Thanks for joining us at the Canadian Breakpoint, a Canadian infectious diseases podcast by
Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases physician
from Saskatoon.
Today we're bringing you a highly requested topic, congenital syphilis, and we welcome
Dr. Jared Bullard, provincial laboratory section head of pediatric infectious diseases in Winnipeg,
as well as Dr. Karsten Kruger, antimicrobial stewardship fellow at CHEO.
Dr. Purewal.
All right, welcome everyone.
Thank you so much for joining us for another episode of our podcast, the Canadian Breakpoint.
Today we have two very special guests on our podcast, who will be talking a little bit
about epidemiology and our project for congenital syphilis in Canada.
So we have Dr. Jared Bullard and Dr. Karsten Kruger.
Dr. Jared Bullard was born in Nassau, Bahamas, and moved to Winnipeg with his family when
he was young.
He is a product of Manitoba training, having completed his medical degree, including DSE
in HIV immunology, pediatric and medical microbiology, and residencies and a fellowship in infectious
diseases all through the University of Manitoba.
He is currently the section head of pediatric infectious diseases and associate professor
in the departments of pediatrics and child health and medical microbiology and infectious
diseases.
During the pandemic, Dr. Bullard helped define the methodology for studying the infectivity
of SARS-CoV-2 and the clinical spectrum of COVID in Canadian children.
He is currently working towards redefining the epidemiology diagnosis and management
of congenital syphilis.
His personal interests include his family, wife, Dr. Pamela Skrabeck, and future Dr.
Bullard's daughter, Taya, and son Donovan, traveling and high level of sarcasm.
And then we have Dr. Kruger.
Dr. Karsten Kruger attended medical school at the University of Calgary, pediatrics residency
at the University of Toronto, and an ID fellowship at the University of Ottawa.
Currently he is completing an antimicrobial stewardship fellowship at CHEO and is co-principal
investigator of the National Canadian Pediatric Surveillance Program, also known as CPSP study,
on congenital syphilis.
So welcome.
Thank you.
Happy to be here.
Thanks for having us.
Awesome.
So today we're going to be talking about a very important topic.
I think we've seen some media coverage around this.
In our local hospitals, I think province-wide, where I'm in Saskatchewan, Dr. Bullard's in
Manitoba, we're definitely seeing a rise in our numbers here as well.
And so kind of without further ado, I think I'll hand it over to Dr. Bullard to let us
know a little bit about the epidemiology.
So our podcast is really geared towards all audiences.
So we have nurses, pharmacists, physicians, trainees, and really across the world.
So why don't we talk a little bit about the epidemiology in Canada in the last few years
and specifically focusing on congenital syphilis.
Yeah.
When I think about this, and I've had a fall of seven years or so at this point to really
dig into it, syphilis has been making a comeback in Canada in very specific populations.
And so when we were first seeing it, and it's kind of across the country as well in larger
urban centres, we were thinking primarily our GVMSN population.
Right.
And that was a variety of different reasons that was occurring.
Part of it was in the early 2010s, more related to applications that were used for anonymous
sex.
And there was many challenges with that.
And as a result, we started to see more and more cases of syphilis.
As public health started to get a little bit more involved, trying to leverage how to use
these applications and softwares, they managed to get kind of a hold on it to some degree
in the GVMSN population.
But simultaneously, we were starting to see increases in our heterosexual populations
as well.
Right.
And we've seen that with other STIs as well.
Gradually, what you saw was a migration of syphilis specifically into certain different
populations.
And so when we're talking about the Prairie provinces in particular, we were seeing it
in our Indigenous First Nations populations, both urban, remote and northern communities.
And a lot of that has to do with factories associated with being Indigenous, which I
think Carson will talk about quite a bit more from our study.
I think a lot of us are very familiar with the poverty and substance use and mental health
and all the access to health care.
And because you suddenly have it in the heterosexual population, you have it in women of reproductive
age as well.
And from that, it stems that if you aren't managing to find all of the women who have
syphilis, we're not diagnosing it, we're not treating it.
We'll see more higher syphilis clothing since that's where we started to see a lot more
cases.
Now, Alberta kind of gave us a little bit of an early hint to it in the 2000s, saying
like, we have a problem.
We have syphilis numbers in babies that were potentially higher than anywhere else in the
country.
It subsequently went away.
But then now, seeing it again, primarily Prairie provinces, using these boxes for it.
And then with the COVID pandemic, it really just kind of has not been able to be addressed
as much as it possibly could.
