Infectious Diseases At A Glance in Durham Region

Infectious Diseases At A Glance in Durham Region Last Updated: November 2017 Highlights The rates of all reported infectious diseases combined are highest among youth and young adults aged 15 to 29 and among older adults aged 90 and older. Chlamydia was the most commonly reported infectious disease in Durham Region males and females. The rate of enteric illness was higher in the northern municipalities of Durham Region (Brock, Scugog and Uxbridge combined) in most years and in Clarington since 2013. Rates of salmonellosis have been increasing in both Durham Region and Ontario since 2003. The rate of influenza was higher in the northern municipalities of Durham Region from 2013 to 2016 compared to Durham Region as a whole. Although chlamydia rates decreased between 2011 and 2013 among both Durham Region and Ontario females and levelled off among Durham Region males, rates increased again between 2014 and 2016. The rate of chlamydia is higher most years in Ajax, Pickering, and Oshawa than Durham Region as a whole, and lower in Whitby, Clarington, and the northern municipalities of Durham Region. Incidence rates of gonorrhea have been increasing since 2009 in both Durham Region and Ontario, especially among males. Incidence rates of syphilis have increased since 2013 in Ontario and 2014 in Durham Region. The rate of hepatitis C infection is consistently higher in Oshawa than in other Durham Region municipalities, and higher than in Durham Region as a whole. The rate of latent tuberculosis infection is consistently higher in Ajax than in Durham Region as a whole and the rate has increased since 2011. Rates for all reportable infectious diseases included in the report are either similar or lower in Durham Region compared to Ontario with the exception of legionellosis. There were more cases than expected in 2016 for adverse events following immunization, cyclosporiasis, gonorrhea, invasive group A streptococcal disease, hepatitis A, influenza, Lyme disease, salmonellosis, shigellosis, and infectious syphilis. There were fewer cases than expected for hepatitis C. Page 1 of 56

Introduction Ontario's Health Protection and Promotion Act (1) requires that physicians, nurses, other regulated health professionals, hospitals, and laboratories report a number of infectious diseases to the local Medical Officer of Health. The Durham Region Health Department investigates and manages identified cases and contacts of infectious diseases and enters them into the integrated Public Health Information System (iphis) as outlined in the Ministry of Health and Long-Term Care's Infectious Disease Protocol (2). The most common source of case finding is through notice of confirmed test results from a laboratory. There may be considerable under-reporting of cases because an infected person with mild or no symptoms may not seek medical care and/or medical professionals may not order laboratory testing. A list of reportable infectious diseases is available as Appendix 1. This report includes confirmed cases, unless otherwise noted, of reportable infectious diseases according to provincial case definitions provided in the Infectious Disease Protocol (3). We included probable cases along with confirmed cases for some diseases (noted in the comments below each graph where relevant) from 2009 onward. This enabled comparison to previous years because the case definitions changed in 2009. For all indicators, we analyzed data by the residence of the case at time of diagnosis. This report includes indicators with relevance to public health programming, referenced in the Ontario Public Health Standards (OPHS) (4). The Ontario Ministry of Health and Long- Term Care published the OPHS under the authority of Section 7 of the Health Protection and Promotion Act (1). This report includes charts and tables for the following indicators for Durham Region: All reportable infectious diseases: incidence rate; age-specific incidence rate Most common reportable diseases All enteric diseases: incidence rate; age-specific incidence rate; incidence rate by municipality Campylobacter enteritis: incidence rate; incidence rate by municipality Giardiasis: incidence rate Salmonellosis: incidence rate; incidence rate by municipality All vaccine preventable diseases: incidence rate Influenza: incidence rate; age-specific incidence rate; incidence rate by municipality Pertussis: incidence rate; age-specific incidence rate Invasive pneumococcal disease (IPD): incidence rate All sexually transmitted and blood-borne infections: incidence rate Chlamydia: incidence rate; age-specific incidence rate; incidence rate among youth aged 15 to 19, adults aged 20 to 24, and adults aged 25 to 29; incidence rate by municipality Gonorrhea: incidence rate; age-specific incidence rate; incidence rate by municipality Syphilis: incidence rate Hepatitis B, chronic: incidence rate Hepatitis C: incidence rate; incidence rate by municipality Latent tuberculosis infection: incidence rate; incidence rate by municipality Page 2 of 56

Age-standardized incidence ratios for selected reportable diseases (males, females, & both sexes combined) Number of confirmed cases of selected reportable diseases in Durham Region among both sexes For more detailed, topic specific reports that include infectious disease data please go to the Health Statistics in Durham Region webpage found at durham.ca/healthstats. The Health Neighbourhoods project presents indicators, including infectious disease indicators, for 50 Health Neighbourhoods in Durham Region. Public Health Ontario has a variety of reports that include infectious disease data including the Reportable Burdensome Infectious Disease Incidence Snapshot, Monthly Infectious Disease Surveillance Reports, Reportable Diseases Trends in Ontario tool, West Nile Virus surveillance, and Vector-Borne Disease Surveillance Reports. For more information or if you require this information in an accessible format, please contact the Durham Health Connection Line at 905-666-6241 or 1-800-841-2729. Page 3 of 56

Definitions Definition: Age-standardized incidence ratio The ratio of the number of cases observed in the population of interest to the number of cases that would be expected if the population had the same age-specific incidence rates as a standard population. For this report, we used Ontario as the standard population. Since statistical estimates may be unstable when the number of events is small, we used confidence intervals to determine whether an age-standardized incidence ratio was statistically different from one. A ratio with confidence intervals greater than one indicates that the incidence rate is higher in Durham Region than Ontario, whereas a ratio with confidence intervals less than one indicates that incidence is lower in Durham Region. Definition: Incidence rate The total number of cases per 100,000 population. This rate depicts the "true" picture of disease in a community. Definition: Age-specific incidence rate The total number of cases in a specified age group per 100,000 population in that age group. The numerator and denominator refer to the same age group. For some indicators, the count of total cases displayed is more than the sum of male and female cases because of unspecified or other gender. Page 4 of 56

All reportable infectious diseases All reportable infectious diseases are included in these rates with the exception of adverse vaccine events; chickenpox (varicella); Clostridium difficile infection; gastroenteritis, institutional outbreaks; & respiratory infection outbreaks in institutions. Institutions include long-term care homes, hospitals, retirement homes, child care centres and schools. Page 5 of 56

