Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003
MEENA R. ABRAHAM: Good morning. I have a few slides and some background information because I think it’s important to understand-- because I don’t know if everyone’s up to speed on the definitions, and then you can see why we looked at this issue. A couple of congenital syphilis definitions: a confirmed case is a very specific definition of an infant having been found to have Treponema Pallidum, which is the bacteria. And a syphilitic stillbirth is a fetal death when the mother was untreated or inadequately treated. What we really focused on were presumptive congenital syphilis cases because that’s where all of our cases are. So the definition of that is an infant whose mother was untreated or inadequately treated, and by inadequately treated, we mean a non-penicillin regimen or therapy less than 30 days to delivery, and/or an infant with the inactive Treponema test or evidence from physical exam, (inaudible) X-ray, and these other tests.
This is just a quick snapshot of what congenital syphilis looks like in Maryland, and Baltimore City is separated out from the rest of Maryland. So you can see the trend that Baltimore City has obviously the higher rates compared to the rest of Maryland. But you can see we’ve made a lot of progress in reducing congenital syphilis. Now, the concern is if you look at 2001 to 2002, you see the trend starting to go back up. And that’s really what prompted this investigation. I also wanted to let you know what some of the screening requirements are in Maryland because I know they vary from state to state. There are, of course, recommendations that are national, but then the actual mandated requirements can vary. For a pregnant woman, it’s required that a provider screen at the first prenatal visit or at delivery if she had no prenatal care. We have a requirement for screening during the third trimester prenatal care visit, which is at any time 28 weeks and later. Treatment should be rendered within one week. The case has to be reported to the health officer immediately.
And in Baltimore City, we also have it as a mandated requirement that all women are screened at the time of delivery for syphilis. What providers have to is if an infant is born to an untreated positive woman, they have to evaluate the infant and treat and report to the health officer the contact information and results of the testing. The health officer has to investigate immediately the individual that’s been reported within their jurisdiction and then let the state health department know if someone is not within their jurisdiction. Treatment guidelines-- this is, again, for syphilis during pregnancy-- penicillin is the only recommended treatment, and this is very important for looking at this issue. And the treatment for primary, secondary, and early latent is a single dose injection; and for late latent, or unknown duration, it’s a series of three injections, one each week for three weeks. In treatment, titer should be drawn at the time of treatment so that you can measure the change or response to treatment. titers may be repeated to look for re-infection during pregnancy. One of the issues is that you may not be able to assess if the treatment is successful during pregnancy because it can take up to six months to see the four-fold decrease titer.
So background: congenital syphilis is preventable. We have a concern in Maryland, and in Baltimore City, particularly, about the increase in rate from 2001 to 2002. Historically, we’ve all used an STD disease surveillance intervention approach to look at this issue. Reducing perinatal infections is one of the four priority areas in Baltimore City from our FIMR program, so the question was what else can be done to eliminate congenital syphilis? So why do we do the case reviews? One, to determine why a woman was not adequately tested or treated prior to admission for delivery; to identify opportunities for prevention of congenital syphilis; and to identify opportunities for care coordination between the STD department and other providers. So this is just a snapshot of looking at 2002 cases.
All the FIMR programs in Maryland reviewed all the congenital syphilis in the state, so this was the first time we had all looked at a common outcome that was a special outcome, because normally we look just at deaths. So you can see here that Baltimore City contributed 59 percent of the cases for 2002. This, now, is the years 2000 to 2002-- because we looked at three years-- and there were 27 cases of congenital syphilis. And again, these are all, as you can see, presumptive congenital syphilis cases, and 70 percent of the cases were because the mother had not been treated. Looking at racial breakdown, you can see that in Baltimore City, if you look at the right column, the majority of our births are to Black women, the majority of the syphilis and pregnancy cases are to Black women, and the majority of congenital syphilis cases were to Black women.
Looking at the maternal age distribution, one of the concerns is that, like, about 75 percent of these cases happen to be to women under the age of 30, so there’s a trend towards younger women being infected with syphilis. Looking at STD history among the women who had congenital syphilis, 44 percent of them had a history of syphilis infection in the past as well, and 67 percent of them had some other type of STD in addition to syphilis. Looking at some of the risk factors, we tried to break down some of the main risk factors for acquiring syphilis. And you can see that multiple partners, exchange of sex for drugs, injection drug use, and a partner who had a risk-- it’s kind of all over the place. There isn’t one thing in particular that jumps out. They’re all sort of evenly distributed except for the partner. Looking at initiation of prenatal care, because this is really where we expect to identify cases of syphilis and also to make sure that the women are treated, the cases of congenital syphilis if you look across, we have it compared to-- congenital syphilis compared to syphilis in pregnancy compared to births in 2002, that 11 percent of the congenital syphilis cases had third trimester, 26 percent had no prenatal care compared to 2.5 percent of the births that had no prenatal care.
