1. Sexually Transmitted Disease (STD) Surveillance Report, 2004 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 2004 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 HIV/AIDS in Minnesota: Annual Review

6. United States: State-Specific Chlamydia Rates, 2003 SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2003 Surveillance Slides. STDs in Minnesota: Annual Review

7. United States: State-Specific Gonorrhea Rates, 2003 STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2003 Surveillance Slides.

8. United States: State-Specific P&S Syphilis Rates, 2003 STDs in Minnesota: Annual Review SOURCE: Centers for Disease Control & Prevention, Division of STD Prevention. 2003 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, 1994-2004 † * P&S = Primary and Secondary. † While P&S syphilis numbers decreased in 2004, first quarter numbers for 2005 indicate an increase back to 2003 levels.

11. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review STDs in Minnesota: Number of Cases Reported in 2004 Total of 14,703 STD cases reported to MDH in 2004:  11,601 Chlamydia cases  2,957 Gonorrhea cases  145 Syphilis cases (all stages)

12. CHLAMYDIA STDs in Minnesota: Annual Review

13. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Rate per 100,000 persons > 300 151 - 300 76 - 150 0 - 75 2004 Minnesota Chlamydia Rates by County City of Minneapolis 886 City of St. Paul 639 Suburban # 168 Greater Minnesota 149 (407 cases missing residence information) # 7-county metro area, excluding the cities of Minneapolis and St. Paul 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 FillmoreMower Crow Wing Nobles Murray Grant Sibley Brown Lake of the Woods Rock Redwood Douglas Kandiyohi Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Lincoln Blue Earth Scott Stevens Anoka Houston Steele Dodge Traverse Nicollet McLeod Hennepin Lac qui Parle Chippewa Benton Wabasha Carver Pennington Big Stone Cottonwood Waseca Le Sueur Yellow Medicine Red Lake Sherburne Watonwan Clearwater Mille Lacs Wadena Kanabec Chisago Mahnomen Pipestone Washington Ramsey

14. 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. Chlamydia Infections in Minnesota by Residence at Diagnosis, 2004 Total Number = 11,601 (407 missing residence information)

15. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Gender Minnesota, 1994-2004

16. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Age Minnesota, 1994-2004

17. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Rates by Race/Ethnicity Minnesota, 1994-2004 * 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, 1994-2004 * Persons of Hispanic ethnicity can be of any race.

19. GONORRHEA STDs in Minnesota: Annual Review

20. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 2004 Minnesota Gonorrhea Rates by County Rate per 100,000 persons > 100 20 - 100 0 -19 City of Minneapolis 276 City of St. Paul 190 Suburban # 40 Greater Minnesota 21 (96 missing residence information) # 7-county metro area, excluding the cities of Minneapolis and St. Paul 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 FillmoreMower Crow Wing Nobles Murray Grant Sibley Brown Lake of the Woods Rock Redwood Douglas Kandiyohi Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Lincoln Blue Earth Scott Stevens Anoka Houston SteeleDodge Traverse Nicollet McLeod Hennepin Lac qui Parle Chippewa Benton Wabasha Carver Pennington Big Stone Cottonwood Waseca Le Sueur Yellow Medicine Red Lake Sherburne Watonwan Clearwater Mille Lacs Wadena Kanabec Chisago Mahnomen Pipestone 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, 2004 Total Number = 2,957 (96 missing residence information)

22. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Gender Minnesota, 1994-2004

23. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Age Minnesota, 1994-2004

24. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates by Race/Ethnicity Minnesota, 1994-2004 * 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, 1994-2004 * Persons of Hispanic ethnicity can be of any race.

