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What’s the Overdose Death Rate in Your County?

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Opioid Overdose Rate | Deaths per 100,000 population ages 15-64 by county from 2012 to 2016. (Source: NORC, University of Chicago.)

A new interactive map shows the county-by-county impact of opioid drug overdoses. A researcher describes some of the challenges of reporting overdoses in rural areas and what researchers did to address them.

If you’ve got a couple minutes, Michael Meit has a favor to ask. He’ll try not to take up too much of your time. 

“What I want is for people to go to the online tool, click on their county, pull up that 8 ½-by-11 fact sheet, and send it to all their local elected officials, health department staff, medical personnel, and others,” Meit said.  

And? 

“Start a community dialog about drug overdose deaths in their community,” Meit said. 

Meit, co-director of the Walsh Center for Rural Health Analysis, is part of an initiative launched last week that provides a county-by-county look at the impact of opioid deaths across the country. A press release calls the project the “first ever interactive data visualization of national county-level opioid overdose mortality rates.” 

The project is collaboration of the Walsh Center (part of NORC at the University of Chicago) and USDA Rural Development. 

Despite years of public discussion and news coverage, many communities don’t understand the extent of their opioid-abuse problem, Meit said. “People by and large still have no idea how bad things are in their communities,” he said. 

The tool gives the rate of drug-overdose deaths for about three quarters of all counties in the United States. A fact sheet for each of those counties compares local data to state and national figures. 

By the afternoon that the data tool was released, a handful of news organizations with online presence had already published stories about their county’s overdose rate, lending credence to the idea that the overdose rate is still news.  

Meit said rural America needs to be part of the overdose discussion because the stakes are so high there. But rural research always presents unique challenges. 

About a quarter of the U.S. counties do not have overdose death data because the number is suppressed. One reason the CDC leaves out the number is to protect individuals’ confidentiality. When the number gets too small, it may be possible to identify the people represented by the statistics. 

Rural counties are especially susceptible to having their overdose deaths suppressed for this reason. To get the number of deaths over the confidentiality threshold, researchers aggregated overdose data over five-year periods. Even with that provision, the map lacks overdose data for about 25 percent of counties. 

That’s not necessarily bad news, Meit said. “One explanation [for suppressing the county’s data] is that there are so few people there,” he said. “The other is that there are so few deaths there, and that’s a good, good thing. I suspect it’s a little of both.” 

Using the five-year numbers also means that the current overdose rate is likely higher than the figure on the map, since overdose rates have been climbing quickly in recent years. 

The overdose data comes from the CDC. (The specifics are here.) While the numbers are the best available, they likely understate the scope of the overdose problem, perhaps by about a third, one recent study says. Meit said data reliability is always harder in rural areas. 

“When issues of under-reporting are involved, it always tends to be worse in rural areas than in urban ones,” he said. Medical examiners may have less training and resources to determine causes of death. And the smaller size of communities may make them more likely to protect families from the stigma of a drug death. 

The map also includes layers of other data such as race/ethnicity, age, education, and income. Those data let users see a visual connection between those factors and the overdose problem. That’s not to provide the “answer” to the overdose problem. “Again, that information is there help start the conversation,” Meit said.  

He said future versions of the map will include “solutions” layers such as the location of treatment centers and hospitals or access to grant sources. 

In a press release, USDA Assistant to the Secretary of Rural Development Anne Hazlett said USDA would work with rural communities to help them address the “monumental challenge” of drug deaths. 

“Local leaders in small towns across our country need access to user-friendly and relevant data to assist them in building grassroots solutions for prevention, treatment, and recovery,” she said.  

This article was originally published by Daily Yonder

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West Virginia Research Reveals Disparity in Infant Mortality Rates

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Dr. Lauri Andress, an assistant professor at the West Virginia University School of Public Health, speaks about infant mortality issues during the Mountain State Racial Justice Summit, Saturday, at the BridgeValley Community and Technical College in South Charleston. Photo: Chris Dorst, Gazette-Mail

In West Virginia, it is 1.7 times more likely for a black infant to die before their first birthday, compared to a white infant.

This is one of the figures that came from Dr. Lauri Andress’ research on infant mortality.

At first, Andress, an assistant professor in the West Virginia University School of Public Health, struggled to find state-specific data on the issue, she said during a presentation at the Mountain State Racial Justice Summit, held at BridgeValley Community and Technical College’s South Charleston campus in West Virginia.

