Advocates for Evidence-Based Health Policy Speakers
Battling The Great Imitator
Congenital syphilis (CS) cases in the U.S. are the highest they have been in the past 20 years with a substantial increase from 9.2 to 23.3 cases per 100,000 live births between 2013 and 2017. Rates are disproportionately higher among racial and ethnic minorities, with Blacks having 6 times the rate of Whites. Babies with CS can die soon after birth or develop long-term physical and mental health problems. Hospital costs for a newborn baby with CS is about $5000 (2012 estimate) higher than the cost for an uninfected infant, not including indirect costs such as the long-term special education and health needs of child with a disability. Current guidelines recommend that all pregnant women get screened for syphilis at the first prenatal visit, with additional testing for high risk women at 28 to 32 weeks gestation and at delivery.
A recent study assessed CS prevention strategies in New York City (NYC), identifying gaps at the individual, provider, and systems-level. Thirty-one percent (21/68) of the women positive for syphilis did not receive timely prenatal care or testing, while 6% (4/68) who received timely care were not tested for syphilis. The authors defined timely prenatal care and testing as being received ? 45 days before delivery, to ensure that effective treatment is provided at least 30 days before delivery. Surprisingly, 24% (5/21) of the women indicated not having health insurance as the reason for no prenatal care despite Medicaid being available to all pregnant women in NYC. Although the study did not distinguish immigration status, Medicaid coverage for undocumented pregnant women varies across the U.S.
Nationwide, the proportion of women screened early in pregnancy is low with geographic, racial, and ethnic variations. Although USPSTF and CDC guidelines recommend early and repeat screening, 6 states do not require prenatal syphilis testing. Among states with mandatory screening, 62% require just one test with 84% indicating it should happen in the first prenatal visit.
All states should adopt screening laws that align with the USPSTF/CDC guidelines. State legislatures and health departments should take this opportunity to refocus on primary prevention strategies to educate women and girls about sexually transmitted diseases and reproductive health, with targeted approaches to reach racial and ethnic minority communities. Finally, policymakers should increase awareness about enrollment in Medicaid among pregnant women, as it is unconscionable for pregnant women not to have health insurance in the U.S.
This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Satcher Health Leadership Institute. It is written by Debbie Vitalis, PhD. She is a Health Policy Leadership Fellow.
Abstract
Congenital syphilis occurs when syphilis is transmitted from a pregnant woman to her fetus; congenital syphilis can be prevented through screening and treatment during pregnancy. Transmission to the fetus can occur at any stage of maternal infection, but is more likely during primary and secondary syphilis, with rates of transmission up to 100% at these stages (1). Untreated syphilis during pregnancy can cause spontaneous abortion, stillbirth, and early infant death. During 2013-2017, national rates of congenital syphilis increased from 9.2 to 23.3 cases per 100,000 live births (2), coinciding with increasing rates of primary and secondary syphilis among women of reproductive age (3). In New York City (NYC), cases of primary and secondary syphilis among women aged 15-44 years increased 147% during 2015-2016. To evaluate measures to prevent congenital syphilis, the NYC Department of Health and Mental Hygiene (DOHMH) reviewed data for congenital syphilis cases reported during 2010-2016 and identified patient-, provider-, and systems-level factors that contributed to these cases. During this period, 578 syphilis cases among pregnant women aged 15-44 years were reported to DOHMH; a congenital syphilis case was averted or otherwise failed to occur in 510 (88.2%) of these pregnancies, and in 68, a case of congenital syphilis occurred (eight cases per 100,000 live births).* Among the 68 pregnant women associated with these congenital syphilis cases, 21 (30.9%) did not receive timely (?45 days before delivery) prenatal care. Among the 47 pregnant women who did access timely prenatal care, four (8.5%) did not receive an initial syphilis test until <45 days before delivery, and 22 (46.8%) acquired syphilis after an initial nonreactive syphilis test. These findings support recommendations that health care providers screen all pregnant women for syphilis at the first prenatal care visit and then rescreen women at risk in the early third trimester.
PMID: 30286056
You must be logged in to post a comment.