Transcript + NCHS natality files PRAMS Active Bacterial Core surveillance

Integrated perinatal infections
surveillance: the labor and
delivery record to the rescue
MCH EPI Conference, 2004
Atlanta, GA
Stephanie Schrag, D Phil
Division of Bacterial and Mycotic Diseases
Centers for Disease Control and Prevention
Perinatal infections burden
• Pregnant and post-partum women
– Pregnant women at increased risk for infections
or infectious complications (eg, influenza)
– 78% of childbirth-related prolonged
hospitalizations are due to infection*
• Neonates
– Perinatal sepsis among top 10 causes of death
– Infection contributes to preterm delivery
– Early infections contribute to severe lifelong
morbidity
*Hebert et al., Obstet Gynecol. 1999. 94:942-7
Unique opportunities for prevention
of perinatal infections
• Limited time frame for disease transmission
• Eradication of pathogen in mother not always
required to prevent transmission
• Health care provider plays key role in prevention
implementation
– Pre-conception, prenatal and intrapartum interventions
• Interventions can greatly reduce disease
– Perinatal GBS disease: 39,000 prevented since 1993
– Congenital rubella syndrome: 1 US case last year
Surveillance integration challenges
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Perinatal infections surveillance:
Current approaches
NCHS natality files
Provider surveys
(eg,ACOG)
PRAMS
Active Bacterial Core surveillance
FoodNet
HIV strain surveillance
Disease-specific surveillance
(eg, rubella, syphilis, sepsis)
What is missing from these
systems?
Sustained tracking of prevention practices
(this becomes even more important as
disease incidence declines)
The labor and delivery (L&D)
record
The birth of Birth-Net
• Periodic, population-based review of L&D
records in Emerging Infections Program
(EIP) areas (selected counties in 11
states)
• Idea grew out of state hepatitis B
prevention programs
• The EIPs have conducted two L&D
reviews and are planning a review of
2003/2004 births
Birth-Net design and methods
• Weighted sample survey using state birth
certificate file as sampling frame for random
selection of births (app. 400-600) from each
state
• Abstraction of L&D records using a standard
form that includes:
– maternal demographics and prenatal visits
– perinatal infections screening counseling, tests
and results (syphilis, rubella, HIV, hepatitis B,
GBS, toxoplasma)
– brief L&D history
– prevention interventions administered
% tested
GBS and Hepatitis B antenatal testing,
1998-9, ABCs
100
90
80
70
60
50
40
30
20
10
0
GBS
HbSAg
MD NY CT GA TN CA MN OR
Schrag et al. 2003. Obstet Gynecol 102:753-60
% tested
The impact of state laws on HIV testing,
1998 and 1999, ABCs
100
90
80
70
60
50
40
30
20
10
0
TN MD GA MN NY CA CT OR
Opt-out
policy
Mandatory NB testing of HIV unknown
mothers w/48h results, fall, 1999
Schrag et al. 2003. Obstet Gynecol 102:753-60
How Birth-Net data have been used
• Revise perinatal group B streptococcal
disease guidelines to recommend
universal prenatal screening
• Guide rubella post-partum vaccination
policies
• Provide local feedback to promote
prevention efforts
• Evaluate impact of prenatal testing laws
• Evaluate accuracy of birth certificate data
Challenges / Limitations
• Timeliness: birth certificate files are available 39 months after close of calendar year
• Survey design and analysis: requires calculation
of sample weights and familiarity with sample
survey analysis
• Labor: Person time for chart review; resolving
HIPAA issues etc.
• Limitations of L&D record: limited prenatal care
information; limited baby information; limited
maternal demographics; not everything that
happens is documented
Vision for the future
• Expansion of Birth-Net to non-EIP states
– A CDC HIV-led project has the objective of
developing a “how to” manual for states
• Improved integration of infectious issues
into Birth-Net
– Improved collaboration within CDC (eg,
Perinatal Infections Working Group)
– Improved integration in state health depts
(eg, CT)
• Improved integration of non-infectious
MCH issues into Birth-Net
Acknowledgments
Anne Schuchat
Elizabeth Zell
Aaron Roome
Katie Arnold
Janet Mohle-Boetani
Ruth Lynfield
Monica Farley
The Active Bacterial Core surveillance team