Chapters Transcript Congenital Syphilis: An Epidemic Driven by Social Determinants of Health Elizabeth Daniels, MD, discusses how congenital syphilis can lead to stillbirth, prematurity and significant neonatal morbidity. We are happy to be back to early bird rounds, and we thank you all for joining us. Um, today we have Doctor Elizabeth Daniels who specializes in infectious disease. Um, so we'll look forward to her presentation today, but before we get started, I have just a few reminders. Um, so please keep your cameras turned off and your mics muted during this, um, talk. There will be time at the end if you have any questions, you're welcome to unmute then or type your questions in the chat. Um, and as well, the QR code will be going up for all of you to scan for credit at the very end. And with that said, we'll go ahead and give our attention to Doctor Daniels. Hi, everyone. Thanks so much for having me. Um, I think I interacted with many of you. Um, as I said, I'm Elizabeth Daniels. I newly joined the PAD division as an assistant professor this summer. Um, but I actually came to Washington for Medical School 10 years ago and haven't left. So, um, was here for medical school residency and then PIT fellowship. Um, so again, thanks for having me. Uh, today, I get to talk to you all about congenital syphilis, which is such an important topic. I'm sure something that's been coming up in everyone's practices, um, and something that's been getting a lot of attention nationally. Um, and was the focus of my fellowship research. And the point that I really want to drill home is that, uh, congenital syphilis is an epidemic, and part of what's made it so challenging to tackle is that it, uh, is really driven by social determinants of health. So I don't have much to disclose. I, I gave a similar talk last year for a group at Ascension Health and received an honorarium. My objectives for today are to, sorry? OK, sorry. Uh, I thought that I heard someone. My objectives for today are to talk about the changing epidemiology of congenital syphilis, talk about the diagnosis and management of syphilis during pregnancy, and then, of course, the diagnosis and management of congenital syphilis, and then to think through some novel strategies that we should be considering to reduce congenital syphilis rates. So, again, I hope that congenital syphilis is something that um everyone has been hearing about through the news or uh through medical journals. Um, we hear some headlines that I've seen. Um, the CDC has called this an An epidemic that needs concerted action drawing attention to the fact that we're seeing now 10 times the number of impacted babies as we were in 2012, uh, calling attention to the fact that congenital syphilis has jumped tenfold over the last decade. Um, infants just being born, um, with syphilis and growing numbers all across the country. Something that really needs all of our attention. Just to make sure that we're on the same page, I wanted to define congenital syphilis. So congenital syphilis, as I think most people here know, as a serious congenital infection that results from the vertical transmission of the spiroche reponema pallidum pictured on the right to a fetus during pregnancy. This infection is really important because it can cause significant morbidity and mortality. Congenital syphilis is associated with stillbirth, with prematurity, um, and babies who, um, survive but are untreated can go on to have multi-organ manifestations. I saw one paper that quoted a case fatality rate as high as 31%, which feels really high to me, but again, this is a serious disease. I get a lot of questions about kind of how the timing of maternal infection impacts the risk of congenital syphilis. The risk of transmission to an infant is higher, uh, with the earlier stages of maternal infection. So, um, like primary or secondary syphilis, and then with the later gestational age at the time of infection. Um, so if somebody is newly infected with syphilis in the third trimester. Um, we see transmission rates, um, in the range of 60 to 100% with primary or secondary syphilis during pregnancy, 40% during early latent, and then less than 8%, uh, with late late maternal infections. So I will say I think sometimes it is hard to accurately date our maternal infections and make this assessment. Oh want to share some data from the CDC um showing uh rates of reported cases of congenital syphilis, and I think that this is really interesting. Um, this graph here shows rates of reported congenital syphilis by a year of birth starting in the 1940s when we first started tracking this data, um, and going to 2021 or 2022. Um. You can see at the start of data collection rates were quite high, um, in the range of over 600 cases per 100,000 live births. And then with the widespread availability of penicillin, uh case rates just plummeted. There was a definition change in the early 90s, which may be why there's this little blip in the graph. Um, but for most of the early 2000s, early 20 teens, we were not seeing much congenital syphilis at all. Um, but that started to change now a little over 10 years ago, um, because since, um, 2012, the rate of congenital syphilis has significantly increased every single year. Here I am sharing, um, national 2022 data in a little bit more detail. Again, highlighting that our congenital syphilis cases have increased 937% in the last decade. I think that's really shocking. Um, that means that in 2022, we had 3700 