National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention Division of STD Prevention Congenital Syphilis Slips Through the Cracks: Lessons from Guam Mary L. Kamb, MD, MPH CDC Division of STD Prevention, Atlanta, GA Bernadette Schumann, MPA STI Program, Guam Department of Public Health and Social Services
Syphilis Highly transmissible • Sexually through vaginal, rectal and oral sex (to ~ 1 year) • From mother-to-child during pregnancy ( in utero infection) up to 4+ years after maternal exposure Most infections are asymptomatic or unrecognized Fetal and infant sequelae can be catastrophic Exquisitely sensitive to injectable penicillin regimens • No reported resistance Treponema pallidum ssp. pallidum
Mother-to-Child Transmission of Syphilis (Congenital Syphilis) High risk pregnancy - Untreated, up to 80% of P/S cases → fetal or infant death or other adverse birth outcome - Untreated, ~ 52% of asymptomatic (latent) infections → an adverse birth outcome* Adverse birth outcomes* include - Stillbirth (after 20 weeks): 21% of affected pregnancies - Neonatal death: 9% - Prematurity or low birth weight: 6% - Congenital infection in newborn: 16% Early testing important Syphilitic stillbirths are often not recognized * Gomez et al, Bull World Health Org, 2013: Meta-analysis evaluating studies evaluating birth outcomes of women with and without syphilis, primarily asymptomatic (latent) infections
U.S. Syphilitic Stillbirths by Gestational Age, 1995-2016 Syphilitic Stillbirths by EGA in U.S., 1995-2016 59 57 Syphilitic Stillbirths 52 46 45 40 38 37 36 35 34 33 30 29 28 24 23 22 21 16 11 5 3 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 99 UNK Estimated Gestational Age (weeks)
U.S. Syphilitic Stillbirths by Gestational Age, 1995-2016 Syphilitic Stillbirths by EGA in U.S., 1995-2016 59 57 Syphilitic Stillbirths 52 46 45 40 38 37 36 35 34 33 30 29 28 24 23 22 21 16 11 5 3 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 99 UNK Estimated Gestational Age (weeks)
CDC STI Screening Recommendations in Pregnancy* Syphilis - Routine screen at 1 st prenatal visit - Re-screen in 3 rd trimester (28-32 weeks) and at delivery if: - high prevalence setting - high personal/partner risk - positive screening oddslot test in 1 st trimester - Do not discharge neonate if maternal serologic status is unknown - Promptly treat mother with parenteral penicillin (if allergic, desensitize) & treat all sex partners - Test women with a stillborn or early infant death * Consistent with ACOG Recommendations with minor wording differences https://www.obgproject.com/2016/10/16/std-screening-pregnancy-cdc-recommendations/
Guam Largest U.S. territories in Pacific Population 163,000 Small island: 544 sq. km Common ethnic groups: - Chamorro - Asian - Chuukese (FSM state) - Other Pacific Islander
Guam: Increasing, high P/S syphilis case rates in reproductive-aged women, new CS cases (2013) Rate per 100,000 live births Data not available 0 1.8 – 3.4 4.0 – 7.2 7.6 – 13.0 14.7 – 19.1 19.5 – 63.3 30.4 per 100,000 live births
Epi-Aid sought to answer the following questions: What is the coverage of syphilis (and other STI) screening in Guam? • What proportion of pregnant women receive recommended STI screening tests? For women with lack of or late screening for syphilis, what factors are associated with this? • What factors are amenable to intervention? • Systems level, personal behavioral and other factors
Epi-Aid Methods Retrospective cohort study: All women delivering a live or stillborn infant at Hospital during calendar year 2014 - N=865, excluding 1 infant from each of 5 twin pairs Standardized chart abstractions - Demographic data, reproductive health history, timing of prenatal visits, dates and results of syphilis and other STI testing, insurance status, type of provider Linked lab test results from public and private laboratories in Guam - Allowed timing of testing to be determined
