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Sexually Transmitted Diseases:
Original Article

Using Social Network and Ethnographic Tools to Evaluate Syphilis Transmission

ROTHENBERG, RICHARD B. MD, MPH*; STERK, CLAIRE PHD; TOOMEY, KATHLEEN E. MD, MPH; POTTERAT, JOHN J. BA§; JOHNSON, DAVID BA; SCHRADER, MARK BA, MPA; HATCH, STEFANI MA*

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From the *Department of Family and Preventive Medicine, Emory University School of Medicine, and the Rollins School of Public Health, Emory University, the Georgia Department of Human Resources, Division of Public Health, Atlanta, Georgia, and the §El Paso County Department of Health and Environment, Colorado Springs, Colorado

The authors thank Julie Sosebee, Carl Cotton, and Cynthia Noel for their invaluable work in the clinical and epidemiologic management of people involved in this outbreak.

Rerint requests: Richard B. Rothenberg, MD, Department of Family and Preventive Medicine, Emory University School of Medicine, 69 Butler Street, SE, Atlanta, GA 30303.

Received for publication June 8, 1997, revised September 2, 1997, and accepted October 6, 1997.

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Abstract

Background and Objectives:: Partner notification has been the cornerstone for the prevention and control of syphilis in the United States. This technique may not make full use of contextual data that an ethnographic and social network approach can offer.

Goals of the Study:: The occasion of a syphilis outbreak among young people was used to investigate the applicability of a social network approach and to test the validity of several traditional approaches to syphilis epidemiology.

Study Design:: An outbreak of syphilis was investigated by interviewing both infected and noninfected people, by directing resources based on network association, by creating and evaluating network diagrams as an aid to the epidemiologic process, and by including ethnographic observations as part of outbreak management.

Results:: Diagrammatic display of network growth provided a useful alternative to the traditional epidemic curve. Case prevention was demonstrated by identifying uninfected people with multiple concurrent exposures. Concurrent, overlapping exposure in infected people rendered traditional "source" and "spread" criteria moot.

Conclusions:: The current discussions of partner notification may be informed by recognizing that it is a subset of a broader and potentially more powerful approach. This approach calls some basic tenets of syphilis epidemiology into question.

INTERVIEWING PEOPLE WITH SYPHILIS, identifying their sex partners, and bringing those partners to evaluation and treatment have been cornerstones for syphilis control in the United States.1,2 According to current guidelines, the major target of the interview process is the infected person, but some attention is also given to people not found to be infected, but who may have been exposed or who have some other connection to an infected person (a "cluster" interview).3 During the standard interview, a "critical period" guides the elicitation of sex partners: The length of time for which partners are sought is determined by the clinical presentation of the respondent and is usually 3 months for those with primary syphilis, 6 months for those with secondary syphilis, and 1 year for those with early latent syphilis. Process evaluation includes a "source and spread" analysis of the direction of transmission, using the dates of first and last sexual encounter, date of the appearance of symptoms, and date of treatment as guides. Important evaluative measures of the adequacy of this process include examination of the number of contacts identified and brought to medical evaluation, and the number of new, previously undiagnosed people with syphilis brought to treatment.

In recent years, the potential for targeting sexually transmitted disease (STD) interventions by identifying groups of people who may be important in transmission ("core" groups)4–6 has led to a consideration of the role of social and sexual networks in disease transmission, and the potential use of social network and ethnographic concepts in disease investigation.7 We have used these concepts to provide concurrent and retrospective analysis of a syphilis outbreak in a small community near Atlanta, Georgia.

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Methods

Background

A small cluster of people with syphilis was first detected in the spring of 1996 by a nurse who staffs a part‐time STD clinic in a suburban county that is part of the Atlanta metropolitan area. The nurse reported these cases to the regional public health office staff that provides disease investigation services for the county and to the Georgia Division of Public Health. Initial assessment suggested that the outbreak involved a substantial number of people, with groups of people who interacted sexually on a regular basis. Additional help for disease investigation was mobilized from a larger nearby county STD control program. At the onset, an attempt was made to take a network‐oriented approach to the outbreak by interviewing as many people as possible who might be involved in transmission (whether infected or not), and by attempting to record information on standard epidemiologic forms (Centers for Disease Control and Prevention [CDC] 73.54) for use in network analysis. This report summarizes information on 99 people and 10 cases of syphilis, and presents an ethnographic assessment based on follow‐up interviews with key participants.

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Data Management

The standard epidemiologic interviewing form (CDC 73.54) contains all the information needed for network analysis. Relevant data (e.g., diagnoses, dates, contact information) were abstracted from the form to create a database with one observation for each respondent‐contact dyad. The 99 people in this group provided 203 observations. Conversion of routinely collected interviewing information to the format required for network analysis is a straightforward multistep procedure. Data were entered into one of the standard database managers (Microsoft Excel; Microsoft Corporation, Redmond, WA), then converted into a standard database analytic program format (Statistical Analysis Systems [SAS])8 using DBMSCopy.9 We wrote a short SAS program to create an ASCII file that could be used by network analysis software (UCINET10) to produce network measurements and statistics. UCINET also produced an ASCII file that is used by a network visualization program (KRACKPLOT11) to render network graphs. Further details of this process, including the relevant programming, will be provided by the authors on request.

