Episode 3 is a conversation between Larry Prescott, Dr. Judy Levison of Baylor College of Medicine and the Houston FIMR Core Team, and Crystal Casas with San Antonio Metropolitan Health District. The discussion focuses on the importance of community action to address the congenital syphilis epidemic. Guests highlight past action, including legislative efforts, promotion of prenatal care, and San Antonio Metro Health's Healthy Beats Program. They also discuss lessons learned from fetal infant mortality reviews and the importance of relationships between providers, local health officials and the communities they work in.

Larry Prescott 0:00

Welcome to Exploring and Epidemic: Congenital Syphilis in Texas. I'm your host, Larry Prescott.

In this podcast series, we'll be exploring what's happening with syphilis and congenital syphilis in Texas through interviews with national and local experts. We’ll talk about babies being diagnosed with congenital syphilis in Texas. And we’ll also discuss how we, as a care community, can address the rising rates of congenital syphilis in Texas. After all, this is a 100% preventable disease with tests and treatment at our disposal if we all do our part.

Today, we'll be talking about the responses to the increase in the rates of congenital syphilis in Texas. I have with me today two guest speakers, Dr. Judy Levison and Crystal Casas.

Judy Levison 0:46

I'm Dr. Judy Levison. I'm an Obstetrician-Gynecologist with Baylor College of Medicine and with the Harris Health System. I am also the co-lead with theDepartment of State Health Services of the fetal and infant morbidity review related to syphilis and HIV known as FIMRSH.

Crystal Casas 1:06

My name is Crystal Casas, and I am the Field Operations Manager for our San Antonio Metro Health Department STD HIV program. I've been in this position for six years and I currently oversee our team of disease intervention specialists, our HIV data to care program, and, of course, our congenital syphilis program as well.

Larry Prescott 1:30

I'd like to begin by talking with Dr. Levnson. Dr. Levison, now, how are the FIMRs removing barriers to care across the state of Texas?

Judy Levison 1:38

Well, I like to say that we're going from the micro to the macro. Which means learning from individual cases, which then leads us to actions to make system-wide change. In our fetal and infant morbidity review related to syphilis and HIV, or FIMRSH, we are focusing on women who've given birth to a baby affected by syphilis, which can affect brain and bone development, or who have had a stillbirth because of syphilis, which is a preventable tragedy.

What happens is that the Department of State Health Services identifies cases, our team obtains the charts, and then when possible an interviewer meets with the mother to hear her perspective on how her pregnancy went. We present the details to the case review team or CRT, which is about 30 to 40 individuals. The CRT identifies barriers to care, and we develop an action plan. Specifically transportation, education of providers, and education of the public.

Related to transportation, we realized that women with Medicaid have access to Medicaid Transportation, but often miss their appointments, prenatal visits, because they could not find childcare for a young child at home and Medicaid did not allow them to bring a child with them. We met with the Medicaid team in Austin. We demonstrated some of the costs of having a child born with HIV or syphilis if a woman could not access prenatal care and got them to see that it was cost-effective to allow children to come to visits with their mothers.

Regarding education of providers, we sometimes see that a provider didn't test at the proper time or didn't treat appropriately, and we make sure that we speak with each provider and educate them about what the statewide standards of care are. Also this year, in terms of education of the public, we were able to fund some billboards around Houston, with the goal of letting women know that prenatal care is very important and one of the reasons is that they will get tested for syphilis and we can prevent some of these tragedies.

Larry Prescott 3:58

Crystal, what initiatives are happening in the local level in response to the rising rates of congenital syphilis?

Crystal Casas 4:03

This team also includes two field treatment nurses who can actually provide in-home syphilis testing and Bicillin treatment to pregnant females who require such service. The Healthy Beats team also aids with prenatal care linkage as well as referrals to other local resources, such as WIC, Healthy Start, the food bank, and housing. So, we definitely recognize the rise of congenital syphilis cases here locally and that was one of the main initiatives that we started in order to help combat that increase here in San Antonio and Bexar County.

Larry Prescott 5:14

And what type of response are you getting from that initiative?

Crystal Casas 5:17

Larry Prescott 5:45

Dr. Levison, what are some of the lessons that you learned from FIMR?

Judy Levison 5:49

We have learned that there is power in bringing together multiple disciplines to face the congenital syphilis epidemic. Where else do we have the following people meeting together? So in our FIMRSH, we have physicians and nurses from both the public and private sector, social workers, case linkage workers, epidemiologists from the city of Houston, and from the Department of State Health Services in Austin. Women living with syphilis or who have been treated for syphilis and also women living with HIV, and representatives of the realms of mental health, substance use, and the corrections system. So, I think that it's a very unique group that comes together to combat a common problem.

So we need to educate clinicians that syphilis testing needs to be done, not only at the first prenatal visit and in labor and delivery but also in the third trimester, ideally around 28 weeks gestation. The reason is that treatment with penicillin works well in preventing congenital syphilis if it started at least 30 days prior to delivery. Some clinicians are not aware of the law, others are but think, “not in my backyard.” And you just don't know unless you test.

