Continuing Education Meeting:Update on Syphilis, Gonorrhea, and Chlamydia

Jan-Jun 2002

Liz LeeSenior Epidemiologist

Bureau of EpidemiologyHouston Department of Health and Human services

August 14th, 2002

STD’s in Houston/Harris County

• Syphilis

• Gonorrhea

• Chlamydia

In Houston/Harris County,

Jan-Jun 2002

Syphilis - Treponema pallidum

Syphilis Stages of Main Concern

• Focus on Primary and Secondary Stage– INFECTIOUS!

• Infection within one year period

(Early Latent Stage) is also of concern:– Indicates MISSED infectious syphilis cases

• Syphilis in Pregnancycongenital syphilis

Primary and secondary syphilis — Reported rates: United States,

1970–2000 and the Healthy People year 2010 objectiveRate (per 100,000 population)

P&S Syphilis2010 Objective

0

5

10

15

20

25

1970 73 76 79 82 85 88 91 94 97 2000

Note: The Healthy People 2010 (HP2010) objective for primary and secondary syphilis is 0.2 case per 100,000 population.

Primary and secondary syphilis — Rates by gender: United States,

1981–2000 and the Healthy People year 2010 objective

Rate (per 100,000 population)

MaleFemale2010 Objective

0

5

10

15

20

25

1981 83 85 87 89 91 93 95 97 99

Primary and secondary syphilis — Rates by race and ethnicity: United States, 1981–2000 and the

Healthy People year 2010 objective

Rate (per 100,000 population)

WhiteBlackHispanicAsian/Pac IslNat Am/AK Nat2010 Objective

0

30

60

90

120

150

1981 83 85 87 89 91 93 95 97 99

Primary and secondary syphilis — Rates by state: United States and outlying areas, 2000

Note: The total rate of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.2 per 100,000 population. The Healthy People year 2010 objective is 0.2 per 100,000 population.

Rate per 100,000population

<=.2.21-4>4

VT 0.0 NH 0.2 MA 1.1 RI 0.4 CT 0.5 NJ 0.9 DE 1.2 MD 5.8

Guam 0.6

Puerto Rico 4.5 Virgin Is. 2.7

(n=14)(n=29)(n=10)

2.8

0.0

4.0 4.1

1.0 0.3

2.7

5.2

0.2

0.1

3.4 5.9

0.4

0.2 2.1

4.8

0.1

3.3

0.3

4.9

0.5

0.0

0.1 0.3

0.9

0.7

6.3

0.0

0.6

3.5

0.4

0.6

5.9

0.0

9.7

2.0

0.1

1.8

1.1

0.2

0.9

0.2

Harris County is among the 28 counties that account for over 50% of infectious syphilis cases in US

Harris County

Syphilis in Houston/Harris County

Infectious syphilis (P&S)

2000 2001 % increase from 2001 to 2002

# cases citywide 73 95 30%

# of MSM cases 10 35 250%

Alarm of potential outbreak among MSM population!

MSM=“Men who have sex with men”

MSM Syphilis Cases by Stage of Infection:2000 versus 2001

0

1

2

3

4

5

6

7

8

9

10

month/year

num

ber

of c

ases

ELP&S

Increase in MSM P&S

Syphilis in Houston/Harris County

Infectious syphilis (P&S)

Jan-Jun 2001

Jan-Jun 2002

% increase from 2001 to 2002

# cases citywide 52 52 0%

# of MSM cases 24 28 17%

*No decrease in number of cases seen at the citywide level!

*MSM cases continuing to increase!

MSM Syphilis Cases by Stage of Infection

0

2

4

6

8

10

12

Dec

00

J an

01

Feb

01

Mar

01

Apr

01

May

01

J un

01

J ul

01

Aug

01

Sep

01

Oct

01

Nov

01

Dec

01

J an

02

Feb

02

Mar

02

Apr

02

May

02

J un

02

Month/year

Nu

mb

er o

f C

ases

EL

P & S

P&S

Outbreak

Threshold,

4 cases

P&S and EL

Outbreak

Threshold,

7 cases

. Intensif ication of MSM outbreak!

Cumulative MSM P&S syphilis cases: 2002 outbreak threshold and goal

0

5

10

15

20

25

30

35

40

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

cum

ula

tive

P&

S c

ases

reference

2000 actual

2002 outbreak

2002 goal

2002 actual

2001 actual

Cumulative P&S syphilis cases: 2002 outbreak threshold and goal, citywide

0

10

20

30

40

50

60

70

80

90

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

cum

ula

tive

nu

mb

er o

f P

&S

cas

es

reference line

2002outbreak

2002goal

2002actual

2001 actual

Outbreak Level Citywide for Infectious Outbreak Level Citywide for Infectious

(P&S) Syphilis in Houston/Harris(P&S) Syphilis in Houston/Harris

• June 2002, Citywide: – 14 cases of infectious (P&S) syphilis

• Exceeds outbreak threshold

• 64% (9 of 14) cases were MSM cases

• Urgent need to work with MSM community to provide education and screening services!