Each state is required to submit raw data of infant mortality rates to the Centers for Disease Control and Prevention. Some can request an analysis back, but Andress said West Virginia did not because the state has such a small population of African-Americans.

“That’s a factual statement by a statistician that I would expect, but it’s not a statement by your state government that you should stand for,” Andress said. “Because there are ways to think about minorities in the state and get at that analysis.”

Andress worked with CityMatCH, a Nebraska-based public health organization, to use those raw numbers to create an analysis. What that report found was that even though black infants account for only 4 percent of births, they make up 6 percent of infant deaths in the state.

Initially her research wasn’t about minority health, but she said the lack of attention the subject was receiving made her want to look into it more.

“I wasn’t until I got here and found out that African-Americans were not on the agenda in West Virginia that I became passionate about it,” she said. “I can go anywhere else in the United States and they will talk about African-Americans.”

She said other states that also don’t have large minority populations have created reports, adding that it’s not impossible, rather a matter of political will.

West Virginia has a law that requires the state to look into infant and maternal deaths, specifically infant deaths that occur before one year of age. This state law requires the health department to investigate and put together panels for other suspicious deaths, such as opioid and other drug abuse deaths.

There are national standards that must be adhered to while investigating infant deaths, including that the mother or family members are interviewed, according to the National Center for Fatality Review and Prevention.

There are numerous reasons to interview the mother, Andress said. For example, the mother would be able to speak about her experience during the pregnancy and the prenatal care she received.

“There’s things you can’t get from the four corners of a death record,” Andress said. “If they interviewed mothers, we would at least know if there was a difference in what was happening to black moms and white moms that would make a difference in the percentage of black-versus-white infant deaths.”

Andress said there are two reasons she suspects the state might not do that. One is that it can be difficult to get grieving families and mothers to agree to talk, she said. Another reason is because of privacy laws.

“But you’re still up against a national standard and it’s the recommendation that when you’re trying to understand why infants are dying in your region, you’ll do an interview,” she said.

Even when black women have an education and high levels of income, their infants are still dying, but it’s not clear why, Andress said.

Another possible solution, she said, would be to create specialized panels in regions where there is a higher percentage of black women living. She said there is one panel at the state level that convenes in Charleston, but she said that they are overworked.

She adds that this problem is not unique to the Mountain State. Nationally, twice as many black infants die before they reach their first birthday, according to the National Birth Equity Collaborative, and in some cities, the rate of black infant mortality is three-times the national average.

“To understand this issue we need to look at the lives of these women,” Andress said. “This is a historical problem, it doesn’t matter where you are, it’s something that is happening everywhere.”

This article was originally published by the Charleston Gazette-Mail

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In West Virginia, an Outbreak and Few Answers

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High-risk factors for hepatitis A include those experiencing homelessness or who are transient, those who have been incarcerated within the last 6 weeks, and people who use illegal drugs. Those experiencing homelessness are at risk because of the difficulty maintaining hygiene on the streets. Photo: Shutterstock.com
This article was originally published by Rewire.News. 

Opioids and a rise in people experiencing homelessness have been blamed for a hepatitis A epidemic in West Virginia. But advocates for the homeless say the local census doesn’t support that.

West Virginia has been struggling with an outbreak of hepatitis A, according to local public health officials.

The most populous county in the state found itself the “major epicenter of a major hepatitis A outbreak,” said John Law, a public information officer at the Kanawha-Charleston Health Department (KCHD). Since March, West Virginia’s Department of Health and Human Resources (DHHR) has reported nearly 1,400 new cases of hepatitis A, an unprecedented increase. According to DHHR, the majority of the hepatitis A cases have been in Kanawha, Cabell and Putnam counties. Two cases have been reported in a northern West Virginia jail, and there have been at least two confirmed deaths.

Police and health officials say that the epidemic may be linked to a possible rise in people experiencing homelessness in West Virginia. But advocates for the homeless say the local census of people experiencing homelessness doesn’t support that theory. Others blame opioid usage for the state’s surging rates of hepatitis A.

Hepatitis A is a contagious disease often transmitted by food or water contaminated by fecal matter. People who are homeless or transient, those who don’t have access to proper sanitation, drug users, and the recently incarcerated may be at high risk, as well as anyone who has contact with higher-risk individuals. Symptoms of hepatitis A include whole body fatigue, fever, loss of appetite, diarrhea, nausea, and vomiting, as well as abdominal, joint, and muscle pain. Dark urine, itching, weight loss, and yellow skin and eyes (jaundice) are also common symptoms of infection.

