Public Health and Injection Drug

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King County, Washington, 1990-1999. MMWR 2000; missions to inpatient detoxification pro- 48:636-40. Public Health and 6. Gibbs DA, Hamill DN, Magruder-Habib K. Popu- grams were excluded. For this analysis, lations at increased risk of HIV infection: current knowl- clients were categorized as (1) heroin Injection Drug Use edge and limitations. J Acquir Immune Defic Syndr 1991;4:881-9. users who did not use cocaine, (2) cocaine users who did not use heroin, and MMWR. 2001;50:377 (3) users of both heroin and cocaine. THIS ISSUE OF MMWR FOCUSES ON IN- Trends in Injection To examine geographic patterns of jection drug use and highlights ways heroin use and injection drug use, New that state and local health depart- Drug Use Among Jersey cities, boroughs, and town- ments monitor injection drug use- Persons Entering ships were categorized as either (1) ur- related health issues and develop in- ban areas including major cities (i.e., terventions to prevent substance abuse Addiction Newark, Paterson, Jersey City, Eliza- and infections among injection drug us- Treatment—New beth, Camden, and Trenton) and other ers (IDUs). Substance abuse and ad- urban centers and surrounding areas diction are major underlying causes of Jersey, 1992-1999 (e.g., Atlantic City, New Brunswick, preventable morbidity and mortality in East Orange, and Hoboken) or (2) sub- the United States.1 The risks increase MMWR. 2001;50:378-381 urban and rural areas (Eagleton Insti- tute of Politics, Rutgers University, un- when illicit substances are injected, 2 figures omitted which contributes to multiple health published data, 1994). and social problems for IDUs, includ- INJECTION DRUG USE IS ASSOCIATED WITH From 1980 through the early 1990s, ing transmission of bloodborne infec- high risk for transmission of blood- the proportion of users who injected tions (e.g., human immunodeficiency borne infections, including human im- heroin, cocaine, and both drugs de- 1 virus [HIV] and hepatitis B and C in- munodeficiency virus (HIV) and hepa- clined ( ; Community Epidemiology fections) through sharing unsterile drug titis B and C. Since 1993, the proportion Work Group, unpublished data, 2000; injection equipment and practicing un- of persons admitted to New Jersey ad- ADADS, unpublished data, 1999; and safe sex.2 In the United States, approxi- diction treatment centers for illicit drug New Jersey Department of Health and mately one third of acquired immuno- use who reported injecting drugs has Senior Services, unpublished data,1991). deficiency syndrome cases3 and one half increased, reversing a decline that be- In 1995, the proportion of heroin users 1 of new hepatitis C cases4 are associ- gan in approximately 1980 ( ; Com- reporting injection began to increase. ated with injection drug use. Fatal drug munity Epidemiology Work Group, un- The proportions who reported inject- overdoses also contribute to death published data, 2000). This report ing drugs were, respectively, for heroin/ among IDUs.5 Although the number of summarizes an analysis of trends in in- cocaine, 43% (2810 who injected of persons who inject illicit drugs (pri- jection drug use among persons admit- 6514 admitted) in 1995 and 45% (2270 marily heroin, cocaine, and amphet- ted to New Jersey addiction treatment of 5074) in 1999; for heroin/no co- amine) is not available, approxi- programs during 1992-1999; the find- caine, 31% (3401 of 10,990) in 1995 and mately one million persons in the ings suggest substantial increases in in- 37% (3796 of 10,386) in 1999. The pro- United States are active IDUs.6 jection use among young adult heroin portions for cocaine/no heroin users users throughout the state and an in- were small in both years, 2% (282 of crease in heroin use among young 11,609) and 2% (144 of 8142). REFERENCES adults who reside in suburban and ru- The largest increases in the propor- 1. McGinnis JM, Foege WH. Mortality and morbidity attributable to use of addictive substances in the ral New Jersey. tion of heroin/no cocaine and heroin/ United States. Proceedings of the Association of Ameri- New Jersey’s Alcohol and Drug Abuse cocaine users who reported injecting can Physicians 1999;111:109-18. 2. Cherubin CE, Sapira JD. The medical complica- Data System (ADADS) provided data for were among clients aged 18-25 years, tions of drug addiction and the medical assessment this report, including demographic in- with increases in injecting in this age of the intravenous drug user: 25 years later. Ann In- formation, client reports of substance group beginning in 1993. Among cli- tern Med 1993;119:1017-28. 