Figure 1: All reportable infectious diseases incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 244.7 248.0 231.4 181.0 244.9 178.3 178.1 193.0 226.0 289.1 262.0 303.4 320.9 319.1 333.6 385.0 341.1 367.5 398.5 407.0 428.0 411.3 405.0 Durham Female Rate 338.8 319.4 304.7 257.7 329.9 271.9 248.2 284.7 315.9 347.9 337.4 376.1 379.9 380.7 430.0 481.7 468.0 502.8 511.9 459.4 474.6 484.8 477.6 Ontario Male Rate 341.5 410.7 345.1 317.7 357.1 338.0 338.1 331.3 362.7 373.8 353.9 409.8 397.4 405.0 416.7 491.0 423.6 452.0 495.4 480.1 534.2 537.5 530.3 Ontario Female Rate 421.1 447.6 363.9 333.8 375.6 357.5 363.2 345.6 392.0 397.2 374.4 430.5 412.7 423.9 470.9 550.1 494.4 536.0 571.4 511.0 560.8 565.5 559.0 Durham Male Cases 554 573 543 435 602 447 457 505 603 789 730 862 928 936 991 1,156 1,038 1,131 1,245 1,289 1,373 1,337 1,585 Durham Female Cases 774 745 724 627 821 691 646 757 857 966 958 1,089 1,121 1,144 1,314 1,492 1,473 1,604 1,657 1,508 1,577 1,632 1,871 Durham Total Cases 1,328 1,318 1,267 1,062 1,421 1,138 1,103 1,259 1,459 1,755 1,689 1,952 2,051 2,081 2,308 2,649 2,512 2,739 2,902 2,797 2,950 2,970 3,455 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Crude reportable infectious disease incidence rates increased steadily since 2001 in males and females and were higher among females in both Durham Region and Ontario. Trends in chlamydia have the strongest influence on trends in overall infectious disease rates. Chlamydia has accounted for over half of all reported infectious diseases since 2010. Page 6 of 56

Figure 2: All reportable infectious diseases age-specific incidence rates, Durham Region and Ontario, 2012 to 2016 combined Rates and Cases 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Durham Male Rate 334.2 147.8 78.6 514.5 1311.5 979.6 531.0 404.8 304.2 303.9 257.7 239.4 261.8 228.1 234.2 356.7 420.9 567.9 767.5 Durham Female Rate 270.4 107.6 86.6 1332.9 2131.7 1034.4 552.4 375.0 278.8 210.2 163.0 191.2 184.6 177.6 167.9 230.0 285.6 455.5 780.0 Ontario Male Rate 341.1 158.1 99.5 436.3 1088.2 901.1 612.1 421.1 344.5 306.9 251.4 228.6 219.7 192.7 203.3 270.7 367.4 542.8 972.1 Ontario Female Rate 288.8 129.5 97.4 1198.8 1706.9 892.5 518.5 337.3 236.3 182.0 162.3 157.5 150.5 150.8 164.5 224.6 317.7 503.8 821.4 Durham Male Cases 304 144 81 609 1,597 1,012 518 415 337 377 357 276 234 162 113 118 97 68 37 Durham Female Cases 237 101 85 1,494 2,464 1,055 577 415 325 274 228 224 172 137 91 95 93 103 104 Durham Total Cases 541 245 166 2,104 4,061 2,067 1,095 830 662 651 585 500 406 299 204 213 190 171 141 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rates of all reported infectious diseases are highest among youth and young adults aged 15 to 29 and among older adults aged 90 and older. As with overall rates, the age distribution of chlamydia has the strongest influence on this distribution. Chlamydia accounted for over half of all reported infectious diseases between 2012 and 2016. Page 7 of 56

Figure 3: Ten most common reportable infectious diseases in Durham Region, 2012 to 2016 combined Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. * We included probable cases along with confirmed cases for these diseases to be consistent with other reporting. Chlamydia was the most commonly reported infectious disease in Durham Region males and females for 2012 to 2016. Chlamydia accounted for a much larger proportion of all reportable diseases among females (62 percent) than among males (47 percent). Page 8 of 56

Table 1: Twenty most common reportable infectious diseases in Durham Region, 2012 to 2016 combined Reportable Disease Total Percent Total Rank Male Percent Male Rank Female Percent Chlamydia 55.1% 1 46.7% 1 62.0% 1 Influenza 10.7% 2 10.9% 2 10.5% 2 Latent tuberculosis infection 8.3% 3 5.8% 6 10.2% 3 Gonorrhea 6.9% 4 8.1% 3 5.9% 4 Campylobacter enteritis * 5.6% 5 7.0% 5 4.5% 6 Hepatitis C 5.5% 6 7.6% 4 3.8% 7 Salmonellosis * 5.1% 7 5.4% 7 4.9% 5 Giardiasis * 1.7% 8 2.3% 8 1.2% 9 Invasive pneumococcal disease * 1.6% 9 1.9% 9 1.3% 8 Hepatitis B carriers 1.2% 10 1.6% 10 0.9% 10 Non-infectious syphilis 0.8% 11 1.1% 12 0.6% 12 Invasive group A streptococcal disease 0.7% 12 0.8% 15 0.7% 11 Amebiasis * 0.7% 13 0.9% 13 0.4% 15 Infectious syphilis 0.7% 13 1.3% 11 0.1% 27 HIV/AIDS 0.5% 15 0.9% 14 0.1% 26 Lyme disease * 0.5% 16 0.5% 18 0.5% 14 Legionellosis * 0.5% 17 0.7% 16 0.3% 21 Pertussis (whooping cough) * 0.4% 18 0.3% 23 0.5% 13 Active tuberculosis 0.4% 19 0.4% 19 0.4% 16 Viral meningitis 0.4% 20 0.5% 17 0.3% 19 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Female Rank * We included probable cases along with confirmed cases for these diseases to be consistent with other reporting. Influenza was the second most commonly reported infectious disease among Durham Region males and females accounting for close to 11 percent of all reportable diseases between 2012 and 2016. Among Durham Region females, latent tuberculosis infection was the third most commonly reported infectious disease at just over 10 percent. Among males, gonorrhea was the third most commonly reported infectious disease accounting for eight percent of all reportable diseases. Page 9 of 56