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Analytic Approaches

We used network‐based measures to examine the temporal evolution of the outbreak, to visualize the interrelationship of subsets of people within the network (e.g., infected people, their sexual partners, and other ethnographically definable groups), to calculate the probability of direct sexual contact with an infected person as a function of selected characteristics, and to review in detail network connections, dates of sexual exposure, and clinical presentation of people with syphilis. We calculated the following statistics for the overall network and for comparison of subgroups12: components (the number of groups within which there was a connection of some length among all people); degree (the number of direct sexual connections each person has with others, or "partners per case" in STD parlance); betweenness (a measure of the frequency with which a person falls on the shortest line that connects two others); information centrality (a measure of the average of all possible pathways between individuals); and k‐core (the number of people with k contacts who are connected to each other). We examined the change in "microstructures" associated with the growth in sexual connections among people involved in the outbreak. These microstructures, defined in the notes for Table 3, quantify the intensity of interaction among participants. We used follow‐up ethnographic interviews to compare reported sexual and social behavior of selected participants 6 to 12 months after active involvement in syphilis transmission.

Table 3
Table 3
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Network Visualization

In a network of this size, a single display of all participants is not visually informing, but does confirm the impression of substantial interaction provided by network statistics (graph not shown). Subgraphs were used to specify temporal, ethnographic, and epidemiologic associations that may be important in syphilis transmission.

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Results

Overall Ethnographic Assessment

Syphilis was diagnosed in six white female subjects (four of whom were younger than 16 years of age), two white male subjects (both 17 years of age), and two African‐American male subjects (ages 19 and 16 years). Based on routine contact interviewing and investigation of infected and uninfected people, and special ethnographic interviews with key participants, a complex picture of sexual interaction, starting at least 1 year before the diagnosis of the first syphilis cases, emerged. At the center of this outbreak was a group of young white girls (two thirds of whom were 16 years of age or younger) who, in various combinations, met periodically to use drugs and have a variety of sexual interactions with several groups of slightly older boys (Figure 1). The venue was usually the home of one of the girls whose parents were out for the evening. The two major groups of boys differed in their ethnic and economic background. One group was a more affluent set of whites 17 to 21 years of age; the other was a predominantly African‐American group of similar age but of less affluent background. The two groups did not comingle at the parties. The drugs of choice were blunts (short, mild cigars), to which marijuana or cocaine had been added, and alcohol. Multiple accounts corroborated the fact that injectable drugs were not used. Sex was usually public and communal: the girls would have sequential or simultaneous sex partners, experiencing vaginal, anal, and oral sex, occasionally at the same time, and occasionally with more than one partner at a particular orifice. The girls also had sex with each other, and numerous sexual encounters outside the party environment were also documented. During the initial outbreak investigation, we were unable to document the extent of parents' knowledge or understanding (or possible participation) in these activities.

Fig. 1
Fig. 1
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Network Assessment

The overall group contained only two connected components, one of 95 people and one of 4 people. In the overall network, the average degree for each person was three (range, 1–16; Table 1). Those with syphilis had an average of 7.4 sex partners, compared with 2.4 for those without syphilis. This difference was an artifact of interviewing, however, because those without syphilis who were interviewed also had an average of 7.4 sex partners. Similarly, the average overall information centrality was 0.53, but was 0.72 for those with syphilis and 0.73 for those without syphilis who were interviewed. The pattern for betweenness deviated somewhat, however, in that those without syphilis who were interviewed had an average betweenness of 1.73, compared with 4.06 for those with syphilis, suggesting that those with syphilis were in fact more central within this network than those without, and that their greater centrality was not an artifact of interviewing. The largest k‐core had a k of 8, and consisted of 19 people (that is, there were 19 people who each had 8 contacts and were connected to others with 8 contacts). There were two k‐cores each with a k of 7, and there were 13 people in each of these groups.

Table 1
Table 1
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Probability of Contact With an Infected Person

Based on graph connections, an infected person had a probability of 0.33 of being connected sexually to another infected person. The probability that an uninfected person was connected to an infected person was also 0.33. Based on interviews, the proportion of infected contacts named by people with syphilis was 0.26 and the proportion of infected contacts named by people without syphilis was 0.27 (Table 2). This proportion varied somewhat with the underlying characteristics of the interviewed person, but in only one subgroup was the difference large (0.48 of contacts to white, uninfected people were infected; 0.30 of contacts to white infected people were infected). This difference, and other variations among subgroups, was related to the differential sexual mixing patterns among subgroups.

