Syphilis Screening Among Women Arrestees at the Cook County Jail -- Chicago, 1996

Cook County (Chicago) Department of Corrections (i.e., Cook County Jail {CCJ}) is one of the largest jail systems in the United States, with a daily census of approximately 10,000 arrestees. CCJ contracts with Cermak Health Services (CHS) * to provide medical services, including routine syphilis screening, to arrestees at CCJ. On January 6, 1996, the Chicago Department of Public Health (CDPH) STD/HIV Program, in collaboration with the CCJ, CHS, and CDC, implemented the Rapid Plasma Reagin (Stat RPR) Project at CCJ to improve syphilis identification and treatment rates among women. This report describes the project and provides data from the first year of operation. The findings indicate that Stat RPR yields a higher treatment rate for women arrestees than routine syphilis testing.

The Stat RPR project provides testing on admission to all women arrestees entering CCJ during the second shift (3 p.m.-11 p.m.), Monday through Friday. All women arrestees who are screened consent to testing. A four-step protocol is followed. First, CDPH staff perform the Stat RPR (a 15-minute on-site test using venipuncture blood), then a routine quantitative RPR is performed on site for all samples that were reactive to Stat RPR. Second, CDPH staff review the Chicago syphilis registry, a computerized database of reactive syphilis serologies (screening and confirmatory) and treatment histories, to determine whether women arrestees with reactive serologies are in the registry and require treatment based on standard serologic criteria (CDC's 1993 STD treatment guidelines {1}). Third, CDPH staff notify the CCJ physician's assistant (PA) of women with reactive serologies who have an indication for treatment. Finally, the PA provides on-site clinical examination, diagnosis, and treatment to women arrestees within a few hours after the initial test.

Women admitted on the weekend and during the first and third shifts on weekdays received off-site syphilis screening using a quantitative RPR. Arrestees with reactive serologies who met standard criteria for treatment were examined at the CCJ STD clinic, usually within 3-5 days of testing.

Of the 616 women with positive Stat RPR tests during 1996, a total of 158 (26%) had indications for treatment. Of these, 125 (79%) received treatment the same day, eight (5%) received treatment at a later date at CCJ, and 25 (16%) were released before receiving treatment. A total of 133 (84%) women with indications for treatment were treated before release; of these, 128 (96%) were later confirmed as having syphilis by fluorescent treponemal antibody absorbed (FTA-ABS). Of the 25 women released before treatment, six (24%) could not be located on follow-up, and 12 (48%) were not followed up.

Of the 597 women with positive screening tests by routine RPR, 226 (38%) had indications for treatment. Of these, 94 (42%) received treatment at CCJ, and 132 (58%) were released before receiving treatment. Of women who received treatment at CCJ, 91 (97%) were later confirmed as having syphilis by FTA-ABS. Of the 132 women released before treatment, 60 (45%) could not be located on follow-up, and 24 (18%) were not followed up. Women screened with Stat RPR were more likely than women screened with routine RPR to receive treatment before release (relative risk=2.0; 95% confidence interval=1.7-2.4).

Reported by: H Beidinger, MPH, J Jenks, D Broussard, Chicago Dept of Public Health. Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note

Editorial Note: Rapid STD diagnosis and treatment before release is critical for syphilis control and prevention in incarcerated populations because many arrestees are released within a few days after entering a jail facility (2). After release, many arrestees are difficult to reach, may not seek treatment in the absence of symptoms (3), and may have limited access to health care (2,4). The findings in this report indicate that rapid syphilis screening methods improve syphilis treatment rates. Compared with routine screening methods, the use of on-site Stat and quantitative RPR substantially reduced the percentage of women with reactive serologies released before receiving treatment and the percentage of women requiring follow up after release.

As syphilis rates among women in Chicago have declined and as screening in CCJ has increased, the proportion of disease that occurs in CCJ women arrestees has increased. In 1995, CCJ reported 10% (108 of 1041) of early syphilis cases among women in Chicago. After implementation of the Stat RPR project in 1996, early syphilis morbidity reported from CCJ increased to 22% of the city's total (176 of 803). Compared with 1995, early syphilis morbidity rates per 100,000 women in Chicago in 1996 decreased by 24% (68 to 52). Although the findings from this study do not establish a direct association between syphilis morbidity in Chicago and in CCJ, they indicate that declining syphilis morbidity in Chicago may be related, in part, to improved syphilis diagnosis and treatment of women arrestees who would not otherwise be diagnosed and treated outside the jail.

This project demonstrates that Stat RPR screening in jails can substantially improve the treatment rates of women with reactive serologies for syphilis before release and prevent the release of infected women to the community where disease and transmission of infection could continue unabated. Broad implementation of such interventions could help decrease overall syphilis morbidity in Chicago and the United States.

References

1. CDC. 1993 Sexually transmitted diseases treatment guidelines. MMWR 1993;42(no. RR-14).

2. Beltrami J, Cohen D, Hamrick J, Farley T. Rapid screening and treatment for sexually transmitted diseases in arrestees: a feasible control measure. Am J Public Health 1997;87:1423-6.

3. Blank S, McDonnell D, Rubin S, et al. New approaches to syphilis control: finding opportunities for syphilis treatment and congenital syphilis prevention in a women's correctional setting. Sex Transm Dis 1997;24:218-28.

4. Glaser J, Greifinger R. Correctional health care: a public health opportunity. Ann Intern Med 1993;118:139-45.

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