Monthly Archives: July 2017

Compulsory Viral Hepatitis Screening is a Pathway to Elimination

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

At the International AIDS Society’s (IAS’) 4th Annual HIV/Viral Hepatitis Co-Infection Meeting in Paris, France, aside from all of the various data regarding rates of infection around the globe and various approaches to eradicating Hepatitis B and C (HBV/HCV, respectively) by the World Health Organization’s (WHO’s) target year of 2030, one assertion rang true throughout: all of these projections and approaches will require robust Harm Reduction measures to be put in place.

For the uninitiated, Harm Reduction measures are various laws, regulations, and statutes put into place in order to reduce injury or death from a specific cause; a good example of this would be a Seat Belt Law. As they relate to Viral Hepatitis (VH), Harm Reduction statutes include various methods of reducing the likelihood of infection (and thereby death), such as the mandatory use of Prescription Drug Monitoring Programs (PDMPs), ID requirements for the purchase of prescription opioid drugs, and prescriber education about the risks of prescribing opioids and proper opioid usage. One set of measures, however, would serve several purposes: mandatory or compulsory screening requirements for HIV, Hepatitis B, and Hepatitis C.

"Hepatitis" on a screen, with a stethoscope

Photo Source: CTV News

A handful of states (CT, FL, MA, NY, and PA) have considered or passed mandatory screening guidelines for the Birth Cohort (people born between 1945-1965). These guidelines are largely inefficient, because they rely upon an “Opt-In” method of screening, meaning that patients are offered screening, and must accept – it’s optional. Additionally, these measures focus only on the Birth Cohort, and understandably so, as they represent the largest percentage of existing HCV cases. These approaches, while well-intentioned, must be amended and updated on a national level, in order to effectively combat the spread of both HBV and HCV.

An estimated 70% of new Acute HCV infections are related to Injection Drug Use (IDU) by People Who Inject Drugs (PWIDs). That none of these screening guidelines make mention of these facts is indicative of our inability to accurately capture the data we need in order to adequately assess the scope and scale of the epidemic. Statistics at the state and national levels are largely reached using modeling that projects an estimated number that ostensibly accounts for underreporting. PWIDs are, however, notoriously difficult patients from whom to capture data, in no small part because we see them consistently in only a handful of healthcare settings: Hospitals for overdoses, Prisons, Jails, and Juvenile Detention Centers for incarceration, and Rehabilitation facilities. In addition, Syringe Services Programs (SSPs) are another excellent point of data collection, but it must be handled differently than those previously listed.

The most effective method of screening is to make it compulsory (mandatory) on an “Opt-Out” basis in which patients are informed that screening for HIV, HBV, and HCV are part of a required set of screenings, and they must provide “informed refusal” of the test. This requires that all hospitals, clinics, justice/incarceration settings, and rehabilitation facilities adopt this method of screening in order for the most effective use of time and money that will result in the most accurate data captures. When opioid and heroin users overdose and are the recipient of emergent care services, this is the prime location to capture data from PWIDs. The same holds true for those who are moved into justice settings, as well as those who enter rehabilitation services. Additionally, with the use of rapid HCV antibody testing, this can be accomplished in a relatively short period of time. The important part is ensuring that each Positive test result is followed up with an immediate secondary confirmatory screening, rather than scheduling a second appointment.

These types of compulsory screening requirements are paramount to achieving the WHO’s goal of eradication of HBV and HCV by 2030. Once patients know their status, with proper linkage to care services, they can be cured of HCV and treated for HBV with relative ease. This will, of course, require an investment on the part of state, Federal, public, and private partners, and until we have Federal movement on these issues, the best location to start is at the state-level. Personally, I am working on an endeavor with one of West Virginia’s delegates to work on building a workable and FUNDED compulsory screening requirement as close to the one I suggested above, given the complex nature of WV’s budgetary constraints. We at HEAL Blog invite you to do the same, in order to ensure that compulsory screening becomes a reality.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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National Academies Panel Recommends Rethink on Opioids

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

A new report released by the National Academies of Science, Engineering, and Medicine (NASEM) makes several pointed recommendations about the way the United States Food and Drug Administration (FDA) approaches prescription opioid drugs, a class of pain relievers that are highly addictive and serve as a potential gateway to heroin, once supplies and sources of prescription drugs run dry (NASEM, 2017a). The panel, ordered under the Obama Administration’s FDA head in 2016, spent a year looking at the burgeoning opioid and heroin epidemics in the U.S. in an effort to better address these issues at every level of government (Diep, 2017). Among these recommendations are suggested guidelines for how the FDA considers the approval, regulation, and class scheduling of prescription opioid drugs.

National Academies of Science and Engineering Medicine

Photo Source: NASEM

Throughout the 1990s and early-2000s, pain advocates and pharmaceutical companies successfully lobbied the FDA to expand the indications (approved usage) for various high-powered opioid pain relievers that had previously been reserved for major surgeries, injuries, and palliative care. Purdue Pharma, in particular, scored a big win with its groundbreaking product, OxyContin, one of the first high-powered opioids to become commercially successful. What Purdue failed to mention while they were handing out free 30-day trial coupons for doctors to give to patients was that the drug was highly addictive. By the late-1990s, however, it became abundantly clear that these drugs had a high rate of addiction.

