Uncovering the Effect of Co-morbidities
  on the Houston Syphilis Outbreak
        and the HIV Epidemic
   through Epidemi...
Collaboration


    Epidemiologist/Biostatistician        Sr. Health Planner/STD Data Manager
     HIV/STD Surveillance Pr...
Houstonians living with HIV/AIDS
   significantly contributed to
    and were affected by the
 2007/2008 Syphilis Outbreak.
Outline
•   Collaboration
•   Study Objectives
•   Epidemiological Trend
•   Houston Syphilis Outbreak
•   Data matching
•...
Biological Significance of
   Syphilis and HIV Co-morbidity

                                                        The d...
Public Health Significance of
    Syphilis and HIV Co-morbidity
Timing of Diagnoses Among the
   People with Co-Morbidity
...
Objectives
1. To evaluate the effect of co-morbidities
   on the 2007-2008 Houston Syphilis
   Outbreak using epidemiologi...
Epidemiological Trend
Data Sources




• HIV/AIDS data stored in the HIV/AIDS
  Reporting System (eHARS)
• All STD data maintained in the Sexual...
HIV Cases by Diagnosis Year
                                   in Houston/Harris Co., TX 1999-2007

                  1600...
Trend of New HIV Diagnosis and
        HIV-Syphilis Co-Morbidity (n=11,567)
                                     in Housto...
Primary, Secondary and Early Latent
 Syphilis Cases by Diagnosis Year
                                          in Houston...
Trend of New Syphilis Diagnosis and
HIV-Syphilis Co-Morbidity (n=3,490)
                                       in Houston/...
Houston Syphilis Outbreak
2007-2008
        Houston Syphilis Outbreak
• Outbreak: Number of cases exceed the
  expected number based on outbreak thr...
2007-2008 Houston Syphilis Outbreak
         P & S Syphilis Thresholds: City-wide
                                        ...
Number of Cases




                                               0
                                                   10...
Number of Cases




                                                    0
                                                ...
Houston Syphilis Outbreak
            Response Plan
• Enhanced surveillance
  – Weekly analysis of early Syphilis cases
  ...
Houston Syphilis Outbreak
     Response Plan Participants
• Bureau chief of          • Field operations (DIS)
  HIV/STD pr...
Syphilis Outbreak Response Effort
•   Expanded prophylaxis treatment protocol
•   Targeted activities for enhanced surveil...
Disease Burden
• Houston ranks 2nd in the nation
• 53% of early cases were detected in the
  P&S stages in 2007
• P&S Syph...
Population & Geographic Areas
• MSM between 20-39 years old
• Individuals who engage in anonymous sex
• Individuals who ex...
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

• Allo...
Inclusion Criteria
HARS
• 13 years and older at HIV diagnosis
• Houston/Harris county residents

STD-MIS
• Primary and Sec...
Matching Results
                   in Houston/Harris Co., TX



        35,995 records                    833 records
   ...
Demographics of People with
HIV-Syphilis Co-Morbidities (n=246)
            in Houston/Harris Co., TX 2007-2008
By Sex    ...
Demographics of People with
   HIV-Syphilis Co-Morbidities (n=246)
                    in Houston/Harris Co., TX 2007-2008...
Risk Factors of People with
  HIV-Syphilis Co-Morbidities (n=246)
                in Houston/Harris Co., TX 2007-2008

By ...
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)


                              Area A
         ...
Spatial Distribution of Syphilis Cases
              in Houston/Harris Co., TX 2001-2005




2001

       2002

          ...
Spatial Distribution of Syphilis Cases
           in 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




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




                          Area A

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




                       Area A



   ...
Conclusions
• Most of the HIV+ individuals who
  contracted Syphilis during the Outbreak
  were
  – African American
  – A...
Conclusions

• Houston Syphilis Outbreak Response Plan
  outlines coordinated efforts between the
  health department and ...
Take Home Message


Houstonians living with HIV/AIDS
   significantly contributed to
    and were affected by the
  2007/2...
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 ...
Acknowledgements
The HDHHS HIV/STD Surveillance Program
The HDHHS HIV/STD Prevention Program
The Community Health Statisti...
References
• [Journal of the American Osteopathic Association, 2004
  Nusbaum,M.R. ; Wallace,R.R.; Slatt,L.M.; Kondrad,E.C...
Thank you!!

