RIVERSIDE COUNTY: Woman on a mission to get clean needles to drug users

Motivated by friends' deaths, she is setting up a nonprofit group and lobbying local officials -- with some offering resistance and some expressing support.

Growing up, Katie Chamberlain walked the straight and narrow as a “dorky straight-A student.”

The Riverside resident attended a Christian school until ninth grade. The stark reality of drugs hit home the second week of classes, when a classmate died of a heroin overdose.

Over the years, the 27-year-old watched with sadness and despair as too many friends fell victim to illegal narcotics.

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Hepatitis C cases on rise in northeast Indiana, Allen County proposes needle-exchange program

FORT WAYNE, Ind. (October 6, 2015) — Officials in northeastern Indiana’s Allen County have taken a first step toward creating a needle exchange to combat the county’s growing hepatitis C cases.

The Fort Wayne-Allen County Board of Health unanimously approved a resolution Monday calling for a needle-exchange program to slow the spread of the disease among intravenous drug users.

Allen County has had about 270 new hepatitis C cases during the first nine months of 2015. That’s more than in any of the past three years.

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Why needle exchange programs work

 By Kara Blake

As a vocal advocate for harm reduction and needle exchange services, I have often been asked, “why needle exchange?” To public health professionals, needle exchange programs (NEPs) are an obvious and urgently needed intervention. Research study after research study continues to show conclusively that NEPs reduce the transmission of HIV and viral hepatitis, are tremendously cost-effective, and provide a range of other services that benefit the participants and greater community. Even though the evidence is clear, public and political pushback against NEPs persists across the country. Cape Cod is no exception.

Without proper information, it might make sense that a citizen or politician may be resistant to the idea of a needle exchange. How could this intervention possibly support drug users? Won’t this only perpetuate their addiction and its consequences? Won’t this facility increase crime and drug use in my community? The answer, plainly, across the board, is no.

Someone who accesses a needle exchange is making what can be the first contact with a professional about their addiction. Recognizing that not all people using drugs are ready, willing or able to stop using at that moment, staff compassionately discuss and educate participants on the potential harms associated with their drug use, and how to reduce those harms. Rather than shame drug users and require abstinence, staff meet and talk with people where they are in their addiction without judgment. This approach is called “harm reduction.” Through such relationships, participants are also able to access services such as screening for HIV, hepatitis C and sexually transmitted infections, access to Narcan and overdose prevention, enrollment in health insurance, and referrals to substance use treatment and medical care.

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What’s behind Hepatitis C increase in Franklin County?

GREENFIELD — As Hepatitis C rates have risen sharply in Franklin County, neighboring Hampshire County has seen a slower trend and a lower rate, tempered perhaps by prevention efforts.

Franklin County’s rate of 131 newly discovered Hepatitis C cases per 100,000 residents in 2014 was just under the statewide rate of 134, while Hampshire County trailed with a rate of 73. This is a population-adjusted measure, using numbers collected by the Mass. Department of Public Health. In simple numbers, Franklin County had 94 new cases in 2014 and Hampshire County 116.

Greenfield saw 40 newly discovered cases of the blood-borne liver disease in 2014, while its larger sister to the south saw 29. Northampton’s population of 28,549 at the last census outnumbered Greenfield 3 to 2.

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Huntington needle exchange program set to launch

HUNTINGTON, W.Va. — West Virginia’s first-of-its-kind syringe exchange program will launch Wednesday in Huntington and Cabell County.

“The community has recognized a need and demand of this service for some time and we’re just excited to be able to offer it,” said Michael Kilkenny, the physician director for the Cabell-Huntington Health Department.

The pilot project will involve education and treatment resources to make clean needles more readily available. There will also be efforts to stop the spread of infectious diseases, like hepatitis B and hepatitis C, by giving addicts points of contact within the health department.

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Hepatitis C cases prompt public health emergency in Fayette County

FAYETTE COUNTY -State Health Commissioner Jerome Adams, M.D., M.P.H., has declared a public health emergency for Fayette County, allowing the county health department to establish a syringe exchange program as part of a broader effort to reduce the spread of Hepatitis C.