Table 2
Table 2
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Network Visualization

The intensity of interaction between the African‐American men and the white girls was greater than that between the white men and white girls, although this intensity did not appear to lead to greater transmission to the African‐American men (Figure 1). Visualization of these groups and all their sex partners uncovered the importance of several people not specifically identified with these groups (e.g., N43 and S30) who served as bridges between the two groups of men.

The temporal evolution of network formation, using the date of first sexual contact with anyone in the network as the date of entry, demonstrates a substantial buildup of sexual activity during the second half of 1995, with further intensification of such activity into the first half of 1996 (Figure 2). The sexual genesis of this outbreak had occurred a year or more before the period of intense interviewing and investigation in the spring of 1996, at which time all the cases of syphilis were actually diagnosed. Several people diagnosed with syphilis had been active during the early period (S21, S9, S1, S11, S32) and of these, three had early latent syphilis and two had secondary syphilis. Their moment of infection and subsequent infectivity cannot be known with certainty, but would suggest that important sexual activity antedated the cutoff periods used as criteria for interviewing.

Fig. 2
Fig. 2
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The increasing sexual interaction demonstrated by visualization of the changing network (Figure 2) is substantiated by the occurrence of microstructures‐small groupings of people that can heighten transmission.12 Such structures include cliques, n‐cliques, k‐plexes, and k‐cores (see Figure 2 for definitions). There was a dramatic increase in the number of these microstructures over the period of observation (Table 3), indicating a rapidly increasing potential for transmission. All cases of syphilis were diagnosed during the last period depicted, although, as noted, some probably contracted the disease earlier.

When only people with syphilis and their sex partners are visualized (Figure 3), it is apparent that at least one infected person (S30) had no known contact with another infected person. Perhaps even more important, a substantial number of people (N41, N26, N18, N10, N42, N13) had contact with two or three infected people but were not found to be infected at the time of evaluation, suggesting that syphilis may have been prevented by epidemiologic treatment of these people. The diagram also pinpoints a subcluster of cases (S1, S2) for whom few contacts were elicited and no further cases emanated. These cases suggest a deficiency in the case‐finding process, because, unlike other cases, they do not appear to be part of this complex web of sexual interactions.

Fig. 3
Fig. 3
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Simultaneous examination of the sexual connections among people with syphilis only, including their clinical presentation and their dates of first and last contact with each other (Figure 4), highlights the considerable concurrency that occurred. For example, S11, who had secondary syphilis at the time of diagnosis, had conconcurrent sexual relationship with five other infected people, and for at least four of these, the period of contact overlapped. Similar situations apply to S9 and S17. In view of the presumed duration of secondary and early latent syphilis, the source of infection would be impossible to define.

Fig. 4
Fig. 4
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Ethnographic Follow‐up

Follow‐up interviews, focusing on the current situation and network changes, were conducted between 6 and 12 months after the initial interviews with a subsample of eight of the adolescent women. The interviews were held outside the clinic setting, and subjects voluntarily participated in the 30‐ to 60‐minute session with one of us (C.S.).

Based on their personal history and their comments about others', these young women revealed that many had continued to be sexually active with multiple partners in the context of drug and alcohol use. There were, however, some important changes. A few young women no longer participated because they had moved or because of stricter parental supervision. In the past, gatherings had tended to be at the home of one of the young women, but had moved to local motel and hotel rooms. The originally identified social network had fragmented into several smaller groups. For example, one of the African‐American men who was central in the original network was apparently no longer willing to engage in group sex and tended to consort with a single (changeable) partner at a time. Several women also claimed to demur from group sex, although group use of alcohol and drugs had continued for them. Two women stated that they would "get high" with the group and have sex with one of the male partners, either in their car or in a hidden public setting. Other women stated that they were in a steady sexual relationship with a man from the original group involved in the outbreak. One of the main motivators for sexual risk reduction was the unconfirmed rumor that one of the men in the central group had been identified as HIV positive. The women interviewed all appeared to agree that most parents had not taken action in response to the outbreak, nor were there increased levels of communication at home regarding drug use and sexual activity.

Thus, the ethnographic data indicate that some social network changes had occurred that might inhibit continued disease transmission (e.g., fewer sexual exposures in groups), but that the basic behavior patterns had not changed greatly. The clinic staff indicated that they maintained more contact with the men than with the women, many of whom began attending the family planning clinic. Two women in the original cluster of 18 were pregnant at the time of their treatment for syphilis. Clinic record and verbal reports indicated that an additional 13 women, 8 from the original cluster and 5 others involved in the outbreak, became pregnant subsequent to completion of their treatment.

