POPS Chapter 23 - Congenital Syphilis
DSHS considers women with the ability to become pregnant between the ages of 14-45 to be of childbearing age.
Following up on women diagnosed with syphilis or associated with a syphilis case who can become pregnant remains a high priority for field staff. Pregnant women with syphilis remain the highest priority for field follow-up. Timely treatment (adequate treatment for the surveillance stage of syphilis initiated at least 30 days prior to delivery) of syphilis in pregnant women can prevent a diagnosis of congenital syphilis in infants, as well as any detrimental effects of in-utero exposure to syphilis.
23.1.1 Pregnancy Ascertainment
Pregnancy ascertainment is a critical piece of syphilis investigations; known pregnancy status allows for field staff to recommend appropriate medication, make appropriate referrals, and prevent congenital syphilis. Pregnancy ascertainment should always be documented when appropriate.
Pregnancy status on reactor field records can often be obtained from the provider. If the provider did not obtain pregnancy status on the client, the DIS must obtain pregnancy status when they contact the client.
Appropriate questions to ask a client with the capacity to become pregnant when attempting to obtain pregnancy status include:
- When was your last normal menstrual period (LMP)?
- LMP varies, use key dates and assist the client to remember
- What medications are you taking?
- Helps to ascertain contraception, incidental antibiotics, PrEP status, etc.
- How many children do you have?
- Obtain the age(s) of the child(-ren)
- Father(s) of the child(-ren)
- Potential contact opportunity
- When was your last pregnancy?
- Document if the client was pregnant in the last year
- Can lead to obtaining a non-reactive test
- Helps to determine if there was CS exposure, syphilitic stillbirth, or miscarriage
- Document if the client was pregnant in the last year
If a client reports that they cannot become pregnant or are using Long Acting Reversible Contraception (LARC) there is no need to offer a pregnancy test. If pregnancy status cannot be ascertained through the questions above, a pregnancy test should be offered when appropriate.
Additional questions to ask clients who are not pregnant, but have the capacity to become pregnant and are of childbearing age:
- What are your plans regarding future pregnancies?
- When would you like to become pregnant again?
- What referrals would you like?
Self-reported pregnancy status by the client is an acceptable means of pregnancy ascertainment.
Pregnant women identified through disease intervention efforts should be referred to prenatal care.
Referrals include: Prenatal Care, Medicaid, CHIP-Perinatal, WIC, local federally qualified health centers (FQHCs) or private medical providers, etc.
Women with the capacity to become pregnant should be offered the appropriate referrals.
Referrals include: Healthy Texas Women, local FQHCs, private medical providers, community-based organizations (CBOs), etc.
Clients should be assessed for intimate partner violence and sex trafficking and given referrals as appropriate.
184.108.40.206 Pregnancy Ascertainment Minimum Standards
- 90% of all syphilis reactors who are of childbearing capacity are to have a documented pregnancy status.
- 80% of all syphilis contacts (partners, clusters, associates) who are of childbearing capacity are to have a documented pregnancy status.
23.1.2 Treatment Adequacy and Documentation
To reduce the number of probable congenital syphilis cases, a woman of childbearing capacity must be adequately treated for their surveillance stage of syphilis in accordance with the CDC STD treatment guidelines. Infants born to women with untreated or inadequate treatment at the time of delivery are classified as probable congenital syphilis cases. Appropriate documentation of treatment is essential for determining treatment adequacy.
If a client reports a history of syphilis and previous treatment from out of state, but ICCR is unable to obtain documentation of a historical syphilis diagnosis and treatment, then the client must be retreated. If the client reports a history of syphilis from out of country and does not have documentation of treatment, then the client must be retreated.
23.1.3 Field Follow-up for Women of Childbearing Capacity with Inadequate Treatment
The purpose of the Follow-up Treatment Restart (F4) Field Record is to reduce the number of women who deliver infants classified as congenital syphilis cases due to inadequate treatment for their syphilis diagnosis.
A Treatment Restart Field Record must be initiated if a jurisdiction receives notification of a reactive syphilis lab results (excluding BFPs) with any indication that a woman is pregnant through provider, DIS, or laboratory report and
- Through record searching: documentation of inadequate treatment for the syphilis case classification (confirm case classification) OR
- Through a review of syphilis lab results: any missed investigations with sustained two-dilution titer rises with the absence of documented treatment (missed case).
Recommended (Capacity Permitting):
- Initiate an F4 field record for treatment restart using the same criteria as above regardless of pregnancy status, and
- When women of childbearing capacity who present to the clinic and are previously inadequately treated, begin a new treatment regimen, and miss follow-up treatment appointments.
