1. Highlights from the Sexually Transmitted Disease (STD) Surveillance Report, 2012 Minnesota Department of Health STD Surveillance System Minnesota Department of Health STD Surveillance System www.health.state.mn.us/std

2. Announcements

3. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota Rate per 100,000 by Year of Diagnosis, 2002-2012 * P&S = Primary and Secondary

4. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

5. CHLAMYDIA STDs in Minnesota: Annual Review

6. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis, 2002-2012 202 per 100,000 340 per 100,000

7. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Chlamydia Infections by Residence at Diagnosis Minnesota, 2012 Total Number of Cases = 18,048

8. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Chlamydia Rates by Gender Minnesota, 2012

9. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 2002-2012 * Persons of Hispanic ethnicity can be of any race. 2012 rates compared with Whites: Black = 11x higher American Indian = 5x higher Asian/PI = 2x higher Hispanic = 3x higher

10. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 2002-2012 * Persons of Hispanic ethnicity can be of any race.

11. GONORRHEA STDs in Minnesota: Annual Review

12. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea in Minnesota Rate per 100,000 by Year of Diagnosis, 2002-2012

13. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Gonorrhea Infections in Minnesota by Residence at Diagnosis, 2012 Total Number of Cases= 3,082

14. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Gonorrhea Rates by Gender Minnesota, 2012

15. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 2002-2012 * Persons of Hispanic ethnicity can be of any race. 2012 rates compared with Whites: Black = 26x higher American Indian = 8x higher Asian/PI = 0x higher Hispanic = 2x higher

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 2002-2012 * Persons of Hispanic ethnicity can be of any race.

17. SYPHILIS STDs in Minnesota: Annual Review

18. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Syphilis Rates by Stage of Diagnosis Minnesota, 2002-2012 * P&S = Primary and Secondary

19. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Primary & Secondary Syphilis Infections in Minnesota by Residence at Diagnosis, 2012 Total Number of Cases = 118

20. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2012

21. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 2002-2012 * Persons of Hispanic ethnicity can be of any race.

22. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota: Annual Review Topics in the spotlight: Chlamydia and Gonorrhea among Adolescents and Young Adults (15-24 years of age) Early Syphilis Among Men Who Have Sex With Men in Minnesota Topics in the spotlight: Chlamydia and Gonorrhea among Adolescents and Young Adults (15-24 years of age) Early Syphilis Among Men Who Have Sex With Men in Minnesota

23. CHLAMYDIA AND GONORRHEA AMONG ADOLESCENTS & YOUNG ADULTS (15-19 year olds) (20-24 year olds) STDs in Minnesota: Annual Review

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases in 2012 (n = 18,048) MN Population in 2010 (n = 5,303,925) Chlamydia Disproportionately Impacts Youth

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Disproportionately Impacts Youth MN Population in 2010 (n = 5,303,925) Gonorrhea Cases in 2012 (n = 3,082)

26. STDs in Minnesota: Annual Review Early Syphilis Among Men Who Have Sex With Men in Minnesota Early Syphilis Among Men Who Have Sex With Men in Minnesota

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

28. Early Syphilis † Cases Among MSM by Age Minnesota, 2012 (n=158) MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Mean Age = 38 years Range: 15 to 74 years

29. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † (ES) Cases Co-infected with HIV, 2006-2012 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

30. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

31. SURVEILLANCE SUMMARY

32. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

33. Future Updates to STD Reporting New case report form to accommodate changes in gonorrhea treatment guidelines Case report form will be able to be filled out on a computer and printed to be mailed or faxed in Link will be put up on MDH website to indicate interest in future online “provider portal” for direct online reporting Letters will be sent in late May/early June to providers to introduce new case report form, provide link to sign up for future “provider portal” online reporting, and highlight new gonorrhea treatment guidelines Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

34. INCREASING PREVALENCE OF DRUG- RESISTANT GC Candy Hadsall, RN STD Nurse Specialist MDH

35. Resistance is Increasing Beginning to see resistance to Suprax – –High number of treatment failures in Canada. –Gonococcal Isolate Surveillance Project (GISP) has identified cases, including few in MN –Steepest increase in western US, especially in MSM; started in 2009 –One study = 11.9% of patients + on retest 2-4 weeks after treatment with Suprax Concern: cephalosporins are last effective antibiotic; no new drugs in production

36. 2012 Rev Recommended Tx of Uncomplicated GC (Cervix, urethra, rectum) Ceftriaxone 250 mg IM, single dose PLUS Azithromycin 1 g orally, single dose or doxycycline 100 mg. orally bid x 7 days Note: Fluoroquinolones discontinued in 2007

37. 2012 Alternative Tx for Uncomplicated GC If no ceftriaxone, Cefixime 400 mg po, single dose PLUS Azithromycin 1 gm orally, single dose (or doxy) MUST DO Test of cure in 1 week via culture if possible

38. Test of Cure for GC TOC recommended when: –One week following re-treatment if used alternative treatment and not Rocephin –Treatment failure is suspected –Patients have persistent symptoms Culture recommended unless not available –Poses problems since culture use declined –If unavailable, can use NAATS (GC clears from body within 5 days if responsive to treatment med)

39. Pharyngeal Gonorrhea Infection in mouth and throat sometimes occurs. More difficult to eradicate CDC treatment recommendation: –Ceftriaxone (Rocephin) 250 mg. IM single dose PLUS Azithromycin 1 g orally, single dose (or doxy) Not recommended even prior to 2012: – Cefixime 400 mg po

