Sexually Transmitted Disease (STD)
Surveillance Report, 2003
Minnesota Department of Health
STD Surveillance System
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.
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.
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.
National Context
United States: State-Specific Chlamydia Rates, 2002
253.4
274.3
141.6
195.6
204.9
205.4
193.4
316.9
293.4
191.2
269.4
324.7
211.7
258.9
279.3
297.1
387.3 281.2
158.5
325.6
326.1
291.8
407.7
252.3
313.1
335.0
136.3 261.6
289.2
216.6
273.5
356.8
Guam 355.3
351.0
Rate per 100,000
population
415.3
333.4
412.7
607.1
156.7
126.0
171.9
270.1
288.0
168.3
338.1
318.9
307.2
282.0
414.8
VT
NH
MA
RI
CT
NJ
DE
MD
263.2
<=150.0
(n= 4)
150.1-300.0 (n= 29)
>300.0
(n= 20)
373.2
Puerto Rico 78.7
Virgin Is. 190.6
SOURCE:
Centers for Disease Control & Prevention, Division of STD Prevention. 2002 Surveillance Slides.
STDs in Minnesota: Annual Review
United States: State-Specific Gonorrhea Rates, 2002
49.6
13.6
11.1
11.2
26.6
62.0
7.3
118.2
34.8
13.2
115.1
148.6
50.6
108.2
91.4
99.5
72.6
81.6
74.0
193.8
193.5 121.6
16.7
80.4
102.1
135.1
53.9
160.0
147.8
93.3
171.5
228.1
Guam 31.7
227.5
Rate per 100,000
population
224.6
129.4
254.8
102.2
16.1
9.7
51.1
85.9
95.2
93.8
201.1
176.6
192.9
164.3
241.7
VT
NH
MA
RI
CT
NJ
DE
MD
133.6
<=19.0
(n= 9)
19.1-100.0 (n= 20)
>100.0
(n= 24)
61.1
Puerto Rico 10.8
Virgin Is. 45.1
SOURCE:
Centers for Disease Control & Prevention, Division of STD Prevention. 2002 Surveillance Slides.
STDs in Minnesota: Annual Review
United States: State-Specific P&S Syphilis Rates, 2002
1.2
0.0
0.2
0.0
0.8
1.2
0.6
0.6
0.0
0.0
2.5
4.9
0.3
0.9
0.4
0.8
0.3
3.0
3.9
1.5
3.9
0.7
2.1
2.1
1.0
1.4
0.1
0.6
1.0
2.2
1.3
3.3
Guam 3.9
3.4
Rate per 100,000
population
5.4
2.8
3.4
0.0
0.3
0.6
1.6
1.2
0.8
2.0
1.4
4.3
3.5
3.0
1.7
VT
NH
MA
RI
CT
NJ
DE
MD
3.9
<=0.2
0.21-4.0
>4.0
(n= 7)
(n= 42)
(n= 4)
0.9
Puerto Rico 7.1
Virgin Is. 0.9
SOURCE:
Centers for Disease Control & Prevention, Division of STD Prevention. 2002 Surveillance Slides.
STDs in Minnesota: Annual Review
Overview of STDs in Minnesota
STDs in Minnesota: Annual Review
STDs in Minnesota
Rate per 100,000 by Year of Diagnosis, 1993-2003
Gonorrhea
P&S* Syphilis
220
10
200
9
180
8
160
7
140
6
120
5
100
4
80
60
3
40
2
20
1
0
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
* P&S = Primary and Secondary
Data Source: Minnesota STD Surveillance System
Year
STDs in Minnesota: Annual Review
Rate of P&S Syphilis
Rate of Chlamydia and Gonorrhea
Chlamydia
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)
CHLAMYDIA
STDs in Minnesota: Annual Review
Kittson
Roseau
2003 Minnesota
Chlamydia Rates
by County
Lake of the Woods
Marshall
Koochiching
Pennington
Beltrami
Red Lake
Polk
Cook
Clearwater
St. Louis
Lake
Itasca
Norman
Mahnomen
Hubbard
Becker
Clay
Cass
Aitkin
Wadena
Wilkin
Carlton
Rate per 100,000 persons
Crow Wing
Otter Tail
Douglas
Stevens
Pope
0 - 75
76 - 150
Pine
Todd
Grant
Morrison
Mille Lacs Kanabec
Traverse
151 - 300
> 300
Benton
Stearns
Isanti
Big Stone
Swift
Anoka
Kandiyohi
Lac qui Parle
Hennepin Washington
Ramsey
McLeod
Carver
Renville
Dakota
Scott
Sibley
Lyon
Le Sueur
Rice
Wabasha
Brown
Murray
Rock
Nobles
Cottonwood Watonwan Blue Earth Waseca Steele Dodge
Jackson
755
618
156
131
Goodhue
Redwood
Nicollet
Pipestone
City of Minneapolis
City of St. Paul
Suburban
Greater Minnesota
Wright
Meeker
Chippewa
Yellow Medicine
Lincoln
Chisago
Sherburne
Martin
Faribault
Freeborn
Mower
Olmsted
Winona
Fillmore
Houston
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
Greater MN
28%
Suburban
29%
Minneapolis
27%
St. Paul
17%
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 Rates by Gender
Minnesota, 1993-2003
Males
350
Females
300
Rate per 100,000
250
200
150
100
50
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia Rates by Age
Minnesota, 1993-2003
1400
15-19
25-29
1200
20-24
30-39
Rate per 100,000
1000
800
600
400
200
