Syphilis in Babies

In order to bring awareness to the rising cases of Syphilis on the Navajo Nation, host Amber-Rose discusses this topic with special guests Rebecca Scranton, Faith Baldwin, and Bree Anderson with Arizona Department of Health Services-STI Control Program and Cheryl Cook and Justine Yazzie with Navajo Infectious Diseases Control & Prevention Program under the Navajo Department of Health. In this episode, we discuss the risks syphilis has on both the mother and baby during pregnancy and after birth, prevention methods, treatment options and resources that are available to everyone. 

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This podcast was sponsored by the Arizona Department of Health Services through federal funding from the Health Resources & Services Administration, with support from the Navajo Native American Research Centers for Health (NARCH) Partnership between Diné College and Northern Arizona University through federal funding from the National Institute of Health’s National Institute of General Medical Sciences, award number S06GM142121. The views expressed are the sole responsibility of the program staff and do not necessarily reflect the views of the Arizona Department of Health Services or the United States Government.

Transcript

Intro
Ya'at'eeh. Welcome to the MCH podcast where we discuss maternal and child health topics and provide strategies for improving the health of Navajo families. Amá dóó áłchíní ats’íís baa áháyá baa yadelti (Translation, we will be talking about the health of mothers and children).

Amber-Rose
I am your host Amber-Rose Begay. Hashk’ąąhadzohi nishli, Táchii’nii bashichiin and Tábąąhá dashichei and Naakai Dine’é dashinali. Nataani Nez denashaa. I’m originally from Shiprock, NM where I live and work at Diné College as a project coordinator of the Diné College MCH Project. I am a Navajo woman and mother of 2. Today we are going to talk about syphilis in babies, including prevention, treatment and the effect it has on babies health, if not treated. We invite special guest Rebecca Scranton, Faith Baldwin and Bree Anderson with Arizona Department of Health Services, STI Control program, and Cheryl Cook and Justine Yazzie with the Navajo Nation Division of Public Health Services and HIV Prevention Program. Thank you for joining us today. Can you please introduce yourself and your work?   

Rebecca
Hi, my name is Becca, and I manage the STI control program at the Arizona Department of Health Services.  

Faith
Ya'at'eeh everyone, Hello and good afternoon. My name is Faith Baldwin. I am the NSTI/HIV disease investigator coordinator with the Arizona Department of Health Services.  

Bree
My name is Bree Anderson. I am a CDC field assignee, an epidemiologist in the study control program, working with Faith and Rebecca. I primarily work on syphilis and congenital syphilis.

Cheryl
My name is Cheryl Burke. I work with the Navajo Nation HIV Prevention Program, and I'm here to listen in and and thank you for inviting me, Amber.  

Justine
Hello everybody, my name is Justine Yazzie. I am the HIV health educator with the Navajo HIV Prevention Program. I'm here in Shiprock, New Mexico. Thank you for inviting me to listen in too.

Amber-Rose
Awesome. Ahe'hee to you all. It's nice to have you join us and have you part of our series on maternal and child health. So to start off, what is syphilis and what happens when women have syphilis during pregnancy?

Syphilis is a bacterial infection that is usually passed through sexual contact. The infection can also pass from an expectant mother to their baby any time during their pregnancy. And one thing to know is syphilis is called the Great Imitator because some symptoms are not always noticed and can go easily missed.

Amber-Rose
Okay, Thank you. So when women have syphilis during pregnancy, how does this affect the baby?  

Bree
So syphilis can actually be deadly to babies. Syphilis infection can put the mother and baby at risk for having a miscarriage, stillbirth or even infant death. Babies may look healthy at delivery, but they might go on to develop lots of health problems, including hearing problems, vision problems and problems with their brain and development. If they have an infection that's left untreated, babies exposed to syphilis should receive treatment, which may include a hospital stay of ten or more days. And because this often can't be done on the reservation, it would often require the baby to be transferred off the reservation for treatment.  

Amber-Rose
Okay. Thank you, Bree. So what are the risk factors to contracting and transmitting syphilis to babies?  

