Hepatitis C is on the rise in Appalachian Kentucky, and dirty needles are to blame; officials predict surge of HIV to follow

Kentucky has the highest rate of acute hepatitis C in the nation and public officials predict it could get much worse, Claire Galofaro and Dylan Lovan report for the Kentucky bureau of The Associated Press.

Dirty needles shared by drug users is the primary cause of this upsurge in hepatitis C, a contagious liver disease that destroys the liver, often leads to cancer or cirrhosis, and is the leading cause of liver transplants. It is spread primarily through contact with the blood of an infected person.

Patton Couch talks about his troubles.
(AP photo by David Stephenson)

Patton Couch, 25 and one month sober, is one of thousands of young Appalachian drug users recently diagnosed with hepatitis C. Galofaro tells the story of how one night four years ago, Couch said “he plucked a dirty needle from a pile at a flophouse and jabbed it into his scarred arm” even though he knew most of the addicts in the room probably had hepatitis C.

"All I cared about was how soon and how fast I could get it in," he says. "I hated myself, it was misery. But when you're in the grips of it, the only way I thought I could escape it was one more time."

Public-health officials are also concerned that Kentucky or part of it will become the next Scott County, Indiana, which is dealing with one of the worst American HIV outbreaks among injection drug users in decades, Galofaro notes. She says Scottsburg is much like many Appalachian towns – which have poor and/or few treatment options, and have long been seized by an epidemic of prescription drug abuse.

"One person could be Typhoid Mary of HIV," said Dr. Jennifer Havens, an epidemiologist at the University of Kentucky's Center on Drug and Alcohol Research, who has studied Perry County drug users for years as the hepatitis rate spiraled through small-town drug circles there. Of the 503 drug users she has tracked since 2008, 70 percent have hepatitis C.

“An explosion of hepatitis C, transmitted through injection drug use and unprotected sex, can foreshadow a wave of HIV cases,” Galofaro writes.

In Scott County, 160 people have tested positive for HIV in five months, compared to just 49 drug users testing positive in New York City in all of 2013, Greg Millett, director of public policy for the Foundation for AIDS Research, told Golofaro. “This is a canary in the coal mine for other places with high rates of hepatitis C,” he said.

In a study released last month, the federal Centers for Disease Control and Prevention found that hepatitis C cases across four Appalachian states — Kentucky, Tennessee, West Virginia and Virginia — more than tripled between 2006 and 2012.

Kentucky leads the nation in the rate of acute hepatitis C, with 4.1 cases for every 100,000 residents, more than six times the national average, according to the CDC.

Officials in Appalachian are “scrambling to figure out how to stop it, whether through needle exchange programs, drug treatment or jail,” Galofaro writes.

Kentucky passed a law in March allowing local health departments to create needle-exchange programs. The guidelines have been set, but it is up to the counties to decide whether they want one.

Louisville and Lexington plan to launch needle exchange programs this summer, but “few rural communities have expressed interest,” possibly letting the larger cities work out the details first, Van Ingram, executive director for the Kentucky Office of Drug Control Policy, told Galofaro.

Even with the law in place, the debate about the needle-exchange programs persist. Proponents maintain that “we have to change the way we think” about treatment and that doing nothing is not an option, others told her that in small communities, the “fear of being exposed as a drug user may keep users away,” and others objected on a moral ground, “claiming they facilitate drug use rather than prevent it,” Galofaro reports.

Markey Cancer Center honors those who have battled cancer by displaying art by or about them: Expressions of Courage

To celebrate National Cancer Survivorship Month, the Markey Cancer Center at the University of Kentucky held an art exhibit June 6 to showcase personal artistic expressions crafted by or in memory of a Markey patient whose battle had ended.

UK patient Phillip Meeks brought
a drawing by his daughter, inspired
by the story of his cancer treatment.

The Expressions of Courage event “honored the experiences of those who have battled cancer with a day of recognition and celebration,” a UK news release said.

"We sent out over 6,000 letters," Cindy Robinson, a Markey nurse practitioner and one of the organizers, said in the release. "And we asked people for any type of creative modality that they wanted to share with us, to share their cancer journey, whether it be positive or negative."