Biru Yang, PhD, MPH
HIV Epidemiologist
Bureau of Epidemiology
Houston Department of Health and Human Services...
Questions?
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E:\uncovering the effect of co morbidities on the houston syphilis outbreak and the hiv epidemic through epidemiological analysis and data mapping-final

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E:\uncovering the effect of co morbidities on the houston syphilis outbreak and the hiv epidemic through epidemiological analysis and data mapping-final

  1. 1. Uncovering the Effect of Co-morbidities on the Houston Syphilis Outbreak and the HIV Epidemic through 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 Banerjee HIV/STD Surveillance Program Community Health Statistics Program Bureau of HIV/STD & Viral Hepatitis Prevention
  2. 2. Collaboration Epidemiologist/Biostatistician Sr. Health Planner/STD Data Manager HIV/STD Surveillance Program STD Prevention Program Bureau of Epidemiology Bureau of HIV/STD & Viral Hepatitis Office of Surveillance and PHP Division Disease Prevention & Control Division GIS Analyst Community Health Statistics Program Office of Surveillance and PHP Division
  3. 3. Houstonians living with HIV/AIDS significantly contributed to and were affected by the 2007/2008 Syphilis Outbreak.
  4. 4. Outline • Collaboration • Study Objectives • Epidemiological Trend • Houston Syphilis Outbreak • Data matching • Data mapping • Conclusions • Limitations • Future Directions • Questions?
  5. 5. Biological Significance of Syphilis and HIV Co-morbidity The deadly duo • 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 [Journal of the American Osteopathic Association, 2004 Nusbaum,M.R et al. ] [Lancet Infect.Dis., 2004, Lynn,W.A et al. ]
  6. 6. Public Health Significance of Syphilis and HIV Co-morbidity Timing of Diagnoses Among the People with Co-Morbidity Same Time 38% Syphilis Diagnosis • 62% still had First 14% unprotected sex HIV Diagnosis 3 months after their First 48% HIV or Syphilis diagnoses.
  7. 7. 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
  8. 8. Epidemiological Trend
  9. 9. 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)
  10. 10. HIV Cases by Diagnosis Year in Houston/Harris Co., TX 1999-2007 1600 1400 1433 1444 1423 1417 1200 1206 Number of Cases 1193 1159 1145 1147 1000 800 600 400 200 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 HIV Diagnosis Year
  11. 11. Trend of New HIV Diagnosis and HIV-Syphilis Co-Morbidity (n=11,567) in Houston/Harris Co., TX 1999-2007 1600 4% 4% 3% 5% 1400 5% 6% 6% 7% 8% 1200 Number of Cases 1000 HIV and Syphilis 800 HIV Only 600 400 200 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 HIV Diagnosis Year
  12. 12. Primary, Secondary and Early Latent Syphilis Cases by Diagnosis Year in Houston/Harris Co., TX 1999-2007 900 800 700 Number of Syphilis Cases Early Latent Syphilis 600 Secondary Syphilis Primary Syphilis 500 400 300 200 100 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 Syphilis Diagnosis Year
  13. 13. Trend of New Syphilis Diagnosis and HIV-Syphilis Co-Morbidity (n=3,490) in Houston/Harris Co., TX 1999-2007 900 24% 800 700 600 26% Number of Cases 500 HIV and Syphilis 30% 22% 400 22% Syphilis Only 6% 300 23% 9% 8% 200 100 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 Syphilis Diagnosis Year
  14. 14. Houston Syphilis Outbreak
  15. 15. 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
  16. 16. 2007-2008 Houston Syphilis Outbreak P & S Syphilis Thresholds: City-wide Race Total White Afr. Am. Hispanic Other Unk Mean # of cases/month (36 months) 24.5 6.8 12.4 5.1 0.2 0.1 Standard Deviation (36 months) 8.1 2.6 7.3 2.3 0.4 0.2 Warning Level (Mean + 1 SD) 32.6 9.5 19.7 7.4 0.6 0.3 Rapid Response Level (Mean + 2 SD) 40.6 12.1 26.9 9.8 1.0 0.5 Most Mar-07 30 9 15 6 0 0 Recent Apr-07 33 7 20 5 0 1 Data May-07 40 8 24 7 1 0 Jun-07 55 7 36 11 1 0 Possible Mar-07 Problem Apr-07 Warning Warning single Areas May-07 Warning Warning single Jun-07 RR! RR! RR! single
  17. 17. Number of Cases 0 10 20 30 40 50 60 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 * 2007 includes cases diagnosed and entered into STD*MIS through July 23rd Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Houston/Harris Co. Apr-06 Month of Diagnosis May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Total P&S Cases in the Past Three Years Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
  18. 18. Number of Cases 0 5 10 15 20 25 May-04 30 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 into STD*MIS through July 23rd Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 * 2007 includes cases diagnosed and entered Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Month of Diagnosis May-06 Years, Houston/Harris Co. Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Total P&S Cases Among MSM in the Past Three Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