Bree
So the one thing that we really hope that listeners get out of this recording is that syphilis is increasing nationwide and really anyone can get syphilis. Syphilis it passed when you come into contact intimate and or physical contact with somebody who's active symptom. Infectious lesions or symptoms typically appear on intimate parts of the body. It's usually passed through sex, including anal and oral sex. In the case of oral transmission, the painless lesion may appear on the mouth. So coming into physical contact, for example, kissing someone with a mouth lesion could be enough to pass the infection. If you're having sex with different people, that could increase your chances of being infected. If you only have one sex partner, but your sex partner has other sex partners that can also put you at an increased risk of becoming infected. You're also going to be at higher risk for getting syphilis if you don't feel safe about how to reduce your risk, like using condoms with your partner. During pregnancy, specifically, if you become infected, but you're not able to access prenatal care to receive screening, you might not know that you're infected and you can then pass this infection on to your baby. In Arizona, because of the high rates of syphilis that we've seen and congenital syphilis providers are supposed to screen for syphilis three times during pregnancy. But if your provider doesn't know that they should be screening you during your pregnancy, you might not get screened. And then my last point would be substance use can also impact someone's ability to utilize prevention strategies like condoms or limiting their number of partners or even seeking prenatal care. For some, moms are worried about losing their children if they seek health care because they or their partners might be using substances. So we really just want to make sure that, you know, equitable access to health care is a great way to reduce risk.  

Amber-Rose
Awesome. Thank you for answering that. So as you said, there has been an increase in syphilis cases in the U.S. and also Arizona. What other factors may have led to this rapid increase of cases and if that also exist on the Navajo Nation, what might be other factors that have led to this increase in syphilis cases?   

Rebecca
It's really complicated. Syphilis has been rising in Arizona and across the nation, so we're starting to see infections occurring in areas that previously had either no or low case volumes. And when syphilis enters the community, there are things that can make it really difficult to control because the symptoms can easily go unnoticed, as we mentioned before. You have to look for these infections through routine screening and things like contact tracing, which is where we interview people who have been infected and seek out some of their partners to try and connect them to services. But in the past two years, we've had shortages of test kits that are used for testing STI, and we've also had shortages at STI public health investigation staff who do that work of getting people linked to testing and treatment for syphilis. So folks in rural communities may have to travel very, very long distances and hours to access clinics for routine care and services, especially if testing services are scaled back in their community. So that can be a challenge that is faced in rural parts of our state. Treatment is also a bit tricky to navigate, so some patients may need to receive up to three injections at one week intervals. So if they're having to travel a long distance just to get tested, that trial time then gets even longer when they have to keep coming back for their injections. And this can make completing treatment very difficult. If you have a missed or delayed dose, you then have to restart the treatment from the beginning. And for pregnant persons, the only treatment option is that injectable antibiotic called penicillin. And if you have a penicillin allergy and you're pregnant, you still need to be treated with penicillin. But you have to go through this really special process, usually in a hospital setting to be desensitized that penicillin. So treatment is really, really tricky to navigate, especially in communities where travel is a barrier. And then the final point that I wanted to make on this question is that sexually transmitted infections have really, really deep roots in our social systems. So all the things that cause us to see differences and other health problems like financial stability, access to care, adverse childhood experiences, dating and domestic violence, substance use, and on and on and on. Those are the same things that kind of drive the trends that we see in STIs like syphilis.  

Amber-Rose
What are the Navajo cultural views around syphilis?

Faith
So I just want to preface this that many people, families and regions have different variations of these stories. These are what we're taught to me by the matriarchs of my family. And also I sought an additional viewpoint from an Hataali at the Chinle Service unit, Native Medicine Office. So I took some commonalities between them and the things that they shared. There are many, one thing that we do know is that with, you know, our traditional stories or things that our grandparents or an elder tells us they require critical thinking on our part to help, you know, we need to figure some of these things out. But one good thing is they're always there to first ask them questions. And I may be wrong with my pronunciation, but STI, go back in our history to the separation of the sexes. The creation and many turmoils came from this time, including STI, at the same STI were birthed and released into the world. And that is something that we are still encountering today. So the Navajo word for syphilis is chich'osh.And one thing that I was told with these stories, a common thread was that you were all given one body and we need to maintain it. And that's why these stories are there, there's examples that they'll share. There are ceremonies to help us learn more, and it is also our responsibility to seek that out. I understand that it's also not possible for everyone to do that, but we still do have some people who are very willing to share their knowledge. So STI have been around since, you know, probably separation of the sexes. So there are some, you know, steps that have existed when a person became infected with an STI. First thing they would do is see a diagnostician. And then from there, given traditional herbs. And those herbs were really to help alleviate symptoms and then they were told to isolate from everyone. So that kind of falls in line with what is modern day treatment, where a person would go to a hospital or a clinician, get tested, receive their diagnosis, receive medication, take their medication, and then abstain from sexual intercourse for some time. But a good thing to know is that there's no known traditional medicine at the moment that can be used to cure syphilis. However, our ceremonies and our traditional medicines are very powerful and can help alleviate symptoms or personal worry.For syphilis, it progresses in stages. When it's not treated, the symptoms of each stage might go unnoticed or it might get attributed to something else, and they can even go away without treatment. But that bacteria that syphilis bacteria still remains in the body and can spread to other important systems like the brain or eyes and cause some damage.