220.127.116.11 Expectations for Field Follow-up on Treatment Restart Field Records
Treatment Restart Field Records are high priority field record aimed at preventing a congenital syphilis birth.
All F4 Field Records initiated on women of childbearing capacity should have a minimum of two field visits (am/pm), two phone calls (am/pm), and two SMS (text) messages. If the client is in prenatal care or the field record is initiated due to provider report, field staff may have success working with the provider for treatment re-initiation.
18.104.22.168 Treatment Adequacy Minimum Standards
If client was treated with a course of doxycycline prior to pregnancy, field staff are to confirm that the client received the medication, document the start date of treatment, and confirm that the client completed the appropriate treatment regimen for the diagnosed surveillance stage.
Penicillin G is the only treatment option for pregnant women.
If the client requires more than one dose of Bicillin, field staff are to document each dose of Bicillin separately with the date that treatment was given. Field staff are to confirm that the client completed the appropriate treatment regimen prior to case closure.
There are special considerations for treatment of pregnant women diagnosed with syphilis who report an allergy to penicillin. If penicillin desensitization is indicated, field staff should consult with their medical director for referring a woman into care. Most programs have a standing order with a local hospital to facilitate desensitization. DIS are to confirm that the client was evaluated for desensitization, and desensitized was required (i.e., a penicillin allergy), and adequate treatment was received for syphilis surveillance stage. DIS will document the treatment within the MIS system.
- 95% of women diagnosed with syphilis during pregnancy more than 45 days prior to delivery are to have initiated adequate treatment for their surveillance stage of syphilis prior to labor and delivery.
- 85% of women of childbearing capacity diagnosed with syphilis are to have adequate treatment for their surveillance stage.
23.2.1 Infant Field Records
A Field record should be initiated for all children, regardless of whether or not they already have a congenital syphilis investigation in the system.
- Reactor (T1) Field Records are to be initiated on all reactive syphilis labs on children 10 years of age and younger.
- Congenital Follow-up (F1) Field Records are to be initiated on all infants with negative labs, infants without labs born to a woman with a positive syphilis serology, and any presumptive infants that a jurisdiction may have knowledge of but have yet to receive report.
- “Congenital Investigation” Assignments are to be created for infants at the same time a field record is initiated.
22.214.171.124 Closing Perinatal Field Records
To determine the appropriate field record disposition for the infant field record prior to closure see Conducting Congenital Syphilis Investigations. Follow-up on perinatal field records is a programmatic priority to ensure proper infant evaluation and treatment in accordance with the CDC STD Treatment Guidelines for Congenital Syphilis.
To close a perinatal field record, infant’s congenital syphilis case classification must be determined, and infant’s treatment status must be ascertained.
126.96.36.199 Closing a “Congenital Investigation” Assignment
A “Congenital Investigation” Assignment is to be closed at the completion of the Congenital Syphilis Investigation:
- The Perinatal Field Record has been investigated and dispositioned
- All reported laboratory results have been documented appropriately
- All reported treatment(s) have been documented appropriately
- The congenital syphilis investigation has been submitted via THISIS (Congenital Syphilis Question Package) and the STD-126 or STD-126A (as approved by Central Office Staff) has been completed.
Closing the “Congenital Investigation” Assignment should not take place prior to the completion of the criteria listed above, nor does it pend supervisory approval on the congenital syphilis investigation.
The “Congenital Investigation” Assignment allows for DSHS Central Office to evaluate the length of time a Congenital Syphilis Investigation took.
23.2.2 Out of Jurisdiction Congenital Syphilis Reporting Guidance
The jurisdiction where the infant is born regardless of mother’s address of residence is the jurisdiction responsible for completing the Congenital Syphilis Investigation.
- Example A: Mother’s address is in Katy (Region 6/5S); she delivers in Houston. City of Houston Health Department is responsible for completing the Congenital Syphilis Investigation
- Example B: Mother’s address is in Seguin (Region 8); she delivers in San Antonio. San Antonio Metro Health District is responsible for completing the Congenital Syphilis Investigation
- Example C: Mother’s address is in Texarkana, AR; she delivers in Texarkana, TX. Region 4/5N is responsible for completing the Congenital Syphilis Investigation
The jurisdiction where mother resides regardless where she delivered is the jurisdiction where morbidity is assigned.
- Example D: Mother’s address is Arlington; she delivers at Parkland Hospital in Dallas. Dallas County Health & Human Services will complete the Congenital Syphilis Investigation; the morbidity will be assigned to Tarrant County.
