Nowhere near the point of diminishing returns: correlations between chlamydia testing and notification rates in New South Wales

OBJECTIVE: To examine the relationship between chlamydia testing and chlamydia detection rates in New South Wales, Australia, from 1999 to 2001. METHODS: Correlations between population-based chlamydia testing and notification rates--stratified by age group, area of residence, and year--were determined by linear regression. RESULTS: Strong positive correlations between chlamydia testing and notification rates were observed for both women (r = 0.91, p < 0.001) and men (r = 0.94, p < 0.001). Between 1999 and 2001, the chlamydia test positivity rate increased from 4.3% to 7.3% for women (p < 0.0001) and from 7.8% to 10.5% for men (p < 0.0001). CONCLUSIONS AND IMPLICATIONS: This study suggests that Australia could benefit from a major chlamydia screening program.     

STD screening,testing, case reporting,and clinical and partner notification practices: a national survey of US physicians

OBJECTIVES: This study presents results from a national survey of US physicians that assessed screening, case reporting, partner management, and clinical practices for syphilis, gonorrhea, chlamydia, and HIV infection. METHODS: Surveys were mailed to a random sample of 7300 physicians to assess screening, testing, reporting, and partner notification for syphilis, gonorrhea, chlamydia, and HIV. RESULTS: Fewer than one third of physicians routinely screened men or women (pregnant or nonpregnant) for STDs. Case reporting was lowest for chlamydia (37 percent), intermediate for gonorrhea (44 percent), and higher for syphilis, HIV, and AIDS (53 percent-57 percent). Physicians instructed patients to notify their partners (82 percent-89 percent) or the health department (25 percent-34 percent) rather than doing so themselves. CONCLUSIONS: STD screening levels are well below practice guidelines for women and virtually nonexistent for men. Case reporting levels are below those legally mandated; physicians rely instead on patients for partner notification. Health departments must increase collaboration with private physicians to improve the quality of STD care.     

Comparisons of trends in antiretroviral use and HIV notification rates between three Australian states

Objective: Notification rates for HIV among men who have sex with men (MSM) have been increasing, but this increase has not been uniform across States and Territories. This paper aims to determine whether differences in the levels of antiretroviral therapy (ART) were associated with differences in HIV notification rates between Australian States. Methods: An ecological analysis of HIV notification and S100 drug prescribing data between 1998 and 2005. Main results: HIV notification rates in 2005 per 100 individuals living with HIV were lowest in New South Wales (NSW) (4.5) and higher in Victoria (6.9) and Queensland (7.8). The proportion of individuals receiving ART in 2005 was lowest in NSW (40%) and higher in Victoria (60%) and Queensland (60%). There has been a significant decline in the proportion of individuals living with HIV receiving effective ART per year in NSW (p<0.01 ) and Queensland (p<0.01 ), but an increase in Victoria (p<0.01 ). Conclusion: Those States with the highest HIV notifications per 100 individuals living with HIV did not have the lowest proportion of individuals receiving ART. Implications: These data indicate that the differences in HIV notifications between States do not appear to be due to differences in ART. However, changes in ART over time in some States may be contributing to the rise in HIV notifications.     

Assessing cardiovascular risk in regional areas: the healthy hearts -- beyond city limits program

ABSTRACT: BACKGROUND: Cardiovascular disease (CVD) is more prevalent in regional and remote Australia compared to metropolitan areas. The aim of Healthy Hearts was to determine age and sex specific CVD risk factor levels and the potential value of national risk clinics. METHODS: Healthy Hearts was an observational research study conducted in four purposefully selected higher risk communities in regional Victoria. The main outcome measures were the proportion of participants with CVD risk factors with group comparisons to determine the adjusted likelihood of elevated risk factor levels. Trained personnel used a standardized protocol over four weeks per community to measure CVD risk factor levels, estimate absolute CVD risk and provide feedback and advice. RESULTS: A total of 2125 self-selected participants were assessed (mean age 58 +/- 15 years, 57 % women). Overall, CVD risk factors were highly prevalent. More men than women had >= 2 modifiable CVD risk factors (76 % vs. 68 %, p < .001), pre-existing CVD (20 vs. 15 %, p < .01) and a major ECG abnormality requiring follow-up (OR 2.35, 95 % CI 1.75 to 3.16). A higher proportion of women were obese (adjusted OR 1.39, 95 % CI 1.16 to 1.65), physically inactive (adjusted OR 1.47, 95 % CI 1.20 to 1.80) and reported depressive symptoms compared to men (28 % vs. 22 %, p < .01). CONCLUSIONS: High CVD risk factor levels were confirmed for regional Victoria. Close engagement with individuals and communities provides scope for the application of regional risk management clinics to reduce the burden of CVD risk in regional Australia.     

