Texas Takes Action on Congenital Syphilis: A Conversation With John Hellerstedt
April is STD Awareness Month, and this year, CDC is asking public health and healthcare partners to combat the resurgence of syphilis in the United States. ASTHO spoke with John Hellerstedt, MD, commissioner of the Texas Department of State Health Services, about Texas’s efforts to tackle congenital syphilis, how recent legislative changes and innovative projects are helping Texas prevent and respond to congenital syphilis, and how other health officials can get involved in their own communities.
CDC recently reported a striking increase in the rate of congenital syphilis in the United States. From your perspective, why is congenital syphilis an urgent public health concern, and how can state and territorial health officials be a part of the solution?
Congenital syphilis is a sentinel event which, with proper access to medical/prenatal care, can usually be prevented. The fact that congenital syphilis is seeing a resurgence reflects a healthcare system that presents a variety of barriers which may prevent women from accessing the care they need, prior to and during pregnancy.
State and territorial health officials can be a part of the solution by supporting public health programs which address syphilis infections in women of childbearing age. Through partner services, women can be notified of exposure to syphilis and receive testing and preventative treatment prior to becoming pregnant. Rates of congenital syphilis can be lowered with application of CDC’s recommended STD testing schedule for women who are pregnant. In addition to supporting laws that follow those recommendations, health officials can encourage healthcare providers to enhance the testing of pregnant women, as dictated by a woman’s potential for exposure (e.g., living in a high morbidity area, having another STD within the past year, participating in commercial sex work).
Congenital syphilis is not always preventable. In cases when congenital syphilis cannot be prevented, the impact on the health of the baby can be mitigated with proper testing, treatment, and care before and shortly after delivery. Local and state health authorities can work with major delivery hospitals to ensure that when a case of congenital syphilis occurs, the facility is able to appropriately treat both the mother and the newborn, prior to discharge from the hospital.
In 2015, Texas law was changed to require that pregnant women be screened for syphilis during their third trimester, in addition to their first prenatal visit. Why did this change in policy come about, and what results have you seen since implementing this change?
Prior to 2015, the law required pregnant women to be tested at their first prenatal care visit and again at labor and delivery. Third trimester testing was recommended for women who were in a higher risk category. The delivery test did not prevent the transmission of the infection from mother to baby, but it was helpful in identifying women and babies who needed treatment after delivery, in cases when the mother had sero-converted or when the mother was infected after the first trimester test. Treatment after delivery meant an increased cost to the medical system due to the intense treatment required for the baby.
Local stakeholders proposed new legislation to replace the required delivery testing with a required third trimester test, and recommended testing during labor or delivery for women at higher risk. The legislation would ideally allow new cases to be identified during the third trimester when the mother could receive appropriate treatment more than 30 days prior to delivery. Though we have not yet noted significant changes resulting from the legislation, the Texas Department of State Health Services is working to track its impact. We are monitoring the outcomes of late congenital syphilis to see if there have been cases missed due to sero-conversion or recent infection between third trimester and delivery. We would also like to survey major delivery hospital systems to get a more complete understanding of protocols used for testing at delivery. Due to this legislative change, the responsible public health department is not always notified when a woman delivers, making follow-up for congenital syphilis follow-up (even non-cases) challenging.
Your state is using innovative approaches to identify systemic barriers that affect women’s access to prenatal care. What should other health officials know about Texas’s Fetal Infant Morbidity Review for Syphilis and HIV project?
It is a process modeled after the traditional Fetal Infant Mortality Review (FIMR) model and is supported by the national FIMR for HIV through CityMaTCH. Originally, the plan was to involve only perinatal HIV, but it was determined that this was an opportunity to address congenital syphilis as well. This is not common within most FIMRs for HIV; not all jurisdictions have seen the same level of congenital syphilis involvement. Texas has continued to rank high in the number and rate of congenital cases reported. It requires resources to dedicate time to extract medical charts and conduct maternal interviews. In addition to the resources needed for medical chart abstraction, there is a need for community involvement. The case review team reviews three to four cases per quarter and identifies opportunities to address barriers and systems to positively influence these health outcomes. Once the issues are identified, the community action team, a team identified as key community and agency change makers who can influence systems, meets and develops plans to implement the recommendations.
As of March 2017, fifteen cases have been reviewed and one community action team meeting has been held. Through the review, it has been determined that many of the barriers identified for HIV are equally applicable to the congenital syphilis cases. Even though this is a resource intensive process, systems changes will ultimately lower the burden of disease.
Given your experience in Texas, what are some key actions other state or territorial health officials can take to raise awareness, as well as combat and prevent rising rates of congenital syphilis in their jurisdictions?
- Conduct active surveillance to monitor reporting processes.
- Review case reports for quality assurance and quality improvement purposes.
- Work with key community stakeholders to identify opportunities to lessen the impact of reportable STDs.
- Monitor disease trends impacting women of childbearing age, including outbreaks.
- Identify best practices for early identification and treatment of syphilis and other reportable STDs.
- Identify best practices for partner services, with an emphasis on partners and persons within the social network who may be pregnant.
- Offer preventative treatment to partners who are exposed to a syphilis infection but who test negative.
- Provide technical assistance to programs responsible for completing congenital syphilis reports.
- Provide additional training to public health department field staff to enhance their understanding of congenital syphilis case reporting.
- Automate work queues for public health department field staff to ensure the completion of case reports for pregnant women with syphilis morbidity.
In Texas, we also plan to review the impact of the 2015 law change every two years, as required by the legislature. This review results in a report to the legislature that identifies any negative consequences (i.e., late congenital syphilis cases missed due to a lack of delivery blood). If any negative impacts are identified, the Texas Department of State Health Services will work with lawmakers to provide guidance that addresses unintended consequences. The department will also work with local and regional health departments to disseminate required revisions to Texas law and prenatal testing requirements.