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An outbreak of the AIDS virus among injecting drug users in rural Indiana has spread to at least 135 people, and federal officials are warning communities around the country to look out for similar outbreaks.

The Centers for Disease Control and Prevention said Friday that “urgent action” was needed to control the outbreak in Indiana’s Scott County and said it’s possible other cities or towns are vulnerable.

A combination of easily available prescription painkillers, a poor economy and a lack of education are fueling the Indiana outbreak. And because there’s an epidemic of painkiller abuse across the country, people could be spreading both HIV and hepatitis anywhere, CDC said.

“HIV can gain ground at any time unless you remain vigilant,” Dr. Jonathan Mermin, who directs CDC’s HIV/AIDS center, told reporters.

“The situation in Indiana should serve as a warning. We cannot let down our guard against these deadly infections,” Mermin said.

“The situation in Indiana should serve as a warning."

HIV and hepatitis C both spread via shared needles. In the U.S. 3,900 people become infected each year with HIV because of shared needles. That’s down by 95 percent from the 1980s and CDC is not eager to see the numbers come back up again.

But there’s a potentially deadly combination as drug users get access to pain pills that they grind up and inject. Users in big cities know not to share needles, they have access to testing, education and fresh needles. But drug users in rural areas where there hasn’t been an all-out push to educate people about the risks might not know how dangerous it is, Mermin said.

CDC says an epidemic of opioid abuse is already driving an epidemic of hepatitis. Mermin said there was a 150 percent increase in reports of hepatitis C between 2010 and 2013. “The majority of these are believed to be attributable to injecting drug use,” Mermin said.

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Deaths from opioid overdoses nearly quadrupled from 1999 through 2011.

Add to this the fact that opioid pills are not meant to be ground up and injected, said Indiana State Health Commissioner Dr. Jerome Adams.

“We found that when people are using oral medications and crushing them up, they are not as dissolvable as, say, heroin,” Adams said. They must use a fatter needle, and that means more blood and more virus is getting into the needle. If it’s shared, everyone gets a higher dose of HIV.

“The overprescribing of these powerful drugs has created a national epidemic of abuse and overdose,” Adams said.

“We are asking states to take a close look at their most recent data on HIV and hepatitis C diagnoses,” Mermin said. “This may help identify communities at unrecognized risk of unseen clusters.”

Both the human immunodeficiency virus that causes AIDS and the hepatitis C virus are spread in bodily fluids, including blood. Both can kill people if they are not diagnosed and treated.

“There are children and parents and grandparents who live in the same house who are injecting drugs together as a sort of community activity."

Officials painted a picture of families where grandparents sit down to do drugs with their grandchildren, with everyone freely sharing the same needles.

“There are children and parents and grandparents who live in the same house who are injecting drugs together as a sort of community activity,” said Dr. Joan Duwve, chief medical consultant for the Indiana department of health.

The CDC and Indiana said they found those affected were crushing and cooking extended-release oxymorphone pills. “Syringes and drug preparation equipment are frequently shared (e.g., the drug is dissolved in nonsterile water and drawn up into an insulin syringe that is usually shared with others),” they wrote.

People are shooting up four to 15 times a day, sharing needles with as many as six other people at a time.

It’s clear why they have the time to do so. “Like many other rural counties in the United States, the county has substantial unemployment (8.9 percent), a high propor­tion of adults who have not completed high school (21.3 percent), a substantial proportion of the population living in poverty (19 percent), and limited access to health care,” the CDC and Indiana officials wrote.

“This county consistently ranks among the lowest in the state for health indicators and life expectancy.”

CDC and health officials are tracking down the sexual partners and needle-sharing friends of all 135 cases. It’s a high percentage in a community of only 4,200 people.

For now, CDC is helping Indiana officials track down infections. Needle exchanges are illegal in Indiana, but Gov. Mike Pence, a Republican, has issued an executive order allowing temporary needle exchanges. Doctors from Indiana University have also started helping staff clinics to help drug abusers.