Sexually Transmitted Infections in Melbourne, Australia from 1918 to 2016: nearly a century of data

This paper describes the diagnoses of gonorrhoea, syphilis and chancroid attending a single sexual health service in Melbourne and fills a 40-year gap (1929-1969) in STI notifications for Australia.

Page last updated: 14 December 2017

Emile Jasek, Eric PF Chow, Jason J Ong, Catriona S Bradshaw, Marcus Y Chen, Jane S Hocking , David Lee, Tiffany Phillips, Meredith Temple-Smith, Glenda Fehler, Christopher K Fairley

Keywords: sexually transmitted infections, gonorrhoea, syphilis, chancroid, epidemiology, history, sexual health clinic, Australia

Introduction

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Our aim was to describe trends in the number of bacterial sexually transmitted infections (STIs) diagnosed at Melbourne’s sexual health clinic over a century.

Methods

A retrospective analysis of STI diagnoses (gonorrhoea, infectious syphilis and chancroid) among individuals attending Melbourne’s sexual health service over 99 years between 1918 and 2016.

Results

Substantial increases in STI rates coincided with World War II, the ‘Sexual Revolution of the 1960s and 1970s’, and the last 10 years. Substantial declines coincided with the advent of antibiotics and the HIV/AIDS pandemic. There were also key differences between STIs. Chancroid virtually disappeared after 1950. Syphilis fell to very low levels in women after about 1950 and has only rebounded in men. The declines in gonorrhoea were less marked. A substantial peak in gonorrhoea occurred in women in the early 1970s and rates are currently rising in women, albeit much less than in men.

Conclusions

Both antibiotics and changing sexual behaviour have had a powerful effect on STI rates. These data suggest gonorrhoea is more difficult to control than syphilis or chancroid. Indeed, the past rates suggest substantial endemic gonorrhoea transmission in heterosexuals occurred in the third quarter of last century before the appearance of the HIV pandemic. Worryingly, there is a suggestion that endemic heterosexual gonorrhoea may be returning. The data also suggest that future control of gonorrhoea and syphilis in men who have sex with men is going to be challenging.

Introduction

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A number of countries, such as the United Kingdom have data on sexually transmitted infections (STIs) over the last 100 years 1. However in Australia there is only one paper, by Hall, published nearly 25 years ago that describes notifications of STIs over more than a few decades2. Furthermore, in that paper there is a gap of 40-years in notifications between 1929 and 1969, a time period that includes significant societal changes including a world war, the advent of antibiotics, and the introduction of the oral contraceptive pill2. Considerable efforts have been made by Hall at the time and by the authors of this paper to locate these notifications without success. In the absence of records of these notifications other records may exist to fill this gap in notifications.

A number of publicly-funded sexual health clinics in Australia have been in operation over the last century but only one clinic (Melbourne Sexual Health Centre (MSHC)) has almost continuous recorded data going back to 1918 when it first opened. MSHC has been the only publicly-funded clinic operating in Melbourne over this time for the sole purpose of providing STI care. The clinic is therefore ideally placed to provide historical data over this period and could potentially provide insights into the future 3. Our aim was to describe the number of cases of bacterial STIs at this clinic over the last 99 years. Furthermore, in the discussion of this paper we describe major events or societal changes that occurred around the time of significant changes in the diagnoses of STIs. For each of these we discuss how these events may have influenced the reproductive rate, and therefore the incidence, of STIs, such as for example the discovery of antibiotics for their treatment.

Methods

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This was a retrospective analysis of STIs diagnosed at the STI clinic in Melbourne (now MSHC) over a 99-year period, from 28 June 1918 to 31 December 2016. The STI clinic in Melbourne has had six previous names (Table 1). The clinic has operated continuously in the metropolitan area of Melbourne, Australia over the study period. Over the entire time, the clinic has provided free clinical consultations for the management and treatment of STIs.

Table 1. Names and locations of public sexual health clinics in Melbourne, Australia, from 1918 to 2016.