Avoidable mortality in Victoria between 1979 and 2001

OBJECTIVE: To describe trends in avoidable mortality (AM) in Victoria by sex, degree of socio-economic disadvantage and remoteness. METHODS: The analysis is based on mortality and population data for 1979-2001 supplied by the Australian Bureau of Statistics (ABS) for Victoria. Total and disease-specific AM rates were age standardised using the direct method. For the period between 1997 and 2001, comparisons of total AM rates by sex were made between metropolitan and rural local government areas (LGAs), and between LGAs grouped into quintiles based on socio-economic disadvantage and categories of remoteness. RESULTS: Total AM rates declined significantly (p < 0.05) in both males and females between 1979 and 2001, but were significantly higher in males compared with females. Total AM rates were significantly higher in rural compared with metropolitan LGAs, from 1997 to 2001 in males and in 1998 in females. Total AM rates in the least disadvantaged quintile were significantly lower than those in the most disadvantaged quintile over the entire five-year period in males and in three years in females. Total AM rates were highest in remote LGAs and lowest in highly accessible LGAs. There were significant declines in ischaemic heart disease, stroke and road traffic accident AM rates among males. In females, IHD, stroke, breast and colon cancer AM rates declined significantly. CONCLUSIONS AND IMPLICATIONS: Despite large declines in AM in Victoria, there are significant differences in rates between the sexes and in the population based on socio-economic status or remoteness. These results provide opportunities for policy makers to prioritise public health and health services interventions, targeting population groups and specific disease conditions to reduce health inequalities.     

中国部分中年人群糖尿病患病率、知晓率、治疗率及控制率现况调查

目的描述中国14组中年人群空腹血糖受损（IFG）患病率、糖尿病（DM）患病率、知晓率、治疗率、控制率现状及其近年的变化趋势。方法1998年对14组35～59岁人群进行整群抽样调查，测定空腹血糖并询问DM史及治疗史，用于现况研究。对其中4组曾在1993—1994年进行相同调查的人群进行变化趋势研究。结果14组人群IFG和DM年龄标化患病率分别为0．5％～15．6％（平均4．8％）和0．2％～10．6％（平均4．3％），无性别差异，城市高于农村（P〈0．01），年龄越大患病率越高（P〈0．01）。DM知晓率、治疗率、控制率分别为0％～46．2％（平均33．3％）、0％～46．2％（平均27．2％）和0％～15．4％（平均9．7％）；女性大于男性（P〈0．01），城市高于农村（P=0．031）．年龄越大上述三率越高（P〈0．05），与文化程度无显著关联。在DM知晓者中治疗率平均为81．6％，在治疗者中控制率平均为35．6％，且男女、城乡、年龄组问差异无统计学意义。1993-1994年到1998年4组人群DM患病率平均由3．8％上升到4．6％（P=0．037），知晓率、治疗率、控制率有上升趋势但变化无统计学意义（P〉0．05）。结论中国14组中年人群DM患病率两性之间差异无统计学意义．地区之间差异明显，近年呈上升趋势。DM知晓率、治疗率、控制率总体处于较低水平。解决DM人群防治的关键是改善检出机会和提高治疗效果两个环节。     

Rurality and Other Determinants of Early Colorectal Cancer Diagnosis in Nebraska: A 6-Year Cancer Registry Study, 1998-2003

ABSTRACT:  Background: There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.     

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians.

PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.     