Enteric diseases Enteric diseases are diseases that affect the stomach and intestines and commonly cause symptoms such as diarrhea, nausea, vomiting, stomach pain, and fever. They can be spread by drinking contaminated water, eating contaminated food, or contact with sick people or animals or surfaces that they have touched. People can protect themselves from enteric diseases by washing their hands thoroughly and frequently, using safe food handling practices, and through safe use of drinking and recreational water. Reportable enteric diseases in Ontario include: amebiasis; botulism; brucellosis; Campylobacter enteritis; cholera; cryptosporidiosis; cyclosporiasis; food poisoning, all causes; giardiasis; hepatitis A; listeriosis; paralytic shellfish poisoning; paratyphoid fever; salmonellosis; shigellosis; trichinosis; typhoid fever; verotoxin-producing Escherichia coli (VTEC) infection; and yersiniosis. We included probable cases along with confirmed cases for all enteric diseases with the exception of listeriosis, paratyphoid fever and typhoid from 2009 onward. This enabled comparison to previous years because the case definitions changed in 2009. Page 10 of 56

Figure 4: All enteric diseases incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 125.0 123.8 104.0 89.5 77.7 51.1 73.3 76.8 85.8 72.9 69.3 64.8 67.1 78.1 68.0 64.3 59.8 65.6 76.2 72.6 77.3 69.2 77.2 Durham Female Rate 120.8 117.9 90.0 89.2 87.6 48.0 60.7 70.3 81.1 59.8 62.3 60.4 66.4 61.9 56.0 54.9 60.4 61.8 64.9 68.8 59.6 55.2 66.7 Ontario Male Rate 154.8 145.6 130.9 125.9 126.3 100.0 117.1 110.6 106.8 91.0 88.7 97.4 90.9 97.3 93.1 83.6 89.9 87.4 93.5 91.5 93.5 89.9 93.5 Ontario Female Rate 137.4 128.2 110.1 107.5 109.1 85.6 104.3 88.7 90.6 73.6 71.6 78.4 74.7 77.1 75.6 68.8 71.8 70.7 77.7 72.9 72.8 72.6 75.7 Durham Male Cases 283 286 244 215 191 128 188 201 229 199 193 184 194 229 202 193 182 202 238 230 248 225 255 Durham Female Cases 276 275 214 217 218 122 158 187 220 166 177 175 196 186 171 170 190 197 210 226 198 186 228 Durham Total Cases 559 561 458 432 409 250 346 388 449 365 370 359 390 415 373 363 372 399 448 456 446 411 483 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Rates of enteric diseases decreased between 1994 and 1999 in both Durham Region and Ontario, then remained relatively stable since 2003. Rates were higher in males than females in most years. Page 11 of 56

Figure 5: All enteric diseases age-specific incidence rates, Durham Region and Ontario, 2012 to 2016 combined Rates and Cases 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Durham Male Rate 118.7 67.8 52.4 64.2 67.3 87.1 61.5 66.3 74.9 70.1 77.2 67.7 91.7 67.6 87.0 84.6 85.3 Durham Female Rate 86.7 45.8 30.6 43.7 87.4 78.4 61.3 61.4 57.5 74.4 61.5 59.8 81.6 66.1 42.4 60.5 42.3 Ontario Male Rate 150.4 94.4 65.9 77.2 90.4 102.2 93.4 83.0 80.7 81.0 79.2 73.4 74.8 73.0 72.3 69.7 62.0 Ontario Female Rate 127.9 78.0 43.7 57.2 86.9 87.7 72.6 61.9 56.7 60.3 59.1 61.5 62.5 61.9 59.2 61.8 49.7 Durham Male Cases 108 66 54 76 82 90 60 68 83 87 107 78 82 48 42 28 34 Durham Female Cases 76 43 30 49 101 80 64 68 67 97 86 70 76 51 23 25 29 Durham Total Cases 184 109 84 125 183 170 124 136 150 184 193 148 158 99 65 53 63 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Many enteric illnesses occur more frequently in infants and young children compared to adults. Rates were higher among males than females in most age groups. Durham Region rates were lower than Ontario rates in most age groups but were higher in Durham Region males aged 70 and older than among Ontario males in this age group. Page 12 of 56

Figure 6: All enteric diseases incidence rates, Durham Region by municipality, 2008 to 2016 Rates by Municipality 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pickering 43.6 61.2 50.3 68.9 66.8 82.8 65.0 72.3 65.2 Ajax 44.2 56.9 50.2 38.0 77.7 75.1 62.3 47.3 74.1 Whitby 47.4 60.6 62.0 79.5 62.0 65.9 53.0 60.7 80.1 Oshawa 38.6 51.6 55.0 64.8 61.2 57.7 70.4 49.9 48.5 Clarington 34.7 43.7 50.0 42.5 72.4 86.1 79.6 80.7 93.6 North Durham 54.7 98.4 107.2 89.0 99.8 66.6 96.7 85.0 91.8 Durham Region 62.1 59.5 60.1 63.7 70.4 70.9 68.3 62.3 71.9 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2008 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (2008 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rate of enteric illness was higher in North Durham (Brock, Scugog and Uxbridge combined) in most years and in Clarington since 2013. All other municipalities have rates similar to Durham Region as a whole. Page 13 of 56

Figure 7: Campylobacter enteritis incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 65.4 66.2 44.8 38.3 38.6 26.7 37.4 45.9 36.4 33.3 30.2 27.1 27.3 28.3 30.6 25.6 18.4 24.4 36.2 34.1 32.1 22.5 23.9 Durham Female Rate 69.6 67.3 43.8 46.4 42.2 27.1 28.8 37.2 28.4 26.7 29.2 21.8 25.8 24.0 21.3 22.3 22.6 21.3 21.9 26.5 26.8 16.6 20.8 Ontario Male Rate 71.8 59.5 52.3 48.3 51.1 37.8 45.6 46.7 41.2 37.2 35.8 34.9 34.2 35.2 34.1 28.7 30.5 31.9 34.5 35.7 34.5 29.3 30.3 Ontario Female Rate 65.6 56.4 44.7 44.3 42.9 33.2 39.2 37.5 34.6 29.3 28.5 26.3 27.9 27.4 26.8 23.7 23.8 24.6 28.1 27.7 26.4 23.5 24.8 Durham Male Cases 148 153 105 92 95 67 96 120 97 91 84 77 79 83 91 77 56 75 113 108 103 73 79 Durham Female Cases 159 157 104 113 105 69 75 99 77 74 83 63 76 72 65 69 71 68 71 87 89 56 71 Durham Total Cases 307 310 209 205 200 136 171 219 174 165 167 140 155 155 156 146 127 143 184 195 192 129 150 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Campylobacter enteritis is one of the leading causes of enteric disease in Ontario and occurs primarily in the summer months (5). We included probable cases of Campylobacter enteritis along with confirmed cases from 2009 onward. This enabled comparison to previous years because the case definition changed in 2009. Rates of Campylobacter enteritis decreased between 1994 and 2005 in both Durham Region and Ontario then increased between 2009 and 2012 but have decreased again in recent years. Page 14 of 56