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Discussion

In this outbreak, a small number of syphilis cases illuminated a network of intense, concurrent sexual activity with some unusual ethnographic features. In fact, the overall characteristics of this outbreak deviate markedly from the stereotypic patterns now thought to dominate in the United States,13 wherein minority populations and the exchange of sex for drugs play dominant roles. The use of network and ethnographic tools highlights these characteristics and challenges some of the precepts that form the basis for syphilis control strategies.

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Network Assessment

Network statistical measures document that this group was highly interactive, with a considerable degree of centrality among its members. The existence, for example, of a single connected component that included all but 4 of the participants, and a subgroup of 19 connected people, each of whom had 8 direct contacts, provides direct evidence of this interactivity. The dramatic increase in microstructures during the later phase of the outbreak underscores the type of network structure that facilitates disease transmission. Our approach demonstrated that uninfected people are often as central (i.e., as potentially important in transmission, based on their egocentric networks) as infected people. Because intervention occurred only during a narrow window, compared with the temporal extent of actual sexual activity, the potential importance of these uninfected people for illuminating transmission dynamics is undervalued by traditional methods. Furthermore, the network approach also demonstrated that the boundaries of this network had probably not been reached, as evidenced by the existence of cases that appeared at the margin (S1, S2) or unconnected to other cases (S30).

The network approach demonstrated that the results of interviewing infected and uninfected people were virtually identical for purposes of discovering infected contacts. In this outbreak situation, the probability of being sexually connected to an infected person was the same regardless of whether one was infected. In a closer examination of the clinical presentation and temporal data of people with syphilis, the concept of "source and spread" cases has little meaning. The likelihood of having contracted syphilis from a particular person might appear to be based more on the probabilities of transmission from multiple infected partners than on single transfer of the treponeme.

The traditional presentation of epidemic evolution‐the epidemic curve‐would fail to capture the growth in size and complexity of the sexual substrate from which these cases of syphilis came. The sexual context that generated these cases of syphilis became more intense and more interactive during the latter half of 1995, and intensified even further, both with new participants and new connections, during the first half of 1996. Although there may have been some impact on the transmission of syphilis through active case investigation and epidemiologic treatment, later ethnographic information suggests that disease intervention had little impact on the underlying network behavior that generated these cases.

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Implications for Evaluation

These observations suggest that some of the traditional approaches to syphilis control may not be well founded when dealing with outbreaks associated with highly interactive groups. Interviewing only infected people distorts the extent and nature of sexual interaction, misses the role that some people may play in forming a bridge between subgroups, and fails to identify some infected cases. Using a fixed critical period, based only on the presumed clinical epidemiology of the stage of syphilis, ignores important sexual interactions outside that period and does not give investigators access to individuals who may still be important in transmission, despite their remote contact. Finally, in a situation of considerable concurrence, the goal of establishing source and spread cases may be misplaced because multiple infections to multiple infected partners preclude clear delineation of a chain of infection.

On the other hand, a network analysis suggests several important approaches to evaluation. Formulating network diagrams in real time permits disease investigators to identify critical people (e.g., for follow‐up, reinterview) and critical subgroups (for selective mass treatment). The network approach permits rapid assessment of the type of group, the specific ethnographic characteristics, and the potential for continuing transmission. With ongoing network evaluation, the boundaries of the network and the connections to wholly different geocultural groups can be determined.

As an epidemic investigation proceeds, the changes in the network over time permit a rational estimate of the size of the outbreak and the underlying sexual activity, of the structural characteristics of the group, and of placement of risk behavior (what people do) in the context of risk configuration (how they interact with others). Visualization of the network permits a firmer basis for identifying prevented cases‐for example, the six uninfected people who had contact with two or more infected people‐because the likelihood of infection would have increased with multiple concurrent exposures. The use of a network‐based "epidemic curve" permits better correlation of case‐finding activity with secular trends. The changing configurations of networks are likely to be harbingers of transmission, and a movement away from dense, sexually interacting networks provides a basis for tying program intervention activity to declining transmission. Similarly, routine assessment of networks can be used as a surveillance tool for providing warning of adverse epidemiologic change.

Although, as noted, this outbreak has some unusual ethnographic features, it is not clear whether it represents an unusual network configuration for the transmission of syphilis. Much of the experience of STD control programs in dealing with sporadic and epidemic syphilis over the past several decades is undocumented, and a distribution of the network configurations associated with syphilis is not available. It has been postulated that the more typical syphilis outbreak in the current era‐that associated with the exchange of sex for drugs or money‐may result from differences in the density of sexual networks.14 Inner city networks of people involved in the exchange of sex for drugs are likely to be as dense and interactive as the network described here (Rothenberg RB, Sterk C, Pach A, unpublished observations from an ongoing study of urban social networks), and the outbreak described here may well be typical of current syphilis occurrence. If so, the small number of syphilis cases, given the amount of sexual activity and the extended time period, suggests that a high degree of interactivity may be necessary to sustain transmission, a finding that has been suggested on more theoretical grounds.15

With appropriate training16 and utilization of a database such as CDC's STD Management Information System (Mattock L, Rothenberg RB, personal communication), the process described here can be adopted as part of the preventive activities of many STD control programs. We would caution those who work in STD control, however, against interpreting these findings as simply an admonition to do more "cluster" interviewing. The latter, as noted, is the process of interviewing people who are not directly connected sexually to those with syphilis but who may be important in transmission. As such, cluster interviewing is very much in the spirit of a network approach. Our data suggest, however, that partner notification, its current variants, and its administrative edifice are a subset of a broader approach that examines the complex context of social networks. Use of network and ethnographic methods can be of direct benefit in epidemic control, as was the case here, and may provide insight into the long‐term dynamics of transmission.