"Fayette County is battling a Hepatitis C epidemic tied to intravenous drug use," said Dr. Adams. "County officials have submitted a comprehensive, multi-pronged plan to combat this epidemic, and a syringe exchange is one part of this effort to help reduce the spread of this devastating disease."

Senate Enrolled Act 461 made syringe exchange programs legal in Indiana for the first time, under certain circumstances. The law lays out a set of procedural and substantive requirements that local communities must meet in order for an emergency declaration to be considered by the state health commissioner. 

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A Brief Overview: Outbreaks of Acute HCV Infections in the U. S., by Alan Franciscus, Editor-in-Chief

In this review, I will discuss the outbreaks of acute infections of hepatitis C across the United States in urban and rural centers. 

Before I start discussing this very important issue, I would like to set the stage by going over the case definition of hepatitis C (HCV) acute infection as defined by the Centers for Disease Control and Prevention (CDC): 

“Laboratory-confirmed infection with infection with acute illness of discreet onsite.  An acute illness is considered as the presence of any sign or symptom of acute viral hepatitis plus either jaundice or elevated alanine aminotransferase >400 IU/L. In 2012, the surveillance case definition was expanded to include cases with negative HCV antibody followed by positive antibody within six months.”

To me there are problems with the CDC case definition.  Regarding the first part of the definition—an estimated two-thirds of people acutely infected have few or no symptoms.  This means that they are missing the majority of people who are acutely infected with HCV.  The new case definition regarding prior antibody testing is better, but it does not accurately capture people who are new to injecting drugs or people who have never been tested for hepatitis C.  However, it is understandable how difficult it is to set the criteria to define an acute infection.   Note:  In “Snapshots” this month there is a recap of a study that may provide a test to identify acute cases of HCV.

In the July 2015 HCV Advocate Mid-Monthly Edition, I wrote about an article published in the Annals of Internal Medicine titled “Underascertainment of Acute Hepatitis C Virus Infections in the U.S. Surveillance System: A Case Series and Chart Review,” by S Onofrey, MPH et. al.  The authors concluded that only 1% of acute infections has been reported to the CDC based on their case definition.  Keep the 1% in mind when reading the information below. 

Massachusetts
In July 2011 I wrote about the Massachusetts outbreak of acute HCV among young people who inject drugs.  In the CDC report Massachusetts initiated a comprehensive surveillance system and identified 1,925 new cases of HCV infections among people aged 15-24 years during 2007 to 2009.  Of these cases, 1026 were confirmed new hepatitis C infections and the remaining cases were classified as probable.  It was also interesting that the new hepatitis C infections were not just confined to the major metropolitan and suburban areas of Boston, but high rates were also found in smaller cities and rural areas.  It was also reported that the incidence of new HCV infections were similar in women and men and were seen mostly among non-Hispanic whites.  In the analysis, 72% of the people reported current or past injection drug use.  Among the people who self-disclosed that they injected drugs—85% used heroin, 29% cocaine, 1% methamphetamine and 4% had used other drugs.  Some of the characteristics seen in the Massachusetts outbreaks —rural, young, mostly White using heroin—were the beginning of a trend seen throughout the country. 

Massachusetts has an extensive network of needle exchanges.  One can only imagine what the number of acute infections would be without a needle exchange network.

Wisconsin
In “Notes from the Field:  Hepatitis C Virus Infections Among Young Adults—Rural Wisconsin, 2010,” a report from the CDC issued on May 18, 2012 /61(19);358-358 a number of outbreaks in rural counties of Wisconsin were discussed.  It was reported that in 6 contiguous rural counties of Wisconsin that in persons under 30 yo that the number of HCV infections had increased from an average of 8 cases per year during 2004 – 2008 to an average of 24 cases per year during 2009 – 2010. 

