Best Practices Implementation: Congenital Syphilis Prevention Efforts in Monroe County, New York, 2018

In 2019, more than half of the United States reported increases of both syphilis among females of reproductive ages and congenital syphilis (CS), with 49 states reporting at least 1 CS case, totaling 1870 cases. From 2013 to 2019, CS cases quadrupled in the United States.1–3 New York State (NYS) syphilis morbidity mirrors a similar trend, with CS cases more than doubling from 2013 to 2019. Although successful prevention of CS requires systemic changes to health and public health infrastructures, one route to identify best practices is to seek areas with a documented high CS aversion rate (the number of pregnancies in which syphilis is diagnosed minus reported CS cases out of the total pregnancies in which syphilis is diagnosed).4 In 2019, the primary and secondary syphilis (PnS) rate in NYS, excluding NY City, was 8.4 per 100,000 residents, an increase of 48.4% from 2013. Monroe County (MC), in western NY, had the highest PnS rate in NYS, excluding NY City in 2019 (28.3 per 100,000 residents).2 Despite the highest PnS rates, MC has documented successive years with a high CS aversion rate. Since 2012, MC has experienced a 1364% increase in PnS diagnoses and reported 1 CS case, averting 94.7% of cases from 2012 to 2019. The CS aversion rate for the rest of the state for the same period was 81.9% (P = 0.15). To better explain and explore successes realized in MC's CS prevention efforts, we summarized activities into 2 practices: (1) increased client-centered syphilis screening among disproportionately impacted communities and (2) enhanced integration of sexual health clinic and public health programming. This article describes activities implemented without evaluating the effectiveness of each policy and practice. To complement the best practices provided hereinafter, we created a visual guide summarizing how community stakeholders can coordinate to implement and use the best practices (Fig. 1).Figure 1: Comprehensive display of CS prevention stakeholder involvement from County Health Administration, County Partner Services, County STI Clinic, a network of healthcare provider systems, and the community at large. Practitioners can use this figure to enhance collaborative and clinical service provision and best practices to prevent congenital syphilis.INCREASED CLIENT-CENTERED SYPHILIS SCREENING AMONG DISPROPORTIONATELY IMPACTED COMMUNITIES Informed by national and local data showing CS increases and an association between syphilis and drug-related risk behaviors (DRRBs), specifically among females,5,6 MC providers, Partner Services (PS) staff, and public health officials collaborated to increase syphilis screening among pregnant persons and persons who engage in DRRBs. New York States requires screening all pregnant persons for syphilis at their first prenatal care examination and again at delivery, with additional screening throughout pregnancy recommended for individuals at higher risk and/or residing in areas with high syphilis prevalence.7–9 These screening requirements alone do not reach pregnant persons who receive late/no prenatal care, are not identified as “high risk” by their provider, or acquire infection during pregnancy. Hence, the MC Public Health Commissioner (PHC) distributed a Dear Colleague letter in 2018 advising providers to conduct additional syphilis testing during early third trimester for all pregnant persons regardless of risk, thus influencing changes to testing procedures at local hospitals. Substance use treatment providers and emergency departments were identified as clinical points of contact to promote syphilis screening. In 2018, the MC PHC sent a Dear Community Partner letter to substance use providers recommending syphilis screening for participants upon entry. In addition, the Monroe County Department of Public Health (MCDPH) asked emergency departments to screen for syphilis, specifically when admission was drug related. Early 2018, MC PS staff began targeted outreach to persons who use drugs by setting up mobile testing sites where injection drug use was prevalent and ensuring a “warm handoff” to the MC Sexual Health Clinic. From 2018 to 2020, PS staff had 824 syphilis screening outreach encounters, compared with 391 from 2016 to 2017. Partner Services conducted syphilis serology testing in community settings using a rapid enzyme immunoassay/chemiluminescence immunoassay (finger prick) test for persons with no history of syphilis, no symptoms or known contact to syphilis, or serum, obtained by PS during outreach or clinic visit and then tested stat at the onsite clinic laboratory. Partner Services also conducted behavioral field assessments to assess needs and link people to additional services. Between 2017 and 2019, syphilis tests–performed stat increased approximately 5-fold (33–171) for females. In addition, the MCDPH and PS partnered with the county jail to provide syphilis screening to persons arrested for either solicitation or drug use–related charges. This targeted screening successfully identified 7 females with syphilis in 2018 (compared with zero in 2017)10 representing nearly half (43.8%) of diagnoses among females in jails in NYS, suggesting that the initiative was impactful. ENHANCED INTEGRATION OF SEXUAL HEALTH CLINIC AND PUBLIC HEALTH PROGRAMMING To ensure clinical capacity to respond to increased syphilis screening among people with DRRBs and pregnant persons, the MCDPH enhanced existing clinical and communication features including established infrastructure