Congenital Syphilis Prevention: Intentionally and Equitably Screening for Syphilis in the Third Trimester of Pregnancy

Incidence rates for syphilis have been rising. In pregnancy, it can lead to congenital syphilis (CS). Although the effects of CS on the fetus can vary widely from no detectable symptoms to death, it is preventable with early detection and treatment of maternal syphilis. The Centers for Disease Control and Prevention (CDC) recommends evaluating all patients and testing prenatal patients at "high risk" for infection during their third trimester. Syphilis detection can be delayed by as much as 3-12 weeks, which has the potential to miss cases due to early false-negative results or changing sexual practices and partners during pregnancy. Local Problem: Utah ranks 45 th nationally for CS cases. Data from the Utah Department of Health and Human Services indicated insufficient syphilis testing in the state, prompting concern. Historically, Utah has had a low incidence of syphilis outbreaks in obstetric patients, and providers have not routinely screened for syphilis risk later in pregnancy. Two clinics recruited for this project identified care gaps for third-trimester syphilis testing. Methods: Using the Johns Hopkins evidence-based practice model, a screening tool based on CDC guidelines on patient behavior risk was developed, approved, and implemented over 17 weeks. Eligible patients were identified and screened by medical assistants (MAs) at the clinics, and providers counseled them regarding syphilis testing and CS. Providers and MAs completed pre- and postintervention surveys. Chart audits lab reports were performed to determine the number of patients screened, and testing results among those eligible. Bi-monthly monitoring was conducted throughout implementation, and plan-do-study-act cycles were used to reinforce staff participation and adherence to the screening protocol. Intervention: A screening tool was adopted from the CDC (2021) guidelines and modified to focus screening on the risk behaviors of patients and their partners. MAs screened eligible patients using the tool at their third-trimester lab visit. Providers were asked to review the form and counsel patients as indicated. If ordered, syphilis testing was added to their scheduled labs that day. Results: The rural clinic screened 89% (n = 46) of eligible patients. The urban clinic screened 22% (n = 39) of eligible patients, with 68% (n = 34) of those screenings occurring in the final month of the intervention, primarily attributed to a strong external influence on providers occurring at that time. Barriers to screening reported in the urban clinic included forgetting, cost to patients, time constraints, and lack of sufficient supervisory support. None of the patients tested positive for syphilis. Conclusion: The quality improvement project achieved its overarching goal of implementing evidence-based universal third-trimester evaluation for syphilis risk factors in selected clinics, thereby aligning with the CDC recommendations that all obstetric providers should evaluate all patients for risks of syphilis. Both the urban and rural clinics independently concluded that risk-based screening is not sustainable long-term, but using universal testing in the third trimester is a more feasible "best practice," underscoring the overall project's initiative as useable, feasible, and sustainable. Future studies should focus on a cost-benefit analysis of universal testing, particularly related to private insurance coverage.