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Missouri Opioid Overdose andBloodborne InfectionVulnerability Assessments2020Prepared byMissouri Department of Health and Senior Services,Bureau of Reportable Disease InformaticsAssisted byBureau of HIV, STD, and HepatitisBureau of Health Care Analysis and Data DisseminationBureau of Epidemiology and Vital StatisticsSection for Disease Prevention

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Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 2020For more information, please contact:Missouri Bureau of Reportable Disease InformaticsSection for Disease PreventionDivision of Community and Public HealthMissouri Department of Health and Senior ServicesThis report is accessible via the internet hpSuggested Citation:Missouri Department of Health and Senior Services, Bureau of Reportable Disease Informatics.Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 2020. Availableat http://health.mo.gov/data/opioids/assessments.php. Accessed Month Day, Year.Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 2020ii

The following Missouri Department of Health and Senior Services staff contributed to theseassessments:Bureau of Reportable Disease InformaticsBecca MickelsFei WuAngela McKeeJulie BordersZana StephensonQian LiuGeorge OpokuChristopher MurrellPaula PetershagenLelah HicksGeorgia WittBureau of HIV, STD, and HepatitisBureau of Health Care Analysis and DataDissemination/Bureau of Epidemiologyand Vital StatisticsAndrew HunterWhitney CoffeyEvan MobleyTanner TurleyLoise WambuguhCassady PalmerSruti BanerjeeSection for Disease PreventionDamon FerlazzoNicole MasseyVicky StuartChristine SmithLinda BallAnna LongTara McKinneyTricia CreggerMichelle DenichMissouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 2020iii

ContentsExecutive Summary. 1Abbreviations Used in This Report. 2Introduction . 3Background and Purpose of the Missouri Vulnerability Assessments Project . 4Development of Missouri’s Vulnerability Assessments . 5Stakeholder Feedback . 6Indicators . 9Opioid Overdose Vulnerability Assessment Indicators. 10Bloodborne Infection Vulnerability Assessment Indicators. 10Ranking Methodology . 11Statistical Notes . 15Findings – Opioid Overdose Vulnerability Assessment . 17Findings – Bloodborne Infection Vulnerability Assessment . 19Comparison of the Opioid Overdose and Bloodborne Infection Vulnerability Assessments . 21Comparison of the Missouri and National Vulnerability Assessments . 22Appendix A – Vulnerability Assessment Indicator Ranks and Results . 22Appendix B – Vulnerability Assessment Indicator Counts and Rates . 39Appendix C – Data Sources and Notes for the Vulnerability Assessment Indicators . 52Appendix D – Other Indicators Considered for Inclusion in the Vulnerability Assessments . 60Endnotes . 73Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 2020iv

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Executive SummaryThe Missouri Department of Health and Senior Services, Bureau of Reportable DiseaseInformatics, with funding from the Centers for Disease Control and Prevention’s (CDC’s)National Center for HIV/AIDS (human immunodeficiency virus/acquired immunodeficiencysyndrome), Viral Hepatitis, STD (sexually transmitted disease), and TB (tuberculosis) Prevention(NCHHSTP), conducted county-level vulnerability assessments for 1) opioid overdoses and 2)bloodborne infections in collaboration with an internal workgroup composed of staff frommultiple units. This workgroup, in consultation with CDC staff, developed a methodology andselected indicators within two categories – individual outcomes and community factors. The 23lowest ranked counties were considered to be at greatest risk for each outcome. It is importantto note that a ranking outside of the 23 more vulnerable counties does not indicate that acounty is not at risk for that outcome. There was considerable overlap in the countiesidentified as more vulnerable by each assessment, which are listed in bold font in the tablesbelow. Data for all counties are included in the Appendices so that the results of theseassessments may be used statewide rather than in only the more vulnerable counties.Stakeholder meetings were held to gather community-level feedback on the assessments.More Vulnerable to Opioid n*JeffersonMariesMarionMississippiNew MadridPhelpsPolkPulaskiRipley*St. ClairSt. Francois*St. Louis CityTaneyWarrenWashington*Wayne*More Vulnerable to Bloodborne lpsRipley*St. Francois*St. Louis CityStoneTaneyWarrenWashington*Wayne*Wright**This county was also identified as vulnerable to rapid dissemination of HIV/hepatitis C virus (HCV) infectionamong persons who inject drugs (PWID) in a National Vulnerability Assessment prepared by the CDC.1Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20201

