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

2. 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

3. 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?

4. 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

5. 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

6. 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

7. Estimating Proportion MSM by Neighborhood 2002 NYC Community Health Survey –Phone survey of ~10,000 NYC residents –Sampled to be representative within each neighborhood (N=42) Proportion sexually active 18-64 year old men who reported sex with a man in the past 12 months Grouped neighborhoods Low MSM neighborhoods <15% MSM High MSM neighborhoods  15% MSM

8. 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

9. 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

11. 2002 Rate Ratio (RR)=4.32 95% Confidence Interval (CI)=3.54, 5.27 Incidence of Primary & Secondary Syphilis in Adult Men in High versus Low MSM Neighborhoods

12. Incidence of Amebiasis in Adult Men in High versus Low MSM Neighborhoods

13. 2002: RR=4.52, CI=3.64-5.60 Incidence of Amebiasis in Adult Men in High versus Low MSM Neighborhoods

14. HAART available Incidence of Cryptosporidiosis in Adult Men in High versus Low MSM Neighborhoods

15. 2002: RR=4.93, CI=3.28-7.39 Incidence of Cryptosporidiosis in Adult Men in High versus Low MSM Neighborhoods

16. Incidence of Giardiasis in Adult Men in High versus Low MSM Neighborhoods

17. 2002: RR=4.32, CI=3.72-5.02 Incidence of Giardiasis in Adult Men in High versus Low MSM Neighborhoods

18. Vaccine available Outbreak in MSM * * NYC Department of Health conducted and active vaccination campaign offering free HAV vaccine targeting MSM in response to outbreak Incidence of Hepatitis A Infection in Adult Men in High versus Low MSM Neighborhoods

19. 2002: RR=1.91, CI=1.44-2.53 Incidence of Hepatitis A Infection in Adult Men in High versus Low MSM Neighborhoods

20. Incidence of Syphilis compared to Enteric Pathogens in High MSM Neighborhoods 1998-2002

21. Rate Ratio of Incidence of Enteric Infections and Syphilis in High versus Low MSM Neighborhoods

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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).

29. Table 1. Poisson Regression: Association of Counts of Amebiasis with year and neighborhood* Estimated OR95% CI All years1.0 (referent) 199413.1312.18, 14.20 199515.9314.82, 17.13 199610.619.74, 11.55 199712.2811.33, 13.30 199816.1115.00, 17.28 199914.1313.10, 15.23 200011.0110.18, 11.96 200110.20 9.37, 11.11 200210.8810.01, 11.82 All neighborhoods (13% MSM) 1.0 (referent) A (19% MSM)2.131.95, 2.33 B (19% MSM)9.769.23, 10.33 C (26% MSM)3.433.14, 3.74 D (5% MSM)0.680.59, 0. 79 *only selected neighborhoods shown

30. Table 2. Poisson Regression: Association of Counts of Giardiasis with year and neighborhood* Estimated OR95% CI All years1.0 (referent) 199415.4514.61, 16.35 199513.8313.05, 14.66 199612.9512.19, 13.74 199712.0911.37, 12.85 199812.8012.06, 13.59 199915.4014.57, 16.28 200015.3714.55, 16.24 200113.1612.41, 13.95 200212.3011.58, 13.07 All neighborhoods (13% MSM) 1.0 (referent) A (19% MSM)2.071.94, 2.22 B (19% MSM)7.046.64, 7.47 C (26% MSM)3.042.84, 3.25 D (5% MSM)0.820.75, 0.91 *only selected neighborhoods shown

31. Prevention Activities Collaboration with the Bureau of STD to incorporate prevention of enteric STD into club-based prevention initiative

32. *2002 NYC Community Health Survey Correlation of Percent MSM and Incidence of Syphilis, Amebiasis and Giardiasis Infections, 2002

33. 2002: RR=2.71, CI=1.97-3.73 Incidence of Campylobacteriosis in Adult Men in High versus Low MSM Neighborhoods

34. 2002: RR=3.00, CI=2.07-4.34 Incidence of Shigellosis in Adult Men in High versus Low MSM Neighborhoods