07 June 2010

Dept. of Unintended Consequences: Hepatitis B in West Virginia

This is an addition for archival purposes of a post that originally appeared at Scienceblogs.

Via ProMED Mail comes a news report that about 2,000 people in 5 states are being sought by health departments so they can be checked for hepatitis B infection. The potential source: the Mission of Mercy Dental Clinic, a free dental-care fair held just about a year ago in Berkeley County in the far north-east corner of West Virginia. The potentially infected include 1,137 people who were treated at the two-day clinic and 826 of the volunteers who worked there, from West Virginia, Washington, D.C., Virginia, Maryland, Pennsylvania and North Carolina. Three patients and two volunteers have already been diagnosed. The virus in four of the five matched on molecular fingerprinting, suggesting a common source; the fifth patient refused further testing.

Hepatitis B is blood-borne, so on the surface, this is a story of the tragic consequences of some failure somewhere in the clinic's infection-control procedures. (One reason why it caught my eye, since I'm interested in healthcare-associated infections.) Except that it's not -- or not only. It's important to unpick why such an extraordinarily large number of people may have been exposed at one time. Looked at through that lens, it becomes a story about what can happen when we don't fund basic health care in a timely way.

Some background: West Virginia is one of the poorest states in the country and has some of the highest rates of the usually recognized diseases of poverty: tobacco use, chronic kidney disease, asthma, cardiovascular disease. (Look for West Virginia on these CDC maps of incidence of heart disease and stroke.) But it also has extraordinarily high rates of another health problem that ought to be linked in the public mind to low socioeconomic status, but usually isn't: untreated dental disease. Eric Eyre of the Charleston Gazette (disclosure: a friend and fellow Kaiser Foundation Fellow) took a year-long close look at dental disease in the state in 2006-07 (slideshow, stories). If you're squeamish, I advise skipping the one about the woman yanking her own teeth with pliers after a few shots of moonshine.

Dental disease -- that's not just cavities, but tooth loss, bone loss, abscess, Ludwig's angina, septicemia in the most serious cases -- isn't only a problem for West Virginia, though it happens to be worst there. It's a problem all over the US because, without ever intending to, we've allowed dental care to become a primarily cash-based form of medicine.

If you have a job, you may have dental insurance, though it's a less-common employment benefit than health insurance, and covers comparatively less of the cost of any procedure. If you don't have a job, dental care is entirely out of pocket. If you're poor enough to be on Medicaid, whether or not you have dental coverage depends on which state you live in, because Medicaid dental coverage for adults falls under the portion of Medicaid funded by the states, not the federal government. In the past 12 months, California, Hawaii, Massachusetts, Michigan, Minnesota, North Carolina, and Washington state all cut or tried to cut their contributions to dental Medicaid from their state budgets. If you're the child of a poor family, you are hypothetically entitled to Medicaid-funded dental care, though that depends on being able to find a local dentist willing to accept Medicaid reimbursement; last year, the Government Accountability Office said that children have trouble finding Medicaid-accepting dentists in 43 out of 50 states.

Net result: Untreated dental disease is now the most common disease of childhood, five times more common than asthma according to a 2000 Surgeon General's report, and emergency room visits for dental crises are rising steadily. ERs are not the right place to treat dental problems -- they don't fill cavities or do extractions, though they can drain abscesses and give antibiotics and pain meds -- but as with so much else in US medicine, ERs offer a mandated clinic of last resort when there's nowhere else to go. (For more about the interplay between dental care and ER overcrowding, here's a story I wrote for the June Annals of Emergency Medicine.)

All of that explains why thousands of people from a wide swath of the East Coast were so desperate for free dental care that they were willing to stand in line overnight in a high school parking lot. (The first free dental clinic in West Virginia had to close its doors early after it got 1,100 patients in the first 2 hours.) And also why hundreds of dental-care professionals and students and community volunteers were so eager to help. And why they're all now waiting by the mailbox, wondering whether they're in line for a letter that will tell them where to get tested for infection with a life-long chronic disease.

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