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Preventing Hepatitis C
and HIV Outbreaks
Presenters:
• Joan Duwve, MD, MPH, Chief Medical Officer, Indiana State Departmen...
Disclosures
Jerome Adams, MD, MPH; Joan Duwve, MD,
MPH; Scott Proescholdbell, MPH; Nidhi
Sachdeva, MPH; and Jinhee J. Lee,...
Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relation...
Learning Objectives
1. Inform attendees of the risks of infection disease
outbreaks related to injection drug use.
2. Iden...
Community Outbreak of HIV Infection Linked to
Injection Drug Use of Oxymorphone —
Indiana, 2015
Joan M. Duwve, MD, MPH
Chi...
Disclaimer
□ Joan Duwve has no conflicts to report
□ Trade names will be used in this presentation to
accurately reflect R...
Indiana HIV Outbreak Overview
□ Dec. 2014: 3 new HIV diagnoses in Austin IN
▫ DIS learned 2 had a common-needle sharing pa...
Indiana HIV outbreak: geographic distribution
Scott County pop. 24,000; Austin, IN pop. 4,200
Scott County
Contact Tracing and HIV Testing Results
2/4/2016
Named Contacts 515
Tested 454 (88.1%)
Refused testing 17 (3.3%)
Unable to...
Demographics of individuals infected with HIV
(N=189)
 58% male
 98% non-Hispanic white
 Median age 33.5 years
 93% re...
HIV+
HIV-
Not tested
Number of
Reported
Contacts
Size
Contact tracing network
Contact Type Frequency
Needle-sharing 59.7%
...
Geomapping of 89 HIV positive individuals identified a hotspot in Austin.
44% live within a ½ mile square area where 27% o...
Why Indiana?
Percent Change in Leading Causes of Injury Death*— Indiana,
1999–2009
501.5%
-30.8%
13.9%
22.5%
-11.1%
-100% ...
Geographic Variation in Opioid Prescribing in the
U.S.
Youth and Controlled Substances
Source: Indiana Youth Risk Behavior Survey, 2011
Source: Suryaprasad, Clin Infect Dis; 2014, 59(10):1411-1419
2006 2012
Emerging Epidemic of Hepatitis C Virus Infections A...
Gaps in Treatment Capacity, 2012
(2012 rates per 1,000 people ≥12 years of age)
Rate of past year opioid abuse or dependen...
Why Austin?
At least nine people have died so far this year from prescription
drug overdoses in Scott County, Indiana. Most of the fat...
Why Opana® ER ?
 2010 - reformulation of Oxycontin®
 Opana® quickly replaced Oxycontin® - snorted, injected
 2012 – Opa...
What We Needed to Control the Outbreak
 Expand HIV/HCV testing and capacity for early detection
 Routine HIV testing at ...
Credit: Philip Peters, MD; NCHHSTP/DHAP/Epidemiology Branch; CDC
Cumulative HIV infections associated with injection of
Op...
Community Outreach Center with One-Stop Shop
 Insurance enrollment
 Care coordination
 Syringe service program
 HIV an...
Communications
Acknowledgements
• Scott County Health Department
• Clark County Health Department
• Disease Intervention Specialists (EMA...
Tackling the Prescription Drug
and Opioid Abuse Epidemic
Jerome M. Adams, MD, MPH
Indiana State Health Commissioner
Lessons from Indiana
• Be aware… of risk factors and trends in your
community
• Look for touchpoints… and unique
opportuni...
Be Aware
Suryaprasad Clin Infect Dis; 2014, 59(10):1411-1419
Prescribing correlates with IDU,
unsafe injection practices, and
overd...
Scott County HIV Outbreak
• Rural injection of Rx oral opioid = largest
ever HIV outbreak in IN, largest IDU HIV
outbreak ...
Adapted from and with permission of Phil Peters, CDC
HIV Infection: Tip of a High-Mortality
Iceberg
HIV
Infection
Overdose...
Look for opportunities to intervene
Public Health and Policy
Behavior Change
Ignorance, denial
Ambivalence, conflicted
emotions. (Barriers!!!)
Collect info, s...
Outbreak Control
Interventions
• Little HIV awareness: multiple educational efforts including billboards,
infographics, we...
Indiana Syringe Exchange Law
• Local health officer declares to county/municipality:
– There is an epidemic of hepatitis C...
Bending the transmission curve…
Epidemic Curve 2.18.2016
1 1
2
1 1
8
3
5
9 9
1
9
7
18
14
11
22
17
9
5 5
3 3
5
2
1 11
0 0 0...
Continuum of HIV care in Austin, Indiana
May 15, 2015
N=156 N=95 N=87 N=69 N=33 N=0
Mean VL: 431,836
N=113
Continuum of HIV care in Austin, Indiana
February 18, 2016
Total diagnosed=189 (189 confirmed). Persons were ineligible if...
Partner…
… and speak to your
audience…
What I learned as an advocate
Public health does not always easily translate to
public policy, particularly in areas with ...
Transformative public health leadership is less about
knowing what to do, and more about knowing how to
get people to do i...
Syringe exchange programs=
Community Partnerships
• Need comprehensive programs, not handouts
– Handouts don’t facilitate ...
