Communicable Diseases

Abstract

A communicable disease is one that can be transmitted or spread from one person or species to another, through either direct or indirect contact [1]. A multitude of different communicable diseases are currently reportable in Texas including tuberculosis and many types of sexually transmitted diseases. Incidence rates for communicable diseases in this chapter are presented as crude rates, without age-adjustment.

Full text

17
A.G. Ramirez et al. (eds.), The South Texas Health Status Review:
A Health Disparities Roadmap, DOI 10.1007/978-3-319-00233-0_4, © The Author(s) 2013
A communicable disease is one that can be transmitted or spread from one person
or species to another, through either direct or indirect contact [ 1 ]. A multitude of
different communicable diseases are currently reportable in Texas including
tuberculosis and many types of sexually transmitted diseases. Incidence rates for
communicable diseases in this chapter are presented as crude rates, without
age-adjustment.
Tuberculosis
Tuberculosis (TB) is a chronic infection caused
by the Mycobacterium tuberculosis bacterium.
Although most people infected with M. tuber-
culosis harbor the bacterium with no symptoms
(latent TB), some people do eventually develop
active TB disease. TB is spread from person to
person through the air. Only people with active
TB disease can spread the bacteria to others [ 2 ].
TB usually affects the lungs, although it some-
times can also affect other parts of the body
such as the brain, the kidneys, or the spine. TB
disease can cause serious health problems,
including death, if left untreated [ 2 ].
A total of 11,181 TB cases were reported in
the USA in 2010 [ 3 ]. In addition to these active TB cases, more than 11 million
people in the USA are estimated to currently have latent TB infection [ 4 ]. TB inci-
dence in the USA was much higher among African-Americans (7.0/100,000),
Asians (22.5/100,000), and Hispanics (6.5/100,000) than among non-Hispanic
whites (0.9/100,000) in 2010 [ 3 ]. Nationwide, males have a higher risk of TB
Chapter 4
Communicable Diseases
Tuberculosis (TB)
Within South
Texas, TB
incidence
among Hispanics was
almost five times
higher than among
non-Hispanic whites.

18
disease than females, and people in older age groups are more at risk for TB than
people of younger ages [ 5 ]. Foreign- born persons are also disproportionately
affected by TB. In 2010, the incidence of TB disease was 11 times higher among
foreign-born persons in the USA than among persons born in the USA [ 3 ]. A TB
infection can develop into active TB disease as a result of conditions or exposures
that can reduce a person’s immunity such as HIV infection, diabetes, or chemo-
therapy treatment. Other risk factors for TB include low income, long-term drug or
alcohol use, and living or working in prisons or nursing homes [ 6 ].
Tuberculosis in South Texas
The incidence of active TB disease in South Texas during 2006–2010 was
8.2/100,000, a higher incidence of TB than individuals living in the rest of Texas
and nationwide (Fig. 4.1 ). The 2006–2010 average annual incidence of TB in South
Texas was 2.3 times higher than the TB rate reported nationwide in 2010.
Hispanics in South Texas had a higher incidence of TB (10.2/100,000) than did
Hispanics in the rest of Texas (7.3/100,000) in 2006–2010. TB incidence among
South Texas Hispanics was almost fi ve times higher than the incidence among non-
Hispanic whites (Fig. 4.2 ).
Among Hispanics, the TB incidence increased sharply with age, in contrast with
a more gradual age increase among non-Hispanic whites (Fig. 4.3 ). Hispanics aged
45 or older had the highest TB incidence, 17.4/100,000.
Males in South Texas had an incidence of TB more than twice as high as the
incidence in females. When stratifying by sex and race/ethnicity, TB incidence
0
1
2
3
4
5
6
7
8
9
South Texas Rest of Texas Nationwide
Rate per 100,000
Location
Fig. 4.1 Incidence of active tuberculosis (TB) disease by location. Source : Texas data: TB/HIV/
STD Epidemiology and Surveillance Branch, Texas Department of State Health Services, 2006–
2010. Nationwide data is for 2010 only, obtained from Pratt et al. 2011 [
3 ]
4 Communicable Diseases