The recommendations put forth by NASEM as the FDA to adopt a position they term “opioid exceptionalism,” where “…the FDA thinks about opioid drugs differently from other products, …taking a public health approach to drug approvals and to other decisions about postmarket (sic) surveillance” (Servick, 2017). This would require the FDA to take into account the following:

  • benefits and risks to individual patients, including pain relief, functional improvement, the impact of off-label use, incident opioid use disorder (OUD), respiratory depression, and death;
  • benefits and risks to members of a patient’s household, as well as community health and welfare, such as effects on family well-being, crime, and unemployment;
  • effects on the overall market for legal opioids and, to the extent possible, impacts on illicit opioid markets;
  • risks associated with existing and potential levels of diversion of all prescription opioids;
  • risks associated with the transition to illicit opioids (e.g., heroin), including unsafe routes of administration, injection-related harms (e.g., HIV and hepatitis C virus), and Opioid Use Disorder (OUD); and
  • specific subpopulations or geographic areas that may present distinct benefit-risk profiles (NASEM, 2017b)

These recommendations come on the heels of a June recommendation by the FDA that pharmaceutical company, Endo, voluntarily remove its product, Opana ER, from the market in response to the public health crisis it says is in part because of illicit use of the drug by Injection Drug Users (IDUs) (Mandal, 2017). Endo recently complied with that request, despite insisting that it believes the drug to be safe when used properly (Ramsey, 2017).

Opana ER (Extended Release) is a reformulation of the drug in an effort to stem abuse by patients who were crushing the drug in order to snort it. This reformulation involved coating it with a plastic coating that Endo promised would make it “abuse deterrent/resistant.” Opana abusers, however, were quick to find a way around this by melting down the drug and its the plastic coating, filtering out the plastic through mesh, and injecting the drug directly into their bloodstream, resulting in a more intense effect (McEvers, 2016). Rather than alleviate abuse, Opana ER ended up creating a deadlier epidemic, as users were sharing needles to inject the drug, fostering the spread of both HIV and Hepatitis C (HCV). Once supplies of Opana ER dried up, those users often moved directly to heroin, as it is both cheaper and more readily available.

The NASEM recommendations will no doubt result in outcry from both pain advocates and pharmaceutical companies desperate to retain profits. Should they be adopted, the U.S. may finally be able to break its near-thirty-year abusive relationship with opioid pain killers.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Viral Hepatitis Funding Lowest in States Most at Risk

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The Centers for Disease Control and Prevention (CDC) recently released the data related to Viral Hepatitis (VH) surveillance in the U.S. for 2015, and the picture is…grim. While many states saw relatively stable rates of new Acute Hepatitis C (HCV) infections, two states – AL and PA – experienced 100% increases from 2014 (CDC, 2017). CDC funding for states’ respective Viral Hepatitis programs, however, tends to fall short in states where rates of infection are high relative to the population (The AIDS Institute, 2017).

Infection rates are generally calculated by taking the number of total infections, dividing that by a state’s total population, and multiplying that result by 100,000 to calculate how many people, on average, will be infected for every 100,000 residents. For example:

The state of West Virginia reported 63 new cases in 2015; the state has a population of 1,844,000, so 63/1,844,000 = 0.00003416 x 100,000 = 3.416 rate of infection.

West Virginia, despite being the 14th least populous state (including the District of Columbia), has the second highest rate of new HCV infections in the U.S., second only to Massachusetts, which has a rate of 3.7. The following chart lists the top ten states in order of highest infection rate, their respective populations, and the amount of funding in those states for VH:

Chart showing 10 states with highest viral hepatitis infections also having lowest state budgets to combat the disease, including MA, WV, KY, TN, ME, IN, NM, MT, NJ, NC

The above chart seems to be indicative of two things irrespective of a state’s population: (1.) certain states make VH funding a priority, while others do not; (2.) states are simply not receiving enough funding from the Federal government and the CDC to bring their VH programs up to funding levels adequate enough to effectively combat VH.

Each of these states has a number of factors contributing to their respective rates of infection: (1.) Aging populations (Baby Boomers born between 1945-1965); (2.) High rate of Injection Drug Use related to opioid drugs, heroin, or stimulants; (3.) Sharp increase in the number of tests administered, resulting in higher rates of positive results.

What is clear is that funding for VH is woefully inadequate if the U.S. intends to eradicate HCV from the U.S. by 2030.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Illicit Tattoos and Piercings Increase Risk of Hepatitis C

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Early this month, police in Pulaski, Virginia arrested four men for unlicensed tattooing – a misdemeanor offense with a fine of $2,500 and a maximum penalty of one year in jail. The investigation into the illegal tattooing operations began in May 2017, when police received a warning from the Pulaski County Health Department (PDHD) of a rapid increase in the number of new Hepatitis C (HCV) infections in patients who had recently received a tattoo in the area surrounding Meadowview Apartments near the 800 block in Pulaski (WDBJ 7, 2017).