More than 30 artists responded and shared a vast array of talents, from paintings, sculptures and quilting to dancing, singing, and readings of poetry and short stories, just to name a few.

"The artwork is very moving and inspiring, and actually will bring tears to your eyes if you read some of the pieces," Robinson said. "We have some pieces here from patients that are no longer with us, and we personally know those people."

Shawna Cassidy Quan of Richmond was one of the survivors in attendance, having been diagnosed with four different primary cancers over 15 years. Her expression of courage was an essay about her struggles with her multiple diagnoses.

"You figure out the answers to a lot of your problems even while you're sitting down writing," Quan said in the release. "It's just been a wonderful, therapeutic thing for me."

Norton Cancer Center and Markey patient Phillip Meeks traveled nearly two hours from Jeffersonville, Ind., to attend the event. His art piece was a drawing by his daughter, who was inspired by the story of his treatment.

In 2012, Meeks' was diagnosed with acute myeloid leukemia, which required a bone-marrow transplant to survive. The odds of getting one were not in his favor because as an African American, only 7 percent of the bone marrow registry is African-American, and as an adoptee he did not have any biological siblings or parents to be tested.

The day he was admitted to the hospital, Meeks said in the release that they found a token underneath his hospital bed: one side said "Believe in Miracles" while the other side said "Faith."

"To me, that was God's way of saying that I'm there with you, you know, don't be scared," Meeks said.

A donor match was found for him, and he received his life-saving transplant in January 2013.

Meeks, along with many survivors and their families, said that the Expressions of Courage event was not only a day to showcase talent, but a day that survivors could show their appreciation to the staff of Markey.

"I just want to give back," Meeks said. "That's my big thing. How can you thank so many people that are involved in saving your life? There's not a gift that you can give that's big enough. Hopefully this is my one little piece to say thank you for everything that everybody has done for me."

Tips on how to avoid getting bitten by mosquitoes

By Melissa Patrick
Kentucky Health News

Spending time outdoors is one of the great pleasures of summer. Unfortunately, this is also the active season for the 50 mosquito species that call Kentucky home. These mosquitoes are more than just a nuisance; some carry disease, making it important to protect yourself from them.

Photo from cdc.gov

Chikungunya is the latest mosquito-born virus transmitted in the U.S., although most cases in the U.S. are still caused by infections acquired from travel to the Caribbean, South America or the Pacific Islands, according to the federal Centers for Disease Control and Prevention. It is rarely fatal, but commonly causes fever, severe joint pain and other symptoms.

Kentucky had 17 confirmed cases of Chikungunya last year as well as eight probable ones, all in residents who had traveled recently to the Caribbean. and none of the cases were fatal. The state also had three confirmed cases of other mosquito-borne illnesses in 2014, including two dengue fever cases and one West Nile case, according to the Kentucky Cabinet for Health and Family Services.

Repellents

Insect repellents are your best guard against mosquitoes.

Four products have been registered with the U.S. Environmental Protection Agency for use as mosquito repellents: DEET (diethyltoluamide), picaridin, IR3535, and some oil of lemon eucalyptus and para-menthane-diol products.

Consumer Reports tested 15 products that represented each of these recommended repellents by spraying the products on the forearms of the testers, waiting 30 minutes, exposing their forearms to mosquitoes and ticks, and then measuring the number of bites every hour.

Based on this experiment, the magazine recommended Sawyer Fisherman's Formula (20 percent picardin) and Repel Lemon Eucalyptus (30 percent oil of lemon eucalyptus) as its first and second choice for repellents.

"It was the first time in the history of Consumer Reports testing insect repellents that the non-DEET formulations did better than the deet products," Sue Byrne, the magazine's senior editor of health and food, told Darla Carter of The Courier-Journal.

These products were followed by Repel Scented Family (15 percent DEET); Natrapel 8 Hour ( 20 percent picardin); and Off! Deepwoods VII (25 percent DEET).