19
estimates ranged from 14.0/100,000 in Hispanic males to 1.1/100,000 in non-His-
panic white females (Fig. 4.4 ).
In 2006–2010, the incidence of TB in Bexar County (5.3/100,000) was lower
than the incidence in South Texas as a whole (8.2/100,000). However, TB esti-
mates in Webb County (15.2/100,000) and the four-county Lower Rio Grande
Valley region (12.3/100,000) were 1.5–2 times higher than in all of South Texas
(Fig. 4.5 ).
0
2
4
6
8
10
12
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
South Texas
Rest of Texas
Fig. 4.2 Incidence of active tuberculosis (TB) by location and race/ethnicity, 2006–2010. Source :
TB/HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
0
2
4
6
8
10
12
14
16
18
20
0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
Rate per 100,000
Age Group
Hispanic Non-Hispanic White
Fig. 4.3 Incidence of tuberculosis in South Texas by age group and race/ethnicity, 2006–2010.
Source : TB/HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health
Services
Tub e rc u lo sis

20
HIV/AIDS
HIV (human immunodefi ciency virus) is a human retrovirus that infects and slowly
depletes a type of white blood cells known as T-lymphocytes or CD
4+ T-lymphocytes.
These white blood cells are essential to maintaining an effective immune response.
HIV gradually destroys the body’s ability to fi ght infections and certain cancers by
damaging or killing immune system cells [ 7 ]. People with HIV have what is called
HIV infection. Some of these people will develop AIDS (acquired immunodefi ciency
syndrome) as a result of their HIV infection [ 7 ]. HIV is most commonly transmitted
0
2
4
6
8
10
12
14
16
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
Males Females
Fig. 4.4 Incidence of tuberculosis in South Texas by sex and race/ethnicity, 2006–2010. Source :
TB/HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
0
2
4
6
8
10
12
14
16
South Texas Bexar County Webb County Lower Rio Grande
Valley
Rate per 100,000
Location
Fig. 4.5 Incidence of tuberculosis in selected South Texas locations, 2006–2010. Source : TB/
HIV/STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
4 Communicable Diseases

21
by having unprotected sex with a partner who is
infected. HIV can also be spread through contact
with infected blood such as sharing drug needles
or syringes or through contaminated blood trans-
fusions. Women infected with HIV can transmit
the virus to their babies during pregnancy or
birth or through breast milk [ 8 ].
Many people do not have any symptoms
when they fi rst become infected with HIV. This
“asymptomatic” infection period can differ
greatly among individuals. Some people may
begin to experience symptoms within just a few
months, while others may remain symptom free
for more than 10 years [ 8 , 9 ]. AIDS refers to the
most advanced stages of HIV infection [ 8 ].
People with AIDS often contract opportunistic
infections that do not usually affect healthy people. In AIDS patients, these infec-
tions are frequently severe and are sometimes fatal, because the immune system has
been so damaged by HIV that it can no longer resist bacteria, viruses, parasites, or
other microbes [ 9 ]. People with AIDS are also particularly susceptible to certain
cancers [ 10 ]. No cure exists for HIV or AIDS. However, a number of drugs cur-
rently exist that can slow the progression of HIV infection as well as fi ght associated
cancers and infections [ 9 , 10 ].
In 2008, approximately 1.2 million individuals in the USA were estimated to be
living with either HIV or AIDS, of which an estimated 20 % were undiagnosed
and unaware that they had HIV [ 11 ]. There were an estimated 17,774 AIDS deaths
in the USA in 2009. The HIV/AIDS epidemic in the USA continues to dispropor-
tionately affect minority groups. The rate of new HIV infection in 2010 was more
than eight times higher in African-Americans and almost three times higher in
Hispanics than in non-Hispanic whites [ 12 ]. In 2009, 77 % of newly diagnosed
HIV cases in the USA were male [ 11 ]. Major risk factors for HIV/AIDS include
having unprotected sex with multiple partners or with men who have sex with
men, sharing needles during drug use, or already having hepatitis, tuberculosis
(TB), or another sexually transmitted disease (STD) such as syphilis, herpes, or
chlamydia [ 7 , 10 ].
HIV/AIDS in South Texas
In 2006–2010, the average annual incidence of HIV/AIDS in South Texas was
11.3/100,000, a lower rate than the incidence in the rest of Texas (18.1/100,000).
Overall, the incidence of HIV/AIDS was about 60 % higher in the rest of Texas than
in South Texas (Fig.
4.6 ). In South Texas, Hispanics had a higher incidence of HIV/
AIDS (11.4/100,000) than non-Hispanic whites (8.2/100,000) (Fig. 4.6 ).
HIV / AIDS
Despite
lower
overall rates
than the rest of the
sate, South Texas
Hispanics had higher
rates of HIV/AIDS
than South Texas
non-Hispanic whites.
HIV/AIDS

