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Does Core Area Theory Apply to Sexually Transmitted Diseases in Rural Environments?

Gesink, Dionne C. PhD*; Sullivan, Ashleigh B. MPH*; Norwood, Todd A. MSA; Serre, Marc L. PhD; Miller, William C. PhD§

Sexually Transmitted Diseases: January 2013 - Volume 40 - Issue 1 - p 32–40
doi: 10.1097/OLQ.0b013e3182762524
Original Study

Background Our objective was to determine the extent to which geographical core areas for gonorrhea and syphilis are located in rural areas as compared with urban areas.

Methods Incident gonorrhea (January 1, 2005–December 31, 2010) and syphilis (January 1, 1999–December 31, 2010) rates were estimated and mapped by census tract and quarter. Rurality was measured using percent rural and rural-urban commuting area (rural, small town, micropolitan, or urban). SaTScan was used to identify spatiotemporal clusters of significantly elevated rates of infection. Clusters lasting 5 years or longer were considered core areas; clusters of shorter duration were considered outbreaks. Clusters were overlaid on maps of rurality and qualitatively assessed for correlation.

Results Twenty gonorrhea core areas were identified: 65% were in urban centers, 25% were in micropolitan areas, and the remaining 10% were geographically large capturing combinations of urban, micropolitan, small town, and rural environments. Ten syphilis core areas were identified with 80% in urban centers and 20% capturing 2 or more rural-urban commuting areas. All 10 (100%) of the syphilis core areas overlapped with gonorrhea core areas.

Conclusions Gonorrhea and syphilis rates were high for rural parts of North Carolina; however, no core areas were identified exclusively for small towns or rural areas. The main pathway of rural sexually transmitted disease (STI) transmission may be through the interconnectedness of urban, micropolitan, small town, and rural areas. Directly addressing STIs in urban and micropolitan communities may also indirectly help address STI rates in rural and small town communities.

No geographically defined core areas were found for rural North Carolina, suggesting that rural sexually transmitted infection transmission may depend on the interconnectedness of urban, micropolitan, small town, and rural areas.

From the *Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; †Cancer Care Ontario, Toronto, Ontario, Canada; Departments of ‡Environmental Science and Engineering and §Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC

We thank the North Carolina Department of Public Health for their collaboration on this project, as well as Garnet Bass from the North Carolina Rural Economic Development Center and the Rural Health Research Program at the Sheps Center in North Carolina.

Supported by National Institute of Allergy and Infectious Diseases (R01 AI067913).

Conflict of interest: None.

Correspondence: Dionne C. Gesink, PhD, Dalla Lana School of Public Health, University of Toronto, 155 College St, 6th Floor, Toronto, Ontario, M5T 3M7. E-mail:

Received for publication May 9, 2012, and accepted September 18, 2012.

© Copyright 2013 American Sexually Transmitted Diseases Association