Read the Labels

The U.S. Food and Drug Administration strongly recommends that you read the labels of all insect repellents before use and then use them as instructed, paying careful attention to the age limitations and precautions.

"As long as you read and follow label directions and take proper precautions, insect repellents with active ingredients registered by the U.S. Environmental Protection Agency do not present health or safety concerns," according to the FDA website.

Multiple sources say it is also important to not use combination products that contain both sunscreen and insect repellent. Sunscreen is meant to be applied often, while insect repellent is meant to be used sparingly.

High doses of DEET have been known to cause rashes, disorientation and seizures, according to the U.S. National Library of Medicine.

The FDA also notes that concentrations of any of the active ingredients above 50 percent "generally do not increase protection time" and that products with less than 10 percent of the active ingredient "offer only limited protection, about one or two hours."

Insect repellents and children

Adults should always apply insect repellents for children, making sure they don't get any on their hands, around their eyes, on any cuts or irritated skin. Spray repellents should always be applied outdoors, to avoid inhaling them.

The FDA recommends that DEET not be used on children under 2 months of age and that oil of lemon eucalyptus products not be used on children under 3 years old.

The American Academy of Pediatrics recommends that products with more than 30 percent DEET not be used on children, and that you use just enough repellent to cover exposed skin. It also recommends immediately washing off the repellent, and washing any clothes worn while exposed to the repellent, before wearing them again.

KidsHealth recommends that if you use DEET products on children, you should adjust the concentration of product by the number of hours your kids will be outside, using a lower concentration if they are only out for an hour or two and a higher concentration, which will last longer, if they will be out longer.

Non-repellent protections

In addition to advice on repellents, the University of Kentucky College of Agriculture, Food and Environment's Entomology Department website offers these suggestions to avoid mosquitoes:

• Minimize the standing water around your house; this is where mosquitoes breed.
• Use larvicides if it is impractical to eliminate a breeding site.
• Remove tall weeds and overgrowth in your yard; mosquitoes like to rest here during the day
• Keep windows, doors and porches tightly sealed and keep your screens in good repair.
• Stay indoors during the evening hours.
• Wear long-sleeved shirts and pants when outdoors.

UK Entomology says most devices that claim to attract, repel or kill mosquitoes don't work, or are unproven. It says "bug zappers" kill only a small percentage of mosquitoes, and studies have found that portable electronic devices using high-frequency ultrasonic sound are "of negligible benefit in deterring mosquitoes and reducing bites." The website does say that citronella oil offers "a degree of protection," but you need multiple candles to be effective.

Citing costs, Bevin has said he would shut down Kynect; actually, insurance companies pay for it; Medicaid is another matter

By Molly Burchett and Al Cross
Kentucky Health News

The governor's race between Democrat Jack Conway and Republican Matt Bevin will spotlight the Patient Protection and Affordable Care Act, an issue that affects all Kentuckians at least indirectly.

Conway, in his eighth year as attorney general, says he would have voted for the law. Bevin, who was the most conservative candidate in his primary, has said he would shut down the state's health-insurance exchange, Kynect, that was established under the law, because it will cost the state hundreds of millions of dollars.

Actually, Kynect is paid for by insurance companies that sell policies in Kentucky. Bevin appears to be referring to the projected cost of expanding Medicaid, another Obamacare-related move that Democratic Gov. Steve Beshear made at the same time he created Kynect. It raised the program's income limit to 138 percent of the federal poverty level, from 69 percent.

The federal government is paying the entire cost of the Medicaid expansion for the first three years. In 2017, the state will pay 3 percent, gradually rising to the law's cap of 10 percent in 2020. A study for the state projects that the expansion will pay for itself until 2021 by expanding health-care jobs and generating economic activity and tax revenue.

Bevin has scoffed at those projections. Conway has said the state needs to provide health coverage, but only what it can afford.

As Kentuckians, voters, and consumers of health insurance, you may be asking: What's going on with Obamacare in the state? Are we able to afford it? Who and what should we believe? While the cost of Medicaid expansion is debatable, it's becoming clear that Kynect has avoided the problems plaguing other state-run exchanges.