0%

10%20%

30%40%

50%60%70%

80%90%

100%

2000 2001 Jan-Jun 2002

time period

Gender Distribution of early syphilis (P&S and EL) cases

Female

Male

P&S Rate, CitywideJan-Jun in 2001 v. 2002

rates per 100,000

Time Period P&S cases pop rate

Jan-Jun 2001 52 3,400,578 1.5Jan-Jun 2002 52 3,400,578 1.5

No change in rate!

Healthy people 2010 goal: 0.2/100,000 per year

P&S Rate, CitywideJan-July in 2001 v. 2002

rates per 100,000

Time Period P&S cases pop rate

Jan-July 2001 54 3,400,578 1.6Jan-July 2002 61 3,400,578 1.8

Increase in rate!

Rates of Infectious (P&S) Rates of Infectious (P&S) Syphilis by GenderSyphilis by Gender

(rates per 100,000)(rates per 100,000)

Increase in Males Decrease in

Females

Time Period Male cases Male rate Female cases Female rate

Jan-Jun 2001 38 2.2 14 0.8Jan-Jun 2002 43 2.5 7 0.4

Rates of Infectious (P&S) Syphilis Rates of Infectious (P&S) Syphilis by Age Groupsby Age Groups

(rates per 100,000)(rates per 100,000)

Age Group P&S cases rate P&S cases rate

under 15 0 0.0 1 0.115-19 6 2.4 4 1.620-29 21 3.8 12 2.230-39 14 2.5 18 3.240-49 8 1.5 12 2.350+ 3 0.4 5 0.7

Total 52 1.5 52 1.5

Jan-Jun 2002Jan-Jun 2001

Shift in Age Group:

20-29 y.o. 30-39 y.o.

Rates of Infectious Syphilis (P&S) by Race/Ethnicity

(rates per 100,000)

Race/Ethnicity P&S cases rate P&S cases rate

Asian 0 0.0 0 0.0Black 31 4.9 21 3.3Hispanic 10 0.9 12 1.1

White 11 0.8 19 1.3Other 0 0.0 0 0.0

Total 52 1.5 52 1.5

Jan-Jun 2001 Jan-Jun 2002

Largest increase in WhitesHighest rate in Blacks

Rates of infectious (P&S) Syphilis by Race and Gender

(rates in 100,000)

Race/Ethnicity by Sex P&S cases rate P&S cases rate

Asian Male 0 0.0 0 0.0Asian Female 0 0.0 0 0.0

Black Male 20 6.8 16 5.5Black Female 11 3.3 5 1.5

Hispanic Male 9 1.5 9 1.5Hispanic Female 1 0.2 3 0.6

White Male 9 1.3 18 2.5White Female 2 0.3 1 0.1

Jan-Jun 2001 Jan-Jun 2002

Highest increase in White Males

Highest rate in Black Males

Increasing Syphilis and HIV Co-Infection Rates

Percent HIV Positive Among Interviewed Syphilis Clients with Known HIV Status

Year 2001 Jan-May 2001 Jan-May 2002

All syphilis 10% 12% 19%

Early syphilis 16% 19% 29%

Cit

y-w

ide

P&S syphilis 22% 26% 39%

All syphilis 49% 54% 56%

Early syphilis 53% 54% 58% MS

M

P&S syphilis 56% 56% 60%

Rates: MSM, P&S J-J 2001

Rates of MSM P&S Syphilis by Zip Code Area,in Houston/Harris County, Jan-Jun 2001

Rates of MSM P&S Syphilis by Zip Code Area,in Houston/Harris County, Jan-Jun 2002

Congenital syphilis — Rates for infants <1 year of age: United States, 1981–2000

and the Healthy People year 2010 objective

Rate (per 100,000 live births)

Cong. Syphilis2010 Objective

0

25

50

75

100

125

1981 83 85 87 89 91 93 95 97 99

Note: The Healthy People 2010 (HP2010) objective for primary and secondary syphilis is 0.2 case per 100,000 population.The surveillance case definition for congenital syphilis changed in 1988.

Congenital Syphilis in Houston/Harris(rates per 100,000)

Congenital Syphilis

# of cases Crude Rates (per 100,000 births)

Year 2000 32 51Year 2001 22 34

Jan-Jun 2002 16 23*

Healthy People 2010 Objectives: 1 per 100,000!

