Congenital Syphilis in Shelby County, Tennessee: Past and Present Morrell K, MPH; Konnor RY, PhD-c, MPH; King C, MD; Keskessa A, MD, MPH; Kmet J, MPH; Chapple-McGruder T, PhD, MPH Shelby County Health Department, Memphis TN

Congenital Syphilis Rates by Region, United States, Data Source: Centers for Disease Control and Prevention 1

Case Definition Shelby County Health Department  Surveillance case definition includes both probable and confirmed cases. 2  All infants born to mothers who have untreated or inadequately treated syphilis are considered probable cases.  Asymptomatic infants and stillbirths are included in surveillance case definition.

Screening and Reporting Laws Shelby County Health Department  Congenital syphilis is reportable in all 50 states and DC  46 states (90%) require prenatal syphilis screening (as of 2001). 3  34 require one test (typically at first visit)  9 require two tests (second in 3 rd trimester)  3 states only require second test in third trimester for women at high risk → (Tennessee) 4

Background Shelby County Health Department  Syphilis during pregnancy can lead to adverse birth outcomes.  More than half of infants are asymptomatic at birth. 5  More likely to occur where mothers have inadequate antenatal visits. 6  Prevention- early detection and/or treatment at least 30 days before delivery.

Background Shelby County Health Department  Transmission can occur at any stage of pregnancy.  The longer the interval between infection and pregnancy, the more benign the outcome in the infant. 7  Change in Primary and Secondary (P&S) Syphilis among females usually followed by similar change in Congenital Syphilis (CS). 8

Congenital Syphilis and Female P&S Syphilis Rate, United States, Data source: Centers for Disease Control and Prevention 8

Objectives  Describe and examine the association between female P&S syphilis and CS rates in Shelby County from  Describe the current epidemic by reporting:  demographics of female P&S cases;  characteristics of mothers of infants with CS;  prenatal care utilization among mothers of infants with CS.  Review recommendations for prenatal syphilis screenings in a high-incidence area. Shelby County Health Department

Data Sources  Case data:  NETSS ( )  STDMIS ( )  Birth data: Tennessee Vital Statistics ( )  Population data: US Census (1990, 2000) Shelby County Health Department

Analysis  Rate Calculations:  CS rate per 100,000 live births  Female P&S syphilis rates per 100,000 population  Association between annual P&S and CS rates measured using Spearman Correlation  Access to prenatal care and screening assessed through case reviews in STDMIS. Shelby County Health Department

Congenital and Female P&S Syphilis Rates by Year, Shelby County, Shelby County Health Department

Congenital and Female P&S Syphilis Rate Changes, Shelby County, % change congenital syphilis rate % female P&S syphilis rate % Shelby County Health Department

Spearman Correlation Results Variable N (# years of data) MeanStd DevMedianMinMax CS rate Female P&S rate H o : Rho = 0  Rho ≠ 0 Rho s = 0.87 p <.0001 Shelby County Health Department

Demographics of Female P&S Cases and Mothers of Infants with CS, Shelby County, Shelby County Health Department Demographic GroupMothers of Infants with CSFemale P&S Syphilis Cases N%N% TOTAL % % Race/Ethnicity Black, not Hispanic3997.5% % Age Group 10— %5418.5% 20— %9632.9% 30— %6120.9% 40—49**5719.5% 50+**248.2%

Shelby County Health Department Characteristics of CS Cases, Shelby County, Infant vital statusN% Born Alive % Infant case classification Probable % Symptom status of infant Classic signs of congenital syphilis512.5% Asymptomatic3587.5% Mother's marital status Single, never married3075.0% Married512.5% Unknown512.5% Mother's prenatal care status Yes2050.0% No1947.5% Unknown12.5%

Time of Prenatal Care Entry among Mothers of Infants with CS, Shelby County, Shelby County Health Department  “Prenatal Care” = at least one visit before the date of delivery N% TOTAL (in prenatal care) % Entered Prenatal Care > 30 days before delivery % Entered Prenatal Care <= 30 days before delivery 210.0% Unknown 15.0%

Testing and Treatment among Mothers who Received Prenatal Care, Shelby County, Shelby County Health Department 17 Mothers in Prenatal Care > 30 Days Before Delivery 6 treated during pregnancy 1 treated adequately 5 not treated adequately 11 not treated during pregnancy 2 not screened until delivery 8 infected between initial screenings and delivery 1 false negative test?

CDC Prenatal Syphilis Screening Recommendations for a High-Incidence Area  Serologic testing for syphilis should be obtained:  at the first prenatal screening; and  weeks’ gestation; and  at delivery  No infant or mother should leave the hospital unless maternal serologic status has been documented at least once during pregnancy. Shelby County Health Department

Conclusions  Observed positive relationship between female P&S and CS cases in Shelby County.  Targeted testing among all women of childbearing age a strategy to decrease new CS cases.  Efforts should be made to increase prenatal care utilization to improve early syphilis screening. Shelby County Health Department

Conclusions  Improve provider awareness of:  The need for screening according to CDC recommendations in high-incidence area.  The need for partner screening and risk-reduction counseling among all pregnant women. Shelby County Health Department

Limitations  Infants who are not infected with syphilis can be included among those with probable CS.  Reporting of CS cases may not include stillborn births. Shelby County Health Department

Acknowledgements  Shelby County Infectious Disease Surveillance Unit  Tennessee Department of Health  Council for State and Territorial Epidemiologists Shelby County Health Department

References 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance Atlanta: US Department of Health and Human Services; Evans HE, Frenkel LD. (1994). Congenital Syphilis. Clin Perinatol 21: Retrieved May 1, 2011 from: Hollier LM, Hill J, Sheffield JS, Wendel GD. (2003). State laws regarding prenatal syphilis screening in the United States. Am J Obstet Gynecol; 189: Tennessee Code Annotated , Title 68 Health, Safety, and Environmental Protection. Retrieved June 1, 2011 from: Genc M, Ledger WJ. (2000). Syphilis in Pregnancy. Sexually Transmitted Infections; 76: Saloogee H, Velaphi S, Goga Y, Afdapa N, Steen R, Lincetto O. (2004). The Prevention and management of congenital syphilis: an overview and recommendations. Bulletin of the World Health Organization, June Retrieved June 1, 2011 from: 7. Wicher V, Wicher K, (2001). Pathogenesis of maternal-fetal syphilis revisited. Clin Infect Dis 33: Retrieved May 1, 2011 from: 8. Centers for Disease Control and Prevention. (2010). Congenital Syphilis – United States, 2003—2008. Morbidity and Mortality Weekly Report / 59(14); Retrieved June 1, 2011 from: 9. Centers for Disease Control and Prevention. Congenital Syphilis Case Investigation and Reporting Form Instructions. Retrieved June 1, 2011 from: World Health Organization. (2007). The Global elimination of congenital syphilis : rationale and strategy for action. Retrieved June 1, 2010 from: Kamb ML, Newman LM, Rily PL, Mark J, Hawkes SJ, Malik T, Broutet N. (2010). A Road Map for the Global Elimination of Congenital Syphilis. Retrieved June 1, 2011 from: Shelby County Health Department

Questions? Kristen Morrell Shelby County Health Department Shelby County Health Department

Recommendations from WHO Four Pillar Strategy to Eliminate Congenital Syphilis Ensure advocacy and political commitment Increase access to and quality of services Screen/treat pregnant women and partners Establish surveillance, monitoring and evaluation Image: Kamb et al. 11