cases, including almost 300 stillbirths and infant deaths, and that was a 30% year to year increase from 2021. This increase in congenital syphilis directly tied, absolutely tied to an ongoing increase in primary and secondary syphilis in people of childbearing potential. So, what this graph, um, on the side here actually shows two things. In the thick blue bars, it shows congenital syphilis cases among infants. And then in the thin blue line, it shows the rate of primary and secondary syphilis among, um, Females aged 15 to 44 years, and you can see this is the same curve. So that makes you realize that we really have to focus on, um, those infections and those people of childbearing potential if we want to curb congenital syphilis cases among babies. Um, this represents a real shift in epidemiology. So previously, women aged 15 to 44 years really didn't have high rates of syphilis. Um, that rate has increased substantially over the last 10 years, and there's also been a shift, uh, in the male to female rate ratio of syphilis infections, as reported by the CDC. What's so frustrating about this, anything tragic about this, um, is that congenital syphilis is fundamentally preventable. So we can prevent almost every case of congenital syphilis if we can get people into timely prenatal care. Supports timely syphilis testing, provide timely stage appropriate maternal treatment, and then identify any maternal treatment failure, relapse, uh, reinfection, or serial conversion during pregnancy. We have a deadline to do this, and that deadline is 30 days prior to delivery. That's when we have to start effective treatment, and that can be really hard to do. So to help think about how we can improve our care, the CDC has developed a few different frameworks, um, to identify missed opportunities for congenital syphilis prevention, and I'll show you the two frameworks. This is the first one. So this framework tried to classify congenital syphilis cases nationally based again on the missed opportunities. So, um, examples of missed opportunities included no timely prenatal care and no timely syphilis testing, um, or, uh, no adequate maternal treatment despite receipt of timely syphilis diagnosis. And those are the two most common opportunities identified, uh, both nationally and then when I reviewed our local data, those were our opportunities locally as well. Other opportunities. There can be late identification of sero conversion during pregnancy. Um, rarely, there are cases where people lack syphilis testing despite receipt of timely prenatal care, but that's less common. And I think the kind of good news buried here is that very rarely are there cases where there are clinical evidence of congenital syphilis, despite maternal treatment completion. So, again, if we can get people into care, provide syphilis testing, provide syphilis treatment in a timely way during pregnancy, we can prevent these cases. The CDC has updated their framework in the last few years, um, to shift away from thinking about prenatal care as kind of the necessary entry point for congenital syphilis prevention, uh, and instead just focusing on whether or not pregnant people were tested for syphilis in a timely way and then whether or not they were treated appropriately in a timely way. And based on this updated framework, um, they, it's kind of a similar. A different way of saying the same thing. They found that um our most common opportunities um were inadequate treatment, um, followed by no documented timely tests. I think a lot of what makes this epidemic so challenging to tackle and why, despite really a lot of focus on this problem, we're still seeing high rates of congenital syphilis, is that syphilis is a disease that's associated with adverse social and structural determinants of health. Um, and this is something that became really glaringly obvious to me when I started reviewing our local cases in the BJC system. I just was so struck by the stories of these families and just over and over by how, um, much difficulty people had establishing prenatal care, um, and some other themes, like how many interactions there were with our prison system, how much housing and stability these families faced. Uh, there's a lot of in. To the A lot about For sex trafficking. Um, and then the last thing that was very striking to me in looking at the charges of these mothers and infants was the amount of Children's division involvement. So these families are facing a lot, and I think that we need to understand this background, um, if we're going to understand really how to provide holistic care to these families. So I wanted to talk about Detail. First, and I think very importantly, congenital syphilis is strongly associated with limited prenatal care. Uh, so nationwide, almost 30% of individuals, um, who had a baby with a congenital syphilis pregnancy outcome did not get any prenatal care. Um, I also found a logistic regression model developed by a group in California that identified no where late prenatal care is the strongest predictor of a congenital syphilis pregnancy outcome. And then when I looked at our own cases in the BJC system, 60% of individuals who had an infant with congenital syphilis received limited or no prenatal care. Again, the association with substance use is also very, very strong, and this has been going on for a long time. So there were high rates of congenital syphilis back in some urban areas in the 90s, and at that point, that was associated with cocaine