Congenital Syphilis in Shelby County, Tennessee: Past and Present

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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
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Congenital Syphilis Rates by Region, United
States, 2005-2009
Data Source Centers for Disease Control and
Prevention1
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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
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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
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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
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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 (PS) Syphilis
  among females usually followed by similar change
  in Congenital Syphilis (CS). 8

Shelby County Health Department
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Congenital Syphilis and Female PS Syphilis Rate,
United States, 1995-2008
Data source Centers for Disease Control and
Prevention8
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Objectives

• Describe and examine the association between
  female PS syphilis and CS rates in Shelby County
  from 1990-2009.
• Describe the current epidemic by reporting
• demographics of female PS 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
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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
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Analysis

• Rate Calculations
• CS rate per 100,000 live births
• Female PS syphilis rates per 100,000 population
• Association between annual PS and CS rates
  measured using Spearman Correlation
• Access to prenatal care and screening assessed
  through case reviews in STDMIS.

Shelby County Health Department
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Congenital and Female PS Syphilis Rates by Year,
Shelby County, 1990-2009
Shelby County Health Department
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Congenital and Female PS Syphilis Rate Changes,
Shelby County, 1990-2009
  1990 2009 change
congenital syphilis rate 233.3 76.5 - 67
female PS syphilis rate 147.4 13.0 - 91
Shelby County Health Department
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Spearman Correlation Results
Variable N ( years of data) Mean Std Dev Median Min Max
CS rate 20 126.0 103.0 85.9 13.1 373.5
Female PS rate 20 38.6 36.3 27.7 5.6 147.4
Ho Rho 0 è Rho ? 0

Rhos 0.87
p lt .0001
Shelby County Health Department
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Demographics of Female PS Cases and Mothers of
Infants with CS, Shelby County, 2005-2009
Demographic Group Mothers of Infants with CS Mothers of Infants with CS Female PS Syphilis Cases Female PS Syphilis Cases
  N N
TOTAL 40 100.0 292 100.0
Race/Ethnicity        
Black, not Hispanic 39 97.5 270 92.5
Age Group        
1019 6 15.0 54 18.5
2029 16 40.0 96 32.9
3039 16 40.0 61 20.9
4049 57 19.5
50 24 8.2
Shelby County Health Department
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Characteristics of CS Cases, Shelby County,
2005-2009
Infant vital status N
Born Alive 40 100.0
Infant case classification    
Probable 40 100.0
Symptom status of infant    
Classic signs of congenital syphilis 5 12.5
Asymptomatic 35 87.5
Mother's marital status    
Single, never married 30 75.0
Married 5 12.5
Unknown 5 12.5
Mother's prenatal care status    
Yes 20 50.0
No 19 47.5
Unknown 1 2.5
Shelby County Health Department
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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

  N
TOTAL (in prenatal care) 20 100.0
Entered Prenatal Care gt 30 days before delivery 17 85.0
Entered Prenatal Care lt 30 days before delivery 2 10.0
Unknown 1 5.0
Shelby County Health Department
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Testing and Treatment among Mothers who Received
Prenatal Care, Shelby County, 2005-2009

• 17 Mothers in Prenatal Care gt 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
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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
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Conclusions

• Observed positive relationship between female PS
  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
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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
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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
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Acknowledgements

• Shelby County Infectious Disease Surveillance
  Unit
• Tennessee Department of Health
• Council for State and Territorial Epidemiologists

Shelby County Health Department
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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 21149-55. Retrieved
   May 1, 2011 from http//www.ncbi.nlm.nih.gov/pubm
   ed/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 1891178-83.
4. Tennessee Code Annotated 65-5-602, Title 68
   Health, Safety, and Environmental Protection.
   Retrieved June 1, 2011 from http//www.tn.gov/tcc
   y/tnchild/68/68-5-602.htm
5. Genc M, Ledger WJ. (2000). Syphilis in Pregnancy.
   Sexually Transmitted Infections 7673-9.
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 33354-63. Retrieved May 1, 2011 from
   http//cid.oxfordjournals.org/content/33/3/354.ful
   l
8. Centers for Disease Control and Prevention.
   (2010). Congenital Syphilis United States,
   20032008. Morbidity and Mortality Weekly Report
   / 59(14)413-417. Retrieved June 1, 2011 from
   http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5914a1h
   tm.
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/ConSyphI
   nstr11-2003.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/2007/9
    789241595858_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 fromhttp//www.hindawi.com
    /journals/ogi/2010/312798/

Shelby County Health Department
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Questions?

• Kristen Morrell
• Shelby County Health Department
• Kristen.Morrell_at_shelbycountytn.gov
• 901-544-6990

Shelby County Health Department
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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
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