The jump in West Virginia cases is alarming because, nationally, annual reports of hepatitis A cases have remained relatively stable, with a 95 percent decline since a vaccine became available in 1995, according to the Centers for Disease Control (CDC). Until this year, West Virginia reported an infection rate lower than or comparable to many other states. According to Janet Briscoe, the KCHD director of epidemiology, in an interview with local News Channel 3 WSAZ: “Before the outbreak, hepatitis A cases were rare in our region.” In 2010, previously the most recent year with the highest number of new cases, the state reported only 16 new cases.

Currently in West Virginia, “we are seeing it particularly in our homeless population. Maybe not the traditional on-the-street population, but the itinerate homeless—couch surfers,” Law of the DHHR said in an interview with Rewire.News. Those experiencing homelessness are at risk of hepatitis A due to the difficulty maintaining hygiene on the streets or without a permanent home.

Spotlight on Poverty and Opportunity, a nonpartisan forum on issues surrounding poverty in the nation, reports a total of more than 1,300 people experiencing homelessness in West Virginia, though it’s unclear how their count defines homelessness. An accurate, current count for both West Virginia and its capital proves hard to find because different agencies define homelessness differently.

As defined in a report from the Substance Abuse and Mental Health Services Administration, the point-in-time (PIT) count from the Department of Housing and Urban Development (HUD): “tallies the number of people in a community who are experiencing homelessness on a single night.” The PIT count taken in January for the entire state of West Virginia, according to the Western Virginia Continuum of Care, was higher than in years past, up by 9 percent, totaling 304 persons (including children) experiencing homelessness. But because of rural terrain and the difficulty reaching or finding many unknown people, this count may be low.

As reported in the Charleston Gazette-Mail, Charleston, West Virginia, Police Chief Steve Cooper stated last January there had been an influx of “several hundred” homeless people in the city and that homelessness in West Virginia is difficult to quantify.

This also makes linking the hepatitis A outbreak to homelessness difficult.

The outbreak in West Virginia “has been connected with the outbreaks in both California and Kentucky,” Law said. Though the original source of the infection remains unknown, researchers speculate that it first began in California, then spread. In addition to West Virginia, this year has seen newer outbreaks in Massachusetts, Missouri, Ohio, Arkansas, and Nashville, Tennessee.

According to Ellen Allen, executive director of Covenant House, a continuation of care site in Charleston that seeks to help the homeless through long-term support, PIT numbers have changed very little in the last five years—despite what is being claimed by the Charleston police department and mayoral office. “That’s not accurate at all. They know the homeless population has not tripled. This has been a point of contention with them,” she said in an interview with Rewire.News. She noted that local law enforcement have participated directly in the PIT count each year, which has stayed around 300 for Charleston.

Last month, a segment on News Channel 3 WSAZ ascribed an increase in the Charleston homeless population to people from out of state. According to Ronald Chandler, a man experiencing homelessness interviewed by WSAZ, many of these out-of-state individuals found their way to West Virginia after other states began to “crackdown” on the population.

Allen disagrees, saying Covenant House sees many in the new homeless population coming from rural parts of West Virginia itself. “We’re not seeing them come from all over the country. We’re seeing them from areas like the devastated coal communities,” she said, noting Boone County as an example.

Nationally, numbers of people experiencing homelessness have been on the rise, with a 9 percent increase specifically in “unsheltered homelessness” in 2017 and 12 percent in “chronic homelessness” in 2017.

For Allen, community resources such as shelters serve as gatekeepers for the health of the high-risk population, offering access to resources like vaccines that some would not be able to easily obtain otherwise. “We try to respond collectively as a community, to get everyone immunized that we can,” Allen said. “We also know [the hepatitis A outbreak] is being driven by opioid addiction and we are arguably the epicenter of that as well.”

As of September 28, among the 1,395 hepatitis A cases in West Virginia, 76 percent report drug use, and 11 percent of the total number of people infected are considered homeless.

When it comes to individuals experiencing homelessness, “That particular population is sometimes difficult to access and make realize they need to be vaccinated and tested,” said Law. “We are reaching out to them in as many ways as we possibly can. For instance, we have provided vaccinations at shelters and soup kitchens.”