Abbreviations Used in This ReportACES Adverse Childhood ExperiencesAIDS Acquired Immunodeficiency Syndrome (stage 4 HIV)BEMS Bureau of Emergency Medical ServicesBEVS Bureau of Epidemiology and Vital StatisticsBHCADD Bureau of Health Care Analysis and Data DisseminationBHSH Bureau of HIV, STD, and HepatitisBRDI Bureau of Reportable Disease InformaticsCDC Centers for Disease Control and PreventionCSTE Council of State and Territorial EpidemiologistsDESE Missouri Department of Elementary and Secondary EducationDHSS Missouri Department of Health and Senior ServiceseHARS enhanced HIV/AIDS Reporting SystemEMS Emergency Medical ServicesER Emergency RoomESSENCE Electronic Syndromic Surveillance for the Early Notification of Community-based EpidemicsHBV Hepatitis B VirusHCV Hepatitis C VirusHIV Human Immunodeficiency VirusIDU Injection Drug UseLPHA Local Public Health AgencyNAS Neonatal Abstinence SyndromeNCHHSTP National Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionPAS Patient Abstract SystemPDMP Prescription Drug Monitoring ProgramPWID Persons Who Inject DrugsSPHL Missouri State Public Health LaboratorySSP Syringe Services ProgramSTD Sexually Transmitted DiseaseSUDT Substance Use Disorder TreatmentTB TuberculosisWebSurv Missouri’s Communicable Disease RegistryMissouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20202

IntroductionOpioid misuse is a growing problem in Missouri as well as throughout the nation. In 2017, 1 outof every 65 deaths in Missouri was due to an opioid overdose.2 From 2001 to 2015, Missouriresident opioid-related inpatient hospitalizations more than doubled, from 5,332 visits to11,119 visits. Opioid-related emergency room (ER) visits increased just over 2.5 times (from4,344 to 11,259) in the same time period. The number of ER visits due to heroin in particulargrew during this time. In 2001, heroin accounted for only 3.9 percent of all opioid-related ERcases, but that figure had increased to 38.6 percent by 2016.3Opioid misuse via injection is a risk factor for several bloodborne conditions, including HIV,hepatitis B virus (HBV), and hepatitis C virus (HCV). In fact, intravenous opioid use is the leadingrisk factor for hepatitis C. 4,5 Outbreaks of bloodborne diseases due to needle sharing related toopioid misuse and misuse of other drugs have been reported in other states.6,7 In addition,recent outbreaks of hepatitis A have been found among people who use drugs, includingopioids.8 Missouri has also seen a rise in neonatal abstinence syndrome (NAS) hospitaldischarges as the opioid epidemic has grown. From 2010 to 2016, the number of Missouri NAShospital discharges grew 5.5 times (from 426 discharges to 2,342 discharges).9The Missouri Department of Health and Senior Services (DHSS), local public health agencies(LPHAs), and partners are responding to the epidemic, but these organizations have limitedresources. The ability to accurately describe and measure the epidemic is critical for utilizingthose available resources and providing effective responses. The County-level VulnerabilityAssessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject Drugs,United States is a helpful resource.10 (For the remainder of this report, this document will bereferred to as the “National Vulnerability Assessment.”) This assessment identified 13 Missouricounties as vulnerable to bloodborne infection outbreaks among people who inject drugs(PWID): Bates, Cedar, Crawford, Hickory, Iron, Madison, Ozark, Reynolds, Ripley, St. Francois,Washington, Wayne, and Wright. All of these counties are relatively rural. Yet multiple types ofdata (mortality, inpatient hospitalization, ER visit, communicable disease, etc.) indicate thatother areas of the state are impacted as well.Please note: Throughout this document, graphics specific to the opioid overdose assessmentare presented in orange, while graphics specific to the bloodborne infection assessment arepresented in blue. Graphics representing data utilized in both assessments are presented inyellow.Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20203