3. CDC. HIV/AIDS surveillance report, 2000. At- use before entering treatment, and ents aged 18-25 years, the increase was lanta, Georgia. US Department of Health and Hu- whether the client usually injected from 22% (587 who injected of 2709 man Services, Public Health Service, CDC, 2000;12. 4. Alter MJ, Moyer LA. The importance of prevent- drugs (ADADS, unpublished data, admitted for heroin use) in 1993 to 46% ing hepatitis C virus infection among injection drug 1999). Data were analyzed for clients (1326 of 2893) in 1999. In 1993 and users in the United States. J Acquir Immune Defic Syndr Hum Retrovirol 1998;18(suppl 1):S6-S10. admitted during 1992-1999 who re- 1999 among persons aged 26-34 years, 5. CDC. Unintentional opiate overdose deaths— ported using heroin and/or cocaine; ad- 30% (1802 of 5990) and 32% (1744 of

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5434) were injecting; among persons in the northeastern United States dur- tion trends, to direct and extend pre- aged Ն35 years, 50% (2624 of 5209); and ing the 1980s and early 1990s has been vention efforts to new populations, and 39% (2997 of 7655) were injecting. attributed, in part, to increases in heroin to reach young adults and their sex part- During 1993-1999, among persons purity, from Ͻ10% to Ͼ50%.3 Purer ners before they begin injecting heroin aged 18-25 years, the patterns of ad- heroin allows users to maintain their ad- and other drugs. missions for treatment of heroin use diction by inhaling (snorting), which were substantially different for those re- has a lower risk for transmission of HIV REFERENCES siding in urban areas compared with and other bloodborne infections than 1. Mammo A. Drug abuse differentials in Newark: epi- demiologic trends in drug abuse. Proceedings of the suburban/rural areas. Admissions for injecting. However, during the period Community Epidemiology Work Group, vol 1. De- treatment of heroin use decreased of increases in the proportion of young cember 1999:139-55. Rockville, Maryland: US De- among urban residents from 2018 in heroin users in New Jersey who re- partment of Health and Human Services, National In- stitute on Drug Abuse. 1993 to 1076 in 1999 and increased ported injecting, the purity of heroin 2. Des Jarlais DC, Perlis T, Friedman SR, et al. Behav- among suburban/rural area residents continued to be Ͼ60%.* Another ex- ioral risk reduction in a declining HIV epidemic: injection drug users in New York City, 1990-1997. Am J from 691 to 1817. During this period, planation may be population shifts from Public Health 2000;90:1112-6. the number of young heroin users who the cities to suburban and rural areas 3. Substance Abuse and Mental Health Services Ad- ministration. Analyses of substance abuse and treat- reported injecting as their usual method that may have contributed to the re- ment need issues, analytic series A-7. Rockville, Mary- of drug use increased substantially gional changes in heroin use and in- land: Substance Abuse and Mental Health Services among suburban/rural residents from jection. However, U.S. census data for Administration, 1998. 232 in 1993 to 920 in 1999; the num- 1990 through 1998 indicate that sub- *Among 23 U.S. cities surveyed in 1999, Newark and Philadelphia (the two largest heroin distribution cen- ber of injectors remained approxi- urban growth in New Jersey resulted ters for the area) had the highest mean heroin purity mately the same among urban resi- from increases in the number of resi- levels (72% in Philadelphia and 67.5% in Newark) dents, from 355 in 1993 to 406 in 1999. dents aged Ͼ35 years while the num- (Drug Enforcement Administration, Department of Jus- tice, unpublished data, 1999). The proportion of residents who re- ber of young adults in these regions ported injecting increased in both geo- declined. graphic groups from 33.6% in 1993 to The findings in this report are sub- Soft Tissue Infections 50.6% in 1999 for suburban/rural resi- ject to at least three limitations. First, dents and from 17.6% to 37.7% for ur- data on behaviors of drug users admit- Among Injection ban residents. ted to addiction treatment programs Drug Users— may not be generalizable to behaviors Reported by: A Kline, PhD, A Mammo, PhD, R Cul- of New Jersey heroin users not admit- San Francisco, leton, PhD, J Ryan, MA, R Schadl, MA, TO Connor, MPA, G Rodriguez, DSW, G DiFerdinando, MD, New ted