- Example E: Mother’s address is Georgetown; she delivers in Austin. Austin Public Health is responsible for completing the Congenital Syphilis Investigation; the morbidity will be assigned to Williamson County (Region 7).
- Example F: Mother’s address is Ciudad Juarez, MX; she delivers in El Paso. City of El Paso Department of Health will complete the Congenital Syphilis Investigation; the morbidity will be assigned to Mexico.
Collaboration may be required between jurisdictions to complete the congenital syphilis investigation: if the mother received prenatal care in another jurisdiction or if the infant is transferred to a hospital in another jurisdiction after delivery.
23.2.3 Minimum Standards for Congenital Syphilis Investigations
- 85% of perinatal syphilis field records (reactor and follow-up) are to be dispositioned in 7 days of initiation.
- 95% of perinatal syphilis field records (reactor and follow-up) are dispositioned correctly.
- 85% of “Congenital Investigation” Assignments are closed within 30 days following initiation.
- 95% of Congenital Syphilis Investigation Reports are completed, approved by a supervisor, and submitted to DSHS Central Office Congenital Syphilis Staff (Congenital Syphilis Question Package Closed) within 30 days of notification to the Reporting Jurisdiction.
A congenital syphilis investigation should be initiated on all infants born to woman with any positive syphilis serology within 30 days of delivery.
A complete congenital syphilis investigation does not need to not to occur for infants born to women who are biological false positives, who never met syphilis case criteria, who miscarried (delivered prior to 20 weeks’ gestation and smaller than 500 grams), or who delivered out of state.
For investigations meeting the criteria above, only a field record and “Congenital Investigation” Assignment should be completed.
Multiple sources may be required for retrieving the necessary information for completing a medical chart abstraction for a congenital syphilis investigation. Congenital Syphilis investigators will need to contact the facility of birth and obtaining and/or confirming both mother’s and infant’s lab result(s), treatment(s), and medical record numbers to expediate the request for full hospital medical records. Medical records may also need to be requested from the prenatal care provider and in some cases, a pediatrician.
23.3.1 Medical Chart Abstractions
The congenital syphilis investigator must review several sources of information to complete the Congenital Syphilis Investigation.
1. MATERNAL SYPHILIS CASE FILE
Required information from the maternal syphilis case for reporting include:
- Diagnosing lab result(s)
- Clinical stage of syphilis
- Surveillance stage of syphilis
- Mother’s syphilis treatment
A comprehensive review of the mother’s syphilis case file must occur during the congenital syphilis investigation. Maternal case classification should be reviewed and validated by the congenital syphilis investigator to ensure to that the mother initiated adequate treatment appropriate for her surveillance stage of syphilis at least 30 days prior to delivery in accordance with the CDC’s STD Treatment Guidelines for syphilis. If the investigator determines that the maternal syphilis case classification is incorrect, the investigator should notify DSHS Central Office so that the morbidity may be modified.
2. LABOR AND DELIVERY HOSPITAL RECORD(S)
Required information from the labor and delivery hospital records for reporting include:
- Delivery facility
- Maternal gravida and para
- Syphilis test result from labor and delivery*
Supplemental information that is requested for reporting that is located in the labor and delivery hospital records include:
- Mother’s marital status
- Mother’s insurance status
- Additional medical conditions
- Mother’s residency status during pregnancy∆
- Mother’s substance use during pregnancy~
- Usually determined by the results of a urine drug screen or a serological toxicology screen
- Mother’s incarceration history during pregnancy∆
- Mother’s housing stability during pregnancy~∆
- Mother’s current or previous involvement with Child Protective Services
- Location of birth
- Type of birth
- Mother’s medical record number
∆ Mother’s residency during pregnancy, incarceration stability during pregnancy, and housing stability may require additional record searching.
~Mother’s substance use during pregnancy may also be obtained from the mother’s syphilis case file, only if the mother was diagnosed and interviewed for partner services during the current pregnancy.
Required information regarding prenatal care that can often found in the mother’s labor and delivery hospital record(s)
- Prenatal care provider
- Prenatal care engagement
- Number of prenatal care visits
- Data of first prenatal care visit
- The number of trimesters that prenatal care was received
- Mother’s syphilis testing history during pregnancy+
- Syphilis test result at first prenatal visit*
- Syphilis test result at the third trimester (28-32wks) prenatal visit*
- Syphilis test result at labor and delivery*
- Mother’s HIV status* HIV test is required at the first prenatal visit
- HIV test is required in the third trimester
*Mother’s syphilis testing history may also be obtained from mother’s syphilis case file or other reporting sources.
