Vulnerabilities Assessments: Identifying jurisdictions with increased risk of infectious disease among people who inject drugs
The United States is currently facing an urgent crisis involving use of opioids, such as heroin, fentanyl, and prescription opioids, as well as other drugs, such as methamphetamines and cocaine. Opioid-related overdose deaths were almost six times as high in 2018 as they were in 1999, and infectious diseases, including viral hepatitis and methicillin-resistance Staphylococcus aureus (MRSA), have dramatically increased as a result of this crisis.
Disease outbreaks among people who use drugs have devastating effects in communities for illness, suffering and costs associated with treatment and care.
- Since 2015, there have been multiple HIV outbreaks associated with injection drug use; 11% of all people with an HIV diagnosis in 2018 reported injection drug use. The average lifetime HIV-related medical cost for one person with HIV is $510,000.
- A nationwide outbreak of hepatitis A, primarily among people who use drugs and/or people experiencing homelessness, has spread across the United States since 2016, with 37,691 cases affecting more than 35 states as of February 5, 2021. More than 60% of cases have resulted in hospitalization, and 354 people have died. These outbreaks have resulted in illness and loss of life nationwide, as well as an estimated financial toll of at least $367 million in hospital costs alone.
- Rates of invasive MRSA associated with injection drug use more than doubled from 2010–2018 in the sites monitored by the Emerging Infections Program. Nationwide, hospitalization due to injection drug use-related infections (not including viral hepatitis and HIV) -- such as endocarditis, MRSA, and other bacterial and fungal infections -- cost over $700 million in 2012 alone.
Vulnerable Counties and Jurisdictions Experiencing or At-Risk of Outbreaks
A 2014-2015 outbreak of HIV infection among a rural network of persons who inject drugs (PWID) underscored the intersection of the expanding crises of opioid misuse, injection drug use, and associated increases in bloodborne infectious diseases. The Centers for Disease Control and Prevention (CDC) conducted a national assessment to identify U.S. communities potentially vulnerable to rapid spread of HIV, if introduced, and new or continuing high rates of hepatitis C virus infections among PWID. Jurisdictions also consulted with CDC and provided evidence that their jurisdiction is experiencing or at risk for significant increases in hepatitis infections or an HIV outbreak due to injection drug use.
Map includes top 220 vulnerable counties determined to be at-risk of outbreaks from the 2016 national assessment (in pink), jurisdictions determined to be experiencing or at-risk of significant increases in viral hepatitis infection or HIV outbreak due to injection drug use following CDC consultation (in teal), and states that did not request a CDC consultation for experiencing or at-risk of significant increases in hepatitis infections or an HIV outbreak due to injection drug use (in white).
Data Sources: ESRI, EUROPA, CDC Consultations on Determinations of Need Requests
Van Handel MM, Rose CE, Hallisey EJ, et. al. County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject Drugs, United States. J Acquir Immune Defic Syndr. 2016 Nov 1;73(3): 323-331external icon.
State-led Vulnerability Assessments
In 2018, CDC released emergency funding in response to the opioid overdose epidemic and launched activities to directly fund 41 states and the District of Columbia to develop and disseminate jurisdiction-level vulnerability assessments (JVAs). The Council of State and Territorial Epidemiologists (CSTE) was funded to provide technical assistance to these jurisdictions to complete the JVAs.
The assessments used local, more timely data to identify sub-regional areas at high risk for opioid overdoses and/or bloodborne infections associated with non-sterile injection drug use (IDU). Jurisdictions then used the findings to identify prevention and intervention gaps and develop and initiate multi-sector plans to address gaps. Findings from the JVAs may differ from the national assessment due to differences in methods or changes in outcomes over time. These potential differences should be considered when making decisions about prevention planning and interventions. The national assessment provides useful and consistent information across the country. The JVAs provide timely and a more sensitive portrait of local needs to inform prevention planning and rapid scale-up of targeted services.
To complete the assessments, six main steps were applied by jurisdictions, with support from CSTE, to identify sub-regional areas at high risk for opioid overdose or bloodborne infections from non-sterile injection drug use. This information was used to develop and initiate implementation of plans to address prevention and intervention needs.
- Indicator Identification
The first step was to identify and prioritize indicators that were timely, available at the sub-regional level (e.g., county, ZIP code), and associated with the outcomes of interest, such as overdose deaths or new hepatitis C virus (HCV) infections. Core indicators used by states included: socio-economic indicators – employment status, poverty status, income, and health insurance coverage; opioid-related indicators – drug overdose mortality, opioid prescriptions, buprenorphine prescribing potential by waiver, drug-related arrests; and infectious disease indicators – acute HCV infection rate, endocarditis hospitalizations.
- Data Collection and Exploration
- Developing the Assessment: Overview of the Three Primary Assessment Approaches
- Identifying Prevention Gaps
- Developing Plan to Address Gaps
- Collaboration, Communication, and Dissemination Strategies
CSTE Jurisdiction Vulnerability Assessment Toolkit
CSTE, in partnership with CDC, developed a toolkit of resources for jurisdictions planning to conduct or update their assessments in the future. This toolkit provides guidance, tools, and additional examples of state-led assessments for epidemiologists and other public health professionals seeking to assess their jurisdictions’ vulnerability level. The guidance in the toolkit reflects the technical assistance delivered to states in response to challenges and questions that arose during project implementation.
Several states have released their assessment findings and plans online. These resources can be found at: