2006
Division of Disease Prevention
2006 Program Summary
Director’s Message Web site Information
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Section I: Community Services
Health Education/Risk Reduction Public Information Hotline Services Capacity Building Community Planning Program Evaluation Monitoring System (PEMS)
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5 5 6 6 6 7
TABLE OF CONTENTS
Section II: Field Services
HIV Prevention, Counseling, Testing, Referral and Partner Services Sexually Transmitted Disease Prevention Program Chlamydia Prevention Program Viral Hepatitis Prevention Program Training Unit
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8 8 9 9 10
Section III: Health Care Services
Health Care Planning AIDS Drug Assistance Program State Pharmaceutical Assistance Program (SPAP) Ryan White Title II Consortia-Based Services Early Intervention Services Virginia HIV/AIDS Resource and Consultation Centers
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11 11 12 12 13 13
Section IV: Health & Research Informatics
2006 Highlights Capacity Building for HIV Surveillance Linking HIV/AIDS Surveillance with Geographic Information Systems (GIS) STD Surveillance Network (SSuN)
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14 15 16 16
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Section V: HIV/AIDS Surveillance Program
CORE HIV/AIDS Surveillance HIV Incidence and Resistance Programs HIV Behavioral Surveillance Medical Monitoring Project Capacity Building
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17 17 18 18 19
TABLE OF CONTENTS
Section VI: Newcomer Health Program Section VII: Outbreak Response
Outbreaks Cutting Edge Screening Events Community Outreach Public Information
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21 21 22 22 23
Section VIII: Pharmacy Services Section IX: Tuberculosis Control and Prevention
Consultation and Technical Assistance Disease Surveillance Direct Assistance Education and Training Collaboration with the Division of Consolidated Laboratory Services Homeless Incentive Program Drug Funding Other Accomplishments
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D I R EC TO R ’ S M E S S AG E
In 2006, the Division of Disease Prevention continued to educate citizens of the Commonwealth on ways to protect their health against HIV/AIDS, sexually transmitted diseases, and tuberculosis. Through our programs, we have provided leadership and support to local health departments, medical providers and community-based organizations across the state, in the prevention, surveillance and treatment of HIV, sexually transmitted diseases, and tuberculosis. Additionally, the Newcomer Health Program assists health departments in providing essential health services to refugees and immigrants, and the Central Pharmacy provides medications and vaccines to health departments statewide. In this document, you will find highlights of the initiatives for each of our program areas for 2006. You will find information on the services provided through our Community Services unit, such as health education, community planning, evaluation, and public information. You can continue to explore our Field Services unit, which offers counseling, testing and treatment services. Our Health Care Services unit coordinates statewide HIV health and support services as well as manages the Ryan White Part B program and the AIDS Drug Assistance Program. Through our Health & Research Informatics unit, we are able to use information science and technology to provide innovative and enhanced approaches to HIV/AIDS, TB, and STD data research. The Virginia HIV/AIDS Surveillance Program functions as the central repository for all reports of all adults and children diagnosed with or exposed to HIV/AIDS in Virginia. Providing initial health assessments for new refugees entering the Commonwealth are the key target audience for the Division’s Newcomer Health Program. Our Outbreak Response unit is dedicated to community outreach and outbreak response. Explore our Pharmacy Services section to learn more about how the Division provides pharmaceuticals, vaccines and pharmaceutical services, across the state. Learn more about our Tuberculosis Control and Prevention Program’s services to control, prevent and eliminate tuberculosis from the Commonwealth of Virginia. Please visit the Division’s Web site at http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/. Here, you will find more information on our programs, upcoming events and data and statistics. Sincerely, Kathryn Hafford, Acting Director
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DIVISION
OF
D I S E AS E P R E V E N T I O N
W E B S I T E I N FO R M AT I O N
Month January February March April May June July August September October November December Total
Visits per month 7,810 8,366 12,619 10,513 12,197 13,050 12,381 9,451 11,619 12,558 7,146 13,637 131,347
Visits per day 251 298 407 350 393 435 399 304 387 405 238 439
Average Web visits per month: 10,945 Average Web visits per day: 359
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C O M M U N I T Y S E RV I C E S
The Community Services unit is responsible for establishing and monitoring contracts for HIV prevention services, coordinating public information campaigns; managing the HIV, STD and Viral Hepatitis Hotline, developing educational materials; provision of capacity building, technical assistance and training for community-based organizations (CBOs); coordinating community planning for HIV prevention; and conducting program evaluation. HEALTH EDUCATION/RISK REDUCTION The Division managed 40 contracts with 21 organizations for HIV prevention services including Comprehensive Risk Counseling and Services (CRCS), HIV testing, individual, group and community-level interventions, basic and intensive street outreach, presentations, lectures and health fairs. New contracts were awarded for the Primary Prevention with People Living with HIV grant program beginning January 1, 2006. The Every Newborn Can Be HIV Free campaign was launched in December to promote HIV testing of pregnant women, ensure appropriate treatment for HIV-infected women and their infants, ensure timely reporting of HIV-infected pregnant women and encourage the adoption of rapid testing in labor and delivery units. The Virginia Hospital Association partnered with VDH on a letter to hospitals across the state. The mailing, which included both patient and provider materials and a copy of CDC’s new counseling and testing guidelines, was completed in early 2007. CBOs conducted 7,778 HIV tests during 2006 and identified 69 (.9%) new positives. This is 38% increase over the number of tests conducted by CBOs in 2005. Data Summary
Intervention Type HIV Testing Basic Street Outreach Intensive Outreach, Individual & Group Interventions Comprehensive Risk Counseling and Services Community Level, Health Communications, Social Marketing Individuals Reached/ Contacts Made 7,778 57,868 11,104 137 25,730
PUBLIC INFORMATION The Division issued a statewide news release and fact sheet for HIV for National HIV Testing Day. The Division purchased statewide radio advertisements promoting testing. During the radio campaign, calls to the Division’s hotline increased by 21% compared to the same time period the previous year.