So we can see that in this population, it’s a higher proportion of women who had late or no prenatal care. Then, we also wanted to look at when was syphilis infection diagnosed? And what you can see here is among the congenital syphilis cases, the detection occurs later, which is obvious because that’s why they qualified to be congenital syphilis case, because these are women who were infected at the time of delivery. But looking at women who had syphilis in pregnancy but were successfully treated, you can see the majority of them were identified, 41 percent, in the first trimester. And then, we tried to break it down to if you look at the congenital syphilis cases, what happened during the screens if they went to prenatal care? So we had 41 percent were negative at the initial screen during prenatal care. Then, out of those, 36 percent became positive in the third trimester of screening, were found to be positive during the third trimester of screening; and 64 percent were positive at delivery.
Now, again, all of these women, the 27 were positive at delivery, but this is just a breakdown of they were negative at the initial screen, and then when were they identified to be positive? Fifty-nine percent of them were positive at the initial screen, and then 19 percent of them were treated but then became re-infected during pregnancy. And this chart is looking at when they were diagnosed and found to have a positive *RPR compared to when they were treated, and what I want you to really look at is 15 percent of the congenital syphilis cases were diagnosed in the first trimester, but only four percent were treated. The question is what’s happening in terms of identification to treatment with congenital syphilis cases compared to those who had syphilis in pregnancy but then were successfully treated. So looking at the time from positive screen to treatment among women with syphilis in pregnancy, 18.5 percent were tested and treated on the same day.
Among the remaining women, average time to treatment was 13 days, ranging from two to 49 days. When we look at the congenital syphilis cases, 18.5 percent again were tested and treated on the same day. But for the remaining women, average time to treatment was 36 days, ranging from one to 63 days. So you can see the difference between looking at women who had syphilis during pregnancy, which ones were successfully treated and those who ended up with syphilis infection at delivery. One of the key issues is the lag from detection to treatment. Because we were collaborating with the STD department at the health department, we also wanted to look at how the health department was able to manage the cases. And if you look at the congenital syphilis cases, 44 percent of these women had a history of syphilis. And out of those, 67 percent the health department did have the titer history on hand. So if the provider called them, they were able to get a titer history for that woman. Eighty-one percent of the congenital syphilis and 93 percent of the syphilis in pregnancy cases, the women were contacted.
They were able to identify the woman. And then, we also have a breakdown of partner contact. So it’s not that it’s 100 percent or perfect, but the health department is able to actually help because they have titer history available, they’re able to contact the patient and get them into treatment, and they’re also able to do pretty good contact tracing for partners. We also just wanted to look at what the birth outcomes were. Unfortunately, we didn’t have data for the syphilis and pregnancy because the health department, they track the women until they’re treated and then that’s it; they close the file. So the congenital syphilis was the only cases that we knew the birth outcomes. You can see that 11 percent had very low birth weight compared to 3.2 of all live births, 30 percent low birth weight compared to 13.6, and then the infant-- there was one infant death.
From having done this case review process using the FIMR approach, we were really able to look at what are all the different systems of care that interact with this woman that could prevent syphilis infection, at least prevent the congenital syphilis? And some of the things, very quickly, that we learned was that screening, testing, and treatment does not always meet the recommended standard, obviously, because we had this lag from time of diagnosis to treatment. We also found that there was lack of onsite stock of penicillin therapy in some of the private clinics, and the patient is given a prescription that has to go fill a prescription somewhere else, then come back with the therapy. So really, we need to work on educating providers that the health department can really help them make sure the women get treated. So instead of sending her to go get a prescription filled, it would make more sense to send her directly to the health department clinic where she could be treated.
We also found that women are infected between routine syphilis screenings during pregnancy. Screening a woman once is not going to ensure the fact that she’s not going to get infected later. And a lot of times a patient, if she’s considered low-risk, the partner risk is not assessed. And we know that both partner and patient risk needs to be assessed, and there’s a need for safe sex education during pregnancy. There’s a lot of issues between care coordination between providers serving high-risk women. We looked at some Department of Corrections cases and found that we really could help get the women into care once they’re released from there. We also found that there were at times no documentation of the maternal syphilis test results or history in the infant charts. There’s poor communication between OB and pediatric providers. Sometimes, the *RPR test result is not available until a woman has been discharged following a delivery or if she ends up at an ER visit, which then again leads to delay in treatment. And sometimes, providers wait not just with the positive *RPR test, but they want to wait for the follow up *FTA testing, etcetera, and we want to look into the risks and benefits of presumptively treating women because these are high-risk women, and we may not be able to get them back in again for treatment.
So our key findings are that repeated syphilis screening is effective, syphilis testing and delivery, which again is a requirement only in Baltimore City, is essential to identify infection among women because we found there are those with no prenatal care that may not have been tested at the third trimester visit that became infected after third trimester screening or became re-infected after third trimester treatment. We also found that there was indeed opportunity for improved coordination, and really, between the health department and providers because I don’t think providers are aware of the resources that are available to them through the health department, again, between obstetric and pediatric providers, between the detention facilities and the health department. And also, we’re looking at how can we do better follow-up of patients with the Maternal/Child Health programs? And these are acknowledgements of all the different people who are involved in the study. Thank you.