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. 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. Houstonians living with HIV/AIDS
significantly contributed to
and were affected by the
2007/2008 Syphilis Outbreak.

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

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. 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. 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. Epidemiological Trend

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. 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. 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. 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. 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. Houston Syphilis Outbreak

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. 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. 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. 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. 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. 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. 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. 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. Population & Geographic Areas
• MSM between 20-39 years old
• Individuals who engage in anonymous sex
• Individuals who exchange sex for drugs or
money

24. Geographic Areas of Interest
Area A
Area B
Area C

25. Data Matching

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. 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. 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. 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. 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. 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. Data Mapping

33. Average Rates of HIV
by Zip Codes (1999-2008)
Area A
Area B
Area C

34. Average Rates of Syphilis
by Zip Codes (1999-2008)
Area A
Area B
Area C

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. Spatial Distribution of Syphilis Cases
in Houston/Harris Co., TX 2001-2005
2001
2002
2003
2005
2004

37. Spatial Distribution of Syphilis Cases
in Houston/Harris Co., TX 2006
Male
Female

38. Spatial Distribution
of Syphilis cases (n=833)
in Houston/Harris Co., TX 2007-2008

39. Spatial Distribution of HIV-Syphilis
Co-morbid cases (n=246)
in Houston/Harris Co., TX 2007-2008

40. Education

41. Linguistic Isolation

42. Poverty

43. Location of Facilities/Providers
where Syphilis Diagnoses occurred
Area A
Area B
Area C

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. 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. 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. 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. Take Home Message
Houstonians living with HIV/AIDS
significantly contributed to
and were affected by the
2007/2008 Syphilis Outbreak.

49. Limitations
• Incomplete addresses
• Only included one syphilis diagnosis
• Limited behavior information

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. 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. 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. 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. Questions?