use. Um, I think that one Of the drivers, unfortunately, of the increase in syphilis among people of childbearing potential over the last decade has been increased methamphetamine and injection drug use, and that's been associated with these increases in primary and secondary syphilis since 2013, and more papers are published on this association every day. Um, here's an example of, uh, publication out of Arizona and Georgia calling attention to substance use among people with syphilis during pregnancy. Um, this one is from Chicago. This is from Mississippi. Mississippi has seen a 1,000% increase in their congenital syphilis cases. So this is something that we absolutely need to be prepared to address with our families. Um. In my review of our BJC system cases, I found that over half of individuals with congenital syphilis outcomes from their pregnancies had a history of substance use, and I wasn't looking at marijuana. I wasn't looking at alcohol or tobacco. Really, what I saw was a lot of cocaine, a lot of methamphetamine use, and a lot of opioid use. Um, so again, it's so important to think about how to support these individuals, um, during their pregnancies and Um, really provide what is called syndemic care. Um, and then this is intertwined, of course, with limited or no prenatal care. Um, so substance use was a predictor of limited or no prenatal care in my data. Um, There are also um differences in different racial and ethnic groups and the impact of congenital syphilis nationwide. So this is data from the CDC that shows that um American Indian and Alaska Native groups, um, as well as native Hawaiian and Pacific Islander and black African American groups are just really disproportionately impacted um by this issue. This is a slide that I took from the Illinois Department of Public Health, just kind of further reflecting on the inequity in syphilis, um, showing that different groups have, um, higher odds of birthing a child with congenital syphilis. And I, I think that this kind of data is really a call to action. OK. So with all of that, with all of that information about how high our congenital syphilis rates are and how difficult a problem this is to solve, I wanted to provide some action items on what we all can be doing to prevent congenital syphilis, and I have 4 action items. One is we all need to be promoting timely maternal syphilis testing. And then doing our part to ensure appropriate maternal treatment, acknowledging that we're pediatricians. So we really need to work with our OB colleagues on this front, um, at a kind of higher public health level, there need to be conversations about partner services, uh, to prevent cases of maternal reinfection, and then our task as pediatricians is to provide infant treatment and follow up. And then again, to accomplish these goals, I think in the back of our mind, we need to remember all of these social and structural barriers um based by our patients that make getting into prenatal care and getting testing and getting treated so hard. So, to first talk a little bit more about testing, it used to be that syphilis testing was just recommended once during pregnancy, and that really, um, in our current climate is no longer adequate. So, the current recommendation is that all people in Missouri and Illinois should be tested for syphilis 3 times during pregnancy. Uh, test at the first prenatal visit, then retest at 28 weeks and then test again at delivery and that way we're not missing these cases uh later in. I like, uh, this universal testing approach because I think that there's a lot of stigma associated with syphilis and uh a lot of attempt to kind of assess risk and, um, I, I think that that really To take stigma out of it and in areas where there's a lot of syphilis, which is Missouri and Illinois, and really all of the United States right now, um, providing this universal testing 3 times in pregnancy. Um, again, why do we need to test at multiple points during pregnancy? Pregnant people have sex, um, so retesting is going to identify, um, erro conversion during pregnancy, these later infections, as well as maternal reinfection and relapse, um, and I just kind of thought over and over as I was looking through all these cases that really every healthcare opportunity is an opportunity for the syphilis testing. We all need to have a high index of suspicion for syphilis during pregnancy. I know most of us on this call are not the ones seeing pregnant people, um, but when we're seeing our teenage patients, I think it's important to remember that the manifestations of syphilis are really protean. Um, I've seen several times at this point, the Schenker primary syphilis mistaken for HSV. People keep swabbing this ulcer and it keeps being negative for HSV, and I've gotten calls saying, what do we do to manage, uh, HSV with a negative PCR test? And the answer is, please test for syphilis too. Um, the rash of secondary syphilis can look like anything, and I've seen that misdiagnosed as a viral like anthem or dermatitis or tinia. And then a final opportunity that I just want to call attention to is that if a pregnant person, um, or really one of our teenage patients too is found to have a new STI, um, that should be a flag to prompt testing for all STIs. Moving on to talk a little bit about maternal treatment. As I said earlier in my talk, timely maternal treatment is really essential and is a cornerstone of congenital syphilis prevention. We can prevent these cases if we initiate