Clinic Name

Clients

Location

Period

Government Clinic for Males

Males only

440 Lonsdale Street, Melbourne

1918 – 1929

Government Clinic for Females

Females only

372-378 Little Lonsdale Street, Melbourne

1918 – 1929

Unknown

Males and females

372-378 Little Lonsdale Street, Melbourne

1929 – 1948

Unknown

Males and females

201 Little Lonsdale Street, Melbourne

1948 – 1961

Government Clinic

Males and females

136 Gertrude Street, Fitzroy

1961 – 1979

Melbourne Communicable Diseases Centre

Males and females

364-370 Little Lonsdale Street, Melbourne

1979 – 1992

Melbourne Sexual Health Centre (MSHC)

Males and females

580 Swanston Street, Carlton

1992 – present

The primary analysis involved the number of diagnoses of gonorrhoea, infectious syphilis, and chancroid, by sex. Several data sources were used to provide data for the 99-year period (Table 2).

Table 2. Description of data sources.

Year

Description of data sources

1918-1982

Admittance registers (Photo 1) housed in the MSHC archive included line-by-line consultation data. An admittance register is a list of individuals and their specific diagnoses.

1926-1964

Clinic ledgers included aggregate consultation data. A clinic ledger is a list of monthly total of the number of clients with specific diagnoses. These have been used when data from admittance registers is unavailable.

1982-2001

Laboratory book data records all clients who had at least one laboratory investigation for a STI and their specific diagnoses.

2002-2016

Individual consultation data were available from the current clinic practice management system database, which is a custom built medical software package used to record all consultations. This is the only dataset with sexual practice information, where men who have sex with men or women can be differentiated. For the purpose of analysis men who had sex with other men in the previous 12 months were defined as MSM and all other men as heterosexual males.

Photo 1. Admittance registers housed in the MSHC archive included line-by-line consultation data for the period 1918-1982.

Photo 1 show the spines of some of the admittance registers housed in the MSHC archive that included the line-by-line consultation data for the period 1918 to 1982.

We include these three STIs because they are mostly symptomatic and therefore diagnosed cases will reflect the cases presenting to the clinic. Chlamydia was not included in this analysis because it was only relatively recently discovered (1970s) and is largely asymptomatic so the diagnoses strongly reflect testing practices, and not necessarily changes in the incidence of infection4. We have provided the raw number of chlamydia diagnoses in Supplementary Table S1 for reference. Data on trichomoniasis has been previously published5.

Syphilis cases were recorded over the entire period by stage; we included infectious syphilis (primary, secondary and early latent (<2 years)) and cases without stage specified, and excluded congenital, tertiary and late latent (>2 years) cases. Definitions of these stages over time were not available. There was no standardised definition for the diagnosis of gonorrhoea or chancroid over the entire 99 year study period. There were a number of years with incomplete or missing data, described in Table 3. For these years, to provide full year data we have taken the average of the periods preceding or following these periods and assumed there were no substantial changes from year to year.

Table 3. Formulas of adjusted data.

Year

Available data

Adjusted number used in analysis

Males

Females

1918

No data

6 months

(1918 number) 2

1926

6 months

12 months*

(1926 number) 2

1964

1 month

12 months*

Average of (1961-1963 number)

1965 and 1966

No data

12 months*

Average of (1961-1963 number)

1967 and 1968

No data

12 months*

Average of (1969-1971 number)

1969

7 months

12 months*

(1969 number) 12/7

1982

12 months*

6 months

(1982 number) 2

2002

6 months

6 months

(2002 number) 2

* Data not adjusted.

We calculated sex-stratified annual rates for gonorrhoea and syphilis separately. Data for women were available from 1918 and for men only from 1926 as data from earlier years are missing. We calculated sex-stratified annual rates for these two diagnoses made at the centre using the annual population of the greater metropolitan area of Melbourne as the denominator6,7. In the last 10 years, MSHC diagnosed about 40% of infectious syphilis notifications and 30% of gonorrhoea notifications in Victoria. We assumed the male-to-female ratio was 1:1 in Melbourne and did not change substantially over the study period. We presented a 3-years centred moving average for the rates of diagnoses for each STI over the study period. These have been calculated for every year by taking the average of the year itself, the previous year and the subsequent year. Chancroid diagnoses were presented as the raw number of diagnoses due to low numbers of diagnoses.