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References

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12. Wasserman S, Faust K. Social Network Analysis. Cambridge, United Kingdom: Cambridge University Press, 1994.

13. Nakashima AK, Rolfs RT, Florck ML, Kilmarx P, Greenspan JR. Epidemiology of syphilis in the United States, 1941-1993. Sex Transm Dis 1996; 23:16-23.

14. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: Implications for prevention strategies. J Infect Dis 1997; 174(Suppl 2):S201-S213.

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Potterat, JJ; Muth, SQ; Brody, S
Sexually Transmitted Diseases, 27(): 644-645.

Sexually Transmitted Infections
The great pretender returns to Dublin, Ireland
Hopkins, S; Lyons, F; Mulcahy, F; Bergin, C
Sexually Transmitted Infections, 77(5): 316-318.

Bulletin of the American Mathematical Society
Contact network epidemiology: Bond percolation applied to infectious disease prediction and control
Meyers, LA
Bulletin of the American Mathematical Society, 44(1): 63-86.

Violence and Exploitation Against Women and Girls
Who wins in the status games? Violence, sexual violence, and an emerging single standard among adolescent women
Krauss, BJ; O'Day, J; Godfrey, C; Rente, K; Freidin, E; Bratt, E; Minian, N; Knibb, K; Welch, C; Kaplan, R; Saxena, G; McGinniss, S; Gilroy, J; Nwakeze, P; Curtain, S
Violence and Exploitation Against Women and Girls, 1087(): 56-73.
10.1196/annals.1385.001
CrossRef
Intelligence and Security Informatics: Biosurveillance, Proceedings
Incorporating geographical contacts into Social Network Analysis for contact tracing in epidemiology: A study on Taiwan SARS data
Chen, YD; Tseng, CJ; King, CC; Wu, TSJ; Chen, HC
Intelligence and Security Informatics: Biosurveillance, Proceedings, 4506(): 23-36.

Cadernos De Saude Publica
The relevance of social network analysis on the epidemiology and prevention of sexually transmitted diseases
Perisse, ARS; Nery, JAD
Cadernos De Saude Publica, 23(): S361-S369.

Sexually Transmitted Infections
Determinants of STD epidemics: implications for phase appropriate intervention strategies
Aral, SO
Sexually Transmitted Infections, 78(): I3-I13.

Journal of Infectious Diseases
Social context, sexual networks, and racial disparities in rates of sexually transmitted infections
Adimora, AA; Schoenbach, VJ
Journal of Infectious Diseases, 191(): S115-S122.

Annual Review of Public Health
Network analysis in public health: History, methods, and applications
Luke, DA; Harris, JK
Annual Review of Public Health, 28(): 69-93.
10.1146/annurev.publhealth.28.021406.144132
CrossRef
Dermatologic Clinics
Syphilis management and treatment
van Voorst Vader, PC
Dermatologic Clinics, 16(4): 699-+.

Journal of Infectious Diseases
Determinants and consequences of sexual networks as they affect the spread of sexually transmitted infections
Doherty, IA; Padian, NS; Marlow, C; Aral, SO
Journal of Infectious Diseases, 191(): S42-S54.

American Journal of Public Health
Structural and Social Contexts of HIV Risk Among African Americans
Friedman, SR; Cooper, HLF; Osborne, AH
American Journal of Public Health, 99(6): 1002-1008.
10.2105/AJPH.2008.140327
CrossRef
Microbes and Infection
Magic bullets need accurate guns - syphilis eradication, elimination, and control
Garnett, GP; Brunham, RC
Microbes and Infection, 1(5): 395-404.

Clinical Infectious Diseases
A preventable outbreak of tuberculosis investigated through an intricate social network
Fitzpatrick, LK; Hardacker, JA; Heirendt, W; Agerton, T; Streicher, A; Melnyk, H; Ridzon, R; Valway, S; Onorato, I
Clinical Infectious Diseases, 33(): 1801-1806.

Addiction
Methods for identifying and assessing groups in health behavioral research
Rapkin, BD; Dumont, KA
Addiction, 95(): S395-S417.

