Aeortad oy be US. DEPARTMENT OF HEALTH AN UMAN SERVICES PUBLIC HEALTH'SERVICE ‘Sexually Transmitted Diseases Journal of the American Venereal Disease Association ‘April: Jane 1988, Volume 15 Number 2 Temporal and Social Aspects of Gonorrhea Transmission: the Force of Infectivity RICHARD B. ROTHENBERG, MD, MPH, AND JOHN J. POTTERAT, BA ‘Theoretical consideration of the epidemiology of sexually ‘transmitted diseases (STD) suggests that the key determinants of transmission dynamics are the duration of infectiousness ‘and the extent to which subgroups in the population interact sexually, We used two empirical correlates to represent these ‘concepts: (1) the force of infectivity, calculated by summing ail the days of potential infectivity (the time between last sexual ‘exposure and treatment of the contact) generated by a xiven ‘case, and then summing the days for all cases within a given Subgroup; (2) self-selection, representing the observed proba bility that members of a given subgroup select yeaual partners {from within their own group. Using data gathered in Colorado ‘Springs, Colorado, we estimated that a single group male, heterosexual, military personnel res atens, generated 27% ofthe force of infectivity. Subgroups that select >50% of their sexual partners from outside their socio- ‘demographic boundaries generated a rate forthe force of infec tivity that was 45 times higher than the rate for self-selectors. ‘These findings confirm the core group theory and suggest strategies for control of STD. OVER THE PAST 12 YEARS, a number of mathemat- ical models have been proposed to study sexually trans- mitted diseases (STD).'* The simplest of these models involves random interactions between infectious and susceptible individuals in a homogenous population.* Based on “mass-action” equations, the simple model is satisfying in concept and mathematical construction, but it bears little relationship to the reality of human sexual interaction. Accordingly, more complex models have been developed,* involving individuals with differ- cent levels of sexual activity and symptomaticity. These models have shown that gonorrhea, for example, re- ‘mains endemic in populations in which the average re- productive rate (ie., the ability of an infectious case to reproduce itself) is at least 1. Further, the endemic con- figuration consists of some subgroups with high repro- ductive rates (core groups) and others with low rates. A. "This work was presented in part at the Sixth International Society for ‘STD Research Meeting, July 1~Augus 2, 1985, Brighton, England. Reprint request: Dr. Richard Rothenberg, Center for Environmen- tal Health and lajury Control, Centers for Disease Control, Atlanta, Georgia 30333. ‘Reveived for publication on October 3, 1986, and in revised form on ‘August 10, 1987, 88 From the Canter for Environmental Health, Centers for Disease Contro, Atlanta, Georgia; and the E! Paso County ‘Health Department, Colorado Springs, Colorado recent empirical estimate of national occurrence of gon- orrhea that was based on local data’ appears to confirm this, Construction of these models requires estimation of a large number of parameters, but these can be reduced to two basic types: (/) the duration of infectiousness, which refers to the period of time that an infected individual in the community and potentially transmitting disease: ‘and (2) sexual interaction, which connotes the propen- sity of subgroups (defined by stable sociodemographic characteristics) to have sexual contacts within or outside their own group. In this study, we explore empirical data to estimate these parameters and to define the popula- tion dynamics of gonorrhea for a specific community Lethods ‘Study Population Data for this study were extracted from case inter- ‘views and contact investigations of 769 (97°) of the 793 cases of gonorrhea reported to the El Paso County Health Department (Colorado Springs, CO) during Jan- uary-June 1981. The population structure and methods used for epidemiologic assessment have been described in detail In this analysis we focused on the 1770 undu- plicated case-contact pairs identified during this six- month period. Of this total, 1129, including 688 in- fected pairs, had dates available for calculating the time intervals of interest. Population subgroups were defined on the basis of ‘gender, sexual orientation, geographic location, race, and employment status. For this geographic area, the relevant descriptors included heterosexual men, homo- sexual men, and heterosexual women; white, black, and hispanic individuals; persons residing in core, adjacent, and peripheral areas (as defined in previous analyses”);and employed, unemployed, and military persons. Prostitutes