#1Congenital Syphilis in Louisiana and Related Provider Interventions Presenters: - Elizabeth Lindsay, MPH – Perinatal Surveillance Supervisor - Lawrencia Gougisha, MPH, BSN, RN – Perinatal Case Manager LOUISIANA DEPARTMENT OF HEALTH#2■ Louisiana Overview Largely rural, low population density outside major cities Majority of Louisiana has a Health Professional Shortage Area (HPSA) or low- income population designation Limited access to OB/GYN specialty in rural areas Poor transportation infrastructure in rural parts of the state STI testing and treatment services have been limited as a result of COVID-19 Caddo Bossier De Soto 7 Sabine Webster Red River Claiborne Lincoln Union Bienville Jackson Natchitoches Vernon Beauregard 5 Calcasieu Cameron Winn Allen Morehouse 8 Ouachita Richland Caldwell Grant La Salle Catahoula Franklin Concordia Tensas 6 Rapides Avoyelles Evangeline Jefferson Acadia Davis 4 Pointe West Feliciana East Feliciana East St. Landry Coupee Baton St. Martin West Rouge Baton Rouge Iberville St. Mary St. Helena Washington Tanahoa Livingston St. Tammany Ascension James 3 John Terrebonne Charles Lafourche Iberia Vermilion St. Bernard Plaquemines *Data from PRISM (Patient Reporting Investigation Surveillance Manager); LDH Bureau of Infectious Diseases, Office of Public Health, United States Census Bureau LOUISIANA DEPARTMENT OF HEALTH#3P&S Syphilis Congenital Syphilis Gonorrhea Chlamydia HIV Louisiana STI/HIV Rankings 2018 to 2020 2018 Diagnoses Ranking 2019 Diagnoses Ranking 2020 Diagnoses % Change 2019 to 2020 rd 699 3 th 700 9" 704 1% 43 1st st 68 5th 63 7% a 12,043 3 nd 36,293 2' 12,800 36,131 3r rd 15,483 21% 2nd 32,997 9% th 973 4 th 881 4 727 17% LOUISIANA DEPARTMENT OF HEALTH#4Case Rate (per 100,000 live births) 120 100 80 60 50 40 20 Congenital Syphilis Rates Louisiana and the United States, 2011-2020 Louisiana United States 92.3 83.5 63.3 71.3 73.6 72.8 111.4 108.6 29.1 52.7 48.5 33.1 23.3 16.2 11.6 12.4 9.0 8.4 9.2 T 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Birth Year LOUISIANA DEPARTMENT OF HEALTH#5Congenital Syphilis - Louisiana In 2020: . • • 71% of cases occurred in four regions of Louisiana: New Orleans (Region 1), Alexandria (Region 6), Shreveport (Region 7) and Monroe (Region 8). 79% of mothers were Black, 17% were White and 4% were Hispanic/Latina. 76% of mothers were under the age of 30 at the time of delivery. 89% of mothers received timely prenatal care that began at least 2 months prior to delivery. Among them, ■ 32% did not receive a test at their first prenatal care visit. ■ 25% did not receive a third trimester test. Caddo Bossier De Soto Webster 7 Red River Sabine Claiborne West Carroll Lincoln Ouachita Richland Madison Union Morehouse 8 Bienville Jackson Natchitoches Vernon Beauregard 5 Calcasieu Cameron Allen Caldwell Winn Tensas Grant Rapides La Salle 6 Catahoula Franklin rev Avoyelles Concordia West Feliciana East Feliciana Pointe St. Landry Coupee East Baton St. Helena Washington 9 Tanahoa Evangeline Jefferson Acadia Davis St. Tammany Orleans St. Bernard 4 Lafayette West Rouge Baton Rouge Iberville Livingston Ascension St. Martin John Iberia Vermilion St. Mary James Assumption Charles Lafourche 3 Terrebonne Plaquemines LOUISIANA DEPARTMENT OF HEALTH#6Congenital Syphilis Louisiana, 2020 Total Cases Case Definition Presumed Case Syphilitic Stillbirth Maternal Race/Ethnicity Black/African American White Hispanic/Latina Number Percent 63 100% 60 60 95.2% 3 4.8% 50 79.4% 11 17.4% 2 4.2% Maternal Age at Delivery 15-19 7 11.1% 20-24 23 36.5% 25-29 18 28.6% 30-34 14 22.2% 35+ 1 1.6% Frequency of Prenatal Care No Prenatal Care 1-4 Prenatal Visits 5-8 Prenatal Visits 5 9 7.9% 14.3% 16 25.4% 9-13 Prenatal Visits 19 30.2% 14+ Prenatal Visits 14 22.2% Insurance During Pregnancy Government/Public Private ☑∞o 54 85.7% 8 12.7% None/Unknown 1 1.6%#7Louisiana State HIV & Syphilis Testing Laws 2007: Louisiana State Law has required that every physician attending any pregnant woman offer a syphilis and HIV test to the woman at the first examination during pregnancy. 