Form 0920-21EE Att 3b_Component 2

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Att 3b_Component 2_5-28-2021

Core Viral Hepatitis Outbreak Prevention Activities

OMB: 0920-1353

Document [docx]
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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

-----------------------------------------------------------------------------------------------------------------------------------------------------


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


-----------------------------------------------------------------------------------------------------------------------------------------------------


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










































21


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCooley, Laura A. (CDC/DDID/NCHHSTP/DVH)
File Modified0000-00-00
File Created2021-08-04

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