Figure 8: Campylobacter enteritis incidence rates, Durham Region by municipality, 2008 to 2016 Rates by Municipality 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pickering 19.6 29.5 17.5 21.9 26.9 34.0 31.4 22.7 21.4 Ajax 16.7 19.0 15.5 7.1 32.3 30.2 24.8 16.9 17.5 Whitby 19.1 22.1 20.1 30.2 22.0 27.2 20.7 17.4 21.0 Oshawa 17.3 20.5 20.9 28.5 28.0 25.1 30.3 14.0 15.6 Clarington 14.3 18.9 19.8 16.1 28.3 38.0 30.9 22.9 29.0 North Durham 20.0 45.5 34.5 34.5 44.6 33.3 50.1 34.0 45.9 Durham Region 25.9 23.9 20.5 22.8 28.9 30.2 29.4 19.5 22.3 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2008 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (2008 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. We included probable cases of Campylobacter enteritis along with confirmed cases from 2009 onward. This enabled comparison to previous years because the case definition changed in 2009. Rates of Campylobacter enteritis were higher in the northern Durham Region municipalities (Brock, Scugog and Uxbridge combined) in most years, while all other municipalities have rates similar to Durham Region as a whole. Page 15 of 56

Figure 9: Giardiasis incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Rate 21.5 15.5 18.8 18.8 11.1 9.7 6.8 6.4 11.2 8.9 10.0 6.8 10.6 7.7 9.6 8.9 6.1 6.2 8.6 7.9 8.4 8.3 6.0 Ontario Rate 25.0 24.7 23.0 21.2 18.6 17.2 17.1 17.2 15.7 13.2 12.6 13.2 12.3 13.0 12.9 12.1 11.3 10.4 10.9 11.1 10.6 11.3 10.1 Durham Male Cases 57 32 47 52 23 24 15 16 29 31 34 19 29 32 34 29 23 23 31 22 41 38 23 Durham Female Cases 41 40 42 39 32 25 20 18 31 18 22 20 33 14 24 25 15 16 24 29 14 17 17 Durham Total Cases 98 72 89 91 55 49 35 34 60 49 56 39 62 46 58 54 38 39 55 51 55 55 40 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Giardiasis is common in Ontario, especially in institutions and child care centres where children are not yet toilet trained (5). We included probable cases of giardiasis along with confirmed cases from 2009 onward. This enabled comparison to previous years because the case definition changed in 2009. Due to small numbers, we combined male and female cases to create more stable rates. Rates of giardiasis decreased between 1994 and 2011 in Ontario but have remained relatively stable since then. In Durham Region, rates decreased between 1994 and 2001 but have remained relatively stable since then. Page 16 of 56

Figure 10: Salmonellosis incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 22.5 21.6 22.6 19.6 17.1 8.8 19.5 19.5 21.0 17.2 14.4 20.1 16.6 26.9 15.8 18.0 21.4 21.1 22.7 18.9 20.9 24.0 27.3 Durham Female Rate 21.4 18.4 17.3 14.4 22.1 6.7 14.6 19.9 24.3 15.8 16.6 21.1 21.4 24.6 20.9 19.4 23.2 22.6 24.4 23.8 22.3 22.9 26.9 Ontario Male Rate 25.9 26.4 24.0 23.3 28.3 19.9 19.7 21.8 20.2 16.1 17.1 23.8 19.4 22.9 19.7 18.2 22.3 20.6 24.9 20.0 25.1 22.9 24.6 Ontario Female Rate 25.9 25.6 23.8 23.2 30.2 20.0 20.5 20.6 20.2 16.3 16.8 23.8 18.5 22.4 18.8 19.5 21.9 21.1 25.3 20.3 24.6 23.8 25.6 Durham Male Cases 51 50 53 47 42 22 50 51 56 47 40 57 48 79 47 54 65 65 71 60 67 78 90 Durham Female Cases 49 43 41 35 55 17 38 53 66 44 47 61 63 74 64 60 73 72 79 78 74 77 92 Durham Total Cases 100 93 94 82 97 39 88 104 122 91 87 118 111 153 111 114 138 137 150 138 141 155 182 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Salmonellosis is the second most common enteric infection in Ontario but experts estimate that only one percent of all infections are ever clinically recognized (5). We included probable cases of salmonellosis are included along with confirmed cases from 2009 onward. This enabled comparison to previous years because the case definition changed in 2009. Rates of salmonellosis decreased between 1994 and 2003 in both Durham Region and Ontario but have been increasing since then. Page 17 of 56

Figure 11: Salmonellosis incidence rates, Durham Region by municipality, 2008 to 2016 Rates by Municipality 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pickering 12.0 15.3 21.9 20.8 19.4 20.2 12.6 33.1 22.4 Ajax 14.7 18.0 20.1 16.8 28.8 24.2 23.1 17.7 30.8 Whitby 13.3 22.1 24.2 30.2 21.2 20.9 19.2 21.2 32.9 Oshawa 10.7 19.8 19.0 21.4 20.4 20.7 27.2 19.5 19.1 Clarington 15.5 9.4 19.8 19.5 28.3 22.4 23.2 32.7 37.6 North Durham 7.3 27.3 32.7 18.2 25.0 19.3 20.7 20.4 20.4 Durham Region 18.4 18.7 22.3 21.9 23.6 21.4 21.6 23.4 27.1 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2008 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (2008 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. We included probable cases of salmonellosis along with confirmed cases from 2009 onward. This enabled comparison to previous years because the case definition changed in 2009. In most years, the rate of salmonellosis is similar in the Durham Region municipalities to Durham Region as a whole. Page 18 of 56