2014: Act 459 - Third Trimester Testing Law: Louisiana law requires "opt-out" syphilis and HIV testing for all women at the first prenatal visit, the 1st prenatal visit in the 3rd trimester and at delivery (if testing/status is not noted in medical charts) LOUISIANA DEPARTMENT OF HEALTH#8Partnership with Medicaid ►Data sharing ►Provider Outreach خدا DATA KNOWLEDGE ACTION LOUISIANA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH#9Syphilis screening during pregnancy among Medicaid enrollees Objective: Reduce the number of congenital syphilis cases by increasing access to appropriate syphilis treatment and utilizing Medicaid syphilis testing of pregnant women to improve provider services Focus on syphilis screening during the 3rd trimester since data indicated many providers were not retesting during the 3rd trimester LOUISIANA DEPARTMENT OF HEALTH#10Federal & State Support ▶2016: Established Regional Congenital Syphilis Case Review Boards for each OPH region to identify factors contributing to CS and opportunities for interventions Strengthened collaboration between Central Office, Regional Medical Team Leadership and Disease Intervention Specialists (DIS) ▶2016: Established Regional STD/HIV Task Forces in each OPH region •Increased STD/HIV awareness and engagement in communities across the state LOUISIANA DEPARTMENT OF HEALTH#11Federal & State Support contd. ► 2017-18: CDC STD AAPPS Supplemental Funding for Enhanced Congenital Syphilis Response • Developed an effective CS case management model and hired 2 Perinatal Case Managers Hired a CS Nurse Educator to promote provider awareness of LA screening and testing laws and adherence to CDC-recommended screening and treatment guidelines Hosted 2 CS conferences with support from Denver Prevention Training Center in two high morbidity regions 2019: Louisiana Sanitary Code §107 (Laboratory and Healthcare Facility Reporting Requirements) updated with required reporting of negative results for specific disease conditions, including HIV, hepatitis C and syphilis. ► 2021-2022: Perinatal Case Management program expanded to two additional regions • Plan to expand program state-wide LOUISIANA DEPARTMENT OF HEALTH#12Perinatal Case Management Specific focus on women of childbearing age (15-44 years) living with syphilis ■ Currently located in central and northern Louisiana Support access to transportation services, housing assistance, and food banks • Support engagement in prenatal care, WIC, and Nurse-Family Partnership (NFP) More one-on-one sexual and reproductive health education, with focus on syphilis and congenital syphilis prevention ■ Strengthened outreach efforts for PrEP and HIV prevention among women of childbearing age. ■ Strengthened communication and relationships with local providers, internal/external partners, and community-based agencies LOUISIANA DEPARTMENT OF HEALTH#13Bicillin Delivery Programs (2019) SHOT Syphilis Home Observed Treatment There has been a continued increase in the number of women with syphilis in Louisiana. Louisiana ranks #1 in the nation for congenital syphilis case rates. Louisiana's rate is 4x the national average. Untreated syphilis infections can lead to severe health issues. In pregnant women and newborns, syphilis can cause: miscarriage, stillbirth, low birth weight or other birth defects Syphilis can be treated and cured with antibiotics. If you are diagnosed with syphilis, your healthcare provider may be able to refer you for treatment at home. LOUISIANA DEPARTMENT OF HEALTH Pa Louisiana HealthHub SHPDirectRX Benzathine Penicillin (Bicillin L-A) Delivery Program Untreated syphilis infections can lead to severe health issues. In pregnant women and newborns, syphilis can cause: miscarriage, stillbirth, low birth weight or other birth defects Bicillin is the only CDC-recommended treatment for syphilis in pregnant women. You may qualify to receive deliveries of individual Bicillin doses for your patients free of charge. For more information, contact the Office of Public Health (OPH) Disease Intervention Specialist (DIS) in your area, or the OPH STD/HIV Program (SHP) SHPDirectx Coordinator at (800) 992-4379 AQUISIANA DEPARTMENT OF HEALTH Louisiana, HealthHub LOUISIANA DEPARTMENT OF HEALTH#14SHOT Syphilis Home Observed Treatment There has been a continued increase in the number of women with syphilis in Louisiana. Louisiana ranks #1 in the nation for congenital