Santa Cruz County

Agenda Item
Approved with additional direction
Dec 10, 2019 9:00 AM

Consider Syringe Services Program policy that manages secondary exchange by allowing clients who only exchange on behalf of others to exchange for a maximum of two people, accept and file an evaluation of syringe litter, and direct the Health Services Agency to return in June 2020 with recommendations to improve syringe litter reporting and response, as outlined in the memorandum of the Director of Health Services


Department:Health Services Agency: Administration DivisionSponsors:Director of Health Services Agency Mimi Hall
Category:HSA - Board LetterProjects:Master Calendar
Functions:Health & Human Services

Board Letter

Recommended Actions:

1)              Approve a Health Services Agency (HSA) Syringe Services Program policy that manages secondary exchange by allowing clients who only exchange on behalf of others to exchange for a maximum of two people, effective January 2020.


2)              Accept the evaluation of syringe litter in Santa Cruz County in partnership with the California Department of Public Health, titled “Syringe Access and Disposal in Santa Cruz County” dated November 2019.


3)              Direct HSA to return in June 2020 with recommendations to improve syringe litter reporting and response through a centralized system across all partners.


Executive Summary

California’s 50 syringe service programs (SSPs), including the program operated by the County of Santa Cruz, are a crucial part of the care continuum for people who use drugs and collaborate closely with other parts of the public health, medical, and social services systems. SSPs are central to the State’s efforts to end the HIV and hepatitis C virus (HCV) epidemics, expand access to substance use disorder treatment, and to end the opioid overdose crisis.


On September 24, 2019, the Board directed the HSA to collaborate with the California Department of Public Health (CDPH) to conduct an evaluation of syringe litter in the community, and to develop a plan to manage secondary exchange in response to program data showing a reduction in primary exchange during fiscal year 2018. The design, implementation, and analysis for the syringe litter evaluation took place from July through November 2019. Additionally, HSA facilitated meetings to listen to the concerns and feedback from community members and partner agencies. The findings from these activities highlight the need for continued engagement with community partners, improved data collection efforts related to secondary exchange and community-acquired needle sticks, and increased accessibility to syringe services and safe-disposal options.



On June 11, 2019, the Health Services Agency (HSA) presented to the Board a 2017-2019 Biennial Report and presentation on the Syringe Services Program (SSP). During this meeting the Board directed HSA to return on September 24, 2019 with updates for the following programmatic elements of HSA’s SSP (deferred to December 10, 2019):


Directive #1 Return September 24th with a plan to manage the secondary exchange program, and at that time the Board will vote on a six-month pilot to increase the hours at Emeline and Watsonville clinics;


Directive #3 Collaborate with the CDPH [California Department of Public Health] to complete a study of syringe litter to be conducted in Santa Cruz County, and return to the Board by September 24, 2019 to report on the findings and provide recommendations [in conjunction with #2 of the directed actions];


Exhibit A, “HSA Progress on SSP Board Directives, June to November 2019”, includes the full list of Board directives from June 11, 2019 with HSA’s noted progress.


HSA administers the SSP through its Public Health Division. The goal of the SSP is to protect and promote Santa Cruz County residents’ health and safety by preventing the spread of infectious diseases associated with injection drug use, and by decreasing the number of improperly disposed syringes in the community. SSPs are an evidence-based strategy to prevent the spread of communicable diseases, such as HIV and hepatitis C.


Communicable disease data from the last five years in Santa Cruz County especially demonstrate an ongoing need to improve coverage of services for persons injecting drugs, as noted in Exhibit B, “Risk for Infectious Diseases Associated with Injection Drug Use in Santa Cruz County, November 2019”.




Exhibit C, “Syringe Access and Disposal in Santa Cruz County, November 2019”, includes the syringe litter evaluation’s methods and key findings.


From June through November 2019, HSA collaborated with CDPH to evaluate the facilitators and barriers to proper syringe disposal and syringe access across Santa Cruz County. Additionally, HSA partnered with Downtown Streets Team to assist with the visual inspection in the community, and trained volunteers to implement the survey. The evaluation includes findings from individual field surveys and focus group discussions with persons who inject drugs or medications, and visual inspections of syringe and injection-related litter in public spaces across the County.  Data collection tools, processes, and analysis were methodically implemented to reduce epidemiological biases within the resources available. The analysis and findings within the report shed more light on the needs of our community.


Following are some key findings from the evaluation regarding barriers to safe syringe disposal:

·              A common complaint expressed by participants was that the County SSP services are too limited, leading to a scarcity of both supplies and safe disposal options.


·              Most participants properly dispose of syringes most of the time, while some participants also reported inappropriate disposal practices that could contribute to reuse or public safety hazards.


·              Multiple barriers to safe syringe disposal were common among participants. Common barriers included limited operating hours and locations of designated disposal sites, and lack of transportation or mobility to disposal sites.


