1. Integrated perinatal infections surveillance: the labor and delivery record to the rescue
MCH EPI Conference, 2004
Atlanta, GA
Stephanie Schrag, D Phil
Division of Bacterial and Mycotic Diseases
Centers for Disease Control and Prevention

2. Perinatal infections burden
Pregnant and post-partum women
Pregnant women at increased risk for infections or infectious complications (eg, influenza)
78% of childbirth-related prolonged hospitalizations are due to infection*
Neonates
Perinatal sepsis among top 10 causes of death
Infection contributes to preterm delivery
Early infections contribute to severe lifelong morbidity
*Hebert et al., Obstet Gynecol :942-7

3. Unique opportunities for prevention of perinatal infections
Limited time frame for disease transmission
Eradication of pathogen in mother not always required to prevent transmission
Health care provider plays key role in prevention implementation
Pre-conception, prenatal and intrapartum interventions
Interventions can greatly reduce disease
Perinatal GBS disease: 39,000 prevented since 1993
Congenital rubella syndrome: 1 US case last year

4. Surveillance integration challenges1. .

5. 2.
+ …..

6. 3. + .

7. Perinatal infections surveillance: Current approaches
Provider surveys (eg,ACOG)
NCHS natality files
PRAMS
Active Bacterial Core surveillance
FoodNet
HIV strain surveillance
Disease-specific surveillance
(eg, rubella, syphilis, sepsis)

8. What is missing from these systems?
Sustained tracking of prevention practices
(this becomes even more important as disease incidence declines)

9. The labor and delivery (L&D) record

10. The birth of Birth-Net
Periodic, population-based review of L&D records in Emerging Infections Program (EIP) areas (selected counties in 11 states)
Idea grew out of state hepatitis B prevention programs
The EIPs have conducted two L&D reviews and are planning a review of 2003/2004 births

11. Birth-Net design and methods
Weighted sample survey using state birth certificate file as sampling frame for random selection of births (app ) from each state
Abstraction of L&D records using a standard form that includes:
maternal demographics and prenatal visits
perinatal infections screening counseling, tests and results (syphilis, rubella, HIV, hepatitis B, GBS, toxoplasma)
brief L&D history
prevention interventions administered

12. GBS and Hepatitis B antenatal testing,
1998-9, ABCs
Schrag et al Obstet Gynecol 102:753-60

13. The impact of state laws on HIV testing,
1998 and 1999, ABCs
Opt-out policy
Mandatory NB testing of HIV unknown mothers w/48h results, fall, 1999
Schrag et al Obstet Gynecol 102:753-60

14. How Birth-Net data have been used
Revise perinatal group B streptococcal disease guidelines to recommend universal prenatal screening
Guide rubella post-partum vaccination policies
Provide local feedback to promote prevention efforts
Evaluate impact of prenatal testing laws
Evaluate accuracy of birth certificate data

15. Challenges / Limitations
Timeliness: birth certificate files are available 3-9 months after close of calendar year
Survey design and analysis: requires calculation of sample weights and familiarity with sample survey analysis
Labor: Person time for chart review; resolving HIPAA issues etc.
Limitations of L&D record: limited prenatal care information; limited baby information; limited maternal demographics; not everything that happens is documented

16. Vision for the future Expansion of Birth-Net to non-EIP states
A CDC HIV-led project has the objective of developing a “how to” manual for states
Improved integration of infectious issues into Birth-Net
Improved collaboration within CDC (eg, Perinatal Infections Working Group)
Improved integration in state health depts (eg, CT)
Improved integration of non-infectious MCH issues into Birth-Net

17. Acknowledgments Anne Schuchat Elizabeth Zell Aaron Roome Katie Arnold
Janet Mohle-Boetani
Ruth Lynfield
Monica Farley
The Active Bacterial Core surveillance team