Because hepatitis A is a virus, treatment only addresses symptoms until the virus has run its course. The CDC, DHHR, and Law all urge those who qualify to prevent contracting the virus by getting vaccinated—though it’s a little more complicated than simply getting a shot, according to Law. “With hepatitis A, if you are vaccinated within two weeks of exposure, you will most certainly be protected against it. The dichotomy there is that you sometimes don’t manifest any symptoms until well after that two-week window.”

On August 25, the CDC distributed information to all state and local health departments about an investigation into hepatitis A infections specifically in people who are experiencing homelessness or who use illicit drugs.

At the end of August, West Virginia Public Broadcasting reported that at Gov. Jim Justice’s (R) request the CDC assigned six “subject matter experts” to “manage the outbreak,” assisting with technical tasks such as data management and case investigation strategies and procedures. The CDC’s Division of Viral Hepatitis has been monitoring and assisting many states since March 2017. The CDC did not respond to multiple requests from Rewire.News for comment.

“This outbreak is continuing; we have seen it across the country,” Law said. “The best thing is you can do, certainly, is to get vaccinated.”

According to a KCHD press release, in West Virginia “most adults have not been vaccinated for Hepatitis A.” Though beginning in 2006 the vaccine did become recommended vaccine, it is required only for children attending state preschool in West Virginia.

“The numbers we are seeing [of hepatitis A] have been lab-confirmed numbers. There is probably a larger number out there,” Law said. “These are the people who are sick enough to go to a health-care provider or hospital.”

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Appalachia Continues to Struggle with Hepatitis A Outbreak

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The infectious liver disease hepatitis A has hit Appalachia hard during the past several months. But your risk of contracting the disease depends on several factors.

“So it’s very important to understand that there are certain groups of people that are at increased risk, as opposed to the general population,” West Virginia commissioner of public health Rahul Gupta said.

Up until this point, the outbreak in West Virginia has mostly affected people who are using illicit drugs (both injection and non-injection), people who are homeless or mobile, and those who have been recently incarcerated.

Basically, hepatitis A, a contagious liver infection, is transmitted by food, water, or personal contact with an infected person. But unlike its cousins hepatitis B and C, hepatitis A is not transmitted by needles and it does not cause long-term liver damage, nor does it become chronic. But it can make you very sick — mimicking major flu symptoms and making the afflicted jaundiced.

Graphic: Alexandra Kanik/Ohio Valley Resource

“We’re seeing that a little over 50 percent or a little over half of the population who exhibits symptoms are having to be hospitalized,” Gupta said.

And there’s no real treatment — you just, treat the symptoms. But there is a vaccine to prevent hepatitis A.

Although hepatitis A is not transmitted by needles, more than half of those infected have also tested positive for hepatitis B or C.

West Virginia is not the first state to report a hepatitis A outbreak. Michigan, California and Kentucky have also been hit, although neither Michigan nor California saw as many cases as Kentucky and West Virginia.

Kentucky’s outbreak started in August, 2017 — 1,788 cases have been reported to date. West Virginia’s outbreak began a few months later.

“We noticed our first case in January of this year. It has multiplied exponentially since then,” John Law, public information officer for the Kanawha-Charleston Health Department, said.

Since March 2018, West Virginia has seen 1,318 cases — about half of which are in Kanawha County. By comparison, in 2017, West Virginia reported six cases of acute hepatitis A.

Law said his department is trying to get a handle on the outbreak by partnering with organizations that are already working with illicit drug users and those experiencing homelessness, such as Covenant House and the free clinic Health Right.

Graphic: Alexandra Kanik/Ohio Valley resource

“As a collaborative effort, then, we sent out a letter with the health department to all the shelters, etc., encouraging them to have every new client come through Health Right to have like a established physical just to check them over and screen them for any kind of vaccinations and hopefully give them hepatitis A vaccination then,” Angie Settle, Health Right’s executive director, said.

She said they also went to some of the local recovery centers and did mass hepatitis A vaccinations. So far, Settle said Health Right has given close to 2,000 vaccinations. The DHHR has distributed more than 24,000 vaccines statewide.

So do you need a vaccine? If you work in food prep, or come in close contact with those at risk, it’s probably wise. And if you don’t, one of the best ways to protect yourself is just to wash your hands frequently, especially after using the bathroom.

This article was originally published by West Virginia Public Broadcasting

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