Rural communities face hepatitis outbreak among injection drug users
A hepatitis epidemic is emerging in Appalachia in the wake of a harrowing trend: more rural drug users are sharing dirty needles to inject heroin and crushed opioid pain pills.
Health experts fear the practice could undermine nationwide efforts to halt new cases of hepatitis, an infectious disease that threatens the liver. And they’re concerned that a hepatitis outbreak could precede the rise of HIV, another blood-borne virus that can be transmitted through contaminated needles.
Appalachia: Hepatitis B Cases Up 114%
Three Appalachian states – Kentucky, West Virginia and Tennessee – are fighting a sharp rise in hepatitis B infections “primarily among people who inject drugs,” says Aaron Harris, M.D, an epidemiologist for the U.S. Centers for Disease Control and Prevention (CDC).
Cases of acute hepatitis B increased 114 percent during 2009-2013 in those three states, Harris notes in the CDC’s Morbidity and Mortality Weekly Report released January 29, 2016.
Since 2010, an estimated 75 percent of the hepatitis cases were tied to injection drug use in Appalachia – up from 53 percent in the three prior years.
“If hepatitis B virus infection is left undiagnosed and untreated, the virus can lead to serious liver damage and even death,” Harris says. “Evidence-based prevention strategies – including increasing hepatitis B vaccination coverage, testing and linkage to care activities – and education campaigns targeting persons who inject drugs are urgently needed.”
Nationwide, incidence of hepatitis B is stable (1 case per 100,000 persons) but the CDC notes in its new report: “the increase in (Appalachian cases) has the potential to impede the nation’s hepatitis B elimination strategy.”
A Bigger Burden: The Explosion of Hepatitis C
A surge in the more serious hepatitis C infection among rural young adults was reported last year by the CDC.
Acute cases of hepatitis C skyrocketed 364 percent from 2006-2012 among people under 30 in central Appalachia: Kentucky, Tennessee, Virginia and West Virginia, the CDC reported. Similar increases were noted in Massachusetts, Wisconsin and upstate New York.
Known as a “silent disease,” the symptoms of hepatitis C may not appear for years or decades. But up to 70 percent of those infected will develop chronic liver disease, health experts say.
Injection drug use is the most common way that hepatitis C is spread in the United States. Rural areas had “more than double” the rate of hepatitis C cases as urban areas, the CDC reports, and 73 percent of all cases were tied to injection drug use.
“The increase in acute (hepatitis C) infections in central Appalachia is highly correlated with the region’s epidemic of prescription opioid abuse and facilitated by an upsurge in the number of persons who inject drugs in these four states,” the CDC noted in its May 2015 Morbidity and Mortality Weekly Report.
Since many people with hepatitis C do not show symptoms, the problem could be vastly under-reported, the CDC says.
A Needle-Sharing Catastrophe: Scott County, Indiana
The rise in needle-sharing among drug users — who are in the grip of an opioid addiction crisis — has devastated other rural communities.
Scott County in southern Indiana is battling what is proportionally the worst HIV outbreak in the nation’s history, according to the Indiana State Department of Health. At least 183 new cases of HIV occurred last year in this small rural community with a population under 24,000 people.
Most of the Scott County users were infected with HIV after injecting Opana (oxymorphone), a time-release narcotic painkiller. More than 80 percent were co-infected with hepatitis C, the CDC reports.
“Many family members will use drugs together,” Joan Duwve, chief medical consultant to the Indiana Department of Health, told the Courier-Journal. “There are children, parents and grandparents who live in the same house, who are injecting drugs together, sort of as a community activity.”
A public health emergency was declared in Scott County and also Monroe County, Indiana last year after hepatitis C infections there rose by more than 50 percent.
Nationwide, the unprecedented abuse of prescription painkillers and heroin is taking a grim toll on American families.
There were 47,055 drug overdose deaths in 2014 in the United States, an all-time high and a 6.5 percent increase over 2013, according to the CDC. More Americans died from drug overdoses in 2014 than any previous year on record, and death from accidental prescription drug overdose has surpassed car accidents as the nation’s leading cause of unintentional death.
West Virginia had the highest rate of drug overdose deaths in 2014, with 35.5 deaths per 100,000 people, followed by New Mexico (27.3), New Hampshire (26.2), Kentucky (24.7) and Ohio (24.6).
Saving Lives with Clean Needles, Integrated Testing & Treatment
Temporary needle exchange programs are now halting the spread of HIV cases in Scott County, following an executive order by Indiana Governor Mike Pence. Kentucky, West Virginia and Ohio have also implemented needle exchange programs to fight the heroin epidemic and slow the spread of hepatitis B and C.
The programs give drug users clean syringes and sterile injection equipment as a method of harm reduction. They also provide HIV and hepatitis testing and care, and treatment for drug addiction.
“The research and 25 years of experience shows that people who go to needle exchange programs are more likely to enter drug treatment,” says Daniel Raymond, Policy Director for the Harm Reduction Coalition in New York.
“These programs provide counseling and referrals to help people take the first step in treatment, and navigate an often difficult system,” Raymond says. “Many programs have good referral agreements with drug treatment programs, which can expedite entry into treatment when someone asks for help.”
Raymond says needle exchange programs engage an otherwise hard-to-reach population with valuable screening and education services. And they offer vaccination for hepatitis B (there is currently no vaccine for hepatitis C, although research on developing such a vaccine is underway).
The CDC supports needle exchange programs as a bridge to treatment and key part of an overall disease prevention strategy, according to a statement released by the agency in December, 2015.
“Outbreaks in Indiana and elsewhere have been powerful reminders that people who inject drugs can be at very high risk for HIV and hepatitis C, and studies have shown that syringe services programs are cost saving, and can reduce the risk of infection without increasing drug use,” notes the statement from Dr. Jonathan Mermin, Director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
“Overall, unsafe injection drug use accounts for approximately 8 percent of new HIV infections in the United States, and in recent years it has contributed to a 150 percent increase in acute cases of hepatitis C infections,” Mermin notes. “Because these infections can spread from drug users to others, syringe services programs can help protect whole communities.”
Local authorities can now access federal funds to pay for staff, transportation and certain other costs associated with needle exchange programs. That’s because an omnibus bill approved by Congress in December 2015 lifted the longstanding funding ban on the programs.
“The new federal funding policy on syringe exchange programs will help integrate more counseling and support, and strengthen collaboration with other parts of the public health, drug treatment and health care system,” Raymond says.
To fight the current opioid crisis, health experts also recommend greater access to naloxone (Narcan), an effective antidote that can reverse an opioid overdose. They emphasize the need for safer prescribing of prescription opioids and effective treatment for addiction — including medication therapies such as buprenorphine and naltrexone that can reduce strong opioid cravings and prevent relapse.