Form 0920-21EE Att 3b_Component 2

Annual Performance Report—Component 2

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Component 2: Core Viral Hepatitis Prevention Activities

Reporting Agency

Reporting jurisdiction
Contact name (person completing form)
Contact phone number (xxx-xxx-xxxx)
Contact email address
Additional contact name(s) (if applicable)
Additional contact phone number(s) (xxx-xxx-xxxx)
Additional contact email address(es)
Date of report submission (MM/DD/YYYY)
Reporting Period (Complete this form with information from Reporting Period selected)	Select one □ Year 1 □ Year 2 □ Year 3 □ Year 4 □ Year 5

2.1—Support viral hepatitis elimination planning and surveillance,

and maximize access to testing, treatment, and prevention

Measures 2.1.1.a – 2.1.1.b

• Establishment and maintenance of a viral hepatitis elimination technical advisory committee (or coalition) with membership to support jurisdictional viral hepatitis elimination planning

• Conduct at least two meetings per year of the viral hepatitis elimination technical advisory committee (or coalition)

Have you established a viral hepatitis elimination technical advisory committee (or coalition) to support viral hepatitis elimination planning?	Select one □ Completed □ In progress		□ Not started
Identify the stakeholder groups represented on this committee (or coalition). (select all that apply)	□ Public health □ Corrections □ Criminal justice, law enforcement □ Medicaid □ Injury prevention services □ Substance use and mental health services □ Healthcare providers □ HIV care providers □ Hospitals		□ Laboratories □ Community-based organizations □ Local harm reduction coalition members □ Non-profit/advocacy groups □ People with viral hepatitis lived experience □ Other, specify: > > □ N/A (committee not established)
Does the committee (or coalition) plan to support elimination for hepatitis C and/or hepatitis B? (select all that apply)		□ Hepatitis C □ Hepatitis B		□ N/A (committee not established)
During this reporting period, when did the committee (or coalition) meet? (MM/DD/YYYY)	> >		> >
	□ N/A (committee not established)
If the committee (or coalition) met during this reporting period, please submit a copy of meeting agenda(s).		Select one □ Submitted □ Not submitted □ N/A (committee not established)

Measure 2.1.1.c

• Development and maintenance of a viral hepatitis elimination plan with support from the technical advisory committee (or coalition)

Have you developed a viral hepatitis elimination plan as part of this cooperative agreement?	Select one □ Completed □ In progress	□ Not started
Does it contain plans for elimination of hepatitis C and/or hepatitis B? (select all that apply)	□ Hepatitis C □ Hepatitis B	□ N/A (plan not started)
If the viral hepatitis elimination plan is completed, please submit a copy.	Select one □ Submitted □ Not submitted □ N/A (plan not started)

Measures 2.1.2.c, 2.1.4.a

• The jurisdictional viral hepatitis elimination plan addresses recommendations for increasing HCV RNA reflex testing

• The jurisdictional viral hepatitis elimination plan addresses provider training in prescribing hepatitis C and hepatitis B treatment

Does your viral hepatitis elimination plan address recommendations for increasing HCV RNA reflex testing?	Select one □ Yes □ No	□ N/A (plan not started)
Does your viral hepatitis elimination plan address provider training in prescribing hepatitis C treatment?	Select one □ Yes □ No	□ N/A (plan not started)
Does your viral hepatitis elimination plan address provider training in prescribing hepatitis B treatment?	Select one □ Yes □ No	□ N/A (plan not started)

Measures 2.1.2.a – 2.1.2.b

• CLIA-certified laboratories that conduct testing for at least 80% of all anti-HCV results identified in the jurisdiction

• The proportion conducting HCV RNA reflex testing was assessed; feedback with recommendations conducted

Have you worked with your surveillance and/or epidemiology teams to identify the total number of CLIA-certified laboratories in your jurisdiction that report hepatitis C antibody testing results?	Select one □ Yes □ No
Of those, have you selected the subset that reports at least 80% of the hepatitis C antibody testing results in your jurisdiction?	Select one □ Yes □ No	□ N/A (labs not identified)
Of the subset, have you performed a needs assessment to identify key barriers and challenges to increasing HCV RNA reflex testing?	Select one □ Yes □ No	□ N/A (labs not identified)
What proportion of the subset is conducting HCV RNA reflex testing?	Select one %: □ Unknown	□ N/A (labs not identified)
Have you provided recommendations to increase HCV RNA reflex testing?	Select one □ Yes □ No	□ N/A (labs not assessed)

Measures 2.1.3.a – 2.1.3.b

• The top 5 highest volume health systems in the jurisdiction identified

• The proportion of health systems promoting routine HCV and HBV testing assessed; feedback with recommendations was conducted

What are the top 5 highest volume health systems in your jurisdiction?	1. 2. 3. 4. 5. □ Unknown
Have you assessed how many of these health systems are promoting routine HCV testing?		Select one □ Completed □ In progress	□ Not started
If so, what percent of health systems are promoting routine HCV testing?		%: □ Unknown	□ N/A (health systems not assessed)
Have you assessed how many of these health systems are promoting routine HBV testing?		Select one □ Completed □ In progress	□ Not started
If so, what percent of health systems are promoting routine HBV testing?		%: □ Unknown	□ N/A (health systems not assessed)
Have you provided feedback to the top 5 highest volume health systems with recommendations on promoting routine HCV and/ or HBV testing?		Select one □ Yes □ No	□ N/A (health systems not assessed)

Use this space if needed to provide additional information related to Section 2.1

Was Section 2.2 funded?

