Vulnerability index

OTTUMWA — Opioids have been the focus of much of the federal effort to fight drug abuse in recent years, raising concerns for some that the effort deprived states with serious meth problems the funding to continue that fight.

But a change buried in Congress’ massive spending bill, which was passed late last year, could change that.

The Associated Press reports that the change, which had bipartisan support, will allow federal money earmarked to fight opioid addiction to be used in programs that target meth and cocaine as well.

Changing the funding has implications that go beyond addiction. Joe Caldwell, an HIV and Substance Use Coordinator with the Iowa Department of Public Health, said in an interview last year that the funding had public health implications.

“Methamphetamine never really went away,” Caldwell said. “Due to just a general lack of funding, meth-specific funding … that continues to be a hurdle.”

Those implications are clearly seen in the state’s vulnerability index, a measure that attempts to assess each of Iowa’s 99 counties’ risk of a major HIV or Hepatitis C outbreak. The index grew out of responses to a crisis in an entirely different state.

In January 2015, state officials began tracking an outbreak of HIV after 11 confirmed cases were reported in Scott County, Indiana. That was more than double the average annual number. By April, the count was up to 135 new HIV infections, driven by opioid abuse. Shared syringes, like the ones used in Indiana, have long been known as a transmission route for HIV and Hepatitis C.

Wapello County is at the top of the Iowa Department of Public Health’s list for areas to watch. Caldwell said the goal of the state’s vulnerability index is to get ahead of outbreaks, ideally interrupting them. He said federal funding helped each state develop assessment tools after the lessons were learned from Indiana.

Wapello County is red on the Vulnerability Index map. The assessment gives it the fourth-highest risk of overdoses and ranks highest for the HIV/HCV outbreak risk. Appanoose County is on both lists, too — second on the disease outbreak risk and seventh for overdose. Only one other area county shows up on either list. That’s Jefferson County, ranked as the third-highest county for overdose risk.

What does it mean?

There’s a big issue to keep in mind. Caldwell emphasized that high risk in Iowa means something very different than high risk in the states hit hardest by the opioid epidemic. Secondly, the assessment looks at key indicators that are most predictive of outbreaks, but predictions are not the same as guarantees.

“This isn’t necessarily saying be on alert, there’s an HIV or Hepatitis C outbreak coming,” Caldwell said.

Randy Mayer, the IDPH’s Hepatitis chief, said poverty and higher unemployment rates generally track with higher rates of drug use. That includes intravenous drugs. So does access to mental health services and even primary care physicians.

For those markers, there is good news. They are generally known to local government leaders and are often already priority issues in the community.

“These are things that people can address in their counties,” Mayer said.

So, rather than being a definitive statement that the public needs to be on alert, the assessment is more of a tool to get key people in public health fields thinking about what different areas might need in the future.

Officials want to use the assessment to get ahead of any potential outbreaks in Iowa. To Caldwell, it’s a tool to “start the conversation.” Mayer agreed. But what does the conversation sound like?

Well, to start with, it’s an easier conversation than in other parts of the country. “We started with knowing that we had no counties that were even close to being on that [federal] list,” Mayer said. “We see this as a preparedness exercise.”

That doesn’t mean HIV and Hepatitis C are not present in Iowa. They are. But they have never exploded into the kind of out-of-control outbreak Scott County saw. The goal now is to make sure they never do.

The conversation touches on sensitive topics, though. There are legislative hurdles before some proven strategies, like syringe programs, can be enacted in Iowa. Mayer said there appears to be bipartisan interest in such programs, especially as awareness has grown that they go further than just providing clean needles for addicts.

“Drug treatment is a big part of that,” he said. The programs help build trust between addicts and counselors so that, when the person is finally ready to get clean, they have someone to turn to.

New support from the federal government, including the Trump administration as part of the effort to end the HIV epidemic, could increase access to such programs.

For Iowa, monitoring is essential. Experts will also continue refining the tools they already have. Mayer said future work may identify additional traits that let health experts home in even closer on areas that are at risk. It’s hard to say what they will be, though, or what response they require.

“What are they, and what are they something we can do something about?” he said. “We’re very early on this, and there’s more information to come.”

Matt Milner can be reached at and followed on Twitter @mwmilner


Managing Editor

Matt Milner currently serves as the Courier's Managing Editor. Milner is a trained weather spotter and is usually outside if there are storms. He joined the Courier in 2002.

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