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

27. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review 2004 Minnesota P&S Syphilis Rates by County Rate per 100,000 persons > 1.0 0.21 – 1.0 0 – 0.2 City of Minneapolis 4.2 City of St. Paul 1.0 Suburban # 0.4 Greater Minnesota 0.0 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 FillmoreMower Crow Wing Nobles Murray Grant Sibley Brown Lake of the Woods Rock Redwood Douglas Kandiyohi Jackson Meeker Goodhue Winona Isanti Faribault Dakota Freeborn Olmsted Lincoln Blue Earth Scott Stevens Anoka Houston Steele Dodge Traverse Nicollet McLeod HennepinLac qui Parle Chippewa Benton Wabasha Carver Pennington Big Stone Cottonwood Waseca Le Sueur Yellow Medicine Red Lake Sherburne Watonwan Clearwater Mille Lacs Wadena Kanabec Chisago Mahnomen Pipestone Washington Ramsey # 7-county metro area, excluding the cities of Minneapolis and St. Paul

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, 2004 Total Number = 27

29. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates † by Age Minnesota, 1994-2004 † While P&S syphilis numbers decreased in 2004, first quarter numbers for 2005 indicate an increase back to 2003 levels.

30. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary &Secondary Syphilis Rates by Gender Minnesota, 1994-2004

31. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 1994-2004 * 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, 1997-2004 * Persons of Hispanic ethnicity can be of any race.

33. ADOLESCENTS & YOUNG ADULTS 15-19 year olds 20-24 year olds STDs in Minnesota: Annual Review

34. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia Cases in 2004 (n = 11,601) 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 2004 (n = 2,957)

36. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of adolescents & young adults diagnosed with chlamydia or gonorrhea in 2004 (n=9,089) Cases% of Total Male2,068 23% Female7,02077% Transgender 1< 1% White3,88643% Black2,55728% Am Indian 3294% Asian/PI 2533% Other/Unknown2,06423%

37. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Characteristics of adolescents & young adults diagnosed with chlamydia or gonorrhea in 2004 (Continued) Cases% of Total Hispanic 5666% Non-Hispanic5,06956% Unknown3,45438% Minneapolis2,07123% St. Paul1,46516% Suburban MN2,45627% Greater MN2,78131% Unknown 3163% 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, 1994-2004

39. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Gonorrhea Rates for Adolescents & Young Adults by Gender in Minnesota, 1994-2004

40. EMERGING TRENDS: -Drug Resistant Gonorrhea -Syphilis among MSM -Chlamydia Rate Double since 1996 EMERGING TRENDS: -Drug Resistant Gonorrhea -Syphilis among MSM -Chlamydia Rate Double since 1996 STDs in Minnesota: Annual Review

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

42. 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

43. 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) CDC recommends non-quinolone therapy for infections acquired in HI, CA, and other areas with high QRNG prevalence 2004 Prevalence of QRNG in MN five times higher than in 2002

44. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG in Minnesota, 1999 - 2004 Year# Resistant Isolates# Isolates TestedQRNG Prevalence 1999-200101,3650% 200242681.5% 200353631.4% 2004283338.4%

45. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Prevalence of QRNG Among Male GISP † Participants by Mode of Transmission in Minnesota, 2002 - 2004 Gay/BisexualHeterosexual Year# Resistant# TestedPrevalence# Resistant# TestedPrevalence 20020380.0%11520.7% 20034458.9%11680.6% 2004186726.9%41772.2% † The Gonococcal Isolate Surveillance Project (GISP) is a sentinel surveillance system established by the CDC to monitor antimicrobial resistance in Gonorrhea among males. The Red Door Clinic in Minneapolis is one of the participating clinics. The data shown has been collected through this project.

