Georgia epidemiology report, Vol. 19, no. 10 (Oct. 2003)

October 2003

volume 19 number 10

Division of Public Health http://health.state.ga.us
Kathleen E. Toomey, M.D., M.P.H. Director
State Health Officer
Epidemiology Branch http://health.state.ga.us/epi
Paul A. Blake, M.D., M.P.H. Director
State Epidemiologist
Mel Ralston Public Health Advisor
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D.
Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
Georgia Department of Human Resources
Division of Public Health Epidemiology Branch
Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517
Please send comments to: Gaepinfo@dhr.state.ga.us
The Georgia Epidemiology Report is a publication of the Epidemiology Branch,
Division of Public Health, Georgia Department of Human Resources

Obstetrical Practices for Prevention of
Perinatal Infections in Metropolitan
Atlanta, 1998-1999
Infections transmitted from mother to newborn, including those transmitted during pregnancy or during labor and delivery, are leading preventable causes of neonatal disease. Obstetrical and perinatal providers have the important role of screening women and infants to identify those at risk, and providing appropriate preventive measures. A 2001 audit of obstetrical charts at Georgia delivery hospitals provided an opportunity to assess prevention practices for 5 perinatally transmitted diseases, including hepatitis B, syphilis, rubella, human immunodeficiency virus (HIV), and group B streptococcal (GBS) disease.
The audit was a retrospective cohort study of 1998-1999 live births conducted in the 20-county Atlanta Metropolitan Statistical Area (MSA). A stratified random sample of maternal labor and delivery charts at 30 delivery hospitals, with a minimum sample of 20 charts per hospital, was abstracted, for a total of 866 charts, representing 125,778 live births over two years. Each record was weighted for analysis according to the likelihood of being chosen for review. In addition to disease prevention practices, we collected data on maternal demographics, prenatal care, history of drug use, source of payment for labor and delivery, receipt of intrapartum antibiotics and postpartum rubella vaccination. Maternal race and ethnicity data were also collected from birth registry files to ensure complete information when these variables were missing from labor and delivery records.
Maternal Demographics, and Obstetrical Outcomes
In our sample, 7% of mothers were younger than 20 years. Sixty-two percent of mothers were white and 34% black; 9% were of Hispanic ethnicity. This corresponds closely to the demographics of residents who gave birth in the 20-county Atlanta MSA (63% white, 33% black, 9% Hispanic). For 30%, Medicaid was the source of payment for labor and delivery. Ten percent of deliveries were premature (less than 37 weeks gestation), with 4% delivering before 35 weeks. Twenty-one percent of infants were delivered by cesarean section.
Prenatal Care
The Kessner Index, which combines the trimester at first prenatal visit and the number of prenatal visits stratified by the gestational age at delivery, was used to quantify prenatal care. We found that 53% of pregnancies had adequate care, 39% had intermediate care, and 7% inadequate care. Risk factors for inadequate prenatal care were maternal age younger than 20, nonwhite race, and Hispanic ethnicity.
Screening Practices for Perinatal Infections
Figure 1 summarizes obstetrical screening practices for 5 perinatally transmitted diseases during 1998-1999. Universal screening for hepatitis B virus, syphilis and rubella have been accepted standards of obstetrical care for many years, reflected in the high prevalence of screening for these conditions in 1998-1999. At the time, the Centers for Disease Control and Prevention (CDC) recommended universal counseling and voluntary HIV testing as part of prenatal care, but not routine HIV testing. Providers were also asked to choose between two practices for the prevention of GBS, one of which was prenatal screening. This explains the lower prevalence of testing for HIV and GBS in our sample. Recommendations for HIV and GBS screening during pregnancy have been revised since this birth cohort, and universal testing is now recommended for all 5 conditions, as discussed below.
Perinatal Hepatitis B Prevention
Transmission of hepatitis B from mother to child rarely occurs before delivery, and commonly occurs at birth. Infection during the perinatal period or early childhood is associated with a high risk of chronic infection in the child with serious consequences; twenty-five percent of infants who develop chronic infection die from cirrhosis, complications of liver failure, or hepatocellular carcinoma as adults. During childhood, infection is often asymptomatic, and transmission
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may not be recognized because testing is not routine. Providing hepatitis B immune globulin and hepatitis B vaccine to exposed infants within 12 hours after birth, followed by vaccine doses at 1 to 2 months and 6 months of age, can prevent transmission in nearly all cases. Perinatally exposed infants should also undergo serologic testing ~6 weeks after completing the 3-dose series to ensure that immunity has developed and that infection has not occurred. Correct management of the exposed infant relies on identification of mothers with hepatitis B during pregnancy, usually by screening for the hepatitis B surface antigen (HBsAg). 1
In the Atlanta MSA, screening for hepatitis B virus was documented for 94% of pregnancies, typically at the first prenatal visit. The observed prevalence of hepatitis B surface antigen (HBsAg) was unexpectedly low: approximately one per 1000 mothers, representing about 63 women per year in the Atlanta MSA. Using HBsAg seroprevalence estimates provided by a 1988-1994 population study (NHANES III), we estimate that approximately 500 of the ~125,000 pregnant women per year in Georgia are hepatitis B-infected, and of these, at least 250 would be expected to live in the MSA. Fewer than the expected number of HBsAg-positive women were identified in our sample, suggesting the possibility that many high-risk pregnancies were unscreened or inaccurately recorded. Incomplete identification of hepatitis B-infected mothers is one of many potential medical errors that can lead to failure to prevent perinatal hepatitis B infection. Numerous examples of other medical errors have been documented in screening, interpreting, documenting, and responding to maternal HBsAg status.2 This reinforces the recommendation that hospital policies include a routine hepatitis B vaccine birth-dose for all infants.3 Recommendations include routine vaccination of all infants within 12 hours after birth and screening mothers at delivery for HBsAg if prenatal screening was not done. Infants born to HBsAg-positive mothers require an accelerated vaccination schedule and post-vaccination serologic testing. Despite high levels of maternal screening in our sample, the potential for perinatal hepatitis B transmission is still a concern.
Perinatal Syphilis Prevention
Syphilis may be transmitted across the placenta, as the infant is delivered, or during nursing. Infection of the fetus before the fifth month of gestation is rare; therefore, diagnosing and treating the mother early in pregnancy usually ensures that the fetus will not be infected. If fetal infection occurs, inflammatory changes of mucosa, skin, liver, and bones are prominent, and if untreated may result in late stillbirth, neonatal death, and infant disorders including deafness, neurologic impairment, and bone deformities such as saddle nose, bowed tibias ("saber shins") and malformed teeth.
Studies have shown that over one third of pregnancies resulting in syphilitic children have had prenatal care and about half had a nonreactive serologic test during the first trimester of pregnancy.4 Therefore, repeated serologic testing is warranted at delivery for high-risk patients. Georgia Law (OCG 31-17-4 and GCRR 290-5-21-.03) requires that maternal syphilis testing occur at the initial prenatal visit and that a second specimen be taken during the third trimester, or within 6 hours after delivery. National guidelines for patients living in communities with a high incidence of syphilis suggest a second syphilis test at 28 weeks of gestation to allow time for treatment of infections acquired during pregnancy, and a third test at the time of delivery.5-7 During 1998 and 1999, Fulton County was a high-incidence county.
In our sample (n=866), the recommended syphilis test at the first prenatal visit was common, and ninety-five percent of mothers were screened for syphilis at least once. However, repeat testing was rare,

