1. HIV in Southeastern Indiana: Lessons Learned from an Unprecedented Outbreak
Jennifer Walthall, MD MPH
Deputy Health Commissioner and Director of Health Outcomes
Indiana State Department of Health
August 17, 2015

2. Unusual Features Number of cases (175) Rural setting (most are urban)
Percentage of injection drug use (96% vs 3%)

3. Outbreak Notification
In late 2014, 3 new HIV diagnoses in Austin
DIS learned 2 had shared needles--contact tracing
Identified 8 more new infections in jurisdiction with <5 new HIV infections annually
All cases report injection of the opioid analgesic oxymorphone (Opana® ER and generic ER)
ISDH HIV/STD Division creates contact maps, determines cluster description and cause
Rural injection of oral opiate = only HIV cluster of its kind, largest HIV outbreak in Indiana
Illustrates importance of screening, surveillance/reporting, follow-up, and critical role of DIS

5. Why Austin?
Expanding epidemic of injection drug use heralded by dramatic increase in acute HIV infections
2006
2012
Suryaprasad Clin Infect Dis; 2014, 59(10):

6. Why Austin?
Expanding epidemic of injection drug use heralded by dramatic increase in acute HIV infections
2006
2012
Suryaprasad Clin Infect Dis; 2014, 59(10):

7. Why Austin?
Expanding epidemic of injection drug use heralded by dramatic increase in acute HCV infections
MMWR Morb Mortal Wkly Rep 2015, 64(17): , “Increases in Hepatitis C Virus Infection Related to Injection Drug Use Among Persons Aged ≤30 Years — Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012”
* Among person reporting known risk: 138 urban, 127 non-urban

8. Community Capacity Building
Scope of Response
Outbreak
Community Capacity Building
Media and Messaging
Syringe Exchange
One-Stop Shop
Addiction Treatment
Medical Care
Laboratory Testing
Epidemiology
Epidemiology: case investigation, contact tracing, surveillance database, indicator tracking, county profiles
Laboratory testing: rapid testing (field), confirmatory testing (ISDH Lab), phylogenetic testing (CDC Lab)
Medical care: care coordination, HIV/HCV treatment at Austin clinic and Scott County Jail, PrEP
Addiction treatment: inpatient detox, outpatient support, medically-assisted therapy, Naloxone
One-Stop Shop (COC): insurance enrollment, ID cards, birth certificates, immunizations, testing, care coordination, mental health services
Syringe exchange: COC and mobile unit by Scott County Health Department using donations
Media: press releases/briefings, talking points, YANA campaign
Community capacity building: federal, state, and local support, including visits by leadership at different levels

9. Timeline February 10 – ERC, ISDH leadership notified
February 20 – incident command system activated
February 24 – local partners identified and communication plan initiated
February 25 – IHAN message issued
February 27 – CDC Epi-Aid requested

10. Timeline March 2 – DIS blitz
March 3 – FSSA meeting for HIP 2.0 support
March 9 – Addiction services added
March 10 – Scott County Community meeting
March 13 – Media campaign begins
March 18 – 55 cases
March 23 – DOC added to response

11. Timeline March 25 – Executive order declared
March 26 – Incident command in Austin deploys mobile ground center (76 cases)
March 30 – HIP 2.0 PE goes live
March 31 – HIV clinic begins in Austin
April 1 – Community Outreach Center has fully operational “One Stop Shop” (83 cases)

12. Timeline April 3 – Limited syringe exchange approved
April 11 – Community Clean-Up Day, national media on site (99 cases)
April 20 – Executive order extension allows for recovery phase to begin (129 cases)
April – NPR onsite
April 24 – MMWR and CDC telebriefing
April – Visit from CDC, SAHMSA, HHS, HRSA (138 cases)

13. Timeline
April 29 – Syringe exchange bill (SEA 461) passes general assembly
April 30 – Cascade of care blitz begins
May 5 – Governor Pence signs SEA 461
May 24 – Executive order expires
June 8 – Time article issued
June 12 – LHD tour of one-stop shop
June 16 – CDC debriefing in Austin
June 25 – Last day of COC operations

14. Epidemiology Update: 8.10.15 Total cases: 175
Total co-infections with hepatitis C: 146 (86%)
Total COC services: 1679 (as of 6/9)
Total needle exchange participants: 182
Contacts remaining to trace: 3
Positivity rate among tested contacts: 40%
All patients requesting inpatient detox placed
As of

15. Demographics of Cases Median age 32 years, range 19-56 Male 55%
100% non-Hispanic white
Of 112 interviewed:
108 (96%) injected drugs
10 (7.4%) commercial sex work, all female
High poverty (19.0%) and unemployment (8.9%)
Low educational attainment (21.3% no high school)
High proportion without health insurance
135 cases identified by April 24
Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015; U.S. Census