22
In South Texas, the incidence of HIV/AIDS was more than 4.5 times higher in
males (18.8/100,000) than females (4.1/100,000). Individuals aged 20–44 had
signifi cantly higher rates of HIV/AIDS than other age groups. The incidence of
HIV/AIDS was about two times higher in South Texas metropolitan counties
(12.1/100,000) than in nonmetropolitan counties (5.8/100,000). Bexar County
had a higher incidence of HIV/AIDS (16.8/100,000) than South Texas as a whole
(11.3/100,000), whereas the incidence of HIV/AIDS in Webb County (9.9/100,000)
was lower than that seen in all of South Texas. The incidence of HIV/AIDS in the
Lower Rio Grande Valley region (10.9/100,000) was similar to the incidence in
South Texas as a whole (Fig. 4.7 ).
Syphilis
Syphilis is a sexually transmitted disease (STD) caused by the Treponema pallidum
bacterium. Syphilis has been called “the great imitator” because many possible
symptoms are associated with the disease, and these symptoms often mirror ones
seen in many other diseases [ 13 , 14 ]. Syphilis is most commonly spread by sexual
contact with an infected individual [ 13 ]. The syphilis bacterium is transmitted by
direct contact with a syphilis sore; sores usually occur on the genitals or anus but
can also occur on the lips or in the mouth. Syphilis can also be transmitted from an
0
5
10
15
20
South Texas Bexar County Webb County Lower Rio
Grande Valley
Rate per 100,000
Location
Fig. 4.7 Incidence of HIV/
AIDS in selected South Texas
locations, 2006–2010.
Source : TB/HIV/STD
Epidemiology and
Surveillance Branch, Texas
Department of State Health
Services
0
5
10
15
20
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
South Texas
Rest of Texas
Fig. 4.6 Incidence of HIV/
AIDS by location and race/
ethnicity, 2006–2010. Source :
TB/HIV/STD Epidemiology
and Surveillance Branch,
Texas Department of State
Health Services
4 Communicable Diseases

23
infected mother to her baby during pregnancy
[
14 ]. The primary stage of syphilis is character-
ized by one or more small, round sores, called
chancres, that are located where the bacterium
entered the body. Because chancres are usually
not painful, can occur inside the body, and heal
without treatment, symptoms of primary syphi-
lis may go unnoticed. If left untreated, the syphi-
lis infection progresses to the secondary stage,
which is usually marked by a skin rash.
Symptoms of secondary syphilis may be mild
and will also go away without treatment.
However, without treatment, syphilis infection
is still present in the body. Although there may
be no outward signs or symptoms for many
years after secondary syphilis, untreated syphi-
lis infection may damage internal organs such
as the heart, brain, nervous system, eyes, bones,
and joints. Late-stage syphilis infection, which occurs in about 15 % of untreated
individuals, can cause blindness, deafness, mental illness, paralysis, heart disease,
and even death [
13 , 14 ]. Untreated syphilis in pregnant women is associated with a
high risk of adverse pregnancy outcomes such as miscarriage, stillbirth, preterm
birth, and infant mortality [ 14 , 15 ]. Syphilis is curable with antibiotics, but treat-
ment cannot repair damage already done to the body by syphilis infection [ 14 ].
In 2010, 45,834 new cases of syphilis (at all stages) were reported in the USA
including 13,774 cases of primary and secondary syphilis. Nationwide, the inci-
dence of primary and secondary syphilis was seven times higher among men than
among women in 2010. The incidence of primary and secondary syphilis in the
USA was eight times higher among African-Americans and two times higher among
Hispanics than among non-Hispanic whites [ 16 ]. The age-specifi c incidence of
syphilis in the USA varied depending on race/ethnicity and sex, although among
both Hispanic and non-Hispanic white women, the highest incidence of primary and
secondary syphilis was observed among those aged 20–24 [ 15 ]. Men who have
unprotected sex with other men have a higher risk of syphilis infection than the
general population [ 16 , 17 ]. Other risk factors for syphilis include having unpro-
tected sex and having sex with multiple partners [ 13 , 17 ].
Syphilis in South Texas
Overall, the average annual incidence of syphilis (all stages) during 2006–2010 was
lower in South Texas (19.8/100,000) than in the rest of Texas (25.9/100,000).
However, Hispanics in South Texas had a higher incidence of syphilis (21.9/100,000)
Syphilis
Despite
lower overall
rates than
the rest of the state,
the incidence of
syphilis among South
Texas Hispanics was
more than two times
higher than South
Texas non-Hispanic
whites.
Syphilis