Analyses were conducted using SPSS version 23 (SPSS Inc., Chicago IL). Ethical approval for this was obtained from the Alfred Hospital Ethics Committee (approval number 473/15).

Results

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Over the 99-year period, there were 77,290 gonorrhoea, 9,381 syphilis, and 1,048 chancroid diagnoses among individuals attending the clinic.

Gonorrhoea

Figure 1 shows the rate of gonorrhoea by sex per 100,000. For men, the rates fell to a low in 1953, then rose until about 1980, fell dramatically until about 2000, from which time they steadily rose again. In women, there were two peaks (in 1930 and in 1972), after which rates declined to very low levels but began rising again in the early 2000s.

Figure 1. Centred 3-year moving average of the annual adjusted rate of gonorrhoea diagnoses by sex in sexual health clinics in Melbourne, 1918-2016. Raw number of gonorrhoea diagnoses in each year by sex and male sexual practice is presented in Supplementary Table S1.

Figure 1 is a line graph that shows the centred 3-year moving average of the annual adjusted rate of gonorrhoea diagnoses in sexual health clinics in Melbourne. The primary axis is for men and the secondary axis is for women and the figure spans 1918 to 2

Syphilis

Figure 2 shows the rate of syphilis by sex per 100,000. Rates in men fell rapidly from a peak in 1928 to almost zero by about 1990. During this decline two substantial peaks occurred in 1942 and 1949. Rates in men began to rise again from early 2000s to the levels not seen since the 1940s. In women, rates fell from 1918 to an initial nadir in 1924, and then rose to peak in 1929. They then fell fairly rapidly to very low levels from the 1950s.

Figure 2 is a line graph that shows the centred 3-year moving average of the annual adjusted rate of syphilis diagnoses in sexual health clinics in Melbourne. There are lines for both males and females and the figure spans 1918 to 2016. There are multiple

Chancroid

Figure 3 shows the number of chancroid diagnosis by sex for males from 1926 and for women from 1918. In men, two peaks occurred in 1927 and then again in 1950 with virtually no cases between these peaks or after 1952. In women only a few sporadic cases were seen in the years before the mid-1940s.

Figure 3 is a line graph that shows the raw number of chancroid diagnoses in sexual health clinics in Melbourne. There are lines for both male and female diagnoses and the figure spans 1918 to 2016. There are multiple peaks and troughs seen for both sexes

Discussion

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This is the first paper describing the temporal trends of three key STIs over a period of nearly 100 years in any part of Australia and importantly fills the 40-year gap between 1929 and 1969. This historic data may be Australia’s only complete record for this period 2. In our data the rises and falls of STIs occurred at similar times to key historical events that may have influenced changes in the rates of different STIs. While some of the changes were specific to Australia, most trends broadly mirror those seen in the UK and elsewhere8,9. These historical trends may offer guidance for the future public health interventions for Australia, as we enter an era when most STI rates are again rising rapidly.

There are a number of factors that need to be considered when interpreting our data. Firstly, we did not have a denominator for most of the time periods. This is why we displayed the data as a rate for the Melbourne population. This method too is a weakness because it’s likely that the proportion of cases diagnosed in Melbourne who attended the clinic varied over time and also clearly this significantly underestimates the rate, MSHC currently diagnoses about 30-40% of the notifications of both syphilis and gonorrhoea in Victoria. Additionally, it is likely the age distribution of the population of Melbourne would have changed over the 99-year period. However, this data was not publicly available over this period and we were not able to adjust for this as a potential confounder in our analysis. Nevertheless, our data are the only continuous data in Australia and the general trends observed are very large in magnitude and fit with overseas data. While there were seven different iterations of the same clinic over 99 years, all clinics existed continuously and for the same public health purpose. Secondly, we also acknowledge strongly that no causality can be implied, although some associations are likely given their plausible nature such as the large declines in rate of syphilis and gonorrhoea diagnoses with the beginning of the mass production of penicillin in the late 1940s10. We have taken the liberty of suggesting possible reasons for these changes, acknowledging these suggestions are hypotheses, for which it is unlikely firm evidence for or against them will ever be forth coming. Finally, the data was taken from four distinct sources for the length of the study. The way these sources were recorded was different, and it is likely that both changes in the way data was recorded and improvements in testing methodologies with increasing sensitivity over time have occurred and influenced the rate of STIs diagnosed. However, the magnitude of the changes is large and not likely to be influenced greatly by these changes. Acknowledging these biases we point out that these data do provide the first continuous record of STIs in Australia’s second largest city.

