1. Sexually Transmitted Disease (STD) Surveillance Report, 2011 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. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 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.

6. Changes in Rate Calculations for 2011 This 2011 data release includes rates calculated using revised population estimates for the calendar years between 2000 and 2010 U.S. Censuses Previously published rates dating back to 2001 have been updated in this release Data from the 2010 U.S. Census, released in 2011 reflected substantial growth among populations of color and American Indians in MN. Populations with the greatest increase were Black or African American, Asian/Pacific Islander, and Hispanic/Latino. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

7. National Context STDs in Minnesota: Annual Review

8. Chlamydia—Rates by State, United States and Outlying Areas, 2010 National Rate = 422.6 per 100,000 population Source: Centers for Disease Control & Prevention, Division of STD Prevention. 2010 Surveillance Slides.

9. Gonorrhea—Rates by State, United States and Outlying Areas, 2010 Source: Centers for Disease Control & Prevention, Division of STD Prevention. 2010 Surveillance Slides. National Rate = 99.6 per 100,000 population

10. Primary and Secondary Syphilis—Rates by State United States and Outlying Areas, 2010 National Rate = 4.5 per 100,000 population Source: Centers for Disease Control & Prevention, Division of STD Prevention. 2010 Surveillance Slides.

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

12. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota Rate per 100,000 by Year of Diagnosis, 2001-2011 * P&S = Primary and Secondary

13. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota: Number of Cases Reported in 2011 Total of 19,547 STD cases reported to MDH in 2011:  16,898 Chlamydia cases  2,283 Gonorrhea cases  366 Syphilis cases (all stages)  0 Chancroid cases

14. CHLAMYDIA STDs in Minnesota: Annual Review

15. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Rate per 100,000 persons > 300 151 - 300 76 - 150 0 - 75 2011 Minnesota Chlamydia Rates by County City of Minneapolis 848 City of St. Paul 795 Suburban # 271 Greater Minnesota 198 (728 cases missing residence information) # 7-county metro area, excluding the cities of Minneapolis and St. Paul St. Louis Itasca Cass Lake Polk Beltrami Aitkin Pine Cook Koochiching Otter Tail Clay Roseau Marshall Becker Todd Stearns Kittson Swift Lyon Pope Morrison Wilkin Renville Carlton Martin Rice Wright Norman Fillmore Mower Nobles Murray Grant Sibley Brown Rock Redwood Douglas Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Scott Stevens Anoka Nicollet McLeod Chippewa Wabasha Carver Pennington Hubbard Crow Wing Lake of the Woods Clearwater Kandiyohi Lincoln Blue Earth Mille Lacs Houston Steele Traverse Dodge Wadena Hennepin Kanabec Lac Qui Parle Benton Big Stone Cottonwood Waseca Chisago Le Sueur Mahnomen Yellow Medicine Pipestone Red Lake Sherburne Watonwan Washington Ramsey

16. 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, 2011 Total Number of Cases = 16,898

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 2001-2011

18. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 2001-2011

19. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Chlamydia Rates by Gender Minnesota, 2011

20. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 2001-2011 * Persons of Hispanic ethnicity can be of any race. 2011 rates compared with Whites: Black = 11x higher American Indian = 4x higher Asian/PI = 2x higher Hispanic = 3x higher

21. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 2001-2011 * Persons of Hispanic ethnicity can be of any race.

22. GONORRHEA STDs in Minnesota: Annual Review

23. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 2011 Minnesota Gonorrhea Rates by County Rate per 100,000 persons City of Minneapolis 211 City of St. Paul 132 Suburban # 30 Greater Minnesota 14 (91 cases missing residence information) # 7-county metro area, excluding the cities of Minneapolis and St. Paul St. Louis Itasca Cass Lake Polk Beltrami Aitkin Pine Cook Koochiching Otter Tail Clay Roseau Marshall Becker Todd Stearns Kittson Swift Lyon Pope Morrison Wilkin Renville Carlton Martin Rice Wright Norman Fillmore Mower Nobles Murray Grant Sibley Brown Rock Redwood Douglas Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Scott Stevens Anoka Nicollet McLeod Chippewa Wabasha Carver Pennington Hubbard Crow Wing Lake of the Woods Clearwater Kandiyohi Lincoln Blue Earth Mille Lacs Houston Steele Traverse Dodge Wadena Hennepin Kanabec Lac qui Parle Benton Big Stone Cottonwood Waseca Chisago Le Sueur Mahnomen Yellow Medicine Pipestone Red Lake Sherburne Watonwan Washington Ramsey > 100 30 - 100 11 - 29 0 - 10

24. 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, 2011 Total Number of Cases= 2,283

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 2001-2011

26. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 2001-2011

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Gonorrhea Rates by Gender Minnesota, 2011

28. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 2001-2011 * Persons of Hispanic ethnicity can be of any race. 2011 rates compared with Whites: Black = 26x higher American Indian = 6x higher Asian/PI = 0x higher Hispanic = 2x higher

29. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 2001-2011 * Persons of Hispanic ethnicity can be of any race.

