E:\uncovering the effect of co morbidities on the houston syphilis outbreak and the hiv epidemic...

Uncovering the Effect of Co-morbidities on the Houston Syphilis Outbreak

and the HIV Epidemicthrough Epidemiological Analysis and Data Mapping

17th Texas HIV/STD Conference

Biru Yang; Hickmon Friday; Riju Stephen; Amanda Kubala; Lupita Thornton; Michael Thomas;

M. Aaron Sayegh Deborah BanerjeeHIV/STD Surveillance Program

Community Health Statistics ProgramBureau of HIV/STD & Viral Hepatitis Prevention

Sr. Health Planner/STD Data ManagerSTD Prevention Program

Bureau of HIV/STD & Viral HepatitisDisease Prevention & Control Division

Epidemiologist/BiostatisticianHIV/STD Surveillance Program

Bureau of EpidemiologyOffice of Surveillance and PHP Division

Collaboration

GIS AnalystCommunity Health Statistics

ProgramOffice of Surveillance and

PHP Division

Houstonians living with HIV/AIDSsignificantly contributed to and were affected by the

2007/2008 Syphilis Outbreak.

Outline• Collaboration• Study Objectives• Epidemiological Trend• Houston Syphilis Outbreak• Data matching• Data mapping• Conclusions• Limitations• Future Directions• Questions?

Biological Significance of Syphilis and HIV Co-morbidity

• Co-morbid STDs increase susceptibility of acquiring and transmitting HIV 2 to 5 fold

• Relapse of syphilis infection is more likely in the HIV-positive patient

The deadly duo

[Journal of the American Osteopathic Association, 2004 Nusbaum,M.R et al. ][Lancet Infect.Dis., 2004, Lynn,W.A et al. ]

Timing of Diagnoses Among the People with Co-Morbidity

• 62% still had unprotected sex 3 months after their HIV or Syphilis diagnoses.

Public Health Significance of Syphilis and HIV Co-morbidity

Same Time38%

HIV Diagnosis First48%

Syphilis Diagnosis

First14%

Objectives

1. To evaluate the effect of co-morbidities on the 2007-2008 Houston Syphilis Outbreak using epidemiological analysis

2. To emphasize the utility of spatial data analysis to public health events

Epidemiological Trend

Data Sources

• HIV/AIDS data stored in the HIV/AIDS Reporting System (eHARS)

• All STD data maintained in the Sexually Transmitted Disease Management Information System (STD*MIS)

HIV Cases by Diagnosis Year in Houston/Harris Co., TX 1999-2007

1433 1444 1423 1417

1159 1145 11471206 1193

1999 2000 2001 2002 2003 2004 2005 2006 2007

HIV Diagnosis Year

Trend of New HIV Diagnosis and HIV-Syphilis Co-Morbidity (n=11,567)

in Houston/Harris Co., TX 1999-2007

1999 2000 2001 2002 2003 2004 2005 2006 2007

HIV Diagnosis Year

HIV and SyphilisHIV Only

4% 4% 3% 5%

5% 6% 6% 7% 8%

Primary, Secondary and Early Latent Syphilis Cases by Diagnosis Year

1999 2000 2001 2002 2003 2004 2005 2006 2007Syphilis Diagnosis Year

es Early Latent SyphilisSecondary SyphilisPrimary Syphilis

Trend of New Syphilis Diagnosis and HIV-Syphilis Co-Morbidity (n=3,490)

1999 2000 2001 2002 2003 2004 2005 2006 2007

Syphilis Diagnosis Year

HIV and SyphilisSyphilis Only

22%30% 22%

Houston Syphilis Outbreak

2007-2008 Houston Syphilis Outbreak

• Outbreak: Number of cases exceed the expected number based on outbreak thresholds

• Multiple outbreak thresholds

• Exceeded outbreak threshold in June 2007

2007-2008 Houston Syphilis Outbreak

P & S Syphilis Thresholds: City-wide

Total White Afr. Am. Hispanic Other Unk24.5 6.8 12.4 5.1 0.2 0.18.1 2.6 7.3 2.3 0.4 0.2

32.6 9.5 19.7 7.4 0.6 0.340.6 12.1 26.9 9.8 1.0 0.5

Most Mar-07 30 9 15 6 0 0Recent Apr-07 33 7 20 5 0 1Data May-07 40 8 24 7 1 0

Jun-07 55 7 36 11 1 0Possible Mar-07Problem Apr-07 Warning Warning single

Areas May-07 Warning Warning singleJun-07 RR! RR! RR! single

Warning Level (Mean + 1 SD)Rapid Response Level (Mean + 2 SD)

Standard Deviation (36 months)

Mean # of cases/month (36 months)

Total P&S Cases in the Past Three YearsHouston/Harris Co.

Month of Diagnosis

* 2007 includes cases diagnosed and entered into STD*MIS through July 23rd

Total P&S Cases Among MSM in the Past Three Years, Houston/Harris Co.

