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HomeMy WebLinkAboutMINUTES - 04191994 - IO.12 TO: It �' BOARD OF SUPERVISORS 1 .0.-12 Contra FROM: INTERNAL OPERATIONS COMMITTEE Costa L Em County March 28 1994 i /• DATE: SUBJECT: REPORT REGARDING THE STATUS OF COMMUNICABLE DISEASE CONTROL AND PREVENTION EFFORTS IN CONTRA COSTA COUNTY SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: 1 . ACCEPT the attached report. from the Health Services Director on the status of funding and programs in the area of communicable diseases . 2 . COMMEND the Health Services Director and his staff for the excellent "HIV/AIDS Epidemiology Report" dated March, 1994, a copy of which is attached to this report and encourage the Department to continue to keep these figures updated in the coming months and years. 3 . COMMEND the Health Services Director and his staff for the paper entitled "Reducing HIV Transmission Among Injecting Drug Users - Syringe Exchange in Contra Costa County" and ENDORSE the Department ' s plans to determine whether the community could support development of a syringe exchange program in Contra Costa County, following the process and general timeline outlined in the attached paper. 4 . AUTHORIZE the Health Services Director and his staff to continue to participate in discussions regarding the formation of an East Bay AIDS Foundation, with the objective of insuring that this effort is fully coordinated with the efforts of the San Francisco AIDS Foundation and the AIDS program providers in Contra Costa County, and that it does not duplicate programs already being provided in this County. 5 . REQUEST the. Health Services Director to continue to make approximately quarterly reports to our Committee on the subject of communicable diseases, with an emphasis on HIV/AIDS and tuberulosis, with the next report to be made approximately the latter part of June, 1994 . CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINI A OMMENDATION OF BOARD COMMITTEE APPROVE OTHER JEFF SMITH SUNNE WRIGHT McPEAK SIGNATURE(S): ACTION OF BOARD ON AAPPROVED AS RECOMMENDED X OTHER The Reverend Curtis Timmons spoke in favor of the needle exchange program and commended the Board for its action. Supervisor Torlakson 'requested that a report be developed on the number of people with aids who need hospital beds, and the projected increase, based on infection rates, noting that is part of the issue of why more hospital beds are needed in this County. Mark Finucane, Director of Health Services, advised he will provide the above report on . hospital bed needs, and spoke of the need for a broad community supported program as a Public Health function. VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS(ABSENT=-- ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTED 74- Contact: PHIL BATCHE R.CLERK OF THE BOARD OF cc: See Page 2 SUPERVISORS AND COUNTY ADMINISTRATOR BY DEPUTY ;ii I 1 .0.-12 -2- BACKGROUND: For the past several years, the Health Services Department has been reporting on a quarterly basis to the Internal Operations Committee on AIDS and, more recently, on tuberculosis . Attached is the most recent report on this subject. We would note the fact that the County has received an additional $500, 000 for HIV services funded by the Ryan White Comprehensive AIDS Resource Emergency Act to be used as outlined in Mr. Finucane' s report. It is also important to note the efforts which are being made by the department to begin to work with the community to gauge the level of support for a needle exchange program in this County, should such a program become a legal possibility in the future. We agree with the gradual effort which is proposed in the attached report. The Board' s support for this effort to work with the community does not necessarily commit the Board of Supervisors to any particular needle exchange program or to any such program at all, certainly not until all legal barriers have been removed. However, it is essential to work with the community in a community education effort and try to fashion a potential program which would have the greatest possible level of community support. We are also encouraging the Health Services Director and his staff to stay in touch with those parties who are urging the formation of an East Bay AIDS Foundation in an effort to influence the direction such a proposal will take and insure that what may be established is consistent with the efforts which are being made by the San Francisco AIDS Foundation and the AIDS program providers in this County. Finally, we are pleased to see the expansion which is taking place in the Directly 'Observed Therapy (DOT) program as a part of our Tuberculosis Control Program. We are asking the Health Services Director to continue to provide quarterly reports to our Committee on these subjects because of their vital importance to thee community and the County. cc : County Administrator Health Services Director Wendel Brunner, M.D. , Public Health Director Francie Wise, Director, Communicable Disease Control, HSD Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Mark Finucane, Director Jeff Smith,2nd District Gayle Bishop,3rd District 20 Allen Street Sunne Wright McPeak,4th District sr_- c Martinez, California 94553-3191 Tom Torlakson,5th District (510)370-5003 FAX(510)370-5098 County Administrator °, '',,• �' Phil Batchelor °• r County Administrator ;• ' . March 24, 1994 To: IntenaI Operations Com ittee Itl�- From: Mark Finucane, Director, Health Services Department by Wendel Brunner, M.D., Assistant Health Services Director for Public Health Subject: Quarterly Report on Communicable Diseases AIDS HIV/AIDS EPIDEMIOLOGY REPORT An updated report on the HIV/AIDS epidemic in Contra Costa County has been published this month and is attached for your information. RYAN WHITE CARE ACT FUNDING Contra Costa County has received a $500,000 increase for HIV services funded by the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. This totals$1.2 million for fiscal year 1994-95 in CARE funded services. Increases in food, home care, housing, case management, and transportation services will assist people with HIV and their families throughout the county. Of these newly funded services, 95% ($475,000) will be contracted to community-based agencies. The Contra Costa HIV/AIDS Consortium and its planning component, the HIV Planning Council, have worked successfully to assess the needs of people with HIV, to establish service priorities and to make funding allocations. We would like to commend the hard work and commitment of these community members who generously give their time to this work. REDUCING HIV TRANSMISSION AMONG INJECTING DRUG USERS Included with this report is a strategy paper entitled "Reducing HIV Transmission Among Injecting Drug Users: Needle/Syringe Exchange in Contra Costa County". Our goal is to determine the community support for development of a needle/syringe exchange program in Contra Costa County. To be effective, such an intervention must have broad community support and be part of a comprehensive public health plan which provides prevention education, targeted outreach, ongoing support for behavior change, substance abuse treatment alternatives,HIV counseling and testing in addition to health and social services for people with HIV disease. Merrithew Memorial Hospital&Clinics Public Health • Mental Health • Substance Abuse Environmental Health Contra Costa Health Plan Emergency Medical Services • Home Health Agency Geriatrics A-345 (2/93) Report to the Internal Operations Committee Page 2 On Communicable Disease in Contra Costa County PROPOSED EAST BAY AIDS FOUNDATION As requested by members of the Internal Operations Committee, the Health Services Department, in conjunction with the HIV/AIDS Consortium which is the broad-based coalition developing the AIDS response in Contra Costa County, has been exploring the potential for development of an East Bay AIDS foundation as proposed by the Alameda County Health Care Services Agency and the Office of the Mayor of Oakland. Mark Finucane and Supervisor Tom Powers met with Eugene Richards, Alameda County HIV/AIDS Services Director, and Judith Briggs Marsh from Mayor Elihu Harris' office to discuss their plans for this foundation. Mark Finucane will also be meeting with David Kears, the Director of the Alameda County Health Care Services Agency, to discuss this. Contra Costa has a strong, unified community response to the AIDS epidemic and we are eager to enhance these partnerships. It is crucial to determine whether the proposed new foundation would enhance our collaborative efforts or whether it would be a duplication. Increasing the resources available for direct services to clients is essential, and we are concerned about the possible development of duplicative administrative structures. The Health Services Department will present the information gathered and our recommendations as soon as this investigation and analysis have been completed. TUBERCULOSIS As mentioned in our previous report the Tuberculosis Control Program is expanding the program of Directly Observed Therapy (DOT). We have added two employees to the TB Program who are now trained to do DOT. In addition, we are working with the Pittsburg Pre- School Coordinating Council and have trained three of their outreach workers to do DOT. In the past, we have only been able to follow tuberculosis patients who were identified as being at risk for noncompliance with therapy and to follow only a few patients on preventive therapy, primarily children. We will now be able to expand our DOT program to include: All persons coming out of jail who are on preventive therapy, TB cases who are children, and people who may be a risk for noncompliance but not in the categories defined. Expansion of the DOT program will allow us to more closely track people who may be a public health risk unless therapy is completed. The following is a list of the various risk categories we now use to determine who should be on DOT: • History of alcohol or drug using adolescent • Homeless. • History of non compliance with TB medications • History of TB treatment in the past • History of being in a correctional facility • Poor compliance during initial therapy • Slow sputum conversion/clinical improvement • Adverse reaction to TB medications • Too ill to manage their own medications • Children of any of the above categories Report to the Internal Operations Committee Page 3 On Conununicable Disease in Contra Costa County We have followed approximately 15-18% of our TB patients each year through DOT for the past four years. We will be following 25-30% of our TB cases and 15-20% of persons on preventive therapy by the end of 1994. Directly Observed Therapy plays a significant role in reducing the number of treatment failures due to noncompliance and new diseases which can develop in the absence of adequate preventive therapy. Additionally, one of the most important roles of DOT in tuberculosis control is the reduction in the potential for development of drug resistant disease. IMMUNIZATION In our last report we mentioned that 48% of children under two years of age were under immunized. We are utilizing immunizations coupons and an Immunization Outreach worker to encourage increased immunization awareness and access to service. We have now added daily Immunization Clinics in all three areas of the county. We are also holding many clinics each month in Headstart sites, WIC clinics, churches and other community center