were relatively few in number and were counted among the employed women. This breakdown provided a total of 81 mutually exclusive subgroups. Duration of Infectiousness: the Force of Infectivity The unit of analysis in epidemiologic studies of STD. is usually the infectious sexual encounter. This event takes place within a temporal continuum, however. along which we define four important intervals. (1) Ac- quaintanceship: the period from first social contact to first sexual encounter; (2) exposure: the time from first to last sexual encounter; (3) case treatment delay: the period between last sexual encounter and treatment of the case; and (4) contact treatment delay: the period from the last sexual encounter between case and contact to the treatment of the contact. Our focus in this analysis is on the second and fourth intervals. Since a case may have a number of contacts, the case treatment delay is not unique and is duplicated in part or in whole for each of the case’s contacts. The contact treatment delay is unique, however, because it can represent the period of | ‘time that a particular contact is in the community. po- tentially infected, and capable of transmitting the dis- cease to others. If this period of potential infectivity is summed over all the contacts to a given case. it repre- sents the total force of infectivity generated by that par- ticular case. When we group cases with similar sociode- mographic attributes together, we then have a force of infectivity (ie., total days of potential transmission) generated by the group. This summation is offered as the empirical equivalent of duration of infectiousness. It permits partitioning of the total infectiousness generated within a community among the subgroups that may be of particular importance. ‘Sexual Interaction: Group Self-Selection Group self-selection is defined as the propensity of individuals within a given subgroup to choose others from the same subgroup as sexual contacts. For this segment of the analysis, only two of the variables (race ‘and location) were used in forming a total of nine sub- ‘groups. Thus, a nine-by-nine matrix is used in the com- parison of cases and contacts. This construct forms the basis for an empirical estimation of the degree of sexual interaction among subgroups in a population. Results, Distribution of Time Intervals When plotted as frequency distributions (figs. | and 2), the two key intervals, exposure and contact treat- ment delay. display marked skewing to the right, Both ASPECTS OF GONORRHEA TRANSMISSION 89 ie Be Fig. 1. Intervals for exposure to gonormea for each case-contact ‘pele were grouped, and he percentage fling into each time interval 's poted, can be modeled with good fit as a negative exponential distribution (R? > 0.90 for both) as predicted theoreti- cally.‘ The median exposure was 19 days (mean, 182 days). Roughly one-third of the case-contact pairs had single exposures, but >14% had a duration of sexual contact of longer than one year. The curve for contact treatment delay was somewhat less extreme. with a me- dian of 15 days and a mean of 39 days. Only 2% of contacts were treated on the same day as the case. Sixty- seven per cent of contacts were treated within one month, and 7% of contacts remained untreated in the community for three months or more. At the extremes of exposure. i... one-time contacts vs. exposure of 300 days or more. there is an inverse relationship between exposure and contact treatment delay. Those with one-time exposures had relatively Jong contact treatment delays (mean, 32.5 days; median, 21.6 days); those with long exposures had shorter con- tact treatment delays (mean, 23.9 days: median. 6.3, days). This finding suggests that long-term relationships predispose to rapid evaluation of sexual partners. Force of Infectivity As noted, when the contact treatment delay days are summed over all the contacts to a given case, they repre- sent the force of infectivity generated by that case. When like cases are grouped together, summation over all such eee 2 Fig. 2. Contact treatment delay intervals for each case-contact pa wore grouped and the percentage fling to time intervals sped For curve fiting, he frst point (representing those pars where case ‘and contact were treated on the same day) was omtte.90 ROTHENBERG AND POTTERAT ‘TABLE 1, Dstibution ofthe Force of infectivity” of Gonorrhea in Colorado Springs, Colorado, January-June 1981 —WHITE_ BLACK HISPANIC _ Unempi_ Military Employed | Unempi_ Miltary Employed | Unemp! Employed] cow | 38 au | 1 x | wm 6 xo | loorosx! Adjacent, | 2 | Ot | “ Perpnera | 17 a2 (52 | 280 1 a | our ne Core “3 Car) 1 ‘376 | 346 156 40, 10 5 Female adjacent. |_10s_ 03017 SOO La] 78 