Month of Diagnosis

* 2007 includes cases diagnosed and entered into STD*MIS through July 23rd

Houston Syphilis Outbreak Response Plan

• Enhanced surveillance– Weekly analysis of early Syphilis cases– Geographic mapping of cases by screening sites or by risk factors

• Disease investigation and follow-up activities– Syphilis interviews and partner elicitation/notification

• Outreach screening and education efforts– Increased Syphilis testing or referral for testing in high-risk individuals– Increased education/information about Syphilis for targeted populations

• Community involvement– Mobile unit screenings in collaboration with community partners

• Improved diagnostic and treatment methods– Expanded Syphilis Prophylaxis Treatment Protocol– Provider visit surveys

Houston Syphilis Outbreak Response Plan Participants

• Bureau chief of HIV/STD prevention

• STD program manager

• Surveillance• Syphilis elimination

coordinator• Public health advisor-

special projects coordinator

• Field operations (DIS)• Mobile clinic staff• Syphilis Elimination

Advisory Committee • Community-based

organizations• Community leaders

Syphilis Outbreak Response Effort

• Expanded prophylaxis treatment protocol• Targeted activities for enhanced surveillance• CBO’s and community mobilization• Syphilis rapid response mobile STD clinic

Disease Burden

• Houston ranks 2nd in the nation • 53% of early cases were detected in the

P&S stages in 2007• P&S Syphilis increased by 28% in January

through June of 2007 compared to the same period in 2006

• Approximately 1/3 of Houstonians with new Syphilis infections in 2007 were also HIV positive

Population & Geographic Areas

• MSM between 20-39 years old• Individuals who engage in anonymous sex• Individuals who exchange sex for drugs or

Geographic Areas of Interest

Area A

Area B

Area C

Data Matching

Matching Software: Link King

• Free software• Browser-based• SAS application but

no SAS experience is needed

• Allow manual review• Random sample

validationhttp://www.the-link-king.com/

Inclusion CriteriaHARS• 13 years and older at HIV diagnosis • Houston/Harris county residents

STD-MIS• Primary and Secondary Syphilis • Diagnosed in 2007 and 2008• 13 years and older at Syphilis diagnosis • Houston/Harris county residents

833 records(STD*MIS)2007-2008

Matching Results in Houston/Harris Co., TX

35,995 records(eHARS)

1983-2010

263 linkages

Among 833 Syphilis cases, 246 (30%) had an HIV diagnosis before or during the Syphilis Outbreak

Demographics of People with HIV-Syphilis Co-Morbidities (n=246)

By Sex

• Most of the HIV-Syphilis co-morbidity were in young men between 20-39 years old

By Age Group

Female5%

Male95%

30-3930%

20-2950%

13-197%

40-4911%

Demographics of People with HIV-Syphilis Co-Morbidities (n=246)

By Race/Ethnicity

• African Americans accounted for 54% of the co-morbidity

Black54%

Other2%

White22%

Hispanic22%

Risk Factors of People with HIV-Syphilis Co-Morbidities (n=246)

By Risk Group

• MSM accounted for 80% of the co-morbidity

MSM/IDU3%

MSM80%

Heterosex 9%

Risk Not Identified

Data Mapping

Average Rates of HIV by Zip Codes (1999-2008)

Area A

Area B

Area C

Average Rates of Syphilis by Zip Codes (1999-2008)

Area A

Area B

Area C

Comparison: Average Rates of HIV and Syphilis

by Zip Codes (1999-2008)

HIV Syphilis

Area A

Area B

Area C

Area A

Area B

Area C

Spatial Distribution of Syphilis Casesin Houston/Harris Co., TX 2001-2005

Female

Spatial Distribution of Syphilis Casesin Houston/Harris Co., TX 2006

Spatial Distribution of Syphilis cases (n=833)

Spatial Distribution of HIV-Syphilis Co-morbid cases (n=246)

Education

Linguistic Isolation

Poverty

Location of Facilities/Providers where Syphilis Diagnoses occurred

Area A

Area B

Area C

Mobile clinic visits vs. HIV cases in Houston/Harris Co., TX 2007

6 - 15

16 - 27

28 - 40

41 - 95

Height= Mobile clinic outreach frequency

Area A

Area B

Area C

Mobile clinic visits vs. HIV cases in Houston/Harris Co., TX 2008

6 - 15

16 - 27

28 - 40

41 - 95

Height= Mobile clinic outreach frequency

Area A

Area BArea C

Conclusions

• Most of the HIV+ individuals who contracted Syphilis during the Outbreak were – African American– Aged 20-39 at HIV diagnosis– MSM– Living in the same area where the Syphilis

outbreak occurred

Conclusions

• Houston Syphilis Outbreak Response Plan outlines coordinated efforts between the health department and community partners to reduce the outbreak episodes

• Data mapping helped the Outbreak Response target activities for enhanced surveillance and continued follow-up

Take Home Message

Houstonians living with HIV/AIDSsignificantly contributed to and were affected by the

2007/2008 Syphilis Outbreak.

Limitations

• Incomplete addresses • Only included one syphilis diagnosis• Limited behavior information

Future Directions

• Collaborations• Investigate the syphilis re-infection rate

among HIV+• Design better intervention strategies to

focus at HIV+ individuals• Evaluate the effect of education, linguistic

isolation and poverty on Co-morbidities

Acknowledgements

The HDHHS HIV/STD Surveillance ProgramThe HDHHS HIV/STD Prevention ProgramThe Community Health Statistics Program

Bureau of EpidemiologyAdelowale Awosika-Olumo, Bureau ChiefBureau of HIV/STD & Viral Hepatitis Prevention Marlene McNeese-Ward, Bureau Chief

Sources of Support: This study was supported by Cooperative Agreements. Its contents are solely the responsibility of the authors and do not represent the official views of the funding agencies

References• [Journal of the American Osteopathic Association, 2004

Nusbaum,M.R. ; Wallace,R.R.; Slatt,L.M.; Kondrad,E.C. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus]

• [Lancet Infect.Dis., 2004, Lynn,W.A.; Lightman,S. Syphilis and HIV: a dangerous combination]

Thank you!!

Biru Yang, PhD, MPH HIV EpidemiologistBureau of EpidemiologyHouston Department of Health and Human ServicesTel: 713-794-9181E-mail: Biru.Yang@cityofhouston.net

Questions?

E:\uncovering the effect of co morbidities on the houston syphilis outbreak and the hiv epidemic...

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