and in Fulton County (n=303), only 17% of women had two prenatal tests before admission, and 53% were tested at the time of delivery. Positive tests for syphilis were rare in the overall population, at 8 per 1000 women, but 5% of mothers in the sample were unscreened at any time during pregnancy or delivery, leaving potential for disease transmission. Particular attention should be given to enhancing screening practices in high-risk communities until disease rates are significantly reduced.
Congenital Rubella Prevention
Rubella in early pregnancy can lead to fetal death, premature delivery, and congenital defects that vary with gestational age at infection. Common sequelae of early fetal infection are deafness, cataracts, glaucoma, congenital heart disease, and mental retardation. A high rate of insulin-dependent diabetes mellitus has been reported in survivors of congenital rubella. The risk of fetal infection falls as gestational age increases, and is low after the 20th week. In older children and adults, rubella is usually a mild disease and may be difficult to recognize.
The live attenuated rubella vaccine should not knowingly be administered to a pregnant woman because the vaccine virus can cross the placenta and infect fetal tissue. Despite this, no congenital rubella syndrome has been identified among the offspring of over 800 women who accidentally received the vaccine during pregnancy. 9 The postpartum period provides an ideal opportunity to vaccinate non-immune women. National guidelines recommend universal childhood vaccination against rubella, combined with postpartum vaccination of rubella-susceptible pregnant women as a strategy for elimination of congenital rubella syndrome.8
In the Atlanta MSA, 95% of mothers were screened for rubella immunity. Among non-immune mothers (6% of those screened), only 45% had documented rubella vaccination before hospital discharge. This estimate was the lowest rate among the 8 states that conducted similar audits. No documentation of vaccine refusal was found, suggesting that missed opportunities resulted from lack of attention and lack of hospital policies to vaccinate non-immune postpartum mothers. A national survey of hospitals recently found that only 21% of hospitals have policies for postpartum rubella vaccination. As of 1999, only Puerto Rico and Nevada had passed legislation requiring postpartum rubella vaccination.5
HIV Prevention Practices
HIV may be transmitted from mother to child in utero, at delivery, or postpartum. Multiple factors affect the risk of transmission, including maternal viral load, virus strain, co-infections such as syphilis and other sexually transmitted infections, vitamin A deficiency, and obstetrical procedures. Most events occur during delivery or late in pregnancy. Because transmission during early pregnancy is rare, HIV does not affect organogenesis, or cause low birthweight or stillbirths. The AIDS Clinical Trial Group Protocol 076 (ACTG 076) demonstrated that zidovudine (ZDV) given to pregnant women after the first trimester and during labor and to newborns during their first 6 weeks could reduce perinatal transmission by 68%. Current recommendations are that HIV-infected pregnant women be offered highly active antiretroviral therapy (HAART) that includes ZDV in an effort to suppress viral load below detectable levels.10 Because of concerns about teratogenicity of antiretrovirals during the first trimester, it may be advisable to begin new antiretrovirals after the first trimester. Studies have also shown benefit for delivery by cesarian section even when HAART is used and maternal viral load is less than 1000 copies.11
At the time of this study, the 1995 Public Health Service Guidelines recommended that all pregnant women receive counseling about the risk of perinatal HIV and be offered voluntary HIV testing. However, only 66% of women in the Atlanta MSA underwent HIV testing, and no evidence was found that testing was offered to the others but declined. HIV testing was more common among teenagers, women with intermediate or adequate prenatal care, women who used Medicaid to pay for labor and