Amber-Rose
Thank you for that, Faith. Are there cultural implications to a timely syphilis diagnosis and treatment?

Faith
There are quite a bit. There are some traditional and what we consider cultural norms nowadays. But for Navajos, as natives, Dine at people, we are a matriarchal society. So women have a ton of responsibilities impacting their ability to make time and for their health and take care of themselves. So they may be here having to take care of the family, the ranch, the farm, the animals. There's a lot of responsibility on them. So they might just deprioritized themselves in order to take care of everyone else. And beyond that, know women are the clan mothers and they're the ones who continue the our clan system. So there's these, I guess, higher cultural implications that really, really do play an effect on how women can get to treatment or seek testing. It becomes very, very heavy. And with that is also the saying T'aa who ajit'eego t'eiya, which you know also relates to we only have one body, we need to maintain it. But what if someone does become infected with an STI? There's going to be, you know, implications of guilt and things that they need to continue to work through. And then, of course, some of our own things that are happening to our people are they have these, like historical traumas. You know, there is some discouragement of getting certain tests and whether it's a traditional view or maybe our grandmas, our moms, someone had a really bad history with some of our clinical areas. So things are still fresh in our minds with things like this forced sterilizations, unethical studies that happen with blood samples between a tribe and a state college. And then there's also distress of certain systems, distrust of U.S. or tribal or state governments or run agencies. There's a lot that really plays into what might hinder or get someone timely to syphilis or any type of a STI testing or treatment. And of course, another big thing, a big barrier is we might not have access to culturally competent services, so we may not feel that the provider or the facility is taking into account our traditional views or some of the things that we're taught. And then right now there's this big move to decolonize a lot of what we've learned. And part of that is also some of our understanding of sexualit, STIs. So these are all things that are happening around us. And it might play a part in getting to timely testing or treatment.

Amber-Rose
Great. Thank you so much, Faith, for that insight. So is there a stigma to getting tested for syphilis? And also, can you also talk about how a person is tested for syphilis?  

Rebecca
 So the syphilis test is typically going to be a blood test. So it typically means a vein a puncture. So they're going to put a needle in your arm to take a little sample of blood. And then there's actually going to be two tests that are run because the syphilis test is not specific. So the first test is going to be just positive or negative, and then the second test is going to give you a quantitative result. So it's going to give you an actual number and you can monitor that number to determine treatment response. You can look at it to determine if someone may have been re-infected. There's a lot of things that number can tell you. And so when you get tested, if you have one test that is positive, it should cause the second test to run to confirm that you truly have syphilis and it's a new infection. So that's the test. There's not a lot of great other options for testing. They're looking at finding other ways to test folks because, you know, just the act of getting a needle in your arm can be scary for folks. So that is something that our testing methodologies could probably improve upon is having more options for people. But right now, the blood test is typically the way that it's going to happen. There's a few fingerprint rapid tests, but sorry, finger sticks where it's just a little needle in your finger. But even that can be scary for folks. And as far as whether there's a stigma protesting, we wish there wasn't. Testing should be celebrated. It is a really important part of protecting your sexual health and the health of your family. But many people are nervous about getting tested. And it's really understandable because right now there's still a lot of stigma around the world and in our state and in our local communities associated with sexually transmitted infections. You know, we have clients who may not want others to know that they're sexually active or that they're engaging in, quote, risky behaviors, especially in small towns where if you're only testing option, is the same place where you have family members or friends who work there. Testing can be scary for that reason. Sometimes testing can be scary even when the infection is curable, like syphilis. Some people may not know that they've been infected. Again, these are often asymptomatic, so people are not going to have symptoms that they perceive. They're going to go unnoticed. So if they don't know that they've been infected or they don't know that you can get STIs like syphilis through anal and oral sex, not just vaginal sex, they know they need testing. And sometimes clients may not be aware that their partner has other sex partners, so they themselves may just have one partner, they may think that their partner only has them as a partner. But if that's not the case, they may not know that they actually need to be tested. And there is a little bit of a time where after infection you might have a false negative result. So you may think you're negative because your test told you you were negative and then later it turns positive. So that's also a problem. So we really do encourage testing for syphilis and other STIs. Regardless of what you think your risk, may be it's just a great way to take care of your sexual health, to take care of the health of your partners and your families as well.  