Testing at high risk venues = Jail/
Hospital/ SEP partnerships
• Need for testing in jails
– Sheriffs don’t want the hassl...
Medication assisted treatment= Partnerships
with providers, payers, community
• People don’t understand the concept, or th...
Diversion/ early release/ alternatives to
incarceration = partnership with the courts and
the community
• Need more of the...
Naloxone = partnership with first
responders, families
• We administered over 5000 doses in IN last yr
• Many still feel i...
Coverage= Partnership with
payers, Medicaid, hospitals,
docs
• Almost all HIV positive were uninsured
• Healthy Indiana Pl...
Be Aware
• Hepatitis rates are an indicator of IVDU, and
harbinger of potential HIV outbreak.
• KNOW YOUR LOCAL OVERDOSE S...
Be Aware
• Need to do state and local vulnerability
assessments
– CDC has released these, but can and should supplement
– ...
Look for opportunities to intervene
• Test at high risk venues
• Comprehensive SEPs
• Consider PREP among high risk indivi...
Partner
• Law enforcement
– Local, County, State police all play different but
important roles
– Prosecutors and judges ha...
Partner
• Hospitals
– Major touchpoint (ER), have resources, have
community standing, can advocate
• Faith based community...
Partner
• Federal partners (CDC, SAMHSA, HHS, etc)
other agencies (AG, Judicial, Mental Health,
Medicaid, etc)
• With the ...
Preventing
Hepatitis and HIV
Outbreaks
After Scott County: NC’s Overdose and
Communicable Disease Collaboration
Disclosure statement
• Scott Proescholdbell, MPH, has disclosed no
relevant, real or apparent personal or
professional fin...
Learning Objective
• Outline North Carolina’s plan to reduce
injection drug use and associated infectious
disease transmis...
Overview
• NC Overdose Situation
• NC Hepatitis C Situation
• Collaboration
• Next Steps
NC OVERDOSE EPIDEMIC
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014
Analysis by Injury Epidemiology and Su...
65
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Deathsper100,000population
Year
Motor Vehicle Traffic (Unintentional)
Drug P...
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014
Analysis by Injury Epidemiology and Su...
NC Heroin Deaths: 2008-2015*
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2008- 2015*
*2015 d...
NC Heroin Deaths: 2014
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2014
Analysis by Injury E...
Heroin Hosp. and ED Overdoses: 2008-2014
Source: N.C. State Center for Health Statistics, Vital Statistics-Hospital Discha...
Recent Publications on Heroin Increases
Rate of Unintentional/Undetermined Prescription Opioid Overdose Deaths
and Rate of Outpatient Prescriptions Dispensed for ...
NC HEPATITIS C
Hepatitis C
• Most commonly transmitted
through injection drug use
• 75%‒85% of infected develop
chronic illness
CDC, 2010
Numberofcases
Year
Reported Acute Hepatitis C Cases
NC, 2000‒2014
Characteristic N (%)
Race/ethnicity
White
Black
Hispanic
Other
96 (85%)
5 (4%)
3 (3%)
9 (8%)
Age (years)
<20
21-30
31-40
4...
Rates of reported acute hepatitis C cases
by NC county, 2014
What about chronic hepatitis C in NC?
• Not reportable by law
• Use CDC national prevalence projections
(1.1%) and census ...
Changing Landscape of Hepatitis C Treatment
• Older drugs
– Prolonged treatment
– Serious side effects
• New direct acting...
NC HIV
~110,000 people
with chronic HCV
in NC
HIV in NC
~110,000 people
with chronic HCV
in NC
HIV Infection Rates Diagnosed in NC
119 131 144 157 170 182 194 208 221 234 244 256...
CROSS OVER EFFORTS
Reducing
New HCV Infections
• Targeted HCV/HIV screening
• Accessible mental health services and substance use disorder tr...
NC Collaboration
• Enhanced surveillance
• Sharing of information
• Increasing communication
• Joint presentations
NC HARM REDUCTION EFFORTS
Number of Two Dose Naloxone Kits Distributed by the North Carolina
Harm Reduction Coalition by County
8/1/2013 - 2/1/2016 ...
Number of Opioid Overdose Reversals with Naloxone Reported to the
North Carolina Harm Reduction Coalition by Date
8/1/2013...
Number of Opioid Overdose Reversals with Naloxone Reported to the
North Carolina Harm Reduction Coalition by Date
1/1/2015...
Number of Opioid Overdose Reversals with Naloxone Reported to the
North Carolina Harm Reduction Coalition by County
8/1/20...
Counties with Law Enforcement Carrying Naloxone (44)
As of February 1, 2016 (34 reported reversals)
App State University P...
NC TRACKING & MONITORING
NC DETECT / ED Data Mandate
GS § 130A-480
(a) For the purpose of ensuring the protection of the public health, the State H...
NC DETECT Overdose Visits
Source: North Carolina NC DETECT
Access to NC DETECT
• NC DETECT web application access for
– Local Health Departments
– Data Providers (Hospitals, EMS, Po...
Hot Topics Dashboard
Click on a point to
access line listing
NC COORDINATED RESPONSE
North Carolina Injury and Violence Prevention Branch, Partners
Poisoning Death Study
Comprehensive Community Approach
Chro...