24
than did Hispanics in the rest of Texas (18.7/100,000). In South Texas, the incidence
of syphilis among Hispanics was more than two times higher than the incidence
among non-Hispanic whites (Fig. 4.8 ).
South Texas females had a much lower incidence of syphilis (13.3/100,000)
than males (26.4/100,000). The incidence of syphilis in South Texas was highest
among individuals aged 20–29 (more than 45/100,000). Syphilis incidence was
about three times higher in South Texas metropolitan counties (21.5/100,000) than
in nonmetropolitan counties (7.2/100,000) in 2006–2010. The incidence of syphi-
lis was higher in Bexar County (34.8/100,000) than in South Texas as a whole
(19.8/100,000) in 2006–2010. However, syphilis incidence was lower in Webb
County (13.6/100,000) and in the Lower Rio Grande Valley region (12.9/100,000)
compared to all of South Texas during this timeframe (Fig. 4.9 ).
0
5
10
15
20
25
30
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
South Texas
Rest of Texas
Fig. 4.8 Incidence of syphilis by location and race/ethnicity, 2006–2010. Source : TB/HIV/STD
Epidemiology and Surveillance Branch, Texas Department of State Health Services
0
5
10
15
20
25
30
35
40
South Texas Bexar County Webb County Lower Rio Grande
Valley
Rate per 100,000
Location
Fig. 4.9 Incidence of syphilis in selected South Texas locations, 2006–2010. Source : TB/HIV/
STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
4 Communicable Diseases

25
Chlamydia
Chlamydia is a sexually transmitted disease
(STD) caused by the Chlamydia trachomatis
bacterium . Chlamydia bacteria live in vaginal
fl uid and semen and can be transmitted to a
partner during vaginal, anal, or oral sex .
Chlamydia can also be transmitted from an
infected mother to her infant during a vaginal
childbirth. Chlamydia can also be found in
the throat, and eyes in both sexes [ 18 , 19 ].
Individuals frequently do not know that they are
infected with chlamydia, because symptoms of
chlamydia are often mild or completely absent.
This is problematic, because if left untreated,
chlamydia infection can cause irreversible
reproductive and other health problems, particularly in women [ 18 ]. Chlamydia is
the most frequently reported notifi able disease in America, with more than 1.3 million
cases reported in 2010 [ 16 , 18 ]. However, because most individuals are unaware
that they have chlamydia and thus do not get tested, underreporting of this disease
is considerable. It is estimated that 2.8 million persons in the USA are actually
infected with chlamydia every year [ 18 ].
In 2010, the reported incidence of chlamydia infection among women in the
USA was more than two-and-a-half times higher than the incidence among men,
most likely because a greater number of women are screened for chlamydia than
men. Among US women, the highest age-specifi c chlamydia incidence was observed
among those aged 15–24, while age-specifi c incidence of chlamydia in men was
highest among those aged 20–24 [ 16 ]. If sexually active, teenage girls and young
women are at higher risk of chlamydia infection than older women, because the
cervix has not yet fully matured [ 18 ].
Nationwide, the incidence of chlamydia among African-Americans is more than
eight times higher than the incidence among non-Hispanic whites. Chlamydia inci-
dence is also more than four times higher among Native Americans and nearly three
times higher among Hispanics than among non-Hispanic whites [ 16 ]. Other risk factors
for chlamydia include having unprotected sex and having multiple sex partners [ 18 ].
Chlamydia in South Texas
The average annual incidence of chlamydia in South Texas was 429.4/100,000
in 2006–2010, a higher rate than the incidence of chlamydia in the rest of Texas
(387.4/100,000). Although Hispanics also had a higher incidence of chlamydia
in South Texas than in the rest of Texas, for non-Hispanic whites, incidence in
South Texas was similar to the incidence in the rest of Texas (Fig.
4.9 ).
Chlamydia
Within South
Texas,
chlamydia
incidence was almost
three times higher
among Hispanics than
among non-Hispanic
whites.
Chlamydia

