Episode 4: Health Department Calling: Public Health Follow-Up and Partner Services

Host Larry Prescott welcomes co-host Amy Carter, DSHS Congenital Syphilis Coordinator to the podcast. They are joined by Maria Martha Hernandez and Lupita Thornton from the City of Houston for a conversation about the role of Disease Intervention Specialists (DIS) in Public Health Follow Up and Partner Services. They explore the work of DIS work is done, experiences from the field, and highlight the specialized work of our congenital syphilis investigators. This episode’s guests and hosts share real stories from the field and highlight why the health department contacts not only individuals who have tested positive for syphilis but also those who may have had a syphilis exposure.

Weblinks:

https://www.dshs.state.tx.us/hivstd/info/cs/public.shtm

https://www.dshs.state.tx.us/hivstd/info/cs/fimr.shtm

https://www.dshs.state.tx.us/hivstd/info/cs/program.shtm

https://www.dshs.state.tx.us/hivstd/

Welcome to Exploring an Epidemic Congenital Syphilis in Texas. I'm your host Larry Prescott. In this podcast series, we will explore what's happened with syphilis and congenital syphilis in Texas through interviews with national and local experts. Talk about babies diagnosed with congenital syphilis in Texas and discuss how we can address the rise 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.

Welcome everyone to our podcast, Exploring an Epidemic Congenital Syphilis in Texas. I'm your host, Larry Prescott and I have with me now our new host, you've heard her once before but we want to introduce her to you as our new co-host today and going forward, Amy Carter. Come on in Amy and give us a little bit about yourself.

Thank you, Larry. I'm glad to be back. I have now transitioned from Dallas County to the department of state health services and am the congenital syphilis coordinator. So, I work with all of our programs across the state of Texas now with their reporting and capacity building of congenital syphilis and serve as a resource for them.

Well, I'm so glad to have you on board as our co-host as we continue to explore this epidemic in Texas as well. Today we have special guests with us from the Houston Health Department, Lupita Thornton and Maria Martha Hernandez.

I'm Lupita Thornton. I'm with the City of Houston Health Department. I have 33 years with the Houston Health Department and I'm proud to say I started out as a disease intervention specialist and now one of the program managers. I currently do quality assurance for the program and special projects which also involves the congenital syphilis component. My heart is with public health and I'm excited to be part of this podcast.

I am Maria Hernandez. I am a public health investigator specialist with the City of Houston Health Department in Harris County. I conduct investigations for all childbearing, pre-natal and labor and delivery reactors reported to the health department. I also conduct the general syphilis investigations on infants that are reported to be exposed to mothers diagnosed with syphilis and I am proud to say that I'm very passionate about the work I do.

Well, I want to thank you Lupita and Martha being here with us today, as we continue to explore this epidemic and we're going to focus this episode if you will, on a service that's being provided by local health departments as well as regional health departments throughout the state of Texas known as public health follow-up.

And we are going to ask you to give us some insight on exactly what Public Health Follow-Up is, as well as those people that we identify that conduct public health follow-up. So I want to thank both for you for being here to do that.

Thank you. And it's good seeing you Larry, Houston was the home for you for many, many, many years. So it's good to be part of this podcast with you.

Yes, yes, yes. 25 years there so it was really good and all great experiences and I still can call it home as well. So this is great and I'm glad to have Maria, one of my babies as I call them, because since I've helped train her early on appreciate her being here today as well and Martha we are so glad to have you on board as well.

Thank you Mr. Prescott, it's good to see you and you too Amy.

I'd like to begin with you Lupita, can you just give us an idea or clear context of exactly what is public health follow up and what all that entails and the individuals involved?

Sure. Absolutely Larry. So public health follow up has been in place across the country and it's a strategy that we use, to intervene in the spread of a sexually transmitted disease. There's individuals that are hired to do the specific job of public health follow up and these individuals are called a disease intervention specialist. DIS.

And the DIS are specially trained to conduct education, be able to go out and notify clients that either they've been exposed or they have tested positive for a sexually transmitted disease. We're trained to go out and conduct screenings out in the field. We're able to draw blood in the field. We're able to conduct partner elicitation.

It's very important that we actually get the entire social network of that individual to be able to intervene in the spread because it's not only sex partners and needle sharing partners that the infection can be spread to. It's the social network, it's who they're hanging out with, who they may be having sex with or sharing needles with the same group.