CDC PRESCRIPTION DRUG OVERDOSE
(PDO) PREVENTION FOR STATES (PFS)
DEVELOPMENT OF
COMMUNICATIONS PROTOCOL
Development of Injury Warning
• IVPB had new role in response
• IVPB ‘thin’ bench and lack of response experience
– Must c...
NC Injury Warning
Communication Protocol
1. Activation
2. Investigation/
Monitoring
3. Communication
For more information…
Scott Proescholdbell, MPH
scott.proescholdbell@dhhs.nc.gov
Nidhi Sachdeva, MPH
nidhi.sachdeva@dhhs.n...
Preventing Hepatitis C
and HIV Outbreaks
Presenters:
• Joan Duwve, MD, MPH, Chief Medical Officer, Indiana State Departmen...
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Preventing Hepatitis C and HIV Outbreaks

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  1. 1. Preventing Hepatitis C and HIV Outbreaks Presenters: • Joan Duwve, MD, MPH, Chief Medical Officer, Indiana State Department of Health • Jerome Adams, MD, MPH, State Health Commissioner, Indiana State Department of Health • Scott Proescholdbell, MPH, Epidemiologist, Injury and Violence Prevention Branch, North Carolina Department of Health and Human Services • Nidhi Sachdeva, MPH, Injury Prevention Consultant, Division of Public Health, North Carolina Department of Health and Human Services Prevention Track Moderator: Jinhee J. Lee, PharmD, Public Health Advisor, Division of Pharmacologic Therapies, SAMHSA, and Member, Rx and Heroin Summit National Advisory Board
  2. 2. Disclosures Jerome Adams, MD, MPH; Joan Duwve, MD, MPH; Scott Proescholdbell, MPH; Nidhi Sachdeva, MPH; and Jinhee J. Lee, PharmD, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
  3. 3. Disclosures • All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months. • The following planners/managers have the following to disclose: – John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest: Starfish Health (spouse) – Robert DuPont – Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center
  4. 4. Learning Objectives 1. Inform attendees of the risks of infection disease outbreaks related to injection drug use. 2. Identify lessons learned by Indiana public health officials during their investigation and response to a 2015 outbreak of HIV infections linked to injection drug use. 3. Describe North Carolina’s collaboration between injury and infectious disease programs to reduce injection drug associated harms. 4. Provide accurate and appropriate counsel as part of the treatment team.
  5. 5. Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015 Joan M. Duwve, MD, MPH Chief Medical Officer, Indiana State Department of Health; Associate Dean for Public Health Practice, Indiana University Richard M. Fairbanks School of Public Health jduwve2@isdh.in.gov
  6. 6. Disclaimer □ Joan Duwve has no conflicts to report □ Trade names will be used in this presentation to accurately reflect Rx drug use patterns
  7. 7. Indiana HIV Outbreak Overview □ Dec. 2014: 3 new HIV diagnoses in Austin IN ▫ DIS learned 2 had a common-needle sharing partner ▫ Contact tracing  8 additional infections by January 23 ▫ Only 5 HIV infections had been reported 2004-2013 □ As of Feb. 4, 2016: 189 individuals diagnosed with HIV ▫ All linked to Austin, IN ▫ Infections were recent and from a single strain of HIV ▫ 91% co-infected with Hepatitis C □ Source of infection: injection of the prescription opioid, oxymorphone (OPANA® ER)
  8. 8. Indiana HIV outbreak: geographic distribution Scott County pop. 24,000; Austin, IN pop. 4,200 Scott County
  9. 9. Contact Tracing and HIV Testing Results 2/4/2016 Named Contacts 515 Tested 454 (88.1%) Refused testing 17 (3.3%) Unable to locate 28 (5.4%) Other 16 (3.1%) Other Tested 26 Total Tested 480 HIV positive 189 (39.4%) Indiana State Department of Health Division of HIV/STD
  10. 10. Demographics of individuals infected with HIV (N=189)  58% male  98% non-Hispanic white  Median age 33.5 years  93% reported injecting drugs  All oxymorphone, some methamphetamine and heroin as well 0 20 40 60 80 Age at HIV Dx #ofPeopleDxwithHIV Indiana State Department of Health Division of HIV/STD
  11. 11. HIV+ HIV- Not tested Number of Reported Contacts Size Contact tracing network Contact Type Frequency Needle-sharing 59.7% Sex 5.7% Needle-sharing AND sex 9.7% Social contact 25.0% Credit: Romeo Galang, MD, MPH; Division of HIV/AIDS Prevention; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
  12. 12. Geomapping of 89 HIV positive individuals identified a hotspot in Austin. 44% live within a ½ mile square area where 27% of Austin’s population resides. The estimated infection rate within this hotspot is 34 cases/1,000 people.
  13. 13. Why Indiana? Percent Change in Leading Causes of Injury Death*— Indiana, 1999–2009 501.5% -30.8% 13.9% 22.5% -11.1% -100% 0% 100% 200% 300% 400% 500% 600% Unintentional Poisoning Unintentional MV Traffic Suicide Firearm Unintentional Fall Homicide Firearm Source: WISQARS *Age-adjusted rates Source: CDC WISQARS
  14. 14. Geographic Variation in Opioid Prescribing in the U.S.