Population Health and Aging
New data and tools for integrating discrete and continuous population modeling strategies
Koopman, JS; Jacquez, G; Chick, SE
Population Health and Aging, 954(): 268-294.

Sexually Transmitted Diseases
Commentary - Gonorrhea surveillance: The missing links
Rothenberg, R; Potterat, JJ
Sexually Transmitted Diseases, 29(): 806-810.

Sexually Transmitted Diseases
Partner notification in the real world: A four site time-allocation study
Macke, BA; Hennessy, M; McFarlane, MM; Bliss, MJ
Sexually Transmitted Diseases, 25(): 561-568.

American Journal of Public Health
Selective risk taking among needle exchange participants: Implications for supplemental interventions
Valente, TW; Vlahov, D
American Journal of Public Health, 91(3): 406-411.

Journal of Infectious Diseases
Chlamydia trachomatis omp1 genotypic diversity and concordance with sexual network
Cabral, T; Jolly, AM; Wylie, JL
Journal of Infectious Diseases, 187(2): 279-286.

Eurosurveillance
Evaluation of A Patient Referral Contact Tracing Programme for Hepatitis B and C Virus Infection in Drug Injectors
Brewer, DD; Hagan, H
Eurosurveillance, 14(): -.
ARTN 19170
CrossRef
Sexually Transmitted Infections
Risk network structure in the early epidemic phase of HIV transmission in Colorado Springs
Potterat, JJ; Phillips-Plummer, L; Muth, SQ; Rothenberg, RB; Woodhouse, DE; Maldonaldo-Long, TS; Zimmerman, HP; Muth, JP
Sexually Transmitted Infections, 78(): I159-I163.

American Journal of Drug and Alcohol Abuse
Gender differences in HIV risk behaviors among young injectors and their social network members
Montgomery, SB; Hyde, J; De Rosa, CJ; Rohrbach, LA; Ennett, S; Harvey, SM; Clatts, M; Iverson, E; Kipke, MD
American Journal of Drug and Alcohol Abuse, 28(3): 453-475.

Proceedings of the National Academy of Sciences of the United States of America
Modeling dynamic and network heterogeneities in the spread of sexually transmitted diseases
Eames, KTD; Keeling, MJ
Proceedings of the National Academy of Sciences of the United States of America, 99(): 13330-13335.
10.1073/pnas.202244299
CrossRef
Journal of Urban Health-Bulletin of the New York Academy of Medicine
The urban environment and sexual risk behavior among men who have sex with men
Frye, V; Latka, MH; Koblin, B; Halkitis, PN; Putnam, S; Galea, S; Vlahov, D
Journal of Urban Health-Bulletin of the New York Academy of Medicine, 83(2): 308-324.
10.1007/s11524-006-9033-x
CrossRef
Perspectives on Sexual and Reproductive Health
The Contexts of Sexual Involvement And Concurrent Sexual Partnerships
Paik, A
Perspectives on Sexual and Reproductive Health, 42(1): 33-42.
10.1363/4203310
CrossRef
Sexually Transmitted Infections
Populations, pathogens, and epidemic phases: closing the gap between theory and practice in the prevention of sexually transmitted diseases
Blanchard, JF
Sexually Transmitted Infections, 78(): I183-I188.

Clinical Infectious Diseases
The transformation of partner notification
Rothenberg, R
Clinical Infectious Diseases, 35(): S138-S145.

Sexually Transmitted Infections
Gonorrhoea and chlamydia core groups and sexual networks in Manitoba
Jolly, AM; Wylie, JL
Sexually Transmitted Infections, 78(): I145-I151.

International Journal of Std & AIDS
The global burden of disease attributable to contaminated injections given in health care settings
Hauri, AM; Armstrong, GL; Hutin, YJF
International Journal of Std & AIDS, 15(1): 7-16.

Journal of Infectious Diseases
Identification of networks of sexually transmitted infection: A molecular, geographic, and social network analysis
Wylie, JL; Cabral, T; Jolly, AM
Journal of Infectious Diseases, 191(6): 899-906.

Journal of Infectious Diseases
Social structural and behavioral underpinnings of hyperendemic hepatitis C virus transmission in drug injectors
Brewer, DD; Hagan, H; Sullivan, DG; Muth, SQ; Hough, ES; Feuerborn, NA; Gretch, DR
Journal of Infectious Diseases, 194(6): 764-772.

Journal of Womens Health
Social support networks and maternal mental health and well-being
Balaji, AB; Claussen, AH; Smith, DC; Visser, SN; Morales, MJ; Perou, R
Journal of Womens Health, 16(): 1386-1396.
10.1089/jwh.2007.CDC10
CrossRef
International Journal of Std & AIDS
Network structural dynamics and infectious disease propagation
Potterat, JJ; Rothenberg, RB; Muth, SQ
International Journal of Std & AIDS, 10(3): 182-185.