maternal treatment 30 days prior to delivery. It actually doesn't have to be completed 30 days prior to delivery, it just has to be started. I have seen concern for penicillin allergy lead to unnecessary treatment delays. Um, as again, I think many people on this call know, um, penicillin allergies are commonly reported, but 90% of those probably aren't real. So, uh, you need to be very careful and thoughtful about making sure that that doesn't delay necessary treatment. Um, the treatment of primary and secondary and early latent syphilis during pregnancy is one dose of penicillin. And I think that that's pretty straightforward and pretty achievable for our OB providers. Uh, some providers do administer a second dose of penicillin one week after the first dose to anybody who has syphil during pregnancy. That's an option for the guidelines, but that's not necessary. Um, for these early cases, that one dose of penicillin is sufficient. Um, however, where I see us running into problems, and I, where a lot of the cases of people who were diagnosed with syphilis but didn't get timely effective treatment, um, during pregnancy come from or that pregnant people are frequently diagnosed with late latent syphilis. And to treat that, we need 3 weekly doses of IM penicillin, and they have to be timed really specifically. The goal is to give them Um, for 3 weeks in a row on the same day, and if the dose is delayed by 9 days, greater than 9 days, the series is supposed to start again. And this is so hard to achieve for people who have transportation limitations, for people who Um, don't have a consistent healthcare provider. Um, and this uh scenario, um, is something that I think we have to be really thoughtful about, um, just how we can support our patients and actually achieving this course of therapy, um. Some like to use doxycycline as an oral alternative to IM injections, but that unfortunately is not adequate treatment during pregnancy. We don't think that that uh actually treats the fetus. And then just a plug about our partners, we can't forget about our partners in there, um, because our pregnant patients can get reinfected with syphilis if we don't treat their partners effectively. OK. So, again, I think everyone in this group is a pediatrician. So where we really get engaged is when the baby is born, and now we're all figuring out what to do. So, there are so many different manifestations of congenital syphilis, and when we learned about this in medical school, I think this is kind of the list that people see. Um, people talk about these horrible in utero manifestations, including miscarriage, stillbirth, perinatal death. Talk about these early, uh, manifestations of congenital syphilis, including syphals, um, lymphadenopathy, bony changes, um. Um, anemia, thrombocytopenia, and then textbooks are full of these pictures of late manifestations of congenital syphilis that I hope we never see because our job is to prevent all of this. But, um, the Hutchinson teeth and the frontal bossing and the mulberry molars and the saddle nose, um, But what struck me when I started seeing more and more of these cases is that many of our newborns have no symptoms at all. And so that makes this, I think, an especially tricky diagnosis to make, because we need to do our physical exam and look for these manifestations, but, uh, healthy, well appearing baby may still have an incubating syphilis. Um, I wish that we had a single test that told us whether or not a baby has congenital syphilis. I think everyone knows that we don't have that test. Instead, what we have are these case scenarios. Um, so babies are classified as having proven, highly probable, possible, less likely or unlikely congenital syphilis based on a constellation. Of maternal and infant factors. And really, we're just doing our best with, um, what is very outdated and inferior testing. Our testing for syphilis with RPRs and BDRLs. It's all testing and it's, it's not great. The sensitivity and the specificity is not perfect. There's so many issues with it. So we're kind of doing the best that we can, um, with these flawed test methodologies. Um, I imagine that most people here have looked at that algorithm in the red book. I try to break it down a little bit more simplistically in my mind, um, and so maybe this breakdown will be helpful for some of you. Um, I think of cases of proven or highly probable congenital syphilis or possible congenital syphilis cases where there were missed opportunities and um the pregnant person was not treated, um, in a timely manner during pregnancy, either because of a late diagnosis or lack of testing or a lack of effective treatment. Um, in cases that proven are highly probable congenital syphilis or something else confirming. Um, that diagnosis, like an abnormal physical exam finding or a lab finding, um, or the infant RPR is fourfold higher than the maternal delivery tighter. In cases of possible congenital syphilis, there was lack of effective maternal treatment, but the baby looks fine and their labs look great. The evaluation is unconcerting. And then with cases of less likely and unlikely congenital syphilis, those are cases where we were able to deliver optimal care. Cases of less likely congenital syphilis occur when somebody is diagnosed with syphilis during pregnancy, but does get that appropriate timely treatment. And then cases of unlikely congenital syphilis are those that are diagnosed inappropriately treated even before pregnancy. On the CDC