·              Participants reported perceptions of police encounters, searches, surveillance of exchange sites, confiscation of lawfully obtained supplies, and parole/probation conditions as barriers to access health care services, including syringe disposal. Prior law enforcement encounters related to syringe possession were associated with improper disposal practices.


Focus group participants noted the value of self-efficacy through participation in the SSP:


“When you’re sick you have to take care of that first and worry about the rest. But if that is removed from the equation it’s one step toward a decision to better your situation. You start somewhere, just having clean needles, OK I’m taking care of myself a bit. Sometimes that snowballs into ‘I don’t want to use as much as I have been,’ you know? It can. That’s what harm reduction is, start somewhere.”


“For us drug addicts out there it’s a problem, it’s an addiction, and I think clean needles is safe needles. I think that makes a difference. I have a lot of friends who do use the needle exchange. I think that has a lot [to do with] recovery - they give hope. It’s like, if they can do it, well, I can change things too.”


Concurrent with the evaluation, HSA conducted community outreach to listen to concerns and obtain feedback regarding SSP services. The outreach included a meeting with partner organizations who dispose of syringe litter, local jurisdictions, and community listening sessions. A summary of these activities can be found in Exhibit D, “Summary of SSP-Related Community Engagement, July to November 2019”.  


Opportunities for County SSP Improvements


This evaluation process has highlighted opportunities for improvement to incorporate into the program, including:


-              Data Improvements: HSA will review data entry processes for participant encounters and update the database. In addition to sustaining the practice of posting monthly productivity reports online, HSA will explore opportunities to improve how data is regularly communicated to the public.


-              Referrals: continue to review opportunities to enhance the program’s referral and linkage practices, including how to strengthen the existing partnership with HSA’s Medication-Assisted Treatment program.


-              Found Syringe Reporting: explore piloting the implementation of a consolidated method for the community to report found syringes in public spaces, such as the Citizen Connect app. The development of this pilot will be based on the initial feedback from the meeting with agencies who conduct regular syringe disposal (Exhibit D), and ongoing collaboration with community stakeholders.


-              Sharps Disposal Access: continue to partner with local jurisdictions to situate sharps disposal kiosks in additional locations, and more appropriate or accessible locations.


-              Community-Acquired Needle Sticks: per the direction from the County Health Officer, direct all healthcare providers to report community-acquired needle sticks to the HSA Communicable Disease Unit. The ongoing surveillance of these incidents will inform thoughtful strategies for prevention.


-              Community Engagement: Create opportunities for consumers to be involved in the design and conduct of programmatic services. Focus group participants had a number of specific suggestions for improving SSP services, indicating that they have a good understanding of where unmet need is in the community. HSA will also increase outreach efforts to key stakeholders (pharmacies, law enforcement, consumers, public, etc.) to increase awareness of the program and related laws, and promote ongoing collaboration. The feedback from the community listening sessions demonstrate a desire from the community to be included and acknowledged when developing the SSP program.




The evaluation findings indicate that people who do not have adequate access to new syringes also do not have access to appropriate disposal options. Participants in the evaluation who said they needed a new syringe in the last month but did not have one were almost six times more likely to dispose of syringes improperly. Many participants report multiple barriers to proper syringe disposal, including limited operating hours of disposal locations (including the County SSP), distance of disposal locations, and lack of transportation or mobility to disposal locations. The findings from the visual inspection suggest that additional syringe disposal kiosks in non-stigmatizing locations are needed, which also matches the data collected from focus group discussions.


During the two-week inspection period of cross-sectional data collection, observation teams found 310 syringes (includes syringes with intact needles as well as syringe barrels without needles) and 506 pieces of injection equipment. Non-sharp injection equipment (e.g., syringe caps, sterile water vials, etc.) was found 1.6 times more often than syringes (sharps).


Syringe litter was not proportionately located throughout the community during the inspection period; it was often aggregated into piles and found near encampments, away from public bystanders. Out of the 310 syringes found in the visual inspection, three specific piles accounted for 60% (n=186) of the syringe litter found. Still, 40% (n=114) of syringes were found alone or in smaller piles (in groups of 2 to 12) in more public areas, such as outhouses, parking lots, or the tree outside the downtown public library.


Overall, during the two-week visual inspection, the amount of syringes that were disposed of safely vastly outnumbered the amount of syringe litter in the community. For every 1,000 needles disposed of properly within Santa Cruz County, about 10 needles were found to be disposed of improperly as litter.


Secondary Syringe Exchange


The term secondary syringe exchange (SSE) refers to efforts to utilize peer networks, including friends and family members, to support safe injection practices in people who inject drugs but are unable or unwilling to access SSP services when they are available. It is distinct from primary syringe exchange, where the participant is accessing syringes and services for themselves only. SSE and other forms of peer-delivered services are a common practice among SSPs nationwide that builds on the trusting relationships that SSPs develop with those they serve in order to provide a simple but vital public health resource. In California, according to CDPH Office of AIDS, 30% of syringes distributed by SSPs were through SSE networks.