locations. Community based organizations have been working cooperatively with our program giving outreach to the communities we jointly serve and providing sites for the community outreach Immunization Clinics. Attached is a copy of an article from Pediatrics entitled "Health Insurance and Preventive Care Sources of Children at Public Immunizations Clinics." The survey which gathered information was done in Contra Costa County in cooperation with our Immunization Program. The purpose was to determine the barriers to children receiving immunizations. The study found that people come to public clinics secondary to barriers which include finances, waiting period for appointments and lack of ongoing personal provider. It is difficult for us to address the private provider waiting time or coverage provided by HMOs for immunizations. However, we will plan, given this finding, to initiate referrals for people identified in our clinics to an ongoing source of medical care if they do not have one. i SEAL Contra Costa County -- -_ Health Services Department PUBLIC HEALTH DIVISION a CO REDUCING HIV TRANSMISSION AMONG INJECTING DRUG USERS SYRINGE EXCHANGE IN CONTRA COSTA COUNTY BACKGROUND Contra Costa County has the highest rates of infection among injecting drug users surveyed anywhere in the State of California. There is documented evidence of continuing new infections despite more than seven years of community-based prevention programs, bleach distribution and instruction on disinfecting syringes and needles. The Health Services Department is aware of the tremendous need to stop transmission of HIV infection among injecting drug users, their sexual partners, and their babies. With the support of the affected communities the Department has long sought legal means to pilot a syringe exchange program in Contra Costa County. A syringe exchange program should be seen as one element in a multi- service program which includes prevention education, support for behavior change, HIV counseling and testing, drug treatment, and medical and social services. Only after community support for such a program was evident, we would proceed with thoughtful implementation and stringent evaluation, following decriminalization of such programs. The Contra Costa County Board of Supervisors in April 1993, endorsed Assembly Bill 260, which would have allowed local health jurisdictions to legally pilot programs which exchange clean syringes for contaminated ones. A majority of both houses of the legislature has passed this measure on two occasions. Both were subsequently vetoed by Governor Pete Wilson. In the past year, the Boards of Supervisors of San Francisco, Marin and Alameda Counties, and the City Council of Berkeley have declared a local emergency regarding the AIDS epidemic among injection drug users. This action has been taken in support of the exchange programs currently operating without legal sanction within their jurisdictions. OBJECTIVES Our current goal is to determine whether the community could support development of a syringe exchange program. To be effective, such an intervention must have broad community support and must be part of a comprehensive public health plan which addresses community education, targeted outreach, ongoing support for behavior change, substance abuse treatment alternatives, HIV counseling and testing, and health and social services for people with HIV disease. Reducing HIV Transmission Among Injecting Drug Users Page 2 Syringe Exchange in Contra Costa County In order to assess the level of community support for syringe exchange as a prevention intervention in Contra Costa County we must discuss the issues with community leaders, policy makers, and affected community members to determine the perceived barriers to such a program and to develop effective prevention strategies that are welcomed by the community. Health Services Department staff will organize and co-sponsor with community organizations a series of community forums to openly discuss HIV prevention including consideration of the development of syringe exchange programs once we can legally support their implementation. Additionally, by calling on identified community leaders, enlisting their support in this process, and addressing current concerns, we can make community members more aware of the extent of the epidemic in their communities, of services which now exist, and of the role each person can play in stopping the spread of HIV. Once we have met with community members and policy makers throughout the county, we will determine the acceptance of syringe,exchange as a component of a comprehensive HIV prevention plan for Contra Costa County. At that time, if the legal constraints are removed, the Health Services Department will integrate this strategy into its HIV prevention programs. Reducing HIV Transmission Among Injecting Drug Users Page 3 Syringe Exchange in Contra Costa County TIMELINE* March 14 - 31 Health Services Director meet individually with members of the Board of Supervisors to discuss plans for HIV prevention including assessment of community support for syringe exchange March 1 - 31 HIV/AIDS Program develop informational packets on HIV prevention and syringe exchange programs for presentation at meetings and forums April 1 - 15. Health Services Director and Public Health Division staff meet with elected officials of the most affected cities to discuss the development of HIV prevention campaigns including assessment of community support for syringe exchange. Discuss goals for a summit of elected officials on AIDS Policy and Leadership scheduled for September. April 1 - 30 Identify county departments which will have a role in the community assessment process regarding syringe exchange and begin to schedule meetings to take place in late April and early May Identify church leaders, community organizations, and law enforcement leaders to discuss sponsorship of community forums. Schedule meetings to take place in May and June May 15 - 30 Meetings with church leaders, law enforcement leaders, and community leaders and organizations July - August Meet with advisory boards including Substance Abuse Advisory Board, Public & Environmental Health Advisory Board, HIV/AIDS Consortium and others in the county to discuss the need for HIV prevention campaign and to describe the organization of community forums September 1- 15 AIDS Leadership & Policy Workshop (Summit for elected officials) October 1- 15 First community forum in West County to discuss prevention campaign and to evaluate support for development of a syringe exchange policy January 15 - 30 Forum in East County February 15 - 30 Forum in Central County *Timeline may be adjusted to allow.fleribiliryfor involvement of community organizations HelpingTB patients help themselves heal County outreach staff brings medication to patients By KATE DARBY RAUCH Staff-w 13 test positive In a makeshift garage off a Richmond alley, Michael Boone wipes grease from his hands, takes a swig of orange soda. at Pinole school then pops a pill.Then another one.Then a PINOLE—Out of about 300 Pinole Val- = Hours earlier,a resident of the Concord ley High School students and staff given Homeless Shelter went through the same tuberculosis skin tests Tuesday, 13 tested routine,gulping water between pills.And positive,fewer than expected. ; in North Richmond,Antioch and Martinez, A positive skin test for tuberculosis several other people follow suit. doesn't necessarily mean the person has All of these people have tested positive the disease• x for tuberculosis. And as they undergo The testing, conducted by the county treatment,all are being watched. Health Department.was-done after a stu- "I don't mind taking medicine or stuff, dent was reported to have tuberculosis last but I wouldn't do it on my own,"Boone, week.People in close contact with the stu- 48,said.smiling as he fingered a large red dent were tested. pill."Because I'd rather take my medicine Health Department communicable dis- - than be dead,this is a blessing." ease experts will return to the school Tues- One of the best tools emerging in the day with a portable X-ray machine for fol- fight against tuberculosis is a treatment low-up testing. i method called directly observed therapy, Chest X-rays will help determine if tu- or DOT. In DOT, health rare workers berculosis is present in the lungs,said Sir- bring medication to patients at a place of lura Taylor,a county public health nurse. i their choosing,from back yards to BART If X-rays show signs of disease, the stations,and watch them take their pills, next step is a sputum test,which helps week after week,month after month. narrow down the extent and character of Facing growing concern about noncom- tuberculosis. .;- pliance —tuberculosis patients not taking Tuberculosis is highly treatable with a e..;�^ their medication—the Contra Costa regimen of medication. jt!• r4 County Health Department hired two more The positive TB test results at the full-time DOT outreach workers three- school may or may not be related to the weeks ago,bringing the total to three.The student diagosed with the disease.Taylor �. increased effort, say health officials, is said.TB infection usually comes from pro. needed to address some frightening new longed exposure,she said. twists of the age-old disease. "Our staffing level with just one person wasn't adequate." said.Charles Crane, a also play a major role, as more people medical consultant for the county rubercu- share small quarters or become homeless. losis control program."A couple of things "Crowded housing is:probably the most in the lest couple of years are disturbing. important paRof this,"Crane said.Crack Drug resistance is going up...and people users often share cramped quarters in with AIDS are now more susceptible to crack houses,the homeless often five in MANN D.FRENElI,— TB." packed shelters,and prison overcrowding RICHMOND RESIDENT Michael Boone,left,receives his weekly tuberculosis medication from Chuck Primous,a Extremelycontagious is a recognized emblem,he said. county disease intervention specialist.Primous has been delivering medicine to patients countywide for seven ears. People with AIDS are more susceptible 9 P tW�' Y Tuberculosis is a bacterial infection of to developing active cases of tuberculosis. the lungs that can be an active disease or Crane said because their immune systems [its of tuberculosis today is the growth of By encouraging people to comply with seven years.Pnmous has watched peop'.e inactive.Active tuberculosis is highly con- are suppressed or less efficient,decreasing virulent drug-resistant strains. Some treatment,directly observed therapy is crit- take their pills in a variety of settings— tagious,primarily spread through the air their ability to fight off illness. "HN in- strains are proving resistant to a variety of ical in slowing the spread of drug-resistant prisons, parks, shelters, restaurants and when infected people trough or sneeze. creases your risk of disease."Increasingly, drugs, creating enormous treatment disease."That's one of the more important sidewalks. People can test positive for tuberculosis in- the AIDS and tuberculosis are spreading in challenges. - roles of DOT,"Brunner said. Increased people power was criticaih-- fection without ever developing the tandem. Though multiple-drug-resistant tubercu- needed,he said."Man,TB is just too much disease. Accesss to regular medical care, from losis is more of a problem in East Coast Persi eMe is heeded