Georgia epidemiology report, Vol. 15, no. 9 (Sept. 1999)

September 1999

volume 15 number 9

Division of Public Health
http://health.state.ga.us
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The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Health Information Branch, Division of Public Health, Georgia Department of Human Resources
Prenatal care provider survey: Screening and treatment of infections during
pregnancy

Georgia TB Reference Guide
Background and Methods

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Epidemiology and Health Information Branch
Acting Director Kathleen E. Toomey, M.D.,M.P.H.
Acting State Epidemiologist Paul A. Blake, M.D.,M.P.H.
Epidemiology Section
Chief
Paul A. Blake, M.D., M.P.H.
Public Health Advisor
Mel Ralston
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D.
Jeffrey D. Berschling, M.P.H. Paul A. Blake, M.D., M.P.H. Jane E. Koehler, D.V.M., M.P.H. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphics

Screening for sexually transmitted diseases (STDs) is an important component of the medical care of pregnant women. STDs are strongly associated with adverse outcomes of pregnancy, including premature rupture of membranes, preterm labor, low birth weight, congenital infections, and infant death. STDs may influence pregnancy outcomes through direct infection of the fetal membranes, fetus or newborn, or indirectly, by initiating disease processes that result in illness in the mother or infant. STDs linked to adverse pregnancy outcomes include bacterial vaginosis, gonorrhea, syphilis, trichomoniasis, and maternal infection with chlamydia, herpes simplex virus (HSV), human immunodeficiency virus (HIV), and hepatitis B virus. Screening for STDs, as well as rubella and group B streptococcus (GBS), is recommended as part of routine prenatal care. Recognition of the influence of STDs on pregnancy outcomes is reflected in recommendations for the screening of pregnant women published by the Centers for Disease Control and Prevention (CDC) in 1998 (Table 1).
Georgia has among the higher rates of infant mortality in the United States, and ranks in the top 10 for incidence of chlamydia, gonorrhea, and syphilis, the three major bacterial STDs which are reportable. The high STD incidence among women in Georgia may be a significant and modifiable factor in the high rate of infant mortality. Providers of prenatal care can play a critical role in preventing adverse pregnancy outcomes associated with STD by performing recommended screening tests and initiating appropriate treatment of these infections. To assess prenatal screening practices, the Georgia Division of Public Health, in cooperation with the Medical Association of Georgia (MAG), the Georgia Academy of Family Physicians, the Georgia Chapter of the American College of Obstetrics and Gynecology, and the Division of STD Prevention (CDC), conducted a survey of prenatal care providers in Georgia. The objectives were to identify current screening and treatment practices for STDs and other infections associated with adverse pregnancy outcomes to be able to use this information to educate perinatal care providers about appropriate screening recommendations.
A standardized questionnaire was mailed in late 1998 to 3082 providers of prenatal care (obstetricians, family practitioners and nurse midwives) in Georgia. Mailings were sent in a manner that assured the anonymity of respondents. One month later, a second mailing was made to providers who had not responded to the first mailing. The survey included questions about syphilis, gonorrhea, chlamydia, herpes, HIV, bacterial vaginosis, trichomonas, human papillomavirus (HPV), hepatitis B, GBS, and rubella screening, diagnosis, and treatment practices. Practitioners were also asked about perceived barriers to STD screening, as well as sources from which they obtain information on changing practice standards.
Results
A total of 1290 (42%) surveys were returned. Of these, 618 were from providers who did not perform prenatal care. Further analyses were conducted on surveys from the 556 respondents who provided prenatal care. Forty three percent of prenatal care providers were female; 75% were white; 12% African-American; 6% Asian; 4% Hispanic. Obstetricians comprised 73% of respondents, nurse midwives 16%, and family practitioners 9%. The most common practice setting was private practice offices, reported by 77% of those
Georgia Department of Human Resources Division of Public Health, Epidemiology Section Epidemiology & Health Information Branch Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2586