SSE has been scientifically evaluated, and studies have found that this mode of service delivery extends the effectiveness of SSPs and fills gaps in community access. This has been supported in the evaluation findings (Exhibit C “Syringe Access and Disposal in Santa Cruz County, November 2019”). In the focus groups, participants commented on how secondary exchange creates opportunities to provide mutual assistance within their community:


“Just tonight, someone didn’t have [a new syringe], she didn’t have the right size [syringe] that she wanted. Somebody else had the right size but had just used it, and she took it. And I was like… really? And I said stop and I went and found one for her.”


Since 2016, the program has seen a decline of primary exchange, and an increase in secondary exchange. In 2018, 68% of syringes distributed by the County SSP were through SSE networks, as compared to only 54% in 2017. Based on current research of known best practices for SSPs (Exhibit F), the Grand Jury findings from 2017 (Exhibit E) and the syringe litter study conducted by HSA (Exhibit C), the increase in secondary exchange is likely due to inaccessibility of the County SSP. As one focus group participant stated:


“There’s nothing wrong with Emeline [the County SSP site in Santa Cruz] right now, just except that there’s these really specific hours. It’s not a lot of hours if you’re out here in survival mode. And if you’re on the west side and trying to get to Emeline, that’s a long way to go.”


The survey findings indicate that increasing accessibility of the County SSP will allow more participants to access the County program directly (i.e. primary exchange). The increase in primary exchange may lead to a decrease in the percentage of secondary exchange. In the evaluation’s field survey, 69% of survey participants who experienced a recent need for a clean syringe answered that they needed access to new syringes in the afternoon and evening. However, the County SSP is primarily open in the morning. The County SSP will explore piloting an adjusted schedule to provide greater accessibility for participants, not to exceed the Board-directed 10 hours per week (Exhibit F “County Board of Supervisors SSP Directives, June 18, 2014”).


Due to community concern regarding oversight of community organizations utilizing the County SSP secondary exchange to conduct syringe services, HSA recommends establishing a policy where participants who are exchanging only on behalf of others are allowed to exchange for a maximum of two people. This limitation of SSE strives to ensure that participants may continue to use non-IDU peer networks, such as exchanging on behalf of friends, loved ones and family, while limiting organized, large scale, community-wide syringe distribution as an SSE.


Restrictions on secondary syringe exchange are not supported by evidence-based best practices of SSPs or the findings of the Syringe Access and Disposal in Santa Cruz County evaluation (Exhibit C). There is a possibility that this restriction may further exacerbate inaccessibility of SSP services. However, HSA’s recommendation is driven by the community concern consistently voiced during the past six months and documented during the SSP Listening Sessions in November 2019 (Exhibit D).


HSA will consider additional recommendations to improve the County SSP, included in Exhibit C “Syringe Access and Disposal in Santa Cruz County” and Exhibit E “Sharper Solutions, County of Santa Cruz Grand Jury Findings, June 2017”. Evidence-based strategies to implement an effective SSP, a summary of which can be found in the Centers for Disease Control and Prevention document, “Evidence-Based Strategies for Preventing Opioid Overdose, 2018” (Exhibit G), will be continuously reviewed for local application.


Strategic Plan Element

This item supports the following County Strategic Plan Elements:

1.A. Comprehensive Health & Safety: Health Equity

1.B. Comprehensive Health & Safety: Community Support

1.C. Comprehensive Health & Safety: Local Justice

6.A. Operational Excellence: Customer Experience

6.D. Operational Excellence: Continuous Improvement


Meeting History

Dec 10, 2019 9:00 AM Video Board of Supervisors Regular Meeting

1) APPROVED a Health Services Agency (HSA) Syringe Services Program policy that manages secondary exchange by allowing clients who exchange on behalf of others to exchange for a maximum of two people, effective January 2020, and to add two additional hours to Santa Cruz and Watsonville sites where these exchanges take place;

2) ACCEPTED the evaluation of syringe litter in Santa Cruz County in partnership with the California Department of Public Health, titled “Syringe Access and Disposal in Santa Cruz County” dated November 2019;

3) DIRECTED that HSA return in June 2020 with recommendations to improve syringe litter reporting and response through a centralized system across all partners, and return on or before February 12 with contract(s) or contract amendments with providers to collect additional needles in the "hot spots" throughout the community and what the cost for that would be; additionally

4) DIRECTED setting a future Board study session by March 2020 on the IV drug crisis facing our county, with presentations requested from the Sheriff's Office, the Superior Court, and the Health Services administration, on the law enforcement, criminal justice system, treatment and prevention efforts that are being made to address this crisis; and additionally

5) DIRECTED that HSA have some regular meetings with the Grant Park neighbors to provide an opportunity to exchange ideas, which could include Human Services Department and other affected agencies

MOVER:Bruce McPherson, Fifth District Supervisor
SECONDER:Ryan Coonerty, Chair, Third District Supervisor
AYES:John Leopold, Zach Friend, Ryan Coonerty, Greg Caput, Bruce McPherson