for one person to handle." Rarely fatal,tuberculosis can seriously money for doctors to transportation to clin- cities,primarily New York,health officials Health officials here and nationwide are The number of people served by ;he affect infants,the elderly and people suf- its,also is significant in successfully diag- here fear it's spreading west."We're wor- promoting DOT. DOT program,currently 14, ranges from . fering from other serious illness. nosing and treating tuberculosis. ried....It's an enormous potential prob- DOT outreach workers are trained to be about five to 25,changing as peopie star. In the past 10 years,tuberculosis rates Sbid medical lem," said Wendel Brunner. director of persistent,tracking down patients,return- and finish treatment,Primous said. have jumped dramatically nationwide.The public health for the county."We'd like to ing again and again to their homes or The new wor:cers will be used to ex. number of cases reported by the county in- Tuberculosis is highly treatable with a keep it that way." meeting places.Sometimes they offer food pand the DOT caseload in the commun;r. ceased from 60 in 1985 to 117 in 1992. strict medical regimen.Standard treatment A few cases of resistant tuberculosis or treats. and in county prisons.in addition to im- In 1993,the number dipped to 110,a usually requires a combination of antibiot- have shown up in the county,he said. In many states,legal action can be tak- proving tuberculosis health education<er sign that aggressive treatment may be its taken twice or more, weekly for six Usually tuberculosis involves a variety en for noncompliance. vices countywide. slowing the increase.Crane said.The rate months or longer.Sticking to the regimen of bacteria working together. The strop- If patients puree impossibiv uncoopera- Michael Boone,who lives•.vuh a wirer: of tuberculosis is growing most rapidly in is essential. gest are potentially the most drug-renis- tive here,the county District Attorney's Of- of relatives and in shelters. had his ::•<• East County. Studies show that many people have a cant. Treatment is designed to rail all fice has the power to force hospitalization bout of tuberculosis about three year}ai; Crane and other experts said several difficult time following medical treatment strains. until treatment is complete. factors contributed to the rapid spread. —taking pills when and for as long as pre- When people dont take all their medi- About five cases have been referred to He was very sick :hen. he .among them are the AIDS epidemic,the scribed. Tuberculosis can be particularly cation, or sake it off and on, stronger the district attorney :n the past several credits Dor with itegting >am his crack epidemic and the escalating prison tricky since[he treatment invoives many strains,those mostly likely to be drug-re- years,said Charles Primous.senior disease " fan.it helped me a lit." population.Poverty and the growing short-. pills and lasts for months. sistant.can survive.spreading drug-rests- intervention technician for:he county. Moving:imund frequently:nakus keec- age of low-income housing in the Bay Area One of the most alarming charactens- cant bacteria:o others. The oniv DOT worker counr%-ide for ing track of meutc:ne uuficult. aid PEDIATRICS Health Insurance and Preventive Care Sources of Children at Public Immunization Clinics Tracy Lieu, MD' Mark Smith, MD, MBAJ; Paul Newacheck, DrPHJ; Dottie Langthorn, PHNq' Pravina Venkatish, BS; and Ruth Herraddra �. ABSTRACT. Background. Recent proposals to reform is improved and organizational barriers are also removed. immunization financing aim to help more children re- Pediatrics 1994,93:1-6; immunization, health insurance, ceive vaccines at their sources of primary care.Under the primary care, clinic,Medi-C41,private insurance. current system,referrals of children from the private sec- tor may strain public immunization clinics,but scant in- formation exists on what proportions of public clinic pa- ABBREVIATION.HMO,health maintenance organization tients actually have insurance or primary care sources. Objective. To describe the health insurance, usual More than one third of all 2-year-olds in the United sources of health care,and referral patterns of children at y low-cost public immunization clinics. States have not received all recommended vaccina- nes:g,•. Cross-ePctional vtudv based on face-to-face, tions.,-'The patchwork nature of the public and pri- . structured interviews. vate systems responsible for vaccine purchasing and Setting. Public immunization clinics at three sites in administration may hamper efficient immunization Contra Costa County. delivery?•4 President Clinton's call for increased fed- Participants. Five hundred thirty-eight parents of eral funding of immunization programs aims to iat- children awaiting immunizations. prove delivery as well as reduce cost to parents(New Results. Thirty-four percent of families at these public York TithesFebruary. ry 1, 1993 immunization clinics had Medicaid alone,whereas 24% '1,10 had private insurance. Of those with private insurance, One disadvantage of the present system is that pa- almost one third had at least partial coverage forvaccines. tients who already have health insurance or sources Sixty-two percent of families had sources of preventive of comprehensive preventive care services may seek care other than the immunization clinic,and most would vaccines at low-cost public immunization clinics due have preferred to receive their vaccines at these sources. to inadequate insurance coverage or nonfinancial bar- Most in this group named cost as the main barrier to im- riers.Increasing vaccine costs and Iagging reimburse- munizations at primary care sources;but one third of this ment from Medicaid and private insurance have led group,including almost all the families insured by health growing numbers of physicians to refer children to maintenance organizations,named the wait for appoint- ments at their usual source of care as the main barrier to public clinics for immunizations in recent years.64 Re- receiving vaccines there.Two thirds of Medicaid patients ferrals from the private sector may create additional and at least one third of privately insured patients were strains for public clinics, which are already dealing either uninformed or mistaken about whether their in- with funding cutbacks and vaccine shortages 3•' Fur- surance covered vaccines. ther, because immunization-only clinics do not offer Conclusions. Financing reform may improve immuni- other preventive services, their use increases frag- zation delivery and reduce the load on public clinics. mentation of health supervision. However,legislation to improve immunization financing Scant information exists on how much shifting of Will not achieve optimal results unless parent education p:.vate sector patients to public im:lunization dirties actually occurs.'The extent of such shifting, and the From the'Roust Wood JohnsonClinical Scholars P and§institute reasons for itwill determine whether current for Health Policy Studies,University n of Califoua,San an Francisco, , rrro- scv;tKaiser p Family Foundation.Menlo Park.CA:and 11mmuniration Program,Contra posals for reform will be effective. In this study, we Costa County Hralth D—mrtrnent.CA surveyed faradlies seeking :UnlInunlzatioris at pubic Received for publication Jun 14,1993;accepted Jul 29,1993. clinics- (1) to determine the proportions of children Reprint requests to(T.L)The Permanente Medical Group 3451 Pledtnont Ave,Oakland,cn 94011. with Medicaid or private insurance; (2) to evaluate PEDIATRICS(ISSN 0031 4005).Copyright O 1994 by the American reasons for choosing the clinic for immu- n Aetd- p emy of Pediatrics. nizations; and (3) to describe their usual sources of PEDIATRICS Vol. 93 No.3 March 1994 1 I SESSION: V 1 I OPERATOR:mnggtsM1:311Aeaner1, 19J shnnudlsti �oalaul _p2tx 7 1 5 i _ I . I s: s: COMMENTS: or HW:A000 I health care and the barriers to obtaining immuruza- (Copies of the interview instrument are available from the authors lions at these sources. on request).The study protocol was approved by the University of We chose Contra Costa County in northern Cali- California,San Francisco Committee on Human Research. The interview focused on the oldest child brought for immu- fornia as the setting for this study because its immu- nizations in each family.It included one question about Medi-Cal nization clinics offered all recommended childhood (Medicaid)coverage and another about private insurance cover- vaccines at minimal cost, without appointments or age at the time of the interview.Two questions covered whether physical examinations, and without financial screen- the child's insurance or Medi-Cal paid for any part of his or her vaccines. The interview also covered sources of preventive and ing. The county hada population of approximately g P P PP sick care,source of referral to the immunization clinic,reason for 803 000 in the 199()census and a per capita income Of choosing the public clinic, source of child's last immunization, 24 308 in 1989.`" The county's population was 70% willingness to accept immunizations at potential alternative out- white, II% Latino, 9% black, and 9% Asian.' Ap- reach sites•and demographic information.Questions on insurance proximately 137c of the county's children were Medi- coverage and health care sources were modified from the National Health Interview Survey. Cal-eligible. At the time of the study,California Med- The (chit' test was used for comparisons of categorical data, icaid reimbursed private physicians for vaccines and with Yates'continuity correction for 2 x 2 tables. administration, at rates ranging from 49% to 76% of usual fees.' RESULTS METHODS Study population' Face-to-face interviews were conducted with parents of chit- A total of 582 families attending the county's public dren attending public immunization clinics in Contra Costa immunization clinics were approached for inter- County in northern California,during 5 weeks in August through ar- d t agreed 0 views.Of this total,538 families (92%) a September 1992. The county health department operated immu- g P nization clinics at three public health centers during four weekly ticipate and were included in the study sample. afternoon sessions:in Pittsburg on Mondays from 1:30 to 4:00 Pin, Twenty-eight parents (5%) declined to be inter- in Richmond on Mondays and Wednesdays from 2:00 to 4:00 rM, viewed,and 16 (3%) were clu due to language and in Concord on Fridays from 2:00 to 4:06 Pst.There was a fee for barriers or other reasons Table 1 howl the demo- vaccines of$2 per child,up to a maximum of$5 per family;this fee was waived in cases of need. The advertising for (hese clinics graphic characteristics o respondents in- consisted of information flyers distributed in school registration eluded in this survey. Most respondents (74%) were packets and a press release sent to local newspapers. The public mothers.Of note, >30%of respondents had attended health department delivered most of its vaccines through immu- at least some college.Latinos comprised a higher pro- nization clinics, but also delivered vaccines to patients already portion(39%)of the study group than of the county's enrolled in its comprehensive health screening clinics. Study interviews were conducted at three of the four afternoon general population (11%). clinic sessions each week. Each parent waiting in-line was ap- Most families (76%D) brought one child for ilrimu- proached by one of two