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delivery, and black women. Women who were black or Hispanic were 16 times more likely to have been screened, and black/Hispanic women who paid for delivery using Medicaid were 38 times more likely to have been screened.
The changing epidemiology of HIV infection in the U.S. suggests that women, and especially African-American women, in both the urban and rural South are at increasing risk of acquiring HIV infection. The inability to correctly identify HIV-infected women through elective screening resulted in the birth of an estimated 280 to 370 infected infants in 2000 in the U.S. In 2001, CDC issued guidelines that HIV screening be included as a routine part of prenatal care and strengthened the recommendation that all pregnant women be tested for HIV.12 The guidelines recommend simplifying the testing process and allowing for various types of informed consent. They also recommend that providers explore reasons for refusal of testing, and conduct HIV testing at delivery when prenatal testing was not done. Some states have successfully elevated maternal HIV testing rates with "opt-out" policies, requiring HIV testing unless the woman specifically refuses, or through mandatory newborn HIV testing if the mother's HIV status is unknown.
GBS Screening Practices
Group B streptococcus is the most common cause of sepsis among newborns. Rates of neonatal "early-onset" (during the first week of life) GBS disease have fallen dramatically with the introduction of two strategies (risk-based and screening-based strategies) that identify pregnancies at risk and target use of prophylactic intrapartum antibiotics. At the time of this study, consensus guidelines suggested that obstetrical providers choose one of the two strategies, but did not favor one strategy over the other. We found that in the Atlanta MSA, fifty-five percent of mothers underwent GBS screening during 1998-1999, and 45% of pregnancies were presumed to have been managed by the other (risk-based) strategy. Through analysis of multi-state data, CDC determined that the screening-based strategy (screening for maternal carriage of GBS by vaginal-rectal culture between 35 and 37 weeks gestation) is at least 50% more effective in prevention of neonatal GBS disease than the riskbased strategy.13 Accordingly, the 2002 guidelines now recommend universal screening of pregnant women for GBS, using the risk-based approach only when results of the GBS screening test are not available at the time of delivery.14 More information on the new GBS prevention guidelines is found in the May 2003 GER, and at http://www.cdc.gov/ mmwr/preview/mmwrhtml/rr5111a1.htm.