0100 Peripheral [e286] 0 [ae] on 30m] 78 ery coe | 0 ws 5 | 6 1m 0 3 9 Homosx| Adjacent | 98 ge [Tana o 0 of 0 0 & penprea! | 20 «915 [en] 3 | 0k TOTAL = 71-2100] * Deine a ie ume in days Between last sexual exposure of contact wih case and eatment of contact cases produces a force of infectivity for the group. Table 1 presents the foree of infectivity generated for cach of the 81 subgroups of interest in the population. It is ap- parent that black, core, heterosexual, military men con- tribute 27% (3092/11628) of the total days of potential infectivity generated within the community. This group is followed, at some distance, by employed, peripheral white women (7%) and by employed, peripheral, white, heterosexual men (6%). If rates, in the form of contact treatment delay days pper 100 persons per year, are calculated, a slightly dif- ferent picture emerges. Black, unemployed, peripheral, heterosexual men generate the highest rate (568 days per 100 persons per year), followed by black, unemployed, core women (517), black, military, core women (477) and hispanic, unemployed, core, heterosexual men (448) (see table 2). Although the total membership in these latter three groups is small, they demonstrate a high intensity of potentially infectious sexual activity SelfeSelection ‘The matrix of nine race-area groups of cases vs, those for contacts is displayed in tables 3 and 4. The percent- age in each box represents the proportion of total con- tacts to a given case subgroup that emanates from a given contact subgroup. For simplicity, unimportant combinations (ie., <10%) have been omitted. The fre- quency of self-selection is displayed on the diagonal along with selected combinations whose frequency was >10%, Table 3 shows the pattern for heterosexual men and their female contacts. Heterosexual men appear to ‘choose partners from the same subgroup, with only sev- eral exceptions. Their choices lie, for the most part, ‘TABLE 2. Rat ofthe Force of Infect of Gonorinea in Colocado Springs, Colorado, January-June 1981 wire: ‘Military Employed core | 28 2 4 Heterosx) Adjacent 3 3 1 Peripheral 2 1 6 Core | 18 135 7 Female ‘Adjacent |" 20 0 5 Peripneral | 95 ° 5 Core oe ey Homosx! adjacent | 85 67 7 Peripneral | 20 4 3 BLACK Unemp! a v7 2 0 st 5 0 3 368 1 2 | 163 ° 2 a a] 3 a 20 365 0 98 | 150 ° 22 6 ar 76 o 100128 oa ° 6 7 0 0 ° ° 0 188 0 70 12 0 7 28VoL iseno? ASPECTS OF GONORRHEA TRANSMISSION OL ‘TABLE 3. Pattems of Self-Slecton: Heterosexual Men with Gonorthea and Their Contacts, Colorado Springs, Colorado, January-June 1881 CONTACTS: WOMEN . wore, BLACK HISPANIC No. ot (Gore Adjacent Peripheral Core Adjacent Peripheral Gore Adjacent Peripheral] Contacts Core [0% 0 warre Adjacent 7%] 50 8 Periph 69% 8 Core 25% 91 BLacK ‘Adjacent Be . 2 Periph 3% a re 0% 10 HISPANIC Adjacent Be 4 Periph “5% 3%, mn art ‘The percentages represent the proportion of contacts who emanate from a given race-area ‘grouping. In general. the majority of fe ‘contacts come from the same group as the men {i.e along the diagonal, but when this is not the case, the proportions are indicated. The tomaining proportions are omitted for the sake of clay along the diagonal of self-sclection. In sharp contrast. virtually every subgroup of women seeks black core men, preferentially, and this preference produces the vertical, pattern shown in table 4. The pattern for homosexual, men (not shown) is difficult to assess since this group is, associated with only 15% of reported cases of gonorrhea in the area, but there is a suggestion of preferential con- tact between gay hispanic men and gay white men. Interaction of Force of Infectivity and Self-Selection Many of the case-contact group interactions were inimal (table 1). Of the 81 subgroups, only 16 had a total of #30 contacts. These may be divided into six groups that select “self” > 50% of the time, and ten ‘groups that select “self” < 50% of the time. As table $ shows, the self-selectors chose 63% of their contacts from within (as expected), compared with 20% for the non-self-sclectors. The remaining 65 subgroups self-se- lected 26% of the time. Non-self-selectors generated al- ‘most twice the force of infectivity as did self-selectors (47% vs, 27%) and had a rate for force of infectivity per 100 persons per year that is four and one half times hhigher (45 vs. 10.1). When these two groups were com- pared with the remainder (table 5). it was apparent that the proportion of infected contacts is the same in all three groups. Finally, 63% of infected contacts to self- selectors came from the same population group. as compared with 23% for non-selfselectors. This means that 77% of the infected contacts to non-self-sclectors are found outside those population