Form 0920-21EE 3c_Component 3

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Comp 3_APR_Form_Year2_12-08-2021_Aug2022_clean

Component 3: Special Projects

OMB: 0920-1353

Document [docx]
Download: docx | pdf

Annual Performance Report—Component 3

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Component 3: Special Projects—Prevention, Diagnosis, and Treatment Related to the Infectious Disease Consequences of Drug Use


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 (5/1/21-9/30/21)

□ Year 2 (10/1/21-9/30/22)

□ Year 3 (10/1/22-9/30/23)

□ Year 4 (10/1/23-9/30/24)

□ Year 5 (10/1/24-4/30/26)



Was Component 3 funded?

Select one

□ No NOTE: Stop here if not funded


□ Yes

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



3.1—Improve access to services for people who inject drugs (PWID)

in settings disproportionately affected by drug use



List all types of settings serving PWID


During the reporting period were component 3 activities conducted at one or more syringe services programs (SSPs)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or substance use disorder (SUD) treatment programs (non-hospital based)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or hospital-based substance use disorder (SUD) treatment programs?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more hospital-based programs (excluding SUD treatment programs which are included separately above)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more health centers (non-hospital based)?

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more sexually transmitted infections (STI) clinics? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more mobile clinics? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more emergency departments? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more correctional facilities? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at one or more homeless services? 

□ Yes

□ No

During the reporting period were component 3 activities conducted at another type of setting? 

□ Yes, specify: __________________

□ No

Note: If more than one other type of setting, list the first other type here and describe the additional other type(s) individually in the following questions. 

During the reporting period were component 3 activities conducted at a second other type of setting? 

□ Yes, specify: __________________

□ No

Note: If more than two other types of settings, list the second other type here and describe the additional other type(s) individually in the following questions. 

During the reporting period were component 3 activities conducted at a third other type of setting?

□ Yes, specify: __________________

□ No






Measures 3.1.1.a – 3.1.1.b

  • Number of PWID served, by setting serving PWID (syringe services programs, substance use disorder treatment programs, correctional facilities, emergency departments, hospital-based programs, sexually transmitted disease clinics, homeless services, health centers, other)

  • Syringes distributed, by setting serving PWID



During this reporting period, number of:

Setting type serving PWID


Clients served

PWID served

Syringes distributed

SSPs

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A






Measures 3.1.2.a – 3.1.2.d

  • Number of PWID who are linked to substance use disorder treatment, by setting serving PWID

  • Number of PWID assessed for opioid use disorder, by setting serving PWID

  • Number of PWID with opioid use disorder, by setting serving PWID

  • Number of PWID with opioid use disorder who are linked to medication for opioid use disorder, by setting serving PWID





During this reporting period, number of:

Setting serving PWID


PWID linked to substance use disorder treatment

PWID assessed for opioid use disorder

PWID with opioid use disorder

PWID with opioid use disorder who were linked to medication for opioid use disorder

SSPs

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A






Measures 3.1.3.a, 3.1.4.a – 3.1.4.d

  • Number of clients tested for anti-HCV, by setting serving PWID

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

  • Number of clients positive for anti-HCV tested for HCV RNA, by setting serving PWID

  • Number of clients testing positive for HCV RNA, by setting serving PWID

  • Number of HCV RNA (+) clients linked to hepatitis C treatment, by setting serving PWID




During this reporting period, number of:

Setting serving PWID


Clients tested for anti-HCV

Clients testing positive for anti-HCV

Clients positive for anti-HCV tested for HCV RNA

Clients testing positive for HCV RNA

HCV RNA (+) clients linked to hepatitis C treatment

SSPs

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A





Measures 3.1.3.b, 3.1.4.e – 3.1.4.f

  • Number of clients screened (anti-HBc, HBsAg, anti-HBs) for HBV, by setting serving PWID

  • Number of clients testing positive for HBsAg, by setting serving PWID

  • Number of HBV (+) clients linked to hepatitis B care, by setting serving PWID



During this reporting period, number of:

Setting serving PWID


Clients screened for HBV (anti-HBc, HBsAg, anti-HBs)

Clients testing positive for HBsAg

HBV (+) clients linked to hepatitis B care

SSPs

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A






Measures 3.1.3.c, 3.1.4.g – 3.1.4.h

  • Number of clients screened for HIV, by setting serving PWID

  • Number of clients testing positive for HIV, by setting serving PWID

  • Number of HIV (+) clients linked to HIV treatment, by setting serving PWID




During this reporting period, number of:

Setting serving PWID


Clients screened for HIV


Clients testing positive for HIV

HIV (+) clients linked to HIV treatment

SSPs

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A









Measure 3.1.4.i

  • Number of clients referred for treatment for bacterial or fungal infections, by setting serving PWID




During this reporting period, number of:

Setting serving PWID

Clients treated or referred for treatment of bacterial or fungal infections

SSPs

questions will be skipped if not applicable

>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown




Measures 3.1.5.a – 3.1.5.d

  • Number of hepatitis A vaccination doses administered to clients, by setting serving PWID

  • Number of clients who completed hepatitis A vaccination series, by setting serving PWID

  • Number of hepatitis B vaccination doses administered to clients, by setting serving PWID

  • Number of clients who completed hepatitis B vaccination series, by setting serving PWID



During this reporting period, number of:

Setting serving PWID


Hepatitis A vaccination doses administered

Clients who completed hepatitis A vaccination series

Hepatitis B vaccination doses administered

Clients who completed hepatitis B vaccination series

SSPs

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, non-hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


SUD treatment programs, hospital-based

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Hospital-based programs (excluding SUD treatment programs which are included separately above)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Health centers (non-hospital based)

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


STI clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Mobile clinics

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Emergency departments

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Correctional facilities

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Homeless services

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, first

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, second

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown


>

□ Unknown


>

□ Unknown


Other type of setting described above, third

questions will be skipped if not applicable

>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A



>

□ Unknown


>

□ Unknown

□ N/A

>

□ Unknown

□ N/A

>

□ Unknown

□ N/A












Measures 3.1.6.a – 3.1.6.c, 3.1.7.a

  • Number of new confirmed acute hepatitis B cases reported among PWID in the jurisdiction

  • Number of new confirmed acute hepatitis C cases reported among PWID in the jurisdiction

  • Number of new confirmed HIV cases reported among PWID in the jurisdiction

  • Jurisdiction reports data on hepatitis C continuum of care for PWID in the jurisdiction, consistent with CDC guidance


How many new confirmed acute hepatitis B cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?

>

□ Unknown

How many new confirmed acute hepatitis C cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?

>

□ Unknown

How many new confirmed HIV cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?

>

□ Unknown

Do you report hepatitis C viral clearance cascade data for reported cases among people reporting a history of injection drug use in your jurisdiction?

Select one

□ Yes

□ No




Please use this space to provide information about challenges and successes experienced when implementing Strategy 3.1 activities. Include additional contextual information that would help us interpret your annual performance data.


For example, the number of locations associated with each setting type, or other explanatory notation, could be listed here if needed.








































11


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCooley, Laura A. (CDC/DDID/NCHHSTP/DVH)
File Modified0000-00-00
File Created2022-08-11

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