The CDC investigated 25 cases during 2010 of the adults under 30 years old who resided in the 6 counties.  Of these patients 7 had jaundice (a rare symptom of acute HCV).  All 21 had positive antibody tests.  Twenty-one had positive EIA with signal-to-cutoff ratio or had a test to confirm the presence of HCV RNA (viral load test).  Additionally, seventeen patients were interviewed. Of the patients who were interviewed (17 pts) 94% had either injected drugs, snorted drugs or both.

The age group that had the highest prevalence was those 20-29 yo, which is a national trend of people who inject drugs in rural areas. No information about the sex of the patients was given in the report.  

Ohio
In Ohio, the number of confirmed cases of acute cases HCV was 112 in 2013 and 105 in 2014.  The demographics are similar to the demographics in other outbreaks across the U.S. —mostly white, equally divided among gender and many of the acute cases occurred in rural settings. 

Indiana
The May 1st issue of the Morbidity and Mortality Weekly Report (MMWR), contained “Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone—Indiana, 2015, by C Conrad,” which describes a recent outbreak of HIV and HCV in a rural community of Indiana.  On January 23, 2015 the Indiana State Department of Health began an investigation on an outbreak of HIV after 11 cases were reported and confirmed.  Although little attention was given to HCV there was a confirmed HIV/HCV coinfection rate of 84.4%!  All of the people who injected drugs reported crushing, dissolving and injecting oxymorphone tablets as well using other drugs including methamphetamine and heroin.  The total number of people who tested positive for HIV was 135.  The community in rural southeastern Indiana had a population of 4,200.  The age range was 18 to 57 yo (median 35 yo), 54.8% were male.  

The response to the outbreak is best summed up by a statement in the MMWR: “A public health emergency was declared on March 26 by executive order.  The response has included a public education campaign, establishment of an incident command center and a community outreach center, short-term authorization of syringe exchange, and support of comprehensive medical care including HIV and hepatitis C virus care and treatment as well as substance abuse counseling and treatment.”  Hopefully, the ‘short-term’ will be changed to ‘permanent.’

Maine
On July 6, 2015 the Portland Press Herald reported on a surge of hepatitis C cases: during 2013 to 2014 the incidence of acute HCV increased from 9 to 31 cases and there were 14 cases in the first 6 months of 2015.   The users who were interviewed stated that they had started with opiates like Oxycontin and switched to heroin. This is a recurring theme.   Maine has 5 needle exchange programs.  

Kentucky, Tennessee, Virginia and West Virginia (2006-2012)
The CDC released an MMWR report on May 8, 2015 titled “Increases in Hepatitis C Virus Infection Related to Injection Drug Use Among Persons Aged ≤ 30 Years –Kentucky, Tennessee, Virginia, and West Virginia, 2006—2012,” by J E Zibbell and Colleagues detailing the outbreaks in the Appalachia region of the U.S.   

A total of 1,377 cases of acute HCV were reported to the CDC during the period 2006-2012 from Kentucky, Tennessee, Virginia and West Virginia.  There were 1,374 cases reported where the age was available—616 (44.8%) were ≤ 30 yo (median age 25 yo—range in urban and non-urban 6-30 yo).

The number of persons who were non-Hispanic whites in non urban settings was 247 (78.4%); males, 156 (49.5%); in urban counties, 249 (82.7%) cases were non-Hispanic whites, and 155 (51.5%) were males. See Figure 1 below.   

Comments:  The trend of acute HCV outbreaks that started in Massachusetts is continuing across the United States.  This includes more adolescents and young adults injecting, infecting as many women as men and in rural more than urban settings.   What is even more disturbing is the reaction of the local and state governments—needle exchange being started post-outbreak rather than establishing needle exchange as prevention.  Almost every outbreak has resulted in the establishment of a needle exchange program after an outbreak.  If needle exchange programs had been in place before an outbreak many of the HIV and HCV infections could have been prevented. 

Figure 1

Figure 1.  Incidence of acute hepatitis C among persons ≤ 30, by urbanicity and year –Kentucky, Virginia, Tennessee, and West Virginia, 2006 –2012.

