Hepatitis & Local Prevention Funding Scarcity

Cash Crisis
How a lack of local prevention dollars could lead to more viral hepatitis outbreaks
by Larry Buhl

A series of hepatitis A outbreaks has erupted across the U.S., most notably among the homeless population in San Diego, sending the number of cases nationally surging twenty-eight percent year over year.

The hepatitis A outbreak, as well as the surge in hep C due to the opioid crisis, is putting a strain on already underfunded state and local health departments.

I spoke with Laura Hanen, interim executive director and chief of public affairs of the National Association of County and City Health Officials (NACCHO) about how these departments are having to do more with less. She started with some pretty grim dollar figures.

Laura Hanen: Simple answer, there’s not enough money. Congress appropriates money to Health and Human Services (HHS), which gives money to CDC, which gives money to the Division of Viral Hepatitis. That division gets $34 million, an incredibly small amount of money given the crisis. They distribute that $34 million to state governments, and on average that comes out to $90,000 per state. That is a minuscule amount of money, compared to what is given to HIV, which receives $787 million. We don’t have funding for a robust surveillance system to understand and address the epidemic.

Larry Buhl: What can a state do with $90,000?
Not a lot. And if each state only gets 90,000 per, you can imagine the local departments don’t get anything at all. Unless large urban areas get money from their city councils or board of supervisors, and even then it isn’t much. We haven’t prioritized spending on viral hepatitis. That is very unfortunate given the burden of hepatitis B and C in particular in the U.S., and, if we can’t prevent, test and treat, then we’re not going to get our arms around this epidemic. We will continue to pay dearly in medical costs because we can’t get upstream and put resources into surveillance so we’ll know who is most impacted and where we need to be targeting our precious resources.

Describe surveillance for viral hepatitis.
Case reporting and following up on contacts. What health departments do to know how many acute and chronic cases. Working with doctors to follow up on lab reports.
We don’t have good numbers because we don’t have good data. So you have to rely on national phone surveys. Even if you know cases in your state, you don’t know the cases in your county. You need to know cases in your zip code to get to those who are most at risk and most impacted.

I’ve also heard that there’s attrition among city and county health department employees. Why is that?
Since the recession of 2008, local health departments have lost 55,000 employees, through budget cuts, layoffs. You’re losing capacity at local level to keep people healthy and safe. It’s not likely there’s going to be a big infusion of cash so that health departments can rebuild that capacity. You’re doing more with less and it continues to be a challenge for local health departments to do their jobs.

What activities are cut first?
We have seen cuts in preparedness. [Departments are] not doing as much outreach and education around vaccines or environmental health inspections. We’ve seen cuts in preparedness funding, thirty percent over the last decade. Even when you flat fund programs, over time that’s still a cut because you’re not keeping up with inflation and the growing population.

Where is the breakdown in funding?
Congress has the power of the purse and they appropriate funding every year. Money for HHS sits in the Labor, Health and Human Services, and Education Appropriation Bill. The Division of Viral Hepatitis has received minor increases but it’s been basically flat for a very long time. When you look at the macro picture for federal funding, there is a law, the Budget Control Act of 2011 that put severe budget caps on federal discretionary spending. The twelve appropriations bills live under tight budget caps. Therefore there have not been significant increases for the CDC for quite some time.

Vaccination rates for adults are woefully low. We’re not meeting our healthy people 2020 targets. With adults it’s an education and cost issue. You’re more likely to get a vaccine if your provider recommends it. Whether that’s flu, or Zoster for shingles or hepatitis A and B. If your doctor says you need it based on your risk and age, you’re more likely to get it.

Or not get it if you don’t have a primary doctor.
Right. We need to continue to be vigilant and get the word out about getting recommended vaccines. We’ve divested from our public health infrastructure.

Larry Buhl is a multimedia journalist, screenwriter, and novelist living in Los Angeles. Follow him on Twitter @LarryBuhl.