Individuals may not be having sex with each other, but there might be one common person. So therefore the disease intervention specialist has to be able to hone in and be able to identify who and what and when. So that's an important skill of a disease intervention specialist.

We need to make sure that, of course everyone gets treated timely, that they get treated with the appropriate regimen of medication. It's just a whirlwind of responsibilities and skills and duties that the disease intervention specialists are trained to do.

Well. It sounds like they do quite a bit and I'll reiterate, Amy and I both performed that job duty in our younger or earlier parts of our career. It sounds like these individuals are multi-taskers. What type of individuals are you looking for to fulfill that particular position?

Right. When we're looking to hire someone to be a disease intervention specialist, we're looking for someone who can communicate very well. They need to be able to communicate at different levels, make certain that not only the clients but the medical providers and any clinician that they communicate with, will be able to communicate at their level as well. We're looking at somebody who is not afraid to do field activities.

I remember a time when I was working in one of the health department clinics and there was a particular person that I remember a lot because this young lady went for a pregnancy test and she was thinking she was pregnant because she had abdominal pain and her belly was growing.

So after they did that pregnancy test, they discovered she wasn't pregnant. They did a pap smear. She went home. They got the test results a couple of late days later and they were trying to reach her and calling her, but she wouldn't respond. So I had to go in the field and go talk to the person, knock on her door, let her know that we have some results to talk to her about it and if she can go into the clinic. And she stated she didn't have a way to get there.

So I offered to transport her to the clinic and we gave her, her results. This young lady was diagnosed with cancer and she also was diagnosed with HIV and syphilis at the same time. While we were there, I did the public health follow up and I spoke to her about signs and symptoms and everything. We noticed that she was very sick. She sounded like she had a very bad cough where she was having some spells where she couldn't even breathe.

She was scared. You know, she had received some very hard results and I ended up offering that I can take her in person, transport her to the hospital and she accepted. And later I found the doctor that was seeing her called me and said that I had saved her life by taking her to the emergency room where they offered her the care she needed for the cancer and got her started into care for HIV.

And two months later or maybe four months later, I can't remember the timeframe. She went back to the clinic and she was a totally different person. I couldn't recognize her of how beautiful and healthy she looked. And she went to thank me and tell me that she was very glad that I had helped her and very thankful. That was one story that I hold dear to my heart because I felt that I can make a change in the community.

Yeah. I think that's one thing that we all kind of have hit on is like this non-judgmental aspect of being a DIS and going into these places where a lot of people don't want to go into, but you could have these great impacts on people's lives like Maria Martha, you pretty much helped keep somebody living.

I had a client at one point who wasn't informed when they delivered their baby of their syphilis status and even their infant syphilis status and the baby had a lot of complications. And so they were very panicky, didn't know what was going on. And then we had this whole conversation with them and we were able to get them calmed down, get them the care that they needed. And that's that impact that as a DIS you have. It's behind the scenes.

A lot of people don't realize that this is something that the health department's doing. This is somewhere where we're really intersecting with people where they're at and not judging them for what's going on in their life, but really getting them the services that they need. But at the same time, you still have to be able to flip that switch and talk to the provider with some authority and some knowledge as well.

You find a lot of different challenges with this position and we talked about notification as well as elicitation because we know that providers and community based organizations elicit partners, but only a DIS can notify partners. Can you just give us a brief description or the difference between the two?

Yeah, absolutely Larry. So the disease intervention specialists are the only ones who are trained to do partner elicitation and notification. So yes, if a doctor of a provider has a good relationship with their patient, they certainly can discuss that with them but they can't notify we're going to let them know if they've been exposed. And of course it's all done confidentially. We cannot tell them who name them.

You know, we always say it's somebody who cared enough about you to share your information with us. And so we want to give you the opportunity to test and receive treatment if needed. So there are different ways of being able to notify someone that they have been exposed. So that's something that the DIS are trained to do and we do it daily. From the morning to the evening, we're notifying clients of their positive results or if they've been exposed.

You did say Larry special individuals and within the disease intervention specialist community, there's even more specialized DIS as we like to call them. Especially in Texas in our high morbidity areas like Dallas and San Antonio and down there in Houston too, who specifically deal with our congenital syphilis and with our moms and our babies, because those conversations are different.

