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

Congenital Syphilis Rates by Region, United States, 2005-2009

Data Source: Centers for Disease Control and Prevention1

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.

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 3rd trimester)

3 states only require second test in third trimester for women at high risk→

(Tennessee)4

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.

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

Congenital Syphilis and Female P&S Syphilis Rate, United States, 1995-2008

Data source: Centers for Disease Control and Prevention8

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

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

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

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

Shelby County Health Department

Congenital and Female P&S Syphilis Rate Changes, Shelby County, 1990-2009

1990 2009 % change

congenital syphilis rate 233.3 76.5 - 67%

female P&S syphilis rate 147.4 13.0 - 91%

Shelby County Health Department

Spearman Correlation Results

VariableN

(# years of data) Mean Std Dev Median Min Max

CS rate 20 126.0 103.0 85.9 13.1 373.5Female P&S rate 20 38.6 36.3 27.7 5.6 147.4

Ho : Rho = 0 Rho ≠ 0

Rhos = 0.87

p < .0001

Shelby County Health Department

Demographics of Female P&S Cases and Mothers of Infants with CS, Shelby County, 2005-2009

Shelby County Health Department

Demographic Group Mothers of Infants with CS Female P&S Syphilis Cases

N % N %

TOTAL 40 100.0% 292 100.0%

Race/Ethnicity

Black, not Hispanic 39 97.5% 270 92.5%

Age Group

10—19 6 15.0% 54 18.5%

20—29 16 40.0% 96 32.9%

30—39 16 40.0% 61 20.9%

40—49 * * 57 19.5%

50+ * * 24 8.2%

Shelby County Health Department

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%

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) 20 100.0%

Entered Prenatal Care > 30 days before delivery 17 85.0%Entered Prenatal Care <= 30 days before delivery 2 10.0%Unknown 1 5.0%

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

pregnancy1 treated

adequately5 not treated

adequately

11 not treated during

pregnancy

2 not screened until delivery

8 infected between initial screenings and

delivery

1 false negative test?

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

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

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

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

Acknowledgements

Shelby County Infectious Disease Surveillance Unit

Tennessee Department of Health

Council for State and Territorial Epidemiologists

Shelby County Health Department

References1. 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/8013182.3. 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.htm5. 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.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.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.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

Questions?

Kristen MorrellShelby County Health DepartmentKristen.Morrell@shelbycountytn.gov901-544-6990

Shelby County Health Department

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