26
Chlamydia incidence was almost three times higher among Hispanics than
among non-Hispanic whites in South Texas (Fig. 4.10 ).
The incidence of chlamydia among South Texas females (666.3/100,000) was
more than 3.5 times higher than the incidence among males (185.8/100,000). As
observed nationwide, individuals aged 15–24 had a much higher incidence of chla-
mydia than any other age groups. In South Texas, individuals aged 20–24 had an
incidence of 1,970.7/100,000.
Overall, chlamydia incidence was signifi cantly higher in South Texas metro-
politan counties (443.9/100,000) than nonmetropolitan counties (322.2/100,000)
(Fig. 4.11 ).
0
50
100
150
200
250
300
350
400
450
500
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
South Texas
Rest of Texas
Fig. 4.10 Incidence of chlamydia by location and race/ethnicity, 2006–2010. Source : TB/HIV/
STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
0
100
200
300
400
500
600
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
Metro
Non-metro
Fig. 4.11 Incidence of chlamydia in South Texas by county designation and race/ethnicity, 2006–
2010. Source : TB/HIV/STD Epidemiology and Surveillance Branch, Texas Department of State
Health Services
4 Communicable Diseases

27
In 2006–2010, the incidence of chlamydia was higher in Bexar County
(578.5/100,000) than in South Texas as a whole (429.4/100,000). However, chla-
mydia incidence estimates were lower in Webb County (340/100,000) and the
Lower Rio Grande Valley region (333.5/100,000) than in South Texas (Fig. 4.12 ).
Gonorrhea
Gonorrhea is a sexually transmitted disease
(STD) caused by the Neisseria gonorrhoeae
bacterium. This bacterium grows easily in
many parts of the reproductive tract, including
the cervix, uterus, and fallopian tubes in
women, and the urinary tract in both women
and men [ 16 , 20 ]. Gonorrhea can also grow in
the throat, mouth, eyes, and anus. Gonorrhea
bacteria can be transmitted by contact with the
penis, mouth, vagina, or anus of an infected
individual; ejaculation is not necessary for the
disease to be spread. Gonorrhea can also be
transmitted from an infected mother to her baby
during childbirth [ 20 ]. If left untreated, gonor-
rhea can cause permanent health problems in
both sexes, and can cause a painful testicular condition called epididymitis in men.
Untreated gonorrhea infection also appears to increase the risk of both transmitting
and acquiring HIV [ 16 , 20 ]. Gonorrhea can usually be successfully treated and
Gonorrhea
Despite
lower overall
rates than
the rest of the state,
South Texas
Hispanics had a
higher incidence of
gonorrhea than non-
Hispanic whites.
0
100
200
300
400
500
600
700
South Texas Bexar County Webb County Lower Rio Grande
Valley
Rate per 100,000
Location
Fig. 4.12 Incidence of chlamydia in selected South Texas locations, 2006–2010. Source : TB/HIV/
STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
Gonorrhea