Select one

□ No NOTE: Stop here if not funded

□ Yes

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2.2—Increase access to hepatitis C and/or hepatitis B testing and referral to care

in high-impact settings

Measures 2.2.2.a – 2.2.2.b

• Jurisdiction established relationship with partners in high-impact settings to identify high priority facilities for expansion of testing for HCV and/or HBV in high-impact settings, by setting type (syringe services programs, substance use disorder treatment programs, correctional facilities, emergency departments, hospital-based programs, sexually transmitted disease clinics, homeless services, health centers, other)

• Number of clients seen, by setting

Setting	Relationship established to expand HCV testing	Relationship established to expand HBV testing	Number of clients seen during this reporting period
Setting 1 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	Select one □ Yes □ No	Select one □ Yes □ No	> □ Unknown □ N/A
Total number of settings: >			TOTAL: >

Measures 2.2.2.c – 2.2.2.f, 2.2.3.a

• Number of clients screened for hepatitis C (anti-HCV), by setting

• Number of clients positive for anti-HCV, by setting

• Number of clients tested for HCV RNA, by setting

• Number of clients positive for HCV RNA, by setting

• Number of clients positive for HCV RNA linked to treatment, by setting

	During this reporting period, number of:
Setting	Clients screened for hepatitis C (anti-HCV)	Clients positive for anti-HCV	Clients tested for HCV RNA	Clients positive for HCV RNA	Clients positive for HCV RNA linked to hepatitis C treatment
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 2.2.2.g – 2.2.2.h, 2.2.3.b

• Number of clients screened for hepatitis B, by setting

• Number of clients positive for HBsAg, by setting

• Number of clients positive for HBsAg linked to care, by setting

	During this reporting period, number of:
Setting	Clients screened for hepatitis B	Clients positive for HBsAg	Clients positive for HBsAg linked to hepatitis B care
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >

Use this space if needed to provide additional information related to Section 2.2

Was Section 2.3 funded?

Select one

□ No NOTE: Stop here if not funded

□ Yes

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2.3—Improve access to services preventing viral hepatitis

and other bloodborne infections among people who inject drugs (PWID)

Measures 2.3.3.a – 2.3.3.d

• Number of hepatitis A vaccination doses administered to clients in the high-impact settings, by setting

• Number of clients in the high-impact settings who completed hepatitis A vaccination series, by setting

• Number of hepatitis B vaccination doses administered to clients in the high-impact settings, by setting

• Number of clients in the high-impact settings who completed hepatitis B vaccination series, by setting

	During this reporting period, number of:
Setting	Hepatitis A vaccination doses administered	Clients who completed hepatitis A vaccination series	Hepatitis B vaccination doses administered	Clients who completed hepatitis B vaccination series
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 2.3.1.a – 2.3.1.d, 2.3.2.a

• Number of syringe services programs (SSPs) in the jurisdiction

• Number of visits in the jurisdiction, by SSP

• Number of unduplicated SSP clients in the jurisdiction, by SSP

• Mean (median) syringe coverage rates, by SSP

• Number of clients linked to substance use disorder treatment by SSPs in the jurisdiction, by SSP

	During this reporting period, number of:
Syringe services programs (SSPs) in jurisdiction	Client visits	Unduplicated SSP clients	Clients linked to substance use disorder treatment	Mean (median) syringe coverage rates during this reporting period
SSP 1 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 2 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 3 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 4 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 5 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 6 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 7 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 8 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 9 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 10 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 11 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 12 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 13 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 14 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 15 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 16 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 17 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 18 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 19 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 20 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 21 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 22 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 23 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 24 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 25 Name: >	> □ Unknown □ N/A	□ Unknown □ N/A	□ Unknown □ N/A	>
SSP 26 Name: >	> □ Unknown □ N/A	□ Unknown □ N/A	□ Unknown □ N/A	>
SSP 27 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 28 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 29 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 30 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 31 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 32 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 33 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 34 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 35 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 36 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 37 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 38 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 39 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 40 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 41 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 42 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 43 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 44 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 45 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 46 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 47 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 48 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 49 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
SSP 50 Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	>
Total number of SSPs: >	TOTAL: >	TOTAL: >	TOTAL: >	Overall mean (median): >

Use this space if needed to provide additional information related to Section 2.3

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