References:
1. CDC. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination. MMWR 1991; 40(No. RR-13):1-19.
2. Anderson TA, Wexler DL. States Report Hundreds of Medical Errors in Perinatal Hepatitis B Prevention; Avoid tragic mistakes--vaccinate newborns against HBV in the hospital. http://www.immunize.org/catg.d/ p2062.htm
3. CDC. Impact of the 1999 AAP/USPHS Joint Statement on Thimerosal in Vaccines on Infant Hepatitis B Vaccination Practices. MMWR 2001; 50(No. 06):94-7.
4. Tramont EC. Treponema pallidum (Syphilis). In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, fifth edition. 2000, Churchill Livingstone, p. 2483.
5. Schrag SJ, Arnold KE, Mohle-Boetani J, et al. Prenatal screening for infectious diseases, United States, 1998-1999: missed opportunities for prevention. Obstet and Gyn 2003 [in press].
6. Wendel GD, Sheffield JS, Hollier LM, Hill JB, Ramsey PS, Sanchez PH. Treatment of Syphilis in Pregnancy and Prevention of Congenital Syphilis. CID 2002; 35 (Suppl 2), pp. S200-S209.
7. CDC. Guidelines for the Prevention and Control of Congenital Syphilis. MMWR 1988; 37 (suppl no. S-1).
8. CDC. Control and Prevention of Rubella: Evaluation and Management of Suspected Outbreaks, Rubella in Pregnant Women, and Surveillance for Congenital Rubella Syndrome. MMWR 2001; 50(No. RR-12):1-23.
9. Gershon AA. Rubella Virus (German Measles). In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, fifth edition. 2000, Churchill Livingstone, pp. 1709-14.
10. CDC. U.S. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions To Reduce Perinatal HIV-1 Transmission in the United States. MMWR 2002; 51(No. RR-18):1-38.
11. Ioannidis JPA, Abrams EJ, Ammann A, et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads <1,000 copies/mL. J Infect Dis 2001; 183:539-545.
12. CDC. Revised Recommendations for HIV Screening of Pregnant Women. MMWR 2001; 50(No. RR-20):59-86.
13. Schrag SJ, Zell ER, Lynfield R, et al. A population-based comparison of strategies to prevent early-onset group B streptococcal disease in neonates. NEJM 2002; 347:233-81.
14. CDC. Prevention of Perinatal Group B Streptococcal Disease, Revised Guidelines from CDC. MMWR 2002; 51(No. RR-11):1-22.
This article was written by Katie Arnold, M.D., Emily Kahn, Ph.D., M.P.H., Katherine Bryant, M.P.H., and Luke Shouse, M.D., M.P.H.

Figure 1:

Proportion of pregnant women screened for perinatally transmitted diseases during pregna
disease, 20-county Atlanta MSA, 1998-19

Percent Screened

100

94

95

95

90

80

70

66

60

55

50

40

30

20

10

0

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

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

October 2003

Volume 19 Number 10

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for July 2003

Selected Notifiable Diseases

Total Reported for July 2003
2003

Previous 3 Months Total

Ending in July

2001

2002

2003

Previous 12 Months Total

Ending in July

2001

2002

2003

Campylobacteriosis

76

224

198

192

703

686

706

Chlamydia trachomatis

2713

8478

8581

8433

34916

36804

38040

Cryptosporidiosis

6

36

28

22

193

166

121

E. coli O157:H7

4

14

22

8

49

63

36

Giardiasis

51

249

237

172

1202

996

951

Gonorrhea

1424

4705

4859

4297

21065

20615

19776

Haemophilus influenzae (invasive)

3

17

22

12

98

109

76

Hepatitis A (acute)

10

264

118

67

759

793

488

Hepatitis B (acute)

21

86

143

63

431

526

497

Legionellosis

1

5

2

8

13

11

29

Lyme Disease

0

0

2

4

0

4

10

Meningococcal Disease (invasive)

1

6

9

4

51

46

33

Mumps

0

0

0

0

7

4

1

Pertussis

1

10

11

4

39

27

31

Rubella

0

0

0

0

1

0

0

Salmonellosis

262

513

582

562

1875

2043

2167

Shigellosis

77

72

369

370

347

1354

2018

Syphilis - Primary

1

23

28

19

113

119

110

Syphilis - Secondary

25

89

72

89

328

318

414

Syphilis - Early Latent

19

160

161

131

620

745

747

Syphilis - Other**

21

207

176

114

905

863

758

Syphilis - Congenital

0

8

2

1

28

21

7

Tuberculosis

19

122

170

92

668

645

545

* 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: 09/02-08/03 Five Years Ago: 09/98-08/99 Cumulative: 07/81-08/03

Total Cases Reported* <13yrs >=13yrs Total

0

1,620 1,620

11

1,656 1,667

211

26,804 27,015

Percent Female

AIDS Profile Update
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

24.9

34.1

7.8

1.5

11.2

1.9

43.5

24.5

35.9

16.6

3.8

19.6

1.6

22.6

18.1

47.1

17.0

5.3

13.7

1.9

14.9

Race Distribution (%) White Black Other

20.6 74.6

4.9

20.2 77.4

2.3

33.3 64.1

2.6

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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