0920-1353 Component 1: Core Viral Hepatitis Outbreak Response and

Annual Performance Report—Component 1

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Component 1: Core Viral Hepatitis Outbreak Response and Surveillance 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

1.1—Develop, implement, and maintain plan to rapidly detect and respond to outbreaks of hepatitis A, hepatitis B, and hepatitis C

Measure 1.1.1.a

• A documented plan for responding to outbreaks of hepatitis A, hepatitis B, and hepatitis C infections

Outbreak type	Plan status	Topics covered (select all that apply)	Date plan was last reviewed (MM/DD/YYYY)
Hepatitis A	Select one □ Completed □ In progress □ Not started	□ Community/person-to-person □ Foodborne — associated with an infected food handler □ Foodborne — associated with contaminated food □ Waterborne □ Other, specify:	> > > > >
Hepatitis B	Select one □ Completed □ In progress □ Not started	□ Community/person-to-person □ Healthcare-associated □ Other, specify:	> > >
Hepatitis C	Select one □ Completed □ In progress □ Not started	□ Community/person-to-person □ Healthcare-associated □ Other, specify:	> > >

Measure 1.1.1.b

• CDC is notified of outbreaks within 5 business days of identifying the outbreak

Jurisdiction-assigned outbreak ID1	Outbreak type (select all that apply)	Date outbreak was confirmed (MM/DD/YYYY)	The outbreak was reported to CDC	The outbreak was reported to CDC but later determined not to be an outbreak
>	□ Hepatitis A □ Hepatitis B □ Hepatitis C □ Other, specify: >	>	Select one □ < 5 business days after confirming outbreak □ > 5 business days after confirming outbreak □ Was not reported to CDC	Select one □ True (this was not an outbreak) □ False (this was a confirmed outbreak)
>	□ Hepatitis A □ Hepatitis B □ Hepatitis C □ Other, specify: >	>	Select one □ < 5 business days after confirming outbreak □ > 5 business days after confirming outbreak □ Was not reported to CDC	Select one □ True (this was not an outbreak) □ False (this was a confirmed outbreak)
>	□ Hepatitis A □ Hepatitis B □ Hepatitis C □ Other, specify: >	>	Select one □ < 5 business days after confirming outbreak □ > 5 business days after confirming outbreak □ Was not reported to CDC	Select one □ True (this was not an outbreak) □ False (this was a confirmed outbreak)
>	□ Hepatitis A □ Hepatitis B □ Hepatitis C □ Other, specify: >	>	Select one □ < 5 business days after confirming outbreak □ > 5 business days after confirming outbreak □ Was not reported to CDC	Select one □ True (this was not an outbreak) □ False (this was a confirmed outbreak)
>	□ Hepatitis A □ Hepatitis B □ Hepatitis C □ Other, specify: >	>	Select one □ < 5 business days after confirming outbreak □ > 5 business days after confirming outbreak □ Was not reported to CDC	Select one □ True (this was not an outbreak) □ False (this was a confirmed outbreak)
>	□ Hepatitis A □ Hepatitis B □ Hepatitis C □ Other, specify: >	>	Select one □ < 5 business days after confirming outbreak □ > 5 business days after confirming outbreak □ Was not reported to CDC	Select one □ True (this was not an outbreak) □ False (this was a confirmed outbreak)

¹ A jurisdiction-assigned unique name or identifier for an identified outbreak. For jurisdictions reporting via HL7, this is PHIN variable code=INV151 and data element identifier=77981-9.

Measure 1.1.1.c

• CDC is notified of all cases associated with an outbreak within 30 days of case investigation start date

For the purposes of this form, is ‘Case investigation start date’ being used?		Select one □ Yes □ No
If not, please indicate what your health department is using.

Jurisdiction-assigned outbreak ID (corresponding to IDs from 1.1.1.b)	Number of outbreak-associated cases	Number of outbreak-associated cases reported to CDC within 30 days of case investigation start date (as determined for each case)
>	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):
>	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):
>	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):
>	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):
>	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):
>	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):	Hepatitis A: Hepatitis B: Hepatitis C: Other (specified above):

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Use this space if needed to provide additional information related to Section 1.1

1.2—Systematically collect, analyze, interpret, and disseminate data to characterize trends and implement public health interventions for hepatitis A,

acute hepatitis B, and acute and chronic hepatitis C

Measure 1.2.1.a

• Jurisdiction receives reporting of all (positive/detectable, negative/undetectable) HBV DNA and HCV RNA results at the state or local health department