subgroups. Discussion Since the 1970s, efforts to control gonorthea in the United States have centered on screening asymptomatic ‘TABLE 4, Pattems of Sa-Selection: Women with Gonorrhea and Thelr Contacts, Colorado Springs, Colorado, January-June 1981 CONTACTS: HETEROSEXUAL MEN WHITE puck _ HISPANIC No, of Gore Adjacent Perioneral ‘Adjacent Peripheral Core Adjacent Peripheral] Contacts core [38% Ey wore, ‘adjacent |~29% [2s a Periph em, n Core BLACK ‘Adjacent we 82 erion 2% % Core, aa 7 HISPANIC Adjacent 5 Periph 4 330 “The percentages represent the proportion of contacts who emanate trom a glen race-area ‘grouping, Se-selection is indicated along the diagonal, The proportion of contacts which ‘comes from the core-black grouping is. in most instances the highest, The remaining propor tions are omitted for the sake of clanty‘TABLE 5. Comparison of Subgroups of Patents with Gonortnea Who Have High and Low Sell Selectivity, Colorado Springs, Colorado, 92 ROTHENBERG AND POTTERAT January-June 1981 HIGH Number 6 Self-selection (percent) 63 Force of Infectivity (days) (percent) 3090 (27) Force of Infectivity (rate per 100 persons per year) 10.1 Infected Contacts 41 Infected contacts from same subgroup (percent) . 6 women and interviewing symptomatic men. Interview= ing strategies have been slow to change, perhaps in part because STD programs, with limited resources, must confront the numbing prospect of enormous case loads. Considerable theoretical and empirical evidence now exists, however, to suggest that a small proportion of ‘cases of gonorrhea plays the major role in transmission (See references 17 and the extensive citations in refer- ence 4). Further, population subgroups from which these cases arise can be identified. ‘We have used two measures, force of infectivity and self-selection, as surrogates for two critical variables in the mathematical model: duration of infection and group interaction, These measures provide an opportu- nity to assess transmission dynamics in a particular community. Based on the accessible portion of the pop- ulation with gonorrhea, this analysis confirms the theo- retical notion that gonorrhea endemicity is maintained by the presence of core groups, within which intense transmission takes place. The force of infectivity, a ‘measure of the amount of potential infective time that a population subgroup generates, provides quantitation of the importance of a given group to overall transmission. Self-selection, a measure of sexual interaction among, groups, suggests the presence of subsets within the core. While some groups appear to maintain endemicity through selection of similar partners, others propagate infection beyond their sociodemographic boundaries. This latter group, the non-self-selectors, may be of par- ticular importance in overall transmission dynamics. The efficiency with which gonorrhea is transmitted by all groups is relatively constant. The dynamics of gonor- GROUP Low REMAINDER 10 65 20 26 5487 (47) 3049 (26) 45 13.3 48 46 23 31 rca transmission appears to relate to the interaction of subgroups rather than to the biology of infection. In Colorado Springs this approach provides evidence for the importance of black, military, heterosexual n and their partners in transmission of disease. However, this particular result cannot be assumed to hold in gen- eral. Within a given area the groups that are critical 10 the propagation of gonorrhea vary. The force of infectiv- ity and the degree of self-selection are generic, however, and may be calculated from routinely collected program. data. These measures permit specification of core groups and identification of those groups that maintain local endemicity and those that seek outside sexual en- counters. This strategy provides a rational basis for tar- geting and evaluating control efforts, References 1, Lajmanovich A, Yorke JA. A deterministic mode! for gonorrhea ina nonbomogenous population. Math Bios 1976: 24:22) 36. Yorke JA. Hethcote HW, Nold A, Dynamics and control of the twansmission of gonorthea. Sex Transm Dis 197K: $:51-6, 3. Hetheote HW, Yorke JA, Nold A. Gonorrhea modeling: a com- arson of control methods. Math Bios 1982; 58:93-109, 4. Hethcote HW, Yorke JA. Gonorrhea transmission dynamics and ‘control. Lecture Notes in Biomathematics no, 56. Beri Sovinger-Veriag, 1984, 5. Potterat JJ, Dukes RL, Rothenberg RB. Disease transmission by Iheterosexual men with gonorthea: an empinclesimat. Sex ‘Transm Dis Sex Transm Dis 1987; 14(1 1-4, 6, Powterat I, Rothenbers RB, Woodhouse DE, Muth JB, Prats Cl Fogle JS. Gonorrhea s social disease. Sox 7. Rothenberg RB. The geography of gonorrhea: empirical demon ‘tration of core group transmission. Am J Epidemiol 1983, 117688-98