They look a little different. We do that the same partner services, public health follow-up interview, where we're asking about partner, we're asking about where you're meeting the people you have sex with, how you're supporting yourself, having those whole social conversations. But in those three areas, we go a little deeper with some of our moms and we have what are called maternal interviews.

So these are super in depth. We talk about all sorts of stuff through her entire pregnancy, her whole experience, the experience she has with her healthcare providers and we get a lot of good information. Maria Martha does some of these in Houston and so I wanted to ask you Maria Martha, if you can share a little bit about how those interviews happen and what makes them so different and unique?

Yes, we do interviews on labor and delivery moms that have either a new infection or rise in titer at delivery. And with those interviews, we have to go a little more in depth of what happened throughout their pregnancy, their testing, their visits. And we have to do a lot of educating, not only with the patient but also with the providers so that we can make sure that baby is born healthy.

As we talk to the mothers, the patients, we also do a lot of intervention. We talk to them about their needs but what could we have done better to help women in similar situations as themselves? And we get a lot of feedback. Most of the times, once you start talking to them about their needs and what could we have done better, what could they have liked to have happened differently that could have made a difference in what happened to them?

It's very helpful when we're at that point because they open up and they start talking and giving you additional information that I have brought back to what I do, because I'm a congenital syphilis specialist where I do investigations on mothers that have had babies with probable cases of syphilis.

And that has really helped me as I do the interviews, understand and see how I can intervene and how I can help and what other things I can do when they tell me, "I wish I would've had this done during my prenatal care. I wish I would've known. I could have had additional testing during my pregnancy."

And like Lupita was mentioning earlier, sometimes they get the names of the partners and we can initiate them and we can get them treated. We talk about exposures and how that can affect them getting the infection again and how they can create a risk reduction step to help them not get syphilis or protect themselves and protect their baby.

And that is something I love to do. That's my passion. And sometimes by even helping one person, I'm able to help others because I see what I can do different with other cases. And that's something that is very important.

So I'd like to talk about a little scenario also that we were able to help an infant. One of the major issues with having a congenital baby is that the moms either have a mental disorder or are on drugs and most of the time it's both. Both situations. In this scenario, it happened to be that mom tested positive for drugs was having mental issues, the CPS took the child away from her and put him in a foster home and we noticed that they did not keep the baby for treatment for syphilis.

So I had to work with the CPS to try to locate the foster mom and so when I called to introduce myself, let them know who I was and why I was calling and asked had the baby had been sick and did they notice any type of symptoms related to syphilis? And she says, "Well, the baby's healthy but she just has maybe a little cold." And I said, "Can you describe what you're seeing?"

And so when she described it I said, "No, we need to bring the baby in as soon as possible." So I met them at the hospital. They did hospitalize the baby. The baby did have congenital syphilis and the symptoms that she has was snuffles. And so the baby had a lot of mucus drainage from her nose. And that certainly is one of the symptoms that we look for.

And so they kept the baby for the 10 days and treated the baby according to CDC guidelines. But that's something else we do. We also are, what we call recalling the baby back in, to ensure that a baby had proper testing and of course the treatment.

Yeah. And with those snuffles, that's a very contagious sign or symptom in an infant. So even those caregivers could have been exposed to syphilis with that mucus in the nose and stuff.

And we did test them and we did test the parents and there was a caregiver also that was helping take care of the baby. So we tested all of them. You're right Amy, thanks for that.

Yeah. Because the signs and symptoms in the infants are different. So we do have that conversation. I know when I would interview pregnant people, they would be freaking out because I could not imagine being pregnant and getting this news and knowing that this is something that could transmit from myself to my infant.

And so having that conversation with the mom or the pregnant person about how, what this is and why we're being so proactive about getting you in, getting you treated, why we're saying you got to come in at seven days optimally, no more than nine days or we're going to restart your treatment.

And what to expect when they deliver is well because these babies are going to have a lot of follow up. They're going to get tested. They're going to, in some cases, they're going to have long bone x-rays, they're going to have lumbar punctures, all these really invasive medical interventions as well as a 10 day stay in the hospital and usually in the NICU. So nobody wants to go home without their baby.

Absolutely. Right.