Background and Purpose of the Missouri Vulnerability Assessments ProjectDuring the summer of 2018, the CDC utilized the Cooperative Agreement for EmergencyResponse: Public Health Crisis Response – CDC-RFA-TP18-1802 mechanism to award OpioidCrisis Supplemental Funding to jurisdictions impacted by the opioid overdose epidemic. OnAugust 31, 2018, Missouri was one of the states notified that it would receive one year offunding under this award for a project from the CDC’s NCHHSTP. This project requires awardeesto develop and disseminate jurisdiction-level vulnerability assessments that identify subregional(e.g., county, census tract) areas at high risk for i) opioid overdoses and ii) bloodborneinfections (i.e., HIV, hepatitis C, hepatitis B) associated with nonsterile drug injection. Missouriis utilizing this opportunity to create a state-specific vulnerability assessment methodology.The overall purpose of the project is that awardees use the findings from the assessments todevelop plans that strategically allocate prevention and intervention services and distributefindings to key stakeholders in formats that support action. This will allow the use of theassessments’ findings to target services that will maximally reduce risk of overdoses and risk ofbloodborne infection spread through nonsterile drug injection.11The Opioid Crisis Supplemental Funding was awarded for the period from September 1, 2018,through August 31, 2019. Therefore, the vulnerability assessments, the plan for allocatingprevention and intervention services, and all related activities were required to be completedduring this timeframe. On June 27, 2019, CDC notified DHSS that a 90-day no cost extension tothe project was granted to all awardees. The award and project end date were extended untilNovember 30, 2019. On November 5, 2019, CDC notified DHSS that a further 120-day no costextension to the project was granted to all awardees. The award and project end date werefurther extended until March 29, 2020.Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20204

Development of Missouri’s Vulnerability AssessmentsThe NCHHSTP portion of Missouri’s opioid crisis funding was assigned to the Bureau ofReportable Disease Informatics (BRDI). Upon receipt of the award, BRDI assembled an internalworking group of stakeholders from DHSS. This workgroup includes representatives from BRDI;the Bureau of HIV, STD, and Hepatitis (BHSH); the Bureau of Health Care Analysis and DataDissemination (BHCADD); the Bureau of Epidemiology and Vital Statistics (BEVS); and theSection for Disease Prevention. This workgroup met frequently, often weekly, throughout theproject period to select indicators, develop a state-specific methodology, and refine thevulnerability assessments based on additional feedback received.Staff from these units were selected to participate based on their knowledge and experiencerelated to the opioid epidemic, bloodborne outbreaks, and related data. BHCADD managesMissouri’s Enhanced State Opioid Overdose Surveillance grant and staff were able to draw uponknowledge of the opioid epidemic they had gained from that project. This unit also managesthe death portion of Missouri’s vital statistics program and hospital/ER data through the PatientAbstract System (PAS). BRDI manages Missouri’s communicable disease registry (WebSurv), theenhanced HIV/AIDS Reporting System (eHARS), and the state’s syndromic surveillance system(ESSENCE – Electronic Syndromic Surveillance for the Early Notification of Community-basedEpidemics). BRDI creates annual epidemiologic profiles of HIV and viral hepatitis. Furthermore,BHCADD, BEVS, and BRDI staff include several research analysts and epidemiology specialistswith experience performing data analysis, creating maps, and writing reports. These staff arealso familiar with external resources such as the U.S. Census Bureau website. BHSH providesprevention, education, and access to care information for individuals impacted by HIV/AIDS,STDs, and hepatitis.The internal workgroup reviewed previously created resources such as CDC’s NationalVulnerability Assessment and internal DHSS documents that utilized ranking methodologies,such as the Primary Care Needs Assessment 2015.12 As part of the grant activities, CDC offeredguidance on the project and arranged several conference calls and webinars to share examplesfrom other states as well as CDC, such as the Social Vulnerability Index.13Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20205