16. Laboratory Results HIV specimens HCV specimens
Almost all analyzed specimens are one cluster
Most infections acquired within past 6 months
HCV specimens
Multiple strains and clusters
HCV has been repeatedly introduced over years to decades
Many infections are recent

17. HIV Outbreak Diagnoses by Week

18. Drug Use Among HIV+ Cases
Multigenerational sharing of injection equipment (insulin syringe)
Daily injections: 4-15
Number of partners: 1-6 per injection event
OPANA® ER – crush-resistant formulation: half-life 7-9 hours
Early Release, MMWR Morb Mortal Wkly Report 2015, April 24, 2015

19. Outbreak Control Interventions
Very few insured: established “one-stop shop”
No HIV/HCV care: state provided resources (IU), HRSA
Little HIV awareness: multiple educational efforts including billboards, infographics, webinars, TV/radio, newspaper, Jeannie White Ginder community event at Austin HS
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
Most focus on HIV infection: HCV effort gaining momentum as extent of HIV epidemic better defined and addressed

20. Incident Command Structure

21. Incident Command Structure

22. One-Stop Shop

23. Initial Objectives Implement ICS and Command Structure
Establish Local Executive Policy Group
Local policy group identified through local collaboration and input; meetings began first day ISDH Command Staff on ground
Establish Community Outreach Center (One Stop Shop)
One Stop Shop operational in temporary/mobile location within 3 hours of arriving on scene
Community Outreach Center/ One Stop Shop operational within 48 hours of deployment

24. Initial Objectives Implement Needle Exchange Program (SCHD)
Provided technical expertise in development of Scott County Needle Exchange Program
SCHD submitted and received approval from local officials and State Health Commissioner on 4/4/15
Coordinate Licensing, Records and Insurance Registration at One Stop Shop
Partner State Agencies reported to Scott County on 3/30/15 and operational at mobile site 3/30/15; set up and fully operational in Community Outreach Center by 4/1/15
Identify community sector groups to be engaged for partnership based upon the jurisdictional risk assessment; ISDH will provide a template. This is based on the Public Health & Healthcare Coalition Assessment tool developed by CDC/ASPR.
Identify top three hazards per District from successful completion of each jurisdictions HVA and select one of the three to train and exercise with District Healthcare Coalition
Assist District healthcare coalition in addressing coalition gaps identified during assessment conducted in BP3 utilizing Healthcare Coalition Development Assessment Factors and participate in follow up evaluation and after action items meant to address gaps that have been identified.

25. Initial Objectives Coordinate HIV Testing, Treatment and Prevention
Working with ISDH HIV/STD Division; establish goals and outcomes for HIV Contact Tracings, Testing, Care Coordination and Treatment
Clark County DIS led the DIS efforts
Develop long-term strategy for continued care and recovery
Foundations Family Medicine providing care and prevention
Expansion of Mental Health/ Substance Abuse Treatment, Services and Programs locally
data
-who is authorized to share data
-what types of data can be shared
-data use and re-release of parameters
-what data protections are suffficient
-legal, statutory, privacy and intellectual property considerations
We realize the importance of working with PHN within each of the local health dept but also know the reality of sensitive information and often times lack of shared information; even locally which presents larger issues when/if an outbreak or incident occurs. Working through these questions at the local health depts will answer a lot of questions going forward in our planning.
In addition to standard formalized procedures for communicating within own jurisdiction, the LHD will work with respective district coalition to develop a s district-wide notification during public health emergencies annex to the ISDH interagency notficiation during public health emergencies plan and ISDH Comms Plan

26. Scott County Health Department
Provided HIV testing training, needed testing supplies, arranged for volunteer testers from around the state to cover their testing hours, technical assistance in the development and implementation of their NEP
Supported hiring of additional PHN (candidate started June 15, 2015)
Provided a full time HIV tester (contract employee) for continuation at SCHD, Needle Exchange/OSS site and other community testing events

27. Scott County HD SEP Community Outreach Center and mobile unit
Donations accepted for needles, supplies--no state or federal funds
ID cards issued
One-for-one model
Partnership for disposal

28. Syringe Exchange Program
169 persons among
estimated 500 PWID

29. HIV Testing
The following LHDs, Hospitals and Organizations have received training on HIV testing since beginning of response.
Scott County Health Dept
Jefferson County Health Dept
Jackson County Health Dept
Switzerland County Health Dept
Floyd County Health Dept
St Vincent Salem Hospital
Scott County School District 2
Foundations Family Medicine
*the Miami County Police Dept also received training on HIV and HCV basic facts
This not only addresses the requirements of Ebola but touches on most if not all requirements of ANY infectious disease as displayed by MERS, HIV, TB, etc

30. Continuum of HIV care in Austin, Indiana August 17, 2015
Total diagnosed=175 (175 confirmed). Persons were ineligible if deceased (n=1) or outside of the jurisdiction (n=5); estimates are based on the number of eligible persons (n=169); ** Patients engaged in care if have at least one VL or CD4 *** Percent on ARVs increases to 65% and virally suppressed increases to 30% when denominator changed to number engaged in care. Clinical services were initiated 3/31/15. ART data updated through 8/17/15.

