1.  Missed Opportunities for Congenital Syphilis Prevention in Baltimore City Stephanie Atueyi, MPH Candidate 2014 University of Florida April 11 th, 2014

2.  Outline  Introduction  National congenital syphilis case definition  Epidemiology of Syphilis  Syphilis in women  Congenital syphilis  Rationale for an assessment  Review of previous studies  Study design  Results and Discussion  Public Health Competencies

3. Introduction: Syphilis in Pregnancy  An infection caused by Treponema Pallidum  Can result in mother-to-child transmission (congenital syphilis)  Major complications  Preterm births  Stillbirths  Bone abnomalities  Prevention of congenital syphilis is a “winnable battle” Healthy People 2020. Healthypeople.gov. Disparities. [Online] December 29, 2010. [Cited: March 31, 2014.]

4. Risk Factors  Risk Factors  Uninsured  Living in poverty  Sex workers  Illicit drug use  Or living in communities with high syphilis morbidity

5. Epidemiology  There has been a drastic decline in the rate syphilis  A decline of 95.4% since 1990 for primary and secondary syphilis in woman  A decline of 92.4% from 1991 to 2005 for congenital syphilis  Trends of congenital syphilis tend to follow trends for P&S syphilis in women  Rates increased during 2005-2008 period Centers For Disease Control and Prevention. CDC.gov. Sexually Transmitted Disease Surveillance 2012. [Online] Center for Disease Control and Prevention, January 7, 2014. http://www.cdc.gov/std/stats12/default.htm

6. Reported Cases of Congenital Syphilis Among Infants and Rates of Primary and Secondary Syphilis Among Women Centers For Disease Control and Prevention. CDC.gov. Sexually Transmitted Disease Surveillance 2012. [Online] Center for Disease Control and Prevention, January 7, 2014. http://www.cdc.gov/std/stats12/default.htm

7. Epidemiology cont. The highest rates occur in:  The southern region of the United States  Women aged 20 to 24 years  African Americans Centers For Disease Control and Prevention. CDC.gov. Sexually Transmitted Disease Surveillance 2012. [Online] Center for Disease Control and Prevention, January 7, 2014. http://www.cdc.gov/std/stats12/default.htm

8. Congenital Syphilis: Rates by of Birth and Mother’s Race/ Ethnicity United States, 2003-2012 Centers For Disease Control and Prevention. CDC.gov. Sexually Transmitted Disease Surveillance 2012. [Online] Center for Disease Control and Prevention, January 7, 2014. http://www.cdc.gov/std/stats12/default.htm

9. National Objectives to Reduce Rates of Congenital Syphilis  Healthy People 2020  reduce congenital syphilis rates to 9.6 new cases per 100,000 live births  Government Performance and Results Act  reduce congenital syphilis rate to 10 cases per 100,000 live births Centers For Disease Control and Prevention. CDC.gov. Sexually Transmitted Disease Surveillance 2012. [Online] Center for Disease Control and Prevention, January 7, 2014. http://www.cdc.gov/std/stats12/default.htm Healthy People 2020. Healthypeople.gov. Disparities. [Online] December 29, 2010. [Cited: March 31, 2014.]

10. Congenital Syphilis in Maryland  Maryland has one of the highest rates in the US  second highest rate of congenital syphilis in 2011  Congenital syphilis rate exceeded 20 cases per 100,000 live births from 2005 to 2011  In 2012, the rate decreased to 16 cases per 100,000 live births  Baltimore City accounted for 50% of congenital syphilis cases in 2012 Centers For Disease Control and Prevention. CDC.gov. Sexually Transmitted Disease Surveillance 2012. [Online] Center for Disease Control and Prevention, January 7, 2014. http://www.cdc.gov/std/stats12/default.htm

11. Screening for Syphilis in Pregnancy in Maryland  Screen for syphilis in pregnant women at first prenatal care visit  Screen at the beginning of the first trimester (28 weeks)  Screen at time of child labor and delivery  Syphilis is a notifiable disease, and should be reported to the health department within 48 hours

12. Rationale for Project  High rates of congenital syphilis cases  A need to determine:  Missed opportunities of congenital syphilis prevention  causes or risk factors  potential strategies for prevention and reducing risk

13. SettingMethodTimeframeDefined Missed Opportunities Results New York City, NY Health Department Missed Opportunities for Preventing Congenital Syphilis Infection in New York City. Patel, Sameer J. MD, MPH, et al., et al. 4, s.l. : Obstetrics & Gynecology, 2012, Vol. 120. 882- 888 Retrospective case review Jan 2000 to Dec 20091) No maternal treatment 2) Lack of syphilis screening 3) Late maternal treatment 4) Inappropriate maternal treatment ** Women who did not receive prenatal care were excluded 195 cases were reported: 29% of pregnant did not receive syphilis screening ; 13% received delayed treatment; 11% women received no therapy; Overall 63% of the mothers had a missed opportunity Marcopa County, AZ Health Department Opportunities for the Prevention of Congenital Syphilis in Maricopa County, Arizona. Taylor, Melanie M. MD, MPH, et al., et al. 4, s.l. : Sexually Transmitted Diseases, 2008, Vol. 35. 341-343 Retrospective case review Jan 2000 to Dec 2005n/a130 cases were reported ; missed opportunities found were lack of prenatal care; lack of prenatal screening; and delayed treatment Grady Memorial Hospital in Atlanta, GA Missed Opportunities for Congenital Syphilis Prevention in an Urban Southeastern Hospital. WARNER, LEE MPH, et al., et al. 2, s.l. : Sexually Transmitted Diseases, 2001, Vol. 28. 92-98. retrospective chart review July 1990 to Jun 1993n/a157 cases identified; delayed or missed syphilis screening, diagnosis, and/or treatment. Missed opportunities were related to number of prenatal care visits Previous Studies

