Congenital Conundrum
By Sean Price Texas Medicine July 2018

July_18_TM_Public Health_Eppes

All diseases can be destructive, but there’s something especially pernicious about one that spreads from a pregnant mother to a baby.

“Congenital infections are often devastating to babies, and people are completely not expecting that,” said Catherine Eppes, MD, an obstetrician-gynecologist and expert in maternal-fetal medicine who is also an assistant professor at Baylor College of Medicine in Houston. “So it’s usually a pretty profound surprise.”

A wide range of diseases cause birth defects, and each poses unique issues. Texas Medicine looks at three that are especially problematic in Texas because of their stubborn rates: syphilis, cytomegalovirus (CMV), and HIV.

Syphilis: Refighting an old battle

There are three big things to remember about syphilis: It has been treatable since penicillin became widely available in the 1940s; it was almost eliminated in the United States by 2001; and it’s come roaring back since.

Syphilis rates increased almost every year since 2000, according to the U.S. Centers for Disease Control and Prevention (CDC). Most of those increases have taken place among men, especially gay men. But since 2013, women have made up a much larger share of cases. Between 2015 and 2016, the syphilis rate rose 35.7 percent among women compared with a 14.7 percent rate increase among men.

In 2016, Texas had the sixth-highest rate in the nation for congenital syphilis cases, with 71 cases, or 17.8 per 100,000 live births, according to CDC. 

Texas has stepped up its efforts. In 2015 the legislature passed, with the Texas Medical Association’s support, Senate Bill 1128. At the time, pregnant women were tested for syphilis at their first prenatal visit. The new law added testing in the third trimester. 

Prenatal screening is usually effective in detecting syphilis, and — unlike many congenital illnesses — syphilis is curable. The best strategy for preventing syphilis, HIV, and other sexual transmitted diseases is old but effective: Encourage all forms of protected sex, says Kimberly Carter, MD, an OB-gyn and assistant professor at Dell Medical School at The University of Texas in Austin.

Dr. Eppes says better education campaigns and stronger cooperation among public health officials and physicians also are needed. While syphilis cases by law must be reported to health authorities, the reporting also could be improved. 

“If a [syphilis] test is reported as positive right now, [public health officials] don’t know if it’s a pregnant woman or not,” Dr. Eppes said. “That alone would be valuable.”

CMV: Under the radar

CMV is sometimes compared to Zika virus. Both cause mild or no symptoms; both are hard to test for; and both can cause terrible birth defects. 

Zika rightfully has received a lot of attention, Dr. Carter says, but CMV surprisingly gets very little. 

“It’s not that [Zika] doesn’t cause a lot of harm, it just doesn’t cause a lot of harm in the United States,” Dr. Carter said. “CMV causes more microcephaly than Zika has ever dreamed of causing. The number one [non-genetic] cause of deafness is CMV.”

The CDC reports that about one out of every 200 U.S. babies have congenital CMV. But what’s tricky about tracking CMV is that only about one in five babies with the virus will get sick or have a long-term health problem. Dr. Eppes says CMV affects at least 4,000 babies in Texas each year, but the real number is almost certainly higher.

“We don’t know the true number because it’s not a reportable condition,” she said. “But it’s a huge volume of patients probably compared to other congenital infections.”

Despite being widespread, many patients don’t know about CMV and many physicians don’t prioritize it in patient discussions, says Shanna Combs, MD, a Fort Worth OB-gyn and past chair of the TMA Committee on Reproductive, Women’s, and Perinatal Health. 

“It’s something we’re all taught about in medical school, but it’s not something we think about on a day-to-day basis,” she said.

There is no vaccine for CMV. The best way to fight it is simply promoting good hygiene, Dr. Carter says. It’s most often spread through saliva and other bodily fluids of children. 

Mass screening for CMV is not helpful because the tests are difficult to interpret, and the illness is not reportable to health authorities because there’s no scientifically proven treatment, Dr. Eppes says. Nevertheless, it is important to test a woman once birth defects are detected.