and practices, collaborative partnerships with PS and clinical staff, and comprehensive data and communication systems. The MCDPH's no cost patient-centered clinic provides 5 days a week for walk-in visits; transportation to the clinic during outreach visits; stat syphilis testing (rapid plasma regain test) using an onsite laboratory-technician; and same-day, no-cost treatment for any person who tests positive for syphilis and his/her exposed partners. Early 2018, a self-reported history of injection drug use was added to the indications for performing a stat syphilis test in the clinic. Staff are trauma informed, carry a sexual health positive attitude, and participate in monthly webinars hosted by NYS Clinical Education Initiative and weekly staff meetings, which keep them currently informed on sexual health treatment guidelines, data trends, and cases to focus efforts. Foundational to continued CS prevention success in MC was strengthening an existing partnership between MCDPH clinic and county PS staff for comprehensive PS engagement and warm handoffs. The clinic embedded PS staff on-site for rapid PS engagement and partner elicitation to reduce community transmission, early 2019. The warm handoff more specifically included transfer of patients between field PS and MCDPH and/or PS staff on-site at the clinic. When PS staff identified individuals who tested positive for syphilis in the field or who agreed to visit the clinic for a blood draw, PS staff navigated patients to the clinic and introduced them to a clinical staff who could better assist. Although data are limited on benefits of warm handoffs, there are studies and information that support patient contact and engagement for successful patient referrals.11 Data collection, data sharing, and access to real-time information are critical components of CS case management, patient follow-up, and treatment. A shared electronic health record is used between PS and MCDPH clinic staff, allowing for real-time information exchange and presumptive partner treatment. Furthermore, marginal partners can be identified and contacted using the shared electronic health record, which is equipped to collect marginal information, nicknames, and reverse search by various fields, which can be crosschecked with Rochester's electronic health information exchange system. In addition, both MC Sexual Health Clinic and PS collect and share demographic, behavioral, and clinical data via Netsmart's myInsight to discuss community trends. Partner Services also share epidemiological data and updates with emergency departments within MC's network of Healthcare Provider Systems. Data are used to identify and understand trends, and as discussion points to strategize collaborative approaches to care and services between healthcare partners. DISCUSSION Through community outreach, local partnerships to increase syphilis testing, and clinical capacity to respond to an increase in syphilis diagnoses, MC has and continues to avert CS cases despite high PnS rates. Strategically implementing vertical communication with external partners and community members, and horizontal communication internally with PS staff, clinicians, and county staff led to a cohesive understanding about the severity of CS. Identifying disproportionately affected populations and providing access to testing and referral services helped detect syphilis among people who lacked access—either because of physical inaccessibility or because of fear, stigma, and misinformation.12,13 The MCDPH built relationships with local communities to help identify patients' needs and risk behaviors and ensure retention of sexually transmitted infection care. In addition, policies and Dear Colleague letters directly from the PHC set standards of practice for additional syphilis screening and emphasized the current CS issue. Figure 1 visually summarizes best practices for averting CS using 4 networks: county health administration, healthcare provider systems, county sexual health clinics, and county PS. This figure is a potential guide on how sexual health providers can adopt client engagement strategies, assess CS risks, and collaborate efforts to ensure consistent and timely screening and treatment. The figure summarizes the totality of MC practices put into place to limit cases of CS locally. The individual adjustments to policies and procedures described previously were not assessed for effectiveness, so identifying which practices were most influential is not possible. However, implementation of third trimester screening has been recommended by others including the Centers for Disease Control and Prevention.14 Because an increasing proportion of CS cases are missed because of late identification of seroconversions, implementing universal early third trimester screening for syphilis is recommended as a best practice.15–17 Best practices identified in MC can be adopted at both local and national levels to mandate or promote syphilis screening in jail and correctional facilities18; ensure clinics are equipped and accessible; include staff who are trained to support patients; screen all pregnant persons regardless of risk when pregnancy is diagnosed, during early third trimester, and again at delivery18; and reach individuals not receiving routine sexually transmitted infection services such as frequent users of emergency departments and those engaged in DRRBs. Implementing these best practices and increasing coordination between various community stakeholders can result in improved sexual health for pregnant persons and prevent CS.