Yeah, no, that's fair.
Yeah, I think most of our data, so I think Carson will bring this up as well.
But just looking at the rates, I mean, definitely Alberta was leading and then Saskatchewan,
Manitoba kind of trailing behind.
And really, in terms of the last few years, we've really seen the spikes in congenital
syphilis and really focusing on that childbearing age, women of childbearing age being infected.
So when did...
So in my experience, CPSP, which is the Canadian Pediatric Surveillance Program, usually targets
rare infections when we're doing surveillance.
So how did syphilis kind of make, I guess, its appearance in CPSP's reporting?
How did that come about?
Yeah, so the CPSP is a joint program of the Canadian Pediatric Society and Public Health
Agency of Canada and aims to improve health of children by facilitating surveillance and
research into any manner of childhood disorders that are high in disability, morbidity, or
cost to society, despite their relative rarity.
It came to the attention of the CPS Committee in the late 2010s when you really started
to see an increase in nationally reported cases of congenital syphilis.
And so myself, as a previous member of that committee, put together a team with Dr. Bullard
to help surveil this and try to understand the Canadian landscape of how we could prevent
it and how it was presenting and how it was being managed.
Oh, that's really important.
So I think definitely seeing the trends over time, looking at, I think a lot of us locally
are also trying to see, and we're trying to see over the last few years, why is this happening?
What population is this happening in?
But it's nice that we have a central collaboration now with other centers and larger centers,
which can also help out some of the smaller centers that are seeing this rise in numbers
because obviously you need funding and support systems from a public health standpoint as
well.
Right?
So we're very fortunate that we were able to do a project like this.
I think, Kristen, you brought up kind of the main objectives of the project, but just for
our listeners, just so they know kind of what was the clinical question or the hypothesis
that we, or what are we trying to aim from this project?
So as a surveillance study, we predominantly had objectives rather than hypotheses, but
we aimed to describe the minimum incidence and distribution of cases nationally of confirmed
and probable congenital syphilis cases.
We also wanted to identify common risk factors of pregnant people who had an affected infant
and the treatment they received during pregnancy.
And then finally, we also wanted to describe the testing management and complications of
infants with confirmed or probable congenital syphilis.
Yeah.
So really looking at it from many multiple angles, which is, I think, the way that we
have to look at congenital syphilis and these rates because there's a lot of moving parts.
There is, I think even in our study, you guys will probably talk about this as well.
Just kind of looking at the risk factors and reinfection rates.
I mean, there's so many layers to this, right?
And that's kind of what we're seeing locally as well.
So I know a lot of our audience is excited to hear what are the preliminary study findings
and really what were the results.
And I guess just for the audience to be aware, the study started back in our data is from
January 2022, right, till December 31st.
I think it was June 2021 was when the study started.
Okay.
Perfect.
And so, and basically, and it's still ongoing, just so that our audience knows, and that's
kind of why there's some preliminary results.
So do you want to maybe give our audience some of the results and then we can all talk
about and kind of elaborate on the areas of it as well?
Sure.
So to date, we've had 166 cases of confirmed or probable congenital syphilis reported through
the study infrastructure.
You know, the mean age of birthing parent was 27 years, but there was a wide range,
17 to 39.
You know, many of the individuals lived in an urban area, predominantly two thirds, and
a third of them were from rural areas.
The prairies were overrepresented, but sort of 79, 80% of all reported cases coming from
there.
The population groups of the pregnant people were largely unknown, 40% of them were unknown,
45% were reported as having First Nations background, though this was all physician
reported.
Right.
And then sort of moving into the risk factors, there was a large amount of unknown data,
keep in mind that we're surveilling pediatricians who may not have access to the pregnant person's
chart or these questions may not have been asked.
But the most common risk factor we saw was substance use in pregnancy.
So that was present in 66% of cases, and then was followed with, you know, previous child
protection involvement sort of in about a third of cases.
You know, but things like housing insecurity and social assistance, you know, those were
less well known to pediatricians.
You know, in terms of substances that were used, methamphetamines were the most common,
sort of representing about half of the right substances.
Okay.
You know, it's important to note, though, that although this study, like reports on
substance use as a risk factor, you know, substance use in the context of like structural
risk factors like houselessness and income inadequacy, gendered and racial violence,
these things are important and couldn't be well described in our data set.
But you know, substance use we did find was associated with increased odds of inadequate
prenatal care, lack of maternal treatment and a diagnosed sexually transmitted or blood
porn co infection with significant P values.