for treatment. Second, changes in Jersey Dept of Health and Senior Svcs. J French, MA, numbers of drug users admitted to California, Drug-Watch Associates, Gaithersburg, Maryland. C addiction treatment may not reflect Bruzios, PhD, P Murray, PhD, Eagleton Institute of Poli- 1996-2000 tics, Rutgers Univ, New Brunswick, New Jersey. changes in numbers of drug users in the community. Third, the proportion of MMWR. 2001;50:381-384 CDC Editorial Note: The findings in heroin users admitted for treatment who 1 figure omitted this report suggest substantial in- inject could be affected by increased out- creases in injection use among per- reach efforts, special treatment initia- SOFT TISSUE INFECTIONS (STIS), INCLUD- sons admitted to New Jersey treat- tives, or changes in IDUs’ interest in ing abscesses and cellulitis, are a com- ment centers since 1995. By 1999, the treatment. In New Jersey, except for the mon complication of injection drug use. number of persons aged 18-25 years ad- decrease in availability of inpatient In 1997, 54 (32%) of 169 injection drug mitted for treatment of heroin use and detoxification, there have been no users (IDUs) in one San Francisco both the number and percentage who changes in any of these factors. neighborhood had a drug-injection– reported injecting were higher among In response to the trend in injection related abscess or cellulitis.1 To char- residents of suburban/rural areas than drug use, in 2000, the New Jersey De- acterize STIs among IDUs, data from urban areas. partment of Health and Senior Ser- San Francisco General Hospital (SFGH) Decreases in heroin use in urban ar- vices initiated substance abuse treat- discharge and billing records were ana- eas may reflect risk reduction result- ment services for young heroin users lyzed. This report summarizes the re- ing from intensive efforts to reduce the who resided in the eight suburban/ sults of that analysis and presents the transmission of HIV and acquired im- rural counties with the highest propor- case report of one IDU with an STI. The munodeficiency syndrome in these tion of injecting among young heroin findings indicate that STIs are among communities.2 Another possible expla- users. This program underscores that the most common diagnoses among pa- nation for these changes is a substan- public health agencies can use data from tients admitted to SFGH. Preventing tial decrease in heroin purity. De- substance abuse treatment programs to STIs among IDUs in San Francisco will creased injecting among heroin users detect emerging drug use and injec- require coordinated action involving

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health-care providers, public health Hospital Record Review stance treatment services, and stan- agencies, substance abuse treatment, From FY 1996-97 through FY 1999- dardization of community medical and community outreach, syringe ex- 2000, the number of ED discharges for surgical STI treatment with an empha- change programs, IDUs, and commu- STIs increased 103%, from 1292 to sis on expanding community-based nity-based organizations. 2619. The number of admissions to treatment and prevention. SFGH inpatient and emergency de- SFGH decreased slightly (11%), and the partment (ED) discharge and billing re- number of hospital admissions and ED Reported by: D Ciccarone, MD, Dept of Family and Community Medicine, Univ of California, San Fran- cords for fiscal years (FYs) 1996-97 discharges increased 41%, from 2787 cisco; JD Bamberger, MD, San Francisco Dept of Pub- through 1999-2000 were searched for to 3922. lic Health, San Francisco; AH Kral, PhD, BR Edlin, MD, Urban Health Study, Univ of California, San Fran- patients aged 15-74 years with pri- STIs at different anatomic sites were cisco; CJ Hobart, Univ of California, San Francisco; mary diagnoses of abscess and/or cel- four of the top 13 inpatient discharge A Moon, San Francisco General Hospital, San Fran- cisco; EL Murphy, MD, Dept of Laboratory Medi- lulitis of the trunk, buttocks, or ex- diagnoses at SFGH in FY 1999-2000; cine, Univ of California, San Francisco; P Bourgois, PhD, tremities (International Classification of STIs at all sites was the leading cause Dept of Medical Anthropology, History and Social Diseases, Ninth Revision [ICD-9]) codes of admission for medical or surgical Medicine, Univ of California, San Francisco; HW Har- ris, MD, DM Young, MD, Dept of Surgery, Univ of 682.2-682.7 and 682.9). Records with treatment. Skin incision and drainage California, San Francisco. primary diagnoses