syphilis case rates. Louisiana's rate is 4x the national average. • • Pilot project in Regions 4, 6, and 7 for pregnant women and their partners. . Project now active in four regions Primary goal: increase access to appropriate treatment Eligible patients meet the following criteria . • No history of penicillin allergy Must have access to working telephone landline or cellular service Untreated syphilis infections can lead to severe health issues. In pregnant women and newborns, syphilis can cause: miscarriage, stillbirth, low birth weight or other birth defects Syphilis can be treated and cured with antibiotics. If you are diagnosed with syphilis, your healthcare provider may be able to refer you for treatment at home. LOUISIANA DEPARTMENT OF HEALTH Louisiana Health Hub ● • . Live in an area with 911 and EMS Any pregnant women must also have no complications of pregnancy which would preclude treatment in the home Home visits conducted by OPH Nurses accompanied by Disease Investigation Specialists and/or Perinatal Case Managers Sava#15Successes Increased treatment adherence/compliance Collaboration with healthcare providers. Cases of congenital syphilis averted LOUISIANA DEPARTMENT OF HEALTH#16Challenges • • • Difficult to locate clients/establish contact Not all staff were comfortable entering select neighborhoods where clients resided. Clients who are not eligible to receive home treatment (i.e. PCN allergy, no home phone service, decreased availability to EMS in the area, clients with complicated pregnancies). LOUISIANA DEPARTMENT OF HEALTH#17SHPDirectRX Benzathine Penicillin (Bicillin L-A) Delivery Program Untreated syphilis infections can lead to severe health issues. In pregnant women and newborns, syphilis can cause: miscarriage, stillbirth, low birth weight or other birth defects ■ Facilitate timely syphilis treatment by utilizing Disease Intervention Specialists to deliver Bicillin to private OB/GYN providers and community health centers that do not maintain the medication on- site Bicillin is the only CDC-recommended treatment for syphilis in pregnant women. You may qualify to receive deliveries of individual Bicillin doses for your patients free of charge. For more information, contact the Office of Public Health (OPH) Disease Intervention Specialist (DIS) in your area, or the OPH STD/HIV Program (SHP) SHPDirectRx Coordinator at (800) 992-4379 LOUISIANA DEPARTMENT OF HEALTH STD/HV Program Louisiana Health Hub этолим Агерга LOUISIANA DEPARTMENT OF HEALTH#18SHPDirectRX Implemented in October 2019 through a partnership with the Centers for Disease Control and Prevention ■Piloted in Regions 4, 6, and 7 and limited to OB providers ▪Expanded statewide during COVID-19 response. ▪Medical providers are responsible for administering the injections, as well as assuring that patients are suitable candidates for bicillin injections Lifts burden of cost from provider (one dose ~$1,500) ■360 syringes of bicillin provided through this program; over 70 patients treated LOUISIANA DEPARTMENT OF HEALTH#19Successes ▶Smooth, efficient process ▶Increased cooperation from community providers due to removal of financial liability Increased treatment accessibility for patients. Challenges Disagreement among providers over proper treatment protocol. Clients who require multiple Bicillin doses. LOUISIANA DEPARTMENT OF HEALTH#20Acknowledgements ► Dr. DeAnn Gruber, Director, Bureau of Infectious Disease Samuel Burgess, Program Director, STD/HIV/Hepatitis Program ▶ Dr. Chaquetta Johnson, Program Director, OPH Immunization Program Anthony James, Deputy Director of Programs, STD/HIV/Hepatitis Program ►Joy Ewell, CDC Lead Public Health Advisor Dr. Mohammad Rahman, CDC Epidemiologist Dr. Stephanie Taylor, STD Medical Director ► Jessica Fridge, STD/HIV/Hepatitis Surveillance Manager ➤LDH Regional Medical Directors ►All Perinatal Case Managers All LDH Disease Intervention Specialists LOUISIANA DEPARTMENT OF HEALTH#21Contact information Elizabeth Lindsay, MPH - Perinatal Surveillance Supervisor ■Email: [email protected] ■Phone: 504-568-7047 ▶Lawrencia Gougisha, MPH, BSN, RN - Perinatal Case Manager ■Email: [email protected] ■Office: 225-242-4907 ■Cell: 225-385-1779 LOUISIANA DEPARTMENT OF HEALTH