  15. 15. Youth and Controlled Substances Source: Indiana Youth Risk Behavior Survey, 2011
  16. 16. Source: Suryaprasad, Clin Infect Dis; 2014, 59(10):1411-1419 2006 2012 Emerging Epidemic of Hepatitis C Virus Infections Among Young Non- Urban Persons who Inject Drugs in the United States, 2006–2012
  17. 17. Gaps in Treatment Capacity, 2012 (2012 rates per 1,000 people ≥12 years of age) Rate of past year opioid abuse or dependence RateofOA-MATcapacity Source: Jones, CM, et. al. National and State Treatment Need and Capacity forOpioid Agonist Medication-Assisted Treatment. AJPH 2015 2015 Aug;105(8):e55-63 17
  18. 18. Why Austin?
  19. 19. At least nine people have died so far this year from prescription drug overdoses in Scott County, Indiana. Most of the fatalities involved Opana, according to county coroner Kevin Collins. Reuters
  20. 20. Why Opana® ER ?  2010 - reformulation of Oxycontin®  Opana® quickly replaced Oxycontin® - snorted, injected  2012 – Opana® ER reformulated, impossible to crush/snort  Short half-life 3-4 hours when injected = multiple injections/day  Cost $160/40 mg tablet = pill sharing  Higher Morphine Equivalent Dose than heroin  You know what you’re getting
  21. 21. What We Needed to Control the Outbreak  Expand HIV/HCV testing and capacity for early detection  Routine HIV testing at venues with high-risk persons (jails, addiction services, ERs)  Active outreach testing to at-risk population  Get all HIV-infected individuals on ARV  Develop systems to keep at-risk individuals uninfected  Systematic retesting and education of high-risk persons  SSP and HIV PrEP (Pre Exposure Prophylaxis)  Increase addiction treatment services  Medication-assisted treatment  Behavioral Health  Recovery Support
  22. 22. Credit: Philip Peters, MD; NCHHSTP/DHAP/Epidemiology Branch; CDC Cumulative HIV infections associated with injection of Opana® ER, by date of diagnosis, SE Indiana (N=188)
  23. 23. Community Outreach Center with One-Stop Shop  Insurance enrollment  Care coordination  Syringe service program  HIV and Hep B/C testing  Immunizations  Referral to substance abuse treatment
  24. 24. Communications
  25. 25. Acknowledgements • Scott County Health Department • Clark County Health Department • Disease Intervention Specialists (EMAC states) • Foundations Family Medicine • Indiana University, Division of Infectious Diseases • University of Louisville, Division of Infectious Diseases • CDC – Division of STD Prevention – Division of HIV/AIDS Prevention (DHAP) – Division of Viral Hepatitis (DVH) – Epidemic Intelligence Service (EIS) Program Office • Indiana Department of Mental Health and Addiction (DMHA) • Indiana State Department of Health (ISDH)
  26. 26. Tackling the Prescription Drug and Opioid Abuse Epidemic Jerome M. Adams, MD, MPH Indiana State Health Commissioner
  27. 27. Lessons from Indiana • Be aware… of risk factors and trends in your community • Look for touchpoints… and unique opportunities to intervene • Partner.. and speak to your audience/ in their language
  28. 28. Be Aware
  29. 29. Suryaprasad Clin Infect Dis; 2014, 59(10):1411-1419 Prescribing correlates with IDU, unsafe injection practices, and overdoses 2006 2012
  30. 30. Scott County HIV Outbreak • Rural injection of Rx oral opioid = largest ever HIV outbreak in IN, largest IDU HIV outbreak in US • 188 HIV cases in a rural county that never had more than 3 in one year • Almost all cases report injection of the opioid analgesic oxymorphone (Opana® ER and generic ER) • All white, significant poverty (19.0%), unemployment (8.9%), lack of education (21% no high school), and lack of insurance
  31. 31. Adapted from and with permission of Phil Peters, CDC HIV Infection: Tip of a High-Mortality Iceberg HIV Infection Overdose, Bacterial infections Hepatitis C virus Infection Injection Drug use Substance Use Disorder Social Determinants 188 diagnoses 5 deaths during contact tracing 287 Hep C + total, 92% of HIV+ coinfected with Hep C Network of at least 500 PWID Got your attention now?