So far, the Centers for Medicare and Medicaid Services has dispensed more than $4.9 billion in grants to help launch state-run exchanges. Kentucky received $253 million for the initial planning and development phases of Kynect. Now its $28 million annual cost is covered by a fee on insurance companies, state officials say.

Despite federal support and their own revenue sources, many of the 17 state-based exchanges are expecting deficits this year and in the future. Many will continue to rely on leftover federal funds to pay for operations this year, report Darius Tahir and Paul Demko of Modern Healthcare. Hawaii announced this week that it would close its exchange and transfer clients to the federal exchange because of continued funding problems.

Kynect officials say it isn't having such problems because the state has ensured that Kynect is self-supporting through fees on insurance plans.

"The governor committed that the exchange would be self-supporting and would not rely on state General Fund dollars," said Jill Midkiff, spokeswoman for the Cabinet for Health and Family Services. "Kentucky’s sustainability plan employs an existing assessment on insurers that was previously used to fund Kentucky Access, the state’s high-risk pool, which was closed [since] individuals previously enrolled are now eligible to purchase a plan through Kynect."

But to transform Kentucky Access into Kynect, Beshear used executive orders that bypassed the General Assembly, where Republicans control the Senate. They have questioned his use of executive powers but generally have not been critical of Kynect.

The fee on insurers is a 1 percent, broad-based assessment on companies offering plans through the exchange. While insurers don't pass this fee directly to consumers, it almost certainly figures into their calculation of premium calculation and thus is indirectly paid by policyholders. The federal exchange is financed in a similar way, but its fee is 3.5 percent, meaning higher costs for insurers and policyholders.

In most cases, premiums for Kynect policies are reduced by a federal income-tax subsidy that is a key part of Obamacare.

"The vast majority of Kentuckians buying health insurance through Kynect are eligible for some kind of payment assistance or subsidy," Beshear said in commenting on most health-insurance companies recent requests for premium increases. "That cost will vary from family to family, so talking about rate changes in a vacuum isn’t a very effective way to gauge how much those rate fluctuations may affect policyholders or those shopping for insurance."

Bevin says he would move Kynect customers to the federal exchange, but the U.S. Supreme Court could rule this month that the tax subsidies are not supposed to be available through the federal exchange. The plaintiffs in the case cite a passage of the law that opponents say was a drafting error and does not make sense when the law is viewed as a whole.

If the court agrees with the plaintiffs, and Congress doesn't change the law, states using the federal exchanges will see spikes in insurance premiums, and millions of people could be at risk of losing their insurance. Bevin has not said what he would do in case of such a ruling.

Independent Drew Curtis is also running for governor.

Another Kentucky school district goes tobacco-free and e-cigarette free; efforts largely led by students in Webster County

The Webster County school board voted unanimously May 26 to make all district property, vehicles and buildings officially tobacco-free, Matt Hughes reports for the Webster County Journal-Enterprise. As in some other school districts, efforts for the ban were largely led by students.

“This is something the Youth Experiencing Success Youth Council has been working on for years,” said board member Mickey Dunbar, who has worked closely with Youth Empowerment Services. “I think it is very important that we educate our students' minds and educate them about their bodies.”

The ban will go into effect July 1 and includes all tobacco products, including vapor devices, commonly known as e-cigarettes. It also extends to school-sponsored trips, all sporting events and all school functions.

“I will enjoy being able to walk out of a basketball game without having to navigate a gauntlet of cigarette smoke,” Dunbar told Hughes. “I think this will set a good precedence for the other schools in our area.” Webster County is in the West Kentucky Coalfield.

The YES Youth Council and its adult sponsor first approached the board last fall, and said that while supportive, the board voiced concerns that the community would not be supportive, especially during ballgames. But since then, Hughes said, board members "have gotten a lot of positive feedback from the community."

As of May 2015, Kentucky reported 40 tobacco-free school districts, which include 500 individual schools, according to the Tobacco Free Schools Kentucky website. This amounts to 40 percent of Kentucky's students.