Larry Prescott 7:31

So what has been a response to the provider education around the requirements for congenital syphilis?

Judy Levison 7:37

And this is where we are very open to suggestions because reaching clinicians who are not in academic centers has been a challenge. I tend to pick up the phone and talk to each one for each individual case. And one of my questions to them is, how could we get this word out? I think people are overwhelmed by their emails and often delete things that they think are not relevant to them. And we are looking for creative ways to reach clinicians around Texas. We also need to reach the general public and to get people to understand that early prenatal care includes syphilis testing and treatment if needed and without treatment, there's a risk of stillbirth. And we have seen a number of women who at maybe four and a half months of pregnancy lost their babies because they hadn't been seen early and hadn't been tested and hadn't been treated.

Larry Prescott 8:32

Crystal, are you doing anything locally to bring awareness of maternal and congenital syphilis in the San Antonio area?

Crystal Casas 8:38

Yes, most definitely. Because maternal and congenital syphilis is a hundred percent preventable, having these collaborative conversations is very important. Part of those conversations do include us strengthening our relationships between medical providers and the local health department. We really want to encourage medical providers to test more regularly for syphilis. If perhaps a patient of theirs is testing positive for gonorrhea and chlamydia throughout their pregnancy because that's evidence that there might be the possibility of syphilis showing up sometime throughout that pregnancy.

And then, of course, if there's any doubt or confusion, we encourage an open line of communication with the local health department in order to bridge that gap of information. Perhaps there's some sort of information that we can provide that would be useful to the provider regarding that patient.

Because we have a designated congenital syphilis specialist, we also encourage providers to allow that individual to either virtually or once we can visit in

person again, to stop by and provide their medical team with information about congenital syphilis and testing and treatment as well.

Lastly, we highly encourage our medical providers to participate in local FIMR meetings. So that way they can learn firsthand about these congenital syphilis cases that are impacting the local community, but also too because we appreciate their expertise to the conversation. They're also seeing it firsthand. They see the patients who are impacted by positive syphilis tests. And these are opportunities for us to have those conversations to really try and make decisions that will impact our community for the better.

Okay, and are you receiving adequate participation?

So, when we do have providers attend, they are really thankful for the opportunity to be a part of the conversation and to really hear firsthand what's happening with these cases that we are highlighting. So it has been a great learning experience, I think, for both sides. And of course we, the local health department, we appreciate any feedback that these providers give because we do our best to take that and figure out ways to improve the services that we are providing as well.

Those on a part of the congenital syphilis team attend the other FIMRs that are occurring throughout the state. So they can also learn more about what's happening in Houston, what's happening in Dallas, and that then of course allows them to really gain insight on what Texas looks like overall as it relates to congenital syphilis.

Great, yeah. And then Dr. Levison, I wanted to come back to you for a moment. If you don't mind, I wanted to ask about any statewide efforts being conducted to address the increase in rates of congenital syphilis in Texas.

When we first started our first FIMRSH in 2014, 2015, we were initially focusing on Houston, and what we then were hearing was that there was a lot of congenital syphilis happening in San Antonio. Again, we're looking at both HIV and syphilis, and we were also picking up cases in Dallas.

Now we have FIMRs going on in San Antonio, Dallas, and Houston. So that has expanded our reach, and if there is not a FIMRSH in the local area, but we're aware of a case of HIV or syphilis, we will sometimes be able to review that in Houston.

Well along that line, I'd like to ask you, Crystal, what is your message to the health professionals in Texas on maternal and congenital syphilis?

As I mentioned previously, I would really encourage medical professionals to reach out to the local health department, to have that conversation with us about mutual patients, so that we could possibly fill in the gap where maybe they're missing information on a particular patient or maybe we have additional treatment history or testing history that could be helpful as they evaluate their patient. And really ensuring that that line of communication is open because we are definitely here to help them provide better care to their patients.

I’ll pose a question to both of you about the building of relationships in terms of the providers, local health departments, community-based organizations, and helping provide awareness and all of that. I'll start with you, Dr. Levison, can you speak a minute about the importance of building these types of relationships?

Yes. I think, for me, the challenge is how do you keep people aware of what the latest practices are and what standards of care are? When I have reached out, I've tried to make it clear that I am not blaming the clinician for perhaps not knowing, but if anything that I feel like we have failed, then it's our responsibility as public health people to get the message out. And so I think that has helped to approach them in a non-threatening way. And my hope is that they will then share some of their experiences with their colleagues.

The hope is that we provide a source of information that could be further used by the providers with their peers and those that they engage, to promote the messaging and really get the word out there about congenital syphilis and the importance of testing and timely treatment.

The goal really is to continue to promote the message that congenital syphilis, unfortunately, is very much so on the rise here in Texas, but I think as we all work together and solidify our communication and the working relationships we have together, then the more prepared we will all be as a state to combat this rise in congenital syphilis.

Well, I want to thank Dr. Levison and Crystal for being with us today and sharing the information that they had for our congenital syphilis podcast here in Texas.

Exploring an Epidemic: Congenital Syphilis in Texas was developed by the Texas Department of State Health Services in collaboration with the Denver Prevention Training Center.