40. What About EPT? Treatment recommendation for partners of individuals who test positive for gonorrhea and refuse to come into clinic: –Cefixime (Suprax) 400 mg orally, single dose PLUS - Azithromycin 1 gm. orally, single dose No change in treatment guidelines

41. Different Focus When Addressing Gonorrhea in Minnesota Since large majority of cases are in Twin Cities and suburbs, important to: –Pay attention to geography – of clinic, of clients –Do detailed sexual histories, risk assessments; identify and discuss social/sexual networks –Treat prophylactically when indicated. Treat positives quickly and appropriately. (CDC Guidelines) –Get partners into clinic for treatment –When not possible, provide EPT for all partners –Report untreated cases to MDH right away

42. What Should Clinicians Do in 2013? Be alert to treatment failures in patients who received Suprax as alternative treatment AND In patients who return with symptoms after treatment when partner(s) are treated with EPT Do not stop using Suprax in designated situations, especially if patient/partner would not otherwise get treated Update treatment protocols; decide on clinic’s ability to collect cultures; see if lab does cultures

43. GOAL: Treat as many people as possible as long as we still have an effective treatment, including partners through EPT

44. Recommendations for GC (and CT) Re-Screening after Treatment In patients who are positive and have uncomplicated cases, and do not return with symptoms, no changes Re-screen all patients who were positive 3 - 4 months after treatment, or whenever seek care within 12 months if did not return at 3 months

45. Repeat Infections Repeat CT and GC infection rates at rescreening 3-4 months later are high, 10-30%, usually because partners not treated Risk of serious reproductive health sequelae increases with every subsequent infection –Upper tract infection (PID) more common with re- infection than initial infection –Repeat CT: 2x odds of ectopic pregnancy; 4x odds of pelvic inflammatory disease (PID) 1 1 - Hillis et al 1997

46. What Else Can Clinicians Do? Ask patients about sex of partners and include treatment/EPT Put as much information as possible on case report forms Call MDH if suspect treatment failure Be able to explain disease investigation when necessary. Make a connection with a Disease Investigator at MDH – 651-201-5414.

47. Candy Hadsall candy.hadsall@state.mn.us 651-201-4015 candy.hadsall@state.mn.us

48. TOOLS TO INCREASE CHLAMYDIA SCREENING RATES IN YOUR PRACTICE Anisa Esse, Senior Regulatory Quality Analyst Medica Chlamydia Screening: Provider Toolkit

49. Project Background Health Plans required by DHS Contract to impalement a statewide Performance Improvement Project annually that lasts for 3 years. (PIP)– 3 year project Health Plans work collaboratively together on projects. This performance improvement project (PIP) is a Collaborative effort among four Minnesota health plans: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, and UCare with project support provided by Stratis Health.

50. Project Background Purpose: The goal of this PIP is to increase the rate of Chlamydia screening in women  Barriers discovered: providers lack of knowledge about CT, belief systems, confidence in skills re: talking to youth/parents

51. Intervention Strategies Provider/Clinic interventions  Provider toolkit  Targeted Outreach to Clinics with low Chlamydia screening rates Community level Outreach  Support the implementation of the MN Chlamydia strategy

52. MCP Involvement To fulfill the community outreach component of project; Health plan collaborative approached MCP in November 2012 Important for Health plan collaborative to receive input from MCP members in the development of the provider toolkit

53. Chlamydia Screening: Provider Toolkit The Health plan Collaborative with support from the MCP developed this toolkit to help clinics and providers across the state make simple changes to improve their clinic processes and raise awareness of this public health issue.

54. Chlamydia Screening: Provider Toolkit The toolkit includes: Current information on the status of the disease Sample office protocols Resources for your clinic, patients, and parents Profiles of four Minnesota clinics with successful chlamydia screening efforts The toolkit is available at: http://www.stratishealth.org/pip/documents/Chlamy dia_Toolkit.pdf

55. Upcoming Webinar Topic: Tools to improve chlamydia screening in your practice Date: Monday, April 15, 2013 Time: 12:00 – 1:00 pm Space is limited. To register, email Patty Graham at: patty.r.graham@healthpartners.com. This webinar will be recorded and available for viewing later at http://www.stratishealth.org/pip/chlamydia.html http://www.stratishealth.org/pip/chlamydia.html

56. Upcoming Webinar Presented by: o Paul Erickson, MD, Medical Director, NorthPoint Health and Wellness Clinic o Patty Graham, BA, Quality Consultant, HealthPartners Health Plan o Jenny Oliphant, EdD, MPH, Community Outreach Coordinator for the Healthy Youth Development-Prevention Research Center (PRC), Division of Adolescent Health and Medicine at the University of Minnesota Who should participate: Health care providers, nurses, clinic administration, public health, health educators, social workers, school health staff, youth workers and anyone who interacts with youth

57. Contact Information Anisa Esse Anisa.esse@medica.com 952-992-2562 Project website: http://www.stratishealth.org/pip/chlamydia.html

58. Questions?

59. For more information, contact: STD Surveillance Data Dawn.Ginzl@state.mn.usDawn.Ginzl@state.mn.us, 651-201-4041 Gonorrhea & Chlamydia Technical Assistance Candy.Hadsall@state.mn.us, 651-201-4015 Candy.Hadsall@state.mn.us Chlamydia Screening Provider Toolkit Anise.Esse@medica.comAnise.Esse@medica.com, 952-992-2562