Enteric Illness in Neighborhoods with High Proportions of Men Having Sex with Men

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Enteric Illness in Neighborhoods with High
Proportions of Men Having Sex with Men New York
City
An Ecologic Analysis

• Melissa A. Marx, Julia Schillinger, Susan Blank,
  and Marcelle Layton
•  
• Epidemiology Program Office and Division of
  Sexually Transmitted Disease, Centers for Disease
  Control and Prevention
• Bureaus of Communicable and Sexually Transmitted
  Disease, New York City Department of Health and
  Mental Hygiene

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Enteric Sexually Transmitted Infections in Men
who Have Sex with Men

• Unprotected anal sex puts MSM at risk for genital
  and anal-rectal STI
• Sexual behaviors during which fecal-oral contact
  is common
• Oral-anal
• Digital-anal
• Penile-oral following anal sex
• put MSM at risk for enteric infections

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Why the concern about increases in enteric STI in
MSM now?

• Recently, increases in unsafe sex practices have
  been linked with increases in genital/anal-rectal
  STI
• Increased incidence of syphilis
• High HIV seroprevalence in young/minority
• Are these increases in unsafe sex resulting in
  similar increases in sexually transmitted enteric
  infections?

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Objectives

• Describe trends in enteric infections among adult
  men in neighborhoods with high and low proportion
  of MSM
• Compare trends of enteric infections with trends
  in syphilis from 1998-2002

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Surveillance for STI and Enteric Infections in NYC

• Passive Reports sent by laboratories providers
• All early syphilis investigated detailed risk
  data ascertained
• Reportable enteric infections
• Amebiasis, Campylobacteriosis, Cryptosporidiosis,
  Giardiasis, hepatitis A, Shigellosis
• Not investigated , so no data collected about
  sexual exposures

Unless case is in a risk group (e.g., food
handler, daycare worker) or the pathogen is
Cryptosporidiosis, which is investigated under
drinking water surveillance protocols
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Methods

• Ecologic analysis (individual-level data on
  sexual exposures unavailable for enteric
  infections)
• Data sources
• Numerators Reports of syphilis and enteric
  infections (Amebiasis, Cryptosporidiosis,
  Giardiasis, hepatitis A) in 18-64 year old men
• Denominators Population 18-64 year old men -
  estimated from 1990 and 2000 U.S. Census

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Estimating Proportion MSM by Neighborhood

• 2002 NYC Community Health Survey
• Phone survey of 10,000 NYC residents
• Sampled to be representative within each
  neighborhood (N42)
• Proportion sexually active 18-64 year old men who
  reported sex with a man in the past 12 months
• Grouped neighborhoods
• Low MSM neighborhoods lt15 MSM
• High MSM neighborhoods ?15 MSM

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Data Analysis

• Calculated incidence rates of syphilis and
  enteric infections over time
• Compared incidence in high vs. low MSM
  neighborhoods using Rate Ratios
• Compare incidence rates and Rate Ratios of
  syphilis and enteric infections over time

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Results Distribution of Neighborhoods by
Proportion MSM

• Citywide 13 self-reported MSM (Range 2-26)
• Low MSM neighborhoods
• 33 (79) of neighborhoods
• Average 9 MSM (Range 2-13)
• Represents 2,183,027 men aged 18-64 years
• High MSM neighborhoods
• 9 (21) of neighborhoods
• Average 19 MSM (Range 15-26)
• Represents 620,552 men aged 18-64 years