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia Rates by Race/Ethnicity
Minnesota, 1993-2003
2500
White
American Indian
Hispanic*
Rate per 100,000
2000
Black
Asian/PI
1500
1000
500
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia Rates by Race/Ethnicity Excluding Blacks
Minnesota, 1993-2003
1000
Rate per 100,000
800
White
American Indian
Asian/PI
Hispanic*
600
400
200
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
GONORRHEA
STDs in Minnesota: Annual Review
Kittson
Roseau
2003 Minnesota
Gonorrhea Rates
by County
Lake of the Woods
Marshall
Koochiching
Pennington
Beltrami
Red Lake
Polk
Cook
Clearwater
St. Louis
Lake
Itasca
Norman
Mahnomen
Hubbard
Becker
Clay
Cass
Aitkin
Wadena
Wilkin
Carlton
Rate per 100,000 persons
Crow Wing
Otter Tail
Grant
Douglas
Stevens
Pope
0 -19
Pine
Todd
20 - 100
> 100
Morrison
Mille Lacs Kanabec
Traverse
Benton
Stearns
Isanti
Big Stone
Swift
Lac qui Parle
Wright
Meeker
Chippewa
Hennepin Washington
Ramsey
McLeod
Yellow Medicine
Carver
Renville
Dakota
Scott
Sibley
Lyon
Le Sueur
Rice
Wabasha
Brown
Murray
Rock
Nobles
Cottonwood Watonwan Blue Earth Waseca Steele Dodge
Jackson
359
200
40
20
Goodhue
Redwood
Nicollet
Pipestone
City of Minneapolis
City of St. Paul
Suburban
Greater Minnesota
Anoka
Kandiyohi
Lincoln
Chisago
Sherburne
Martin
Faribault
Freeborn
Mower
Olmsted
Winona
Fillmore
Houston
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
Greater MN
14%
Minneapolis
43%
Suburban
25%
St. Paul
18%
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.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Rates by Gender
Minnesota, 1993-2003
100
Males
Females
Rate per 100,000
80
60
40
20
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Rates by Age
Minnesota, 1993-2003
15-19
25-29
400
20-24
30-39
350
Rate per 100,000
300
250
200
150
100
50
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Rates by Race/Ethnicity
Minnesota, 1993-2003
2000
White
American Indian
Hispanic*
1800
1600
Rate per 100,000
1400
Black
Asian/PI
1200
1000
800
600
400
200
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Rates by Race/Ethnicity Excluding Blacks
Minnesota, 1993-2003
250
225
200
White
American Indian
Asian/PI
Hispanic*
Rate per 100,000
175
150
125
100
75
50
25
0
1993
1994
1995
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
1996
1997
1998
1999
2000
2001
2002
2003
Year
STDs in Minnesota: Annual Review
PRIMARY & SECONDARY SYPHILIS
STDs in Minnesota: Annual Review
Kittson
Roseau
2003 Minnesota
P&S Syphilis
Rates by County
Lake of the Woods
Marshall
Koochiching
Pennington
Beltrami
Red Lake
Polk
Cook
Clearwater
St. Louis
Lake
Itasca
Norman
Mahnomen
Hubbard
Becker
Clay
Cass
Aitkin
Wadena
Wilkin
Carlton
Crow Wing
Otter Tail
Rate per 100,000 persons
Pine
Todd
Grant
Douglas
Stevens
Pope
Morrison
0 – 0.2
0.21 – 4.0
> 4.0
Mille Lacs Kanabec
Traverse
Benton
Stearns
Isanti
Big Stone
Swift
Anoka
Kandiyohi
Lac qui Parle
Hennepin Washington
Ramsey
McLeod
Carver
Renville
Dakota
Scott
Sibley
Lyon
Le Sueur
Rice
Wabasha
Brown
Murray
Rock
Nobles
Cottonwood Watonwan Blue Earth Waseca Steele Dodge
Jackson
5.5
1.7
0.8
0.2
Goodhue
Redwood
Nicollet
Pipestone
City of Minneapolis
City of St. Paul
Suburban
Greater Minnesota
Wright
Meeker
Chippewa
Yellow Medicine
Lincoln
Chisago
Sherburne
Martin
Faribault
Freeborn
Mower
Olmsted
Winona
Fillmore
Houston
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
Greater
MN
11%
Minneapolis
45%
Suburban
34%
St. Paul
11%
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.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Primary & Secondary Syphilis Rates by Age
Minnesota, 1993-2003
9.0
8.0
15-19
20-24
25-29
30-39
Rate per 100,000
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Primary &Secondary Syphilis Rates by Gender
Minnesota, 1993-2003
4.0
Males
Females
3.5
Rate per 100,000
3.0
2.5
2.0
1.5
1.0
0.5
0.0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Primary & Secondary Syphilis Rates by Race/Ethnicity
Minnesota, 1993-2003