Okay.
Yeah, so some of the data I mean, that you're presenting definitely is kind of consistent
with more like resources that are available.
You know, housing, for instance, and just kind of commenting on the factors about most
of the cases were reported from urban centers.
This was in your guys's study, based off of where the testing was done or where the treatment
was obtained.
This was based on the patient's postal code, actually.
Okay.
Yeah.
And yeah, I know like in Saskatchewan locally, there are a lot of although people may be
living in a remote community, their addresses could be, you know, listed in more urban center
for multiple reasons and also migration, right?
So people are moving around and that type of thing.
But so that was something that kind of stuck out to me about your guys's preliminary studies
as well.
But I think a couple of the factors that you're mentioning here all kind of go down to things
that, you know, public health has been watching is really in the part of the public health
sector, resources, prenatal care.
Is it access to care?
You know, that's always a question whenever we think about these rates increasing.
Is it lack of awareness in certain communities?
So I don't know if Dr. Buller, do you want to maybe touch on some of that?
Because I'm sure Manitoba and Saskatchewan are probably seeing a similar trend in terms
of why this is happening.
You're right.
I mean, Saskatchewan and Manitoba have a number of parallels that we can draw on.
When I look at what's been going on with congenital tippus, there's two things that you mentioned
already, the preventative strategies that we can employ and the appropriate endorsing
of those strategies.
And I think that's one of the main things that this study is hoping to inform.
Because we were looking at the case definitions, which is something that public health uses
to say this is the number of kids that were high risk enough that they weren't in treatment.
But we've written that down into probable and confirmed, which we still do.
Now, if you're to look at who ultimately becomes confirmed, that's a small portion of the high
risk exposed infants, when we consider probable.
Right.
And if we eliminate that, we've got maybe a third half of the number.
And so the scope of the problem seems to be less than it actually is.
When in reality, you know, you're spending about 15 to $20,000 per high risk, sickly
controlled child for quality treatment and investigation in the hospital.
And so that's the first step.
You really have to think this is the scope of the problem, what's going on.
And the next point would be to get appropriately a resource for that.
Now, prevention in public health is huge.
That's what their focus is.
Right.
And so there's a variety of ways we can do that.
A lot of it is kind of testing, tracing, and that works okay.
And it works fairly well when we're talking about our GBMSM populations.
But as you kind of alluded to, then, our sublutena is very similar to Gatch when we have our
indigenous population, which has a lot of migration, to be the right word, but they
go from the city up north to the reserve and back.
And it's not really clear where they always are or what their primary residence is.
Yeah.
So that makes it hard to do that contact tracing.
So I think novel strategies kind of have to be employed as well.
But I'm sure there's other things too to say.
I can keep going through.
But I think that, yeah, that's part of what we were looking at too is to say this is,
you know, the actual scope of the problem.
These are the preventative strategies that we think have been used in different provinces.
How effective have they been?
Novel strategies that we can employ because the testing, tracing, and tracing is good,
but it's not seemingly enough at this point.
Yeah, like it's not capturing, I think, the population entirely.
And that's, I think, where we're still getting some of these missed cases where, you know,
where they'll have no prenatal care and no access to the care, but then also we'll have
reinfection rates, right?
So that goes back to contact tracing and treating, testing.
A lot of our centers, we don't have, you know, labs that are testing in all centers.
So some of the samples in our northern communities are going, you know, traveling, the samples
traveling a few hours before we can actually get testing and the turnaround time for testing
is long.
And I know I actually, in my first season, had Dr. Amita Singh come on, who is one of
our STI specialists out in Alberta.
And she talked a lot about her study with the point of care tests.
And I know we've, you know, done a pilot project, implemented some of these measures.
But again, does it really focus on testing and treating when you can't capture some of
this population?
So again, it's multifactorial.
And I think we've kind of brought that up.
But really for this study, kind of the aim, I think this is probably one of the first
studies that I've seen in Canada, across Canada, that's looked at numbers and really looked
at some of these risk factors that we're identifying, because I think that's where some of the hurdle
was is that we don't have a national, prior to this, to my knowledge, and you guys can
correct me if I'm wrong, we didn't really have a national database for these cases that
we were seeing.
And I think it was more so local public health departments that are really putting this data
into their databases, analyzing it at the local standpoint.
But really, I think it's a larger, it's a national problem.
And should be.
And so I'm excited that we finally have something where we can report these cases, because I
think it's important to look at the trends, right?
