and prevention of diseases of great public health importance such as syphilis? Despite the assertions by Ernst and colleagues, the Centers for Disease Control provide only vague r e c o m m e n d a t i o n s that do not specifically address the ED setting. Active hospital surveillance is o n l y s p e c i f i c a l l y r e c o m mended for congenital syphilis in areas that have five or more women w i t h early infectious syphilis per 100,000 population. 2 The CDC states that for patients in general who are at risk for acquisition of STD, laboratory tests should be "available" for STD screening (eg, syphilis and HIV serology), a The CDC further states that patients with diagnosed STD should be " c l o s e l y e v a l u a t e d " for other STDs. 3 Therefore, the extent to which screening should be conducted for patients with presumed STD or STD-related s y m p t o m s in EDs has not been defined by the US Public Health Service. The potential role of EDs to actively participate in infectious disease screening and prevention is becoming clear as i m p o r t a n t studies such as that of Ernst et al are conducted. Previous studies have noted low rates of i m m u n i z a t i o n among ED patients. For example, Polis et al demonstrated that only 8% of pneumococcal vaccine candidates presenting to the ED for u n r e l a t e d complaints had been immunized and that vaccination was feasible in the ED. 4 Although syphilis is a serious concern, even more significant is the poAnnals of Emergency Medicine
tential for prevention and treatment of childhood sepsis and HIV infection with the advent of Haemophilus influenzae type b vaccine and azidothymidine treatment of asymptomatic HIV-infected patients, respectively. However, many questions remain to be answered. Rates of STD are highly population dependent, and there are areas in this country for which screening would be clearly nonproductive; high-prevalence ED populations must be identified. Public hospital EDs represent the likely setting to initiate more comprehensive screening and prevention programs; however, for these hospitals, the tests and vaccinations represent significant direct and generally u n c o m p e n s a t e d costs. These costs must be analyzed along with other factors such as the likelihood, costs, and preventive benefit of follow-up care and earlier treatment of patients, partners, and their offspring. The cost-effectiveness and impact of this approach must also be justified to third-party payers as well as other primary care providers. EDs must be compensated appropriately to maintain these programs where they can be shown to be beneficial. In previous position papers, the American College of Emergency Physicians has already set a precedent indicating that emergency physicians should actively participate in screening and prevention by immunization against childhood diseases s and, with regard to HIV, stating that HIV antib o d y t e s t i n g s h o u l d be " r e c o m mended" to high-risk populations. 6 However, at present, the only immunization history that is consistently obtained in EDs is with regard to tetanus toxoid and only in the setting of a w o u n d . As Ernst et al d e m o n strated, EDs w i t h o u t an e x p l i c i t screening policy appeared to have incomplete screening for syphilis in their high-prevalence population with STD-related complaints. In light of the modern phenomenon of the shifting of primary care to 697/145
EDITORIALS
EDs and the current high rate of underimmunization and increasing incidence of serious communicable diseases such as syphilis and AIDS, emergency medicine should pursue a more prominent role in maintaining public health. How can this be accomplished? First, there must be more careful history taking for immunizations and STD risk of all ED patients. Where shown to be feasible and cost-effective, vaccinations and screening tests should be administered in the ED. In all cases, e m e r g e n c y p h y s i c i a n s should be aware of and use appropriate avenues of referral to private physicians or public clinics. All states require reporting of communicable diseases, yet these laws go unenforced.
To the extent that emergency physicians do consistent reporting, the epidemics can be followed and funding to combat these diseases can be justified. Our specialty must promote education in the recognition and treatment of infectious diseases. Prevention and treatment of infectious diseases have resulted in more lives saved than in any other area of medical care. The ED is becoming the m o d e r n b a t t l e g r o u n d for the frontline attack on the m o d e r n epidemics. The potential for emergency medicine to lead the way in promoting infectious disease public health has never been greater.
Dave A Talan, MD, FACEP Departments of Emergency Medicine
and Internal Medicine Olive View/UCLA Medical Center Sylmar, California 1. Rolfs RT, Nakashima AK: Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. lAMA 1990;264:1432-I437. 2. Centers for Disease Control: Guidelines for the prev e n t i o n and control of congenital syphilis. MMWR 1988;37:1-13. 3. Centers for Disease Control: 1989 Sexually transmitted diseases t r e a t m e n t guidelines. MMWR 1989;38 (S-8):1-43. 4. Polis MA, Davey VJ, Collins ED, et al: The emergency department as part of a successful strategy for increasing adult immunization. Ann Emerg Med 1988; 17:1016-1018. 5. American College of Emergency Physicians: Tetanus i m m u n i z a t i o n r e c o m m e n d a t i o n s for persons seven years of age or older. Ann Emerg Med 1986;15:111-I12. 6. American College of Emergency Physicians: AIDS Statement of principles and interim recommendations for,emergency department personnel and prehospital care providers. Ann Emerg Med 1988;17:1249-i251.
Departments of Emergency Medicine in Universities: The Ohio State Experience In the mid 1800s, the growth of sci: ence in Europe and the United States prompted a trend toward academic specialization. The push for specialization in universities was particularly strong at the graduate and professional level, resulting in the crea t i o n of a c a d e m i c d e p a r t m e n t s responsible for all levels of instruction. Today, university departments are the fundamental administrative units that initiate faculty appointments, promotion, and tenure, and exercise control over the distribution of allocated resources. See related article, p 680. In the United States, emergency medicine faculty are organized as autonomous departments in only 20 of the 126 accredited medical schools. The article by Rusnak et al in this issue of the Annals presents a synopsis of the creation and evolution of those departments and suggests some general strategic principles to assist emergency medicine faculty in creating departments in academic medical 146/698
centers (AMCs). I would like to comment on the recent creation of our own department and present some observations. On July 1, 1990, the Board of Trustees at the Ohio State University established an autonomous Department of Emergency Medicine within the College of Medicine. The Board's resolution noted that emergency medicine had been recognized as a separate specialty since 1979 and that emergency medicine represented a distinct body of medical knowledge. With a total enrollment of 940 students, Ohio State is the fourth largest medical school in the country.1 The event marked the culmination of a long, determined effort by our specialty both within and outside our institution. In the early 1970s the medical college established a committee chaired by a surgeon to study the emergency medicine issue at Ohio State. Recogn i z i n g deficiencies in e m e r g e n c y care, the c o m m i t t e e i n v i t e d Drs Ronald Krome and Peter Rosen to the campus. Both individuals were k n o w n to the c o m m i t t e e chair as Annals of Emergency Medicine
able fellow surgeons with interest and expertise in academic emergency care. They r e c o m m e n d e d recruitment of a full-time medical director, establishment of a residency training program, and the development of an emergency medicine faculty to staff the emergency department. Such proposals had the tentative support of the departments of Surgery and Internal Medicine (the chairman of the Department of Internal Medicine had established a prototype mobile coronary care unit within the community). In 1977 I was asked by the dean to take on the emergency medicine assignment. Realizing that the first step required a substantial upgrading of the clinical service, I tried to recruit excellent clinicians to both provide and supervise patient care. Two of us initially provided partial ED coverage. When we gained some control over revenues generated from professional billing, we quickly expanded to a faculty of five providing 24-hour coverage. The Department of Preventive Medicine had previously sheltered a clinical division (Family 20:6 June 1991