Congestive cardiac failure: urban and rural perspectives in Victoria

Objective: Effective and timely care for congestive cardiac failure (CCF) should reduce the risks of hospitalisation. The purpose of this study is to describe variations in rates of hospital admissions for CCF in Victoria as an indicator of the adequacy of primary care services. Detailed analyses identify trends in hospitalisations, urban/rural differentials and variations by the Primary Care Partnerships (PCP). Setting: Acute care hospitals in Victoria. Design: Routine analyses of age and sex standardised admission rates of CCF in Victoria using the Victorian Admitted Episodes Dataset from 1993–1994 to 2000–2001. Subjects: All patients admitted to acute care hospitals in Victoria with the principal diagnosis of CCF between 1993–1994 and 2000–2001. Results: There were 8359 admissions for CCF in Victoria with an average of 7.37 bed days in 2000–2001. There was a significantly higher admission rate for CCF in rural areas compared to metropolitan in 2000/2001 –(2.53/1000 (2.44–2.62) and 1.80/1000 (1.75–1.85)) – respectively. Small area analyses identified 17 PCP (14 of which were rural) with significantly higher admission rate ratios of CCF compared to Victoria. Conclusion: Small area analyses of CCF have identified significant gaps in the management of CCF in the community. This may be a reflection of deficit in primary care availability, accessibility, or appropriateness. Detailed studies may be needed to determine the relative importance of these factors in Victoria for targeting specific interventions at the PCP level. What does this study add?: Congestive cardiac failure is a major public health problem. In Australia, there is a lack of studies identifying long‐term hospitalisation trends of CCF, as well as small area analyses, especially in regard to rural and urban variations. This study has identified significant variations over an eight year period in admission rates of CCF in rural and urban Victoria. Small area analyses (e.g. at the level of primary care partnerships) have identified rural communities with significantly higher admission rates of CCF compared to the Victorian average. For the first time in Australia, this study has provided a new approach for generating evidence on quality of primary care services in rural and urban areas, and offers opportunities for targeting public health and health services interventions that can decrease access barriers, improve the adequacy of primary care, and reduce demand on the hospital system in Victoria.      

Preventing fractures in large rural centres: sociodemographic sub-groups at risk of osteoporosis from their lifestyle

ABSTRACT: Middle-aged people living in non-metropolitan Victoria have higher hospitalisation rates from osteoporotic fractures than those in metropolitan areas. This may reflect a higher prevalence of lifestyle risk factors for osteoporosis. One-fifth of Victoria's non-metropolitan population live in 'large rural centres'. The aim of the present study was to identify the sociodemographic sub-groups in a 'large rural centre' at risk of osteoporosis because of their lifestyle. Adults on Ballarat's electoral rolls were invited to complete a questionnaire and have their height and weight measured. A total of 335 eligible people participated in the present study (67% response). The sub-groups at risk of osteoporosis were identified using logistic regression analyses. Among women, being single/separated/divorced/ widowed was associated with being underweight and having low dietary calcium. A lack of exercise was associated with not completing high school and smoking with being aged 25–44 years. Among men, low dietary calcium was associated with not completing high school and smoking was associated with being employed in a non-professional/ non-managerial occupation. These sub-groups must be considered when planning preventative strategies for people in 'large rural centres'.     

Chlamydia sentinel surveillance in Aboriginal Community Controlled Health Services finds higher testing and positivity rates among younger people

Objective: To measure chlamydia testing and positivity rates among 16–39 year olds attending Aboriginal Community Controlled Health Services (ACCHSs). Methods: Retrospective non‐identifiable computerised records containing consultation and chlamydia testing data were collected for patients (16–39 years) attending eight ACCHSs during 2008–09 in urban, regional and remote settings for the Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) system. Annual chlamydia testing and positivity rates were estimated. Results: Over two years, 13,809 patients aged 16–39 years (57.8% female, 82.3% Aboriginal or Torres Strait Islander) attended. The annual overall chlamydia testing rate was 13.0% (2008) and 16.0% (2009). Testing rates were higher among females (p<0.001) and among patients aged 16–29 than 30–39 years (males: p=0.01; females: p<0.001). Chlamydia positivity was 8.5% overall; similar in females (8.7%) and males (7.8%) (p=0.46); highest among 16–19 years (females: 17.4%; males: 13.0%), declining to 1.5% among females 35–39 years (p<0.001) and 4.8% among males 30–34 years (p<0.001). Conclusions: Chlamydia testing at these ACCHSs approached recommended levels among some patient groups, however, it should increase. High positivity among younger people highlights they should be targeted. Implications: Young people should be targeted for sexual health interventions. ACCHSs are well placed to provide enhanced sexual health services if appropriately resourced.     

Urbanisation and coronary heart disease mortality among African Americans in the US South.

