Att 3b_Component 2

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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