Source:  http://hcvadvocate.org/news/newsLetter/2015/advocate0815.html#1

Hepatitis C surge in central Ohio may spur needle-exchange program

The boom in heroin use paired with a surge in hepatitis C infections in Franklin County and across Ohio have heightened worries about the spread of other diseases, particularly HIV, and sparked conversations about a local needle exchange.

Hepatitis C, a treatable but sometimes deadly viral disease that attacks the liver, was diagnosed in 719 people in Franklin County five years ago. The number had nearly doubled by last year, to 1,369, according to data from Columbus Public Health. So far this year, the county is on pace to record more than 1,400 cases. In just one year, the number of hepatitis C cases statewide grew from 10,020 in 2013 to 15,887 in 2014.

Some of that most certainly is due to a push for testing at-risk baby boomers that has been fueled by better treatments. But there’s little question among doctors and public-health leaders that needle-sharing by people using heroin and other drugs is playing a role. Last year, 603 of the cases in Franklin County were in people 34 or younger.

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Madison County plans 4 sites for needle-exchange program - SFGate

ANDERSON, Ind. (AP) — Health officials are working to open four needle-exchange sites in a central Indiana county after being granted state approval for the program because of disease being spread among intravenous drug users.

The Madison County Health Department wants to have the sites open by late July or early August — two in Anderson and one each in Alexandria and Elwood.

People using the program will have access to other services at each site, such as substance abuse treatment programs and assistance in obtaining food and housing, county public health coordinator Stephanie Grimes told the Herald Bulletin

Madison County plans 4 sites for needle-exchange program - SFGate

Louisville needle swap aims to stop repeat of nearby HIV, hepatitis C outbreaks

A trio of deadly afflictions is ripping through a rural county in southern Indiana.

More than 130 patients in Scott County, Ind., tested positive for HIV in less than a year, making the community of about 24,000 people the site of one of the worst outbreaks in decades.

Among the infected are 114 who also tested positive for another blood-borne disease — hepatitis C, which attacks the liver.

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Louisville prepares to launch needle-exchange program

LOUISVILLE, Ky. (AP) — Kentucky's largest city is taking the lead as its first to offer a needle-exchange program, but other communities are reviewing such swaps as a way to combat heroin addiction, prevent the spread of diseases and steer drug users toward treatment.

Needle exchanges in Louisville will begin Wednesday in a trailer parked outside the city's Public Health and Wellness headquarters, health officials said Tuesday. The goal is to prevent the spread of HIV and hepatitis C and boost treatment among drug users.

"This is about the public safety of our entire community," said Louisville Metro Council member David Yates.

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Lee County Health Department offers Hep C rapid test

Also looks into creating a needle exchange in response to heroin increase in county 

 DIXON – It's not just law enforcement agencies that are taking a proactive approach to Lee County's increased heroin usage — the health department is making strides, too.

This week, the Lee County Health Department started offering rapid screening for Hepatitis C. It's an action that Administrator Cathy Ferguson hopes will stave off any future heroin-related public health crises, like the one that southeastern Indiana has seen.

According to the latest figures, there are now 162 people in Indiana who have been diagnosed with HIV as part of an outbreak that, officials say, stemmed from the sharing of heroin needles.

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Comment | Benefits of needle exchange programs

Hospitalizations and deaths due to heroin overdoses are on the rise in Kentucky.

According to the Kentucky Injury Prevention and Research Center, the number of Kentuckians hospitalized for heroin overdoses more than doubled from 2011 to 2012. In addition, deaths from heroin overdoses among Kentucky residents have skyrocketed from 12 in 2008 to 215 in 2013. Kentucky also has some of the highest rates of drug overdoses and acute hepatitis C infection in the nation.

This year, the General Assembly enacted and Gov. Beshear signed into law permissive legislation that enables local jurisdictions to establish needle exchange programs (NEP), also known as “harm reduction programs.” To some, a needle exchange may sound like a program that helps intravenous drug users feed their habit. To the contrary, the intent of an NEP is to protect public health and create a path for heroin users to get treatment while preventing the spread of diseases through the sharing of needles.