of ICD-9 codes cor- was the most common primary proce- responding to infections of the fin- dure on all inpatient records. During FY CDC Editorial Note: The findings in gers, toes, face, neck, or head were ex- 1999-2000, 945 persons were admit- this report indicate that many STIs in cluded because infections in these areas ted with a diagnosis of STI (average hos- San Francisco are related to injection are less likely to be related to drug in- pital stay: 3.2 days); 23% had two or drug use and are a major cause of hos- jection. Data were abstracted about de- more admissions, resulting in 1326 ad- pitalization. Some STIs among IDUs are mographics, number of ED discharges missions. In FY 1999-2000, 7% of all complicated by tetanus,2 botulism,3 and and inpatient admissions, average SFGH admissions were for STIs. Of the myonecrosis (D. Bangsberg, Epidemi- length of inpatient stay, and charges for 945 patients, 69% were male; median ology and Prevention Interventions services. age was 42 years (range: 15-74 years); Center, SFGH, personal communica- To estimate the proportion of STIs 64% were uninsured and 20% were re- tion, 2000). that were related to injection drug use, ceiving Medicaid. Possible contributing factors to the 30 medical record numbers were se- Annual inpatient charges for treat- high rate of STIs among San Francisco lected randomly from the STI dis- ment of STIs averaged $9.9 million per IDUs include poor injection site hy- charge lists for the ED and hospital for FY from 1996 to 2000. Because most giene, syringe reuse, intramuscular or each FY from 1996-97 through 1999- patients admitted to SFGH were unin- subcutaneous routes of injection, and 2000. A total of 240 records were se- sured, San Francisco County was re- contaminated drugs. IDUs often con- lected for drug-use history review; 20 sponsible for inpatient charges of ap- taminate needles by touching them to records were excluded because of mul- proximately $5.1 million. surfaces, mouths, or hands.4 Reuse of tiple visits and/or admissions. Of the 220 records selected for re- syringes may increase the chance of bac- view, 188 were located. Of these, 132 terial infections.5 San Francisco IDUs (70%) documented injection drug use with STIs report frequent reuse of sy- Case Report during the preceding 12 months (86% ringes that only they have used.4 State A 42-year-old woman with a 17-year involved heroin). Two (1%) had his- laws requiring a prescription to pur- history of injecting heroin presented to tories of injection drug use more than chase syringes and making possession the SFGH ED with a low-grade fever 1 year before the onset of STI. Fifty- of syringes by IDUs a crime may con- and tenderness and swelling in the left four (29%) had no history of drug in- tribute to the reuse of syringes.6 Sub- deltoid region. Because her veins were jection; of these, 34 (18%) had a cause cutaneous and intramuscular injec- scarred heavily by intravenous injec- for the STI noted in the record, and 20 tion of heroin (either intentional or tion of heroin, she had been injecting (11%) had no documented cause. inadvertent) is associated with STI.1 Use intramuscularly for 10 years. She de- In July 1999, concern over the high of alcohol to clean the skin before in- nied sharing injection equipment but rate of STIs among IDUs led to the for- jection may protect against STI.7 admitted reusing her own syringes mation of a multiagency STI task force In San Francisco, the local health de- without cleaning them. Despite increas- that included representatives of SFGH partment pays most of the costs of car- ing pain and swelling in her left del- administration, researchers, commu- ing for persons with STIs. In 1997, Fed- toid, she continued to inject into that nity clinicians, and the San Francisco eral Social Security Insurance (SSI) area for the 2 weeks before admission. Department of Public Health. The task disability eligibility was amended so that She was hospitalized for intravenous an- force recommended the creation of a drug and alcohol addictions were no tibiotics and incision and drainage of hospital-based STI clinic, community longer qualifying disabilities.8 Be- the abscess. outreach to IDUs, expansion of sub- cause California’s Medicaid program is