Amber-Rose
Great. I like how you say testing should be celebrated, you know, to reduce that stigma and get more people to get tested or get the tests that they need done to make sure that they're healthy, overall. So do all pregnant women get tested for STIs?

Cheryl
All pregnant women should get tested for STIs, but sometimes they don't. Not everyone has access to a provider who can test them, and even they do have a provider, the provider might not know their pregnant patient needs to be tested. So even in a setting where a STI testing is offered, a patient may also choose to opt out of the testing.

Amber-Rose
When does testing occur for a pregnant woman? Is it like the first prenatal care visit that they attend?

Cheryl
Right. So that is one of them. The person should be tested in their pregnancy at their first prenatal appointment early in the third trimester in that delivery.

Amber-Rose
Awesome. Thank you. Next question is what are the next steps for families after diagnosis or maybe after a positive diagnosis of syphilis?  

Bree
So the most important step after a diagnosis is getting timely treatment for you and your partners. The sooner you get treated, the more likely that your family will not experience bad outcomes from the infection. For pregnant women specifically, you can often prevent the poor outcomes from syphilis if you initiate treatment more than 30 days prior to delivery. But even if you miss that window, treatment is still really important and can prevent further health complications. That would also include babies that are born and are positive for delivery. Treatment can also help them prevent any further health complications as well. One of the hardest part about getting an STI is telling your partner, but public health is here to help. The Navajo Nation Department of Health and the County Health Department and the State Health Department all have contact tracers with specialized training in STI and HIV who can help with partner notification. This includes providing anonymous partner notification. When we do this, we don't disclose, disclose who tested positive. We only say that you that they have been exposed to a specific infection and we'd like to help them connect to care and treatment.  

Amber-Rose
 Thank you, Bree. So do you have any suggestions for mothers and their partners to ensure everyone is tested and treated?

Faith
One of the things they can do is ask their provider to test when they go in for their appointment and ask about the results of the tests. And others encourage partners to get tested and treatment. If you're struggling to complete your full treatment, your local health department may be able to help you get you the care you need. And try contacting the Navajo Nation Department of Health or County Health Department for additional support if needed. Keep in mind that a person can be re-infected after treatment and infections during pregnancy are particularly deadly to a newborn. So prevention throughout pregnancy is super important. And if you're not pregnant, but you have a relative or friend who is, you can still play a role in preventing congenital syphilis in the community. There are certain things you can do, like encourage the pregnant person, you know, to attend their prenatal appointments, ask them what they need to help with on the day of their appointment, and assist with what you can. Things that you can do or like offer or seek transportation to or from their appointments for them. If you're able to provide maybe even some gas or food money, because a lot of the people in our area do have to travel long distances to get to these appointments and also perhaps offer childcare. You feed the sheep or horses at home, prepare dinner for them. Just ask them what they need, might need some help with and offer what you're able to do. But if you don't know where to go for testing or treatment, IHS provides testing and treatment, and if you're living off the reservation, you can go to your local health department or visit the Find a clinic section on our website at AZDHS about go forward slash STD.

Amber-Rose
Awesome. Thank you. I like especially that you say like help out and feed the sheep, feed the pets. That is one way, you can, help encourage people to attend their appointments. And I really like how you pointed that out. So how long does treatment take before the syphilis goes away? I know you have been talking about, you know, once it's a diagnosis and then it's treated. Does that mean like a mother can't engage in sexual activity during that time of treatment, so can you explain that for me?  