“I still see situations where people will test for Zika [when birth defects are shown on an ultrasound] but they won’t test for CMV, and of course on an ultrasound they look very similar, just as it does for toxoplasmosis,” she said. “But those [three illnesses] have three very different patterns of follow-up, and toxoplasmosis actually has a treatment. So differentiating between them is another key thing.”

Dr. Carter says CMV can’t be fought unless people know about it,  and Texas physicians need to push for a public health campaign, like one under way in Utah, that highlights prevention.

Dr. Eppes says more research is needed. At least one study under way by the Society of Maternal-Fetal Medicine network, a coalition of academic centers, could provide insight into preventing or treating CMV.

Also, it’s been widely believed that a minority of pregnant women who contracted CMV while pregnant had a baby with birth defects, but the evidence for that belief now looks shaky, Dr. Carter says.

“When we have someone who has CMV in pregnancy and they have a normal baby, are we actually tracking [the child] well enough when they’re 3, 4, 5, 6 years old to see if we’re starting to see the effects of CMV causing neurological problems like deafness?” she asked. “The answer seems to be that we’re not.”  

HIV: No victory lap yet

Efforts to fight congenital HIV are a relative success story. Rates have dropped by more than 90 percent since the early 1990s, and with proper treatment during and after pregnancy, babies’ risk of getting the infection can be as low as 1 percent, CDC reports. Some states, like New York, have used aggressive measures to virtually eliminate congenital HIV. 

But Dr. Eppes says this good news applies less to Texas. “It’s so close that there’s some talk that [congenital HIV] has been eliminated in the U.S., and ‘eliminated’ doesn’t mean zero, but below a certain threshold,” she said. “Texas is not at that level.”

In Texas, the rate of HIV infections per 100,000 people fell only slightly from 16.5 to 16.1 between 2013 and 2016. The state does not report rates of perinatal HIV because diagnoses are not always made at birth. However, Texas’ rate of pediatric HIV diagnoses has bounced around, with a high of 20 cases in 2014 and a low of 10 in 2016, according to the Texas Department of State Health Services.

Texas has several strikes against it, namely the highest rate of people without medical insurance — 16.6 percent in 2016. Drugs for treating HIV are expensive, and most people need insurance to buy them. Also, any barrier that keeps women from getting prenatal care is going to promote congenital illnesses, Dr. Carter says. 

“With HIV and syphilis, they’re going to be caught as soon as you come in [because of state-mandated screening],” she said. “We can attenuate the risk of congenital anything if we know about those risks early, or, even better, before you get pregnant.”

Dr. Eppes notes that understandably many physicians don’t treat people with HIV because they feel they can’t keep up with the ever-changing medications required. But she says doctors need to do a better job of referring HIV patients to practices and health centers that can treat them. 

“I still hear from women that they’re told in doctors’ offices, ‘Oh, our practice doesn’t take care of women with HIV. You’ll have to go somewhere else,’” Dr. Eppes said. Physicians should “not just be telling them to get help somewhere else, but actually connecting them to a place where they can take care of women with HIV.” 

Women most at risk for congenital HIV infections are also at risk for maternal mortality and illness, Dr. Eppes adds. Those populations include African-Americans, Latinos, and people with mental health issues and substance use disorders. Physicians should recognize and learn how to address their common patterns.

 

Learn More

TMA information sheet on CMV: 
www.texmed.org/CMV

CDC information sheet on how to avoid infections during pregnancy:
tma.tips/CDCPreventInfections

 

Tex Med. 2018;114(7):42-43
July 2018 Texas Medicine Contents
Texas Medicine Main Page


Last Updated On

July 05, 2018

Sean Price

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(512) 370-1392

Sean Price is a reporter for Texas Medicine and Texas Medicine Today. He grew up in Fort Worth and graduated from the University of Texas at Austin. He's worked as an award-winning writer and editor for a variety of national magazine, book, and website publishers in New York and Washington. He's also helped produce Texas-based marketing campaigns designed to promote public health. Sean lives in Austin and enjoys hiking, photography, and spending time with his wife and two sons.

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