1. Sexually Transmitted Disease (STD) Surveillance Report, 2009 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. National Context STDs in Minnesota: Annual Review

7. SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2007 Surveillance Slides. United States: State-Specific Chlamydia Rates, 2008 (National Rate = 401.3 per 100,000)

8. United States: State-Specific Gonorrhea Rates, 2008 (National Rate = 111.6 per 100,000) STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2008 Surveillance Slides.

9. United States: State-Specific P&S Syphilis Rates, 2008 (National Rate = 4.5 per 100,000) STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2008 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, 1999-2009 * 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 2009 Total of 16,702 STD cases reported to MDH in 2009:  14,186 Chlamydia cases  2,302 Gonorrhea cases  214 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

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, 2009

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 1999-2009

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 1999-2009

18. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Chlamydia Rates by Gender Minnesota, 2009

19. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 1999-2009 * 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 Minnesota, 1999-2009 * 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, 2009

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 1999-2009

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 1999-2009

26. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Gonorrhea Rates by Gender Minnesota, 2009

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 1999-2009 * 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 Minnesota, 1999-2009 * Persons of Hispanic ethnicity can be of any race.

29. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Quinolone-Resistant Neisseria gonorrhoeae in Minnesota MDH routinely tracked fluoroquinolone resistance in gonorrhea isolates from 1999 – 2008 through the Gonococcal Isolate Surveillance Program (GISP) and continues limited resistance testing. Resistance to ciprofloxacin increased from 0% of isolates among MSM in 1999 to a peak of 28% in 2007. The proportion then decreased in 2008 to 15%. Among heterosexuals, ciprofloxacin resistance increased from 0% of isolates in 1999 to 5% in 2008. As of April 12, 2007 fluoroquinolones were no longer recommended for the treatment of gonorrhea †. † Centers for Disease Control and Prevention.[Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections]. MMWR 2007;56:[332-336].

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, 1999-2009 * P&S = Primary and Secondary

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

33. 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, 2009

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Gender Minnesota, 1999-2009

35. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Age Minnesota, 1999-2009

36. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2009 *0 primary/secondary female syphilis cases were reported in 2009.

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, 2009

38. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 1999-2009 * 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 Disproportionately Impacts Youth

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

42. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of Adolescents & Young Adults † Diagnosed With Chlamydia or Gonorrhea in 2009

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 2009 † 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, 1999-2009 † 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, 2002-2009 † 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, 2009 † 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, 2009 † 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, 2002-2009 † 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, 1999-2009 † 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,1999-2009

51. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Cases Among Adolescents and Young Adults † by Gender and Race, 2009 † 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, 2009 † 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, 2002-2009 † 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, 2009 Adolescents and young adults accounted for 69% of chlamydia and 60% 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 33% of chlamydia or gonorrhea cases, respectively. 34% 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 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 STDs in Minnesota: Annual Review

56. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases by Gender Minnesota, 2001-2009

57. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases by Stage at Diagnosis Minnesota, 2001-2009

58. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † by Gender and Sexual Behavior Minnesota, 2001-2009

59. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases Among MSM by Age Minnesota, 2009 (n=96)

60. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of Early Syphilis † Cases Among MSM, Minnesota, 2009

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

62. SURVEILLANCE SUMMARY

63. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota From 1999-2009, the chlamydia rate increased by 88% while gonorrhea decreased to the lowest reported rate for the past decade. Rates of reported chlamydia, gonorrhea and syphilis decreased in 2009 compared to 2008. 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 63% of the reported cases in 2009. Adolescents and young adults (15-24 years) have the highest rates of chlamydia and gonorrhea, making up 67% of new infections in 2009. Between 2008 and 2009, the chlamydia rate decreased by 2% while the gonorrhea rate fell by 24%. Primary/secondary syphilis cases decreased by 37% among men who have sex with men, who comprised 91% of all male cases in 2009; cases among women remain low.