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linked to SSI, the restriction of federal nity-recruited injection drug users in San Francisco. Clin (NASEN) mailed surveys to 131 SEP di- Infect Dis 2000;30:579-81. disability eligibility has reduced the abil- 2. CDC. Tetanus among injecting-drug users— rectors (compared with 68 in 1994- ity of local municipalities to obtain state California, 1997. MMWR 1998;47:149-51. 1995, 101 in 1996, and 113 in 1997),2-4 3. CDC. Wound botulism—California, 1995. MMWR and federal financial support for the 1995;44:889-92. and followed up with telephone inter- medical costs of persons living with 4. Ciccarone D, Bourgois P, Edlin BR. Biological and views about syringes distributed/ substance addiction. behavioral predictors of soft tissue infections in injec- returned, services provided, and bud- tion drug users. In: Proceedings of Community Epi- In response to the high use of emer- demiology Working Group Meeting. San Francisco, gets and funding during 1998. The gency and inpatient services, SFGH California: National Institutes of Drug Abuse, Decem- methods of this survey were the same ber 2000. 2-4 opened a surgical outpatient STI clinic 5. Gershon RRM. Infection control basis for recom- as previous surveys of SEP activities. in July 2000. As of February 2001, the mending one-time use of sterile syringes and aseptic Among the 131 SEPs contacted, 110 procedures for injection drug users. J Acquir Immune clinic averaged 273 patient visits and Defic Syndr Hum Retrovirol 1998;18(suppl 1):S20- (84%) completed the survey. Some 170 procedures per month. For FY S24. SEPs participated in the survey on the 6. Koester SK. Copping, running, and paraphernalia 2000-2001, the numbers of admis- laws—contextual variables and needle risk behavior condition that their program data be re- sions and ED visits for treatment of STIs among injection drug users in Denver. Human Orga- ported only in aggregate. SEPs oper- are projected to decline significantly nization 1994;53:286-95. ated in 81 cities† and 31 states, the Dis- 7. Murphy EL, DeVita D, Liu H, et al. Risk factors for compared with FY 1999-2000. skin and soft tissue abscess among injection drug us- trict of Columbia, and Puerto Rico.‡ The findings in this report are sub- ers: a case control study. Clin Infect Dis 2001(in press). The largest number of SEPs were in four 8. Bluthenthal RN, Lorvick J, Kral AH, et al. Collat- ject to at least four limitations. First, the eral damage in the war on drugs: HIV risk behaviors states: 21 in California, 14 in New York, hospital and ED discharge records may among injection drug users. International Journal of 12 in Washington, and nine in New Drug Policy 1999;10:25-38. be incomplete or inaccurate. Second, 9. Ciccarone D, Bourgois P, Murphy EL, et al. Risk fac- Mexico. SEPs were classified by the using only primary diagnoses underes- tors for abscesses in injectors of “black tar” heroin: a number of syringes exchanged during timated the number of STIs. Third, cross-methodological approach [Abstract]. Pre- 1998; 107 reported exchanging sented at the 128th American Public Health Associa- because only a small percentage of medi- tion Annual Meeting, Boston, Massachusetts, No- 19,397,527 syringes. The 12 largest cal records were reviewed, the propor- vember 12-16, 2000. programs exchanged 62% of all sy- tion of STIs attributed to injection drug ringes.§ Referral to substance abuse use is uncertain. Finally, hospital charges treatment was provided by 104 (95%) were estimated and are related but not Update: Syringe of the 110 SEPs, 109 (99%) provided equal to the cost to the hospital. alcohol pads, 99 (90%) provided bleach, Primary prevention strategies to re- Exchange 108 (98%) provided male condoms, 80 duce STIs among IDUs include pre- Programs—United (73%) provided female condoms, 104 venting initiation of injection drug use (95%) provided referrals to substance and increasing entry and retention of States, 1998 abuse treatment, 70 (64%) provided on- IDUs in substance abuse treatment (par- site voluntary counseling and testing for ticularly methadone maintenance). For MMWR. 2001;50:384-387 HIV, 26 (24%) for hepatitis C, and 23 IDUs who continue to inject drugs, 2 tables omitted (21%) for hepatitis B. In addition, 21 increasing access to sterile injection (19%) provided on-site medical care, equipment and alcohol swabs and pro- SYRINGE EXCHANGE PROGRAMS (SEPS) 18 (16%) provided hepatitis B vac- moting hygiene (including hand wash- provide sterile syringes* in exchange for cine, 17 (15%) provided tuberculosis ing, cleaning the injection site before used syringes to reduce the transmis- screening, and 14 (13%) provided sexu- injection, using a sterile syringe for ev- sion of human immunodeficiency vi- ally transmitted disease