1. Sexually Transmitted Disease (STD) Surveillance Report, 2008
Minnesota Department of Health
Sexually Transmitted Disease (STD) Surveillance Report, 2008
Minnesota Department of Health
STD Surveillance System

2. Minnesota Department of Health
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. Minnesota Department of Health
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
Minnesota Department of Health
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.
In 2002, 631 CT cases and 146 GC cases were reported as a direct result of the provider reminder letters, alone accounting for a 7% and 5% increase in cases, respectively, between
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.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

6. Minnesota Department of Health
National Context
STDs in Minnesota: Annual Review

7. Minnesota Department of Health
United States: State-Specific Chlamydia Rates, (National Rate = per 100,000)
Minnesota is a moderate incidence state
SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention Surveillance Slides.

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

9. Minnesota Department of Health
United States: State-Specific P&S Syphilis Rates, (National Rate = 3.8 per 100,000)
Minnesota is a moderate incidence state
STDs in Minnesota: Annual Review
SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention Surveillance Slides.

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

11. Minnesota Department of Health
STDs in Minnesota Rate per 100,000 by Year of Diagnosis,
Chlamydia is the most commonly reported communicable disease.
The chlamydia rate decreased between , then increased markedly in 1997.
The chlamydia rate increased by 21% between Part of that increase (at least 1/3) was a result of active surveillance activities initiated in January 2002 that improved completeness of reporting.
The gonorrhea rate generally decreased from 1992 through 1997 and increased 13% between At least 1/3 of that increase was due to the implementation of active surveillance.
The primary & secondary syphilis rate has generally decreased over the past decade. However, in 2001 the rate increased from 0.3 to 0.7 per 100,000. The increase occurred primarily among heterosexual Black women and was associated with crack use. The number of cases among Black women decreased in 2002, but the overall P&S syphilis rate increased again (from 0.7 to 1.2 per 100,000) due to a large increase in cases among White men-who-have-sex-with-men (MSM).
* P&S = Primary and Secondary.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

12. STDs in Minnesota: Number of Cases Reported in 2008
Minnesota Department of Health
STDs in Minnesota: Number of Cases Reported in 2008
Total of 17,650 STD cases reported to MDH in 2008:
14,350 Chlamydia cases
3,036 Gonorrhea cases
263 Syphilis cases (all stages)
0 Chancroid cases
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

13. Minnesota Department of Health
CHLAMYDIA
STDs in Minnesota: Annual Review

14. Minnesota Department of Health
In 2007, there were 148 cases in Beltrami county (108 female, 39 male). One third was White, 50% American Indian. 54% from Bemidji, 40% from the res (Red Lake, Ponemah, Redby). 30% were reported from Planned Parenthood, 35% from Red Lake Indian Hospital.
Population of Beltrami Co. was 39,650 in 2000.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

15. Minnesota Department of Health
Chlamydia Infections by Residence at Diagnosis Minnesota, 2008
In 2007 the Twin Cities, Suburbs, and Greater MN each accounted for 1/3 of the cases.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

16. Minnesota Department of Health
Chlamydia Rates by Gender Minnesota,
The rate is 2.5 times higher among females than males, largely due to a higher level of chlamydia screening among women.
STD Prevalence Study data show almost equal percent positives by gender (11% F, 9% M)
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

17. Minnesota Department of Health
Chlamydia Rates by Age Minnesota,
Adolescents and young adults have the highest rates of chlamydial infection compared to older age groups, for several reasons:
More likely to have multiple sex partners
More likely to engage in unprotected sex
Partners may be at higher risk for being infected
(Females) Biologically more susceptible
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

18. Age-Specific Chlamydia Rates by Gender Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

19. Minnesota Department of Health
Chlamydia Rates by Race/Ethnicity Minnesota,
Persons of color, especially Blacks, and persons of Hispanic ethnicity are disproportionately affected. Possible explanations for the disparity include socioeconomic status, access/utilization of health care, and varying risk among sexual networks. Studies have shown that differences in sexual behavior do not entirely account for STD racial disparities.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

20. Minnesota Department of Health
Chlamydia Rates by Race/Ethnicity Excluding Blacks Minnesota,
Persons of color, especially Blacks, and persons of Hispanic ethnicity are disproportionately affected. Possible explanations for the disparity include socioeconomic status, access/utilization of health care, and varying risk among sexual networks. Studies have shown that differences in sexual behavior do not entirely account for STD racial disparities.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