70
White
American Indian
Hispanic*
60
Rate per 100,000
50
Black
Asian/PI
40
30
20
10
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Primary & Secondary Syphilis Rates by Race/Ethnicity
Minnesota, 1997-2003
30
White
American Indian
Hispanic*
25
Black
Asian/PI
Rate per 100,000
20
15
10
5
0
1997
1998
1999
2000
2001
2002
2003
Year
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
ADOLESCENTS & YOUNG ADULTS
15-19 year olds
20-24 year olds
Chlamydia disproportionately impacts
adolescents & young adults
MN Population in 2000
Chlamydia Cases in 2003
(n = 4,919,479)
(n = 10,714)
25-34 yrs
14%
25-34 yrs
22%
35+ yrs
50%
15-24 yrs
14%
15-24 yrs
70%
35+ yrs
6%
<15 yrs
2%
<15 yrs
22%
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea disproportionately impacts
adolescents & young adults
MN Population in 2000
Gonorrhea Cases in 2003
(n = 4,919,479)
(n = 3,202)
25-34 yrs
27%
25-34 yrs
14%
35+ yrs
50%
35+ yrs
15%
15-24 yrs
14%
15-24 yrs
56%
<15 yrs
2%
<15 yrs
22%
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
Male
2,040
23%
Female
6,652
77%
White
3,753
43%
Black
2,677
31%
Am Indian
304
4%
Asian/PI
274
3%
1,684
19%
Other/Unknown
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)
Hispanic
Cases
541
% of Total
6%
Non-Hispanic
5,334
61%
Unknown
2,817
32%
Minneapolis
2,397
28%
St. Paul
1,421
16%
Suburban MN
2,418
28%
Greater MN
2,456
28%
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.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia Rates for Adolescents & Young Adults
by Gender in Minnesota, 1993-2003
2000
1800
Males
Females
1600
Rate per 100,000
1400
1200
1000
800
600
400
200
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Rates for Adolescents & Young Adults
by Gender in Minnesota, 1993-2003
500
Males
450
Females
400
Rate per 100,000
350
300
250
200
150
100
50
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
EMERGING TRENDS:
- Resurgence of Syphilis
- Drug Resistant Gonorrhea
STDs in Minnesota: Annual Review
Resurgence of Syphilis among Gay/Bisexual
Men in Minnesota
STDs in Minnesota: Annual Review
Early Syphilis* Cases by Stage at Diagnosis
Minnesota, 1993-2003
100
Number of Cases
80
Primary
Secondary
Early Latent
60
40
20
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
* Early Syphilis includes primary, secondary, and early latent stages of syphilis
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Increase in Early Syphilis* among Gay/Bisexual Men
Minnesota, 2002-2003
• 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
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
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
Increasing Prevalence of Drug-Resistant
Gonorrhea in Minnesota
STDs in Minnesota: Annual Review
Background Information

CDC-recommended antibiotic treatments for gonorrhea:
 Ceftriaxone



Cefixime



Single dose therapy, administered by injection
Relatively expensive
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
Prevalence of
Quinolone-Resistant N. Gonorrhoeae (QRNG)
1990s
QRNG prevalent in Asia, >40% in some countries
2000
Hawaii discontinues use of fluoroquinolones following increase in
QRNG prevalence from 1.4% in 1997 to 9.5% in 1999
2001
California discontinues use of fluoroquinolones after reaching
QRNG prevalence of 5% in 2001
2002
CDC recommends non-quinolone therapy for infections acquired
in HI, CA, and other areas with high QRNG prevalence
2003
Increases in QRNG reported in other U.S. states (e.g., MI, MA)
especially among gay/bisexual men
Prevalence of QRNG in Minnesota
Year
# Resistant Isolates
# Isolates Tested
QRNG Prevalence
1999-2001
0
1,365
0%
2002
4
268
1.5%
2003
5
363
1.4%
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
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
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
SURVEILLANCE SUMMARY
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
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review