Journal of General Internal Medicine
Social context of work injury among undocumented day laborers in San Francisco
Walter, N; Bourgois, P; Loinaz, HM; Schillinger, D
Journal of General Internal Medicine, 17(3): 221-229.

Journal of Infectious Diseases
Sexual role and transmission of HIV type 1 among men who have sex with men, in Peru
Goodreau, SM; Goicochea, LP; Sanchez, J
Journal of Infectious Diseases, 191(): S147-S158.

Sexually Transmitted Infections
The interrelation of demographic and geospatial risk factors between four common sexually transmitted diseases
Monteiro, EF; Lacey, CJN; Merrick, D
Sexually Transmitted Infections, 81(1): 41-46.
10.1136/sti.2004.009431
CrossRef
AIDS
Social network dynamics and HIV transmission
Rothenberg, RB; Potterat, JJ; Woodhouse, DE; Muth, SQ; Darrow, WW; Klovdahl, AS
AIDS, 12(): 1529-1536.

International Journal of Std & AIDS
HIV epidemiology in Africa: rich in conjecture, poor in data (reply to letter by Boily et al.)
Brewer, DD; Rothenberg, RB; Potterat, JJ; Brody, S; Gisselquist, D
International Journal of Std & AIDS, 15(1): 63-65.

Social Networks
Social network research and human subjects protection: Towards more effective infectious disease control
Klovdahl, AS
Social Networks, 27(2): 119-137.
10.1016/j.socnet.2005.01.006
CrossRef
Journal of the Royal Society Interface
When individual behaviour matters: homogeneous and network models in epidemiology
Bansal, S; Grenfell, BT; Meyers, LA
Journal of the Royal Society Interface, 4(): 879-891.
10.1098/rsif.2007.1100
CrossRef
Journal of Pediatric Psychology
A review of STD/HIV preventive interventions for adolescents: Sustaining effects using an ecological approach
DiClemente, RJ; Salazar, LF; Crosby, RA
Journal of Pediatric Psychology, 32(8): 888-906.
10.1093/ipepsy/jsm056
CrossRef
AIDS
Emerging future issues in HIV/AIDS social research
Friedman, SR; Kippax, SC; Phaswana-Mafuya, N; Rossi, D; Newman, CE
AIDS, 20(7): 959-965.
10.1097/01.aids.0000222066.30125.b9
PDF (155) | CrossRef
AIDS
HIV/AIDS among African Americans: progress or progression?
Cock, KM; Gayle, HD; Smith, DK; Gwinn, M; Selik, RM; Miller, KS; Dean-Gaitor, H; Ma'at, PI
AIDS, 14(9): 1237-1248.

PDF (221)
AIDS
An exploratory study on the social and genotypic clustering of HIV infection in men having sex with men
Chen, JH; Yam, WC; Lee, SS; Tam, DK; Tan, Y; Mak, WL; Wong, KH
AIDS, 23(13): 1755-1764.
10.1097/QAD.0b013e32832dc025
PDF (2832) | CrossRef
Current Opinion in Infectious Diseases
Can syphilis be eradicated from the world?
Rompalo, AM
Current Opinion in Infectious Diseases, 14(1): 41-44.

PDF (59)
Epidemiology
Concurrent Sexual Partnerships Among Women in the United States
Stancil, TR; Adimora, AA; Schoenbach, VJ; Bonas, DM; Martinson, FE; Donaldson, KH
Epidemiology, 13(3): 320-327.

PDF (771)
Epidemiology
Contextual Factors and the Black-White Disparity in Heterosexual HIV Transmission
Adimora, AA; Schoenbach, VJ
Epidemiology, 13(6): 707-712.

PDF (243)
JAIDS Journal of Acquired Immune Deficiency Syndromes
Concurrent Partnerships Among Rural African Americans With Recently Reported Heterosexually Transmitted HIV Infection
Adimora, AA; Schoenbach, VJ; Martinson, FE; Donaldson, KH; Stancil, TR; Fullilove, RE
JAIDS Journal of Acquired Immune Deficiency Syndromes, 34(4): 423-429.

PDF (330)
JAIDS Journal of Acquired Immune Deficiency Syndromes
Group Sex Events and HIV/STI Risk in an Urban Network
Friedman, SR; Bolyard, M; Khan, M; Maslow, C; Sandoval, M; Mateu-Gelabert, P; Krauss, B; Aral, SO
JAIDS Journal of Acquired Immune Deficiency Syndromes, 49(4): 440-446.
10.1097/QAI.0b013e3181893f31
PDF (277) | CrossRef
Sexually Transmitted Diseases
Social Network Methods for Endemic Foci of Syphilis: A Pilot Project
Rothenberg, R; Kimbrough, L; Lewis-Hardy, R; Heath, B; Williams, OC; Tambe, P; Johnson, D; Schrader, M
Sexually Transmitted Diseases, 27(1): 12-18.

