1. Sexually Transmitted Disease Epidemiology in North Dakota Chlamydia, Gonorrhea, Hepatitis C, Syphilis and HIV Lindsey VanderBusch STD/HIV/TB/Hepatitis Program Manager Sarah Weninger, MPH Viral Hepatitis and STD Program Coordinator

3. Reported Chlamydia by Sex North Dakota, 2012 -2013

4. Reported Cases of Chlamydia by Age Group North Dakota, 2012 -2013

5. Chlamydia Rates by Race/Ethnicity North Dakota, 2012 - 2013 *Person of Hispanic ethnicity may be of any race; 22% of Chlamydia cases have unknown race

6. 2012 Chlamydia: Geographic Map

7. 2013 Chlamydia: Geographic Map

8. Changes from 2012-2013; Chlamydia

9. Chlamydia Follow-Up Conduct Partner Services for Cases who are <14 years, pregnant or who have PID Patient Dispositions ▫A. Infectious Brought to Treatment  2798 (95%) ▫B. Infectious No Treatment  131 (5%): 6% American Indian, 15% White, 79% Unknown Race

11. Reported Gonorrhea by Sex North Dakota, 2012 - 2013

12. Reported Cases of Gonorrhea by Age Group; North Dakota, 2012 – 2013

13. Gonorrhea Rates by Race/Ethnicity North Dakota, 2012 - 2013 *Person of Hispanic ethnicity may be of any race For 2013, 15.6% of GC Cases have unknown race

14. Gonorrhea Rates by Race, 2009-2013

15. GC Rate by County, 2009-2013

16. 2012 Gonorrhea – ND Map

17. 2013 Gonorrhea – ND Map

18. Changes from 2012-2013

19. Gonorrhea Follow-Up Field Staff Conduct Investigations on all GC Cases Patient Dispositions ▫A. Infectious Brought to Treatment  407 (84.4%) ▫B. Infectious No Treatment  75 (15.6%): 3% Black, 5% American Indian, 11% White, 81% Unknown Race

21. 2013* Syphilis is North Dakota 13 Primary & Secondary Cases ▫2 Females, 11 Males ▫7 American Indians, 3 White, 2 Black, 1 Asian 13 Latent Cases

22. 2012 Syphilis – ND Map – Early and Latent Syphilis

23. 2013 Syphilis – ND Map – Early and Latent Syphilis

24. Changes from 2012-2013

25. Syphilis Outbreak, ND-SD 2013-14

28. Enhanced Screening Recommendations All high-risk pregnant women in North Dakota should be screened for syphilis at least three times during the course of pregnancy. This recommendation is made by CDC for areas experiencing high syphilis morbidity. Currently Sioux County in North Dakota qualifies as an area with high syphilis morbidity. ▫Screen 1 should occur at a patient’s first prenatal visit; ▫Screen 2 should occur in the third trimester (between 28-32 weeks) and ▫Screen 3 should occur on the day of delivery. Three screens are essential, even if the first screen is negative. If a woman tests positive, refer to the Treatment Guidelines (link below) for information on treating both mother and child. Any woman who delivers a stillborn infant after 20 weeks gestation should be tested for syphilis, regardless of risk. No infant should leave the hospital without the serological status of the mother having been determined at least once during pregnancy. Treatment Guidelines All persons that have a positive Chlamydia or Gonorrhea test or Residents of Sioux County, between the ages of 15 and 50 who are sexually active or Patients who have sexual partners from Sioux County or Men who have sex with men or All patients with ano-genital lesions or All patients with oral lesions suggestive of a primary syphilitic chancre or All patients presenting with a rash, especially palmar or plantar rashes,alopecia or gummatous lesions Patients with neurological signs or symptoms of unknown cause and syphilis has not yet been ruled out.

