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the rise in hep­ati­tis C? I’m op­ti­mistic but un­der no il­lu­sions. There’s a lot of work to do to build po­lit­i­cal will for this.”

For states that have taken this step, the next hur­dle will be get­ting lo­cal of­fi­cials to agree to set them up, Ray­mond said. Ken­tucky and North Carolina have moved quickly to launch ex­changes in sev­eral hard hit coun­ties. But other states are still strug­gling with lo­cal op­po­si­tion from peo­ple who say that pro­vid­ing free sup­plies to drug users only en­ables them to con­tinue do­ing what they’re do­ing.

A Quiet Dis­ease

Com­pound­ing the prob­lem is a lack of per­ceived ur­gency. Hep­ati­tis C doesn’t kill chil­dren or adults in the prime of life. Most peo­ple in­fected with the virus ex­pe­ri­ence no symp­toms and the se­ri­ous liver dam­age it can cause doesn’t show up for 20 to 40 years af­ter some­one is in­fected.

“HIV is a dreaded dis­ease,” said Brian Strom, who chaired the com­mit­tee that wrote the Na­tional Acad­e­mies of Sciences study. “Hep­ati­tis isn’t and it should be.”

“It is ig­nored largely be­cause of a per­cep­tion that it is tied to drug use and not a threat to the gen­eral public,” he said. “The irony is that now that peo­ple are start­ing to worry about drug users be­cause they’re en­ter­ing the main­stream pop­u­la­tion, it’s go­ing to help hep­ati­tis get the at­ten­tion it de­serves.”

In Scott County, In­di­ana, it took an out­break of HIV in 2015 to mo­ti­vate then-Gov. Mike Pence to de­clare a public health emer­gency and allow a sy­ringe ex­change pro­gram to be es­tab­lished in the com­mu­nity.

Nearly three years be­fore the out­break, public health of­fi­cials were see­ing a sharp in­crease in hep­ati­tis C, and hos­pi­tals were re­port­ing in­creas­ing num­bers of over­dose cases, as well as en­do­cardi­tis (heart in­fec­tion) and skin ab­scesses, all signs of in­jec­tion drug use.

Search­ing for an­swers, In­di­ana public health of­fi­cials at the time sought ad­vice from a small com­mu­nity in cen­tral New York that had quelled a hep­ati­tis C out­break by es­tab­lish­ing a sy­ringe ex­change. But do­ing the same thing in Repub­li­can-led In­di­ana was a non-starter.

Pri­mar­ily a re­sponse to the AIDS epi­demic, sy­ringe ex­change pro­grams were first es­tab­lished in the U.S. in the mid-1980s as largely un­der­ground op­er­a­tions, since most state laws pro­hib­ited them. A ban on fed­eral fund­ing of sy­ringe ex­changes wasn’t lifted un­til last year. To­day there are nearly 200 pro­grams, clus­tered mainly in ma­jor coastal cities.

But to stanch the re­cent spread of hep­ati­tis C, a new study funded by the CDC es­ti­mates the na­tion needs at least 2,200 more pro­grams lo­cated in the mainly ru­ral ar­eas where young drug users are con­tract­ing the dis­ease.

Ac­cord­ing to CDC data, In­di­ana, Ken­tucky, Maine, Mas­sachusetts, New Mex­ico, Ten­nessee and West Vir­ginia have hep­ati­tis C in­fec­tion rates that are at least double the na­tional av­er­age. And Alabama, Mon­tana, New Jersey, North Carolina, Ohio, Ok­la­homa, Penn­syl­va­nia, Utah, Washington and Wis­con­sin have rates that are higher than the na­tional av­er­age.

In ad­di­tion to sy­ringe ex­changes, states need to adopt poli­cies aimed at test­ing more peo­ple at risk for hep­ati­tis C and treat­ing more of those liv­ing with the virus, said John Ward, di­rec­tor of the CDC’s vi­ral hep­ati­tis pro­gram.

More Test­ing

Hep­ati­tis C pri­mar­ily af­fects in­jec­tion drug users and mem­bers of the baby boomer gen­er­a­tion born be­tween 1945 and 1965, when the vi­ral dis­ease is be­lieved to have been trans­mit­ted through the health care sys­tem be­fore in­fec­tion con­trol and other pre­cau­tions were widely adopted.

Test­ing for the vi­ral in­fec­tion is spotty. Alaska, Ari­zona, Con­necti­cut, Hawaii, Iowa, Mis­sis­sippi, New Hamp­shire, Rhode Is­land, South Dakota, Wy­oming and the Dis­trict of Columbia do not con­sis­tently re­port data on hep­ati­tis C to the CDC. Na­tion­wide, tests for the con­ta­gious dis­ease are per­formed so in­fre­quently that the CDC mul­ti­plies re­ported cases by a fac­tor of 14 to es­ti­mate the real num­ber of in­fec­tions.

In a few ma­jor ur­ban cen­ters where in­jec­tion drug use has been preva­lent for decades, hos­pi­tal emer­gency de­part­ments have ex­panded the scope of their hep­ati­tis C test­ing.

Un­til the opi­oid epi­demic started ex­plod­ing in the Ap­palachian re­gion of north Alabama, the Univer­sity of Alabama at Birm­ing­ham Hos­pi­tal wasn’t one of those places.

But in 2015, af­ter droves of peo­ple started com­ing into the emer­gency de­part­ment for treat­ment of drug over­doses, heart valve in­fec­tions and skin le­sions, Gal­braith de­cided to stop ask­ing peo­ple whether they were drug users. In­stead, he di­rected his staff to sim­ply tell pa­tients they were go­ing to run a hep­ati­tis C test on their blood un­less they ob­jected. Only 15 per­cent opted out.

What Gal­braith found was that 11 per­cent of baby boomers tested pos­i­tive for hep­ati­tis C and 7.4 per­cent of peo­ple born af­ter 1965 tested pos­i­tive, rates that were far above the na­tional av­er­age.

Most sur­pris­ing, Gal­braith said, was that 14 per­cent of young white pa­tients tested pos­i­tive for hep­ati­tis C — nearly 18 times the na­tional av­er­age — while only 3 per­cent of young black pa­tients tested pos­i­tive.

He cau­tioned that the high rates he found in the emer­gency de­part­ment do not represent the gen­eral pop­u­la­tion of the Birm­ing­ham area be­cause pa­tients who come to emer­gency de­part­ments for care are dis­pro­por­tion­ately poor and unin­sured.

Af­ter map­ping the res­i­dences of the 1,200 young pa­tients who tested pos­i­tive for hep­ati­tis C in the last two years, Gal­braith found that most lived in ru­ral ar­eas of two nearby coun­ties where heavy in­jec­tion drug use was sus­pected based on county over­dose deaths and hos­pi­tal ad­mis­sions data.

In fol­low-up in­ter­views, he found that the ma­jor­ity of pa­tients who tested pos­i­tive self-iden­ti­fied as past or present in­jec­tion drug users, al­though he es­ti­mates that the real rate is closer to 90 per­cent.

Gal­braith used the data to try to con­vince Alabama law­mak­ers to ap­prove a bill that would cre­ate sy­ringe ex­changes in coun­ties with the great­est risk of spread­ing hep­ati­tis C. It was unan­i­mously ap­proved in the House, but failed to pass the state Se­nate be­fore time ran out this year. He and other public health ad­vo­cates in­tend to try again next year.

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