who provide prenatal care. Sixteen percent reported practicing in both an HMO and private setting, while 8% practiced in a medical schoolaffiliated hospital and/or a clinic setting.
Reported screening practices for syphilis and hepatitis B mirrored recommended screening practices, and most providers use at least one appropriate GBS prevention measure. In addition, high proportions of providers screen for gonorrhea and chlamydia, and 84% performed HIV testing (Table 1). The survey did not include questions that would allow an assessment of the risk status of each providers patient population, so we can not evaluate whether these routine screening rates are appropriate.
Screening women with a history of preterm labor for bacterial vaginosis is an optional recommendation in recent STD treatment guidelines (4); all symptomatic women should be tested. Few practitioners, however, screen high risk women (previous premature birth or pre-pregnancy weight < 50 kg.) for bacterial vaginosis, and few test women who are symptomatic. CDC guidelines recommend testing symptomatic women for bacterial vaginosis and that consideration be given to screening high risk women for bacterial vaginosis. However, only 20% of respondents reported that they routinely test high risk (previous premature birth) and/or symptomatic pregnant women for bacterial vaginosis.
Sex or race of the provider, percentage of patients enrolled in Medicaid, and medical specialty were not associated with adherence to recommended screening practices. Having a written policy on BV screening was associated with a 5-fold increased likelihood of appropriate screening for BV (84% vs 16%, p=0.0001). Providers with a written policy on HIV screening were 7 times more likely to screen all women for HIV (87% vs 13%, p=0.0001) and those with a written policy on GBS screening were 3-fold more likely to screen for GBS (77% vs 23%, p=0.0001). Written policies for BV were more common in managed care settings (p=0.0001), whereas HIV screening policies were more prevalent in publicly funded sites such as community and county clinics or Veterans Hospitals (p=0.09).
Providers generally reported using appropriate diagnostic tests and medications, although 5% reported prescribing doxycycline for pregnant women with chlamydia (contraindicated), 3% reported prescribing azithromycin or a cephalosporin for syphilis (not recommended, ineffective), and 3% reported prescribing an ineffective or contraindicated medication for gonorrhea (quinolone/penicillin/ampicillin). The most common barrier to more comprehensive screening reported by providers was lack of insurance coverage and/or difficulty or inability to obtain reimbursement for these tests.
Conclusions/Recommendations
Most prenatal care providers routinely screen their pregnant patients for syphilis, gonorrhea and chlamydia. However, screening and testing for bacterial vaginosis, GBS, and HIV needs to be made available to pregnant women in many practices. In addition, some providers report inappropriate screening and treatment of STDs, including the use of ineffective and/or contraindicated medications. Although these conclusions may be limited by the moderate response rate, in the past surveys with similar response rates have been useful in assessing prenatal provider practices in Georgia, serving as a basis for health care policy evaluation and innovations (2). As a result of this survey, the Division of Public Health will be sending copies of the STD Treatment Guidelines to all primary care and obstetric/gynecology providers in Georgia with additional information about the importance of prenatal STD screening.
Recent data indicate that bacterial vaginosis can have a devastating impact on pregnant women (and their infants) by increasing the

risk for miscarriage, premature labor and delivery, and post-partum infections. Bacterial vaginosis has an alarmingly high prevalence (20%) among pregnant women in the United States. The prevalence among African-American women may be higher still as many as one out of two women in some clinic settings.
Bacterial vaginosis has been convincingly linked to preterm labor and may be associated with 80,000 preterm births that occur each year in the United States. In Georgia, nearly one out of ten infants born in 1997 were born prematurely (11,190 infants out of a total of 118,169 infants born in 1997 or 9.5 percent of all births that year). Premature rupture of membranes accounted for 1342 of these premature births. African-Americans disproportionately accounted both for premature births and infant deaths due to prematurity in Georgia. The higher prevalence of bacterial vaginosis among AfricanAmericans may be responsible for as much as 30% of this racial disparity in infant mortality(3).
The findings from the 1998 Georgia prenatal care provider survey demonstrate the need for continuing provider education programs. In addition, to increase STD screening as part of routine prenatal care, reimbursement policies by all payers public and private should be evaluated. Lack of appropriate reimbursement may be a significant barrier to full implementation of STD screening and treatment guidelines. Reductions in the number of adverse outcomes of pregnancy may be possible with more widespread acceptance of simple and inexpensive STD screening practices.
Joanna Weisbord M.S.W., M.P.H.(1), Emily Koumans M.D., M.P.H.(2), Kathleen E. Toomey M.D., M.P.H.(3)
1. Epidemiology Program Office, Centers for Disease Control and Prevention (CDC)
2. Division of Sexually Transmitted Disease (STD) Prevention, CDC
3. Georgia Department of Human Resources (DHR), Division of Public Health

References

1.

Goldenberg RL, Andrews WW, Yuan AC, MacKey HT, St

Louis ME. Sexually transmitted diseases and adverse out-

comes of pregnancy. Clinics in Perinatology 1997;24(1):23-

41.

