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.

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. 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 commingle 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 and 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.

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. 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.

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 woman 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 motivations 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.)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 the completion of their treatment.