31. Scott County Jail
Created and implemented HIV testing procedures and protocol
Performed testing on 60 inmates; returning 15 +/- positive results equating to approximately 10% jail population
Completed HIV treatment protocol
Through coordination with ISDH HIV/STD Division provided HIV related services for all HIV positive inmates
Identified all cost associated with HIV testing and care and provided funding to cover identified gaps in care for inmates

32. Community Support
Provided Sharps Containers to local Police, Sheriffs Dept, Volunteer Organizations, EMA
Supplied Police, Fire, EMS with safety gloves and supplies for Community Clean Up efforts and protection
145 pairs of needle-nose pliers
92 pairs of puncture proof gloves
Community Outreach Center designated as Sharps Collection and Disposal Site
Total number of needles collection through community efforts at COC 4,204
Provided training for Opioid overdose treatment, Narcan, and supplies to Scott County first responders (EMS, Fire and Police)

33. Clinical Care Services
Initial HIV specialty service gap in Scott County
During emergency response: partnership with Foundations Family Medicine, AIDS Healthcare Foundation, IU Health Physicians, and MATEC
Long-term within Scott County at Foundations Family Medicine/AHF
Multiple options exist for care outside of scott County

34. Mental Health Services
LifeSpring established satellite location in Austin in OSS
Dual Diagnosis clinic in partnership with IUSM
Partnership with HRSA to designate Scott County as a HPSA for mental health
Multiple options exist for care outside of scott County

35. Challenges: Gaining Local Trust Media not permitted at COC
Press briefings held weekly at City Hall
Information and messaging distributed through volunteers embedded in community
Had two sites staffed with COC flyers including transportation information and phone number for first four weeks
Community Outreach Center flyers sent to EVERY Scott County resident

36. Challenges:
Gaining Local Trust

37. Challenges:
Gaining Local Trust

38. 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
On May 5, 2015, a new law was passed to allow local health departments and law enforcement to work together to start a needle exchange program in their counties if the following criteria are met….

39. Additional Policy Supports
Community Bystander Naloxone law
HIP 2.0 Medicaid waiver

40. Communications

41. Communications

42. Communications

43. Running Total through 6/11
COC Service Summary
Community Outreach Center Service Summary
COC Service
Running Total through 6/11
Total Services
1761
Visitors
1085
Insurance Enrollments
397
Drivers License/State ID
137
Vital Records
247
Immunizations
378
Mental Health
106
Care Coordination
116
HIV Testing
331
Department of Workforce Development 49

44. COC Service Summary

45. Lessons Learned Expect the unexpected
Promptly report new HIV and HCV cases for surveillance
Look for possible clusters of HIV and HCV
Become familiar with local data so any increases are easily identified
County profiles and SEP toolkit located at

46. Lessons Learned 2. Be prepared
Know who to contact for assistance and appropriate health services
Identify your community partners and leadership for assistance in response
If you see something, say something!

47. Lessons Learned 3. Escalation Activate incident command
Identify your mission, goals and indicators of success
Keep everyone informed
Monitor your resources carefully
Plan your de-escalation at the same time

48. Moving Forward HIV/Hepatitis C co-infection care
Hepatitis C eradication model
Needle exchange evaluation
Sustainability planning – partnerships and transition from incident command
Telling the story

49. Moving Forward
Expand HIV/HCV testing efforts and capacity to detect early signals
Routine HIV testing at “sensitive” venues (e.g., jails, addiction services, ERs)
Active outreach testing to at-risk population (e.g., PWID)
Develop systems to keep uninfected uninfected
Systematic retesting and education of high-risk persons
Repeat offer and provision of SSP and HIV PrEP
Decrease opioid over-prescribing and increase addiction treatment services, including MAT
Long-term solutions to improve public health infrastructure and socioeconomic disparities

50. Health Impact Pyramid
Protective interventions, context, and SES factors played a huge role in this outbreak. They were largely missing or challenging and had to be built or mitigated while conducting the outbreak investigation and instituting control measures. Hard to work at top of pyramid when foundation is compromised.

51. Jennifer Walthall jwalthall@ISDH.IN.gov
Questions?
Jennifer Walthall