 Rebecca
Great question. So the recommendation is to wait some. Seven days after treatment is completed before resuming sex. If that's not feasible, condoms are a great way to prevent transmission as well. Patients will likely stay reactive on one or more tests even after a successful treatment. That doesn't mean you still have syphilis. It's just again, those tests are not specific, so patients really should follow their provider's guidance for follow up testing to make sure they have cleared the infection. And then just keep in mind that you can be reinfected during pregnancy. So we said a little bit earlier that it's important to think about prevention during your pregnancy as well. So if you're resuming sex, just keep that in mind throughout your pregnancy.  

Amber-Rose
Thank you. How long can syphilis circulate in the body before the baby is affected?  

 Unfortunately, it's really not long at all. So say mom is infected right before delivery, she may not have even developed symptoms of a syphilis infection, yet she can still pass that infection to her baby. And the child may seem perfectly healthy and they might even test negative at delivery, but they could go on to develop symptoms and adverse outcomes from syphilis. We see some of the worst outcomes when moms are infected during pregnancy, and that's why we recommend testing three times during pregnancy. So that first prenatal visit early in the third trimester and then again at delivery. But the good news is, again, treatment is very good at preventing adverse outcomes.  

Amber-rose
Great. Thank you. What interventions are put into place to slow the number of cases?

Bree
So contact tracing to identify partners in need of treatment is an intervention. Early third trimester testing, preventive treatment for partners to prevent re-infection and also field based treatment to provide care within homes or in other non-clinical settings when travel is a barrier. Another great intervention that I'm sure everyone is familiar with are condoms or other type of barrier methods. Condom access to prevent STI's. A lot of the IHS and 638s have some condom walk ups requests either through the pharmacy or because you know what is going on with some hospital closures or if there are slow to reopening to the public. Some of the places have pharmacy drive thrus, and in those drive thrus, you can request condoms without having to see a provider. Also, there is the CHERP program or also Community Health, Education and Resiliency program. They also provide some mail out condoms so a person can go to their website and request condoms through there and they'll be mailed to them. And they do ship to P.O. Boxes.

Amber-Rose
Awesome. Those are such great resources. I'm glad that CHERP exists because I think that's really important for people who might not be able to ask IHS or other programs for condoms and also maybe education on preventing STIs and syphilis. So are there other resources families should know about in preventing syphilis?   

Rebecca
Sure! If you do have more questions about prevention or want to learn more, you can actually ask us directly at STI@azdhs.gov or you can visit us online at AZDHS.gov\STD And if you are interested in becoming an investigator and providing that linkage to care and services to your community. Not only are we at DHS recruiting for a few positions up north, but the Navajo Nation Department of Health Services is also hiring. So the Department of Health at North, they use the term social hygiene tech. So if you're interested in a position, you can go to their website at www.dpm.navajo-nns.gov\jobs and you can search for social hygiene tech positions.   

Cheryl
Hi Amber, this is Cheryl. I just wanted to add a resource for people out there that are looking for condoms. Luckily we here with the Arizona Department of Health Partners. That is actually where I got my condoms this past week. So, here in Western Agency, Navajo Nation, Western Agency, we do offer condoms here at gas stations. So there's several gas stations in the Cameron area, Leechee area, Tonal, Kaibeto, and Tuba City we've been supplying condoms. And then we also have our mobile health unit that have that we have supplied condoms to as well. And as well as when we are doing our contact tracing with COVID 19 patient deliveries, isolation kits that we deliver, we also include condoms. And that in that way too as well, and our office supplying them for several years now. But they're more than welcome to visit any office across Navajo Nation for these condoms. However, we do not mail them out, so but we try to make it accessible for them wherever they are at, maybe gas stations and places of business.  

Amber-Rose
 Wow, great. Thank you all for joining us today. I really appreciate your time and all of this valuable information you provided. I am so glad that we were able to do this. I'm so glad we're able to address this issue, especially when it comes to the health of our mothers and our babies. So thank you again.  

Rebecca
Just thanks so much for having us. It's always a pleasure to connect and be able to share information. And I know I learned things today, so thank you.  

Amber-Rose
Yes, thank you.

Outro
Ahe’hee. Thanks for listening to the MCH Podcast. For more information about the Diné College MCH project please visit Navajo MCH Project at Diné College on facebook.