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Indiana drafting county profiles of HIV, hepatitis C rates

Effort aims to help officials detect outbreaks, determine eligibility for needle exchange programs.

State health officials are creating profiles of HIV and hepatitis C rates for all 92 Indiana counties to help local officials detect outbreaks of either disease and determine whether they can seek help under a new needle-exchange law, a top state disease expert said Wednesday.

State epidemiologist Pam Pontones told members of the Indiana State Department of Health's executive board that the agency hopes to quickly complete work on those profiles, which also will include intravenous drug use rates for each county.

Having that data will help county health officials determine whether they're facing an outbreak of either virus and — if it's tied to IV drug use — whether they can request state approval for a needle-exchange program to try to contain that outbreak, she said.

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Pa. Law Prohibits Needle Exchanges That Can Save Lives

Tens of thousands of Pennsylvanians crave daily injections of heroin. Beyond the threat of overdose is the threat of being exposed to HIV and hepatitis C, both deadly and expensive illnesses that are easily spread through contaminated needles.

But in Pennsylvania, distributing sterile syringes is a criminal act.

For years, Dianna Pagan feared that giving out clean syringes in Reading would land her in jail. Officials there recently agreed to let her needle exchange operate, though she’s faced numerous setbacks for more than a decade, including being shut down following the threat of prosecution.

Read more: http://www.nbcphiladelphia.com/news/health/Pa-Law-Prohibits-Needle-Exchanges-That-Can-Save-Lives-303210321.html#ixzz3ZnJgqziW

Entering Leg 2 of syringe exchange triathlon

With law enacted, implementation adheres to prescribed steps

Indiana is about to legalize syringe exchange. This herculean bipartisan effort, led by Rep. Ed Clere, R-New Albany, enacted evidence-based public health policy in a state with a long-starved public health system.

As triathlons go, the syringe exchange legislative process was a tough first leg that will be followed by a second leg of policy implementation and a final leg of impact evaluation. We are now at T1 – that transition between Legs 1 and 2. And Leg 2 will be challenging.

Syringe exchange is part of a comprehensive public health effort to reduce HIV and hepatitis C among drug-injecting populations. Programs “exchange” sterile for used syringes, and link participants to screening and treatment for Hepatitis C and HIV, as well as substance abuse treatment. Studies over the past 30 years have demonstrated their effectiveness at reducing hepatitis C and HIV.

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Indiana lawmakers OK needle exchange programs for communities with HIV, hepatitis C outbreaks

INDIANAPOLIS — Lawmakers looking to prevent a repeat of an HIV outbreak that has rocked a southern Indiana county sent Republican Gov. Mike Pence a measure Wednesday that would allow communities to implement needle-exchange programs if they can prove they're in the midst of an epidemic tied to intravenous drug use.

Pence, who opposes needle exchanges as part of anti-drug policy, said in a statement Wednesday that he looks forward to signing the legislation into law.

He said his office worked with lawmakers to develop "a legal framework" that would give state health officials the resources and flexibility they need to handle health emergencies.

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Why Congress should rethink syringe issue

(CNN)If someone told you that your city had started a program providing clean needles to injecting drug users, would that make you want to start injecting drugs yourself? The answer, of course, would be no. Yet for decades, many have stood by the belief that such programs, known as syringe exchange or syringe services programs, promote and encourage drug use. Indeed, for Congress, it became the rationale behind a ban implemented in 1988 that prohibits the use of federal funds for these programs.

But an overwhelming body of scientific evidence continues to show that this is simply not true.

As a result of the recent spikes in HIV and hepatitis C infections among injecting drug users in rural Indiana and Kentucky, the controversial topic of syringe exchange programs has come to the fore again. And this time, scientific evidence and sound public health practices prevailed as both states authorized the implementation of syringe exchange programs to help curb the spread of these two blood-borne diseases that can be spread by contaminated syringes.

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Maine sets a record for drug needle exchanges

The total hit 564,847 last year, up 238 percent since 2010, as heroin use surged and clinics like Portland's worked to prevent cases of HIV and hepatitis C.