So trends that we're seeing, not just in one community, but overall.
And is that correct?
Is this the first kind of large study that we've done in congenital self-lessing Canada?
Yeah, I would say so.
Yeah, you hit the nail right on the head.
This study generated a lot of public health interest, just given the paucity of case-level
data.
The national reporting is one thing, but it doesn't have the amount of detail that our
study has.
Yeah.
And I think, Jared, you brought up another really good important point, which is the
costs that we are seeing.
So costs of treating, testing, treating these infants, even if they fall into the probable
case.
I mean, first step is really, I think the case definitions, and I agree with you, that's
where my challenges were here.
Really working with public health, like here, closely working with public health, but having
kind of different impressions of really what is a confirmed case versus a probable case.
And I think that's so challenging when you're looking at it from a research standpoint and
when you're looking at it from a clinical standpoint, right?
Because some of the data doesn't really overlap and it's challenging from that standpoint.
But then when we look at how many cases, so I think there is some under-reporting for
sure and really minimizing the problem when it is actually larger scale, especially when
you're looking at it from a clinical lens.
And so I think with having a study like this, where we do have a case definition, where
even though it's voluntary reporting, so there are some challenges with that, but I think
having something that's more centralized and almost a unified case definition for all of
us to report these cases, I think is already the first step and the objective for me for
this study.
It was fantastic to see that we could actually all use same case definition and submit these
cases because we know from a clinical standpoint, we're definitely seeing more congenital syphilis
than what the numbers are showing.
So looking point for sure is like here in Manitoba, we have our clinical database of
all the congenital syphilis cases and then public health has their data for all the cases.
And the lab has their database.
When we line them all up, you're like, wow, they're quite different.
Why are they so different?
And that case definition is huge because we have a national case definition and then we
have all the provincial ones too.
And so that's actually something that I've been working on is to realign the case definition.
And it is in fact informed and based on the work that Carson and I and our co-investigators
did that we're trying to make it so that everybody's saying the same thing.
Right.
Yeah, that's huge.
Sorry, Carson, I think I cut you off when you were talking about some of the preliminary
findings there.
Was there anything, I think you had wanted to touch probably a little bit about some
of the treatment and the outcomes and the congenital syphilis cases as well.
Oh yeah.
And just kind of touching on what you had mentioned before, in terms of pregnant people
coming with no prenatal care, about a quarter of our cases we saw that in and only about
another quarter had at least one prenatal visit per trimester.
So a significant portion of people had no screening in pregnancy.
And then of those who did screen positive, about 20% actually didn't end up getting treated
for one reason or another.
We did see that chlamydia and gonorrhea co-infection were fairly common.
And then in terms of the babies, recognizing that we don't know what we don't know in
terms of missed cases, but of those that were reported to us, most of them were diagnosed
within the first month of birth, 97%.
And then about 90% of them had a treatment initiated within the first week of life.
But as you've probably seen, many, over half of our babies had no exam findings of congenital
syphilis.
And so likely would have fallen into that probable category rather than confirmed and
flown under the radar of the national case definition.
Right.
Yeah.
And I think this is always challenging about congenital infections is there's... because
asymptomatic is our most common presentation of most congenital infections.
And so I don't know, this is a challenge I face clinically too, right?
So you're trying to explain to even parents who did get treatment, but then let's say
got reinfected or did not have an adequate response to treatment and trying to tell them
that we still have to treat their infant, although they don't have any clinical findings.
And so I think this is always something that's challenging.
It's brought up by maternal services, it's brought up by NICU doctors.
It's challenging, but I do want... and I haven't done a full congenital syphilis episode because
I'm waiting for our new CPS statement to be released.
And so we'll have Dr. Fennell actually come on an episode as well and talk a lot about
more of the clinical characteristics and et cetera.
So I won't go into that because really this is today's... although I have lots to say
about all of that, but I think today we'll focus a little bit more on the study itself.
So is there something else that you wanted to touch on, Karsten, in terms of the preliminary
findings before we kind of talk about...
So what is all this data going to help us do?
I want answers, right?
Because I'm like part of the...
I'm the group that's like crying for help and I need, I guess, another angle to look
at it.
I don't think what we're currently doing is covering everything and that's challenging.
Yeah.
I think that the study is a good starting place in terms of describing some of the social
factors that could be driving syphilis recurrence sort of across Canada.