research assistants.All parents were eli- nization, whereas 17% brought two children, and i;ihte for iwery;rows t~Yause th^re ,,,as uniformly at least a 10 7% brought three or more. We asked the age of the minute wail. Interviews were conducted in English•Spanish,and Hindi using a structured, closed-ended survey format. This oldest child brought for immunization by each fam- closed-ended interview wascieveloped based on open-ended pilot ily;26% were 5 years old and 11% were 4 years old. interviews with clinic parents prior to the start of the study. Fifteen percent were <12 months old. TABLE 1. Demographic Characteristics and Insurance Sources of Families at Public Immuniza- tion Clinics.Contra Costa Countv,•1992 (n) Education of respondent(N = 532) Less than high school graduate 32(170) High school graduate 36(192) Some college or more 32(170) Ethnicity of respondent(N = 535) Latino 39(209) White 36(192) Black 11 (61) Asian 9 (48) Other 5 (25) Health insurance coverage(N = 538) Medi-Cal only 34(183) Private only 22(117) Medi-Cal and private 2 (11) None 42(227) Does insurance or Medi-Cal pay for any part of child's vaccines? Medi-Cal insured patients(N = 184) Yes 36 (67) No 30 (56) Don't know 33 (61) Privately insured patients(N = 127) Yes 28 (36) No 43 (55) Don't know 28 (36) 2 HEALTH INSURANCE AND PREVENTIVE CARE SOURCES :,......':P�: s 1 PALE. 2 ( PGR AT i„R:noon 1 iIME: 7:A, iD A FE: Decemoer 28, 19,3]I,:CiB::'Sn-rWoisx,;,i;:S �naiat,l;nP iiL,,;t:;} n;r,,,.L;;; ;st:,,; CA.'a,V„Ua11 L,1 A%CC41,116',111 dPFv1`111Q1lE as Elie We asked about the health insurance coverage and main reason for their choice. Privately insured fami- health care sources of the oldest child being seen for lies were less likely than other families to name lo- immunizations in each family Crable 1).Most children cation as the main reason for using the public clinic 'had Medi-Cal alone (34%) or private insurance with (P < •U1)• or without Medi-Cal (24%). The rest (42%) were un- Because multiple reasons may contribute to the use insured. of public health clinics for immunizations, we asked Of the 128 families with private insurance, 25% respondents to rate each of the four factors above as .named one health maintenance organization(HMO), important or not important (Table 2).Cost was rated 15% named a second I-IMO, and 9% named one in- important by the highest proportion of parents(79%), demnity plan as their insurer. The remaining 51% of although convenience of location and not needing the privately insured families named i of 29 other an appointment were also rated important by more than half of parents, In addition, parents were asked health insurers. We asked each family with private insurance or whether they had any other important reasons for Medi-Cal, "Does the child's health insurance, health choosing the public clinic for vaccines. Twenty-two plan, or Medi-Cal pay for any part of the child's vac- parents (4O/o) cited other difficulties with health care cines?" Among privately insured families,a plurality access: most commonly, difficulty finding , doctor (43%) said their insurance did not cover vaccines, who would accept Medi-Cal coverage for immuni- whereas 28%said they did not know.I'Iowever,of the zations. privately insured families, 28% said their insurance paid for at least part of the child's vaccines; half.of S OU", Care and Barriers to Immunizations these said,it covered the cost of vaccines entirely.Sur- of primary care and acute are shown in prisingiy, although all HMOs cover immunizations, ost parents (62%) said their child had a 29 (57%Q) of 51 1-it,10-insured families either mistak- primary care, and most of these named a enly believed that their insurance did not cover vac- doctor's office, private clinic, or HMO as the source. cines or diel nut know. We asked those patients with a source of primary By comparison,approximately one third of the par- care,except those who were already public clinic pa- ents of Medi-Cal-insured children mistakenly be- tients, whether they would have preferred to have sieved it did not cover vaccines and another one-third their child vaccinated at their place of primary care if did not know. The remaining one-third of Medi-Cal cost were not an issue.Sixty-three percent said they parents correctly said it paid for at least part of the would have preferred that their child be immunized child's vaccines. at the primary care source. We asked this group of parents to name the main difficulty with obtaining Reasons for Use of the Public Clinic for immunizations vaccines at that source. Among this group,53% cited During our pilot interviews,parents usually named cost, but 33% cited the waiting period for appoint- four factors--cost, location, not needing an appoint- ments as the main difficulty.Seven parents(4%)said ment, and having recently moved—as reasons for that the vaccines they needed were not being offered. choosing the public clinic for immunizations. To at their source of routine care;six of these were private evaluate the relative importance of these reasons for doctor's offices.Transportation difficulties were cited use of the public immunization clinic, parents were by seven parents as the main difficulty with getting asked (lie most important reason for their shots at their usual source of primary care. choice Table 2). lost parents(54%)chose cost. Mow- Overall, 228 (42%) of the 538 children in the study ever, s minorities chose location (20%)and group had health insurance as well as a source of pre- not needing an appointment (17%). ventive care. Predictably, insurance status was sig- Both privately insured families (P < .001) and un- nificantly associated with having a source of primary insured families (P < .001) were more likeiv than care(P<001):80%of privately insured children,69% Medi-Cal-insured families to name cost as the most of Medi-Cal-insured children,and 47% of uninsured important reason for choosing the public clinic. Pri- children had a regular source of preventive care. vateiv insured(P<.05)and Medi-Cal-insured respon- When the families who had a source of primary care dents (P < .01) were more likely than uninsured re- were stratified by insurance status, similar propor- TABLE 2. Parents' Reasons for Choosing the Public Clinic for immunizations,Contra Costa County. 1992 Families in This Insurance Category Naming Families who Rated This as the Most Important Reason for Their Choice, % (n)• This Reason All Families Medi-Cal Private Uninsured important, `,b (n) It costs less than other places 55(250) 40(62) 66(70) 60(119) 79(424) The location is convenient for me 20 (91) 27(41) 9(10) 20 (40) 74(396) No appointment is needed 17 (78) 23(35) 21(22) 11 (21) 59(318) We recently moved to the area 5 (24) 4 (6) 3 (3) 8 (15) 39(210) Other access problemst 3 (13) 7(10) 1 (1) 2 (1) 5 (22) •Based on these totals for valid responses:456 families,including 154 Medi-Cal, 106 privately insured,and 196 uninsured families. t Twenty-two parents cited other problems with access to immutu7.atiorns in response to an open-ended question asking them to name any other important reasons for chtxwsing the public clinic; 13 nitned this as the most important reason. AP,riCi a5 3 E_iJK, N: 4 I PANE:3 l(„)P_RAf1,',47: noon I 'MME: 7:881 DAEE:Cecemoer 28, 1993 JU l r3: 5 g15k' CSS,lei.` nark; J;' �•tt,.JJ ,��ar- JI', ;5:. �Prir OF: 1 EDIT: PE's: AA's: :t�MMGt1tC•k uu,.nn , i n I. 1­1111 1..1111'a1111 __....__C�V1 LIuiu1K11 at 1 UVIIL t 111111us"auull 4_11111cs,l-ullod Custa County, 1992 ^o(n1 Source of primary care(N = 53.1) Doctor's office, private clinic,or HMO' 34{180) Public health clinic, hospital clinic.or other 28(151) No source of routine care 38(203) Source of acute care(N = 516) Doctor's office. private clinic,or HMO a0(204) Public health clinic,hospital clinic,or other 31(167) No source of acute care 281145) Would you have preferred to get child's vaccines at source of primary care? IN = 322) Yes 63(204) No 16 (51) No preference 21 (67) Main difficulty with receiving vaccine there(N = 189) Cost 57{108) Waiting period for appointments 35 (67) Other access problems 7 (14) Referral source(N = 531) Friend, relative,or school 44(236) No one 28(149) Private or HMO health professional 12 (65) Public health professional 9 (49) Other 6 (32) Place last vaccine was received(N = 512) Public health or community clinic 45(230) Doctor's o(fice, private clinic,or HMO 30(153) Other country 18 (94) HMO, health maintenance organization. tions of privately insured (68%),Medi-Cal(59%),and ever, most parents(55%,or 295)said they would not uninsured families (64%) said they would have pre- have their children vaccinated at a shopping mall. ferred to receive vaccines at their primary care source We did not ask parents whether they would have (P = NS). However,there were significant differences preferred these alternative sites to the public clinic by insurance status in perceived barriers to being vac- or to primary care providers as their source of im- driated at their primary care source. Although almost munizations. half of families with Ivledi-61 (46%) or private in- surance (48%) cited cost as the main barrier, a sig- Subgroup Analysis by Age nificantly higher proportion of uninsured families This study was conducted in late summer, wheii` (7770 named cost as the main barrier(P< .001).Con- children need immunizations to stjrt school,and 69% verseiv, families with Medi-Cal (41%) or private in- of children in our sample were aged 4 years or older. surance(47%)were more likely than uninsured fami- Thestudy's timing could have led families who do not lies (17"x) to cite waits for appointments as the main routinely use the public immunization clinic,but who difficulty with being immunized at their primary care had school-aged children, to be overrepresented in source (P < .001). our sample.To evaluate how the study's timing may have affected our results, we performed analyses Referral Sources and Fotential Outreach Sites stratified by age, assuming that families of toddlers Most parents were either self-referred or had been and infants might be more representative of families referred to the public immunization clinic by a friend who use public clinics at other times of the year. or relative (Table 3). Many were referred by schools. In general,the results of the age-stratified analyses Approximately 12% of families said they.,had been do not support the concern that the study's timing at referred by private health professionals (including the start of the school year caused an overestimate of private doctors, nurses, and clerks and HMO profes- the importance of appointment waits as a barrier at sionals).Among families with Medi-Cal,a higher pro- primary care sources or an overestimate of the pro- portion(21%)had been referred by health profession- portion of patients with insurance and sources of pri- als outside the public health system than families with mary care. There were no significant differences be- private(1217c, P = NS) or no insurance(517c, P< .001). tween school-aged and ,younger children in reasons We also asked where each child in the sample had for using the public health clinic, whether insurance received his last vaccine. Most children had received paid for any part of the child's vaccines,whether the their last vaccines at places other than the public family would have preferred to receive vaccines at the health clinic, including doctor's offices, HMOs, and child's primary care source, or the main barrier to other countries. being