21. Minnesota Department of Health
GONORRHEA
STDs in Minnesota: Annual Review

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

23. Minnesota Department of Health
Gonorrhea Infections in Minnesota by Residence at Diagnosis, 2008
The majority of cases occur among residents of the Twin Cities.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

24. Minnesota Department of Health
Gonorrhea Rates by Gender Minnesota,
Rates of gonorrhea are similar for males and females, unlike chlamydia rates.
The majority of males (~95%) infected with gonorrhea develop symptoms that drive them to seek testing and treatment. In comparison, ~60% of males infected with chlamydia develop symptoms
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

25. Minnesota Department of Health
Gonorrhea Rates by Age Minnesota,
As with chlamydia, adolescents and young adults have the highest rates of gonorrhea.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

26. Age-Specific Gonorrhea Rates by Gender Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

27. Minnesota Department of Health
Gonorrhea Rates by Race/Ethnicity Minnesota,
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

28. Minnesota Department of Health
Gonorrhea Rates by Race/Ethnicity Excluding Blacks Minnesota,
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

29. Prevalence of QRNG in Minnesota by Mode of Transmission, 2002 - 2008 †
Minnesota Department of Health
Prevalence of QRNG in Minnesota by Mode of Transmission, †
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

30. Minnesota Department of Health
SYPHILIS
STDs in Minnesota: Annual Review

31. Syphilis Rates by Stage of Diagnosis Minnesota, 1998-2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

32. Minnesota Department of Health
2 cases from Anoka
3 cases from Dakota
41 cases from Hennepin
8 cases from Ramsey
1 case each from Chisago, Clay, Rice, and Washington
1 case with unknown residence
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

33. Minnesota Department of Health
Primary & Secondary Syphilis Infections in Minnesota by Residence at Diagnosis, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

34. Minnesota Department of Health
Primary & Secondary Syphilis Rates by Gender Minnesota,
Historically, rates have been similar among males and females.
In 2001, the P&S rate among women increased, driven by an increase among Black women. The increase did not continue into 2002 and the female rate decreased to previous levels.
In 2002 the P&S rate among men increased dramatically (3 fold) due to an increase among MSM. The rate continues to increase in 2003 (see Emerging Trend).
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

35. Minnesota Department of Health
Primary & Secondary Syphilis Rates by Age Minnesota,
Unlike chlamydia and gonorrhea, syphilis rates are highest among adults.
The most recent increases (among Black women in 2001 and MSM in 2002) have occurred primarily among year olds.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

36. Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

37. Minnesota Department of Health
Primary & Secondary Syphilis Cases by Race Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

38. Minnesota Department of Health
Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota,
Syphilis rates are highest among Blacks. In 1999, at its lowest rate over the past decade, the rate among Blacks was 21 times higher than the rate among Whites.
Although it has decreased sharply over the past decade, the rate among Blacks increased in 2000 and The increase was primarily among women and was associated with crack use. The Black rate dropped in 2002 as the number of cases among women decreased by 50%.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

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

40. Minnesota Department of Health
Chlamydia Disproportionately Impacts Youth
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

41. Minnesota Department of Health
Gonorrhea Disproportionately Impacts Youth
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

42. Minnesota Department of Health
Characteristics of Adolescents & Young Adults† Diagnosed With Chlamydia or Gonorrhea in 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

43. Minnesota Department of Health
Characteristics of Adolescents & Young Adults† Diagnosed With Chlamydia or Gonorrhea in 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

44. Minnesota Department of Health
Chlamydia Rates Among Adolescents & Young Adults† by Gender in Minnesota,
The rate is 2.5 times higher among females than males, largely due to a higher level of chlamydia screening among women.
STD Prevalence Study data show almost equal percent positives by gender (11% F, 9% M)
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

45. Chlamydia — Positivity Rates by Age and Gender MIPP† Clinics, 2002-2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

46. Minnesota Department of Health
Chlamydia Cases Among Adolescents and Young Adults† by Gender and Race, Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

47. Chlamydia Rate Among Adolescents and Young Adults† by Race, Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review
Numbers above bars indicate female to male rate ratio

48. Chlamydia — Positivity Rates Among 15-24 Year-olds by Race MIPP† Clinics, 2003-2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

49. Minnesota Department of Health
Gonorrhea Rates Among Adolescents & Young Adults† by Gender in Minnesota,
The rate is 2.5 times higher among females than males, largely due to a higher level of chlamydia screening among women.
STD Prevalence Study data show almost equal percent positives by gender (11% F, 9% M)
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

50. Gonorrhea — Positivity Rates by Age and Gender MIPP† Clinics, 2003-2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