I think what this study has shown from a high level is that it's hard for us to sort of
identify the specific drivers of syphilis in specific geographic locales within Canada.
Jared had said it best before, I think that we don't just have one syphilis epidemic in
Canada, we have several.
And the drivers of syphilis are different within each community.
And so I think what we will need to do is look at sort of at a more granular level,
what are the barriers to prenatal care?
What are the predisposing factors to reinfection and pregnancy?
And try to work with public health and patients in their communities to develop these bespoke
prevention strategies that are so desperately needed rather than a one size fits all solution.
But the association that we were able to detect even with our large amount of missing data
of substance use should prompt public health, I think, to continue working to ameliorate
the social circumstances that predispose to that use.
I would agree with that and expand on, there are a couple things that we've done here in
Manitoba already since 2016.
We've been doing prenatal testing for all that CBI for a second delivery as well.
And that actually results in capturing a number of children who we find out are high.
But it's very helpful.
But like you in Saskatchewan, we also see women that we did find early in their pregnancy
who got appropriately treated or responded neurologically and then got reinfected right
around delivery.
So without dealing with whatever the fundamental multifactorial issues are, we're not really
going to get on top of that.
And looking at the different populations, one of the things that we really have said
is, well, maybe we really need to have a much more holistic Indigenous led approach here
in Manitoba, which I think could apply in Alberta and Saskatchewan as well.
So we have an initiative that just started very recently here, but we're hoping that
that is much more well received in general.
Because a lot of the more traditional methods of public health aren't quite achieving the
goals we want it to.
And like you, it's quite frustrating to see these children over and over infected.
And it becomes normal, you said, whether you're used to subscribing to HIV medications, you
can tell a person what you do for syphilis and you don't even have to think about it.
Yeah, it's scary.
Yeah.
It's just not right.
Yeah, no, I definitely, you know, I think the challenge we had here in Saskatchewan,
like initially it was a lot of it was awareness, right?
So like prescriber and physician awareness of testing and making sure to test.
So we've also with the help of public health, been able to do a lot of prenatal testing.
And I think because syphilis is on everybody's radar in the communities, people out in the
communities, because we're not seeing them, you know, the patients out in the community.
And so really having our kind of GPs, family doctors, internists who are actually involved
in their care in maternal care, initially, you know, having them test and treat has really
been part of what we've been focusing on.
But apart from awareness, you know, I brought up something with our public health department
here is that I don't think it's only awareness to a physician level or nursing level.
I think we need to build awareness to the public and something that public health should
deal, you know, is dealing with and is constantly doing that is connecting kind of our resources
to our public.
And so we have started to do some ad campaigns and, you know, local community discussions
in regards to, you know, moms of this birthing age that are trying, you know, are trying
to conceive or, you know, where we're seeing high rates of syphilis to really show them
like what can syphilis do if you do treat yourself and what we can prevent your child
from having.
And I think that's been kind of the angle that we've switched our, at least our webinars
and our awareness talks to.
But again, it's still, you know, I mean, this is a huge problem.
This is not going to be a one fix, one step, and then it's all fixed, right?
So it's going to, like we just talked about, it's multifactorial.
We're going to have to, yeah, I wish it was a snap of the finger.
That would be, it would make our lives easier.
But it's preventative, right?
And that's why we're here today.
We're talking about preventing syphilis because we all know that we can treat congenital syphilis.
We've done it.
We've seen the outcomes.
We've seen our study.
We've seen that most kids that we do identify get treated in the first week, you know, and
they don't have poor outcomes because we can treat them.
But we need to stop them from getting to the stage that Jared and I and Kirsten are seeing
them at.
We need to prevent all of that from even happening.
And so I think that's kind of where our focus is with this study and implementing some of
this.
So I think it's really important to look at risk factors because that's where prevention
really is going to aim at.
So I'm really happy that we were able to have this discussion.
So what is the future of our project?
What are we doing?
What's going forward?
I mean, we're obviously still reporting.
That's one of the things.
And so is there a second kind of analysis that's coming up or?
I think Jerry can speak to this a bit, but we're looking at seeing the cases that were
reported and really sess out which of them would have been captured by the national definition
versus those that were only captured by our study definition, just to sort of highlight
how big of a discrepancy and how big the body of that submerged iceberg is in terms of congenital
syphilis in Canada, at least an estimate of that.
The other thing that we thought about is now we received a message loud and clear from
pediatricians that the barriers of these pregnant people to engaging in prenatal care and preventing
infection are not known to them.