Vaccine preventable diseases Vaccine preventable diseases (VPDs) are infectious diseases that can be prevented by routine vaccinations, mostly given during childhood. Reportable VPDs include: diphtheria; Haemophilus influenzae B disease, invasive; hepatitis A; hepatitis B; measles; meningococcal disease, invasive; mumps; pertussis; poliomyelitis, acute; rabies (human); rubella; rubella, congenital syndrome; Streptococcus pneumoniae, invasive (invasive pneumococcal disease); and tetanus. For this report, we included probable cases of invasive pneumococcal disease, measles, mumps, pertussis and rubella along with confirmed cases from 2009 onward. This enabled comparison to previous years because the case definitions changed in 2009. Page 19 of 56

Figure 12: All vaccine preventable diseases incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Rate 29.7 29.9 27.3 21.9 20.4 12.7 7.2 7.4 4.5 13.6 18.1 15.5 15.2 18.2 13.8 11.3 10.7 11.3 13.7 9.0 10.9 10.0 10.4 Ontario Rate 33.7 51.7 18.2 16.7 21.4 15.2 9.9 7.7 12.6 14.2 17.0 18.0 21.4 18.2 20.7 16.8 13.8 15.4 21.0 12.7 13.1 15.7 14.8 Durham Male Cases 67 73 63 54 47 25 19 17 10 44 40 40 48 64 44 36 29 38 44 35 41 29 29 Durham Female Cases 68 66 66 52 54 39 18 22 14 31 62 49 41 44 39 33 37 33 43 23 30 37 41 Durham Total Cases 135 139 129 106 101 64 37 39 24 75 102 89 89 108 83 69 66 71 87 58 71 66 70 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The grouping of all vaccine preventable diseases excludes influenza, due to the sporadic nature of cases, and chickenpox (varicella) due to underreporting issues. Due to small numbers, we combined male and female cases to create more stable rates. A large measles outbreak occurred in Ontario from 1994 to 1995, which explains the peak in these years. Page 20 of 56

Figure 13: Influenza incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Rate 1.8 4.7 11.4 5.0 26.7 24.8 6.6 8.5 17.1 32.5 4.6 30.7 15.6 17.0 24.4 87.9 11.6 14.4 32.1 35.7 68.9 34.0 74.9 Ontario Rate 8.4 16.1 9.9 7.7 21.6 31.2 13.3 6.6 22.4 40.4 9.9 43.8 23.2 24.6 38.2 117.8 15.6 33.9 67.7 57.5 97.0 78.5 115.3 Durham Male Cases 5 7 21 12 62 63 17 23 46 89 16 88 56 53 73 265 32 47 96 121 201 93 232 Durham Female Cases 3 15 33 12 70 62 17 22 46 90 10 87 35 48 74 270 40 43 108 109 248 249 250 Durham Total Cases 8 22 54 24 132 125 34 45 92 179 26 176 91 101 147 536 72 90 204 230 450 225 503 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Influenza is an acute respiratory illness. In Canada, the influenza season usually runs from November to April. Due to small numbers, we combined male and female cases to create more stable rates. The large number of cases for Ontario and Durham Region in 2009 was due to the H1N1 Pandemic. In addition, recent influenza seasons have also had large numbers of influenza cases. Influenza rates fluctuate from year to year but in general follow the same pattern in Durham Region and Ontario. We provide a summary of influenza activity for each influenza season on the Flu Surveillance page at durham.ca. Page 21 of 56

Figure 14: Influenza age-specific incidence rates, Durham Region and Ontario, 2012 to 2016 combined Rates and Cases 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+ Durham Male Rate 153.9 68.8 17.5 17.7 15.6 18.4 30.8 29.3 26.2 25.0 26.7 38.2 45.9 46.5 53.9 148.1 208.3 317.4 477.1 Durham Female Rate 138.0 45.8 19.4 15.2 19.0 33.3 34.5 28.0 36.9 28.4 32.2 46.1 39.7 49.3 53.5 118.6 159.7 322.8 667.5 Ontario Male Rate 240.5 102.9 38.7 24.7 18.8 24.2 32.1 33.9 37.0 35.6 39.5 47.1 61.1 71.0 103.2 174.2 287.7 485.0 929.1 Ontario Female Rate 203.4 78.6 30.5 27.9 27.6 41.2 53.4 46.9 42.5 39.3 45.3 54.8 61.1 74.1 95.1 164.2 265.6 475.0 823.6 Durham Male Cases 140 67 18 21 19 19 30 30 29 31 37 44 41 33 26 49 48 38 23 Durham Female Cases 121 43 19 17 22 34 36 31 43 37 45 54 37 38 29 49 52 73 89 Durham Total Cases 261 110 37 38 41 53 66 61 72 68 82 98 78 71 55 98 100 111 112 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. In general, young children and the elderly have higher incidence rates of influenza. Page 22 of 56

Figure 15: Influenza incidence rates, Durham Region by municipality, 2008 to 2016 Rates by Municipality 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pickering 15.3 94.0 10.9 7.7 30.2 28.7 46.1 26.9 60.1 Ajax 12.8 87.2 10.0 8.0 21.8 31.9 56.4 19.4 68.3 Whitby 16.6 90.9 6.4 13.5 21.2 35.7 62.9 16.7 72.6 Oshawa 10.0 67.5 11.1 12.3 32.5 36.4 71.7 45.0 74.8 Clarington 62.2 122.7 16.3 11.5 57.7 34.6 88.4 40.4 88.2 North Durham 21.9 65.6 0.0 7.3 39.2 52.6 107.0 73.1 98.6 Durham Region 24.4 87.9 11.6 14.4 32.1 35.7 68.9 34.0 74.9 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2008 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (2008 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rate of influenza was higher in Clarington in some years (2008, 2009, 2012, 2014 and 2016) and higher in the North Durham (Brock, Scugog and Uxbridge combined) from 2013 to 2016. All other municipalities have rates similar to Durham Region as a whole. Page 23 of 56