  19. 19. 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
  20. 20. Houston Syphilis Outbreak Response Plan Participants • Bureau chief of • Field operations (DIS) HIV/STD prevention • Mobile clinic staff • STD program • Syphilis Elimination manager Advisory Committee • Surveillance • Community-based • Syphilis elimination organizations coordinator • Community leaders • Public health advisor- special projects coordinator
  21. 21. Syphilis Outbreak Response Effort • Expanded prophylaxis treatment protocol • Targeted activities for enhanced surveillance • CBO’s and community mobilization • Syphilis rapid response mobile STD clinic
  22. 22. 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
  23. 23. Population & Geographic Areas • MSM between 20-39 years old • Individuals who engage in anonymous sex • Individuals who exchange sex for drugs or money
  24. 24. Geographic Areas of Interest Area A Area B Area C
  25. 25. Data Matching
  26. 26. Matching Software: Link King • Free software • Browser-based • SAS application but no SAS experience is needed • Allow manual review • Random sample validation http://www.the-link-king.com/
  27. 27. Inclusion Criteria HARS • 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
  28. 28. Matching Results in Houston/Harris Co., TX 35,995 records 833 records (eHARS) (STD*MIS) 1983-2010 2007-2008 263 linkages Among 833 Syphilis cases, 246 (30%) had an HIV diagnosis before or during the Syphilis Outbreak
  29. 29. Demographics of People with HIV-Syphilis Co-Morbidities (n=246) in Houston/Harris Co., TX 2007-2008 By Sex By Age Group Female 30-39 5% 30% 20-29 50% Male 95% 40-49 11% 13-19 7% 50+ • Most of the HIV-Syphilis co-morbidity were in young men between 20-39 years old
  30. 30. Demographics of People with HIV-Syphilis Co-Morbidities (n=246) in Houston/Harris Co., TX 2007-2008 By Race/Ethnicity • African Americans Hispanic 22% accounted for 54% of the co-morbidity Black 54% White 22% Other 2%
  31. 31. Risk Factors of People with HIV-Syphilis Co-Morbidities (n=246) in Houston/Harris Co., TX 2007-2008 By Risk Group IDU MSM/IDU 4% 3% Heterosex 9% Risk Not Identified 4% • MSM accounted MSM 80% for 80% of the co-morbidity
  32. 32. Data Mapping
  33. 33. Average Rates of HIV by Zip Codes (1999-2008) Area A Area B Area C
  34. 34. Average Rates of Syphilis by Zip Codes (1999-2008) Area A Area B Area C
  35. 35. Comparison: Average Rates of HIV and Syphilis by Zip Codes (1999-2008) Area A Area A Area B Area B Area C Area C HIV Syphilis
  36. 36. Spatial Distribution of Syphilis Cases in Houston/Harris Co., TX 2001-2005 2001 2002 2003 2005 2004
  37. 37. Spatial Distribution of Syphilis Cases in Houston/Harris Co., TX 2006 Male Female
  38. 38. Spatial Distribution of Syphilis cases (n=833) in Houston/Harris Co., TX 2007-2008
  39. 39. Spatial Distribution of HIV-Syphilis Co-morbid cases (n=246) in Houston/Harris Co., TX 2007-2008
  40. 40. Education
  41. 41. Linguistic Isolation
  42. 42. Poverty
  43. 43. Location of Facilities/Providers where Syphilis Diagnoses occurred Area A Area B Area C
  44. 44. Mobile clinic visits vs. HIV cases in Houston/Harris Co., TX 2007 Area A Area B Area C 0 -5 6 - 15 16 - 27 28 - 40 41 - 95 Height= Mobile clinic outreach frequency
  45. 45. Mobile clinic visits vs. HIV cases in Houston/Harris Co., TX 2008 Area A Area B Area C 0 -5 6 - 15 16 - 27 28 - 40 41 - 95 Height= Mobile clinic outreach frequency
  46. 46. 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
  47. 47. 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
  48. 48. Take Home Message Houstonians living with HIV/AIDS significantly contributed to and were affected by the 2007/2008 Syphilis Outbreak.
  49. 49. Limitations • Incomplete addresses • Only included one syphilis diagnosis • Limited behavior information
  50. 50. 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
  51. 51. Acknowledgements The HDHHS HIV/STD Surveillance Program The HDHHS HIV/STD Prevention Program The Community Health Statistics Program Bureau of Epidemiology Adelowale Awosika-Olumo, Bureau Chief Bureau 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
  52. 52. 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]
  53. 53. Thank you!! Biru Yang, PhD, MPH HIV Epidemiologist Bureau of Epidemiology Houston Department of Health and Human Services Tel: 713-794-9181 E-mail: Biru.Yang@cityofhouston.net
  54. 54. Questions?

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