29. Syphilis Testing RPR—non-treponmal test ▫Followed by antibody titer  Example (1:32 or 1:128) FTA or TP-PA—treponmal ▫Syphilis is confirmed Quantitative RPRRPR +FTA FTA + Syphilis (Past or Present) FTA - Syphilis Unlikely RPR -

30. Syphilis Treatment Benzathine penicillin G (i.e., Bicillin, LA™) remains the preferred treatment for syphilis. Stage of SyphilisRecommended Treatment Primary, Secondary & Early Latent 1 dose of Benzathine Penicillin G, 2.4 million units IM Latent Syphilis > 1 year duration or of unknown duration Benzathine Penicillin G, 7.2 million units total, administered as three doses of 2.4 million units IM each at one-week intervals Tertiary Syphilis Benzathine Penicillin G, 7.2 million units total, administered as three doses of 2.4 million units IM each at one-week intervals Neurosyphilis Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every four hours or continuous infusion for 10 to14 days Syphilis in Pregnancy Pregnant women should be treated with penicillin appropriate for their stage of infection. Pregnant women with penicillin allergy will need to undergo a penicillin desensitation protocol. For more information, please contact the North Dakota Department of Health. Congenital SyphilisTreatment of the baby is dependent on multiple factors. Please consult with the North Dakota Department of Health for the most appropriate protocol for the given situation.

31. Syphilis Staging Primary ▫Primary lesion or chancre ▫Often painless ▫Chancre is contagious Secondary ▫Usually presents as a rash that may take on several different appearances.  The rash may appear as rough, red or reddish brown spots may be found on the palms of the hand or the soles of the feet and usually does not cause itching.  “Great imitator” ▫Fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches and fatigue. Latent Stages ▫Usually asymptomatic Visual Case Analysis done to determine evaluation of sex partners based on staging done by ND DIS.

32. Syphilis Treatment cont. Non-pregnant persons infected with syphilis in whom penicillin is contradicted can be treated with alternative regimens, depending on the stage of syphilis diagnosed. Alternative regimens consist of oral doxycycline or tetracycline and require two to four weeks of treatment. Compliance with these regimens must be monitored. Sexual Contacts: ▫For the management of sexual contacts of infected individuals, testing and treatment depends on the stage of the index case. ▫Presumptive treatment, along with testing, should be given to persons exposed to primary, secondary, early latent syphilis or to those exposed to individuals with latent syphilis of unknown duration with high titers (i.e. 1:32). ▫Partners exposed to an unknown stage of syphilis should be tested and treated presumptively. Long-term sex partners of patients who have latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation findings.

33. Reported Hepatitis C Cases* by Year North Dakota, 2009-2013 * Includes acute and “past or present” infections

34. North Dakota Hepatitis C Cases* by Gender, 2012 - 2013 * Includes acute and “past or present” infections

35. North Dakota Hepatitis C Cases* by Age Group, 2012 - 2013 * Includes acute and “past or present” infections

36. North Dakota Hepatitis C Cases* by Race, 2012 - 2013 * Includes acute and “past or present” infections

37. HIV in North Dakota, 2009 - 2013

38. Living in North Dakota with HIV/AIDS, n=357

39. Living in North Dakota by Gender, n=357

40. Number Living in North Dakota by Age, n=357

41. Living in North Dakota by Race/Ethnicity, n=357

42. Living in North Dakota by Risk Factor n=357

43. 2009 – 2013 HIV/AIDS Status at Time of Diagnosis in ND

44. 2009-2013 Gender of Cases at Time of Diagnosis in ND

45. 2009 – 2013; Risk Factor by Gender

46. 2009 – 2013: Male Risk Factors by Race

47. 2009 – 2013: Female Risk Factors by Race

48. 2009-2013: Race/Ethnicity of HIV/AIDS Cases

49. 2009-2013: Disparity by Race

50. HIV CTR Data 2013 4133 Tested: 81.5% White, 7.5% American Indian ▫White: 56% of Total Number Tested were Female ▫American Indian: 63% of Total Number Tested were Female Risk Factors ▫Injection Drug Use: 5.9% Whites; 16.6% American Indian ▫Had Sex Without a Condom: 90% Whites, 90% American Indian ▫Had Sex with Anonymous Partners: 13% Whites, 17% American Indians ▫MSM: 17% of White Males; 8% of American Indian Males

51. Program Contact Information Sarah Weninger, MPH ▫Viral Hepatitis and STD Program Coordinator ▫sweninger@nd.gov; 701.328.2366sweninger@nd.gov Lindsey VanderBusch ▫STD/TB/HIV/Hepatitis Program Manager ▫lvanderbusch@nd.gov; 701.328.4555lvanderbusch@nd.gov Dee Pritschet ▫TB and HIV Surveillance Coordinator ▫djpritschet@nd.gov; 701.328.2377djpritschet@nd.gov