  32. 32. Look for opportunities to intervene
  33. 33. Public Health and Policy Behavior Change Ignorance, denial Ambivalence, conflicted emotions. (Barriers!!!) Collect info, small pilots, motivation/ public relations Must show success, and gain (vs lose) support Coping strategies, rewards, must deal w burn out Acknowledge and fix problems, remind of goals
  34. 34. Outbreak Control Interventions • Little HIV awareness: multiple educational efforts including billboards, infographics, webinars, TV/radio, newspaper, Jeannie White Ginder community event at Austin HS. #URNotAlone* • Very few insured: established “one-stop shop” • No HIV/HCV care: state provided resources (IU), HRSA, PREP • Syringe exchange illegal: executive orders followed by new law • Limited addiction services (methadone moratorium): raise awareness of MAT, train and accredit providers to prescribe Suboxone®, local mental health provider designated as a FQHC, SAMHSA collaboration
  35. 35. Indiana Syringe Exchange Law • Local health officer declares to county/municipality: – There is an epidemic of hepatitis C or HIV; – The primary mode of transmission is IV drug use; – Syringe exchange is medically appropriate as part of the comprehensive public health response. • The executive/legislative body of county/municipality: – Conducts a public hearing – Votes to adopt the declaration of the local health officer • The county/municipality notifies the ISDH Commissioner and: – Requests the Commissioner to declare a public health emergency – Other measures to address the epidemic have not worked • Commissioner must approve or deny within 10 days from submission – Can request additional information extending the deadline for an additional 10 days
  36. 36. Bending the transmission curve… Epidemic Curve 2.18.2016 1 1 2 1 1 8 3 5 9 9 1 9 7 18 14 11 22 17 9 5 5 3 3 5 2 1 11 0 0 000000 0 2 0 0 4 0 0000 0 00000 3 0 00 00 0 1 1 1 1 1 00
  37. 37. Continuum of HIV care in Austin, Indiana May 15, 2015 N=156 N=95 N=87 N=69 N=33 N=0 Mean VL: 431,836 N=113
  38. 38. Continuum of HIV care in Austin, Indiana February 18, 2016 Total diagnosed=189 (189 confirmed). Persons were ineligible if deceased (n=2) or outside of the jurisdiction (n=4); estimates are based on the number of eligible persons (n=183); ** Patients engaged in care if have at least one VL or CD4 *** Percent on ARVs increases to 66% and virally suppressed increases to 51% when denominator changed to number engaged in care. Clinical services were initiated 3/31/15. ART data updated through 2/18/16. N=183 N=164 N=135 N=111 N=85 100% 90% 74% 61% 46% 0 10 20 30 40 50 60 70 80 90 100 Eligible* Engaged in Care** Care coordination Prescribed ARV's*** Virally suppressed***
  39. 39. Partner… … and speak to your audience…
  40. 40. What I learned as an advocate Public health does not always easily translate to public policy, particularly in areas with different value systems or which are rural or resource poor… We must truly understand community beliefs and obstacles, and speak to citizens in ways that resonate. You can’t “educate” away firmly held beliefs.
  41. 41. Transformative public health leadership is less about knowing what to do, and more about knowing how to get people to do it… RWJ, A new way to talk about social determinants of health Colin Woodard, “The 11 American Nations”
  42. 42. Syringe exchange programs= Community Partnerships • Need comprehensive programs, not handouts – Handouts don’t facilitate clean up, or connection to services – Actually hurt our cause in Austin • Local buy in, local control, targeted, community convinced of “epidemic,” or last resort. – Not proven to be a barrier in Indiana so far*
  43. 43. Testing at high risk venues = Jail/ Hospital/ SEP partnerships • Need for testing in jails – Sheriffs don’t want the hassle or the cost of diagnosis • Need to test in ERs and inpatient settings (e.g. skin infections, endocarditis) – Extra time? Reporting? Who is going to pay? Follow up? Stigma? • Syringe exchanges and substance use disorder treatment venues – Already overworked? Reporting?
  44. 44. Medication assisted treatment= Partnerships with providers, payers, community • People don’t understand the concept, or the options: Methadone vs Suboxone® vs Vivitrol® – Think we are substituting one addiction for the other – Rural/ conservative communities more likely to embrace Vivitrol initially* • MAT can and is being misused and abused – This is hurting our credibility with decision makers – “I believe the science on MAT, I just don’t trust the people I see applying it…” – Need more education about comprehensive recovery approaches (not a magic bullet), and need increased oversight of MAT practices.
  45. 45. Diversion/ early release/ alternatives to incarceration = partnership with the courts and the community • Need more of them/ can’t incarcerate our way out of this problem – All local jails in the area at over 2x capacity • Police, prosecutor, defender, judge, legislators, all key – Lots of fear that weaker enforcement hurts the case. Need both sticks and carrots to change behavior • But very labor intensive to do it right/ hard to implement in resource poor area. Ratio of 10:1 in Hamilton vs 100s:1 in Scott • Not being made equally available to all offenders. – Income? Race? Fair assessment of support systems/ most likely to be successful?