51. Minnesota Department of Health
Gonorrhea Cases Among Adolescents and Young Adults† by Gender and Race, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

52. Gonorrhea Rate Among Adolescents and Young Adults† by Race, Minnesota, 2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

53. Gonorrhea — Positivity Rates Among 15-24 Year-olds by Race MIPP† Clinics, 2003-2008
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

54. Summary of Chlamydia and Gonorrhea Among Adolescents and Young Adults†, Minnesota, 2008
Adolescents and young adults accounted for 69% of chlamydia and 59% 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 39% and 34% of chlamydia or gonorrhea cases, respectively.
36% of gonorrhea or chlamydia cases were in the Cities of Minneapolis and Saint Paul.
† Adolescents defined as year-olds; Young Adults defined as year-olds.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

55. Minnesota Department of Health
Topics of Interest:
Early Syphilis Among MSM
Continuing Increase of Chlamydia
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review
STDs in Minnesota: Annual Review

56. Minnesota Department of Health
Early Syphilis Among
Men Who Have Sex With Men
in Minnesota
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review
STDs in Minnesota: Annual Review

57. Minnesota Department of Health
Number of Early Syphilis† Cases by Gender Minnesota,
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

58. Minnesota Department of Health
Early Syphilis† Cases by Stage at Diagnosis Minnesota,
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

59. Early Syphilis† by Gender and Sexual Behavior Minnesota, 2001-2008
Minnesota Department of Health
Early Syphilis† by Gender and Sexual Behavior Minnesota,
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

60. Early Syphilis† Cases Among MSM by Age Minnesota, 2008 (n=140)
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

61. Characteristics of Early Syphilis† Cases Among MSM, Minnesota, 2008
Minnesota Department of Health
Characteristics of Early Syphilis† Cases Among MSM, Minnesota, 2008
Gay and bisexual men account for 89% of cases among men.
81% of cases among MSM are White, but a disproportionate number of cases (13%) are African American.
70% of cases live in Hennepin County, and 49% in the City of Minneapolis.
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.
MSM=Men who have sex with men
† Early Syphilis includes primary, secondary, and early latent stages of syphilis.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

62. What’s Being Done in Minnesota?
Minnesota Department of Health
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). SEP 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:
Physicians are encouraged to screen men who have sex with men at least annually and to ask about sex partners.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review
STDs in Minnesota: Annual Review

63. Minnesota Department of Health
Continuing Increase of Chlamydia
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review
STDs in Minnesota: Annual Review

64. Minnesota Department of Health
Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis,
Chlamydia is the most commonly reported bacterial STD.
The chlamydia rate decreased between , then increased markedly in The rate increase from occurred across demographic groups (gender, age, race/ethnicity) and could be due to one or more of the following:
Increased sensitivity of diagnostic tests (switch from EIA to LCX or other DNA-amplification test)
Increased screening
Real increase in disease incidence
The chlamydia rate increased by 21% between Part of that increase (at least 1/3) was a result of active surveillance activities initiated in January 2002 that improved completeness of reporting.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

65. Chlamydia Rates in Minnesota, 1996-2008
Minnesota Department of Health
Chlamydia Rates in Minnesota,
From its lowest point in 1996, the incidence rate of chlamydia infection has more than doubled from 115 to 292 per 100,000 persons. In 2008 the rate increased by 7%.
The rate tripled among men (54 to 168) and more than doubled among women (175 to 413).
Rates more than tripled among year-olds and year-olds.
Rates among year-olds increased by 1.8 times (640 to 1,164) and rates among year-olds tripled (567 to 1,715).
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 91% and 88%, respectively.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

66. What’s Behind the Increase?
Minnesota Department of Health
What’s Behind the Increase?
The observed increase since 1996 is most likely due to combination of factors including:
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.
STDs in Minnesota: Annual Review
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

67. Minnesota Department of Health
SURVEILLANCE SUMMARY

68. Summary of STD Trends in Minnesota
Minnesota Department of Health
Summary of STD Trends in Minnesota
From , the chlamydia rate doubled while the gonorrhea rate fluctuated but increased slightly.
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 in recent years the rates of chlamydia and gonorrhea increased the most in the Twin Cities suburbs and Greater Minnesota.
Adolescents and young adults (15-24 years) have the highest rates of chlamydia and gonorrhea, making up 67% of new infections in 2008.
Between 2007 and 2008, the chlamydia rate increased by 7% while the gonorrhea rate fell by 12%. Primary/secondary syphilis cases increased by 87% among men who have sex with men, who comprised 89% of all male cases in 2008; cases among women remain low.
Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review