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A Critical Piece by Whatever Name

Spencer, Jack N. BA

Sexually Transmitted Diseases: January 2000 - Volume 27 - Issue 1 - p 19–20

From the National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia

Reprint requests: Jack Spencer, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, 1600 Clifton Avenue E‐02, Atlanta, GA 30333. E‐mail:

Received for publication April 19, 1999, revised June 15, 1999, and accepted June 25, 1999.

ROTHENBERG1 AND COLLEAGUES have taken a convincing position on the need for “nontraditional approaches to STD control and prevention” in their description of a social network pilot project in Fulton County, Georgia1; however, one could argue that the approach described is not as “nontraditional” as the authors claim. For many years, public‐health managers and supervisors have recognized that the interview of a patient for sexual partners does not always result in the obtainment of the information necessary to effectively interrupt the transmission of sexually transmitted diseases (STDs); in this case, syphilis. As early as the mid‐1940s, mass blood‐testing campaigns were carried out in addition to the interview of the infected patient to identify persons infected with syphilis. As the infectious reservoir was reduced through these campaigns, public health approaches were refined to include field blood testing in areas where known cases of syphilis were high.

In 1950, Fiumara described the following as one of the key pieces of a venereal disease contact interview: “Very often a patient will know of a friend or acquaintance who was exposed to the same person either at the same time he was, or at other times. Or the friend may have been out on a double date with the same objective accomplished. Ask the patient to bring them to the clinic for an examination too. The patient may also have friends with the same promiscuous tastes. These too should be invited to the clinic for examination. Encourage the patient to act as a goodwill ambassador and round up potentially infected individuals.”2

By the mid‐1950s, Robert Swank and associates had described a process for querying syphilis‐infected patients about others in their social network with whom they were not having sex, but who were sexually active or had symptoms of syphilis.3 In the 1960s, this process was given the name cluster case finding,4 and the cluster interview became a required portion of every patient's interview.5

In 1963, nine STD project areas participating in a 3‐month study of cluster interviewing of primary and secondary patients found that (1) 9.3% of persons described as having syphilitic‐like lesions were infected with syphilis; (2) 4.3% of persons described as being a sex partner of a syphilis‐infected person were infected with syphilis; and (3) 2.8% of persons described as sexually active were infected with syphilis.6 In this study, the overall positivity rate for nonsexual partners of infected persons was 3.4% and the positivity rate for nonsexual partners of uninfected persons was 2.0%, compared with the positivity rates of 5.9% and 5.3%, respectively, found in the study by Rothenberg et al.

In the early 1970s, this interview process was further refined by the development of the lot system, which placed all related cases of syphilis‐infected persons and their named contacts in a single “lot” folder, which was evaluated by supervisors and staff as cases were worked.6

There are two inherent values of the Rothenberg pilot study. The first lies not in its “nontraditional” approach, but in its application of social network analysis to a “traditional” approach that has been used sporadically in recent years. Much has been learned about social networks, such as new terminology, new software technology, and more standardized measures (see Table 2). The article correctly points out that much of this analysis technique is not easily assimilated by the average public‐health investigator; however, the concept is easily understood. The second and most important value of the study is in its timing. As the nation embarks on its third attempt this century at the domestic elimination of syphilis, it is crucial that public‐health workers be aware of and proficient at the use of every available tool in the syphilis‐prevention armamentarium; the application of social network interviews and its subsequent analysis is clearly one of these. More importantly, the application of social network methods at the community level, which are described by Rothenberg et al as “street‐centered,” fits nicely with the community‐involvement and partnerships strategy of the National Plan to Eliminate Syphilis in the United States, which calls for members of affected communities to be recruited, trained, and employed for local syphilis‐elimination activities‐including social network intervention.7

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1. Rothenberg R, Kimbrough L, Lewis-Hardy R, et al. Social network methods for endemic foci of syphilis: A pilot project. Sex Transm Dis 2000; 1:12–18.
2. Henderson RH. Control of sexually transmitted diseases in the United States: A federal perspective. Br J Venereal Dis 1977; 53:211–215.
3. Swank R, Axnick, NW. 1963 Review of Cluster Procedure. Paper presented at the 14th Annual Symposium on Recent Advances in the Study of Venereal Diseases; January 1964; Houston, Texas.
4. Department of Health Education and Welfare. Syphilis Epidemiology Report 6. Location: Public Health Services; July 1966; 1:13.
5. Department of Health Education and Welfare. Venereal Disease Field Manual. Location: Public Health Services; July 1962; E-23.
6. Department of Health Education and Welfare. General Disease Epidemiology Report 12. Location: Public Health Service; September 1973; 15.
7. Centers for Disease Control and Prevention. The National Plan to Eliminate Syphilis from the United States. Location: in press; 18–20.

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