Cost of congenital syphilis

Missed opportunities for congenital syphilis prevention in an urban southeastern hospital

BACKGROUND

Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem.

GOALS

To identify missed opportunities for congenital syphilis prevention during prenatal care.

STUDY DESIGN

Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA).

RESULTS

The hospital congenital syphilis prevalence was 8.2 cases per 1,000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01).

CONCLUSION

Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.

Treatment of infants with reactive syphilis serology, New Jersey: 1992 to 1996

BACKGROUND AND RATIONALE

Diagnosis of congenital syphilis is problematic: infants with congenital syphilis are often asymptomatic, and signs in symptomatic infants are frequently subtle and nonspecific. Furthermore, there are no readily available diagnostic tests that provide a definitive diagnosis. Previously, the diagnosis of congenital syphilis was based on a complex set of clinical and laboratory criteria, and only infants with clinically apparent illness or laboratory findings indicating congenital syphilis were classified as cases and reported to health departments and the Centers for Disease Control and Prevention (CDC). To systematize diagnosis and case-reporting, the CDC developed a standardized surveillance case definition in 1988. This case definition includes symptomatic infants as well as asymptomatic infants of mothers with untreated or inadequately treated syphilis during pregnancy. It is intended to be highly sensitive to better estimate the burden of disease in the community. Treatment guidelines for congenital syphilis are intentionally conservative and err on the side of overtreatment so that all potentially infected infants are treated. The congenital syphilis surveillance case definition is compatible with the American Academy of Pediatrics (AAP) and CDC treatment guidelines; thus, the number of infants identified and reported to state health departments and the CDC should reflect the number of infants treated. Hundreds of infants with reactive serologic tests for syphilis (STS) are reported each year to the New Jersey Department of Health and Senior Services (NJDHSS). The majority of these infants do not meet the case definition for congenital syphilis, and most are treated although treatment guidelines indicate that treatment is not necessary.

OBJECTIVE

To determine whether infants with reactive STS in New Jersey are being treated according to the AAP treatment guidelines.

METHODS

Medical records of newborns with reactive STS reported to NJDHSS between July 1, 1992, and June 30, 1996, were reviewed to determine status of infection and compliance with the AAP treatment guidelines. The 1995 NJDHSS Uniform Billing and Hospital Discharge Data was used to estimate the mean cost of hospitalization per day for infants with the diagnosis of congenital syphilis. Results. During the study period, 1669 newborns with reactive STS were reported to the NJDHSS Sexually Transmitted Disease Program. Medical record review was completed for 1480 infants (88%). Infants were classified by CDC surveillance criteria as follows: 0 confirmed cases; 515 (35%) presumptive cases; 16 (1%) syphilitic stillbirths; and 949 (64%) cases that did not meet the definition for congenital syphilis. Of the 512 presumptive cases that survived the immediate perinatal period, 478 (93%) were treated with antibiotics and 459 (90%) were treated according to the AAP treatment guidelines. Only 27 infants (6%) were treated with a single intramuscular dose of benzathine penicillin. Thirty-four infants (7%) were not treated; instead, their physicians chose to follow them clinically and serologically. All of those treated were asymptomatic, and most were born to mothers with a history of adequate treatment before or during pregnancy, but who were without serologic follow-up. Of the 949 infants that did not meet the case definition, 329 infants (35%) were not treated and 620 (65%) were treated with antibiotics. The 508 (82%) infants treated with antibiotics were treated with intravenous or intramuscular antibiotics for 10 days; only 62 (10%) were treated with a singular intramuscular dose of benzathine penicillin. According to NJDHSS Uniform Billing Hospital Discharge Data, 267 infants weighing >/= 2500 g were discharged with a diagnosis of congenital syphilis in 1995. The median number of hospital days for these infants was 10, and the mean cost of hospitalization per day was $1010. Sources of payment of hospital charges for most infants were public in

The hospital cost of congenital syphilis

OBJECTIVE

To determine the hospital cost of caring for newborn infants with congenital syphilis.

STUDY POPULATION

All live-born singleton neonates with birth weight greater than 500 gm at an inner-city municipal hospital in New York City in 1989.

METHODS

We compared the characteristics of 114 infants with case-compatible congenital syphilis with those of 2906 infants without syphilis. Cost estimates were based on New York State newborn diagnosis-related groups (DRG) reimbursements adjusted for length of stay, birth weight, preterm delivery, and selected maternal risk factors, including infection with the human immunodeficiency virus, cocaine use during pregnancy, and history of injected drug use.

RESULTS

For infants with congenital syphilis, the unadjusted mean cost ($11,031) and the median cost ($4961) were more than three times larger than those for infants without syphilis (p < 0.01). After adjustment, congenital syphilis was associated with an additional length of hospitalization of 7 1/2 days and an additional cost of $4690 (both p < 0.01) above mean study population values (7.13 days, $3473).

CONCLUSIONS

Based on the number of reported cases (1991 to 1994), the average annual national cost of treating infants with congenital syphilis is approximately $18.4 million (1995 dollars). This estimate provides a benchmark to assess the cost-effectiveness of strategies to prevent, diagnose, and treat the disease.

Drug therapies for sexually transmitted diseases. Clinical and economic considerations

Sexually transmitted diseases (STDs) are common, and result in immense social and economic costs. In some countries they have a major demographic impact. Because many STDs facilitate the transmission of HIV, the consequences of STDs are further increasing. At the same time, this association between STDs and HIV provides one of the ways in which drug therapy should be very cost effective. The perspective taken in this article is a societal one, and broader issues than those directly related to drug costs and benefits are discussed. However, it is the availability of drugs that has the potential to most quickly and most reliably make a major difference to overall health sector and societal costs as they relate to STDs. For those STDs for which curative therapy is available (particularly Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and Trichomonas vaginalis) there have been large decreases in prevalence in many parts of the world. In contrast, those STDs for which curative therapy is not available (particularly HIV, genital herpes and genital human papillomavirus infection) have had stable or increasing prevalence. For these latter infections, each new case increases the overall prevalence. Numerous features of STDs make clinical and economic evaluation difficult. These include the sensitive nature of the topic, the changing epidemiology and drug susceptibility of individual STDs, the fact that a large proportion of those infected are asymptomatic, difficulties in making specific diagnoses, the fact that often consequences are recognised late, sexual re-exposure and reinfection, and inadequate data on which to do clinical and economic evaluations. Furthermore, risk of acquiring an STD roughly correlates inversely with socioeconomic status, and countries or places with the highest rates of STDs may have the least ability to deal effectively with their diagnosis and management. Most of the direct and indirect costs are incurred by women, since they experience the vast majority of the complications of STDs. Many of these only become apparent years later, which makes it very hard to attribute costs and benefits to a specific episode of infection, and to its treatment. The late and indirect costs, plus the costs of prevention, are hard to quantify. That the major burden of STDs is in adolescents and young adults, socioeconomically disadvantaged groups and women has important implications, including for pharmacoeconomic studies.(ABSTRACT TRUNCATED AT 400 WORDS)