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Large Gonorrhea Outbreak in a Rural California County, 2003 Michael Samuel, Dr.P.H. California Department of Health Services STD Control Branch.

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Presentation on theme: "Large Gonorrhea Outbreak in a Rural California County, 2003 Michael Samuel, Dr.P.H. California Department of Health Services STD Control Branch."— Presentation transcript:

1 Large Gonorrhea Outbreak in a Rural California County, 2003 Michael Samuel, Dr.P.H. California Department of Health Services STD Control Branch

2 Butte County, California

3 Gonorrhea Rates, 1985–2002 Butte County California United States

4 Background County Health Department detected increases in gonorrhea in early 2003 County alerted local medical community in March and May Requested assistance of State STD Control Branch in September –Outbreak investigation –Control measures

5 Methods Case series –Confidential Morbidity Report (CMR) –Laboratory report Interviews –Standardized interview record (IR) –Health educators & Disease Intervention Specialists (DIS) –In-person and by-phone Network analysis –Ask all cases and contacts to name all sexual and social contacts in prior 3 months

6 Methods - Software Case series and interviews –Access –SAS Mapping –ArcView 3.1 Network analysis –Ucinet 6 for windows –NetDraw 1.0

7 Results 1: Demographics and Risk Data

8 GC Cases by Month Butte County,

9 GC Cases by Month Butte County,

10 GC Cases by Month Butte County,

11 Gonorrhea GC Cases Butte County, Cases 148 Unique Adult Case- patients 95 Oroville 62 Interviewed 31 Chico 12 Interviewed 22 Other Butte Co. 13 Interviewed 6 Re-infections 2 cases under 14 yr

12 GC Cases by Gender, Age and Race/Ethnicity-Oroville, 2003 Male 38% (N=36) Female 62% (N=59) Age Race

13 GC Cases “Socioeconomic Status” Oroville, 2003 % Unemployed53 Less than High School Education46 Private Health Insurance 5

14 Where GC Cases Met New Partners Oroville, 2003 Venue% Friend’s House26 Casinos14 Bar/Club 6 Park 6 Motel 4 Liquor Store A 2

15 GC Cases Drug Use Oroville, 2003 Drug% Alcohol47 Marijuana35 Methamphetamine18 Ecstasy 3 Heroin 2 Cocaine 2

16 GC Cases – Race/Ethnicity of Partners Oroville, 2003 Female (%)Male (%) Partner race generally different4126 White73 17 African-American-67 Latino2717

17 GC Case and Partner Incarceration History, Oroville, 2003 Female (%)Male (%) Case2046 Partner4622

18 Variables with Low Frequencies Exchange of money or drugs for sex Specific venues (e.g., X Bar) Men, sex with men

19 Results 2: Visual and Network Analysis

20 Visual Analysis Geographical –Determine geographic distributions Network –Determine sexual and social connections

21 Butte County – “Broken Windows” Environment

22 Oroville Gonorrhea Cases January, 2003

23 Oroville Gonorrhea Cases January–February, 2003

24 Oroville Gonorrhea Cases January–March, 2003

25 Oroville Gonorrhea Cases January–April, 2003

26 Oroville Gonorrhea Cases January–May, 2003

27 Oroville Gonorrhea Cases January–June, 2003

28 Oroville Gonorrhea Cases January–July, 2003

29 Oroville Gonorrhea Cases January–August, 2003

30 Oroville Gonorrhea Cases January–September, 2003

31 Oroville Gonorrhea Cases January–October, 2003

32 Oroville Gonorrhea Cases January–November, 2003

33 Oroville Gonorrhea Cases January–December, 2003

34 Original DIS Network Diagram

35 Butte County Gonorrhea Outbreak, 2003 Sexual and Social Network Diagram Male Case Female Case Sex link Social link Male Uninfected Female Uninfected Arrowhead indicates directionality of naming Sex link ? Male Unknown Female Unknown