immunized at the primary care source. Tod- When asked about potentiai outreach sites for im- dlers and infants were actually more likely than munizations,most parents said they would have their school-aged children to have sources of preventive children receive vaccines at school (89%, or 477) or care (P < .001) and sick care (P < .01). Although the church(73`70,or 391) if they were offered there. Flow- younger children and school-aged children in this 4 FIEALTH INSURANCE AND PREVENTIVE CARE SOURCES SEssic� 7 441'PAGE:4I OPERA:OR: 000n I ilt.1E: 7:381 DATE: Decemoer 28, 1993 1,;CB:;)snarwmsu3/CLsp e!1t76•GiiP •-Wj0U mary•1.0IV 352:x1::u5 �PR1V I I /(ELDi�: PE's: i .QA's: r.nl�ucurc•r ,uw.o��� -- study group were equally likely to have private in- cover more than hall of the nation's employees, are surance(24% vs 24%), the younger children were less exempt from these regulations (Flint, personal com- likely to be uninsured (35%vs 45%,P<.05)and more munication). likely to have Medi-Cal(40%vs 31%,P< .05).Among Some public clinics have implemented financial those families with private insurance in this study screening and prorated fee schedules to obtain more group, younger children were less likely to have payment from patients who have other resources.The HMOs as their insurance sources than older children Contra Costa County clinics where this study was (28% vs 51%, P < .05). conducted had to raise fees for vaccine administration from$2 per child to$5 per child due to funding cut- COMMENT backs in the fall of 1992. Alternatively, public clinics '['his study's results suggest that improving immu- could attempt to reduce their financial burden from nization delivery will require reform of both the fi- privately insured patients by seeking reimbursement nancing and the organization of vaccine services.Ide- from private insurers.However,because privately in- ally, immunizations should be readily accessible at sired patients whose insurance covered at least part usual health care sources. In our study, 42% of fami- of the cost of vaccines comprised only 7%of this pub- lies had both health insurance and a source of primary lic clinic population, the impact of such interventions care.Their presence at the public immunization clinic aLthe public clinics in this study would be limited. signifies financial and organizational barriers to vac- cination at primary care sources. Organizational Reform This study further suggests that financial reform Financial Reform alone will not achieve optimal immunization rates. Cost was the most commonly cited reason for Many privately insured parents in our study did not choosing the public clinic for immunizations,despite know whether their insurance covered vaccines.Only the fact that 36% of families in this study had Medi- one tlurd of the parents who had Medi-Cal were Cal and 24% had private insurance.Universa[vaccine aware that it paid for any part of the cost of immu- distribution systems in which the federal or state gov- nization. These findings are not surprising, given ernments buv all needed vaccines and distribute them previous studies which found a lack of consumer un- free to providers would reduce costs to parents.Our derstanding of health insurance.15•16 Parent education findings suggest that these systems may enable more about the timetable for childhood vaccines,as well as children to be vaccinated at their usual sources of about insurance coverage, needs to be improved to preventive care. Eleven states already have universal capitalize fully on a cost-effective preventive service. distribution systems that provide all vaccines for all Our results show that organizational barriers to children(Sam Flint.personal communication).'How- vaccination, especially waits for appointments, play ever,there is mixed evidence about whether such pro- an important role. Compared with uninsured pa- grams are associated with increased immunization tients, insured patients were more likely to cite con- rates (Boston Globe. 1993).' venience factors—location or not needing an Financial reform may need to include more than appointment—as reasons for their use of the public vaccine purchasing alone.Even if vaccines were made clinics.Almost all the HMO patients at the public im- available free to all providers, families might still face munization clinics who would habe preferred to use charges to obtain immunizations. In one survey, the HMO cited appointment waits as the main barrier. charges for vaccine administration accounted for 30% As more states shift to managed care for Medicaid to 40% of charges for vaccines.13 Further, the Ameri- patients, the effects of appointment waits on the ac- can Academy of Pediatrics recommends that immu- cessibility of immunizations and other preventive ser- nizations be provided during periodic preventive vis- vices will need careful scrutiny. its. In 1991, before the hepatitis B vaccine was added Finally, there may be a tradeoff between optimal to the childhood vaccination schedule, the estimated immunization rates and the comprehensiveness of charges for services recommended by the American children's health care delivery. Immunizations have Academy of Pediatrics during the first year of life in- traditionally been linked with other services in health eluded $213 for immunizations and $276 for physi- supervision visits, but this requirement may present cian visits and other primary services."Thus,reforms yet another barrier to vaccine delivery. One third of which only pay for vaccines may have limited effects the children in this study had no source of preventive on increasing access at primary health care sources care. Even if all vaccines are distributed free to pro- unless vaccine administration and other preventive viders,access problems will persist if preventive vis- services are also covered. its are required for vaccines and access to primary An alternative financing option is for state govern- care providers is inadequate.At a minimum,access to ments to mandate that private insurers cover vaccines vaccines could be improved by using alternative out- as part of minimum benefit packages. Twelve states reach sites.Parents in this studv seemed quite willing have such mandates; one was passed in California to accept schools and churches, but not shopping and took effect January 1, 1993. Approximately one malls, as sites for vaccine delivery. fourth of the families in our study had private insur- ance; some of these families may benefit from man- Limitations dated private insurance coverage of vaccines. How- Several limitations of these findings should be ever, the effects of mandated private coverage will be noted. Most important, the geographic scope of the limited because self-insured employers, which now study population was limited. Similar evaluations in ARTlCLES 5 SESSION: s 1 PAGE:5 1 OFERA TOR:bobh I ilME: 7:581 LWE:December 28, 1993 i JOB:ty>SharkJajSkj,'CLS�eaia�'(; iP ? _� ,iiL i O (1DF:_ I EDIT: oc<• ,. _. .. - other sites would help to determine whether these Contra Costa Countv, California, have either Medic- findings are typical. Compared with other states, aid or private insurance.The main barriers to receiv- California has a larger representation of HMO pa- ing immunizations at the usual preventive care lienls. Based on this studv's findings, the families us- sources were cost and waiting times for appoint- ing public immunization clinics who were insured by ments.If these findings are replicated elsewhere,they the larger HMO in Contra Costa County would ac- would suggest that financing reform has the potential tually have accounted for<U.59c of the children in that to improve vaccination rates,but only if it is combined HN10's population. with improved parent education and reduced nonfi- Although the public clinic population is tradition- nancial barriers to immunizations. ally viewed as high-risk, we could not include the I'..:?: •'i highest risk group of children who never received iin- ACKNOWLE•DG�tENTS r11U111Zat1UnS at all. This study evaluated barriers to immunization at primary care sources, but it did not This work was supported by a grant from the Kaiser Family Foundation.Dr Lieu was supported by(tie Robert Wood Johnson evaluate barriers to immulUzation at the public clinic Clinical Scholars Program. itself; this question was addressed by a previous We are indebted to Tom=Newman, MD,.Bernard Lo, MD, study."Because the study included only public clinic George Rutherford,MD,Loring Dales,MD,Jan Eldred,the Robert users we have not attempted to compare the health Wood Johnson Clinical Scholars of University of California, San care access and opinions of these families with those Francisco, and members of the Association of Bay Area Health of families who received immunizations in other sec- Officials for suggestions on study design. We thank Sam Flint, PhD, Walter Orenstein, MD, and Drs Newman and Lo for tors. thoughtful reviews of the manuscript. We are grateful to Lisa The timing of this study at the start of the school Gates and Mary Rose for their administrative assistance on this vear most likely caused families of school-aged chit- study,and to Lyn Wender for editorial assistance. siren who did not use services at other times of the year to be overrepresented. We could not directly REFERENCES evaluate differences between families who used the public clinics at (his time of vear anti those who used 1. William B. Immunization coverage among preschool children: the them at other tithes. The age-stratified analysis sug- United slates atul selected European countries. Pediatrics. 1990: 82(Suppi):1052-1056 gested that the study's timing did not cause overes- 2, Cutts F,Zell E.Mason D.Bernier R.Dini E,Orenstein W.Monitoring timates of the importance of appointment waits as progress toward US preschool immunimilion goals. JAMA. 1992;267: barriers or of the proportions of public immunization 1952-1955 clinic users with health insurance and sources of pri- 3. UuJ,Rosenbaum S.Medicaid and childhood immunizations:anational Mary care. However, it did Suggest that HMO- study.Children's Orfense Fund. 1992 4. Nadel M.Childhood immunization:opportunities to improve immuni- insured children may have been overrepresented dur- nation rates at tower cost.Testimony before the Senate Cgmrniltee on ing this study period Compared with the rest of the Finance. Subcommittee on Ileallh fur Fanulim and the Uninsured. year. Washington,DC:US General Accounting Office:1992 Information on children's insurance status relied on 5. Voelker R.National vaccine distribution debated.Ant Med News. 1993; parent recall. Bias in responses to insurance questions January 18J,45.476. Schulte),Bown G,Zetznan M.et al.Changing immunizi lion referiar' should have been reduced by the interview introduc- patterns among pediatricians and family practice physicians, Dallas tion, which made clear that all responses were con- County,Texas, 1988.Pediatrics.1991;87204-107 fidential and would not affect children's care at the 7. Arnold r,Schlenker T.The impact ofhealth care financing onchildhood public clinics in any way. However, errors in incur- immunization practices.A10C.1992;146:728-732 ilnce status could still have been introduced by faulty 8. Orange L,More vaccinations being done in public clinics.AAP survey shows.Pediatr NRts.November 1992 recall or embarrassment at lack of insurance coverage. 