Harm Reduction and Infection Control Bryce Koch Public

Harm Reduction and Infection Control Bryce Koch Public Health Nurse

Land Acknowledgement • I acknowledge that the Winnipeg Regional Health Authority provides health services in facilities and communities located on the original lands of Treaty 1 and on the homelands of the Metis Nation. I respect that the First Nation treaties were made on these territories and acknowledge the harms and mistakes of the past, and I dedicate myself to collaborate in partnership with First Nation, Metis and Inuit people in the spirit of reconciliation.

Learning Objectives • Understand the Healthy Sexuality and Harm Reduction team’s role in STI/BBI prevention • Learn about WRHA’s position on Harm Reduction • Understand the current trends in reportable infections (Hep C, HIV, and Syphilis) • Understand how harm reduction can reduce infections in people who use drugs

Bryce Koch RN BN • Public Health Nurse • • • Healthy Sexuality and Harm Reduction Street Connections Previously worked as an emergency nurse Briefly a paramedic before that Harm Reduction Advocate the whole time!

Health Sexuality and Harm Reduction • WRHA • • STI/BBI Tracking/Tracing • • Population and Public Health HIV, Hep C, and Syphilis Street Connections

WRHA Position Statement on Harm Reduction • Harm Reduction is a perspective that focuses on reducing the adverse health, social, and economic consequences of drug/alcohol use, and its principles can be equally applied to other stigmatized and/or criminalized practices and behaviours related to substance use and sex.

Principals of Harm Reduction • Client-centered, non-judgmental and facilitative, rather than coercive • Targets the causes of risks and harms • Is evidence-informed, practical, feasible, effective, and cost effective • Promotes autonomy and dignity • Is transparent and accountable • Challenges policies and practices that maximize harm International Harm Reduction Association, 2010

Injection Drug Use • Needle distribution on the rise • Drugs • • • Meth Opiates Others • Infections Related IV use

2013 -04 -01 22/2/2013 19/4/2013 -07 -06 26/7/2013 13/9/2013 -01 -11 20/12/2013 2014 -07 -02 28/3/2014 16/5/2014 -04 -07 22/8/2014 -10 -10 28/11/2014 16/1/2015 -06 -03 24/4/2015 -12 -06 31/7/2015 18/9/2015 -06 -11 25/12/2015 2016 -12 -02 28/03/2016 20/05/2016 -08 -07 26/8/2016 14/10/2016 -02 -12 20/01/2017 -10 -03 28/4/2017 16/6/2017 -04 -08 22/9/2017 -10 -11 29/12/2017 16/2/2018 -06 -04 25/5/2018 13/7/2018 31/8/2018 19/10/2018 -07 -12 25/1/2019 20 Hep C 18 16 14 12 10 8 Hepatitis C (cases/ week) 6 4 2 0 Dr. Pierre J. Plourde May 2019

HIV • First time that IV transmission surpassed sexual transmission • Expanded Harm Reduction Distribution

Syphilis • 3000% increase in Syphilis since 2012 -2013 • Rates increase in populations that do not regularly access healthcare • • Structurally disadvantaged population (homeless, incarcerated, IV substance use) People who use substance • 30%-40% disclose injection drug use • Congenital Cases are popping up • First cases since the 1950’s

Big Scary Bar Graph Source: Syphilis Surveillance Database, Population and Public Health Program, Winnipeg Regional Health Authority, April 2019

Syphilis • Transmittable via IV drug use (? )

What we are doing for Syphilis • Testing Clinics • • High Traffic Areas Coupled with Flu Clinics • Destigmatizes STI/BBI testing

What we are doing for Syphilis • System Capacity Building • Emergency Paramedics In The Community (EPIC)

Emergency Paramedics in the Community • Community Based Paramedics • Stationed out of Main Street Project • Will be able to treat syphilis • With public health referral

Infections Related to IV Substance Use • • Own Floral (Commensal) Predominantly Staphylococcus Aureus • • MRSA Streptococcus

Abscesses • ~20% in the last 6 months • Staphylococcus Aureus • MRSA • Left alone if under 2 cm’s • Any bigger, needs medical drainage Taken From Black Poppy’s Junk Mail https: //blackpoppymag. wordpress. co m/a-z-of-health/abscesses/

Cellulitis • Inflammation of deeper layers of skin • With or without abscess • More common with poor circulation

Infections • Risk Factors • • • Injection Skill Sterile Supplies The Drugs

Injection Skill • Being able to find a vein • • • Antecubital Fossa (ACF) damage Hand Veins Groin/Neck veins

Injection Skill • Being able to “hit” the vein • • “Flagging” Peer-assisted injection

Injection Skill • Locating Sites • Knowing when to rotate https: //www. catie. ca/en/practical-guides/hepc-indepth/prevention-harm-reduction/safer-injection

Sterile Supplies • Use a new needle every time • Used needles cause more tissue destruction • Bacterial buildup overtime • MRSA, GROUP A

Sterile Supplies • Swabbing the area • Abscesses twice as common w/o swabbing

Sterile Supplies • Cookers • • • Sterile Should not be reused/shared MRSA/Group A Hep B, C HIV

Sterile Supplies • Safer crack use kits • Some substances reduce saliva production • Can transmit Hep C

Filters • Cotton filters • For large particulate • Not Bacteria • Sometimes reused • • Leftover drugs Cotton Fever

Cotton Fever • Benign Febrile Syndrome • Fever, malaise, Increase WBC • • • Pharmacologic • Causes (? ) Immunological Endotoxin • Enterobacter agglomerans

Sterifilt • Filter that attaches to the end of single use needles • • 90% of particles less than 5 microns 99% of particles larger than 5 microns Limited drug retention Limited reusability

HIV and Drug Equipment • HIV • Destroyed after boiling “Cook” for 10 seconds

The Drugs • Sometime the properties of the drugs themselves contribute to infection risk

HIV and Hydromorphone Contin • London, Ontario • Oxy Contin Vs Hydromorphone Contin • Helped HIV live longer on drug equipment

Crystal Meth • Main drug of choice for injection • Cheap and long acting • “High Quality”

Why Do People Use Crystal Meth • Protective • • • Appetite suppression Decreased Reaction time Wakefulness Promotion • Euphoria

Meth and Infections • Vasoconstriction • • • Harder to hit veins Less blood flow to area More likely to go to larger veins (ACF/Neck/Femoral) • Anxiety • Less stable hand movements = more likely to miss

Meth and Infections • Caustic to veins • • PH of 3. 02 to 7. 03 with an average of 5. 0 Causes inflammation

Meth and Infections • Production of Meth • • No sterilization when compared to other drugs Very water soluble, so no need to apply heat • Shaker method • Endocarditis and Meth Use

Endocarditis • Increase seen in Winnipeg • Related to IVDU • Complex Treatment/Long Hospital Stays/Expensive • Could be mitigated with proper harm reduction teachings

Thanks! • Any questions? • Feel free to reach out with any questions around substance use or STI/BBI’s • Contact Info: • • Bkoch@wrha. mb. ca 204 390 0240