Are negative hepatitis B surface antigen (sAg) results currently reportable in your jurisdiction?	Select one □ Yes, all negative lab results are reportable □ Yes, some negative lab results are reportable Specify: □ No
Are negative hepatitis B sAg results currently received by your health department?	Select one □ Yes, all negative lab results are received by the health department (complete reporting) □ Yes, some negative lab results are received by the health department (incomplete reporting) Specify: □ No
If “Yes, all….” what was the first full reporting year that all negative hepatitis B sAg results were available in your jurisdiction?	Year:
Are negative HBV DNA results currently reportable in your jurisdiction?	Select one □ Yes, all negative lab results are reportable □ Yes, some negative lab results are reportable Specify: □ No
Are negative HBV DNA results currently received by your health department?	Select one □ Yes, all negative lab results are received by the health department (complete reporting) □ Yes, some negative lab results are received by the health department (incomplete reporting) Specify: □ No
If “Yes, all…,” what was the first full reporting year that all negative HBV DNA results were available in your jurisdiction?	Year:

Are negative hepatitis C antibody (anti-HCV) results currently reportable in your jurisdiction?	Select one □ Yes, all negative lab results are reportable □ Yes, some negative lab results are reportable Specify: □ No
Are negative anti-HCV results currently received by your health department?	Select one □ Yes, all negative lab results are received by the health department (complete reporting) □ Yes, some negative lab results are received by the health department (incomplete reporting) Specify: □ No
If “Yes, all…,” what was the first full reporting year that all negative anti-HCV results were available in your jurisdiction?	Year:
Are negative / undetectable HCV RNA results currently reportable in your jurisdiction?	Select one □ Yes, all negative lab results are reportable □ Yes, some negative lab results are reportable Specify: □ No
Are negative / undetectable HCV RNA results currently received by your health department?	Select one □ Yes, all negative lab results are received by the health department (complete reporting) □ Yes, some negative lab results are received by the health department (incomplete reporting) Specify: □ No
If “Yes, all…,” what was the first full reporting year that all negative HCV RNA results were available in your jurisdiction?	Year:

Measures 1.2.2.a – 1.2.2.c, 1.2.3.a

• Laboratories that perform viral hepatitis-related testing for the jurisdiction report a minimum of 95% of viral hepatitis-related test results to the state or local health department

• A minimum of 85% of viral hepatitis lab results are entered into the jurisdiction’s viral hepatitis surveillance database within 60 days of specimen collection date

• A minimum of 90% of case reports of hepatitis A, acute hepatitis B, and acute hepatitis C are submitted to CDC by the health department within 90 days of case investigation start date

• A minimum of 90% of case reports of chronic hepatitis C are submitted to CDC by the health department within 90 days of case investigation start date

Have you identified all laboratories that perform viral hepatitis-related testing for your jurisdiction?	Select one □ Completed □ In progress □ Not started
If yes, what percent of these laboratories reported viral hepatitis-related test results during this reporting period?	Number: Total: %: □ Unknown

During this reporting period:
What percent of your viral hepatitis lab results were entered into your viral hepatitis surveillance database within 60 days of specimen collection date?	Number: Total: %: □ Unknown
What percent of your hepatitis A case reports were submitted to CDC within 90 days of case investigation start date?	Number: Total: %: □ Unknown
What percent of your acute hepatitis B case reports were submitted to CDC within 90 days of case investigation start date?	Number: Total: %: □ Unknown
What percent of your acute hepatitis C case reports were submitted to CDC within 90 days of case investigation start date?	Number: Total: %: □ Unknown
What percent of your chronic hepatitis C case reports were submitted to CDC within 90 days of case investigation start date?	Number: Total: %: □ Unknown

Measures 1.2.2.d, 1.2.3.b

• Case reports of hepatitis A, acute hepatitis B, and acute hepatitis C submitted to CDC by health departments are at least 90% complete for age, gender, race/ethnicity, county of residence, and outbreak status

• A minimum of 90% of case reports of chronic hepatitis C submitted to CDC are complete for age, gender, race/ethnicity, and county of residence

	Age	Gender	Race and/or ethnicity	County of residence	Outbreak status
Hepatitis A	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:
Acute hepatitis B	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:
Acute hepatitis C	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:
Chronic hepatitis C	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:

Measure 1.2.2.e

• Case reports of hepatitis A, acute hepatitis B, and acute hepatitis C submitted to CDC by health departments are at least 70% complete for risk factors

Risk behaviors and exposures
Hepatitis A	Acute hepatitis B	Acute hepatitis C
Injection drug use Number: Total: % complete: □ N/A (not reported)	Injection drug use Number: Total: % complete: □ N/A (not reported)	Injection drug use Number: Total: % complete: □ N/A (not reported)
Sexual contact Number: Total: % complete: □ N/A (not reported)	Sexual contact Number: Total: % complete: □ N/A (not reported)	Sexual contact Number: Total: % complete: □ N/A (not reported)
Household contact (non-sexual) Number: Total: % complete: □ N/A (not reported)	Household contact (non-sexual) Number: Total: % complete: □ N/A (not reported)	Household contact (non-sexual) Number: Total: % complete: □ N/A (not reported)
Other contact Number: Total: % complete: □ N/A (not reported)	Multiple sex partners Number: Total: % complete: □ N/A (not reported)	Multiple sex partners Number: Total: % complete: □ N/A (not reported)
Men who have sex with men Number: Total: % complete: □ N/A (not reported)	Men who have sex with men Number: Total: % complete: □ N/A (not reported)	Men who have sex with men Number: Total: % complete: □ N/A (not reported)
International travel Number: Total: % complete: □ N/A (not reported)	Surgery Number: Total: % complete: □ N/A (not reported)	Surgery Number: Total: % complete: □ N/A (not reported)
Homelessness/unstable housing Number: Total: % complete: □ N/A (not reported)	Dialysis patient Number: Total: % complete: □ N/A (not reported)	Dialysis patient Number: Total: % complete: □ N/A (not reported)
Incarceration Number: Total: % complete: □ N/A (not reported)	Transfusion (tissue or organ) Number: Total: % complete: □ N/A (not reported)	Transfusion (tissue or organ) Number: Total: % complete: □ N/A (not reported)
Non-injection drug use Number: Total: % complete: □ N/A (not reported)	Needlestick Number: Total: % complete: □ N/A (not reported)	Needlestick Number: Total: % complete: □ N/A (not reported)
Drug sharing partner Number: Total: % complete: □ N/A (not reported)	Occupational exposure to blood Number: Total: % complete: □ N/A (not reported)	Occupational exposure to blood Number: Total: % complete: □ N/A (not reported)
	Drug sharing partner Number: Total: % complete: □ N/A (not reported)	Drug sharing partner Number: Total: % complete: □ N/A (not reported)
	Homelessness/unstable housing Number: Total: % complete: □ N/A (not reported)	Homelessness/unstable housing Number: Total: % complete: □ N/A (not reported)
	Incarceration Number: Total: % complete: □ N/A (not reported)	Incarceration Number: Total: % complete: □ N/A (not reported)
	Non-injection drug use Number: Total: % complete: □ N/A (not reported)	Non-injection drug use Number: Total: % complete: □ N/A (not reported)
	Tattoo receipt Number: Total: % complete: □ N/A (not reported)	Tattoo receipt Number: Total: % complete: □ N/A (not reported)
	International travel Number: Total: % complete: □ N/A (not reported)

Measure 1.2.3.c

• A minimum of 90% of case reports of chronic hepatitis C are included in a longitudinal surveillance registry, including longitudinal detectable and undetectable HCV RNA test results

Have you developed a longitudinal surveillance registry for chronic hepatitis C?	Select one □ Completed □ In progress	□ Not started
What percent of your chronic hepatitis C case reports are included in your registry?	Number: Total: %:	□ Unknown □ N/A (registry not started)
Does your registry include longitudinal detectable and undetectable HCV RNA test results for the chronic hepatitis C cases?	Select one □ Yes □ No	□ N/A (registry not started)

Measures 1.2.4.a, 1.2.5.a

• Jurisdiction reports data on hepatitis C viral clearance cascade, consistent with CDC guidance

• Prepare and disseminate an annual viral hepatitis surveillance report, including data on hepatitis A, acute hepatitis B, and acute and chronic hepatitis C to support prevention programs and policies

Have you developed a hepatitis C viral clearance cascade?	Select one □ Completed □ In progress	□ Not started
If hepatitis C viral clearance cascade “Completed,” please indicate when the most recent cascade was completed and provide the URL for—or a copy of—the cascade.	□ Date completed (MM/DD/YYYY): □ Please provide URL for cascade, if available: If URL not available, please submit a copy of the cascade with the APR. Select one □ Submitted □ Not submitted
Have you developed a viral hepatitis surveillance report?	Select one □ Completed □ In progress	□ Not started
If viral hepatitis surveillance report “Completed,” please indicate when the most recent report was completed and provide the URL for—or a copy of—the report.	□ Date completed (MM/DD/YYYY): □ Please provide URL for report, if available: If URL not available, please submit a copy of the report with the APR. Select one □ Submitted □ Not submitted

Use this space if needed to provide additional information related to Section 1.2

This section is to be completed in YEAR 1 ONLY

Among all the newly reported hepatitis B cases (acute and chronic) in 2019 among individuals ≤40 years of age, what proportion had an unknown anti-HBC IgM result?	Select one □ None □ <25% □ 25% – <50%	□ 50% – <75% □ >75%
Among those cases that had an unknown anti-HBc IgM result, what proportion were investigated?	Select one □ None □ <25% □ 25% – <50%	□ 50% – <75% □ >75%

Among all newly reported hepatitis C cases (acute and chronic) in 2019 among individuals ≤40 years of age, what proportion of cases were investigated by a public health department?