And so I think we have to go to these families and communities and partner with them to try
to identify at a really granular and local level what the barriers they're experiencing
are so that we can help develop those effective community led prevention strategies.
So that's something that I think Jared and I are looking into in the future.
And I'd be really excited to hear what those findings might be later.
Yeah, that's fair.
I think that we have a really great opportunity here.
The study though is only going to be the next couple of months before it's shut down.
I do encourage people if you have cases, it's important to provide that data.
And I do really appreciate the burden of that is falling on certain provinces and practitioners
to provide it.
And that's true here too.
I think that we can try to get this data if it's important.
I think it's a very useful study in a number of ways.
I think that there will be a need to sit down and then discuss what are we going to do next?
Because we're going to need to measure if our interventions on a public health level
are effective or not.
Repeating this study down the road five years, what have you, might be an important step
to take.
Yeah.
And that's a really good, like important point that you bring up is that it has to be measurable.
So it's difficult, right now, a lot of our public health interventions that we've implemented,
there aren't a lot of repeat or relooks at how measurable this intervention was.
And so is it really helping?
Are we seeing cost effectiveness in our strategies?
I think all of that.
And so definitely here locally, I've done some talks recently with public health and
I already informed them that we're having this episode and that I will be sharing it
with them.
So I urge people to share this with public health, your local public health departments,
because I think some of this will bring out awareness and kind of help guide, is there
some areas that maybe some of us aren't looking at, right?
So some of the risk factors that we really need to tackle, are we looking at it from
all angles?
So before we end the episode, what are some of the kind of key messages that either of
you would like to give our audience, our healthcare professionals out there, public health departments,
kind of what you've learned from the study and may help smaller centers?
Because I know that we don't all have resources in all centers to kind of implement every
intervention, but if we can do anything, what would be some of the key points that you guys
would let us give us an overview for?
I mean, I think people are doing a tremendous job with the resources that they have available
to them.
So just keep up the good work.
If you think about there being a possibility of a pregnant person becoming infected or
reinfected with syphilis during pregnancy, like test, treat, identifying these cases
early for congenital syphilis, it's just so important for their long-term outcomes that
no baby should be discharged without knowing their syphilis status or at least having that
test be pending.
Yeah, and I think I would echo much of that.
The people here in Manitoba and our public health MOHs have been really excellent.
They have a number of infectious disease specialists, health analysts, and pediatricians who work
together to try to make sure that we're getting the needed.
We have a high prevalence of syphilis, so that's why we implemented doing regular prenatal
testing.
And it's important, like Karthik said, make sure that you actually get these carrots for
all of these in the mom and babies as they're born, because that's really important to make
a future decision on what's going on.
Now, none of that necessarily helped in eliminating or preventing this, right?
This is finding new cases, we're treating new cases.
So I think that's going to take a little bit more of a coordinated effort.
I think that many of the problems with where we have high numbers are looking at strategies
and starting to look at some more novel strategies as well, which is encouraging.
And then on the national stage, we have lots of work with definitions, exploratory diagnostics,
and innovative ways of reaching populations.
We have good research coming out talking about different ways we can potentially just treat
and common in STDI.
So there's lots being done.
And I think that I'm seeing, and I think with the redirection of all of our resources post-COVID,
we should be able to hopefully scratch the surface at the very least or make a good dent.
Yeah, now you bring up a fair point.
That's great.
So I think definitely I learned a lot from this study.
I have obviously am in a center where we are seeing a lot of congenital syphilis.
We've done a lot from our public health.
We have a good relationship, I think, ID and public health here that we're able to, we're
lucky that we can implement some of the strategies.
And I think we'll continue to work on those.
But I think definitely looking at some of the risk factors from this study gave me a
good kind of overview of maybe some of the areas that we are missing.
And so hopefully with our next set of analysis, we'll get more information and we'll continue
to report on our end.
So I really want to thank both of you for coming on the podcast.
This was much awaited podcast.
I've had a lot of requests actually from some of the local physicians here, those that have
been reporting just to kind of see what, where is the preliminary, like, you know, what all
our hard work of reporting, what are we seeing?
So I think it was fantastic to have two of our experts in the area on our podcast today.
Before we end the episode, I do want to let everybody know that this is an informational
podcast and there's no way to endorse a product or study and is not in place of an infectious
disease consultation.
Thanks Jared and thanks Carson.
Thank you, Dr. Pirawal and a special thank you to Dr. Bullard and Dr. Kruger.
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