  46. 46. Naloxone = partnership with first responders, families • We administered over 5000 doses in IN last yr • Many still feel it is enabling – Must share stories- i.e. police officer who saved an elderly woman who mixed up her meds, survivor stories – Must develop and speak to connections to recovery • Not all states allow for lay providers • State websites to help teach about naloxone – Optin.IN.gov, dontdie.org
  47. 47. Coverage= Partnership with payers, Medicaid, hospitals, docs • Almost all HIV positive were uninsured • Healthy Indiana Plan = Indiana’s alternative to Medicaid Expansion. HDHP with savings accnt – Higher physician reimbursement so coverage = access (5000+ new providers), mental health parity/ pays for substance use disorder treatment • Re-enrollment (ie maintenance) has been a challenge. Medicaid
  48. 48. Be Aware • Hepatitis rates are an indicator of IVDU, and harbinger of potential HIV outbreak. • KNOW YOUR LOCAL OVERDOSE STATISTICS! – Who ODed, who prescribed, where, from what substances…
  49. 49. Be Aware • Need to do state and local vulnerability assessments – CDC has released these, but can and should supplement – PDMPs – We put together county reports (HIV/HepC/OD) – Look at your reporting processes – People don’t believe you unless you can show them local data, compared to peers
  50. 50. Look for opportunities to intervene • Test at high risk venues • Comprehensive SEPs • Consider PREP among high risk individuals • Need to have conversations about who receives treatment for HCV, who prescribes, and how to pay • Increase availability of addiction recovery services and Naloxone, and increase awareness, acceptance, proper administration of MAT • Coverage for vulnerable populations
  51. 51. Partner • Law enforcement – Local, County, State police all play different but important roles – Prosecutors and judges have particular power to help or to veto initiatives • Legislators – Key to convincing public, getting laws changed, can advocate on your behalf to your boss/bosses
  52. 52. Partner • Hospitals – Major touchpoint (ER), have resources, have community standing, can advocate • Faith based community – Essential for community outreach – Set the tone for controversial moral interventions – Already have infrastructure and contacts – Perfect for counseling (e.g. w MAT), and “after” care
  53. 53. Partner • Federal partners (CDC, SAMHSA, HHS, etc) other agencies (AG, Judicial, Mental Health, Medicaid, etc) • With the community!!! – Via media, town halls, public events – Must know that you care before they care what you know
  54. 54. Preventing Hepatitis and HIV Outbreaks After Scott County: NC’s Overdose and Communicable Disease Collaboration
  55. 55. Disclosure statement • Scott Proescholdbell, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services. • Nidhi Sachdeva, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
  56. 56. Learning Objective • Outline North Carolina’s plan to reduce injection drug use and associated infectious disease transmission.
  57. 57. Overview • NC Overdose Situation • NC Hepatitis C Situation • Collaboration • Next Steps
  58. 58. NC OVERDOSE EPIDEMIC
  59. 59. Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014 Analysis by Injury Epidemiology and Surveillance Unit Medication or drug overdose: X40-X44, X60-X64, Y10-Y14, X85 Medication or Drug Overdose Deaths by Intent North Carolina Residents, 1999-2014 1,306 1,064 203 38 0 200 400 600 800 1,000 1,200 1,400 Numberofdeaths All intents Unintentional Self-inflicted Undetermined Assault
  60. 60. 65 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Deathsper100,000population Year Motor Vehicle Traffic (Unintentional) Drug Poisoning (All Intents) Firearm (All Intents) *Per 100,00, age-adjusted to the 2000 U.S. Standard Population α - Transition from ICD-8 to ICD-9 β – Transition from ICD-9 to ICD-10 National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset Source: Death files, 1968-2014, CDC WONDER Analysis by Injury Epidemiology and Surveillance Unit Death Rates* for Three Selected Causes of Injury, North Carolina, 1968-2014 α
  61. 61. Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014 Analysis by Injury Epidemiology and Surveillance Unit Substances Contributing to Medication or Drug Overdose Deaths North Carolina Residents, 1999-2014 684 202 246 0 100 200 300 400 500 600 700 800 900 Numberofdeaths Prescription Opioid Cocaine Heroin
  62. 62. NC Heroin Deaths: 2008-2015* Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2008- 2015* *2015 data are provisional and likely increase as cases are finalized Analysis by Injury Epidemiology and Surveillance Unit 554% increase from 2010 to 2014 63 75 37 76 147 179 246 174 0 50 100 150 200 250 300 2008 2009 2010 2011 2012 2013 2014 2015*
  63. 63. NC Heroin Deaths: 2014 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2014 Analysis by Injury Epidemiology and Surveillance Unit Sex Age Male 196 18-24 39 Female 50 25-34 83 Race 35-44 67 White 218 45-54 36 Black 24 55-64 16 Other 4 65+ 5
  64. 64. Heroin Hosp. and ED Overdoses: 2008-2014 Source: N.C. State Center for Health Statistics, Vital Statistics-Hospital Discharge 2008- 2013 NC DETECT- Statewide ED Visit data, 2008-2014 Analysis by Injury Epidemiology and Surveillance Unit 213 252 213 311 474 643 1,127 76 75 58 101 122 195 0 200 400 600 800 1000 1200 2008 2009 2010 2011 2012 2013 2014 ED Hosp From 2010 to 2014 a 429% increase for ED visits
