Karla Schmitt, PhD, MPH, ARNP Alignment of Technology, Policy and Law Result in 200% Increase in Perinatal STI Identification Stacy Shiver, BA Karla Schmitt, PhD, MPH, ARNP Susan O'Bryan, MLS Adrian Cooksey, MPH Mary White, (DBA)

Historical Framework 1,000s of landmark publications on STIs in pregnancy Pathogen specific Treatment efficacy Laboratory screening, often with specific assays Cohort often from clinic setting or multiple clinic environments Scope of data limited by access to medical records and extent of funding resources Stacy- total 5 slides on the mechanics of how we get information, how we expect to connect for vital stats info, hardware, software.... these slides should address how a new state of the art technology approach/application enhanced our capacity for case identification     note need to highlight this as a programmatice structural response to create an environment that supports program operations and reduces disease transmission     note what was planned, what succeeded, what failed, what was partial success, and obstancles to get to this point     note the practical pathway.....   Karla- total 5 slides on: a) background (historical underpinings of our disease process understanding, b) primary desired outcome (new standards of care, better understanding of disease processes) and c) data gathered to date.......if we are very lucky a logistic regression statement about association....     note critical elements that have been gathered, believd observed, and what is missing in evidence base; frame historical knowledge on difference in new technology, capacity to control more variables; historical bias versus recent evidence And We will need a  concluding slide on implications for HC delivery systems in FL  and potential policy directives to evolve

Darwinian Framework Evolutionary trajectory……Opportunities to explore During 2005, 3% of all infants born in Fl were delivered to women who had an STD during pregnancy or at delivery Evolutionary trajectory……Opportunities to explore Broader community and population based surveillance analyses Automated linked data sets from diverse source applications Expanded capacity to control variable bias Update knowledge and document “evidence” Revise standards of care and drive policy Identify economic advantage to process improvement Reduce STD associated stigma And if we are very lucky….improve perinatal health outcomes….the critical impetus for a change in our posture

New Law, New Code Re-wrote the Florida Statute section on blood testing of pregnant women broadened testing other than blood required that practitioner inform the woman of the testing that would take place And, retained authority of department to specify conditions. Law Points: Code Points:

Florida Administrative Code 64D-3 Revised the relevant sections clarified requirements in 1st & 3rd trimesters, postpartum made routine CT, GC, Hep B, HIV, syphilis notify the woman of the testing that would take place, and her rights direct ED refer women not yet in care after the 12th week to county health departments required documentation on birth, fetal death certificates of infection and treatment events

Pre-Computer Period Pre-Network Period Interview Record Provider Reports Medical Record Field Record Congenital Record Lab Reports Pre-Network Period Interview Record Provider Reports STD NETSS Medical Record Field Record MIS Computers/Software Congenital Record Lab Reports

Modern Networks and Computers/Software Hospitals Lab Repository PHIN MS Laboratory Vital Stats Providers CDC Clinics

HISTORICAL IMPLEMENTATION OF CHANGE MODERN IMPLEMENTATION OF CHANGE More paper More Duties for Workforce More Dedicated Work Hours MODERN IMPLEMENTATION OF CHANGE Information Management Application of Automation Minimize Impacts to Workforce

Florida’s Application of Technology for STD Full Integration of ELR into PRISM Integration of HARS into PRISM PRISM searches of Florida’s Vital Statistics Database – automated. Bidirectional Communication between PRISM and clinical systems. Access to critical information systems combined with key automation to reduce workloads and improve information management.

Post Modernization Pre Modernization During 2005, 1.3% of all infants born in Fl were delivered to women who had an STD reported during pregnancy or at delivery 3,500 case reports in pregnancy Post Modernization During 2007, 5.5% of all infants born in Fl were delivered to women who had an STD reported during pregnancy or at delivery 13,114 case reports in pregnancy Broader range of infections From one to six Case definitions established Scope of condition details expanded Partner treatment status Baby’s status at end of pregnancy Prenatal care components Prenatal care components: number of visits, first visit, last visit prenatal care provider trimester of testing treatment date interview date morbidity created gestational age Baby details: status at birth DOB birth weight Partner details: date of treatment linkage to cluster, network co-morbidity risk

Observations of Interest Majority of infections identified later in pregnancy than anticipated: 34.5% in 2nd trimester, 35.3% in 3rd trimester No surprise: chlamydia comprised 65% of infections identified in 15-19 group and 17.5%; early latent comprised 20% of infections identified in 20-24 group and chlamydia 50% Prenatal care status known on 47.2%: of those 84% received appropriate treatment Ethnicity distribution remained consistent over time Race distribution both shifted, and reported with higher % “unknown” Prenatal care components: number of visits, first visit, last visit prenatal care provider trimester of testing treatment date interview date morbidity created gestational age Baby details: status at birth DOB birth weight Partner details: date of treatment linkage to cluster, network co-morbidity risk

Observations of Interest Baby status known on 92% 83.4% experienced a live birth 2.2% experienced a live birth, followed with death Small number, ¾ among untreated partners Small number, ¾ associated with syphilis 38% identified as serofast, likely serofast, previously adequately treated; uncertain if followed adequately per protocol unknown significance Prenatal care components: number of visits, first visit, last visit prenatal care provider trimester of testing treatment date interview date morbidity created gestational age Baby details: status at birth DOB birth weight Partner details: date of treatment linkage to cluster, network co-morbidity risk

Policy implications Training specific to perinatal infections for DIS Modules in development for certification curricula Revised processes to increase treatment completion within acceptable intervals Processes to assure partner treatment Law change for partner expedited treatment Law change to assure partner treatment Processes to assure standardized follow-up during prenatal care for repeat testing as indicated (and measurement) KEY POINT: much more work remains to clean and link data, understand how staff entered data, revamp surveillance activities to capture potential of data Prenatal care components: number of visits, first visit, last visit prenatal care provider trimester of testing treatment date interview date morbidity created gestational age Baby details: status at birth DOB birth weight Partner details: date of treatment linkage to cluster, network co-morbidity risk Enhanced case identification highlighted significant prevalence during pregnancy

Questions? Contact: Stacy Shiver Sr. Management Analyst Supervisor Bureau of STD Prevention and Control, Division of Disease Control (850) 245-4327