Figure 16: Pertussis incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Rate 21.5 19.8 19.7 18.2 16.8 11.1 5.2 5.3 2.0 4.4 8.5 7.1 9.1 8.6 5.5 1.3 0.0 0.6 3.1 1.1 2.0 2.6 1.2 Ontario Rate 21.0 18.8 6.5 9.3 16.4 10.6 6.1 3.9 4.4 2.9 5.1 5.2 10.1 7.4 6.7 3.2 1.0 2.2 8.3 2.2 2.3 5.6 3.7 Durham Male Cases 47 43 42 44 37 22 12 10 3 15 14 16 27 27 17 3 0 4 5 4 6 5 2 Durham Female Cases 51 49 51 44 46 34 15 18 8 9 34 25 26 24 16 5 0 0 15 3 7 12 6 Durham Total Cases 98 92 93 88 83 56 27 28 11 24 48 41 53 51 33 8 0 4 20 7 13 17 8 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Pertussis, or whooping cough, is an acute bacterial infection. Violent coughing, which may include a high-pitched inspiratory whoop, is the most well-known symptom (5). The Tdap vaccine protects individuals against tetanus, diphtheria and pertussis. Due to small numbers, we combined male and female cases to create more stable rates. Rates of pertussis have fluctuated over time with Durham Region and Ontario, showing a similar pattern in most years. Page 24 of 56

Figure 17: Invasive pneumococcal disease incidence rates, Durham Region and Ontario, 2003 to 2016 Rates and Cases 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Rate 7.3 8.4 7.7 4.1 7.7 7.1 8.4 9.0 8.9 9.0 7.0 7.4 6.5 7.0 Ontario Rate 8.1 8.5 7.4 7.6 7.6 8.5 10.0 9.6 10.1 10.2 8.3 8.7 8.1 8.6 Durham Male Cases 26 23 24 12 30 22 27 25 29 35 26 29 20 19 Durham Female Cases 14 24 20 12 16 21 24 31 27 22 19 19 23 28 Durham Total Cases 40 47 44 24 46 43 51 56 56 57 45 48 43 47 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2003 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 2003 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2003 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The bacterium Streptococcus pneumoniae causes invasive pneumococcal disease (IPD). This disease can cause serious illnesses such as pneumonia, blood infection, and meningitis (5). Ontario added the pneumococcal conjugate vaccine to their routine immunization schedule in 2005 for children less than two and high-risk children less than five (6). Due to small numbers, we combined male and female cases to create more stable rates. We excluded data prior to 2003 due to inconsistent reporting. Rates in both Durham Region and Ontario increased slightly between 2005 and 2012, then decreased in 2013 and have remained stable since then. Page 25 of 56

Sexually transmitted and blood-borne infections Sexually transmitted infections and blood-borne infections are passed mainly from person-to-person through sexual contact, needle use, blood transfusion, and from mother to infant during pregnancy and delivery (7). Reportable sexually transmitted and blood-borne infections in Ontario include: chlamydial infections; gonorrhea; group B streptococcal disease, neonatal; hepatitis B; hepatitis C; human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS); ophthalmia neonatorum; and syphilis. HIV data is not available for Ontario prior to 2005 so only AIDS data is included in all sexually transmitted and blood-borne Infection totals for those years. Page 26 of 56

Figure 18: All sexually transmitted and blood-borne infections incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 83.5 89.6 87.8 59.9 117.2 85.8 86.9 93.6 116.2 156.5 167.6 188.3 214.0 196.0 221.2 216.8 252.0 263.2 264.4 268.1 265.6 292.8 310.8 Durham Female Rate 183.8 166.8 170.0 138.1 188.0 179.8 170.2 189.9 206.0 238.4 244.7 263.2 284.7 282.5 331.2 327.0 378.1 409.7 393.2 341.8 320.5 369.8 375.8 Ontario Male Rate 139.0 194.3 177.1 155.9 180.5 181.3 185.2 191.8 205.5 215.9 227.9 240.5 252.4 257.9 263.6 276.4 306.3 322.1 327.6 334.4 363.7 392.3 429.8 Ontario Female Rate 242.9 252.6 227.0 201.2 219.1 223.4 232.7 242.6 261.4 267.5 277.1 275.1 288.0 301.1 337.1 359.3 405.9 434.1 428.0 394.9 410.3 435.2 464.6 Durham Male Cases 189 207 206 144 288 215 223 245 310 427 467 535 619 575 657 651 767 810 826 849 852 952 1,026 Durham Female Cases 420 389 404 336 468 457 443 505 559 662 695 762 840 849 1,012 1,013 1,190 1,307 1,273 1,122 1,065 1,245 1,284 Durham Total Cases 609 596 610 480 756 672 666 750 869 1,089 1,163 1,297 1,461 1,425 1,672 1,664 1,958 2,121 2,099 1,971 1,917 2,198 2,310 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rates of sexually transmitted and blood-borne infections have been increasing in Durham Region and Ontario since 1997. There was a decrease in rates between 2011 and 2013 in Durham Region and Ontario females; however, rates have begun to increase again since. Page 27 of 56

Figure 19: Chlamydia incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 50.8 39.0 36.2 33.3 48.8 54.7 53.4 61.5 79.8 83.2 92.2 109.5 124.8 115.6 140.7 145.5 176.1 186.8 193.3 193.5 186.4 207.9 211.7 Durham Female Rate 152.3 126.5 134.7 118.8 140.6 154.2 143.3 162.8 174.3 190.5 197.6 208.6 224.4 226.3 261.1 271.5 324.1 356.7 342.3 293.7 266.9 313.7 321.3 Ontario Male Rate 61.7 53.9 47.7 50.3 66.1 74.8 83.4 92.3 104.5 111.9 122.0 129.6 132.8 138.0 148.4 163.2 190.9 207.7 215.3 215.8 227.0 249.8 271.9 Ontario Female Rate 187.5 164.1 143.2 136.6 150.4 156.6 166.7 179.1 195.9 199.8 210.0 218.4 223.7 232.6 268.0 295.0 341.8 371.1 366.1 336.2 345.8 371.4 393.8 Durham Male Cases 115 90 85 80 120 137 137 161 213 227 257 311 361 339 418 437 536 575 604 613 598 676 699 Durham Female Cases 348 295 320 289 350 392 373 433 473 529 561 604 662 680 798 841 1,020 1,138 1,108 964 887 1,056 1,098 Durham Total Cases 463 385 405 369 470 529 510 594 686 756 818 915 1,024 1,019 1,218 1,278 1,556 1,714 1,712 1,577 1,485 1,732 1,797 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Chlamydia infection is frequently asymptomatic (5). In Ontario, chlamydia is the most commonly reported sexually transmitted infection. The rate is higher among females and increased between 1997 and 2011. The rates decreased between 2011 and 2013 in both Durham Region and Ontario females and levelled off among Durham Region males; however, rates increased again between 2014 and 2016. Page 28 of 56

