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
0
200
400
600
800
1000
1200
1400
1600
1999 2000 2001 2002 2003 2004 2005 2006 2007
HIV Diagnosis Year
Num
ber o
f Cas
es
Trend of New HIV Diagnosis and HIV-Syphilis Co-Morbidity (n=11,567)
in Houston/Harris Co., TX 1999-2007
0
200
400
600
800
1000
1200
1400
1600
1999 2000 2001 2002 2003 2004 2005 2006 2007
HIV Diagnosis Year
Num
ber o
f Cas
es
HIV and SyphilisHIV Only
4% 4% 3% 5%
5% 6% 6% 7% 8%
Primary, Secondary and Early Latent Syphilis Cases by Diagnosis Year
in Houston/Harris Co., TX 1999-2007
0
100
200
300
400
500
600
700
800
900
1999 2000 2001 2002 2003 2004 2005 2006 2007Syphilis Diagnosis Year
Num
ber o
f Syp
hilis
Cas
es Early Latent SyphilisSecondary SyphilisPrimary Syphilis
Trend of New Syphilis Diagnosis and HIV-Syphilis Co-Morbidity (n=3,490)
in Houston/Harris Co., TX 1999-2007
0
100
200
300
400
500
600
700
800
900
1999 2000 2001 2002 2003 2004 2005 2006 2007
Syphilis Diagnosis Year
Num
ber o
f Cas
es
HIV and SyphilisSyphilis Only
6%
8%9%
23%
22%30% 22%
26%
24%
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)
Race
Mean # of cases/month (36 months)
Total P&S Cases in the Past Three YearsHouston/Harris Co.
0
10
20
30
40
50
60M
ay-0
4Ju
n-04
Jul-0
4Au
g-04
Sep-
04O
ct-0
4N
ov-0
4D
ec-0
4Ja
n-05
Feb-
05M
ar-0
5Ap
r-05
May
-05
Jun-
05Ju
l-05
Aug-
05Se
p-05
Oct
-05
Nov
-05
Dec
-05
Jan-
06Fe
b-06
Mar
-06
Apr-
06M
ay-0
6Ju
n-06
Jul-0
6Au
g-06
Sep-
06O
ct-0
6N
ov-0
6D
ec-0
6Ja
n-07
Feb-
07M
ar-0
7Ap
r-07
May
-07
Jun-
07
Month of Diagnosis
Num
ber o
f Cas
es
* 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.
0
5
10
15
20
25
30M
ay-0
4Ju
n-04
Jul-0
4Au
g-04
Sep-
04O
ct-0
4N
ov-0
4D
ec-0
4Ja
n-05
Feb-
05M
ar-0
5Ap
r-05
May
-05
Jun-
05Ju
l-05
Aug-
05Se
p-05
Oct
-05
Nov
-05
Dec
-05
Jan-
06Fe
b-06
Mar
-06
Apr-
06M
ay-0
6Ju
n-06
Jul-0
6Au
g-06
Sep-
06O
ct-0
6N
ov-0
6D
ec-0
6Ja
n-07
Feb-
07M
ar-0
7Ap
r-07
May
-07
Jun-
07
Month of Diagnosis
Num
ber o
f Cas
es
* 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
money
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)
in Houston/Harris Co., TX 2007-2008
By Sex
• Most of the HIV-Syphilis co-morbidity were in young men between 20-39 years old
By Age Group
Female5%
Male95%
50+
30-3930%
20-2950%
13-197%
40-4911%
Demographics of People with HIV-Syphilis Co-Morbidities (n=246)
in Houston/Harris Co., TX 2007-2008
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)
in Houston/Harris Co., TX 2007-2008
By Risk Group
• MSM accounted for 80% of the co-morbidity
MSM/IDU3%
IDU4%
MSM80%
Heterosex 9%
Risk Not Identified
4%
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
2001
2002
2003
2004
2005
Spatial Distribution of Syphilis Casesin Houston/Harris Co., TX 2001-2005
Female
Male
Spatial Distribution of Syphilis Casesin Houston/Harris Co., TX 2006
Spatial Distribution of Syphilis cases (n=833)
in Houston/Harris Co., TX 2007-2008
Spatial Distribution of HIV-Syphilis Co-morbid cases (n=246)
in Houston/Harris Co., TX 2007-2008
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
0 - 5
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
0 - 5
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: [email protected]
Questions?
