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Sexual Network Analysis of a Gonorrhoea Outbreak P De, a E Singh, T Wong, W Yacoub, a M Jolly

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Sexual Network Analysis of a Gonorrhoea Outbreak P De, a E Singh, T Wong, W Yacoub, a M Jolly 280 Sex Transm Infect: first published as 10.1136/sti.2003.007187 on 4 August 2004. Downloaded from ORIGINAL ARTICLE Sexual network analysis of a gonorrhoea outbreak P De, A E Singh, T Wong, W Yacoub, A M Jolly ............................................................................................................................... Sex Transm Infect 2004;80:280–285. doi: 10.1136/sti.2003.007187 Objectives: Sexual partnerships can be viewed as networks in order to study disease transmission. We examined the transmission of Neisseria gonorrhoeae in a localised outbreak in Alberta, Canada, using measures of network centrality to determine the association between risk of infection of network members and their position within the sexual network. We also compared risk in smaller disconnected components with a large network centred on a social venue. Methods: During the investigation of the outbreak, epidemiological data were collected on gonorrhoea cases and their sexual contacts from STI surveillance records. In addition to traditional contact tracing information, subjects were interviewed about social venues they attended in the past year where casual sexual partnering may have occurred. Sexual networks were constructed by linking together named See end of article for authors’ affiliations partners. Univariate comparisons of individual network member characteristics and algebraic measures of ....................... network centrality were completed. Results: The sexual networks consisted of 182 individuals, of whom 107 were index cases with laboratory Correspondence to: Prithwish De, Department confirmed gonorrhoea and 75 partners of index cases. People who had significantly higher information of Epidemiology and centrality within each of their local networks were found to have patronised a popular motel bar in the Biostatistics, McGill main town in the region (p = 0.05). When the social interaction through the bar was considered, a large University, 1020 Pine network of 89 individuals was constructed that joined all eight of the largest local networks. Moreover, Avenue West, Montreal, Quebec, Canada H3A several networks from different communities were linked by individuals who served as bridge populations 1A2; prithwish.de@ as a result of their sexual partnering. mail.mcgill.ca Conclusion: Asking clients about particular social venues emphasised the importance of location in disease Accepted for publication transmission. Network measures of centrality, particularly information centrality, allowed the identification 12 November 2003 of key individuals through whom infection could be channelled into local networks. Such individuals would ....................... be ideal targets for increased interventions. sexual network portrays the sexual inter-relationships identified a cluster of gonorrhoea infection in several within a defined group of people.1 Sexual network neighbouring aboriginal (that is, North American Indian Aanalysis has been used to study the spread of sexually and Me´tis) reservations and industrial towns in the province transmitted infections (STIs) within the context of social of Alberta, Canada. In an earlier case-control study of this http://sti.bmj.com/ interactions. It supplies useful theoretical frameworks, outbreak we discovered a positive association between methodologies and analytical techniques for traditional gonococcal infection and attendance at a motel bar in the contact tracing by identifying specific network members for principal town in the region.11 We were interested in intervention.2 This is in contrast with the epidemic curve and determining whether network methods would corroborate analysis of individual characteristics, which are typically used these findings. Here, we describe the nature of sexual in outbreak investigations but which fail to capture the networks in the outbreak to determine how risk of infection complexity of connections between cases. Network methods accords with a network member’s position within the sexual on September 29, 2021 by guest. Protected copyright. can take advantage of the links afforded by routinely network. We also consider risk in the context of structural collected STI notification data to determine the spatial and differences in a network by comparing a large combined temporal relationships between sexual partners, in both network centred on a social venue with smaller disconnected outbreak and non-epidemic settings.23Furthermore, analysis components. of such sociometric risk networks can be complemented by molecular techniques to identify actual and potential routes of infection transmission.4–7 METHODS The importance of social context in STI transmission, STI services in Alberta include free testing and treatment, particularly in marginalised and reclusive populations, was provided by primary healthcare providers in medical clinics initially recognised by grouping sexually connected people and hospitals, and by public health nurses in health centres into networks.8 The applicability of this technique has been in aboriginal communities. The assay for gonorrhoea detec- demonstrated in studying epidemic transmission of disease. tion in the outbreak region was a nucleic acid detection test In an outbreak of syphilis, network measures were employed (PACE-2 GC, GenProbe, San Diego, CA, USA). All suspected to examine the evolution of sexual links over time and their cases of gonorrhoea were also tested for genital chlamydia impact on disease transmission.9 A combination of ethno- (PACE-2 CT, GenProbe, San Diego, CA, USA). graphic and social network methods were also used to On receipt of a positive laboratory result for either examine the relative position of people in social, sexual, and gonorrhoea or chlamydia, cases and their sex partners are drug using networks in determining causes of HIV persis- required to be reported to the provincial health department tence in the networks.10 by physicians and laboratories. Public health nurses contact In this study, we employed sexual network analysis to the attending physician for information on reported cases, examine the transmission of Neisseria gonorrhoeae infection in which they use to locate infected clients, counsel them about an outbreak. In early 1999, provincial public health staff their infectiousness, identify potentially infected partners www.stijournal.com Sexual network analysis of a gonorrhoea outbreak 281 within the past 3 months, and refer cases and their partners in the network is assigned the average information centrality Sex Transm Infect: first published as 10.1136/sti.2003.007187 on 4 August 2004. Downloaded from for treatment. from all weighted paths on which he/she lies. A computerised surveillance case registry is maintained by A k core is a microstructure of a network in which each the provincial health department, within which each member is connected to at least two or more other members. notification of an STI episode for a case is accompanied by It is a measure of the cohesiveness of a subgroup of information on patient demographics, STI symptoms, treat- individuals among whom there are stronger, more direct, or ment received, results of laboratory tests, details of sexual more frequent links (and thus potential transmission routes) partners identified by the index case, and outcome of partner than between other subgroups within the same network.14 In notification. this analysis, we identified two cores in which each member of a subgroup was connected to at least two other members Study population in the same subgroup. Data collection procedures for this study have been previously By calculating the above three centrality measures and two described in detail.11 Briefly, people who tested positive for cores, we intended to identify individuals who were most urogenital gonorrhoea in the outbreak region and were central in their network and likely to be most influential in reported to the provincial STI case registry system between disease transmission. Firstly, network measures of subjects 1 January 1999 and 31 December 2001 were included in the directly linked to the bar, which was the suspected source of study. Three communities (referred to here as communities infection spread, were compared to those of members on the A, B, and C) experienced 86% of all reported cases. STI periphery of the networks. Secondly, we compared such notification records of these index cases, along with subjects with network members who had lower centrality information about their named contacts (treated and measures in order to define sociodemographic and beha- untreated, tested and untested), were extracted from the vioural risks among those holding key positions in their case registry. Complete demographic and clinical information network. Thirdly, we compared isolate cases—namely, was unavailable for all sexual partners as public health individuals who identify no sex partners and who themselves procedures do not require sexual contacts without laboratory are unnamed by others—with non-isolate cases. We postu- proved infection to be interviewed. In addition to demo- lated that the former may represent higher risk individuals graphic characteristics and STI history, index cases under- who intentionally remain anonymous in casual partnering, went an interviewer administered questionnaire as part of who are unwilling or unable to name their sexual partners,7 the original case-control investigation, in which they were and who presented early on in the outbreak before public asked about attendance
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