28
cured with antibiotics; however, drug-resistant gonorrhea infections are becoming
more common in the U.S., making treatment more diffi cult [ 16 , 20 ].
Gonorrhea is the second-most frequently reported notifi able disease in the
USA. There were 309,341 reported cases of gonorrhea in the USA in 2010; how-
ever, because many people with gonorrhea are asymptomatic and thus do not get
tested, this disease is often underreported [ 16 , 20 ]. The CDC estimates that more
than 700,000 new gonorrhea infections occur each year [ 20 ]. In 2010, the Southern
region of the USA, which includes Texas, had a higher incidence of gonorrhea
than the other regions. Nationwide, the incidence of gonorrhea is currently
slightly higher among women than men, and age-specifi c gonorrhea incidence is
highest among women aged 15–24 and men aged 20–24 [ 16 ]. The incidence of
gonorrhea is nearly 19 times higher among African-Americans, more than 4.5
times higher among Native Americans, and more than twice as high among
Hispanics than among non-Hispanic whites [ 16 ]. Like most STDs, the major risk
factors for gonorrhea include having unprotected sex and sex with multiple part-
ners [ 20 , 21 ].
Gonorrhea in South Texas
Overall, the average annual incidence of gonorrhea in South Texas (98.5/100,000)
was much lower than the incidence of gonorrhea in the rest of Texas (132.1/100,000).
Non-Hispanic whites in South Texas had a slightly lower incidence of gonorrhea
than non-Hispanic whites in the rest of Texas, and Hispanics in South Texas had a
higher incidence than Hispanics in the rest of Texas ( Fig. 4.13 ). The high overall
incidence of gonorrhea observed in the rest of Texas is possibly due to a higher
percent of African-Americans residing in the rest of Texas than in South Texas (as
African-Americans have a higher incidence of gonorrhea than any other USA racial/
ethnic group).
Hispanics had a higher incidence of gonorrhea than non-Hispanic whites, both in
South Texas and in the rest of Texas. In 2006–2010, the average annual incidence of
gonorrhea among Hispanics in South Texas (90.3/100,000) was 2.4 times higher
than among non-Hispanic whites (37.6/100,000) (Fig. 4.13 ).
In South Texas, the incidence of gonorrhea was higher for females (101.3/100,000)
than for males (95.6/100,000). Individuals aged 20–24 had a higher risk of gonorrhea
(408.2/100,000) than all other age groups in South Texas. The incidence of gonor-
rhea was 2.7 times higher in South Texas metropolitan counties (106.5/100,000) than
nonmetropolitan counties (39.3/100,000). Bexar County had a much higher inci-
dence of gonorrhea (185.1/100,000) than all of South Texas (98.5/100,000); how-
ever, the gonorrhea incidence estimates for Webb County (24.7/100,000) and the
Lower Rio Grande Valley region (27.2/100,000) were much lower than for South
Texas as a whole (Fig. 4.14 ). In 2006–2010, the incidence of gonorrhea in Webb
County was almost four times lower than the incidence of gonorrhea in South Texas.
4 Communicable Diseases

29
0
20
40
60
80
100
120
140
All Races Hispanic Non-Hispanic White
Rate per 100,000
Race/Ethnicity
South Texas
Rest of Texas
Fig. 4.13 Incidence of gonorrhea by location and race/ethnicity, 2006–2010. Source : TB/HIV/
STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
0
20
40
60
80
100
120
140
160
180
200
South Texas Bexar County Webb County Lower Rio Grande
Valley
Rate per 100,000
Location
Fig. 4.14 Incidence of gonorrhea in selected South Texas locations, 2006–2010. Source : TB/HIV/
STD Epidemiology and Surveillance Branch, Texas Department of State Health Services
Summary: Communicable Diseases

30
Summary
Table 4.1 Summary table of crude incidence rates in South Texas, the rest of Texas, and
nationwide
a for each of the communicable diseases analyzed
Health indicator
Incidence per 100,000 population
South Texas, 2001–2005 Rest of Texas, 2001–2005 Nationwide, 2010
Tuberculosis 8.2 5.7 3.6
HIV/AIDS 11.3 18.1 b
Syphilis 19.8 25.9 b
Chlamydia 429.4 387.4 426.0
Gonorrhea 98.5 132.1 100.8
a Nationwide estimates are not available for all health indicators in the table
b Signifi es that no nationwide incidence of the health indicator could be found
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