Epi-Aid Findings Good news/Bad news ~ 75% of women had HIV, CT/GC screening, 90% HBV screening during pregnancy 94.5% of women had at least 1 syphilis test during pregnancy or at labor/deliver - BUT … only 2/3 had syphilis screening prior to the 3 rd trimester - Of the women with late or no screening, almost half (40%) had > 4 prenatal visits - Of these, many initiated care in the 1 st trimester (missed opportunity) - Few women (0.5%) had repeat testing during 3 rd trimester or at delivery Birth tourism did not seem major contributor Evaluation of 2014 stillbirths (N=12) identified 1 additional CS case - not been previously reported to DOPH
Epi-Aid Findings – Factors associated with late/lack of screening Late screening = 25-32 weeks; Very late screening = >32 weeks • Lower education : - “HS only”: 2-fold risk vs. some college - <HS: 3-fold risk vs. some college • Certain ethnic groups (Chuukese) • Provider type : - Public provider: 2-fold higher vs. private provider • Lack of insurance : - No insurance: 4.5-fold risk vs. private insurance - Medicaid: > 2-fold risk vs. private insurance - MIP: ~ 4-fold risk vs. private insurance
Summary: Prenatal syphilis screening in Guam One in three women were screened late or not at all during pregnancy - ~40% had four or more prenatal visits Late or no screening associated with: - Delayed or no prenatal care and low number of visits - No insurance, Medicaid, MIP - Public providers Guam findings relevant to U.S. states?
Follow up – Root causes Perceived risk low : - Women attending prenatal care at public clinics are referred to a lab for testing (testing not done in the clinic) - Some women did not go to get their blood tests (low perceived risk by women?) • Are women aware of what/why prenatal tests are done? Systems level issues : - Substantial administrative difficulty achieving Medicaid and MIP care (are women able to be tested at initial visit?) - No standing orders - No tickler system to verify lab tests were done; paper records
Follow up – Root causes Provider education : some unaware of expanded recommendations - Rescreening during 3 rd trimester/delivery - Do not release neonates until maternal syphilis testing results return Limited communications e.g., MCH Dept. (covers prenatal care) and SHP - DoPH SHP not included in meetings on Stillbirths or Neonatal Deaths - Providers depend upon laboratories reporting results to DoPH Cultural/political - High risk pregnancies among Chuukese women not previously fully recognized
Next steps Local dissemination of results to multiple departments Educational opportunity to update providers on recommendations and results of Epi-Aid Identifying routine communications strategies MCH and SHP, such as - MCH providers have contact names in DoPH - Routine meetings/FIMR attendance SHP and other DoPH programs exploring other options, e.g., - Potential of initiating rapid syphilis testing in public clinics - Electronic lab records with tickler systems - Evaluating requirements for women using Medicaid/MIP Special attention to high risk women - Lower education, those without insurance - Reaching out to DoPH FSM: Special attention to Chuuk on prenatal care
Global Call to Eliminate MTCT of Syphilis (Congenital Syphilis) Global elimination initiative launched in 2007 (WHO) WPRO Elimination of MTCT of HIV and Syphilis since 2009 WPRO Elimination of Parent-to-Child Transmission of HIV, Syphilis and Hepatitis B virus (2017) - 2017 Strategic Framework - http://www.eptctasiapacific.org Program targets/ Elimination targets - > 95% women attend antenatal care - > 95% of women tested for syphilis and HIV - > 95% of seropositive women treated for syphilis and/or HIV - Congenital syphilis case rate < 50 per 100,000 live births - HIV infant case rate < 50 per 100,000 live births - MTCT transmission of HIV < 2% (< 5% in breast feeding women) http://www.who.int/reproductivehealth/congenital-syphilis/en/
Acknowledgements – Epi-Aid Team Guam Department of Public Health and Social Services - Bernie Schumann - Ester Mallada - Vince Aguon - Anne Marie Santos Guam Memorial Hospital Authority - Michael Klemme Centers for Disease Control and Prevention - Susan Cha (EIS Officer leading investigation) - Winston Abara - Tranita Anderson - Tasneem Malik - Roxanne Barrow - Mia DeSimone - Mary Kamb
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