case scenarios, um, on the CDCSTD treatment guidelines, um, web page just outlined this in much greater detail, um, or you can kind of look through this redbook algorithm, um, which I think all of us have sort of stared at and had given us a headache at one point. The initial evaluation for congenital syphilis has Get an RPR at the time of delivery for mom and baby. Do a really good physical exam. I also wanna make sure that we're really cognizant, um, that the parent has had recent testing for other STIs. I worry about Overlap between HIV and syphilis cases. So would really advocate for getting uh HIV testing at the time of delivery if we're evaluating an infant for congenital syphilis. Um, hepatitis C is something too that Um, relatively recently, ACOG has recommended as universal screening for all pregnant people, and we are seeing growing numbers of, um, pregnant people impacted by hepatitis C. I think that's also tied to substance use, um, and then making sure that there's timely gonorrhea and chlamydia testing. I frequently get called by people who say, um, mom and baby have a positive RPR. What do I do? And what we really need to know to figure out next steps is get a thorough history, um, for mom, including the timing of, uh, the maternal syphilis diagnosis, how mom was treated, what mom's RPRs were with dates, so we can evaluate the response to therapy and think about any risk for relapse or reinfection. Then again, infants whose mothers were not adequately treated during pregnancy have either proven or highly probable congenital syphilis or possible congenital syphilis, and those infants require further evaluation, and it's a big evaluation. That includes our CBC and our CMP, our lumbar puncture with the CSFBTRL, long bone bones, hearing testing, and then we often recommend head ultrasounds and eye exams, so those are actually optional in the guidelines. We are lucky to live in a time of really effective syphilis treatment. There's kind of a fascinating history out there of really bad ways to treat congenital syphilis that were tried, um, in past years. People are really anchored on mercury as the treatment for syphilis prior to the advent of penicillin. Uh, and that was incredibly toxic. So even though they were giving mercury to, um, adults with syphilis, it was recognized that was too toxic to give to infants. Um, so there was actually this attempt made to give infant wet nurses. The, um, hoping that that would deliver a lower, but still therapeutic dose of mercury to the infants. Unfortunately, what happened there is that everybody was just still poisoned with mercury and the wet nurses also acquired syphilis. So it was just a horrible idea all around. Um, there's also this really interesting, um, history of pyrotherapy. Um, in the early 1920s. So if you have somebody with syphilis and then you infect them with malaria, the malaria causes really high fever, and that can actually help treat this infection. Um, so it's crazy that that was actually Nobel Prize winning in 1927. Again, fortunately, we don't do any of that to our babies. We treat with penicillin. So, as I think most people here know, uh we treat our babies with proven are highly probable congenital syphilis with 10 days of IV penicillin, treat our infants with possible congenital syphilis. Usually with 10 days, although if their evaluations are perfect and follow-up is assured, we could consider one-time injections of IM penicillin for those babies, and then infants with less likely congenital syphilis could just get a single injection. Um, and those with unlikely congenital syphilis don't need treatment at all, and sometimes if they have a reactive IPR we'll still give them, um, an injection of penicillin, um, to be really cautious. Um, the follow-up is where I would ask for all of your help. So people often refer these infants to the infectious disease clinic for follow-up, and we're more than happy to see them. Um, but I will say that coming to our clinic is very difficult for families. Our no show rate is extremely high, uh, and we'll often have kind of far flung infants who are referred to our clinic, and those families just can't make the 2 to 3 hour drive to come see us for follow up for this. Um, and really what they need, um, are repeat RPRs every 2 to 3 months until those RPRs are non-reactive and then close developmental. Monitoring. So, I think kind of any pediatrician who's familiar with this absolutely can provide this follow up. Um, and we're always here to support. Again, we're more than happy to see these babies. They just, I worry sometimes that having an automatic referral to come to our clinic for this, um, just kind of adds a burden to the family, and, and they just, frankly, can't come to see us. Um, we expect that these babies, RPRs will become non-reactive by 6. Months. Uh, if they are uptrending at all or if they're still reactive at 6 to 12 months, and they, we absolutely would want to see these infants, uh, because we would need to evaluate for treatment failure. Uh, however, I will say that this is very uncommon. I very, very rarely, um, see, I, I've never seen an increasing RPR baby, and I've only occasionally seen a case where it was still reactive in that 6 to 12 month, um, time frame. Then I would advocate for referring all of these infants to early intervention or first steps, just to have some additional kind of close developmental monitoring. And then finally, um, I do consider a social work evaluation, um, for these