1. EMERGING TRENDS: -Fluoroquinolone- Resistant Gonorrhea -Syphilis Among MSM -Continuing Increase of Chlamydia EMERGING TRENDS: -Fluoroquinolone- Resistant Gonorrhea -Syphilis Among MSM -Continuing Increase of Chlamydia STDs in Minnesota: Annual Review

2. Prevalence of Fluoroquinolone-Resistant Gonorrhea in Minnesota STDs in Minnesota: Annual Review

3. Background Information CDC-recommended antibiotic treatments for gonorrhea:  Ceftriaxone  Single dose therapy, administered by injection  Relatively expensive  Cefixime  Single dose therapy, administered orally  Production discontinued in 2002; No longer available  Ciprofloxacin, Ofloxacin, Levofloxacin (Quinolones)  Single dose therapy, administered orally  Spread of quinolone-resistant N. gonorrhoeae (QRNG) threatens the efficacy of fluoroquinolones as the frontline treatment for gonorrhea STDs in Minnesota: Annual Review

4. Prevalence of Quinolone-Resistant N. Gonorrhoeae ( QRNG) 2000 2001 2003 2002 1990s QRNG prevalent in Asia, >40% in some countries Hawaii discontinues use of fluoroquinolones following increase in QRNG prevalence from 1.4% in 1997 to 9.5% in 1999 California discontinues use of fluoroquinolones after reaching QRNG prevalence of 5% in 2001 Increases in QRNG reported in other U.S. states (e.g., MI, MA) CDC recommends non-quinolone therapy for infections acquired in HI, CA, and other areas with high QRNG prevalence 2004 Prevalence of QRNG in MN five times higher than in 2002 2005 Prevalence of QRNG in MN continues to increase STDs in Minnesota: Annual Review 2006 CDC recommends fluoroquinolones no longer be used as first-line treatment among men who have sex with men (MSM)

5. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG in Minnesota †, 1999 - 2006 Year# Resistant Isolates# Isolates TestedQRNG Prevalence 1999-200101,3650% 200242681.5% 200353631.4% 2004283308.5% 2005253656.8% 2006193285.8% † For 1999 to 2003 the isolates tested came only from the Gonococcal Isolate Surveillance Project (GISP). GISP is a sentinel surveillance system established by the CDC to monitor antimicrobial resistance in gonorrhea among males. The Red Door Clinic in Minneapolis is one of the participating clinics. For 2004 through 2006 the numbers include isolates from Room 111 in St. Paul and include both males and females.

6. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG by Mode of Transmission in Minnesota, 2002 - 2006 † Gay/BisexualHeterosexual Year# Resistant# TestedPrevalence# Resistant# TestedPrevalence 20020380.0%11520.7% 20034458.9%11680.6% 2004238527%52382.1% 2005248030%12790.4% 2006176327%22580.8% † For 2002 and 2003 the isolates tested came only from the Gonococcal Isolate Surveillance Project (GISP). GISP is a sentinel surveillance system established by the CDC to monitor antimicrobial resistance in gonorrhea among males. The Red Door Clinic in Minneapolis is one of the participating clinics. For 2004 through 2006 the numbers include isolates from Room 111 in St. Paul and include both males and females.

7. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of 2006 QNRG cases (n = 19) All cases were male. 68% of the cases were White 32% of cases were 24 years old or younger and 37% of cases were among 25-29 years olds (Mean age – 29, Median age – 27) 17 of 19 cases (89%) were among gay/bisexual males 6% of cases among gay/bisexual males are also infected with HIV

8. What’s Being Done in Minnesota? The MDH continues to test gonorrhea isolates from Room 111 and Red Door Clinic for Quinolone resistance In 2005 and 2006, through a project funded by APHL and CDC, the MDH conducted surveillance for QRNG among women tested at Red Door Clinic and Room 111; Room 111 continues to submit isolates for women Healthcare providers are encouraged to obtain travel histories of patients and to be alert for treatment failures. Gonorrhea infections acquired in areas with high QRNG prevalence and among MSM should receive non-quinolone therapy Clinicians and laboratories are asked to report suspected treatment failures and resistant gonococcal isolates to the MDH The MDH Partner Services Program follows up on all cases with quinolone resistant gonorrhea and their sex partners to ensure proper treatment STDs in Minnesota: Annual Review

9. Syphilis Among Gay/Bisexual Men in Minnesota Syphilis Among Gay/Bisexual Men in Minnesota STDs in Minnesota: Annual Review

10. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases by Gender Minnesota, 2001-2006 † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

11. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Among Gay/Bisexual Men Minnesota, 2001-2006 YearEarly Syphilis CasesMales Cases (%) MSM Cases (% of males) 20014927 (55) 5 (18) 20028270 (85)56 (80) 20039384 (90)73 (87) 20044841 (85)34 (83) 2005116109 (94)100 (92) 200610490 (88)80 (89) † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

12. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases and Percent MSM, by Age, Minnesota, 2006 † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

13. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gay and Bisexual men account for 89% of cases among men 78% of cases among MSM are White, and 55% are between the ages of 25 and 39 (mean age = 34) 76% of cases live in Hennepin County, and 65% in the City of Minneapolis 40% of cases are also infected with HIV Among cases interviewed by the MDH Partner Services Program:  Internet was the most common venue for meeting partners (44%)  Most reported having anonymous sex (61%), and of these 38% reported no condom use  14% of cases reported use of methamphetamine drugs Characteristics of Early Syphilis † Cases Among Gay/Bisexual Men Minnesota, 2006 † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

14. What’s Being Done in Minnesota? The MDH is continuing awareness campaigns (e.g., Health Notices, press releases) Encouraging physicians to screen gay/bisexual men at least annually and to ask about sex partners The MDH Partner Services Program continues to follow up on cases and sex partners The MDH has implemented innovative prevention strategies (e.g., internet banners, partnering with venues) In 2004, the MDH implemented the Syphilis Elimination Project to:  Provide funding to community based programs to intensify outreach activities among high risk communities (e.g., gay/bisexual communities)  Create an outbreak response plan to better respond to new outbreaks  Assist health care providers to better serve patients at risk for syphilis STDs in Minnesota: Annual Review

15. Continuing Increase of Chlamydia STDs in Minnesota: Annual Review

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis, 1996-2006 115 per 100,000 263 per 100,000

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates in Minnesota, 1996-2006 Between 1996 and 2006 the incidence rate of chlamydia infection more than doubled from 115 to 263 per 100,000 persons. In 2006, the rate increased by 5% The rate almost tripled among men (54 to 152) and more than doubled among women (175 to 372) Rates more than tripled among 25-29 year olds (214 to 723) and tripled among 30-39 year olds (56 to 163) Among 15-19 year olds, rates increased by1.6 times (640 to 1032) and among 20-24 year olds rates increased by 2.7 times (567 to 1549) In this time period, rates more than doubled among Whites, Hispanics, and Asian/Pacific Islanders. The chlamydia rates among Blacks and American Indians increased by 61% and 67%, respectively Across geographic areas, greatest increase was seen in Greater Minnesota where the rates almost tripled between 1996 and 2006

18. What’s Behind the Increase? 1.Improved diagnostic tools with increased sensitivity 2.Improved screening practices by clinicians 3.Improved case reporting among providers 4.Addition of active surveillance component to MDH STD surveillance system 5.Increase of disease in the population Since effects of the first three factors outlined above would have stabilized over time, the increase is most likely due to an actual increase of disease in the population. The observed increase since 1996 is most likely due to combination of factors including: STDs in Minnesota: Annual Review