36 Butte County Gonorrhea Outbreak, 2003 Sexual and Social Network Diagram Male Case Female Case Sex link Social link Male Uninfected Female Uninfected Arrowhead indicates directionality of naming Sex link ? Male Unknown Female Unknown

37 Butte County Gonorrhea Outbreak, 2003 Sexual and Social Network Diagram Male Case Female Case Sex link Social link Male Uninfected Female Uninfected Arrowhead indicates directionality of naming Sex link ? Male Unknown Female Unknown

38 Characteristics of Core Cases DX DateGenderAgeRace/EthCasinoRepeat GCTravel Apr-03M24BlackNNN May-03F26WhiteYNY Jul-03M27BlackNYY Sep-03F25WhiteNNN Sep-03M20HispanicNNN Sep-03F29WhiteYNY Oct-03F23HispanicNNY Oct-03F21WhiteNNY Oct-03F16HispanicNNN Oct-03F17White--N Oct-03F19AsianNNN

39 Butte Gonorrhea Outbreak Network Cluster Cases Note: The address for one of the network cluster cases was a PO Box, thus that case is not included above.

40 “Network” Diagram Month of Diagnosis and Age WEEK AGE

41 Conclusions Large gonorrhea outbreak in rural California County Large proportion GC cases: –White, female –Unemployed, uneducated –Lacked private health insurance –Incarceration history Only venue of note was casinos Re-infection among African-American males Delay in initiating investigation was problematic

42 Conclusions - Network Analysis Detected one large network with very diverse race/ethnicity, age, and geography Included casino and travel history Beyond traditional field investigation, comprehensive network analysis requires systematic collection of data using uniform procedures

43 Limitations – General Study Design –No comparison group Incomplete data –Not provided –Not recorded consistently Limited Local Health Department resource Rotating State staff

44 Limitations Network Analysis Lack of experience with formal network analysis Incomplete data –Connections –Infection status Mapping Missing, incorrect and P.O. box addresses not geocodeable Address is residence and not necessary location of sexual contact(s)

45 Potential Value of Network Analysis Nature of individuals in specific clusters Nature of network structure May help control future outbreak

46 Acknowledgements California Department of Health Services, STD Control Branch –Roxanne Aguirre –Gail Bolan –George Camarillo –Jennifer Chase –Stewart Coulter –Juan Cruz –Denise Gilson –Brian Hughes –Jan King –Marcella Lemus –Terry Lo –Manny Olivas –Shaheed Salahudin Butte County Health Department –Sherry Bloker –Charlotte Freer –Mark Lundberg –Alice Kienzle –Carmen Ochoa –Eric Sawtelle –Lorna Andreatta –Jim Gamez University of California Berkeley –Ben Bellows –Zurab Koberidze CDC –David Callahan –Stu Burman

47 GC Cases in by Month Butte County,

48 For more information contact: Michael C. Samuel or Jan King

49

50 GC Cases Partner Characteristics Oroville, 2003 Female (%) Male (%) Partner(s) likely to have sex with others Partner(s) age Generally Older Generally Younger

51 GC Case and Partner Incarceration History, Oroville, 2003 Female (%)Male (%) Case Jail Prison Juvenile Hall Case Any incarceration Partner Any incarceration

52 Percentage of GC Cases by Reported Number of Partners by Gender, Oroville 2003

53 Reported Number of Sexual Partners Named Number of Sexual Partners

54

55 Limitations – Local Two parallel STD databases, neither complete Separation between Nursing and Health Education Lack of relationship with private laboratories

56 Approaches to Network Analysis Standard Case/Contact/Cluster Approach –Interview cases, contacts, and clusters –treat untreated persons –prevents further spread Network Analysis Approach –Systematic collection of all data –uniform procedures –formally view, study, and understand network –Prevent further spread and prevent/control future outbreaks

57 2 infections Part of key network Named by many Traveled for drugs and sex(+) Drug dealer(+) Incarceration(+) 3 GC infections Incarceration Drug use Prostitution 4 case-patients All African-American males 2 interviewed Repeat Gonorrhea Infections


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