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Integrated perinatal infections surveillance: the labor and delivery record to the rescue MCH EPI 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 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 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

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Perinatal infections surveillance: Current approaches NCHS natality files Provider surveys (eg, ACOG) PRAMS Active Perinatal infections surveillance: Current approaches NCHS natality files Provider surveys (eg, ACOG) PRAMS Active Bacterial Core surveillance Food. Net HIV strain surveillance Disease-specific surveillance (eg, rubella, syphilis, sepsis)

What is missing from these systems? Sustained tracking of prevention practices (this becomes even 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 labor and delivery (L&D) record

The birth of Birth-Net • Periodic, population-based review of L&D records in Emerging Infections 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 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 Schrag et al. 2003. Obstet GBS and Hepatitis B antenatal testing, 1998 -9, ABCs Schrag et al. 2003. Obstet Gynecol 102: 753 -60

The impact of state laws on HIV testing, 1998 and 1999, ABCs Opt-out policy The impact of state laws on HIV testing, 1998 and 1999, ABCs Opt-out policy Mandatory NB testing of HIV unknown mothers w/48 h 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 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 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 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 Acknowledgments Anne Schuchat Elizabeth Zell Aaron Roome Katie Arnold Janet Mohle-Boetani Ruth Lynfield Monica Farley The Active Bacterial Core surveillance team