30. SYPHILIS STDs in Minnesota: Annual Review

31. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Syphilis Rates by Stage of Diagnosis Minnesota, 2001-2011 * P&S = Primary and Secondary

32. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 2011 Minnesota Primary & Secondary Syphilis Rates by County Rate per 100,000 persons > 1.0 0.21 – 1.0 0 – 0.2 # 7-county metro area, excluding the cities of Minneapolis and St. Paul St. Louis Itasca Cass Lake Polk Beltrami Aitkin Pine Cook Koochiching Otter Tail Clay Roseau Marshall Becker Todd Stearns Kittson Swift Lyon Pope Morrison Wilkin Renville Carlton Martin Rice Wright Norman Fillmore Mower Nobles Murray Grant Sibley Brown Rock Redwood Douglas Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Scott Stevens Anoka Nicollet McLeod Chippewa Wabasha Carver Pennington Hubbard Crow Wing Lake of the Woods Clearwater Kandiyohi Lincoln Blue Earth Mille Lacs Houston Steele Traverse Dodge Wadena Hennepin Kanabec Lac qui Parle Benton Big Stone Cottonwood Waseca Chisago Le Sueur Mahnomen Yellow Medicine Pipestone Red Lake Sherburne Watonwan Washington Ramsey City of Minneapolis 15.2 (58 cases) City of St. Paul 4.9 (14 cases) Suburban # 2.4 (52 cases) Greater Minnesota 0.5 (13 cases)

33. 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, 2011 Total Number of Cases = 139

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Gender Minnesota, 2001-2011

35. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Age Minnesota, 2001-2011

36. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2011

37. 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, 2011 Total Number of Cases = 139

38. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 2001-2011 * Persons of Hispanic ethnicity can be of any race.

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

40. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases in 2011 (n = 16,898) MN Population in 2010 (n = 5,303,925) Chlamydia Disproportionately Impacts Youth

41. 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 2011 (n = 2,283)

42. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of Adolescents & Young Adults † Diagnosed With Chlamydia or Gonorrhea in 2011 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. * Total includes 5 cases diagnosed in transgendered persons

43. 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 2011 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

44. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates Among Adolescents & Young Adults † by Gender in Minnesota, 2001-2011 † 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.

45. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia — Positivity Rates by Age and Gender MIPP † Clinics, 2002-2011 † 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.

46. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases Among Adolescents and Young Adults † by Gender and Race, Minnesota, 2011 Males (n = 2,998)Females (n = 8,876) † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

47. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rate Among Adolescents and Young Adults † by Race, Minnesota, 2011 † 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.

48. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia — Positivity Rates Among 15-24 Year-olds by Race MIPP † Clinics, 2002-2011 † 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.

49. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates Among Adolescents & Young Adults † by Gender in Minnesota, 2001-2011 † 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.

50. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea — Positivity Rates by Age and Gender MIPP † Clinics, 2002-2011 † 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.

51. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Cases Among Adolescents and Young Adults † by Gender and Race, 2011 Males (n = 476)Females (n = 914) † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

52. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rate Among Adolescents and Young Adults † by Race, Minnesota, 2011 † 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.

53. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea — Positivity Rates Among 15-24 Year-olds by Race MIPP † Clinics, 2002-2011 † 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.

54. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of Chlamydia and Gonorrhea Among Adolescents and Young Adults †, Minnesota, 2011 Adolescents and young adults accounted for 69% of chlamydia and 65% of gonorrhea cases diagnosed in Minnesota. 74% of chlamydia or gonorrhea cases diagnosed among adolescents and young adults were females. Whites and Blacks accounted for 43% and 31% of chlamydia or gonorrhea cases, respectively. 32% 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.

55. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota: Annual Review Topic of Interest: Early Syphilis Among Men Who Have Sex With Men in Minnesota Topic of Interest: Early Syphilis Among Men Who Have Sex With Men in Minnesota

56. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases by Gender Minnesota, 2001-2011 MSM=Men who have sex with men. Figure does not include cases diagnosed in transgendered persons (1 each in 2004, 2005, 2007, and 2009). † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

57. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases by Stage at Diagnosis Minnesota, 2001-2011 † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

58. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † by Gender and Sexual Behavior Minnesota, 2001-2011 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

59. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases Among MSM by Age Minnesota, 2011 (n=218) MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Mean Age = 35.8 years Range: 15 to 64 years

60. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † (ES) Cases Co-infected with HIV, 2006-2011 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

61. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gay and bisexual men account for 88% of cases among men. 71% of cases among MSM are White, but a disproportionate number of cases (15%) are African American. 52% in the City of Minneapolis and 30% live in the suburbs 57% 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, 2011 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

62. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 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 Effort (SEE). SEE activities include:  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 - includes several archived provider presentations and links to current awareness campaign materialswww.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

63. SURVEILLANCE SUMMARY

64. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota From 2001-2011, the chlamydia rate increased by 90%. Gonorrhea increased for the first time since 2007. Rates of reported syphilis increased slightly in 2011 compared to 2010. Minnesota has seen a resurgence of syphilis over the past decade, 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. However, chlamydia and gonorrhea cases in the Twin Cities suburbs and Greater Minnesota account for 64% of the reported cases in 2011. Adolescents and young adults (15-24 years) have the highest rates of chlamydia and gonorrhea, making up 69% of new infections in 2011. Between 2010 and 2011, the chlamydia rate increased by 9% and the gonorrhea rate increased by 5%. Primary/secondary syphilis cases decreased by 8%. Men who have sex with men comprised 88% of all male cases in 2011; cases among women remain low.