Congenital Syphilis in Shelby County, Tennessee: Past and Present

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 Prevention1

3. Case Definition • 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. Shelby County Health Department

4. Screening and Reporting Laws • 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 3rd trimester) • 3 states only require second test in third trimester for women at high risk → (Tennessee)4 Shelby County Health Department

5. Background • 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. Shelby County Health Department

6. Background • 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 Shelby County Health Department

7. Congenital Syphilis and Female P&S Syphilis Rate, United States, 1995-2008 Data source: Centers for Disease Control and Prevention8

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 Shelby County Health Department

13. Spearman Correlation Results 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

15. Characteristics of CS Cases, Shelby County, 2005-2009 Shelby County Health Department

16. Time of Prenatal Care Entry among Mothers of Infants with CS, Shelby County, 2005-2009 • “Prenatal Care” = at least one visit before the date of delivery Shelby County Health Department

17. Testing and Treatment among Mothers who Received Prenatal Care, Shelby County, 2005-2009 17 Mothers in Prenatal Care > 30 Days Before Delivery 11 not treated during pregnancy 6 treated during pregnancy 1 false negative test? 1 treated adequately 2 not screened until delivery 8 infected between initial screenings and delivery 5 not treated adequately Shelby County Health Department

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 • Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2009. Atlanta: US Department of Health and Human Services; 2011. • 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. • 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. • 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 • Genc M, Ledger WJ. (2000). Syphilis in Pregnancy. Sexually Transmitted Infections; 76:73-9. • 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 • 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.full • 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. • 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.pdf • 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.pdf • 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