The most striking feature in all of the three STIs is the dramatic decline with the introduction of antibiotics in the late 1940s 10,11. Indeed for gonorrhoea and syphilis rates in men and women have never exceeded the levels seen before the pre-antibiotic era. While not well documented, trends in the number of sexual partners and age of first intercourse in Australia suggest that this pre-antibiotic era was associated with substantially lower rates of sexual partner change, implying that if the current rate of partner change were replicated in the pre-antibiotic era, STI rates would have been much higher 12,13. This same dramatic decline with antibiotics also occurred in the UK, Sweden and elsewhere which highlights the fundamental importance of access to health care for the effective control of curable STIs1,14-16. Extending the logic that access to health care for the treatment of STIs reduces their rate, there is the impression that the introduction of the universal healthcare scheme, Medicare, in about 1975 could have lowered gonorrhoea rates for women through greater access to health care. No reduction in men is seen, but rates of STIs were rising rapidly in men most likely because of the large rises in men who have sex with men (MSM) which may have overwhelmed any changes in heterosexual men17. In addition, this change however may simply be an artefact of Medicare which could have artificially lowered rates at the sexual health clinic because women could now seek health care through their general practitioners18. The importance of accessible health care for the effective control of STIs is highlighted in remote Indigenous communities where high STI rates are in part due to reduced access to health care in these communities19.

A second feature of the patterns seen in all three STIs is the rise around the time of world wars20. Rates temporarily rose at around the time men returned to Australia from the World War II which is consistent with social disruption and the greater rate of partner change in young servicemen in foreign cities20. The rise seems short lived although around this time antibiotics were also becoming more available so it is possible that these two factors were both contributing10,11. Again these trends are also evident in the UK and Swedish data1,14.

The third feature that is evident in the trends of gonorrhoea is the influence of changes in sexual risk that occurred over time 12,15,21,22. For example the oral contraceptive pill was introduced on prescription in Australia in 1961 around the time that sexual risk (e.g. increasing partner number and condomless sex) rose in Australia and elsewhere12. The more pronounced rise in gonorrhoea in men compared to women around this time also coincided with the repealing of laws prohibiting same-sex sexual activity between men and the gay and lesbian political movements23. Finally, the precipitous fall in gonorrhoea in men with the appearance of HIV and dramatic reduction in sexual risk among MSM is evident not only in our data but was virtually universal around the world 1,14,15,24. Falls were also seen in women as condom use rose in heterosexuals, but it should be noted that around this time Victoria also regulated sex work which also saw dramatic falls in STIs in sex workers 25-27. More recently the rapid rise in gonorrhoea and syphilis in MSM is a common feature around the world and coincided with successful HIV treatment 22,24,28.

These data also highlight some important differences between gonorrhoea and syphilis, particularly in heterosexuals, which in our data is largely reflected by rates in women. The graphs show that when sexual risk rose after the 1950s, rates of gonorrhoea rose in women but syphilis did not 13. This indicates that for heterosexuals syphilis is an easier infection to control at a population level, although widespread antenatal screening for syphilis was also introduced about this time 13. This suggestion that gonorrhoea is harder to control in heterosexuals is also evident in the last few years of data analysed here, as rates of gonorrhoea but not syphilis were rising in women albeit not to levels seen in the 1970s29. The concept that syphilis is easier to control than gonorrhoea is also supported in the US30 and among Indigenous Australians living in remote settings31 where endemic gonorrhoea is common but syphilis tends to be associated with intermittent epidemics 19.

