Integrated perinatal infections surveillance: the labor and

delivery record to the rescueMCH EPI Conference, 2004

Atlanta, GA

Stephanie Schrag, D PhilDivision 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

1.

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2.

+ …..

3.

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NCHS natality filesPRAMS

Active Bacterial Core surveillance FoodNet HIV strain surveillance

Disease-specific surveillance (eg, rubella, syphilis, sepsis)

Provider surveys (eg,ACOG)

Perinatal infections surveillance: Current approaches

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

GBS and Hepatitis B antenatal testing, 1998-9, ABCs

0102030405060708090

100

MD NY CT GA TN CA MN OR

% t

este

d

GBSHbSAg

Schrag et al. 2003. Obstet Gynecol 102:753-60

The impact of state laws on HIV testing,1998 and 1999, ABCs

0102030405060708090

100

TN MD GA MN NY CA CT OR

% t

este

d

Schrag et al. 2003. Obstet Gynecol 102:753-60

Mandatory NB testing of HIV unknown mothers w/48h results, fall, 1999

Opt-out policy

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 3-9 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 SchuchatElizabeth ZellAaron RoomeKatie ArnoldJanet Mohle-BoetaniRuth LynfieldMonica FarleyThe Active Bacterial Core surveillance team