Figure 20: Chlamydia age-specific incidence rates, Durham Region and Ontario, 2012 to 2016 combined Rates and Cases 10-14 15-19 20-24 25-29 30-39 40-49 50-59 60+ Durham Male Rate 1.9 382.7 1033.1 689.2 229.9 91.1 29.2 5.7 Durham Female Rate 13.3 1145.5 1848.8 786.4 280.8 87.1 18.7 2.7 Ontario Male Rate 2.0 379.6 1032.7 741.3 316.0 112.1 40.9 7.8 Ontario Female Rate 25.0 1292.5 1877.9 874.1 333.8 99.4 30.6 3.9 Durham Male Cases 2 453 1,258 712 460 214 74 16 Durham Female Cases 13 1,284 2,137 802 604 215 48 9 Durham Total Cases 15 1,737 3,395 1,514 1,064 429 122 25 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rate of chlamydia was higher among females in most age groups. Reported rates were highest among youth and young adults aged 15 to 29. In this report, we excluded rates among those aged less than 10 due to small counts. Page 29 of 56

Figure 21: Chlamydia incidence rates in youth ages 15 to 19, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 218.3 132.4 110.3 101.4 103.3 206.1 174.3 131.8 201.4 167.5 170.7 245.4 309.7 264.8 300.2 357.3 370.8 357.0 359.9 309.4 367.0 371.2 514.9 Durham Female Rate 1116 762.5 983.1 794.4 978.4 1106 928.6 957.3 1034 1006 978.2 1152 1282 1172 1323 1313 1468 1516 1230 1056 1005 1150 1291 Ontario Male Rate 155.9 132.5 109.3 111.2 146.8 154.5 184.9 192.3 205.4 219.3 234.0 241.4 228.5 245.6 272.6 319.6 353.2 370.5 379.2 345.7 362.5 383.8 427.5 Ontario Female Rate 1053 931.3 790.6 762.4 864.4 849.1 916.1 963.9 1023 1055 1055 1073 1036 1032 1172 1259 1424 1477 1374 1221 1226 1263 1375 Durham Male Cases 34 21 18 17 18 37 33 26 41 35 37 55 72 63 73 88 92 89 89 75 87 86 116 Durham Female Cases 163 114 151 126 162 192 169 181 200 199 200 246 286 268 311 313 350 361 288 242 225 252 277 Durham Total Cases 197 135 169 143 180 229 202 207 241 234 237 301 358 331 385 401 442 450 377 317 312 338 393 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The chlamydia rate is higher among females aged 15 to 19 than males and increased between 1995 and 2011 in Durham Region and Ontario. Rates decreased between 2011 and 2013 in both Durham Region and Ontario females in this age group and levelled off among males; however, since 2014, rates have begun to increase again in both Durham Region and Ontario males and females. Page 30 of 56

Figure 22: Chlamydia incidence rates in young adults aged 20 to 24, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 290.8 304.1 186.9 268.1 420.7 286.4 329.4 366.0 485.3 480.7 610.0 657.2 777.7 669.6 749.3 841.1 1066 1009 1062 1016 972.1 1037 1079 Durham Female Rate 825.4 890.9 738.0 797.3 908.7 939.5 860.6 1152 1034 1169 1261 1291 1390 1355 1408 1513 1872 2095 2095 1761 1568 1915 1919 Ontario Male Rate 338.7 289.2 258.3 270.3 355.6 388.9 427.4 484.7 554.0 602.5 672.0 671.5 684.9 707.2 754.0 833.2 965.7 1028 995.6 976.3 992.0 1071 1119 Ontario Female Rate 1048 930.9 824.2 780.7 851.5 924.8 944.9 1047 1147 1169 1232 1277 1310 1326 1488 1573 1825 1953 1928 1748 1753 1937 2017 Durham Male Cases 42 44 27 40 64 45 53 61 84 87 113 127 155 136 153 175 227 221 245 244 239 258 272 Durham Female Cases 115 124 101 112 129 136 128 179 168 199 223 235 259 260 274 300 383 442 460 403 368 452 454 Durham Total Cases 157 168 128 152 193 181 181 240 252 286 336 362 415 396 428 475 610 663 705 647 607 710 726 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The chlamydia rate is higher among females aged 20 to 24 than males and increased between 1997 and 2011 in Durham Region and Ontario. Rates decreased between 2011 and 2013 in both Durham Region and Ontario females in this age group and levelled off among males; however, since 2014, rates have begun to increase again among both Durham Region and Ontario males and females. Page 31 of 56

Figure 23: Chlamydia incidence rates in young adults aged 25 to 29, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 125.1 81.6 137.6 73.1 131.4 169.8 185.6 258.6 251.9 346.5 318.4 410.1 334.0 431.4 516.8 440.6 562.9 685.8 671.2 736.1 647.8 695.7 695.2 Durham Female Rate 195.3 199.3 279.9 198.9 205.8 219.8 262.9 278.4 338.4 494.5 433.0 388.5 382.1 514.7 560.4 564.1 688.5 824.1 862.7 826.7 714.5 700.4 831.5 Ontario Male Rate 160.2 150.2 145.4 145.6 205.3 228.8 245.1 293.7 334.2 371.2 384.2 431.9 426.3 462.7 477.2 519.3 600.2 660.9 685.9 692.9 716.4 782.8 819.7 Ontario Female Rate 341.6 311.0 285.9 286.6 316.8 336.2 370.9 394.2 435.2 442.9 462.5 498.6 507.0 557.5 632.5 705.6 789.4 862.8 855.1 811.0 855.1 902.5 940.0 Durham Male Cases 21 13 21 11 20 26 29 41 40 56 53 69 57 75 91 78 103 128 129 145 133 149 156 Durham Female Cases 34 33 45 31 32 34 41 43 53 79 71 65 65 90 101 104 129 156 166 162 144 147 183 Durham Total Cases 55 46 66 42 52 60 70 84 93 135 124 134 122 165 192 182 232 285 295 307 277 296 339 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department August 2017; iphis, Ontario, 1994 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The chlamydia rate is higher among females aged 25 to 29 than males and increased between 1997 and 2011 in Durham Region and Ontario. Rates decreased between 2012 and 2014 in Durham Region females and between 2013 and 2014 in Durham Region males; however, rates have levelled off among Durham Region males and begun to increase again among Durham Region females in this age group. Rates have increased since 2013 in Ontario males and females. Page 32 of 56