STUDY OBJECTIVE: Despite significant declines since the late 1960s, coronary mortality remains the leading cause of death for African Americans. African Americans in the US South suffer higher rates of cardiovascular disease than African Americans in other regions; yet the mortality experiences of rural-dwelling African Americans, most of whom live in the South, have not been described in detail. This study examined urban-rural differentials in coronary mortality trends among African Americans for the period 1968-86. SETTING: The United States South, comprising 16 states and the District of Columbia. STUDY POPULATION: African American men and women aged 35-74 years. DESIGN: Analysis of urban-rural differentials in temporal trends in coronary mortality for a 19 year study period. All counties in the US South were grouped into five categories: greater metropolitan, lesser metropolitan, adjacent to metropolitan, semirural, and isolated rural. Annual age adjusted mortality rates were calculated for each urban status group. In 1968, observed excesses in coronary mortality were 29% for men and 45% for women, compared with isolated rural areas. Metropolitan areas experienced greater declines in mortality than rural areas, so by 1986 the urban-rural differentials in coronary mortality were 3% for men and 11% for women. CONCLUSIONS: Harsh living conditions in rural areas of the South precluded important coronary risk factors and contributed to lower mortality rates compared with urban areas during the 1960s. The dramatic transformation from an agriculturally based economy to manufacturing and services employment over the course of the study period contributed to improved living conditions which promoted coronary mortality declines in all areas of the South; however, the most favourable economic and mortality trends occurred in metropolitan areas.     

Mumps and rubella surveillance in Victoria, 1993 to 2000.

Despite improving childhood coverage of the measles-mumps-rubella vaccine (MMR) in Victoria during the 1990s, mumps and rubella notifications in age groups eligible for vaccination persisted. This study reviewed the mumps and rubella surveillance data from 1993 to 2000 with a specific focus on method of diagnosis. There were 474 notifications of mumps over the seven-year period (annual median 61, range 40 to 77) and 3,544 notifications of rubella (annual median 297, range 66 to 1,165). The highest notifications rates for mumps were consistently among the 1-4 and 5-9 year age groups, whereas there was a marked change in the age distribution of rubella notifications during this interval. A large rubella outbreak occurred in 1995 with 1,165 notifications; the highest notification rates were males aged 15-24 years, infants under one year of age (males and females), and those aged 5-14 years (males and females), respectively. The susceptibility of 5-24 year olds reflects historical changes to the Australian Standard Vaccination Schedule. Rubella notifications returned to baseline levels in 1998 with the highest notification rates in infants aged under one year, and children aged 1-4 years. For both mumps and rubella, the majority of notifications for all age groups were clinically diagnosed, and were most common in children.     

中国35～59岁人群代谢综合征患病率及其变化

目的 了解中国中年(35～59岁)人群代谢综合征(MS)的患病率及变化.方法 利用国家"十五"期间(2004-2005年)的现况调查资料,并与"九五"期间(1998年)的可比资料进行分析.结果 中年人群MS患病率为12.1%,男性高于女性、北方地区高于南方地区、城市人群高于农村人群(P<0.05).同时有肥胖、高血压、血脂紊乱三个因素者占60.4%."十五"期间MS标化患病率(10.0%)与"九五"期间(7.2%)比较差异有统计学意义(P<0.05),且男性大于女性、北方地区大于南方地区.无论南北方地区、城市农村人群,甘油三酯、体重指数、腰围的平均水平都显著高于"九五"期间.结论 中国中年人群MS患病率呈上升趋势.     

The feasibility of recruiting young men in rural areas from community football clubs for STI screening

OBJECTIVE: To investigate the feasibility of recruiting young men from rural football clubs for screening for sexually transmitted infections (STIs). METHODS: Young men aged 16 to 29 were recruited from four football clubs outside of metropolitan areas in Victoria, Australia, and completed a questionnaire about sexual activity, knowledge and history of STIs, and alcohol and drug use, and provided a urine sample for STI testing. RESULTS: One hundred and eight participants completed the questionnaire and 92 (85.2%) also provided a urine sample. More than 90% of eligible players present at the clubs on the night of the study participated. Eighty-seven participants (80.6%) had ever had penetrative sex, with 33 (39.3%) reporting a new sexual partner in the past three months. Among those who had ever had sex, the prevalence of chlamydia was 3.9% (95% Cl 0.8-11.0). While the majority of participants visited their doctor in the past year (78.7%) and were comfortable with the idea of an annual STI screen, few had ever discussed sex or STIs with their doctor or had a previous STI test. CONCLUSION:Young men from rural areas may be at considerable risk of STIs and many have not been previously tested. However, most are willing to participate in screening programs and the high participation rate achieved in this pilot project demonstrates the potential for screening to be successfully extended into non-medical settings such as sporting clubs. IMPLICATIONS: Young people at risk of STIs can be successfully recruited for STI screening from community settings.     