  65. 65. Recent Publications on Heroin Increases
  66. 66. Rate of Unintentional/Undetermined Prescription Opioid Overdose Deaths and Rate of Outpatient Prescriptions Dispensed for Opioids North Carolina Residents, 2012-2013
  67. 67. NC HEPATITIS C
  68. 68. Hepatitis C • Most commonly transmitted through injection drug use • 75%‒85% of infected develop chronic illness CDC, 2010
  69. 69. Numberofcases Year Reported Acute Hepatitis C Cases NC, 2000‒2014
  70. 70. Characteristic N (%) Race/ethnicity White Black Hispanic Other 96 (85%) 5 (4%) 3 (3%) 9 (8%) Age (years) <20 21-30 31-40 41-50 >50 7 (6%) 47 (41%) 27 (24%) 21 (19%) 11 (10%) Gender Male Female Missing 60 (53%) 51 (45%) 2 (2%) Reported risk factors* Injection drug use Multiple sex partners Men who have sex with men History of blood transfusion Missing 42 (37%) 5 (4%) 2 (2%) 1 (1%) 63 (56%) Characteristics of Reported Acute Hep C Cases NC, 2014 (N = 113) *May report >1 risk factor
  71. 71. Rates of reported acute hepatitis C cases by NC county, 2014
  72. 72. What about chronic hepatitis C in NC? • Not reportable by law • Use CDC national prevalence projections (1.1%) and census data to estimate ~110,000 people with chronic HCV in NC
  73. 73. Changing Landscape of Hepatitis C Treatment • Older drugs – Prolonged treatment – Serious side effects • New direct acting antivirals (DAAs) – Shorter treatment – Fewer serious side effects – Highly effective – Expensive – Mainly prescribed by specialists
  74. 74. NC HIV
  75. 75. ~110,000 people with chronic HCV in NC HIV in NC
  76. 76. ~110,000 people with chronic HCV in NC HIV Infection Rates Diagnosed in NC 119 131 144 157 170 182 194 208 221 234 244 256 266 276 287 18 20 20 19 18 18 19 20 20 18 15 15 13 14 14 0 5 10 15 20 25 0 50 100 150 200 250 300 350 Rateper100,000population(NewCases) Rateper100,000population(Prevalence) Year at Diagnosis Prevalence New Cases
  77. 77. CROSS OVER EFFORTS
  78. 78. Reducing New HCV Infections • Targeted HCV/HIV screening • Accessible mental health services and substance use disorder treatment • Comprehensive programs to reduce HCV/HIV transmission (i.e., SSPs) and address stigma/disparities • Make all positive HCV laboratory results reportable by ELR • Expand targeted HCV screening of at-risk populations • Link HCV-infected persons to appropriate care and treatment • Expand primary care capacity to treat HCV in communities Hepatitis C virus (HCV); Electronic Laboratory Reporting (ELR); Regional Networks of Care and Prevention (RNCP); Controlled Substances Reporting System (CSRS); Syringe Services Programs (SSPs) • Support harm reduction (e.g., naloxone) • Identify at-risk persons through CSRS • Strengthen community outreach programs • Link persons to appropriate services o Substance use disorder treatment o Mental health o Other medical and social • Expand targeted HIV testing of at-risk populations • Reach disproportionally impacted minorities through community programs • Link persons to care and maintain engagement through HIV RNCP Conquering the Syndemic: A systems approach to addressing HCV, HIV, and Opioid Overdoses in North Carolina Reducing Opioid Overdoses Reducing New HIV Infections Addressing the Syndemic
  79. 79. NC Collaboration • Enhanced surveillance • Sharing of information • Increasing communication • Joint presentations
  80. 80. NC HARM REDUCTION EFFORTS
  81. 81. Number of Two Dose Naloxone Kits Distributed by the North Carolina Harm Reduction Coalition by County 8/1/2013 - 2/1/2016 ( 20,000+ total kits distributed) Source: North Carolina Harm Reduction Coalition, Feb. 2016 Analysis: Injury Epidemiology and Surveillance Unit
  82. 82. Number of Opioid Overdose Reversals with Naloxone Reported to the North Carolina Harm Reduction Coalition by Date 8/1/2013 - 2/1/2016 Source: North Carolina Harm Reduction Coalition, Feb. 2016 Analysis: Injury Epidemiology and Surveillance Unit 22 15 20 16 15 25 40 15 34 97 47 50 125 28 111 187 128 204197 302 290 0 50 100 150 200 250 300 350 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Numberofopioidoverdosereversals withNaloxonereportedtoNCHRC 35 189 1,510 290 Overall 2,024
  83. 83. Number of Opioid Overdose Reversals with Naloxone Reported to the North Carolina Harm Reduction Coalition by Date 1/1/2015 - 2/1/2016 Source: North Carolina Harm Reduction Coalition, Feb. 2016 Analysis: Injury Epidemiology and Surveillance Unit 0 50 100 150 200 250 300 350 Numberofopioidoverdosereversalswith NaloxonereportedtoNCHRC 1 reversal by Guilford Co Sheriff 1 reversal by Fayetteville Police Dept 1 reversal by Henderson Co Sheriff 4 reversals by Greenville Police Dept 1 reversal by Pitt Co Sheriff 1 reversal by Winston Salem PD 1 reversal by Carrboro Police Dept 1 reversal by Carrboro Police Dept 5 reversals by Fayetteville Police Dept 2 reversals by Fayetteville Police Dept 2 reversals by Pitt Co Sheriff Cramerton PD, 1 reversal, 2015 1 reversal by Fayetteville Police Dept 1 reversal by Winston Salem PD 1 reversal by Fayetteville Police Dept 3 reversals by Winston Salem PD Law Enforcement reversals: 33 2 reversals by Dare PD 1 reversal by Winston-Salem PD