screening. A ery injection, and avoiding needle con- rus (HIV) and other bloodborne infec- median of 2.5 on-site services were pro- tamination) are important prevention tions associated with the reuse of vided by small, 3.0 by medium, 2.0 by goals. Secondary prevention strategies potentially blood-contaminated sy- large, and 7.0 by very large programs. include promoting earlier medical and ringes among injection drug users During 1998, SEPs operated at 534 surgical treatment of STIs. Microbio- (IDUs).1 This report summarizes a sur- sites averaging five sites per program logic testing of street samples of black vey of 1998 SEP activities in the United (median: nine; range: 1-31). Sites in- tar heroin also may help identify the States and compares them with 1994- cluded 202 health van stops, 59 shoot- causes of injection-related STI. Ongo- 1997 SEP activity surveys.1-3 SEPs are ing galleries, 56 sidewalk tables, 51 cars, ing research into the behavioral and bio- an increasingly common HIV preven- 43 storefronts/indoor sites, 30 SEP logic risk factors for STI may identify tion approach that offer a range of pub- workers on foot, 23 health clinics, and additional prevention interventions.9 lic health services in addition to sy- 70 other sites. Delivery of syringes and ringe exchange. other risk-reduction supplies to resi- REFERENCES In October 1999, staff from Beth Is- dences or meeting spots was reported 1. Binswanger IA, Kral AH, Bluthenthal RN, et al. High rael Medical Center and the North by 55 (50%) SEPs, and 94 (85%) al- prevalence of abscesses and cellulitis among commu- American Syringe Exchange Network lowed participants to exchange sy-

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ringes for persons other than them- proximately two thirds of the total SEPs vision of influenza and pneumococcal vaccines to injection drug users at a syringe exchange. J Subst Abuse selves (secondary exchange). The 110 budget for 1998. Treat 2000;18:263-5. SEPs operated a mean of 20 hours per The findings in this report are sub- 7. CDC. Hepatitis B vaccination for injection drug users—Pierce County, Washington, 2000. MMWR 2001; week per program (median: 22 hours; ject to at least three limitations. First, 50:388-90,399. range: 1-140 hours). Sixteen SEPs had the extent of SEP activity probably is 8. Groseclose SL, Weinstein B, Jones TS, et al. Im- syringe shortages that caused four to underestimated because some of the pact of increased legal access to needles and syringes on the practices of injecting-drug users and police of- close temporarily for 16 months (range: known SEPs did not participate in this ficers—Connecticut, 1992-93. J Acquir Immune De- 2-8 months). survey and others may exist that are not fic Syndr Hum Retrovirol 1995;10:82-9. 9. Burris S, Lurie P, Abrahamson D, Rich JD. Physi- The combined operating budget of known to NASEN. Second, the infor- cian prescribing of sterile injection equipment to pre- 105 SEPs was $8,567,662 (range: mation collected was self-reported and vent HIV infection: time for action. Ann Intern Med 2000;33:218-26. Available at http://www.temple 0-$771,053; mean: $80,493; median: may be biased. Third, because 36 (33%) .edu/lawschool/aidspolicy/default.htm. Accessed May $38,000). A total of 51 SEPs in 15 states࿣ SEPs requested that their survey data 2001. 10. Academy for Educational Development. Com- and Puerto Rico received public fund- be kept confidential, some data are in- prehensive approach: preventing bloodborne infec- ing of $5,992,032. From 1994-1995 to cluded only as aggregate state-level in- tions among injection drug users. Washington, DC: 1998,¶ the number of SEPs participat- formation. Academy for Educational Development, 2000. Avail- able at http://www.cdc.gov/idu. Accessed May 2001. ing in the activities survey increased IDU access to sterile syringes can be *“Syringe” refers to both syringes and needles. from 60 to 110 (83%), the number of augmented by methods other than †Cities with multiple SEPs: Detroit, Michigan; India- 8 cities with SEPs increased from 46 to SEPs. During 2000, New Hampshire, napolis, Indiana; Los Angeles, California; Minneapo- 81 (76%), and the number of syringes New York, and Rhode Island adopted lis, Minnesota; New York, New York; Portland, Or- egon; San Francisco, California; Seattle and Tacoma, exchanged increased from 8.0 million new syringe laws that partially or com- Washington, and five others that asked that their pro- to 19.4 million (143%). Nine SEPs re- pletely removed the requirement