2.

Jafari HS, Schuchat A, Hilsdon R, Whitney CG, Toomey

KE, Wenger JD. Barriers to prevention of perinatal group

B streptococcal disease. Pediatr Infect Dis J 1995;14:662-7.

3.

Fiscella K. Racial disparities in preterm births. The role of

urogenital infections. Public Health Reports 1996;111:104-

113.

4.

Centers for Disease Control and Prevention. 1998 Guide-

lines for treatment of sexually transmitted diseases.

MMWR 1998;47(No. RR-1): 70-74.

For readers who would like a copy of the 1998 CDC STD treatment guidelines, please write to:
Office of Communication, NCHSTP Centers for Disease Control & Prevention 1600 Clifton Rd. NE Mailstop E-06 Atlanta, GA 30333 The fax order number is: (404) 639-8628 A copy of these guidelines is also available from the world wide web at: http://www.cdc.gov/nchstp/dstd/dstdp.html

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Table 1. Recommendations for STD screening for pregnant women (Adapted from CDC guidelines4

STD Syphilis HIV Group B Streptococcus Gonorrhea
Chlamydia
Bacterial vaginosis
Trichomonas Hepatitis B Human Papillomavirus

Screening recommendation in prenatal care All All All; alternatively, antibiotic therapy during labor if has risk factors* At first prenatal visit for women at risk or living in an area of high prevalence of gonorrhea During 3rd trimester for women <25 years old, or with new or more than 1 sex partner, or whose partner has other partners All symptomatic women should be tested and all women with history of preterm labor should be screened All symptomatic women All Pap smear recommended for all women unless had one in previous year

*Two approaches to GBS screening are accepted: 1) screening culture for all women, or 2) presumptive antibiotic therapy during labor without culture when certain risk factors (previous infant with invasive GBS disease, delivery at <37 weeks, duration of ruptured membranes >18 hours, intra partum temperature >100.40F or >38.00C, or known GBS bacteruria during this pregnancy) are present.

Table 2. Routine STD screening practices reported by prenatal care providers in Georgia, 1998

STD screened Syphilis HIV Group B Streptococcus Gonorrhea Chlamydia Bacterial vaginosis Trichomonas Hepatitis B Human Papillomavirus

% providers reporting routine prenatal screening 98 84 84 71 71 29 19 98 82

*Two approaches to GBS screening are accepted: universal screening, or presumptive antibiotic therapy during labor when certain risk factors are present.

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The Georgia Epidemiology Report Epidemiology and Health Information Branch Two Peachtree St., NW Atlanta, GA 30303-3186

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Paid Atlanta, Ga Permit No. 4528

September 1999

Volume 15 Number 8

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 1999

Selected Notifiable Diseases Campylobacteriosis Chlamydia genital infection Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for June 1999 1999 32 2980 8 1 9 2042 5 39 8 0 0 4 0 1 0 64 10 10 14 22 11 0 78

Previous 3 Months Total

Ending in June

1997

1998

1999

138

205

147

5218

5664

9911

1

24

31

13

30

6

78

245

148

5365

4664

6201

5

13

20

207

209

131

50

50

34

2

3

0

0

2

0

31

19

23

5

1

2

2

15

9

0

0

0

271

312

286

161

383

42

41

28

28

95

57

55

295

192

109

336

232

81

5

4

0

179

158

190

Previous 12 Months Total

Ending in June

1997

1998

1999

671

849

752

15545

19439

29099

71

116

192

52

51

59

829

1075

1190

19511

18438

21318

42

52

78

551

848

750

127

275

152

2

7

5

1

12

1

111

105

80

16

2

3

26

26

36

0

0

0

1432

1377

1884

1241

1397

651

186

137

116

449

287

231

1300

936

697

1283

977

643

23

15

14

745

622

633

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

Report Period
Latest 12 Months: 7/98 - 6/99 Five Years Ago: 7/93 - 6/94 Cumulative: 7/81 - 6/99

Total Cases Reported *

AIDS Profile Update

Percent

Risk Group Distribution (%)

Female

MSM IDU MSM&IDU HS Blood Unknown

Race Distribution (%) White Black Other

1634

23.1

34.5

14.4

3.8

14.2

1.2

32

21.1 76.8

2.1

2170

17.1

43.2

23

5

13.4

1.5

13.9

30.5

68

1.6

20939

15.7

50.1

19

5.8

12.3

1.9

11

37.4 60.5

2.1

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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