1. Sexually Transmitted Disease (STD) Surveillance Report, 2007 Minnesota Department of Health STD Surveillance System Minnesota Department of Health STD Surveillance System www.health.state.mn.us/std

2. Introduction Under Minnesota law, physicians and laboratories must report all laboratory-confirmed cases of chlamydia, gonorrhea, syphilis, and chancroid to the Minnesota Department of Health (MDH) within one working day. The MDH does not maintain statistics for other, non- reportable STDs (ex: herpes, HPV/genital warts). This slide set describes trends in reportable STDs in Minnesota by person, place, and time. Analyses exclude cases reported from federal and private prisons. STDs in Minnesota: Annual Review

3. Introduction STD surveillance is the systematic collection of data from cases for the purpose of monitoring the frequency and distribution of STDs in a given population. STD surveillance data are used to detect problems, prioritize resources, develop and target interventions, and evaluate the effectiveness of interventions. STDs in Minnesota: Annual Review

4. Interpreting STD Surveillance Data Factors that impact the completeness and accuracy of STD data include:  Level of STD screening by healthcare providers  Individual test-seeking behavior  Sensitivity of diagnostic tests  Compliance with case reporting  Completeness of case reporting  Timeliness of case reporting Increases and decreases in STD rates can be due to actual changes in disease occurrence and/or changes in one or more of the above factors. STDs in Minnesota: Annual Review

5. Interpreting STD Surveillance Data The surveillance system only includes cases diagnosed in conjunction with a positive laboratory test. Cases diagnosed solely on symptoms are not counted. Surveillance data represent cases of infection, not individuals. A person with multiple infections in a given year will be counted more than once. Caution is warranted when interpreting changes in STD numbers that can seem disproportionately large when the number of cases is small. STDs in Minnesota: Annual Review

6. National Context STDs in Minnesota: Annual Review

7. SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2006 Surveillance Slides. United States: State-Specific Chlamydia Rates, 2006 (National Rate = 347.8 per 100,000) STDs in Minnesota: Annual Review

8. United States: State-Specific Gonorrhea Rates, 2006 (National Rate = 120.9 per 100,000) STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2006 Surveillance Slides.

9. United States: State-Specific P&S Syphilis Rates, 2006 (National Rate = 3.3 per 100,000) STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2006 Surveillance Slides.

10. Overview of STDs in Minnesota STDs in Minnesota: Annual Review

11. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota Rate per 100,000 by Year of Diagnosis, 1997-2007 † * P&S = Primary and Secondary.

12. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota: Number of Cases Reported in 2007 Total of 17,057 STD cases reported to MDH in 2007:  13,412 Chlamydia cases  3,459 Gonorrhea cases  186 Syphilis cases (all stages) Note: Chancroid remains extremely rare in Minnesota. There were no cases reported in 2007.

13. CHLAMYDIA STDs in Minnesota: Annual Review

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

15. 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, 2007 Total Number of Cases = 13,412

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 1997-2007

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 1997-2007

18. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Chlamydia Rates by Gender Minnesota, 2007

19. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 1997-2007 * Persons of Hispanic ethnicity can be of any race.

20. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Excluding Blacks Minnesota, 1997-2007 * Persons of Hispanic ethnicity can be of any race.

21. GONORRHEA STDs in Minnesota: Annual Review

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

23. 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, 2007 Total Number of Cases= 3,459

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 1997-2007

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 1997-2007

26. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Gonorrhea Rates by Gender Minnesota, 2007

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 1997-2007 * Persons of Hispanic ethnicity can be of any race.

28. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Excluding Blacks Minnesota, 1997-2007 * Persons of Hispanic ethnicity can be of any race.

29. SYPHILIS STDs in Minnesota: Annual Review

30. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Syphilis Rates by Stage of Diagnosis Minnesota, 1997-2007 * P&S = Primary and Secondary

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

32. 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, 2007 Total Number of Cases = 59

33. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Gender Minnesota, 1997-2007

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Age Minnesota, 1997-2007

35. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2007

36. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review *Includes persons reported with more than one race Primary & Secondary Syphilis Cases by Race Minnesota, 2007 Total Number of Cases = 59

37. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 1997-2007 * Persons of Hispanic ethnicity can be of any race.