Supplemental information that is requested for reporting regarding prenatal care that can often found in the mother’s labor and delivery hospital record(s):
- Last menstrual period
Prenatal care information may be present in mother’s hospital records, if not enough information is present to complete the necessary fields in the Congenital Syphilis QP and the STD-126, then an additional request must be made to the mother’s prenatal care provider.
Health and Safety Code 81.090 - Providers are required by law to test all pregnant women for syphilis at the first prenatal visit, third trimester (no sooner than 28 weeks), and at labor and delivery. Providers are also required by law to test all pregnant women for HIV at the first prenatal care visit and during the third trimester (no sooner than 28 weeks’ gestation); if no third trimester test is found, providers must perform an expedited test for HIV at delivery.
It is recommended by CDC to perform a syphilis test on all women who deliver a stillborn.
3. THE INFANT’S HOSPITAL RECORD(S)
Required information from the infant’s hospital record(s) that is required for reporting include:
- Vital status
- Gestational age
- Birth weight
- Congenital syphilis physical symptom manifestations
- Infant’s syphilis test result(s)
- Non-treponemal lab result(s)
- Treponemal lab result(s)
- Any syphilitic confirmatory lab result(s) showing evidence of spirochetes
- Darkfield and direct fluorescent for antibodies against Treponema pallidum (DFA-TP)
- Polymerase chain reaction (PCR)
- Immunohistochemistry (IHC)
- Special Stain exam
- Radiographic results or findings (long bone x-rays)
- The syphilis-related results from a lumbar puncture
- Cerebral Spinal Fluid Venereal Disease Research Laboratory test (CSF- VDRL)
- Cerebral Spinal Fluid White Blood Cell Count (CSF WBC)
- Cerebral Spinal Fluid Protein Count
- Date of treatment
Supplemental information that is requested for reporting that is located in the infant’s hospital records include:
- Infant’s medical record number
- Infant’s outpatient pediatrician
- The primary caregiver or guardian
Vital Statistics matching is a required activity for congenital syphilis surveillance and reporting. Vital statistic matching has the capacity to capture missing congenital syphilis investigations through matching women of childbearing capacity diagnosed with syphilis to current birth and fetal death certificates.
If a jurisdiction was unaware of the need for a congenital syphilis investigation prior to receiving the Vital Statistics Match, reporting timeframes are extended. Due to the extra time it may take to obtain medical charts existing CS workload, programs will have 45-60 days to complete investigations identified solely through vital statistics matching. Routine congenital syphilis investigations and reporting is still expected to occur.
DSHS Central Office will distribute Vital Statistics matches to jurisdictions and prioritize them prior to distribution.
- 90% of Congenital syphilis investigations identified by Vital Statistics matching as possible congenital syphilis cases by Central Office must be submitted within 45 days of notification to the jurisdiction.
- 85% of Congenital syphilis investigations identified by Vital Statistics matching as not likely to be congenital syphilis cases by Central Office must be submitted within 60 days of notification to the jurisdiction.
23.5.1 Infant Evaluation and Treatment
If an infant is found to be untreated/inadequately treated or evaluated based on the CDC treatment and evaluation recommendations for Congenital Syphilis, and the infant is still inpatient it is recommended that the Congenital Syphilis Investigator discuss the recommendations with the hospital clinic staff. If the infant has already been discharged from the hospital, then the Congenital Syphilis Investigator will contact the pediatrician of record to discuss the appropriate evaluation and treatment. If speaking with pediatrician is unsuccessful, the next point of contact is child’s caretaker to indicate that the infant needs additional medical attention due to exposure to syphilis.
If all of efforts to ensure that the infant receives appropriate treatment and evaluation are unsuccessful, the Congenital Syphilis Investigator will escalate the case to their FLS or program manager who will follow-up with the provider or involve a local clinical advisor (e.g., the medical director). It is recommended that the health department medical director reach out to the caretaker or pediatrician for the purposes of provider education.
Public Health Follow-up Staff are not liable for guaranteeing an infant gets evaluated or treated but should make good faith efforts to do so and document those efforts within the MIS system.
If additional positive serology is reported on an infant previously investigated, program staff will initiate a FR or surveillance assignment to contact the treating medical provider to ensure there are no new indications of disease. If there is a positive non-treponemal lab result at six months of age, staff should discuss the re-evaluation and treatment with the provider, as outlined in the CDC STD Treatment Guidelines.
For women diagnosed with syphilis within 90 days of delivery of their infant(s), a congenital follow-up field record(s) for the infant(s) must be initiated and congenital syphilis investigation(s) must be completed. The investigator will follow-up with the pediatrician to ensure appropriate testing, evaluation, and treatment.