46. Characteristics of the 2004 QNRG cases (n = 28) 71% 0f the cases were White 32% of cases (9) were among men under 30 years of age, the average age for cases was 32.5 years 22 of the 28 cases (79%) were among gay/bisexual males Eighteen percent of cases among gay/bisexual males were also HIV+ A majority of cases reported having multiple sex partners in the previous 60 days Two of the cases reported travel and sexual activity in areas with high QNRG prevalence (Philippines and Hawaii)

47. What’s Being Done in Minnesota? MDH has expanded the current QRNG surveillance system to include women and Room 111 in St. Paul MDH will use the data to guide future treatment recommendations Healthcare providers are encouraged to obtain travel histories of patients and to be alert for treatment failures. Gonorrhea infections acquired in areas with high QRNG prevalence and among MSM should receive non-quinolone therapy Clinicians and laboratories are asked to report suspected treatment failures and resistant gonococcal isolates to MDH MDH Partner Services Program follows up on cases and sex partners

48. Syphilis among Gay/Bisexual Men in Minnesota Syphilis among Gay/Bisexual Men in Minnesota STDs in Minnesota: Annual Review

49. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Early Syphilis Cases by Stage at Diagnosis Minnesota, 1994-2004

50. 48 early syphilis cases diagnosed in 2004, compared with: 92 cases in 2003 82 cases in 2002 49 cases in 2001 34 cases among gay/bisexual men in 2004, compared with: 71gay/bisexual men in 2003 56 gay/bisexual men in 2002 5 gay/bisexual men in 2001 Characteristics of the 2004 gay/bisexual male cases (n=34): 80% White 71% live in Hennepin County Average age = 37 32% HIV+ * Early Syphilis includes primary, secondary, and early latent stages of syphilis. Early Syphilis* among Gay/Bisexual Men Minnesota, 2001-2004

51. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review While the number of cases in 2004 decreased, first quarter data for 2005 indicate an increase back to 2003 levels Despite the decrease in 2004, cases among MSM remain high compared to 2001 (34 versus 5) MSM accounted for 81% of cases among males Internet was the most common venue for meeting partners (78%) Among MSM, most reported having anonymous sex (81%), and of these 41% reported no condom use Early Syphilis* among Gay/Bisexual Men Minnesota, 2004 * Early Syphilis includes primary, secondary, and early latent stages of syphilis.

52. What’s Being Done in Minnesota? MDH is continuing 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 has implemented innovative prevention strategies (e.g., internet banners, partnering with venues) MDH Partner Services Program continues to follow up on cases and sex partners

53. Doubling of the Chlamydia Rate Since 1996 STDs in Minnesota: Annual Review

54. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis, 1994-2004 115 per 100,000 236 per 100,000

55. Chlamydia Rates in Minnesota, 1996-2004 Since 1996 the rate of Chlamydia infection has doubled from 115 to 236 per 100,000 The rate has doubled both among men (54 to 126) and women (175 to 343) Rates have almost tripled among 25-29 year olds (214 to 597) and among 30-39 year olds (56 to 156) Among 15-19 year olds rates have increased 1½ times (640 to 968) and among 20-24 year olds rates have doubled (567 to 1372)

56. Chlamydia Rates in Minnesota, 1996-2004 Rates have also increased by race, doubling among Hispanics, Whites and Asian/Pacific Islanders In this time period, the chlamydia rate for Blacks and American Indians increased by 32% and 60%, respectively Rates have also increased by geography with the most marked increases happening in Greater Minnesota and the suburban 7- county metro area In both areas the rate more than doubled, compared to an increase of 25% in Minneapolis and 64% in St. Paul

57. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review What’s Behind the Increase? 1.Improved testing technology with increased sensitivity 2.Improved screening practices by clinicians 3.Addition of active surveillance component 4.Increase of the disease in the population However, the effect of the first three factors would have leveled off over time so the increase is most likely being driven by an actual increase of the disease in the population. The observed increase since 1996 is most likely due to the combination of four factors:

58. SURVEILLANCE SUMMARY

59. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review Summary of STD Trends in Minnesota Between 2003-2004, the overall chlamydia rate increased while rates of gonorrhea and early syphilis decreased STD rates continue to be 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 While the number of early syphilis cases is down, the numbers among gay/bisexual men are continue to be high Prevalence of antibiotic-resistant gonorrhea has increased five fold between 2002 and 2004