1. Sexually Transmitted Disease (STD) Surveillance Report, 2003 Minnesota Department of Health STD Surveillance System Minnesota Department of Health STD Surveillance System

2. Introduction This slide set describes new cases of chlamydia, gonorrhea, and syphilis in Minnesota by person, place, and time. The slides display data from cases diagnosed through 2003 and reported to the Minnesota Department of Health (MDH) STD Surveillance System. Data analyses exclude federal and private prisoners.

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.

4. Interpreting STD Surveillance Data Factors that impact the completeness and accuracy of the data include:  Level of STD screening and individual test-seeking behavior  Sensitivity of diagnostic tests  Compliance with 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 factors described above. For example, in 2002 MDH added an active component to the previously passive STD Surveillance System. As a result, compliance with reporting improved and the number of chlamydia and gonorrhea cases reported to MDH increased by at least 7% and 5%, respectively, between 2001 and 2002 as an artifact of reporting.

5. National Context

6. United States: State-Specific Chlamydia Rates, 2002 SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2002 Surveillance Slides. STDs in Minnesota: Annual Review

7. United States: State-Specific Gonorrhea Rates, 2002 STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2002 Surveillance Slides.

8. United States: State-Specific P&S Syphilis Rates, 2002 STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2002 Surveillance Slides.

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

10. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota Rate per 100,000 by Year of Diagnosis, 1993-2003 * P&S = Primary and Secondary

11. STDs in Minnesota: Number of Cases Reported in 2003 Total of 14,111 STD cases reported to MDH in 2003:  10,714 Chlamydia cases  3,202 Gonorrhea cases  195 Syphilis cases (all stages)

12. CHLAMYDIA STDs in Minnesota: Annual Review

13. Rate per 100,000 persons > 300 151 - 300 76 - 150 0 - 75 2003 Minnesota Chlamydia Rates by County City of Minneapolis 755 City of St. Paul 618 Suburban 156 Greater Minnesota 131 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. St. Louis Cook Lake Itasca Cass Polk Beltrami Aitkin Pine Koochiching Otter Tail Clay Roseau Marshall Becker Todd Stearns Kittson Swift Lyon Pope Morrison Wilkin Renville Carlton Martin Hubbard Rice Wright Norman Fillmore Mower Crow Wing Nobles Murray Grant Sibley Brown Clearwater Lake of the Woods Rock Redwood Douglas Kandiyohi Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Lincoln Blue Earth Scott Stevens Anoka Mille Lacs Houston SteeleDodge Traverse Wadena Nicollet McLeod Hennepin Kanabec Lac qui ParleChippewa Benton Wabasha Carver Pennington Big Stone Cottonwood Chisago Waseca Le Sueur Mahnomen Yellow Medicine Pipestone Red Lake Sherburne Watonwan Washington Ramsey

14. 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. Chlamydial Infections in Minnesota by Residence at Diagnosis, 2003 Total Number = 10,714 Minneapolis27% St. Paul 17% Greater MN 28% Suburban29%

15. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 1993-2003

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 1993-2003

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 1993-2003 * Persons of Hispanic ethnicity can be of any race.

18. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Excluding Blacks Minnesota, 1993-2003 * Persons of Hispanic ethnicity can be of any race.

19. GONORRHEA STDs in Minnesota: Annual Review

20. 2003 Minnesota Gonorrhea Rates by County Rate per 100,000 persons > 100 20 - 100 0 -19 City of Minneapolis 359 City of St. Paul 200 Suburban 40 Greater Minnesota 20 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. St. Louis Cook Lake Itasca Cass Polk Beltrami Aitkin Pine Koochiching Otter Tail Clay Roseau Marshall Becker Todd Stearns Kittson Swift Lyon Pope Morrison Wilkin Renville Carlton Martin Hubbard Rice Wright Norman Fillmore Mower Crow Wing Nobles Murray Grant Sibley Brown Clearwater Lake of the Woods Rock Redwood Douglas Kandiyohi Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Lincoln Blue Earth Scott Stevens Anoka Mille Lacs Houston SteeleDodge Traverse Wadena Nicollet McLeod Hennepin Kanabec Lac qui ParleChippewa Benton Wabasha Carver Pennington Big Stone Cottonwood Chisago Waseca Le Sueur Mahnomen Yellow Medicine Pipestone Red Lake Sherburne Watonwan Washington Ramsey

21. 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, 2003 Total Number = 3,202 Minneapolis43% St. Paul 18% Greater MN 14% Suburban25%

22. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 1993-2003

23. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 1993-2003

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 1993-2003 * Persons of Hispanic ethnicity can be of any race.