Factors associated with adverse outcomes during influenza outbreaks in aged care facilities

Objective : To explore factors associated with adverse outcomes during influenza outbreaks in residential aged care facilities. Methods : A retrospective cohort study of all outbreaks reported to three Sydney metropolitan Public Health Units during 2017. Results : A total of 123 outbreaks affected 1,787 residents and 543 staff. Early notification to a Public Health Unit was associated with shorter outbreak duration (p<0.001; B=0.674). Resident attack rates and resident mortality rates were lower in outbreaks notified early, on univariate analysis (p=0.034 and p=0.048 respectively) but not on an adjusted model. Staff attack rates were significantly associated with resident attack rates (p=0.001; B=0.736). Data on staff vaccination rates was incomplete and reported coverage rates were low (median 39%). Resident vaccination coverage ≥95% was associated with shorter outbreak duration in univariate testing but not on an adjusted model. Conclusions : Early public health notification is associated with improved outbreak parameters; sick staff may pose a risk to residents, yet vaccination rates are low. Resident vaccination may also be valuable. Implications for public health : Measures that facilitate early PHU involvement in influenza outbreaks should be implemented, such as compulsory reporting requirements and processes that permit easier notification through technology. Actions that enhance staff and resident vaccination coverage should also be undertaken.     

1988—2017年中国居民胃癌死亡趋势分析

目的 分析1988—2017年中国胃癌死亡率时间变化趋势,为制定胃癌防控措施提供科学依据。 方法 数据来源于WHO国际癌症研究中心和《中国卫生统计年鉴》,采用SPSS 22.0汇总和计算1988—2017年中国胃癌死亡率数据,采用Joinpoint回归模型分析胃癌死亡率时间变化趋势。 结果 1988—2017年间,中国居民城市男性、城市女性、乡村男性、乡村女性的胃癌标化死亡率平均年度变化百分比(average annual percent change,AAPC)分别为-2.45%、-2.80%、-2.28%、-2.88%,期间城市男性与城市女性胃癌标化死亡率年度变化百分比(annual percent change,APC)基本没有变化;乡村男性1988—2008年间(APC=-1.19%,P<0.01)与2008—2017年间(APC=-4.71%,P<0.01)不同,乡村女性1988—2004年间(APC=-1.32%,P<0.01)与2004—2017年间(APC=-4.83%,P<0.01)不同。城市男性、城市女性、乡村男性、乡村女性胃癌截缩死亡率AAPC分别为-2.49%、-3.03%、-3.27%、-4.19%,城市女性、乡村男性、乡村女性胃癌截缩死亡率的变化趋势与其标化死亡率的变化趋势基本相似,而城市男性胃癌截缩死亡率仅在1988—1996年期间有下降(APC=-4.91%,P<0.01),1996—2017期间无下降趋势。城市居民中,除男性50～54岁、女性65～69岁胃癌死亡率无下降趋势以外,其他年龄组均呈下降趋势;乡村居民中,除男性30～34岁及75～84岁、女性25～39岁及80～84岁胃癌死亡率无下降趋势以外,其他年龄组均呈下降趋势。 结论 1988—2017年期间中国居民胃癌死亡率总体呈下降趋势,但下降的趋势在城乡之间有差异,乡村居民胃癌死亡率下降幅度高于城市居民,不同年龄之间胃癌死亡率下降趋势有差异。     

Surveillance for sexually transmissible diseases in Victoria, 1983 to 1992

Abstract: Surveillance systems have been developed in Victoria to determine trends in sexually transmissible diseases (STDs). Notifications to the Health Department (including laboratory notification since May 1990) have been supplemented by data about strains of Nasseria gonorrhoeae and cultures for Chlamydia trachomatis processed by the Microbiological Diagnostic Unit, enhanced laboratory surveillance of syphilis, and data on genital herpes and genital warts from the Melbourne Sexual Health Centre. During the period under review the incidence of gonorrhoea declined, rapidly at first, and then more slowly. For women, this trend has continued, while gonorrhoea acquired abroad by men has become relatively more important. Since 1988, gonorrhoea in homosexual men has increased, and rectal isolates have increased concurrently, raising concerns about HIV risk behaviour. Cases of syphilis are likely to be ascertained through STD, antenatal and refugee screening, rather than because of symptoms or contact tracing. Chlamydia is a the most common notifiable STD, despite underreporting and under-diagnosis. In 1991, 832 cases were notified, increasing to 1377 in 1992. In 1992, of the 73 cases (65 per cent of notifications) where the doctor identified a risk, 15 per cent was attributed to homosexual contact, and 27.4 per cent to heterosexual exposure. Limitations in the data include inadequate standard case definitions for many STDs, changes in the statutory requirement for notifications in 1990, underreporting, changes in diagnostic and screening patterns, and lack of detailed demographic data. Education of general practitioners is needed to improve diagnosis and notification of chlamydia.