State law has allowed needle exchanges in Maine since 1997, but the program only became active in 2002. There are four state-certified needle exchange programs, operating at six sites: Portland, Lewiston, Augusta, Bangor, Ellsworth and Machias.

All of Maine’s programs operate without federal or state funding. Federal funding for needle exchange has been banned since 1988 (except for a period from 2009 to 2012) and states often don’t provide funding either, so the programs run mainly on private grants or donations.

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Hepatitis on the Hill —Lucinda K. Porter, RN

I have been doing hepatitis C advocacy for nearly 18 years. My hope and fury have never been greater. We can cure hepatitis C, but people are having a hard time getting the medications. The Centers for Disease Control and Prevention (CDC) recommends HCV testing for baby boomers, but we aren’t doing it. This is the sort of stuff that drives me wild.

HCV Advocate Editor-in-Chief Alan Franciscus asked me if I would attend “Hepatitis on the Hill,” held in Washington, DC on March 9 and 10. After years of complaining about the government’s anemic response to the hepatitis C epidemic, I automatically said “yes.”

Approximately 75 hepatitis advocates met in Washington, DC, for Hepatitis on the Hill. Hosted by the Hepatitis Appropriations Partnership, Hep B United and the National Viral Hepatitis Roundtable, and supported by the National Alliance of State and Territorial AIDS Directors, the event focused on increasing the federal response to the viral hepatitis epidemic in the United States.

Hepatitis C virus (HCV) is killing more Americans every year than HIV is, but dollar for dollar, hep C funding is pennies compared to HIV’s. State health departments’ Viral Hepatitis Prevention Coordinator programs receive less than $1 in federal funding for every person living with viral hepatitis. In the meantime, hep C infection and death rates continue to rise. Immunizing all children against hepatitis B virus (HBV) also continues to be a problem.

Advocates from hep B and C groups attended Hepatitis on the Hill. The first day focused on core issues, particularly why now is the time for this level of advocacy. President Obama’s budgetary request for viral hepatitis programs is double that of previous budgets, and the advocates learned how to ask for support from their senators and congressional representatives.

The next day, advocates visited the offices of their senators and representatives on Capitol Hill, educating their staff on the experiences of people living with hep B and C. At each office, the advocates requested the following:

• Signature of House/Senate letter in support of the president’s proposed FY2016 budget to increase funding of the CDC’s Division of Viral Hepatitis to $62.8 million, and include the request in the member appropriations submissions
• Support the repeal of the federal funding ban on syringe services programs
• That their elected official would join the Congressional Hepatitis Caucus

Senator Bill Cassidy (R-LA), MD, spoke during lunch on Capitol Hill. Cassidy is a hepatologist, committed to issues surrounding viral hepatitis. Ronald Valdiserri, MD (deputy assistant secretary for health, infectious diseases, at the Department of Health and Human Services), and John Ward, MD (director of the CDC’s division of viral hepatitis), also spoke at Hepatitis on the Hill. Ward emphasized the urgent nature of acting now, saying we can prevent approximately 300,000 deaths.

Presentations by Reps. Brett Guthrie (R-KY), Mike Honda (D-CA), Charlie Dent (R-PA) and Hank Johnson (D-GA) were televised at the event. These congressional representatives introduced the Viral Hepatitis Testing Act of 2015 (HR 1101). In addition to being an ally in Congress, Johnson has been public about his hepatitis C status, treatment and eventual cure.

For information about how to support efforts to improve viral hepatitis funding and services, visit Lucinda Porter’s blog (blogs.hepmag.com/lucindakporter). The National Viral Hepatitis Roundtable and Caring Ambassadors Hepatitis C provide ongoing coverage of the latest news and advocacy alerts related to viral hepatitis in the U.S.

Portions of this article by Lucinda K. Porter first appeared in Hep Magazine, March 16, 2015.

http://hcvadvocate.org/news/newsLetter/2015/advocate0415.html#1