While tattoos and piercings were relatively uncommon during the 1980s, the less conservative 1990s gave birth to a rise in the popularity of both. Now, nearly 4 in 10 people born after 1980 have a tattoo, and 1 in 4 have a piercing in a location other than an earlobe (Mercer, 2017). While most people have their tattoos and piercings done by licensed professionals, the high cost of body art leads many people to seek out less reputable, unlicensed tattoos that can be done cheaply and off the books.

Makeshift tattoo artist

Photo Source: India Times

Others, still, manage to acquire their tattoos via even less professional means than that while in jail or prison. In late June 2017, authorities at the Bladen County Jail in Bladen County, North Carolina, found a makeshift tattoo gun after being told that three inmates received tattoos and that one of them had contracted HCV. Jailers then found that two other inmates received tattoos from the makeshift device, and they are now being tested for the disease (Donovan, 2017). Further complicating matters is that jailers are uncertain where the HCV-infected inmate contracted the disease in jail or was infected prior to being incarcerated. Screening for HCV is required during the intake process, but few jails follow this protocol.

Part of the reason why work from licensed artists is so expensive has to do with the safety regulations rightly put in place to avoid the types of infections faced by Pulaski residents. Proper cleaning, sanitation, storage, and tattooing procedures is supposed to be closely monitored by state health departments as part of the licensing process, which does drive up the cost of the practice. However, each state is left to its own devices when it comes to regulating body art. North Carolina, for example, has a law dating back to the 1990s that regulates tattoos, but fails to regulate other forms of body art (e.g. – branding, piercing), meaning that artists to provide those services do not receive the same level of scrutiny as tattoo artists (Mercer).

These safety issues exist in every state in the U.S. Public health officials in Fargo, North Dakota, recently issued a warning after people in the metro region contracted HCV and HIV through illegal tattooing (Filley, 2017). The allure of cheap body art is often the primary reason why people go to “this guy I know who does cheap tattoos.” Unfortunately, “that guy you know” likely isn’t licensed, and putting one’s life into his hands, regardless of the quality of the artwork, may result in longer-term consequences than just a bit of ink.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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U.S. Air Force Clinic Risks Potential Exposure

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

If one thing has been certain in the world of medicine since the discovery of HIV/AIDS, it’s that medical safety standards must always be followed. For 135 people receiving treatment at Al Udeid Air Base clinic in Qatar, a failure to properly “[clean] in a manner [consistent] with sterilization guidelines” opened them to the risk of exposure to HIV, Hepatitis B (HBV), and Hepatitis C (HCV).

Map of Al Udeid Air Base in Qatar

The issue is related to endoscopes – an illuminated optical (camera) used for upper and lower gastrointestinal procedures. As endoscopies are invasive procedures, failing to properly sterilize these medical devices poses a serious risk to anyone who undergoes procedures using them. The process for cleaning endoscopes has been readily available to all medical staff well before April 2008, the date when the devices were identified as having been improperly cleaned. These failures to follow basic sterilization protocols, particularly in a military base medical center, are unacceptable. That no one apparently noticed the improper sterilization methods until April 2016 is simply intolerable.

The issue came to light Monday, June 19, 2017, when the Air Force Surgeon General revealed the information in a press release. Sadly, this is not the first time that the U.S. Air Force (USAF) have had issues with improperly handled endoscopes. In September 2016, 267 patients at the Air Force Academy’s medical clinic in Colorado were notified that they were at risk for a number of infectious diseases due to improperly sterilized endoscopy equipment (Kime, 2016). While these instances are not exactly alike in circumstance, they do bring into question the training and quality of care provided by these clinics.

U.S. military and veteran clinics have consistently come under fire, over the past two decades, in no small part because of their failure to follow basic protocols that have been in place and consistently updated since the early 1990s. Numerous reports over the past two decades indicate a failure on the part of military and veteran medical personnel to protect patients from HIV, HBV, and HCV infection risks, causing many citizens and legislators to bring into question the quality of the healthcare provided. With rare exception, all of these incidents relate to the sterilization of medical implements that are supposed to be adhered to at every level of medical practice, from veterinarians to surgeons, and yet, military medical personnel just can’t seem to get it right.

Photo of Command Surgeon Colonel Walter Matthews

Source: LinkedIn

Every time one of these incidents occur, military personnel attempt to play down the risk of exposure: in the September 2016 Academy issue, Command Surgeon Colonel Walter Matthews said that the risk of infection to patients was “low, but it is not zero.” In the current scandal, Larine Barr, a spokeswoman for the surgeon general, said that the risk of infection is “very small, particularly in a deployed environment” (Losey, 2017). While these platitudes may be a great way to mollify everyone else, they serve as small comfort to those facing the risk of infection.

At what point will military and veteran medical personnel be subjected to the same level of scrutiny as every other part of the medical community? While timeliness and meeting deadlines is understandably important, these are the types of mistakes made by first-year trainees, not those in whose hands the lives and wellbeing of patients is being placed. Clearly, something needs to be done to ensure that all medical personnel are properly trained, and are consistently following every sterilization protocol; if they cannot live up to that very basic standard, they have no business providing medical services.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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