Figure 24: Chlamydia incidence rates, Durham Region by municipality, 2008 to 2016 Rates by Municipality 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pickering 220.4 210.9 335.5 330.4 277.9 248.4 244.2 288.4 295.3 Ajax 262.0 273.8 287.6 340.4 357.9 290.8 281.0 305.7 305.7 Whitby 159.6 208.0 205.3 229.8 241.0 215.7 194.2 210.2 217.8 Oshawa 223.1 246.7 263.8 308.5 320.5 301.6 271.2 307.3 348.7 Clarington 154.2 127.4 176.7 182.5 173.2 174.4 163.5 217.2 201.1 North Durham 103.9 83.8 163.6 125.3 144.4 154.3 141.6 187.1 132.6 Durham Region 202.1 209.5 251.4 273.5 269.1 244.5 227.4 261.7 267.5 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2008 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (2008 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rate of chlamydia is higher most years in Pickering, Ajax, and Oshawa than Durham Region as a whole. The rate is lower in Whitby, Clarington, and the northern municipalities (Brock, Scugog and Uxbridge combined). Most municipalities showed a similar pattern as Durham Region, they increased to 2011 or 2012, decreased to 2014 then have increased since. Page 33 of 56

Figure 25: Chlamydia incidence rates in females aged 15 to 24, Durham Region by municipality, 2008 to 2016 Rates by Municipality 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pickering 1286.7 1265.5 1825.6 1968.3 1551.5 1034.0 1018.0 1530.7 1430.4 Ajax 1518.1 1633.0 1672.3 2103.4 1921.7 1527.8 1479.8 1513.9 1689.0 Whitby 1006.7 1315.5 1200.0 1356.2 1343.7 1212.1 1079.7 1165.9 1334.2 Oshawa 1724.8 1849.5 2103.6 2214.4 2222.6 1919.4 1849.0 1953.0 2434.7 Clarington 1127.2 1058.4 1293.3 1305.1 1164.9 1125.4 949.3 1509.5 1164.5 North Durham 864.6 631.1 1210.0 924.2 1077.6 1282.4 828.2 1455.5 889.5 Durham Region 1361.3 1403.8 1654.6 1787.9 1648.2 1408.3 1293.1 1546.5 1620.4 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2008 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (2008 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. The rate of chlamydia among females aged 15 to 24 is consistently higher in Oshawa than Durham Region as a whole. The rate is lower than Durham Region in Whitby, Clarington, and the northern municipalities (Brock, Scugog and Uxbridge combined) and similar in Ajax and Pickering. Oshawa, Whitby and Ajax showed a similar pattern as Durham Region, rates increased to 2011, decreased to 2014 then have increased since. This increase is greatest in Oshawa. Rates increased between 2014 and 2015 in North Durham, Pickering and Clarington but then decreased between 2015 and 2016. Page 34 of 56

Figure 26: Gonorrhea incidence rates, Durham Region and Ontario, 1994 to 2016 Rates and Cases 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Durham Male Rate 19.9 16.0 13.2 12.1 14.6 15.6 14.0 14.9 12.4 19.1 16.9 19.7 27.3 34.4 31.3 21.3 24.6 27.3 21.8 26.5 35.2 37.8 50.9 Durham Female Rate 26.3 18.9 15.6 12.7 15.7 16.1 16.1 16.9 19.5 17.3 16.2 20.0 23.7 23.3 31.1 27.4 24.8 26.6 27.5 22.2 29.8 34.8 31.6 Ontario Male Rate 35.2 31.7 23.9 20.5 24.0 23.5 29.4 30.5 31.4 33.7 34.7 33.6 39.2 37.8 36.1 32.0 35.5 38.8 38.5 46.1 61.6 63.8 72.3 Ontario Female Rate 25.4 22.8 18.0 13.5 15.6 15.9 19.3 19.0 19.4 21.0 21.8 19.6 22.3 25.5 25.7 24.7 27.9 28.4 26.9 26.6 31.9 31.3 36.2 Durham Male Cases 45 37 31 29 36 39 36 39 33 52 47 56 79 101 93 64 75 84 68 84 113 123 168 Durham Female Cases 60 44 37 31 39 41 42 45 53 48 46 58 70 70 95 85 78 85 89 73 99 117 108 Durham Total Cases 105 81 68 60 75 80 78 84 86 100 93 114 149 172 189 149 153 170 157 157 212 240 276 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 1994 to 2016, extracted by Durham Region Health Department July 2017; and Ontario Population Estimates/Projections (1994 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Like chlamydia, gonorrhea infections are frequently asymptomatic (5). In Ontario, gonorrhea is a commonly reported sexually transmitted infection. In Ontario and Durham Region, rates of gonorrhea are higher among males compared to females. Rates of gonorrhea increased in both Durham Region and Ontario from 1997 to 2006. Rates remained relatively stable between 2006 and 2009 and began to increase again after 2009, especially among males. Page 35 of 56

Figure 27: Gonorrhea age-specific incidence rates, Durham Region and Ontario, 2012 to 2016 combined Rates and Cases 15-19 20-24 25-29 30-39 40-49 50+ Durham Male Rate 34.6 147.0 95.8 60.0 33.2 7.1 Durham Female Rate 116.9 137.6 78.4 33.9 10.9 2.2 Ontario Male Rate 48.5 164.3 171.5 103.6 50.1 11.9 Ontario Female Rate 103.9 134.1 76.7 34.1 12.1 2.1 Durham Male Cases 41 179 99 120 78 38 Durham Female Cases 131 159 80 73 27 13 Durham Total Cases 172 338 179 193 105 51 Data Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis) database, 2012 to 2016, extracted by Durham Region Health Department, August 2017; iphis, Ontario, 2012 to 2016, Public Health Ontario, Accessed August 2017; and Ontario Population Estimates/Projections (2012 to 2016), Ontario Ministry of Health and Long-Term Care, Accessed July 2017. Reported rates of gonorrhea are highest among young adults aged 20 to 24 and among females aged 15 to 19 in both Durham Region and Ontario and also among Ontario males aged 25 to 29. Rates are higher in Ontario males than Durham Region males for all age groups. Rates are similar in Ontario and Durham Region females for all age groups. For this report, we excluded rates among those aged 14 and younger due to small counts. Page 36 of 56