for a gram-specific information be kept confidential. ‡States with SEPs: California21; New York14; Wash- ceived no funds; however, they ex- prescription to purchase syringes and ington12; New Mexico (nine); Connecticut (six); Mas- changed Ͼ185,000 syringes and pro- legal penalties for syringe possession. sachusetts (five); Michigan, Oregon, Pennsylvania, Wisconsin (three each); Colorado, Illinois, Indiana, Min- vided other services using donated Physician prescription of sterile sy- nesota, Montana, Ohio, Puerto Rico, Texas, (two each); supplies and volunteers. ringes to IDUs is another possible and Alaska, Arizona, District of Columbia, Georgia, Ha- mechanism.9 Assuming availability of waii, Kansas, Louisiana, Maryland, North Carolina, New Reported by: MP Singh, MPH, CA McKnight, MPH, Hampshire, New Jersey, Oklahoma, Rhode Island, Ten- D Paone, EdD, S Titus, MPH, DC Des Jarlais, PhD, Ed- sterile syringes for IDUs who con- nessee, and Utah (one each). mond de Rothschild Foundation Chemical Depen- tinue to inject is only one component §States with the largest SEPs: California (four); Wash- ington (three); New York (two); and Illinois, Mary- dency Institute, Beth Israel Medical Center; M Krim, of a comprehensive approach to HIV PhD, American Foundation for AIDS Research, New land, and Pennsylvania (one each). The largest SEPs York, New York. D Purchase, J Rustad, A Solberg, North prevention for IDUs. Other HIV pre- were San Francisco AIDS Foundation, California (2.1 American Syringe Exchange Network, Tacoma, Wash- vention components include sub- million syringes exchanged); Chicago Recovery Alli- ington. ance, Illinois (1.5 million); Point Defiance AIDS Project, stance abuse treatment, community Tacoma, Washington (1.1 million); Seattle-King County outreach, tailored HIV counseling and Department of Public Health Needle Exchange Pro- CDC Editorial Note: The findings of gram, Seattle, Washington (1.0 million); Lower East the 1998 survey indicated growth in the testing, prevention of sexual transmis- Side Needle Exchange Program, New York, New York sion, services in correctional settings, (0.9 million); Alameda County SEP, Oakland, Califor- number of cities with SEPs and in the nia (0.8 million); Street Outreach Services, Seattle, number of SEPs that provide preven- primary drug prevention, and services Washington (0.7 million); Baltimore Department of for HIV-infected IDUs.10 Public Health, Maryland (0.7 million); and Clean tion services for IDUs. Many SEPs, par- Needles Now, Los Angeles, California (0.6 million). ticularly the largest programs, serve as Three large SEPs that exchanged 2.8 million syringes during 1998 asked that their program-specific infor- REFERENCES community-based HIV prevention and mation be kept confidential. health promotion centers for IDUs, in- 1. Normand J, Vlahov D, Moses LE, eds. Preventing ࿣SEPs received public funding in the following: (1) HIV transmission: the role of sterile needles and bleach. states: Arizona, California, Colorado, Connecticut, Ha- cluding IDUs at high risk for blood- Washington, DC: National Academy Press, 1995. waii, Illinois, Massachusetts, Maryland, New Mexico, 5 borne infections. SEPs also provide ad- 2. CDC. Syringe exchange programs—United States, New York, Oregon, Pennsylvania, Puerto Rico, Rhode ditional services (e.g., influenza and 1994-1995. MMWR 1995;44:684-91. Island, Washington, and Wisconsin; (2) counties: Clark, 6 3. CDC. Update: syringe exchange programs— King, Pierce, Skagit, and Snohomish, Washington; pneumococcal vaccinations). Hepati- United States, 1996. MMWR 1997;46:565-8. Pima, Arizona; Boulder, Colorado; Cook, Illinois; and tis B vaccination at a SEP was an im- 4. CDC. Update: syringe exchange programs— Multnomah, Oregon; and (3) cities: Berkeley, Los An- United States, 1997. MMWR 1998;47:652-5. geles, and San Francisco, California; Chicago, Illinois; portant part of the public health re- 5. Hagan H, McGough JP, Thiede H, et al. Volunteer Baltimore, Maryland; Portland, Oregon; Seattle, Wash- sponse to a hepatitis B outbreak among bias in nonrandomized evaluations of the efficacy of ington, and Milwaukee, Wisconsin. 7 needle-exchange programs. J Urban Health 2000;77: ¶From 1998 to March 2001, the number of SEPs IDUs in Pierce County, Washington. 103-12. known to NASEN increased from 131 to 168 (D. Pur- State and local governments funded ap- 6. Stancliff S, Salomon N, Perlman DC, Russell PC. Pro- chase, NASEN, personal communication, 2001).

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