How Texas is working to Address Congenital Syphilis
Syphilis is a sexually transmitted disease from the 1950’s, right? Think again.
Sydney S. Minnerly, M.A., Texas Department of State Health Services
April 19, 2016
Unfortunately, syphilis remains a threat today, with reported cases on the rise in Texas and across the United States.
Syphilis impacts the sexually active population, but it also has a potentially deadly impact on infants. A pregnant woman infected with syphilis can unknowingly transmit the infection to her unborn child. When not treated in a timely manner, congenital syphilis can cause serious physical and mental impairments, including stillbirth or premature death following delivery.
Public health efforts focus on identifying and addressing syphilis cases through a program known as partner services. Partner services staff (also known as Disease Intervention Specialists, or DIS) work with infected persons to identify and locate their sexual partners to ensure prompt testing and, if needed, treatment. DIS also work to identify anyone in an infected person’s sexual or social network who is pregnant and in need of prenatal care and syphilis testing.
As syphilis cases rise in women, there is more potential for increases in congenital syphilis cases. If a woman is identified as pregnant at the time of a syphilis diagnosis, the partner services staff works with her and the diagnosing provider to ensure appropriate treatment, as recommended by the Centers for Disease Control and Prevention (CDC). Timely treatment during pregnancy can prevent the development of adverse health outcomes for the fetus.
What happens when there is a case of congenital syphilis?
Some women arrive in prenatal care late in their pregnancy, leading to late diagnosis and possible congenital transmission. All syphilis cases are reportable to the health department, but when a congenital case is identified, a special case investigation is initiated. Staff review the prenatal and delivery records, work with providers to ensure the mother and infant are treated appropriately, and identify gaps in her care or treatment
Texas public health policy efforts to prevent and reduce new congenital cases
Because congenital cases are preventable, the presence of congenital cases implies there are gaps within the care delivery systems. Nationally, there has been an increase in the number of reported congenital syphilis cases. Texas has reported a significant number of these congenital syphilis cases and continues to work to address this. Although Texas has seen a decrease in the number of reported congenital cases since reporting 126 cases in 2009, public health staff remain vigilant in their work to ensure all pregnant women infected with syphilis are appropriately treated as soon as possible. Staff members also work with the state’s vital records program to ensure all stillbirths and fetal deaths potentially attributed to syphilis are accounted for and reported.
Nationally, states have varied syphilis testing protocols for pregnant women. Prior to 2015, Texas law required that all pregnant women receive syphilis testing at their first prenatal visit and again at delivery. Additional third trimester testing was recommended if the woman was at risk for syphilis or resided in a high-morbidity area.
When Texas recognized that mandating third trimester testing would allow for more timely syphilis treatment prior to delivery, the law was changed to require testing at the first prenatal visit and again during the third trimester (28-32 weeks gestation). Testing at labor and delivery is now recommended for women determined to be at an increased risk for syphilis or if third trimester testing results cannot be verified. This change is expected to promote earlier detection and treatment of syphilis during pregnancy.
Additionally in 2015, Texas fully implemented the Fetal Infant Morbidity Review for Syphilis and HIV Project. This project is modeled after the collaboration between CDC and CityMatCH (a National Maternal and Child Health program focused on the healthcare of urban women, families, and communities) that focuses on FIMR for HIV methodology. That project is designed to identify systemic opportunities to reduce mother-to-child transmission of HIV. Texas decided this methodology was also appropriate for maternal syphilis infections.
As cases are identified, they are prioritized based on the severity of the health outcomes experienced by the infant. Syphilitic stillbirths, fetal deaths, and confirmed cases of congenital syphilis have the highest priority. Probable cases, which comprise the majority of Texas’ cases, are ranked by the level of systemic opportunities missed. A data collector gathers details from the mother’s and infant’s medical records and interviews the mother for her perspective of the systems that may have impacted the outcome of her pregnancy. This information is reviewed by a Case Review Team comprised of community partners and providers. The team identifies missed opportunities and changes that should be implemented to reduce the likelihood of congenital syphilis.
Missed opportunities for diagnosis and treatment of congenital syphilis can occur prior to pregnancy, during prenatal care, or at labor and delivery. During the case review, the team identifies systems within the community that, if altered or improved, could enhance the woman’s experience during pregnancy and decrease the chances of the fetus being impacted by syphilis. Once a number of cases have been reviewed, the team provides recommendations to the Community Action Team, a group of stakeholders capable of implementing change within organizations. The goal of these recommendations is to improve health care and social services for pregnant women. This process has been implemented in southeast Texas one jurisdiction, with plans to replicate it across Texas.
These efforts will not eliminate all congenital syphilis cases. There will still be women who do not receive timely care during pregnancy. What these changes will do over time is help lessen the overall burden of syphilis in Texas, ultimately leading to healthier babies, families, and communities.