Highlights from the
Sexually Transmitted Disease (STD)
Surveillance Report, 2012
Minnesota Department of Health
STD Surveillance System
www.health.state.mn.us/std
Announcements
STDs in Minnesota
Rate per 100,000 by Year of Diagnosis, 2002-2012
* P&S = Primary and Secondary
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
CHLAMYDIA
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia in Minnesota
Rate per 100,000 by Year of Diagnosis, 2002-2012
340 per 100,000
202 per 100,000
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia Infections by Residence at Diagnosis
Minnesota, 2012
Total Number of Cases = 18,048
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
Age-Specific Chlamydia Rates by Gender
Minnesota, 2012
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Chlamydia Rates by Race/Ethnicity
Minnesota, 2002-2012
2012 rates compared with Whites:
Black = 11x higher
American Indian = 5x higher
Asian/PI = 2x higher
Hispanic = 3x higher
* 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
Minnesota, 2002-2012
* 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
Gonorrhea in Minnesota
Rate per 100,000 by Year of Diagnosis, 2002-2012
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Infections in Minnesota
by Residence at Diagnosis, 2012
Total Number of Cases= 3,082
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
Age-Specific Gonorrhea Rates by Gender
Minnesota, 2012
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Rates by Race/Ethnicity
Minnesota, 2002-2012
2012 rates compared with Whites:
Black = 26x higher
American Indian = 8x higher
Asian/PI = 0x higher
Hispanic = 2x higher
* 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
Minnesota, 2002-2012
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
SYPHILIS
STDs in Minnesota: Annual Review
Syphilis Rates by Stage of Diagnosis
Minnesota, 2002-2012
* P&S = Primary and Secondary
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Primary & Secondary Syphilis Infections
in Minnesota by Residence at Diagnosis, 2012
Total Number of Cases = 118
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
Age-Specific Primary & Secondary Syphilis
Rates by Gender, Minnesota, 2012
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Primary & Secondary Syphilis Rates by Race/Ethnicity
Minnesota, 2002-2012
* Persons of Hispanic ethnicity can be of any race.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Topics in the spotlight:
•Chlamydia and Gonorrhea among Adolescents and
Young Adults (15-24 years of age)
•Early Syphilis Among Men Who Have Sex With Men
in Minnesota
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
CHLAMYDIA AND GONORRHEA
AMONG
ADOLESCENTS & YOUNG ADULTS
(15-19 year olds)
(20-24 year olds)
STDs in Minnesota: Annual Review
Chlamydia Disproportionately Impacts Youth
MN Population in 2010
Chlamydia Cases in 2012
(n = 5,303,925)
(n = 18,048)
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Gonorrhea Disproportionately Impacts Youth
MN Population in 2010
Gonorrhea Cases in 2012
(n = 5,303,925)
(n = 3,082)
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Early Syphilis Among
Men Who Have Sex With Men
in Minnesota
STDs in Minnesota: Annual Review
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Early Syphilis† Cases Among MSM by Age
Minnesota, 2012 (n=158)
Mean Age = 38 years
Range: 15 to 74 years
MSM=Men who have sex with men
† Early Syphilis includes primary, secondary, and early latent stages of syphilis.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Early Syphilis† (ES) Cases
Co-infected with HIV, 2006-2012
MSM=Men who have sex with men
† Early Syphilis includes primary, secondary, and early latent stages of syphilis.
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
SURVEILLANCE SUMMARY
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
Future Updates to STD Reporting




New case report form to accommodate changes in gonorrhea
treatment guidelines
Case report form will be able to be filled out on a computer and
printed to be mailed or faxed in
Link will be put up on MDH website to indicate interest in future
online “provider portal” for direct online reporting
Letters will be sent in late May/early June to providers to introduce
new case report form, provide link to sign up for future “provider
portal” online reporting, and highlight new gonorrhea treatment
guidelines
Data Source: Minnesota STD Surveillance System
STDs in Minnesota: Annual Review
INCREASING
PREVALENCE OF DRUGRESISTANT GC
Candy Hadsall, RN
STD Nurse Specialist
MDH
Resistance is Increasing
• Beginning to see resistance to Suprax –
– High number of treatment failures in Canada.
– Gonococcal Isolate Surveillance Project (GISP) has
identified cases, including few in MN
– Steepest increase in western US, especially in MSM;
started in 2009
– One study = 11.9% of patients + on retest 2-4 weeks
after treatment with Suprax
• Concern: cephalosporins are last effective
antibiotic; no new drugs in production
2012 Rev Recommended Tx of
Uncomplicated GC
(Cervix, urethra, rectum)
Ceftriaxone 250 mg IM, single dose
PLUS
Azithromycin 1 g orally, single dose or
doxycycline 100 mg. orally bid x 7 days
Note: Fluoroquinolones discontinued in 2007
2012 Alternative Tx for
Uncomplicated GC
• If no ceftriaxone,
Cefixime 400 mg po, single dose
PLUS
Azithromycin 1 gm orally, single dose (or
doxy)
MUST DO
Test of cure in 1 week via culture if possible
Test of Cure for GC
• TOC recommended when:
– One week following re-treatment if used alternative
treatment and not Rocephin
– Treatment failure is suspected
– Patients have persistent symptoms
• Culture recommended unless not available
– Poses problems since culture use declined
– If unavailable, can use NAATS (GC clears from body
within 5 days if responsive to treatment med)
Pharyngeal Gonorrhea
• Infection in mouth and throat sometimes occurs.