PDF (6518)
Sexually Transmitted Diseases
Patterns of Chlamydia and Gonorrhea Infection in Sexual Networks in Manitoba, Canada
WYLIE, JL; JOLLY, A
Sexually Transmitted Diseases, 28(1): 14-24.

PDF (2160)
Sexually Transmitted Diseases
Networks and Pathogens
KLOVDAHL, AS
Sexually Transmitted Diseases, 28(1): 25-28.

Sexually Transmitted Diseases
Anticipating Outbreaks: A Prevention Role for Integrated Information Systems
ARAL, SK; BERMAN, SM; ARAL, SO
Sexually Transmitted Diseases, 29(1): 6-12.

PDF (119)
Sexually Transmitted Diseases
Sex Partner Selection, Social Networks, and Repeat Sexually Transmitted Infections in Young Men: A Preliminary Report
Ellen, JM; Gaydos, C; Chung, S; Willard, N; Lloyd, LV; Rietmeijer, CA
Sexually Transmitted Diseases, 33(1): 18-21.

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Sexually Transmitted Diseases
Sexual Network Structure Among a Household Sample of Urban African American Adolescents in an Endemic Sexually Transmitted Infection Setting
Fichtenberg, CM; Muth, SQ; Brown, B; Padian, NS; Glass, TA; Ellen, JM
Sexually Transmitted Diseases, 36(1): 41-48.
10.1097/OLQ.0b013e3181860711
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Sexually Transmitted Diseases
How a Net Works: Implications of Network Structure for the Persistence and Control of Sexually Transmitted Diseases and HIV
Rothenberg, R
Sexually Transmitted Diseases, 28(2): 63-68.

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Sexually Transmitted Diseases
Case-Finding Effectiveness of Partner Notification and Cluster Investigation for Sexually Transmitted Diseases/HIV
Brewer, DD
Sexually Transmitted Diseases, 32(2): 78-83.

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Sexually Transmitted Diseases
Gonorrhea, Chlamydia and the Sexual Network: Pushing the Envelope
Zenilman, JM
Sexually Transmitted Diseases, 27(4): 224-225.

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Sexually Transmitted Diseases
The Re-Emergence of Syphilis in the United Kingdom: The New Epidemic Phases
Thomas, DR; Lynch, A; Winter, A; Fisher, MJ; Lighton, L; Simms, I; Fenton, KA; Ashton, M; Turner, KM; Crawley-Boevey, EE; Gorton, R; Maguire, HC; Solomou, M
Sexually Transmitted Diseases, 32(4): 220-226.

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Sexually Transmitted Diseases
Agreement in Reported Sexual Partnership Dates and Implications for Measuring Concurrency
Brewer, DD; Rothenberg, RB; Muth, SQ; Roberts, JM; Potterat, JJ
Sexually Transmitted Diseases, 33(5): 277-283.
10.1097/01.olq.0000204746.58160.c1
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Factors and the Sociosexual Network Associated With a Syphilis Outbreak in Rural North Carolina
Seña, AC; Muth, SQ; Heffelfinger, JD; O’Dowd, JO; Foust, E; Leone, P
Sexually Transmitted Diseases, 34(5): 280-287.
10.1097/01.olq.0000237776.15870.c3
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Recidivism Redux
Rothenberg, R
Sexually Transmitted Diseases, 27(6): 350-352.

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Responding to a Community Outbreak of Syphilis by Targeting Sex Partner Meeting Location:: An Example of a Risk-Space Intervention
Michaud, JM; Ellen, J; Johnson, SM; Rompalo, A
Sexually Transmitted Diseases, 30(7): 533-538.

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Sexually Transmitted Diseases
Large-Network Concepts and Small-Network Characteristics: Fixed and Variable Factors
Rothenberg, R; Muth, SQ
Sexually Transmitted Diseases, 34(8): 604-612.
10.1097/01.olq.0000258358.13825.a8
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Sexually Transmitted Diseases
Clients of Indoor Commercial Sex Workers: Heterogeneity in Patronage Patterns and Implications for HIV and STI Propagation Through Sexual Networks
Remple, VP; Patrick, DM; Johnston, C; Tyndall, MW; Jolly, AM
Sexually Transmitted Diseases, 34(10): 754-760.
10.1097/01.olq.0000261327.78674.cb
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Sexually Transmitted Diseases
Responding to the Epidemics of Syphilis Among Men Who Have Sex With Men: Introduction to the Special Issue
Peterman, TA; Collins, DE; Aral, SO
Sexually Transmitted Diseases, 32(): S1-S3.
10.1097/01.olq.0000180454.23228.80
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Sexually Transmitted Diseases
Using Gay Men’s Sexual Networks to Reduce Sexually Transmitted Disease (STD)/Human Immunodeficiency Virus (HIV) Transmission
Wohlfeiler, D; Potterat, JJ
Sexually Transmitted Diseases, 32(): S48-S52.
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