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Incidence of Primary Secondary Syphilis in
Adult Men in High versus Low MSM Neighborhoods
2002Rate Ratio (RR)4.32 95 Confidence
Interval (CI)3.54, 5.27
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Incidence of Amebiasis in Adult Men in High
versus Low MSM Neighborhoods
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Incidence of Amebiasis in Adult Men in High
versus Low MSM Neighborhoods
2002 RR4.52, CI3.64-5.60
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Incidence of Cryptosporidiosis in Adult Men in
High versus Low MSM Neighborhoods
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Incidence of Cryptosporidiosis in Adult Men in
High versus Low MSM Neighborhoods
2002 RR4.93, CI3.28-7.39
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Incidence of Giardiasis in Adult Men in High
versus Low MSM Neighborhoods
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Incidence of Giardiasis in Adult Men in High
versus Low MSM Neighborhoods
2002 RR4.32, CI3.72-5.02
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Incidence of Hepatitis A Infection in Adult Men
in High versus Low MSM Neighborhoods
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Incidence of Hepatitis A Infection in Adult Men
in High versus Low MSM Neighborhoods
2002 RR1.91, CI1.44-2.53
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Incidence of Syphilis compared to Enteric
Pathogens in High MSM Neighborhoods 1998-2002
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Rate Ratio of Incidence of Enteric Infections and
Syphilis in High versus Low MSM Neighborhoods
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Summary

• Incidence of all enteric diseases studied 2-5
  times higher in high MSM, compared to low MSM
  neighborhoods
• The RR of most enteric diseases have not
  increased recent years
• Neither the incidence nor the burden (RR) of
  enteric infections appear increasing in MSM
  neighborhoods during the syphilis outbreak

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Limitations

• Ecologic data do not address individual risk
• MSM estimated for all years from 2002 survey data
• Did not take into account immigration/emigration
• Limits of power and design
• Did not account for changes in disease reporting
• Bias in health care access and reporting

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Discussion

• High MSM neighborhoods have higher burden of
  enteric diseases than low MSM neighborhoods
• Prevention messages regarding enteric infections
  should be incorporated into STD/HIV prevention
  interventions

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Why are Enterics Infections Stable or Declining
during the Syphilis Outbreak?

• MSM may be reducing safer sex practices
  (oral-anal sex) in favor of risky sex
  (unprotected anal intercourse)
• MSM infected with syphilis may belong to
  different sexual networks than MSM infected with
  enteric pathogens
• One network may be increasing risky sex and
  becoming infected with syphilis
• Others may be practicing oral-anal sex and
  avoiding syphilis but becoming infected with
  enteric infections

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Acknowledgements

• NYCDOHMH data entry staff, and database managers
• Lorna Thorpe, Adam Karpati, Anjum Hajat, Sharon
  Balter, Rick Heffernan for analytical support,
  community survey and census data, and background
  on surveillance protocols
• CDC EPO, particularly Richard Dicker, for
  comments and suggestions on presentation

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Messages to Prevent Enteric Infections in MSM

• MSM
• Avoid sexual contact with feces
• Use barrier protection during all contact with
  feces
• Wash hands immediately after contact with feces
• Inform partners about risks and prevention
  measures
• Get vaccinated for Hepatitis A, if HIV take
  HAART
• Clinicians
• Discuss safe sexual practices with all
  sexually-active patients, especially adult men
• Recommend vaccination and frequent testing for
  sexually-active MSM

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Cryptosporidium
Cryptosporidium parvum oocysts in feces
visualized by a Kinyoun modified acid-fast stain
(A) and immunofluorescence with use of a
monoclonal antibody (Cellabs) to the oocyst wall
(B).
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Table 1. Poisson Regression Association of
Counts of Amebiasis with year and neighborhood
only selected neighborhoods shown
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Table 2. Poisson Regression Association of
Counts of Giardiasis with year and neighborhood
only selected neighborhoods shown
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Prevention Activities

• Collaboration with the Bureau of STD to
  incorporate prevention of enteric STD into
  club-based prevention initiative

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Correlation of Percent MSM and Incidence of
Syphilis, Amebiasis and Giardiasis Infections,
2002
2002 NYC Community Health Survey
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Incidence of Campylobacteriosis in Adult Men in
High versus Low MSM Neighborhoods
2002 RR2.71, CI1.97-3.73
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Incidence of Shigellosis in Adult Men in High
versus Low MSM Neighborhoods
2002 RR3.00, CI2.07-4.34