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Excluding Blacks Minnesota, 1993-2003 * Persons of Hispanic ethnicity can be of any race.

26. PRIMARY & SECONDARY SYPHILIS STDs in Minnesota: Annual Review

27. 2003 Minnesota P&S Syphilis Rates by County Rate per 100,000 persons > 4.0 0.21 – 4.0 0 – 0.2 City of Minneapolis 5.5 City of St. Paul 1.7 Suburban 0.8 Greater Minnesota 0.2 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. St. Louis Cook Lake Itasca Cass Polk Beltrami Aitkin Pine Koochiching Otter Tail Clay Roseau Marshall Becker Todd Stearns Kittson Swift Lyon Pope Morrison Wilkin Renville Carlton Martin Hubbard Rice Wright Norman Fillmore Mower Crow Wing Nobles Murray Grant Sibley Brown Clearwater Lake of the Woods Rock Redwood Douglas Kandiyohi Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Lincoln Blue Earth Scott Stevens Anoka Mille Lacs Houston SteeleDodge Traverse Wadena Nicollet McLeod Hennepin Kanabec Lac qui ParleChippewa Benton Wabasha Carver Pennington Big Stone Cottonwood Chisago Waseca Le Sueur Mahnomen Yellow Medicine Pipestone Red Lake Sherburne Watonwan Washington Ramsey

28. 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, 2003 Total Number = 47 Minneapolis45% St. Paul 11% Suburban34% GreaterMN 11% 11%

29. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Age Minnesota, 1993-2003

30. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary &Secondary Syphilis Rates by Gender Minnesota, 1993-2003

31. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 1993-2003 * Persons of Hispanic ethnicity can be of any race.

32. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 1997-2003 * Persons of Hispanic ethnicity can be of any race.

33. ADOLESCENTS & YOUNG ADULTS 15-19 year olds 20-24 year olds

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases in 2003 (n = 10,714) MN Population in 2000 (n = 4,919,479) Chlamydia disproportionately impacts adolescents & young adults

35. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea disproportionately impacts adolescents & young adults MN Population in 2000 (n = 4,919,479) Gonorrhea Cases in 2003 (n = 3,202)

36. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of adolescents & young adults diagnosed with chlamydia and/or gonorrhea in 2003 (n=8,692) Cases% of Total Male2,040 23% Female6,65277% White3,75343% Black2,67731% Am Indian 3044% Asian/PI 2743% Other/Unknown1,68419%

37. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of adolescents & young adults diagnosed with chlamydia and/or gonorrhea in 2003 (Continued) Cases% of Total Hispanic 5416% Non-Hispanic5,33461% Unknown2,81732% Minneapolis2,39728% St. Paul1,42116% Suburban MN2,41828% Greater MN2,45628% 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.

38. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates for Adolescents & Young Adults by Gender in Minnesota, 1993-2003

39. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates for Adolescents & Young Adults by Gender in Minnesota, 1993-2003

40. EMERGING TRENDS: - Resurgence of Syphilis - Drug Resistant Gonorrhea EMERGING TRENDS: - Resurgence of Syphilis - Drug Resistant Gonorrhea STDs in Minnesota: Annual Review

41. Resurgence of Syphilis among Gay/Bisexual Men in Minnesota Resurgence of Syphilis among Gay/Bisexual Men in Minnesota STDs in Minnesota: Annual Review

42. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis* Cases by Stage at Diagnosis Minnesota, 1993-2003 * Early Syphilis includes primary, secondary, and early latent stages of syphilis