families to see if there's anything that we can do to provide additional support. I have a lot of questions about the optimal management of these infants and their long-term follow-up. I don't think that we really understand the long-term developmental outcomes of infants who are identified as having a possible or proven highly probable congenital syphilis at birth and then treated appropriately in that immediate time frame. There's really a lack of data. Um, potentially their neurodevelopment will be normal. I don't know. Um, I do again think that close follow-up, um, is a good idea and that extra developmental support is a good idea, especially because these infants may have other factors like in utero substance exposure, um, that could also impact their development. The last topic that I wanted to discuss is what novel strategies we can think about to prevent all of these cases of congenital syphilis, and I think um the the main thing that's been On my mind, and I think, uh, on many people's mind, uh, in the public health world is if so many of these people are not able to establish with the prenatal, with prenatal care, that in and of itself is an important goal and certainly we need to be promoting prenatal care, but we also, I think, need to be thinking about how to provide care outside of the traditional kind of OB prenatal care framework, um, thinking about ways to collaborate with substance use, uh, risk mitigation. And treatment facilities and shelters and other housing resources and the justice system and is working to meet people where they are and deliver syphilis care and treatment to people where they are, um, working with the disease investigators at the health department to ensure treatment completion. Um, it's also really important. They are a great resource, and I frequently find myself calling in these cases because they're the only ones that have complete histories of maternal syphilis infections and treatment. Um, and then finally, we're thinking more and more and actually, um, my mentor Hillary Reno on the adult infectious disease side has developed, um, a syphilis linkage to care program. So this is really modeled after the highly, highly successful perinatal HIV linkage to care programs where if a pregnant A person is diagnosed with syphilis during pregnancy, um, then the emergency department that did that diagnosis is able to connect that pregnant person to the health department. Um, and this linkage to care group at the health department, um, will help ensure follow up, which it, it can just be beyond the scope of what the emergency department can do. And then finally, I just wanted to reiterate um what I think every infectious disease doctor will tell you, which is that every encounter with the healthcare system is an opportunity for syphilis testing, and this is the diagnosis that we don't want to miss. So, I know I went through my slides early. It's only 8:35, um, so I'm more than happy to take any questions. No worries on finishing early. We really appreciate your time. Again, if anyone has any questions, um, we'll give you all some time to put them in the chat or to unmute so you can um speak with Doctor Daniels and I will put up the QR code for everyone. And I hope everyone's staying safe in the snow. Mhm So for confirmation of um maternal diagnosis, there are multiple ways to do this. So you start with, uh depending on if you're using the conventional or the reverse algorithm, um. Right now at BJC we start with an RPR which is actually a non-trepomal test. It doesn't directly look for syphilis. And then if that's reactive, then you can confirm with a so-called trepomal test, which is antibody testing, and there are a few different antibody tests depending on, um, which institution you're working with. Um, there are other institutions that do so-called reverse algorithm testing and Um, that means that you start with an antibody test, and then if that is reactive, then that reflexes to the RPR with a tighter, and that is more practical, frankly, for a lot of labs to do. There are a lot of logistic reasons that that's better. Although that has the obvious downside of if your antibodies, if you've ever had syphilis, your antibodies are gonna stay reactive. Um, and so you really need to think about all the tests together and what RPR is and what the titer is and somebody with a history of syphilis to decide if somebody um has a new infection or treatment failure or something like that. Um, there's a question about new testing on the horizon. Gosh, I mean, people are working on it. I don't think anything ready for prime time. There is some rapid syphilis testing that's being explored, um, in groups that have a high likelihood of syphilis. I think that it's just not a perfect test. And, um, from what I've heard from people who have been trying to use this rapid testing, so They just need these confirmatory RPRs and there's, uh, frequent discordant. Um, so, lots of interest in rapid testing. I think more to come, um, but may not be ready for our populations right now. Um, novel testing, that's better than our RPRs and our reponemal antibodies, uh, certainly desired, certainly being worked on, but I, I think nothing imminent. Um, one thing, one point just with the kind of two-step testing algorithm is something that I sometimes see in these babies is people will get an RPR in the baby and then they'll want to see the antibodies on the baby too, to confirm that the baby truly is syphilis. If we had the