The national Australian notification data also show rising rates of gonorrhoea in women as do some international data3,29. This trend may be in part explained by the recent introduction of more widespread and sensitive testing for gonorrhoea that has detected infections that may have been previously missed29. However the concern is that the recent rises in rates among heterosexuals may be real and indicate population rates are rising again. A key public health issue then is how far will it rise? The significance of this finding is that it may herald the start of endemic heterosexual gonorrhoea once again in Australia for the first time in 30 years and the emerging trend requires careful observation.

Finally, the pattern of chancroid suggests it is a particularly easy infection to control at a population level. Not only did it virtually disappear after the early 1950’s, but many of the male cases diagnosed between 1942 and 1952 in Australia were likely to have been acquired overseas, on the basis that 29% were seamen (data not shown). In contrast, while occasional cases occurred in women these infections appeared to be treated without substantial ongoing heterosexual spread on the basis that cases in women were very sporadic. It seems unlikely that these were infections in predominantly MSM because this infection has not been associated with MSM in the past and the very high ratios of men to women occurred only in the latter half of last century with the legalisation of same sex sexual practices23.

Author details

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Mr Emile Jasek1,2, Dr Eric PF Chow1,2, Dr Jason J Ong1,2, Associate Professor Catriona S Bradshaw1,2, Associate Professor Marcus Y Chen1,2, Professor Jane S Hocking3, Dr David Lee1,3, Dr Tiffany Phillips1, Professor Meredith Temple-Smith4, Ms Glenda Fehler1, Professor Christopher K Fairley1,2

    1. 1 Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
    2. 2 Central Clinical School, Monash University, Melbourne, Victoria, Australia
    3. 3 Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
    4. 4 Department of General Practice, University of Melbourne, Victoria, Australia Email address: EJ: emilejasek@gmail.com EPFC: echow@mshc.org.au JJO: jong@mshc.org.au CSB: cbradshaw@mshc.org.au MYC: mchen@mshc.org.au JSH: j.hocking@unimelb.edu.au DL: dlee@mshc.org.au TP: TPhillips@mshc.org.au MTS: m.temple-smith@unimelb.edu.au GF: GFehler@mshc.org.au CKF: cfairley@mshc.org.au

Corresponding author: Dr Eric Chow Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, 3053, VIC, Australia. Phone: +613 9341 6233 Email: echow@mshc.org.au

Contributors

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Christopher K. Fairley conceived the idea of this study. Emile Jasek, Christopher K. Fairley and Eric P.F. Chow designed the study. Tiffany Phillips was involved in data entry and management. Emile Jasek undertook the analysis and interpretation, and prepared the first draft of the manuscript. Eric P.F. Chow and Christopher K. Fairley assisted with data analysis and data interpretation. Meredith Temple-Smith and David Lee were consulted for the historical data during the writing of the manuscript. All authors contributed in data interpretation and revising the manuscript critically for important intellectual content.

Acknowledgements

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We would like to acknowledge the work of David Bradford, Jocelyn Forsyth, Robert Hall, Ian Denham, David Johnston, Karen Kon, Jun Kit Sze, Afrizal Afrizal, and all the previous staff and all the clients who have ever used Melbourne Sexual Health Centre and its precursors, without whom this study would not have been possible.

Funding

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Eric P.F. Chow is supported by the National Health and Medical Research Council (NHMRC) Early Career Fellowship (1091226).

References

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Table S1. Figure 3. Number of chancroid diagnoses by sex in sexual health clinics in Melbourne, 1918-2016. Download CSV (CSV 4 KB)

Year

Gonorrhoea diagnoses

Infectious syphilis diagnoses

Chancroid diagnoses

Chlamydia diagnoses

Female Males Men who have
sex with men
Heterosexual
males
Female Males Men who have
sex with men
Heterosexual
males
Female Males Men who have
sex with men
Heterosexual
males
Female Males Men who have
sex with men
Heterosexual
males