More difficult to eradicate
• CDC treatment recommendation:
– Ceftriaxone (Rocephin) 250 mg. IM single dose
PLUS
Azithromycin 1 g orally, single dose (or doxy)
• Not recommended even prior to 2012:
– Cefixime 400 mg po
What About EPT?
• Treatment recommendation for partners of
individuals who test positive for gonorrhea
and refuse to come into clinic:
– Cefixime (Suprax) 400 mg orally, single dose
PLUS
- Azithromycin 1 gm. orally, single dose
• No change in treatment guidelines
Different Focus When Addressing
Gonorrhea in Minnesota
• Since large majority of cases are in Twin Cities
and suburbs, important to:
– Pay attention to geography – of clinic, of clients
– Do detailed sexual histories, risk assessments;
identify and discuss social/sexual networks
– Treat prophylactically when indicated. Treat positives
quickly and appropriately. (CDC Guidelines)
– Get partners into clinic for treatment
– When not possible, provide EPT for all partners
– Report untreated cases to MDH right away
What Should Clinicians Do
in 2013?
• Be alert to treatment failures in patients who
received Suprax as alternative treatment AND
• In patients who return with symptoms after
treatment when partner(s) are treated with EPT
• Do not stop using Suprax in designated
situations, especially if patient/partner would not
otherwise get treated
• Update treatment protocols; decide on clinic’s
ability to collect cultures; see if lab does cultures
GOAL:
Treat as many people as possible as long
as we still have an effective treatment,
including partners through EPT
Recommendations for GC (and CT)
Re-Screening after Treatment
• In patients who are positive and have
uncomplicated cases, and do not return with
symptoms, no changes
• Re-screen all patients who were positive 3 4 months after treatment, or whenever seek
care within 12 months if did not return at 3
months
Repeat Infections
• Repeat CT and GC infection rates at rescreening
3-4 months later are high, 10-30%, usually
because partners not treated
• Risk of serious reproductive health sequelae
increases with every subsequent infection
– Upper tract infection (PID) more common with reinfection than initial infection
– Repeat CT: 2x odds of ectopic pregnancy;
4x odds of pelvic inflammatory disease (PID)1
1 - Hillis et al 1997
What Else Can Clinicians Do?
• Ask patients about sex of partners and include
treatment/EPT
• Put as much information as possible on case
report forms
• Call MDH if suspect treatment failure
• Be able to explain disease investigation when
necessary.
• Make a connection with a Disease Investigator
at MDH – 651-201-5414.
Candy Hadsall
[email protected]
651-201-4015
Chlamydia Screening:
Provider Toolkit
TOOLS TO INCREASE
CHLAMYDIA SCREENING
RATES IN YOUR PRACTICE
Anisa Esse, Senior Regulatory
Quality Analyst
Medica
Project Background
 Health Plans required by DHS Contract to
impalement a statewide Performance Improvement
Project annually that lasts for 3 years. (PIP)– 3 year
project
 Health Plans work collaboratively together on
projects.
 This performance improvement project (PIP) is a
Collaborative effort among four Minnesota health
plans: Blue Cross and Blue Shield of Minnesota,
HealthPartners, Medica, and UCare with project
support provided by Stratis Health.
Project Background
 Purpose: The goal of this PIP is to increase
the rate of Chlamydia screening in women
Barriers
discovered: providers lack of
knowledge about CT, belief systems, confidence
in skills re: talking to youth/parents
Intervention Strategies
 Provider/Clinic interventions
 Provider
toolkit
 Targeted Outreach to Clinics with low Chlamydia
screening rates
 Community level Outreach
 Support
the implementation of the MN
Chlamydia strategy
MCP Involvement
 To fulfill the community outreach component of
project; Health plan collaborative approached MCP
in November 2012
 Important for Health plan collaborative to receive
input from MCP members in the development of the
provider toolkit
Chlamydia Screening: Provider Toolkit
The Health plan Collaborative with support from the
MCP developed this toolkit to help clinics and
providers across the state make simple changes to
improve their clinic processes and raise awareness of
this public health issue.
Chlamydia Screening: Provider Toolkit
The toolkit includes:
• Current information on the status of the disease
• Sample office protocols
• Resources for your clinic, patients, and parents
• Profiles of four Minnesota clinics with successful
chlamydia screening efforts
The toolkit is available at:
http://www.stratishealth.org/pip/documents/Chlamy
dia_Toolkit.pdf
Upcoming Webinar
Topic: Tools to improve chlamydia screening in your
practice
 Date: Monday, April 15, 2013
 Time: 12:00 – 1:00 pm
 Space is limited. To register, email
Patty Graham at:
[email protected].
This webinar will be recorded and available for viewing
later at
http://www.stratishealth.org/pip/chlamydia.html
Upcoming Webinar
Presented by:
o Paul Erickson, MD, Medical Director, NorthPoint Health and
Wellness Clinic
o Patty Graham, BA, Quality Consultant, HealthPartners Health
Plan
o Jenny Oliphant, EdD, MPH, Community Outreach
Coordinator for the Healthy Youth Development-Prevention
Research Center (PRC), Division of Adolescent Health and
Medicine at the University of Minnesota
 Who should participate: Health care providers, nurses,
clinic administration, public health, health educators, social
workers, school health staff, youth workers and anyone who
interacts with youth
Contact Information
Anisa Esse
[email protected]
952-992-2562
Project website:
http://www.stratishealth.org/pip/chlamydia.html
Questions?
For more information, contact:



STD Surveillance Data
[email protected], 651-201-4041
Gonorrhea & Chlamydia Technical Assistance
[email protected], 651-201-4015
Chlamydia Screening Provider Toolkit
[email protected], 952-992-2562