14. Methods and Study Design  A retrospective case review  congenital syphilis cases reported to Baltimore City Health Department (BCHD)  January 1 st, 2009 to December 31 st, 2012  Maternal and infant data were collected from:  CDC’s congenital syphilis investigation and report form  BCHD information system  Sexually transmitted diseases-management (STD-MIS)  Looked for missed opportunities for congenital syphilis prevention

15. Missed Opportunities  In women who received prenatal care, there was a missed opportunity for prevention if there was:  Lack of syphilis screening:  At the first prenatal visit  during third trimester  Or no screening  Inappropriate maternal treatment  Late maternal treatment  No maternal treatment  Inadequate or no maternal treatment for syphilis diagnosed before pregnancy

16. Methods and Study Design  For every case of congenital syphilis reported to Baltimore City Health Department, a case worker evaluated  Reviewed maternal and infant’s records and completed the CDC’s investigation form  determined the congenital syphilis case status using CDC case definitions for presumptive, confirmed, or syphilitic stillbirth

17. Surveillance Case Definition for Congenital Syphilis  Confirmed case  Use of dark-field microscopy or direct fluorescent antibody  Presumptive case  Untreated or inadequately treated mother at the time of delivery; OR  An infant with a reactive treponemal test plus signs of syphilis  Syphilitic stillbirth  fetal death in untreated or inadequately treated mother at the time of delivery after a 20-week gestation or a fetus weighing >500g.

18. Hypothesis  Mothers did not receive adequate prenatal care, syphilis screening, or adequate treatment  Mothers were at high risk for congenital syphilis

19. Stakeholders  STD/HIV Prevention Program at BCHD  Maternal and Infant Care Program at BCHD  Residents of Baltimore City

20. Results  31 cases of congenital syphilis were reported  30 presumptive cases  1 syphilitic stillbirth  Majority of cases were reported to the health department within 24 to 48 hours from date of newborn delivery  A confirmatory dark-field exam or direct fluorescent antibody test (DFA) was not performed on any of the cases of congenital syphilis.

21. Infant Characteristics  Race and Ethnicity  83% of the cases were African Americans  14% were White  3% of cases were Asian.  Median birth-weight was 2950 g (range 1020 to 4120 g)  Median gestational age was 39 weeks (range 27 to 41 weeks)  Majority of cases were asymptomatic

22. Results cont.  Congenital syphilis rate from 2009 to 2012 in Baltimore  85.1 cases per 100,000 live births  Highest rate of congenital syphilis occurred in 2009  Rates of congenital syphilis in Maryland and Baltimore City were higher than the US average.

23. Reported Cases and Rate of Congenital Syphilis in Baltimore City and Maryland

25. Maternal Characteristics  Median maternal age was 26 years old (range 16 to 40 years).  Only 3 of the 31 (approximately 10%) women did not have any prenatal care  Most common risk factor was drug habit.  All women that received treatment were reported to have received an appropriate treatment with a penicillin regimen.  A dark field or DFA was not conducted on any of the women because lesions were not present.

27. Risk Factors  Illicit drug use had the highest frequency  Other risk factors that were reported were:  Inconsistent or no condom use was reported  multiple sex partners  exchange of sex for drugs or money

28. Missed Opportunities

29.  90% of the mothers (28 of 31 mothers) received prenatal care  96% of the mothers (27 of 28 mothers) who received prenatal care:  first visit more than 30 days prior to date of delivery  screened for syphilis screening at there first prenatal visit  screened for syphilis during their third trimester  Treatment  67% (19 of 28 mothers) received appropriate therapy  14% (4 of 28 mothers) received no therapy  17% (5 of 28 mothers) received late therapy  Causes of inappropriate response :  Reinfection or relapse  Incomplete or equivocal response.

30.  Findings from this special project differ from previous studies  Majority of the mothers were screened for syphilis and treated adequately  Most common cause for inappropriate response was reinfection  Partner services Missed Opportunities

31. Partner Services  Services provided to people with STDs and their partners.  confidential  Medical  Preventative  Psychosocial services  usually provided by health departments  Partners services significantly increased the rate of partners presenting to care.

32. Eliminating Health Disparities  Increased attention and focus on the communities at risk  Increase access and quality of care  Support more research to identify effective strategies to reduce health disparities

33. Public Health Competencies  Monitoring health status to identify and solve community health problems  Using laws and regulations that protect health and ensure safety  Identify & understand the historical context of epidemiology, epidemiologic terminology; study designs & methodology  Monitor and evaluate programs for their effectiveness and quality

34. Limitations  Limited information on whether the mothers stayed care  Presumptive cases  Retrospective review  Syphilis screening in third trimester

35. Conclusion  Congenital syphilis rates in Baltimore City are substantially higher the Maryland and the US  Majority of the cases did received adequate prenatal care and treatment  Reinfection was the common cause for inappropriate serologic response  Partner services and methods to eliminate health disparities should continue to improve

36. Acknowledgments  Glen Olthoff  Carla Latney  Sarah McKune  Susan White