1. Sexually Transmitted Disease (STD) Surveillance Report, 2013 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 with a positive laboratory test. Cases diagnosed solely on symptoms are not counted. This year’s data like 2012 includes cases that had only a lab report and no corresponding case report form. This has increased the number of unknowns in some variables. 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. National Context STDs in Minnesota: Annual Review

7. Chlamydia—Rates by State, United States and Outlying Areas, 2012 National Rate = 453.5 per 100,000 population Source: Centers for Disease Control & Prevention, Division of STD Prevention. 2012 Surveillance Slides.

8. Gonorrhea—Rates by State, United States and Outlying Areas, 2012 Source: Centers for Disease Control & Prevention, Division of STD Prevention. 2012 Surveillance Slides. National Rate = 106.3 per 100,000 population

9. Primary and Secondary Syphilis—Rates by State United States and Outlying Areas, 2012 National Rate = 5.1 per 100,000 population Source: Centers for Disease Control & Prevention, Division of STD Prevention. 2012 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, 2003-2013 * 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 2013 Total of 23,133 STD cases reported to MDH in 2013:  18,724 Chlamydia cases  3,872 Gonorrhea cases  537 Syphilis cases (all stages)  0 Chancroid cases

13. CHLAMYDIA STDs in Minnesota: Annual Review

14. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Rate per 100,000 persons > 300 151 - 300 76 - 150 0 - 75 2013 Minnesota Chlamydia Rates by County City of Minneapolis 933 City of St. Paul 834 Suburban # 245 Greater Minnesota 244 (1,425 cases missing residence information) # 7-county metro area, excluding the cities of Minneapolis and St. Paul

15. 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, 2013 Total Number of Cases = 18,724

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 2003-2013

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 2003-2013

18. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Chlamydia Rates by Gender Minnesota, 2013

19. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 2003-2013 * Persons of Hispanic ethnicity can be of any race. 2013 rates compared with Whites: Black = 10x higher American Indian = 4.5x higher Asian/PI = 2x higher Hispanic = 2.5x higher

20. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 2003-2013 * 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 2013 Minnesota Gonorrhea Rates by County Rate per 100,000 persons City of Minneapolis 359 City of St. Paul 230 Suburban # 49 Greater Minnesota 23 (194 cases missing residence information) # 7-county metro area, excluding the cities of Minneapolis and St. Paul > 100 30 - 100 11 - 29 0 - 10

23. 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, 2013 Total Number of Cases= 3,873

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 2003-2013

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 2003-2013

26. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Gonorrhea Rates by Gender Minnesota, 2013

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 2003-2013 * Persons of Hispanic ethnicity can be of any race. 2013 rates compared with Whites: Black = 26.5x higher American Indian = 7x higher Asian/PI = 0x higher Hispanic = 2x higher

28. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 2003-2013 * 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, 2003-2013 * P&S = Primary and Secondary

31. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 2013 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 City of Minneapolis 26.1 (100 cases) City of St. Paul 7.0 (20 cases) Suburban # 2.5 (55 cases) Greater Minnesota 0.7 (18 cases)

32. 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, 2013 Total Number of Cases = 193

33. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Gender Minnesota, 2003-2013

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Age Minnesota, 2003-2013

35. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2013

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, 2013 Total Number of Cases = 193

37. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 2003-2013 * 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 2013 (n = 18,724) MN Population in 2010 (n = 5,303,925) Chlamydia Disproportionately Impacts Youth

40. Data Source: Minnesota STD Surveillance System (due to rounding % does not = 100) STDs in Minnesota: Annual Review Gonorrhea Disproportionately Impacts Youth MN Population in 2010 (n = 5,303,925) Gonorrhea Cases in 2013 (n = 3,872)

41. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of Adolescents & Young Adults † Diagnosed With Chlamydia or Gonorrhea in 2013 † 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 2013 † 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, 2003-2013 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2010 U.S. Census counts.

44. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases Among Adolescents and Young Adults † by Gender and Race, Minnesota, 2013 Males (n = 3,216)Females (n = 9,527) † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

45. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rate Among Adolescents and Young Adults † by Race, Minnesota, 2013 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2010 U.S. Census counts.

46. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates Among Adolescents & Young Adults † by Gender in Minnesota, 2003-2013 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2010 U.S. Census counts.

47. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Cases Among Adolescents and Young Adults † by Gender and Race, 2013 Males (n = 841)Females (n = 1421) † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds.

48. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rate Among Adolescents and Young Adults † by Race, Minnesota, 2013 † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Rate=Cases per 100,000 persons based on 2010 U.S. Census counts.

49. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of Chlamydia and Gonorrhea Among Adolescents and Young Adults †, Minnesota, 2013 Adolescents and young adults accounted for 68% of chlamydia and 58% of gonorrhea cases diagnosed in Minnesota. 73% of chlamydia or gonorrhea cases diagnosed among adolescents and young adults were females. Whites and Blacks accounted for 36% and 28% of chlamydia or gonorrhea cases, respectively. 33% 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.

50. 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

51. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases by Gender Minnesota, 2003-2013 MSM=Men who have sex with men. Figure does not include cases diagnosed in transgendered persons (1 each in 2004, 2005, 2007, 2009 and 4 in 2013). † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

52. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases by Stage at Diagnosis Minnesota, 2003-2013 † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

53. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † by Gender and Sexual Behavior Minnesota, 2003-2013 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

54. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases Among MSM by Age Minnesota, 2013 (n=261) MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Mean Age = 36 years Range: 18 to 69 years

55. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † (ES) Cases Co-infected with HIV, 2006-2013 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

56. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gay and bisexual men account for 88% of cases among men. 68% of cases among MSM are White, but a disproportionate number of cases (16%) are African American. 51% in the City of Minneapolis and 31% live in the suburbs 46% 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, 2013 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

57. 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. All HIV/Syphilis co-infected cases are assigned to Partner Services for follow-up 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

58. SURVEILLANCE SUMMARY

59. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota From 2003-2013, the chlamydia rate increased by 65%. The rate of gonorrhea increased by 26% between 2012 and 2013. Rates of reported syphilis increased in 2013 compared to 2012 by 60%. Minnesota has seen a resurgence of syphilis over the past decade, with men who have sex with men and those co-infected with HIV 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 58% of the reported cases in 2013. Adolescents and young adults (15-24 years) have the highest rates of chlamydia and gonorrhea, making up 66% of new infections in 2013. Between 2012 and 2013, the chlamydia rate increased by 4% and the gonorrhea rate increased by 26%. Primary/secondary syphilis cases increased by 64%. Men who have sex with men comprised 88% of all male cases in 2013; cases among women remain low but are continuing to increase.

60. Future Updates to STD Reporting New case report form to accommodate changes in gonorrhea treatment guidelines is now available on our website Case report form is be able to be filled out on a computer and printed to be mailed or faxed in Link is up on MDH website to indicate interest in future online “provider portal” for direct online reporting All cases co-infected with HIV/Gonorrhea will be assigned to MDH Partner Services for follow-up Starting in 2015 all Gonorrhea cases have the potential for being contacted by MDH for additional follow-up Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review