Stakeholder FeedbackOne of the CDC’s project requirements was that DHSS organize a new or engage an existingstakeholder group to provide input on the vulnerability assessments’ design, supportdevelopment of data use agreements, and inform the use of the assessments’ findings to targetservices that will maximally reduce risk of overdoses and risk of bloodborne infection spreadthrough nonsterile drug injection. DHSS made several attempts to gain stakeholder feedbackthroughout the project period and will continue to solicit feedback after the vulnerabilityassessments are published and the project period ends. DHSS staff from a variety of programs participated on the internal workgroup andprovided state-level program feedback.DHSS partnered with six LPHAs, one in each HIV Care Region. (A map of the HIV CareRegions and a table listing information about the stakeholder meetings are shown onpage 8.) Each of these LPHA partners collaborated with DHSS to arrange a smallstakeholder meeting in their HIV Care Region. DHSS contracted with a facilitator to runthe meetings, while the LPHA determined and made arrangements for the meetinglocation and developed the list of invitees. These meetings provided community-levelfeedback from a variety of types of stakeholders. Some of the strongest and mostconsistent feedback received across all sessions is briefly noted below.o Individual outcome indicators should be weighted more heavily than communityfactor indicators. The individual outcome indicators provide information on whathas been happening recently and is likely to continue happening in the next fewyears. The community factor indicators should be included but should notreceive as much weight because they are difficult to change. Stakeholders alsoexpressed that overdoses are affecting all populations so social determinantsmay not be as relevant as they are for other public health concerns. Based onthis feedback and suggestions from stakeholders regarding how much additionalweight would be appropriate, the sum of the individual outcome indicators ineach assessment is now multiplied by three (3).o A mental health indicator should be included in the individual outcome portionof the methodology.o Overdose death data should reflect both the individual’s county of residence andthe county of record, which is the location where the individual is pronounceddead and is considered a proxy for location of death. Based on this feedback, thecounties were ranked for overdose deaths by county of residence and alsoranked for overdose deaths by county of record. These ranks were summed, andthe sums were then ranked. This final rank is included as the rank for overdosedeaths in both assessments. A table showing the ranks by county of residenceand county of record is provided at the end of Appendix A. Data for both countyof residence and county of record are provided in the tables in Appendix B.Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20206

o Indicators based on access to care and treatment providers should not beincluded. Stakeholders were concerned that health care access does not equalhealth care utilization or health care need. Further detail about the discussionregarding provider access is available in Appendix D. Some stakeholders didcomment that more deaths may occur among populations farther from hospitalsdue to lack of timely treatment.DHSS staff plan to attend events to promote the assessments document after it ispublished and will gather additional feedback at that time. The specific events have notyet been determined.Readers of this document are encouraged to continue to provide feedback by contactingDHSS. Although it may not be possible to make changes once the document ispublished, this feedback will inform any future versions of the assessments. Feedbackand questions about the document can be directed to the Bureau of Reportable DiseaseInformatics, PO Box 570, Jefferson City, MO 65102.Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 20207

Vulnerability Assessment Stakeholder MeetingsDateApril 16, 2019LocationColumbia/Boone CountyDepartment of PublicHealth and Human ServicesApril 24, 2019Osage Center, CapeGirardeauSt. Louis

Missouri Opioid Overdose and Bloodborne Infection Vulnerability Assessments 2020 3 Introduction Opioid misuse is a growing problem in Missouri as well as throughout the nation. In 2017, 1 out of every 65 deaths in Missouri was due to an opioid overdose.2 From 2001 to 2015, Missouri

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