  84. 84. Number of Opioid Overdose Reversals with Naloxone Reported to the North Carolina Harm Reduction Coalition by County 8/1/2013 - 2/1/2016 (2,024 total reversals reported) 5 reversals in an unknown location in North Carolina and 28 reversals using NCHRC kits from other states reported to NCHRC. Rocky Mount (9) High Point (201) Elkin (1) Asheville (520) Greensboro (335) Maiden (1) Charlotte (66) Wilmington (267) Winston-Salem (89) Source: North Carolina Harm Reduction Coalition, Feb. 2016 Analysis: Injury Epidemiology and Surveillance Unit Burgaw (15) Fayetteville (34) Asheboro (24) Thomasville (31) Rocky Point (22)
  85. 85. Counties with Law Enforcement Carrying Naloxone (44) As of February 1, 2016 (34 reported reversals) App State University Police Watauga Co. Sheriff Ayden Police Dept Bethel Police Department Greenville Police Dept East Carolina Univ Police Dept Pitt Co. Sheriff Canton Police Dept Clyde Police DeptGraham County Sheriff Waynesville Police Dept Haywood Co. Sheriff Clyde PD Maggie Valley PD Orange Co. Sheriff Carrboro Police Dept Cramerton Police Dept Mount Holly PD Fayetteville Police Dept Guilford Co. Sheriff Halifax Co. Sheriff Roanoke Rapids Police Dept Kinston Police Dept Lenoir Co. SheriffPink Hill Police Dept N.C. State Bureau of Investigation and Alcohol Law Enforcement also carry Naloxone-statewide. Agencies that have reported opioid overdose reversals with Naloxone Henderson Co. Sheriff Fletcher PD Waynesville Police Dept Brevard Police Dept Transylvania Co. Sheriff Rutherfordton Police Dept Winston-Salem PD Source: North Carolina Harm Reduction Coalition, Feb. 2016 Analysis: Injury Epidemiology and Surveillance Unit Warren Wilson PD Brunswick Co. Sheriff Butner Police Dept Dare Co. Sheriff Statesville PD Nags Head PD Duck PD New Hanover PD Highlands PD High Point PD
  86. 86. NC TRACKING & MONITORING
  87. 87. NC DETECT / ED Data Mandate GS § 130A-480 (a) For the purpose of ensuring the protection of the public health, the State Health Director shall develop a syndromic surveillance program for hospital emergency departments in order to detect and investigate public health threats that may result from (i) a terrorist incident using nuclear, biological, or chemical agents or (ii) an epidemic or infectious, communicable, or other disease. The State Health Director shall maintain the confidentiality of the data reported pursuant to this section and shall ensure that adequate measures are taken to provide system security for all data and information. The State Health Director may share data with local health departments for public health purposes, and the local health departments are bound by the confidentiality provisions of this section. The State Health Director shall not allow information that it receives pursuant to this section to be used for commercial purposes and shall not release data except as authorized by other provisions of law. *Effective 1/1/2005 *Law modified in 2007 to allow sharing of reported hospital ED data with CDC
  88. 88. NC DETECT Overdose Visits Source: North Carolina NC DETECT
  89. 89. Access to NC DETECT • NC DETECT web application access for – Local Health Departments – Data Providers (Hospitals, EMS, Poison Center) • Authorized users are able to view data from – Emergency Departments – Carolinas Poison Center – Pre-hospital Medical Information System (PreMIS) • Training webinars provided by DPH, NC DETECT • Datasets shared with researchers after DUA and IRB approval
  90. 90. Hot Topics Dashboard Click on a point to access line listing
  91. 91. NC COORDINATED RESPONSE
  92. 92. North Carolina Injury and Violence Prevention Branch, Partners Poisoning Death Study Comprehensive Community Approach Chronic Pain Initiative Opioid Death Task Force Policy and Practice Research North Carolina Prevention and Harm Reduction Drug Take Back Prescription Drug Substance Abuse SAC Poisoning/Overdose Team Communication, Policy, and Advocacy Enforcement SBI and Medical & Pharm Board DPH, DMA, DMH/DD/SAS, ORH Carolinas Poison Center Monitoring Program
  93. 93. CDC PRESCRIPTION DRUG OVERDOSE (PDO) PREVENTION FOR STATES (PFS)
  94. 94. DEVELOPMENT OF COMMUNICATIONS PROTOCOL
  95. 95. Development of Injury Warning • IVPB had new role in response • IVPB ‘thin’ bench and lack of response experience – Must coordinate with others • Several debriefings with key partners • Creation of Early Injury Warning system • IVPB staff added to NC HAN, Situation Report lists • Asked to expand our role
  96. 96. NC Injury Warning Communication Protocol 1. Activation 2. Investigation/ Monitoring 3. Communication
  97. 97. For more information… Scott Proescholdbell, MPH scott.proescholdbell@dhhs.nc.gov Nidhi Sachdeva, MPH nidhi.sachdeva@dhhs.nc.gov Injury and Violence Prevention Branch NC Division of Public Health www.injuryfreenc.ncdhhs.gov | www.injuryfreenc.org
  98. 98. Preventing Hepatitis C and HIV Outbreaks Presenters: • Joan Duwve, MD, MPH, Chief Medical Officer, Indiana State Department of Health • Jerome Adams, MD, MPH, State Health Commissioner, Indiana State Department of Health • Scott Proescholdbell, MPH, Epidemiologist, Injury and Violence Prevention Branch, North Carolina Department of Health and Human Services • Nidhi Sachdeva, MPH, Injury Prevention Consultant, Division of Public Health, North Carolina Department of Health and Human Services Prevention Track Moderator: Jinhee J. Lee, PharmD, Public Health Advisor, Division of Pharmacologic Therapies, SAMHSA, and Member, Rx and Heroin Summit National Advisory Board

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