1918

96

130

1

1919

53

62

0

1920

103

39

6

1921

74

43

1

1922

61

23

0

1923

71

22

2

1924

44

24

0

1925

57

12

0

1926

162

1,698

59

146

0

32

1927

240

1,829

69

304

0

89

1928

269

1,761

164

364

0

66

1929

244

1,490

117

213

2

64

1930

458

1,515

95

151

8

43

1931

545

1,451

143

164

10

78

1932

366

1,344

103

144

0

54

1933

363

1,123

102

117

0

45

1934

336

1,194

50

94

0

32

1935

389

1,185

51

111

0

19

1936

392

1,085

57

80

0

12

1937

297

1,208

32

79

1

3

1938

373

1,355

39

78

0

2

1939

272

1,095

35

68

1

2

1940

163

911

34

90

0

0

1941

128

820

58

132

0

0

1942

95

715

38

159

8

1

1943

316

601

65

122

0

0

1944

164

593

29

83

1

25

1945

83

562

20

66

0

27

1946

52

1,057

15

132

0

47

1947

91

912

13

132

0

52

1948

81

770

21

178

0

50

1949

48

503

27

155

0

81

1950

26

375

26

146

0

123

1951

25

205

31

97

0

32

1952

32

259

12

85

0

0

1953

28

268

5

51

0

3

1954

20

192

5

48

0

0

1955

53

412

10

79

0

0

1956

67

521

17

81

0

0

1957

112

634

4

68

0

0

1958

130

535

15

65

0

1

1959

145

661

9

119

0

0

1960

157

705

16

116

0

1

1961

144

656

5

76

0

1

1962

230

769

2

47

0

1

1963

214

634

4

50

0

4

1964

214

0

0

1965

220

1

0

1966

289

2

0

1967

361

4

1

1968

319

4

1

1969

356

696

13

81

0

1

1970

638

845

6

30

0

0

1971

618

916

11

42

1

1

1972

773

930

4

34

0

0

1973

730

803

8

36

0

0

1974

715

991

1

59

0

0

1975

553

1,127

7

68

0

1

1976

395

954

14

50

0

0

1977

358

1,109

7

30

0

4

1978

368

1,379

8

24

0

5

1979

330

1,201

9

27

0

1

1980

402

1,190

4

37

0

0

1981

333

1,068

7

26

0

0

103

2

1982

280

1,277

8

7

0

1

300

4

1983

373

884

2

7

0

0

408

2

1984

216

651

3

19

0

0

432

6

1985

243

453

1

4

0

0

362

23

1986

137

354

1

6

0

0

261

2

1987

82

218

1

6

0

0

154

2

1988

36

159

1

4

0

0

125

0

1989

44

136

0

1

0

0

104

11

1990

12

93

0

0

0

0

90

78

1991

7

71

0

0

0

0

21

43

1992

5

52

1

1

0

0

0

0

1993

1

41

0

0

0

0

0

0

1994

4

48

0

0

1995

1

46

0

0

1996

2

64

0

0

1997

5

34

0

0

81

1998

3

70

0

0

81

117

1999

5

79

0

0

95

137

2000

5

93

0

0

71

162

2001

11

88

0

0

91

224

2002

14

122

94

28

0

10

4

6

0

0

0

0

186

352

148

204

2003

7

224

191

33

1

10

8

2

0

0

0

0

218

401

130

271

2004

12

209

189

20

2

28

24

4

0

0

0

0

213

425

152

273

2005

15

214

170

44

1

37

36

1

0

0

0

0

257

456

178

278

2006

15

283

252

31

4

60

54

6

0

0

0

0

307

522

236

286

2007

19

203

175

28

5

123

108

15

0

0

0

0

287

498

218

280

2008

28

200

173

27

3

111

104

7

0

0

0

0

327

617

278

339

2009

26

292

239

53

3

139

128

11

0

0

0

0

377

764

412

352

2010

48

418

380

38

4

94

80

14

0

0

0

0

404

911

504

407

2011

43

382

330

52

3

109

92

17

0

0

0

0

352

724

405

319

2012

46

545

487

58

5

162

151

11

0

0

0

0

414

946

511

435

2013

40

704

622

82

14

192

178

14

0

0

0

0

530

1,250

706

544

2014

51

743

679

64

7

273

256

17

0

0

0

0

600

1,360

730

630

2015

96

1,489

1,404

85

21

366

329

37

0

0

0

0

640

1,671

1,048

623

2016

137

1,629

1,525

104

19

406

366

40

0

0

0

0

754

2,079

1,454

625

In this section