So that's one of those things where we have those conversations on both sides, we got to be able to break it down right to the mom, but also have that conversation with the provider. The baby might be negative but they still need to be treated. And this is why.

And you see, this is why all this ties in into why this is such as a specialized position. Because we talking with individuals, we talking with providers, we talking with families. And I think once people understand that it's a service, it's maybe easily more easily acceptable because I'll relate one other thing before I ask about this program that you have in Houston.

When the pandemic first started, the government rolled out what they call contact tracing and contact tracing was actually notifying people who had been exposed to someone who had COVID and this particular contact tracing concept initiated around disease intervention specialists who were the people who were exactly doing this exact same thing for years.

So when the pandemic came out, because I became a participant in doing contact tracing personally myself, so when they started to introduce it I said, "Well, we've been doing this for years." We should just have all DIS doing this pandemic contact tracing because this is what we do 24/7, 7 days a week.

So I just wanted to bring that point in because I mean this is a specialized skill and it takes people with passion in order to do that because not everybody's going to thank you. I mean, we being up in front and honest on a podcast, there's some people who going to call you everything, but you know what, they're going to curse you out, they're going to tell you don't call me, don't message, they going to tell you everything. But that one person-

They're going to call you everything but your name.

Yeah. Right. Exactly. Exactly, exactly, exactly. But then that one person that'll call you like Maria said in a portion earlier, that one person that call you back and say, "Oh, I'm so glad that you called me and notified me about that." That makes a difference and that's what keep us as DIS and public health personnel involved. Because if you know you made a difference in one person's life either that day, that week or that month or even that year, it's well worth it because that's exactly what we do.

And sometimes they do start with cussing or are mad at you when you're calling them but then at the end, after you give them information education and you help them they say, you know what I'm so sorry how I started out with you.

I think we all have gotten that apology call and it makes a difference because it motivates us to keep going. And of course every individual is different so we learn as we go from each one. And that's what makes everything worthwhile when we get that call from at least one individual that says, "I'm so appreciative for you notifying me and giving me this information and helping me with my personal health." At this point I'd like to ask what take home messages do we want to present? Just give us a brief message that you wanted people to receive from this podcast.

Absolutely. So it's very important that our community and our medical providers understand the importance of testing. It's important to know when to test, how to treat and for the clients to be very, very comfortable in having discussions with their medical providers. This is the doctor who's going to deliver your child.

You should be able to talk about STIs with your providers and ask, when are you going to test me and what happens? What's my plan of action if I do test positive for an STI? I think it's important for our moms to be able to communicate and under stand the importance of this. How to intervene in keeping your baby from being delivered with congenital syphilis.

Being a disease intervention specialist is something that is not for everyone as you mentioned earlier, but whoever is doing any type of investigations should be someone that has that empathy with the clients and is able to talk to them, educate them, give them the information, so that they can know every how often they have to test.

What do they need to do, what to look for, because not always do they go to an STD clinic. Sometimes they go to doctors that are not familiar with syphilis and it's important for our community to know what should they be looking for when is it important to go get that checkup?

I'm going to talk really quickly, I know we're short in time but I wanted to talk about a website, My Prenatal Promise. And it does just that, it educates women how to communicate with their provider, how to communicate with your social network about an STI. And then they get to pledge that they're going to do whatever they feel they need to do to keep their baby safe and deliver a healthy baby myprenatalpromise.com.

I want to first thank Maria Martha and Lupita for all their information. The DIS are skilled individuals who work very hard and they're a resource to help you not only advocate for yourself but advocate for your clients on both sides. Whether you get a phone call from somebody saying, "Hey, this is Amy from the health department." Have that conversation.

They're not there to judge you. They're not there to make assumptions. They're there to help you. And for our providers, call your health department when you get a person with syphilis or any other disease because they can help you in ways that you might not be aware of.

Thank you everyone for joining us for this podcast about public health follow-up and congenital syphilis in the state of Texas. We hope that you join us again next week, as we'll be exploring one of the areas in Texas that has some of the highest rates of congenital syphilis in the Rio Grande Valley.

Our co-host for that episode would be Diego Martinez. We'll not only be podcasting in English, but we'll also be podcasting in Spanish. I'm your host, Larry Prescott and look forward to seeing all of you next week. This podcast was developed by the Texas Department of State Health Services in collaboration with the Denver Prevention Training Center.