1. Sexually Transmitted Disease (STD) Surveillance Report, 2008 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, 2007 (National Rate = 370.2 per 100,000)

8. United States: State-Specific Gonorrhea Rates, 2007 (National Rate = 118.9 per 100,000) STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2007 Surveillance Slides.

9. United States: State-Specific P&S Syphilis Rates, 2007 (National Rate = 3.8 per 100,000) STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2007 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, 1998-2008 * 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 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

13. CHLAMYDIA STDs in Minnesota: Annual Review

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

15. Chlamydia Infections by Residence at Diagnosis Minnesota, 2008

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 1998-2008

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 1998-2008

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

19. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 1998-2008

20. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Excluding Blacks Minnesota, 1998-2008

21. GONORRHEA STDs in Minnesota: Annual Review

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

23. Gonorrhea Infections in Minnesota by Residence at Diagnosis, 2008

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 1998-2008

25. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 1998-2008

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

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 1998-2008

28. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Excluding Blacks Minnesota, 1998-2008

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

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, 1998-2008

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

33. Primary & Secondary Syphilis Infections in Minnesota by Residence at Diagnosis, 2008

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Gender Minnesota, 1998-2008

35. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Age Minnesota, 1998-2008

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

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

38. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 1998-2008

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 2008

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

44. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates Among Adolescents & Young Adults † by Gender in Minnesota, 1998-2008

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

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

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

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

49. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates Among Adolescents & Young Adults † by Gender in Minnesota, 1998-2008

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

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

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

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

54. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 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 15-19 year-olds; Young Adults defined as 20-24 year-olds.

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

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

57. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Number of Early Syphilis † Cases by Gender Minnesota, 2001-2008

58. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis † Cases by Stage at Diagnosis Minnesota, 2001-2008

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

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

61. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 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. Characteristics of Early Syphilis † Cases Among MSM, Minnesota, 2008 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.

62. 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. 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: 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. STDs in Minnesota: Annual Review

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

64. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis, 1992-2008

65. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates in Minnesota, 1996-2008 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 25-29 year-olds and 30-39 year-olds. Rates among 15-19 year-olds increased by 1.8 times (640 to 1,164) and rates among 20-24 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.

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

67. SURVEILLANCE SUMMARY

68. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota From 1998-2008, 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.