9, Skolnick A. Should insurance cover routine immunizations) JAMA. 1991;265:2453-2454 CONCLUSIONS 10. California Statistical Abstract.Sacramento,CA;Department of Finance, This study provides one baseline point for evalu- State of California: 1991 I1. Association of Bay Area Governments. Population and Housing Units, ating the effects of future reforms in immunization California Cities and Counties.Projections-90. 1989 financing. When reforms are introduced, studies 12. California Statistical Abstract.Sacramento,CA;State of California: 1991 should examine whether the reforms decrease the 13. Wright J, Marcuse E. Immunization practices of Washington State shifting of privately insured children to public Im- Pediatricians-1989•AFDC. 1992:146:1033-1036 14. Actuarial Research Corporation Premiums for Preventive Pediatric Care munization clinics, and improve financial as well as Recommended by the American Academy of Pediatrics. 1991 nonfinancial access to vaccines. Centralized tracking 15. Marquis M.Consumers' knowledge about their health insurance cov- systems for immunization records,alreadv under de- erage.Health Care Fi,mnc Rev. 1983'5:6540 velopment in certain regions, will enable such evalu- 16. McCall N, Rice T. sangl J. Consumer knowledge of Medicare and ations to be performed. supplemental health insurance benefits.Health Seno Res.1986:20:633-657 17. Gindler J,Cutts F,Barnett-Antinori M.et al.Successes and failures in In conclusion, our study shows that most children vaccine delivery: evaluation of the immunization delivery system in receiving vaccines at public immunization clinics in ruerto Rico.Pediatrics. 1993,91:315-320 6 HEALTH INSURANCE AND PRE-VENTiVE CARE SOURCES SESSION:a PAGE: 6 1 OPERA rpq:bobh I ri.,AE: 7:38 1 DAT December 28, 1993 I JOB:(cPsharsuais kXCLS pnaiat'c;iiP pec;lest J JtarJd iii'J O0F: - - ' HIV/AIDS EPIDEMIOLOGY REPORT CONTRA COSTA COUNTY .?ll • ..a.,—= ,SCJ co u March 1994 Mark Finucane, Health Services Director Wendel'Brunner, M.D., Assistant Director for Public Health Francie Wise, Communicable Disease Control Director Rusty Keilch, AIDS Program Director Prepared by: Juan Reardon, M.D. Denise Johnson Ethel Alderete Nancy Warren Marlina Hartley Table of Contents Reported cases of AIDS in Contra Costa County . . . . . . . . . . . . . . . . . . . . . 1 Total cases reported (1982-1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Mode of infection and gender distribution of AIDS cases (1982-1993) . . . . . . . . . 1 Race/Ethnicity distribution of AIDS cases (1982-1993) . . . . . . . . . . . . . . . . . . 2 Age distribution of AIDS cases (1982-1993) . . . . . . . . . . . . . . . . . . . . . . . . . 2 Year of diagnosis of AIDS cases (1982-1993) . . . . . . . . . . . . . . . . . . . . . . . . 2 Cases under new CDC expanded AIDS case definition (1993) . . . . . . . . . . . . . . 3 Deaths among people with AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 People living with AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Geographic distribution of AIDS cases (by city) . . . . . . . . . . . . . . . . . . . . . . 5 Global view: World, US, California and Bay Area cases . . . . . . . . . . . . . . . . 6 Estimate of Contra Costa residents infected with HIV . . . . . . . . . . . . . . . . . . 6 Local HIV/AIDS epidemic in injection drug users (IDUs) . . . . . . . . . . . . . . . 7 Percent of heterosexual IDUs among new AIDS cases (1982-1993) . . . . . . . . . . . 7 HIV prevalence among IDUs entering treatment . . . . . . . . . . . . . . . . . . . . . . 7 Street surveys in West County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Census tract distribution of IDUs with AIDS . . . . . . . . . . . . . . . . . . . . . . . . 9 Summary of Needle Exchange Activities in Northern California . . . . . . . . . . . . . 9 The AIDS epidemic in Contra Costa County: Fact sheet . . . . . . . . . . . . . . . 10-11 Local HIV/AIDS epidemic among gay and bisexual men . . . . . . . . . . . . . . . . 12 Percent of gay/bisexual men among new AIDS cases (1985-1993) . . . . . . . . . . . 12 HIV prevalence in non-IDU gay/bisexual men tested voluntarily . . . . . . . . . . . . 12 The local HIV/AIDS epidemic among childbearing women, 1988-1992 . . . . . . . 13 Women of reproductive age with AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 HIV in female prostitutes and female IDUs . . . . . . . . . . . . . . . . . . . . . . . . . 14 HIV infection in women attending pre-natal clinics in Contra Costa County . . . . . 14 Children and HIV/AIDS in Contra Costa County . . . . . . . . . . . . . . . . . . . . 15 HIV/AIDS in adolescents in Contra Costa County . . . . . . . . . . . . . . . . . . . . 16 HIV infection in Contra Costa applicants for military service, 1985-1991 . . . . . . 16 California counties with highest cumulative incidence of AIDS . . . . . . . . . . . . 17 Contra Costa cities with the highest cumulative incidence of AIDS . . . . . . . . . . 17 Response to emerging needs and services provided . . . . . . . . . . . . . . . . . 18-19 Site of medical diagnosis of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 How to reporting AIDS cases to the health department (AIDS surveillance) . . . . 20 Reporting AIDS: Summary of legislation . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Cotitra Costa County HIV/AIDS Epidemiology Repoi7; =`>= 1 ...... ..: 1282 PEOPLE WITH..AIDS IN CONTRA COSTA COUNTY ... Through February. 14;.:>:1994, 1282 cases :of AIDS were:::reported to. the Health ... ... . ....Department. This.represents a:cumulative incidence of 15.95 per 10,000 population . using. census dataThis estimate isbased onlyon rep oed cases: .. rt . Acquired Immunodeficiency Syndrome (AIDS) Surveillance Report (Cumulative through 2/14/94) ALL CASES Adult and adolescent cases (n=1273) Mode of HIV infection Males M Females (%) Total (%) Gay or bisexual men 797 (69.4) 0 (0) 797 (62.6) Heterosexual injection drug user 168 (14.6) 65 (52.0) 233 (18.3) Gay/bisexual injection drug user 68 (5.9) 0 (0) 68 (5.3) Hemophiliac 15 (1.3) 0 (0) 15 (1.2) Heterosexual contact 7 (.6) 34 (27.2) 41 (3.2) Transfusion with blood/products 24 (2.1) 9 (13.6) 33 (2.6) None of the above/other 11 69 (6.0) 17 (13.3) IL 86 (6.8) Total IL 1148 (100) 125 (100) IF 1273 (100).. Pediatric cases (n=9) Mode of HIV infection Males (%) Females (%) Total (%) Hemophiliac 1 (16.7) 0 (0.0%) 1 (11.1) Parent at risk or has AIDS/HIV 2 (33.3) 3 (100) 5 (55.6) Transfusion with blood/products 3 (50.0) 0 (0.0) 3 (33.3) None of the above/other 0 (0.0) 0 (0.0) 0 (0) IFTotal 6 (100) 3 (100) 9;:(100)..;:.: 2 March 1994 ALL CASES Race and ethnicity distribution Race/Ethnicity Adult/Adolescent Pediatric Total (%) Cases (%) Cases (%) White, not Hispanic 798 (62.7) 3 (33.3) 801 (62.5) African American, not Hispanic 334 (26.2) 2 (22.2) 336 (26.2) Hispanic 123 (9.7) 3 (33.3) 126 (9.8) Asian/Pacific Islander 12 (0.9) 1 (11.1) 13 (l) Native American/Alaskan 4 (0.3) - 4 (0.3) Unknown 2 (0.2) - 2 (0.2) ........ .. .... Total 1273 (100) 9 (100) .:1282.(100),:;:: Age at the time of AIDS diagnosis New Diagnoses by year Age Groups Total (%) Under 5 6 (.5) 243 5-12 2 (.2) 213 13-19 3 (.2) 193 20-29 157 (12.2) 173 30-39 541 (42.2) 148 40-49 376 (29.3) over 49 197 (15.4) 106 Total 1282 (100) 81 54 41 7 6 15 2 Coritra Costa County HIV/AIDS Epidemiology Report.- 3 ...; ..: .... AIDS CASES,UNDER THE NEW.;AND EXPANDED CDC CASE DEFINITION . ..... . . .:.... .. .. .:::..... ... . In 1993, the expanded AIDS:.surveillance.:case::definition for.adolescents and adults,:(l) was implemented.... by the Centers for Disease.ControTand Prevention (CDC). As a result of the expanded criteria, during: 1993,:292 new cases of AIDS were reported These people;would not.have received an:AIDS diagnosis ;:..under the old.definition criteria, at least.until presenting.one of the diseases in.the old list .. More.than half.of these new.definition cases occurred.:in previous years and only now became reportable. The:characteristics.of themew..definition cases:;.encountered to.date;are:listed below.::::::;::;;:;:;;;::;::;. . ..... 1)1993 Revised Classification System for HIV Infection and Expanded Sur.veillance.Case Definition forAIDS Among.Adolescents and Adults. CDC *MMWR December 18, 1992....:Vol 41/No RR-17. NEW DEFINITION CASES ONLY Total AIDS cases reported meeting the expanded definition criteria only, by mode of infection and gender Mode of HIV infection Males (%) Females (%) Total (%) Gay or bisexual men 143 (59.3) 0 (0) 143 (49.0) Heterosexual injection drug user 51 (21.2) 27 (52.9) 78 (26.7) Gay/bisexual injection drug user 18 (7.5) 0 (0) 18 (6.2) Hemophiliac 2 (0.8) 0 (0) 2 (.7) Heterosexual contact 3 (l.2) 13 (25.5) 16 (5.5) Transfusion with blood/products 2 (0.8) 4 (7.8) 6 (2.1) None of the above/other 22 (9.1) 7 (13.7) 29 (9.9) F- 241Total (100) 51 (100) 292'(100) AIDS cases meeting the expanded definition criteria only, by racelethnicity Race/ethnicity Total (%) White, not Hispanic 156 (53.4) Black, not Hispanic 100 (34.2) Hispanic 32 (11.0) Asian/Pacific Islander 2 (0.7) Native American/Alaskan 2 (0.7) Total ::.. :....:T-29.1(100)..:.. ........ 4 March 1994 IW2 1 1962 lses- n 12 DEATHS AMONG "°S-N21 PEOPLE "°`- 39 DIAGNOSED '"'- 52 WITH AIDS ma- 61 61 IN CONTRA COSTA '"9 72 BY YEAR „90 105 OF DEATH -1 133 1112- 147 1993- � � 123 1399- _ 5 Contra Costa residents living with AIDS (As of February 14, 1994) Mode of HIV infection Males (%) Females (%) Total (%) Gay or bisexual men 262 (61.1) 0 (0) 262 (52.2) Heterosexual injection drug user 90 (21.0) 40 (54.8) 130 (25.9) Gay/bisexual injection drug user 28 (6.5) 0 (0) 28 (5.6) Hemophiliac 6 (1.4) 0 (0) 6 (1.1) Heterosexual contact 5 (1.2) 15 (20.5) 20 (4.0) Transfusion with blood/products 2 (.5) 5 (6.8) 7 (1.4) Parents at risk for HIV 1 (.2) 1 (1.4) 2 (.4) None of the above/other 35 (8.2) 12 (16.4) 47 (9.4) Total 429 (100) 73 (100) <:.:: .502.(100) Race/ethnicity distribution of people living with AIDS Race/ethnicity Adult/adolescent Pediatric Total (%) Cases (%) Cases (%) White, not Hispanic 274 (54.8) 0 274 (54.6) Black, not Hispanic 165 (33.0) 1 (50) 166 (33.0) Hispanic 52 (10.4) 1 (50) 53 (10.6) Asian/Pacific Islander 5 (1.0) 0 5 (1) Native American/Alaskan 2 (0.4) 0 2 (.4) Unknown 2 (0.4) 0 2 (.4) Total IF 500 (100) 2 (100) 502..(100) Cohlra Costa County HIV/AIDS Epidemiology Report:"-.' g CITY DISTRIBUTION OF AIDS CASES IN CONTRA COSTA COUNTY, 1982-1994 Oakley 10 Brentwood -� 10 Bay Point _ 30 Antioch _ 68 Pittsburg _ 110 Alamo 8 Moraga -� 10 Clayton -913 San Ramon - 25 Lafayette _© 26 Danville _ 28 Orinda 32 Pleasant Hill --® 42 Martinez _ 53 Walnut Creek _ 129 Concord _ 186 Rodeo -� 8 Kensington =� 8 El Sobrante _In 19 Hercules —© 20 North Richmond 26 Pinole =� 29 El Cerrito 30 San Pablo = 72 Richmond - 271 I I t I I i 0 50 100 150 200 250 300 The chart includes only cities where five or more residents have been reported. Seven additional Contra Costa cities reported fewer than five cases each. 6 March 1994 ' .. . .. . . .. . .: :::: ...... ....: . . . . . GLOBALIE . ofthe AIDSEP IDEMIC. . . . . .... ..:.:.:.:.. . . ............. . ... ...... . ..::::::. .. . .. : : . : ..: .: . . ..: Cases Deaths . .. .... on ra .os a ; :.....A22 (2/14/94) BAY rea. .. ... .: .::.;:.;:.;.. ..:::: . . . . .....:. ::.:......::.. ..;..::< .: (1/1/94). ........:; ....::.:.;::.;:.::..:..;: .:. ..:.... . .: alp orma. 67 352 . 