Select one □ None □ <25% □ 25% – <50%

□ 50% – <75% □ >75%

Of all of the hepatitis A, acute hepatitis B, and acute hepatitis C infections that you believe (or have estimated) occurred in your jurisdiction in 2019, what proportion do you believe were: 1) reported to the state or local health department in your jurisdiction and 2) a notification was sent to CDC?
Confirmed Hepatitis A			Confirmed Hepatitis B, acute		Confirmed Hepatitis C, acute
Reported to your jurisdiction		CDC was notified	Reported to your jurisdiction	CDC was notified	Reported to your jurisdiction	CDC was notified
Select one		Select one	Select one	Select one	Select one	Select one
□ <25%		□ <25%	□ <25%	□ <25%	□ <25%	□ <25%
□ 25%-<50%		□ 25%-<50%	□ 25%-<50%	□ 25%-<50%	□ 25%-<50%	□ 25%-<50%
□ 50%-<75%		□ 50%-<75%	□ 50%-<75%	□ 50%-<75%	□ 50%-<75%	□ 50%-<75%
□ ≥75%		□ ≥75%	□ ≥75%	□ ≥75%	□ ≥75%	□ ≥75%
Please provide a brief justification for the answer you selected for each acute viral hepatitis infection in the question above.

Was Section 1.3 funded?

Select one

□ No NOTE: Stop here if not funded

□ Yes

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1.3—Systematically collect, analyze, interpret, and disseminate data to

characterize trends and implement public health interventions for

chronic hepatitis B and perinatal hepatitis C

Measures 1.3.1.a – 1.3.1.b, 1.3.1.d, 1.3.2.a

• By December 31st of each year, mother and child matches are ascertained from local/state health department vital records through the end of the prior year by linking all known births to mothers found in viral hepatitis surveillance data base

• A minimum of 90% of case reports of perinatal hepatitis C submitted to CDC within 90 days of case investigation start date

• A minimum of 90% of perinatal infant hepatitis C case reports are linked with a maternal report

• A minimum of 90% of case reports of chronic hepatitis B submitted to CDC within 90 days of case investigation start date

By December 31, were mother and child matches ascertained from health department vital records by linking all known births from the prior calendar year to mothers found in your viral hepatitis surveillance data base?	Select one □ Yes, all □ Yes, some □ No, none
During this reporting period, what percent of your perinatal hepatitis C case reports were submitted to CDC within 90 days of case investigation start date?	Number: Total: %: □ Unknown
During this reporting period, what percent of your perinatal hepatitis C case reports were linked with a maternal report?	Number: Total: %: □ Unknown
During this reporting period, what percent of your chronic hepatitis B case reports were submitted to CDC within 90 days of case investigation start date?	Number: Total: %: □ Unknown

Measures 1.3.1.c, 1.3.2.b

• A minimum of 90% of case reports of perinatal hepatitis C submitted to CDC are complete for age, gender, race/ethnicity, county of residence

• A minimum of 90% of case reports of chronic hepatitis B submitted to CDC are complete for age, gender, race/ethnicity, county of residence

	Age	Gender	Race and/or ethnicity	County of residence
Perinatal hepatitis C	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:
Chronic hepatitis B	Number: Total: %:	Number: Total: %:	Number: Total: %:	Number: Total: %:

Measure 1.3.3.a

• A minimum of 90% of case reports of chronic hepatitis B are included in a longitudinal surveillance registry, including longitudinal detectable and undetectable HBV DNA test results

Have you developed a longitudinal surveillance registry for chronic hepatitis B?	Select one □ Completed □ In progress	□ Not started
What percent of your chronic hepatitis B case reports are included in your registry?	Number: Total: %:	□ Unknown □ N/A (registry not started)
Does your registry include longitudinal detectable and undetectable HBV DNA test results for the chronic hepatitis B cases?	Select one □ Yes □ No	□ N/A (registry not started)

Measures 1.3.3.b – 1.3.3.c

• Jurisdiction reports data on hepatitis B continuum of care, consistent with CDC guidance

• Chronic hepatitis B data and hepatitis B continuum of care data are included in the annual summary of surveillance data

Are you reporting hepatitis B continuum of care data?	Select one □ Yes	□ No
Does your annual viral hepatitis surveillance report include chronic hepatitis B data?	Select one □ Yes □ No	□ N/A (report not started)
Does your annual viral hepatitis surveillance report include hepatitis B continuum of care data?	Select one □ Yes □ No	□ N/A (report not started)

Use this space if needed to provide additional information related to Section 1.3

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