43. 92 early syphilis cases diagnosed in 2003, compared with: 82 cases in 2002 49 cases in 2001 71 cases among gay/bisexual men in 2003, compared with: 56 gay/bisexual men in 2002 5 gay/bisexual men in 2001 Characteristics of the 2003 gay/bisexual male cases (n=71): 79% White 77% live in Hennepin County Average age = 37 42% HIV+ * Early Syphilis includes primary, secondary, and early latent stages of syphilis Increase in Early Syphilis* among Gay/Bisexual Men Minnesota, 2002-2003

44. Similar Increase in Syphilis among Gay/Bisexual Men in Other U.S. Cities Chicago Seattle (King County) Los Angeles New York City San Francisco Boston Miami Houston St. Louis Washington D.C. Baltimore Atlanta Ft. Lauderdale

45. What’s Being Done in Minnesota? MDH launching awareness campaigns (e.g., Health Notices, press releases) Encouraging physicians to screen gay/bisexual men at least annually Community-based programs intensifying outreach activities to reach gay/bisexual men MDH implementing innovative prevention strategies (e.g., internet banners, partnering with venues) MDH Partner Services Program following up on cases and sex partners

46. Increasing Prevalence of Drug-Resistant Gonorrhea in Minnesota STDs in Minnesota: Annual Review

47. Background Information CDC-recommended antibiotic treatments for gonorrhea:  Ceftriaxone  Single dose therapy, administered by injection  Relatively expensive  Cefixime  Single dose therapy, administered orally  Production discontinued in 2002; No longer available  Ciprofloxacin, Ofloxacin, Levofloxacin (Quinolones)  Single dose therapy, administered orally  Spread of quinolone-resistant N. gonorrhoeae (QRNG) threatens the efficacy of fluoroquinolones as the frontline treatment for gonorrhea

48. Prevalence of Quinolone-Resistant N. Gonorrhoeae ( QRNG) 2000 2001 2003 2002 1990s QRNG prevalent in Asia, >40% in some countries Hawaii discontinues use of fluoroquinolones following increase in QRNG prevalence from 1.4% in 1997 to 9.5% in 1999 California discontinues use of fluoroquinolones after reaching QRNG prevalence of 5% in 2001 Increases in QRNG reported in other U.S. states (e.g., MI, MA) especially among gay/bisexual men CDC recommends non-quinolone therapy for infections acquired in HI, CA, and other areas with high QRNG prevalence

49. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG in Minnesota Year# Resistant Isolates# Isolates TestedQRNG Prevalence 1999-200101,3650% 200242681.5% 200353631.4%

50. Implications of Increasing QRNG Options for treatment of gonorrhea will be essentially limited to one class of drugs (cephalosporins) Only two cephalosporins are currently recommended by CDC for treatment of gonorrhea: Cefixime and Ceftriaxone Cefixime is no longer available in the United States Ceftriaxone has to be administered via injection and is more expensive than quinolones

51. What’s Being Done in Minnesota? MDH is expanding the current QRNG surveillance system and will use the data to guide future treatment recommendations Healthcare providers are encouraged to:  Obtain travel histories of patients and their partners; Treat men/women who may have acquired gonorrhea in areas with high QRNG prevalence with non-quinolone therapy  Ask male patients about gender of sex partners; Treat gay/bisexual men infected with gonorrhea with non-quinolone therapy  Be alert for treatment failures Clinicians and laboratories are asked to report suspected treatment failures and resistant gonococcal isolates to MDH

52. SURVEILLANCE SUMMARY

53. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota Between 2002-2003, the overall chlamydia, gonorrhea, and early syphilis rates increased STD rates are highest in Minneapolis and St. Paul STD rates are highest among persons of color Chlamydia and gonorrhea rates are highest among adolescents and young adults; Syphilis rates are highest among adults MN continues to see a resurgence of early syphilis among gay/bisexual men; Approximately half are co-infected with HIV Prevalence of antibiotic-resistant gonorrhea is increasing