1 748 US 3 .....2: .... ..... . : rldetimat : f 11194) ESTIMATE OF CONTRA COSTA COUNTY RESIDENTS INFECTED WITH HIV Based on back calculations, a total of approximately 3,800 Contra Costa County residents are estimated to have been infected with HIV, the virus that causes AIDS. Of these, 19282 (33.7%) have already been reported to have AIDS. Approximately 3,800 Contra Costa residents are estimated to have been infected with HIV New Definition Cases Delayed Reporting g% Old Definition Cases 5% 1994 AIDS cases 26% (projected) 5% Z . .. ::::: : :': : : : HIV only deaths . . . .:.: . . . (projected) 5% . . .:.. 200 1950 51% HIV-Not AIDS in 1994 Contra Costa County HIV/AIDS Epidemiology Report 7 The local epidemic among injection drug users Percent of heterosexual injection drug users among new Contra Costa AIDS cases, 1982-1993 (The actual number of cases is shown inside the histogram bar) Since the first years of the AIDS epidemic in Contra Costa County, Sox increasing number of 24.2% AIDS cases have been 25% ID Us. In addition to increasing numbers, 20% ........ 14.4% ... 142%.. .. ID Us are becoming a 15%- larger 5%larger proportion of the people diagnosed 10% with AIDS in Contra 5% 2.5% Costa. 27.. 46 157.. ox 3 1982-'86 1987-'88 1938--90 199;-'93 HIV prevalence among injection drug users entering treatment in Contra Costa.County tested blindly, by year and race/ethnicity * (xxlxxx= tested positive/total tested) (01/01194) 1989 1990 1991 1992 1993. 1989-93 White *111179 171629 15/468 20/573 16/643 7912492.... 6.1% 2.7% 3.2% 3.5% 2.5% 3.2% . . :.. ....:.... African 26/70 83/267 81/217 66/222 ..48/209... .....304/985 .. 31:1% 37.3%.. 29.7%. : :: > ;; ,.... American 371% 23:0% 30.9% Hispanic 1134 5/82 6/80 7/96 2/117 • 21/409 2.9% 6.1% 7.5% 7.3% 1.7% Other 0/4 2/42 2/40 2/56 1157 7/199 0% 4.8% 5% 3.6% 1.8% Missing 0/1 0/4 115 018 . ... Total 381288. .107/1024 :105%810 95/955.. 67/1027 .41214104.. .. . .... . ... 10.4:% :'':: 13:.0%::: :: :.9.9%:....:. . 6::5%.::::::: ::::. 10.0%:::: IDUs tested at methadone treatment clinics. Clients readmitted during the same calendar year were excluded. Many tests during the five year period were performed on clients who has tested the previous year. 8 March 1994 ' HIV prevalence among injection drug users in Contra Costa County sampled with street surveys The University of California San Francisco Institute of Health Policy Studies, Urban Health Study, has conducted street surveys among injection drug users of several San Francisco Bay Area communities, including Richmond. Surveys in the city of Richmond started in 1991. The following are the HIV prevalence rates found in these communities: 1991 (1) Site No. tested HIV antibody HIV prevalence positive rate San Francisco-West 255 31 12.2% San Francisco-Central 441 79 17.9% San Francisco-South 366 41 11.2% Oakland-Northeast 223 11 4.9% Oakland-West 240 43 17.9% Richmond 222 43: 1992 (2) Site No. tested HIV antibody HIV prevalence, positive .. rate Oakland-Northeast 321 22 6.9% Oakland-West 341 58 17.0% hm nd c o .. .Richmond 82 72 .0 o For more information see references or contact Dr. John Watters, Urban Health Study, (415) 476-3400. 1. Drug Injectors and HIV-1 Infection in the San Francisco Bay Area. Watters, John K., Cheng,Y.T., Bluthenthal,R, et al.International Conference on AIDS, Amsterdam, The Netherlands,July 19-24, 1992. 2.HIV-1 Infection and Drug Injectors in Oakland/Richmond, California.Bluthenthal,Ricky;Estilo,Michelle and Watters, John. International Conference on AIDS, Berlin, Germany, June 7-11, 1993. Contra Costa County HIV/AIDS Epidemiology Report 9 CENSUS TRACT DISTRIBUTION OF INJECTION DRUG USERS WITH AIDS --e Information on census tract of residency at the time of AIDS diagnosis was available for 213 (91.5%) injection drug users diagnosed with AIDS in Contra Costa County. Injection drug users with AIDS resided in 66 different census tracts and concentrated in 16. The shaded areas of the above map represent these 16 census tracts, where 125 (59%) of these people resided. Each of these tracts had five to 14 cases of IDUs with AIDS and the two tracts covering North Richmond had 15 cases in one and 18 cases in the other (Total: 33, 15.5% of all IDU with AIDS) SUMMARY OF NEEDLE EXCHANGE ACTIVITIES-PROGRAMS (NEP) IN NORTHERN CALIFORNIA Monterey County Local NEP 200-900 syringes per week Sonoma County Point North 400 syringes per week San Mateo County APAN 3,000 syringes per week Marin County NEPOM 200 syringes per week Alameda County Local NEP 1,000-1,500 syringes per week San Francisco County Prevention Point 24,000 syringes per week Source: Needle Exchange Working Group (415) 864-5855, x3032 to THE HIV / AIDS EPIDEMIC What is the problem? • AIDS stands for Acquired Immune Deficiency Syndrome, a condition that destroys the body's defenses against certain infections and cancers. AIDS is a fatal disease. • AIDS results from infection with the Human Immunodeficiency Virus (HIV). HIV is passed from one person to another through blood or sexual contact. HIV infection can result from one sexual encounter or from sharing a needle to inject drugs. • Many people with HIV infection appear healthy and do not know they are infected. HIV infection can be detected through an HIV antibody test, but many people most at risk for HIV infection have not yet taken a test. • Although medications can slow the deterioration of the immune system, there is no cure. • AIDS can be avoided, but risky behaviors are difficult to change even knowing the facts. Who is being affected by HIV/AIDS? • Since 1982, 1282 cases of AIDS have been reported in Contra Costa County. At least 774 persons have died. Currently an estimated 3,800 Contra Costans are infected with HIV. To date 1148 men, 125 women, and 9 children have been diagnosed with AIDS. • The majority of people with AIDS are gay and bisexual men (62.6%) or gay/bisexual men who additionally injected drugs (5.3%), although increasing proportions of the people with AIDS are heterosexual injection$rug users, women, African Americans and Latinos. The numbers of such cases are disproportionate to the population size. • Heterosexual injection drug users account for 18.3% of the cases. If the spread of HIV among injection drug users is not dramatically curtailed, this population soon could reach the levels of infection found in areas of the East Coast of the United States (60-70%). Currently the rate of infection among African American injection drug users in Contra Costa is 30%. • At least .5% of the general population, 10%-13% of all drug injectors, 12%-20% of gay and bisexual men, and 1 per thousand women delivering babies in Contra Costa are estimated to be HIV infected. • Increasingly, AIDS is occurring in West County and East County. Of people now living with AIDS, 38.6% now live in Central County, 42.4% in West County and 19% in East County. 0 AIDS among those in poverty puts an increasing burden on the public health care system. IN CONTRA COSTA COUNTY 11 What are the social and economic costs of HIV/AIDS? • AIDS is largely a disease of the young. Already, early deaths of Contra Costa County residents from AIDS represent a loss of 21,000 potential years of life. If all HIV-infected Contra Costa residents develop AIDS, our communities could lose 130,000 potential years of life. • The estimated potential earnings lost by Contra Costa residents who have died from AIDS totals $424 million. Using the same rates for all persons estimated to be HIV-infected, the potential lost earnings could amount to more than $2.5 billion. • The annual cost of medical care for each person with AIDS is now estimated to be$38,000. The lifetime cost of caring for all Contra Costa residents estimated to be HIV-infected could require an additional $300 million. The amount of suffering by these persons and their families is immeasurable. What needs to be done? • Learn all you can about HIV and AIDS. Inform your families and friends and influence them to adopt healthy behaviors. • Increase AIDS awareness so that Contra Costa residents understand the disease. Understanding helps to eliminate unnecessary fear and prejudice and encourages a compassionate and supportive response to those who are infected. • Protect people living with HIV infection from discrimination. • Provide testing, counseling, medical care and support for all people infected with HIV. • Increase HIV/AIDS prevention efforts by county, city and community agencies. • Reach the populations most at risk with concentrated prevention messages and innovative programs. • Expand efforts to involve city, community and church leaders in delivering AIDS prevention messages in the most affected areas of the county. 12 March 1994 The local HIV/AIDS epidemic among gay and bisexual men Percent of gay/bisexual men among new AIDS cases, 1982-1993 (77ze actual number of cases is shown inside the histogram bars) Gay/bisexual men constitute the group from which over 60% 75.996 of all cases have been 80% 65% 68.9% 69.5% reported in Contra 60% Costa and the largest 54.3% group from which new 60% 45.4% cases are emerging. Nevertheless, a declining trend is 4096 observed in the proportion of AIDS cases from this group. 20� 155 .69 . 102 12.1 128 130 8.4 jy 0% 1982-87 1988 1989 1990 1991 1992 1993 HIV prevalence among non-IDU gay/bisexual men tested voluntarily in Contra Costa County publicly funded clinics, 1985-1993 * (xx/xxx= tested positive/total tested) 1985-87 1 1988 1989 T 1990 1 1991 1 1992 1 1993 1985-93 *148/786 84/490 56/443 51/469 45/570 31/643 30/466 445/3867 18.8% 17.1% 12.6% 10.9% 7.9% 4.8% 6.4% 11.5% Data includes only clients without a prior positive test. The tests may be of clients who repeated testing. 20% 17.1% 15% 12.6% 10.9% 10% 7.9% 6.4% 4.8% 5% 48 84:i56 51 45: 31: 3.0 0% 1985-87 1988 1989 1990 1991 1992 1993 Contra Costa County HIV/AIDS Epidemiology Report 13 The local HIV/AIDS epidemic in women Annual HIV prevalence among childbearing women in Contra Costa County and California per 10,000 births r Contra Costa California 30 25 - 20 - 15 52015 7.7 23rl1 .7 12.3 10 5 7.6 6.4 7 6.7 / 0 T 1988 1989 1990 1991 1992 There ivere four HIV infected women among Contra Costa childbearing women tested in 1992 (n=3,258). Two were under 20 years of age. Of all childbearing women tested in 1992 in the state of California nine HIV infected women were under 20 years of age. Five (55%) of these nine resided in the East Bay (Contra Costa-Alameda Counties). Women of reproductive age with AIDS in Contra Costa County, by age group (n=91) Women constitute approximately 9% 50 of adult AIDS cases. 42 Assuming they may 40 also represent 9% of all HIV infections, so 25 some 300 Contra 20 20 Costa women of reproductive age may 10 10 be infected with HIV. , 2ol At least 43 babies 0 have already been 13-19 20-24 25-29 30-34 35-39 40-44 AGE GROUP . born to these women. Data Collected through January is.1994 14 March 1994 HIV seroprevalence in female prostitutes and female injection drug users (IDUs): Between September 1989 and February 1992, 77 female prostitutes were tested for HIV antibodies after a conviction in a local municipal court (Pittsburg, California). During the same period of time, 244 female injection drug users residing in the same area (Pittsburg/Antioch) were blindly tested for HIV upon admission to methadone treatment. Results: Ten of the 77 female prostitutes (13%, 95% CI 7.2%-22.3%) were infected 26 of the 244 female IDUs (10.7%, 95% CI 7.4%-15.2%) were infected HIV infection among women attending pre-natal care clinics in Contra Costa County, 1989-1992 * (xx/xzx= tested positive/total tested) The bold numbers represent HIV infected rates per 1000 pregnant women 1989 1990 1991 1992 1989-1992 White * 0/479 1/810 2/642 0/577 3/2508 1.23 3.11.2 African 4/258 2/305 0/284 4/288 10/1135 American 15.5 6.6 13.9 88 Hispanic 0/378 0/620 0/781 0/855 012634 Other 0/91 1/136 0/187 0/168 1/582. 