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

39. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases in 2007 (n = 13,412) MN Population in 2000 (n = 4,919,479) Chlamydia Disproportionately Impacts Youth

40. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Disproportionately Impacts Youth MN Population in 2000 (n = 4,919,479) Gonorrhea Cases in 2007 (n = 3,459)

41. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of Adolescents & Young Adults † Diagnosed With Chlamydia or Gonorrhea in 2007 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

42. 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. Characteristics of Adolescents & Young Adults † Diagnosed With Chlamydia or Gonorrhea in 2007 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

43. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates Among Adolescents & Young Adults † by Gender in Minnesota, 1997-2007 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2000 U.S. Census counts.

44. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia — Positivity Rates by Age and Gender MIPP † Clinics, 2002-2007 † The Minnesota Infertility Prevention Project (MIPP) is a project funded by the CDC to provide STD testing and treatment to uninsured men and women ages 15-24. Participating clinics include STD, family planning, adolescent, and community clinics.

45. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases Among Adolescents and Young Adults † by Gender and Race, Minnesota, 2007 Males (n = 2,046)Females (n = 7,095) † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

46. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rate Among Adolescents and Young Adults † by Race, Minnesota, 2007 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2000 U.S. Census counts.

47. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia — Positivity Rates Among 15-24 Year-olds by Race MIPP † Clinics, 2002-2007 † The Minnesota Infertility Prevention Project (MIPP) is a project funded by the CDC to provide STD testing and treatment to uninsured men and women ages 15-24. Participating clinics include STD, family planning, adolescent, and community clinics.

48. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates Among Adolescents & Young Adults † by Gender in Minnesota, 1997-2007 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2000 U.S. Census counts.

49. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea — Positivity Rates by Age and Gender MIPP † Clinics, 2002-2007 † The Minnesota Infertility Prevention Project (MIPP) is a project funded by the CDC to provide STD testing and treatment to uninsured men and women ages 15-24. Participating clinics include STD, family planning, adolescent, and community clinics.

50. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Cases Among Adolescents and Young Adults † by Gender and Race, 2007 Males (n = 647)Females (n = 1,285) † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

51. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rate Among Adolescents and Young Adults † by Race, Minnesota, 2007 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2000 U.S. Census counts.

52. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea — Positivity Rates Among 15-24 Year-olds by Race MIPP † Clinics, 2002-2007 † The Minnesota Infertility Prevention Project (MIPP) is a project funded by the CDC to provide STD testing and treatment to uninsured men and women ages 15-24. Participating clinics include STD, family planning, adolescent, and community clinics.

53. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of Chlamydia and Gonorrhea Among Adolescents and Young Adults †, Minnesota, 2007 Adolescents and young adults accounted for 68% of chlamydia and 56% of gonorrhea cases diagnosed in Minnesota. 75% of chlamydia or gonorrhea cases diagnosed among adolescents and young adults were females. Whites and Blacks accounted for 40% and 32% of chlamydia or gonorrhea cases, respectively. Rates 39% of gonorrhea or chlamydia cases were in the Cities of Minneapolis and Saint Paul. † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

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

55. Fluoroquinolone-Resistant Gonorrhea in Minnesota Fluoroquinolone-Resistant Gonorrhea in Minnesota STDs in Minnesota: Annual Review

56. Background: Antibiotic-Resistant Gonorrhea Gonorrhea has developed resistance to nearly every drug used since the advent of antimicrobial therapy.  Tetracycline and penicillins abandoned in 1980s.  Only cephalosporins remain recommended by CDC. Current threat: Quinolone-resistant N. gonorrhoeae (QRNG)  Emerged in Asia in 1990s, spread to U.S. West Coast.  Since 2000, CDC has recommended non-quinolone therapy for populations where QRNG exceeds 5% (Hawaii, California, gay/bisexual men).  April 2007: QRNG >5% among heterosexuals; CDC removes quinolones from gonorrhea treatment recommendations. STDs in Minnesota: Annual Review

57. Surveillance of Antibiotic-resistant Gonorrhea in Minnesota Two STD clinics in Minneapolis/St. Paul send cultures to the MDH on a monthly basis. The MDH lab determines susceptibilities to: AzithromycinCefiximeCeftriaxone CiprofloxacinPenicillinSpectinomycin Tetracycline Clinics are notified of resistant results. The MDH Partner Services Program follows up on all QRNG cases and their sex partners to ensure proper treatment. STDs in Minnesota: Annual Review

58. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Antibiotic-resistant Gonorrhea in Minnesota No isolates were resistant to cefixime or ceftriaxone. One isolate (0.3%) was resistant to spectinomycin in 2004. Data for azithromycin indicate reduced susceptibility rather than resistance.

59. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG in Minnesota †, 1999 - 2007 QRNG=Quinolone-Resistant Neisseria gonorrhoeae † Surveillance from 1999-2001 includes isolates from males at one STD clinic. A second STD clinic was added in 2002 that submits isolates for both males and females.

60. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG in Minnesota by Mode of Transmission, 2002 - 2007 † QRNG=Quinolone-Resistant Neisseria gonorrhoeae † Surveillance from 1999-2001 includes isolates from males at one STD clinic. A second STD clinic was added in 2002 that submits isolates for both males and females.

61. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of 2007 QNRG cases (n = 31) 29 males, 2 females 61% of the cases were White, 10% Asian 37% of cases were 15-24 years old, 16% were 45 or older (Mean age – 31, Median age – 28) 18 of 31 cases (58%) were among gay/bisexual males QRNG=Quinolone-Resistant Neisseria gonorrhoeae

62. What’s Being Done in Minnesota? The MDH continues to monitor gonorrhea isolates for antibiotic resistance and ensure proper treatment of QRNG cases and their sex partners. Clinicians and laboratories are asked to report suspected treatment failures and resistant gonococcal isolates to the MDH. The MDH and CDC recommend against the use of fluoroquinolones for patients testing positive for gonorrhea. STDs in Minnesota: Annual Review QRNG=Quinolone-Resistant Neisseria gonorrhoeae

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

64. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases by Gender Minnesota, 2001-2007 MSM=Men who have sex with men. Figure does not include cases diagnosed in transgendered persons (1 each in 2004, 2005, and 2007). † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

65. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases by Stage at Diagnosis Minnesota, 2001-2007 † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

66. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † by Gender and Sexual Behavior Minnesota, 2001-2007 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

67. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases Among MSM by Age Minnesota, 2007 (n=103) MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

68. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gay and bisexual men account for 93% of cases among men. 74% of cases among MSM are White, but a disproportionate number of cases (15%) are African American. 71% of cases live in Hennepin County, and 59% in the City of Minneapolis. 44% of cases are also infected with HIV. Among cases interviewed by the MDH Partner Services Program:  Commonly reported risk factors were meeting partners on the internet, anonymous sex, and no condom use. Characteristics of Early Syphilis † Cases Among MSM, Minnesota, 2007 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

69. What’s Being Done in Minnesota? The MDH Partner Services Program continues to follow up on early syphilis cases and their sex partners. In 2004 the MDH implemented the Syphilis Elimination Project (SEP). In 2007, SEP:  Developed a clinician toolkit for syphilis testing and treatment;  Created a new outbreak response plan; and  Increased awareness among gay/bisexual men through advertising in magazines, bars, and websites.  SEP website: www.health.state.mn.us/sep Physicians are encouraged to screen men who have sex with men at least annually and to ask about sex partners. STDs in Minnesota: Annual Review

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

71. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis, 1992-2007

72. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates in Minnesota, 1996-2007 From its lowest point in 1996, the incidence rate of chlamydia infection has more than doubled from 115 to 273 per 100,000 persons. In 2007 the rate increased by 4%. The rate almost tripled among men (54 to 153) and more than doubled among women (175 to 390). Rates more than tripled among 25-29 year-olds and 30-39 year-olds. Rates among 15-19 year-olds increased by 1.7 times (640 to 1071) and rates among 20-24 year-olds nearly tripled (567 to 1592). 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 69% and 65%, respectively.

73. What’s Behind the Increase? STDs in Minnesota: Annual Review  Improved diagnostic tools with increased sensitivity  Addition of active surveillance component to MDH STD surveillance system  Improved case reporting among providers  Improved screening practices by clinicians  Increase of disease in the population Effects of the first three factors above would have stabilized over time. Therefore, the sustained upward trend is most likely due to increased screening by providers and/or an actual increase of disease in the population. The observed increase since 1996 is most likely due to combination of factors including:

74. STD SURVEILLANCE SUMMARY

75. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota From 1997-2007, the chlamydia rate more than doubled while the gonorrhea rate grew slowly but steadily. Minnesota has seen a resurgence of syphilis since 2002, with men who have sex with men being especially impacted. Persons of color continue to be disproportionately affected by STDs. STD rates are highest in the cities of Minneapolis and Saint Paul. But from 2006 to 2007 the rates of chlamydia and gonorrhea increased the most in Greater Minnesota. Adolescents and young adults (15-24 years) have the highest rates of chlamydia and gonorrhea, making up 68% of new infections in 2007. Between 2006 and 2007, rates of chlamydia and gonorrhea increased by 4% and 5%, respectively. Primary/secondary syphilis cases increased by 38% among men who have sex with men, who comprised 95% of all male cases in 2007; cases among women remain low.