1. 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

2. Congenital Syphilis Rates by Region, United States, 2005-2009 Data Source: Centers for Disease Control and Prevention 1

3. 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.

4. 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

5. 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.

6. 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

7. Congenital Syphilis and Female P&S Syphilis Rate, United States, 1995-2008 Data source: Centers for Disease Control and Prevention 8

8. Objectives  Describe and examine the association between female P&S syphilis and CS rates in Shelby County from 1990- 2009.  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

9. Data Sources  Case data:  NETSS (1990-2004)  STDMIS (2005-2009)  Birth data: Tennessee Vital Statistics (1990-2009)  Population data: US Census (1990, 2000) Shelby County Health Department

10. 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

11. Congenital and Female P&S Syphilis Rates by Year, Shelby County, 1990-2009 Shelby County Health Department

12. Congenital and Female P&S Syphilis Rate Changes, Shelby County, 1990-2009 19902009% change congenital syphilis rate233.376.5- 67% female P&S syphilis rate147.413.0- 91% Shelby County Health Department

13. Spearman Correlation Results Variable N (# years of data) MeanStd DevMedianMinMax CS rate20126.0103.085.913.1373.5 Female P&S rate2038.636.327.75.6147.4 H o : Rho = 0  Rho ≠ 0 Rho s = 0.87 p <.0001 Shelby County Health Department

14. Demographics of Female P&S Cases and Mothers of Infants with CS, Shelby County, 2005-2009 Shelby County Health Department Demographic GroupMothers of Infants with CSFemale P&S Syphilis Cases N%N% TOTAL40100.0%292100.0% Race/Ethnicity Black, not Hispanic3997.5%27092.5% Age Group 10—19615.0%5418.5% 20—291640.0%9632.9% 30—391640.0%6120.9% 40—49**5719.5% 50+**248.2%

15. Shelby County Health Department Characteristics of CS Cases, Shelby County, 2005-2009 Infant vital statusN% Born Alive40100.0% Infant case classification Probable40100.0% 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%

16. Time of Prenatal Care Entry among Mothers of Infants with CS, Shelby County, 2005-2009 Shelby County Health Department  “Prenatal Care” = at least one visit before the date of delivery N% TOTAL (in prenatal care) 20100.0% Entered Prenatal Care > 30 days before delivery 1785.0% Entered Prenatal Care <= 30 days before delivery 210.0% Unknown 15.0%

17. Testing and Treatment among Mothers who Received Prenatal Care, Shelby County, 2005-2009 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?

18. CDC Prenatal Syphilis Screening Recommendations for a High-Incidence Area  Serologic testing for syphilis should be obtained:  at the first prenatal screening; and  28-32 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

19. 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

20. 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

21. 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

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

23. References 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2009. Atlanta: US Department of Health and Human Services; 2011. 2. Evans HE, Frenkel LD. (1994). Congenital Syphilis. Clin Perinatol 21:149-55. Retrieved May 1, 2011 from: http://www.ncbi.nlm.nih.gov/pubmed/8013182. http://www.ncbi.nlm.nih.gov/pubmed/8013182 3. Hollier LM, Hill J, Sheffield JS, Wendel GD. (2003). State laws regarding prenatal syphilis screening in the United States. Am J Obstet Gynecol; 189:1178-83. 4. Tennessee Code Annotated 65-5-602, Title 68 Health, Safety, and Environmental Protection. Retrieved June 1, 2011 from: http://www.tn.gov/tccy/tnchild/68/68-5-602.htm http://www.tn.gov/tccy/tnchild/68/68-5-602.htm 5. Genc M, Ledger WJ. (2000). Syphilis in Pregnancy. Sexually Transmitted Infections; 76:73-9. 6. 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 2004. Retrieved June 1, 2011 from: http://www.who.int/bulletin/volumes/82/6/424.pdf 7. Wicher V, Wicher K, (2001). Pathogenesis of maternal-fetal syphilis revisited. Clin Infect Dis 33:354-63. Retrieved May 1, 2011 from: http://cid.oxfordjournals.org/content/33/3/354.fullhttp://cid.oxfordjournals.org/content/33/3/354.full 8. Centers for Disease Control and Prevention. (2010). Congenital Syphilis – United States, 2003—2008. Morbidity and Mortality Weekly Report / 59(14);413-417. Retrieved June 1, 2011 from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5914a1htm. 9. Centers for Disease Control and Prevention. Congenital Syphilis Case Investigation and Reporting Form Instructions. Retrieved June 1, 2011 from: http://www.cdc.gov/std/program/ConSyphInstr11-2003.pdfhttp://www.cdc.gov/std/program/ConSyphInstr11-2003.pdf 10. World Health Organization. (2007). The Global elimination of congenital syphilis : rationale and strategy for action. Retrieved June 1, 2010 from: http://whqlibdoc.who.int/publications/2007/9789241595858_eng.pdfhttp://whqlibdoc.who.int/publications/2007/9789241595858_eng.pdf 11. 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:http://www.hindawi.com/journals/ogi/2010/312798/ Shelby County Health Department

24. Questions? Kristen Morrell Shelby County Health Department Kristen.Morrell@shelbycountytn.gov 901-544-6990 Shelby County Health Department

25. 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