7.4 17 Missing 2/525 1/51 0/42 0/72 3/690 ... .; Total 6/173.1. 5/1922 2/1936 4/1960 17/7549. 3.4 .10 2.0 2.3 Contra Costa County HIV/AIDS Epidemiology Report IS . . .. ... .. : .... . . : Children and HVAID.. ... .. .. . .. . .. Nine Contra Costa children (1-12 years) have been reported with AIDS . . . . ;;; At least;43 Contra Costa children were born to,HIV infected women .. ... ..... . . ...... Children's Hospital;Oakland Pediatric AIDS/HIV Program has evaluated;cared for and .. . . . .. . . . . momtore children wit rest ence in Contra Costa.w b:at some tnne presented with.. . ...... . . . . X.: antibodies against ..the HIV virus: Three were not infected perinatally: Of the 43 born . . . ..... .. . ... .... .. ... . .. to;infected mothers; a;third is estimated to be infected. The maternal antibodies present in the othemVill disappear b the second ear: ... . ...... ... ... . > ; Demographic characteristics of the above 46 children r n e hni i Ge d R ce t a /e c t .. ..:.:.:::.;:..;:: .. .. ... . . .. . .::::.. . .:... . .. .. Male= 24.(52:2%) White= 9 ..:......:.. Female= 22 (47:8%) African American= 30 (65.2%). .... ... . His anic 7 15:2% ;;; ..... .. ........ Year wen-A ese child ren were re erre tote:a ove program .. . . ......... . . . ....... .. . . ... 1986-1989= ;;;12 children referred . . 1990-1993= 34 children referred ...... . .. . Risk factor for HIV of the above children's mothers Injection Drug — . . . Use-, 33 (71.7%). Sexual C nta . o ct- 10 (21.7 0 ..; Other= 3 (6.5%) 16 March 1994 HIV ; /AID i S n teen r ' a e s in C >n ; o tr a. Costa . ... . . .: :::::.:::.;:.;:.;. .... ....:... .. Only two of the 1282 Contra;Costa AIDS cases reported:since thebe irinn of g g the epidemic were teenagers at the time of their diagnosis. Many of the 157 peop e. diagnosed.with: AIDS at a e 20 through 29 may have; been infected as . . g teena ers.A total of six HIV infected oun adults from Contra Costa County are g Y g ... . eing cared or and;followed-up:at Oakland Children's Hospital: Five of;the six ;cases are persons with::: emo iia: During: 1992 a;total :of: 951 teenagers presented ;;voluntarily. for testing at publicly funded sites in Contra Costa County: No HIV infections were found. During..1. 9..9...3...., a total of 840 teenagers were teswd,yoluntarily for HIV ;;Two . . .....were:foud.to:be infected; Both were 19 year old women..One,was;an in'ection; rug user; the other reported only heterosexual contacts .. Kaiser Northern California Centers (1) reported that, during 1989, 10;000 .:. , . . members, includin a roximatel 200 teens ers (.15-19) were blindl tested;for g PP ;;> y g X ............HIV..No.HIY infections were.found. . .. . . . ...... ung a and bisexual men 17-19; ears old m the San Francisco Ba Area ggY Y y continue to:have unprotected sex (35.2%) and had a:;4:1% HIV revalence:; 2 ..... . . . Contra Costa teenagers represented 26%: of the 560 cases of penicillin resistant gonorrhea (PPNG):and 15% of the 1,129 cases `of syphilis reported in Contra ... . ..... ....::.::.....:.... osta County between 1 88 and 1991: .... . .. ( ) Seroprevalence..:of HIV--Type 1 in:a Northern California.:Health.Plan:Population.:An:Unlinked.:.. Survey Hiatt RA Capell FJ, Ascher::MS. American Journal of.Public Health Vol..:82, 4, April 1992,40564=567 (2) HIV-I:Seroprevalence.:and Risk Behaviors Among Young Men.who Haw.Sd with Men Lemp .. GF,HirozovaA :GivertzD. et al.San Francis co Dept. of Public Health, San Francisco;:::Ca.,.1993..... HIV prevalence of civilian applicants for military service from Contra Costa County, by year * (xx/xxx= tested positive/total tested) [E/ 1986 1987 1988 1989 1990 1991 1985-91 5/1417 3/1358 4/1245 1/1248 0/978 0/93513%'740.35% 0.22% 0.32% 0.08% 0.0% 0.0% 0.17%ata provided by the U.S.Department of Defense and CDC.Data collection between 10/85-12/91. Codtra Costa County HIV/AIDS Epidemiology Report 17 California counties with the highest cumulative incidence of AIDS Cases per 100,000 population San Francisco 2108.78 Marin- 345.63 Sonoma- 240.69 Los Angeles 240.5 Alameda- 227.58 N Dal•through 9193 San Diego 189.69 San Mateo � 159.2 Solano- 144.79 Contra Costa- ,i 138.93 Sacramento- 128.08 Contra Costa County cities with the highest cumulative incidence of AIDS (Population based incidence per 1,000 residents reported for cities with >50 cases) Richmond12 271 _. San Pablo 72 2.86 Pittsburg 2:33 110 - Walnut Creek 212 129 - Concord 1.7 186 Martinez 1.7 53 Antioch 11 68 Residents of unincorporated areas (i.e. Bay Point, North Richmond) have not been included in this analysis. 18 March 1994 ' Surveillance of the response to needs emerging from the AIDS epidemic in Contra Costa County In the six month period July 1, 1993 - December 31, 1993, 632 unduplicated individuals were provided services by eight agencies funded by the federal government under the Ryan White CARE Act and Housing Opportunities for People with AIDS (HOPWA). For 558 (88.3%) of these clients the following income information was available: . . Income n %, . Less than.$600'per month; 212 38.0% .... . ... . .. . .. ... ... . .... .::Between601 and 900 per. month 253 '' .; Between 901.and $1,200 per month :46 8.2% . . .::.;:.;::. .Over $1;200 per month : 47 8.4% The HIV/AIDS status of 594 (94%) of these clients was known, as follows: : ......HIV/AIDS on . . AIDS l .. 38 :5% . Symptomatic HIV ... l .;1;: .: 17.0%;::.:::.,:. . Non=symptomatic HIV; 175; 29.5% Demographic data and transmission mode distribution of these clients was: n o: . . % . . ...:..::::.:.::.:. .. .:. . .:. ....::. ...ema e ....... ........: .:::;::. .::. ..... ; . . . .. . :. . . :Ga bisexuamen. . . : Gay/bisexual IDUs 14 2.9% ........ IDUs 253 51.7% . ; > . White % ...... ... .. .. .:::: :: ....::. ; . . African A .; ri ... ... 2 . ; . .. . 9. .... . .. .. . .; .............. 8.9%to ; .m . . ...... .... . ... .. . . ..... ... . . Asian % ::::::::::::.. :.:..:..:v 2 at ie American : : . . : . . ... .. .. ... Client information.:was not available;.as follows:.gender:= 16,.race:=::18,.transmission mode.=;:1:1.43;: • eoi tra Costa County HIV/AIDS Epidemiology Report 19 .. . :: .. ...... ... . .. ... .. . ::. .ervicesrovee .. . . . . July-December l... . .. . ::....The following services.::have.:been:reported by..:.community: based.....organizations and agencies serving people with HIV/AIDS m..... ontra Costa County: . ... 42 aoPereceiVed 2732 asofroceris : ......465:people received case:management services at community-based organization, 97;; eo le received sere ces;.at a.:da ;su ort:center in:Richmond . people: P ... ... .. . . . 52 people received counseling to assist them m applying for benefits; . . ' to;which.they were entitled . .... 38;people received housing`assistance ..... ... . ..... ...:::. ....:::. ........ 21:people with AIDS received 3,526 hours of attendant care so that they could remain m their homes . . .... ... .. .... . .. .... :::Me,above list of:services:provided is only a partial one. Data is not available from several organizations.. .. ............ and many individuals assisting those affected by the epidemic but not funded by the CARE Act or:HOPWA. .::; Contra Costa AIDS diagnoses by diagnosing medical center category Medical Facility AIDS Diagnoses Contra Costa County Merrithew Memorial Hospital and Clinics 411 32.1% Kaiser Permanente Facilities in Contra Costa and the Bay Area 316 24.7% Other Public Facilities in Contra Costa County 77 6.0% Other Private Facilities in Contra Costa County 110 8.6% Private Medical Doctors 70 5.5% VA/Naval Hospitals 54 4.2% Hospital/Facilities in other counties 244 19.0% 1282 100.0% The distribution of medical facilities where AIDS cases were diagnosed is likely to mimic the distribution of medical facilities providing health care for HIV infected Contra Costans) Diagnoses at medical facilities in other counties largely reflect diagnoses which occurred at the beginning of the AIDS epidemic when diagnosis and treatment were available only in a few sites of the region. 20 March 1994 REPORTING AIDS CASES All health care providers are required to report AIDS cases to their local health department. AIDS is reportable under the California Code of Regulations, Title 17, Health, Section 2500. HOW TO REPORT: By telephone. By completing a Confidential Morbidity Report (CMR) card. By completing an Acquired Immunodeficiency Syndrome Pediatric or Adult Confidential Case Report Form. WHERE TO REPORT: Contra Costa County Health Services Department AIDS Program 597 Center Street, Suite 200 Martinez, CA 94553 Denise Johnson (510) 313-6793 FAX (510) 313-6721 WHY REPORTING IS NECESSARY: * It is the law. * To monitor trends in HIV-related disease. * To monitor trends in HIV-infection. * To project future numbers of AIDS cases. * To plan for future health care needs and services. * To provide information on the natural history of HIV infection. * To plan prevention and educational activities. * To identify persons in need of specific services from State and local health departments, (i.e. voluntary partner notification, counseling, and treatment). * To obtain funds and develop funding formulas and eligibility criteria for distributing AIDS resources from agencies such as the Health Resources Administration (HRSA), the National Institute on Drug Abuse (NIDA), the Centers for Disease Control and Prevention (CDC) and the millions of dollars to State and local health departments for programs such as AIDS drug distribution, hospice care, outreach programs, prevention programs, coordination of patient services, pediatric AIDS health care and out-of-hospital care programs. ' Contra Costa County HIV/AIDS Epidemiology Report 21 II . . Reporting AIDS. Summary of Le Wation California Adreunistrative Code ;Titie 17 (Section 1603.1): ":.a hospital shall report; the name, date of birth, address, social security number, name of hospital,; the date of os italt P nation, and any other information.required on all confirmed cases of AIDS to the .. . . tate'Department of Health and the county health officer;" California Administrative Code, Title 17'(Section2500, :.250J. 2504, 2505 ;and . very person must report to the Health Officer any diagnosed or suspected case of any of the following diseases or conditions:Acquired,Immunodeficiency Syndrome " .. California Administrative Code, Title 17(Section 2512).: Allows the local health officer; to ` ..... investigate communicable diseases. X. California Health.. and..Safety. Code, (Section 199.21 [i]) HIV.;test results matie Y reported to local.health authorities as art ofAIDS dia nosis . .. . . .. >>. California Health and Safety Code, (Section 199.21,199:22 and ;1603.3) disclosure to public health authorities of result-Of HIV test performed on cadavers. Allows .... . . .... ...... or HI X. , test to be performed on,cadavers without written consent as part of an autopsy or;in conjunction with' anatomical gifts. ..: ..;.. . .. . ....:::.. X. California Health and Safety ;Code,,,.(Section 199.27). Allows for voluntary.;contact .... . tracing,g, with.,,,e;written:consent of-the IV serop ositive individual..: II . > ; . ....:.::. .. .... . . For;information on services available for people with HIV%AIDS. in Contra Costa CountX .y call the;HIV%AIDS program 313=6770 , .. ... . .. . ........ ....::::... . Copies of this report:or additional epidemiological,information ::':: ;' can be obtained by calling 313=6791 � b 0-4 C VGA CD > > ReD ' a� a