Congenital Syphilis by Race/Ethnicity(rate per 100,000)

# cases rate # cases rate # cases rateBlacks 19 168 8 69 10 85Hispanics 11 37 12 38 5 15Whites 2 11 1 5 1 5

Year 2001 Jan-Jun 2002Congenital Syphilis

Year 2000

*Highest rate in Blacks

*Rate as of June already exceeds 2001 levels

In Houston/Harris County,

Jan-Jun 2002

4% Decrease in Gonorrhea

• Jan-Jun 2001• 2559 cases reported

• 75/100,000

• Jan-Jun 2002• 2464 cases reported

• 72/100,000

Healthy People 2000 goal: 100/100,000 per year

1289 12651310

1150

0

200

400

600

800

1000

1200

1400

Nu

mb

er

of

Ca

se

s

Jan-Jun 2001 Jan-Jun 2002Report Period

Gonorrhea by Gender

male

female

Gonorrhea by Age Group

0

200

400

600

800

1000

1200

1400

<14 14-19 20-29 30-39 40-49 50+

Age (in Years)

Nu

mb

er o

f C

ases

Jan-Jun 2001

Jan-Jun 2002

Age Distribution of Gonorrhea by Gender, Jan-June 2002

0

100

200

300

400

500

600

700

<14 14-19 20-29 30-39 40-49 50+Age Group

Nu

mb

er o

f C

ases

Male

Female

Gonorrhea Rates by Race/Ethnicity

*rates per 100,000

Houston/ Harris County

Jan-Jun 2001 rate

Jan-Jun 2002 rate

white 7.1 5.9black 248.7 225.8asian 9.8 11.6hispanic 26.3 22.8

Highest rate among African-Americans

Increase among Asians

276

167

1828

0

50

100

150

200

250

300

Rat

es p

er 1

00,0

00

Black Hispanic

Gonorrhea Rates by Race/Ethnicity and GenderJan-Jun 2002

Male

Female

77004, 77021, 77033

Distribution of Gonorrhea by Provider

Provider Type # cases % cases

HDHHS STD Clinics 970 39%HDHHS Family Planning 35 1%HDHHS Maternity 21 1%Private MD/HMO 906 37%Jail/Correctional 29 1%Other 503 21%Total 2464 100%

Distribution of gonorrhea cases by provider type, Jan-Jun 2002, n=2464

Distribution of gonorrhea cases by provider type, Jan-Jun 2002, n=2464 HDHHS STD Clinics

HDHHS Family Planning

HDHHS Maternity

Private MD/HMO

Jail/Correctional

Other

In Houston/Harris County,

Jan-Jun 2002

No Change in Number of Chlamydia Cases Reported(<1% decline)

• Jan-Jun 2001• 5497 cases reported

• 162/100,000

• Jan-Jun 2002• 5522 cases reported

• 162/100,000

832

4683

898

4569

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Nu

mb

er

of

Ca

se

s

Jan-Jun 2001 Jan-Jun 2002

Report Period

Chlamydia by Gender

Male

Female

0

500

1000

1500

2000

2500

Nu

mb

er

of

Ca

se

s

<14 14-19 20-24 25-29 30-34 35-39 40-49 50+

Age (in Years)

Chlamydia by Age Group

Jan-Jun 2001

Jan-Jun 2002

Largest proportion among 14-19 y.o.

274

248

142 135

15 14

0

50

100

150

200

250

300

Ra

te p

er

10

0,0

00

*

Black Hispanic White

Race/Ethnicity

Chlamydia Rate per 100,000 by Race/Ethnicity

Jan-Jun 2001

Jan-Jun 2002

1697

1594

21637

1,536

1,510

19738

0%

20%

40%

60%

80%

100%

Jan-Jun 2001 cases Jan-Jun 2002 cases

Proportion of Chlamydia Cases by Race/Ethnicity asian

w hite

hispanic

black

77088

7703377033

Distribution of Reported Chlamydia by Provider

Provider Type Percent

HDHHS STD Clinic 11.5%HDHHS Family Planning 7.3%HDHHS Maternity 5.0%Jail/Correctional Facility 2.5%Hospitals 6.7%Private MD/HMO 54.7%Other 12.3%

Total 100.0%

Distribution of Reported Chlamydia by Provider Type, Jan-Jun 2002

Take Home Messages• Houston is experiencing an outbreak of infectious

syphilis• Largest increase in infectious syphilis rates between

2001 to 2002 in White Males• Urgent need to work with private sector and CBO’s

to target intervention program in high risk areas: – Provider/DIS--enhance education and screening

• Increase in congenital syphilis in Houston– Urgent need to improve screening of women of

reproductive age and provide quality prenatal care and appropriate referrals to get adequate treatment

Additional Resources

• www.stdhivtraining.org– On-Line Chlamydia Course

• Latest screening, diagnosis, and treatment of chlamydia

• www.houstonhealth.org– Selected slides from this presentation

• Syphilis, gonorrhea, and chlamydia in Houston/Harris County