antibodies on mom. Then we know that it's a true syphilis infection. So I would just go ahead and like get an RPR on the baby as long again as mom had the both the RPR and the repoal antibodies and not like do an extra poke for the baby to get antibody testing. Yeah, thank you, um, Jenna Puzzle for your comment. I agree. I think that these babies worry a lot of us, um, and they are really hard, they can be really hard to track down. Um, that's part of why, um, I think sometimes people try to refer them to our clinic thinking that way they will see somebody, but then they have such a hard time coming to see us. Um, And I think that it just speaks to how many different, um, and kind of challenging social factors uh may be playing a role um in these families' lives. I do a lot of work, uh, in perinatal HIV prevention and in perinatal HIV there are just so many resources that we can use to, um, ensure that people may get to appointments. We can provide transportation. We can, um, really provide a lot of hand holding. Um, and so there's some thinking about could we do any of that for syphilis also. And I, I agree that community health workers are a critical resource. Yes, false positive RPRs, um, to speak to this question that chat about reasons for false positive RPRs. They are so common. Um, being pregnant is a reason for a false positive RPR. Um, I think other infections can do it. Autoimmune conditions are certainly associated. Um, with having a false positive RPR, I don't lose too much sleep over them. If you have a, a positive RPR but then a negative antibody test. I've talked to one of my adult colleagues about this, and we don't really recommend like a specific workup to try to hunt down the cause of the false positive RPR. Um, but I, I know that they can cause concern for families, and I think it just speaks to how, um, unfortunate a test the RPR is. Hopefully we'll have better testing at some point. Yeah, I think one last thing I'll say just because we're talking about testing is that it really is important to know what your, like, kind of local lab is doing, what algorithm they're using, if they're doing the traditional or the reverse algorithm for syphilis testing. Um, and, um, there are some local labs that may change what algorithm they're using, so just keeping an eye out for that. And on the infectious disease side, we're always more than happy to be a resource to help interpret syphilis testing. We know that this is really confusing for everybody. There's a question about the timing of the three tests in pregnancy. So what I would advocate for and what's advocated for in national guidelines, is to test once at that first prenatal care visit and then to test again around 28 weeks and then at the time of delivery. And the logic there is that you are catching syphilis at the beginning of pregnancy, so you can treat it at the beginning of pregnancy, um, if you can make that diagnosis and then retesting at 28 weeks so that you still have time um to treat, um. Before 30 days before delivery. And then we do that delivery test just to catch any diagnoses that were missed or any late infections or reinfections. And um that delivery testing was something that we added um at BJC within the last, I think, 5 years and, and certainly we are catching um congenital syphilis cases with that delivery test that we would have missed otherwise. Um, so, the public health departments are working hard on this. Um, the, there are kind of numerous Groups, um, both at the state level and then um at the city level, um, trying to maximize our public health interventions and it's really, it's not just Missouri and Illinois, unfortunately, we are seeing this nationally, um, things that Uh, the health department is working on is thinking about some of these collaborative efforts. Like I said, how can we collaborate with our justice system, with our substance use treatment colleagues. Um, they're also advocating nationally for legislation to actually require syphilis testing 3 times during pregnancy, um, and then the Public Health department also has the disease investigation specialists that are following up on these local cases and trying to ensure um Appropriate treatment of any pregnant people uh diagnosed with syphilis, which is a big, big task, um, and again working with some of our adult colleagues on the so-called linkage to care programs, um, but it's, it's a big task. Um, you are, I will put my email in the chat, and people are welcome to email me, um, with any questions about congenital syphilis to, um, uh, and local babies, always feel free to contact the pediatric infectious disease group through Children's Direct. We get a lot of these calls and we're more than happy to help. Yeah, I, I'm not sure about the comment about the county health department not wanting STI reports anymore, um. I, I have worked with the county on many cases. Any more questions? OK. Well, I really appreciate everyone's time. Yeah, we really appreciate your time as well, Doctor Daniels. Um, we, um, I'm gonna go ahead and put the what we can expect for next week with early bird rounds. We thank you all for joining and participating and um asking questions at the end, and if you had any problems with the QR code, you can reach out to me. Um, but other than that, I hope everyone has a great weekend and stay safe out there in the cell. Bye. Created by Presenters Elizabeth Daniels, MD Assistant Professor of Pediatrics (PEFA), Infectious Diseases View full profile