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The Division issued a statewide news release and fact sheet in Spanish and English for National Latino AIDS Awareness Day. For the first time, the Division purchased advertising on Spanish-language radio stations. The Division also participated in the Hispanic Music Festival, hosted by a group of Richmond-based Spanish-language radio stations. Staff provided attendees with literature on HIV and STD prevention and offered on-site HIV testing. During the radio campaign, calls to the Division’s hotline increased by 60 percent compared to the same time period the previous year.
HOTLINE SERVICES Hotline staff answered 4,742 calls and mailed 583,704 pamphlets and posters. Thirty-five percent of callers requested information on HIV testing, 23% requested general information about HIV, and 14% asked about STD testing. Twenty-three percent obtained the Hotline phone number from the phone book, 22% from the internet and 21% from health departments. The How to use a Condom brochure was revised in English/Spanish and distributed.
CAPACITY BUILDING Twenty-three people attended PEMS 1.0 and PEMS 1.0 Refresher courses in February, and 35 people attended PEMS 2.0 courses in February and March. The Division hosted training for Project RESPECT, a Diffusion of Effective Behavioral Intervention (DEBI) curriculum, for 24 people in February. Twenty women attended the DEBI training for SISTA, an intervention for African American women, in April. Forty-six counseling and testing staff attended two Caring for Self While Caring for Others workshops. A Strategic Planning Conference was provided in April for 19 people representing nine unfunded or minimally funded community-based organizations. This meeting was cosponsored by the U.S. Department of Health and Human Services. Fifty-one individuals attended the Division's annual four-day Core Strategies for Street and Community Outreach training in May. OraQuick HIV Testing training was provided for 19 people in June. Thirty-five people, representing 22 faith organizations attended the African American Faith Initiative Training in November.
COMMUNITY PLANNING In 2006, the Virginia HIV Community Planning Committee (HCPC) prioritized target populations for HIV prevention services. The process used utilized both quantitative and qualitative data and included five-year averages of HIV/AIDS prevalence, HIV and AIDS incidence, population size, hazard distribution, available resources, type of risk, and social indicators.
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The Virginia Transgender Health Survey (THIS) was completed in July, yielding 350 surveys, including 229 male-to-female (MTF) and 121 female-to-male (FTM) respondents. THIS provided data and information on access to regular and transgender-related medical care, HIV prevention and treatment services, HIV knowledge, risk behaviors, HIV testing, employment, housing discrimination, sexual and physical violence, social support, self esteem, substance abuse, tobacco use and suicidal ideation and attempts. Copies of the survey report can be found at http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/documents/pdf/THISFINALR EPORTVol1.pdf. As part of the Virginia Transgender Health Initiative, the Transgender Health Risk Assessment: A Clinician’s Guide was completed and distributed. This guide is intended to aid providers in assessing health risks for their transgender clients in an appropriate manner. Additionally, the Virginia Transgender Resource and Referral List, which includes resources and information on providers offering medical care; hormone therapy; support and counseling services; mental health care; legal services; and other services for the transgender community in Virginia was updated. The community services and health care units conducted joint public hearings in each of the five health regions of the state to assess the use of Ryan White Title II funds and issues, barriers, and emerging risk behaviors related to HIV prevention efforts. The Ryan White subcommittee of the Virginia HCPC revised its mission, goals, and objectives to focus on more specific activities geared towards collaboration between care and prevention.
PROGRAM EVALUATION MONITORING SYSTEM (PEMS) PEMS is the Centers for Disease Control and Prevention’s (CDC) secure Internet browserbased software program consisting of standardized data variables for data entry, collecting, and reporting for HIV prevention programs. 2006 marked the second year Virginia’s CBOs used the system to collect and enter PEMS data. The Division hired a PEMS Coordinator in May 2006. The Coordinator provides the Division and its funded contractors with technical assistance, trainings, and quality assurance measures. In November 2006, Virginia was selected by CDC as one of eight pilot sites for the release of PEMS 3.0. PEMS 3.0 enables grantees to share data with their funding agency, generate reports for contract quality assurance, and monitor data collection progress. The reports will be utilized for the quarterly report responses for VDH contractors as well as for the CDC HIV prevention grant.
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F I E L D S E RV I C E S
Field Services is responsible for directing all aspects of confidential HIV and sexually transmitted disease (STD) counseling, testing, partner counseling, referral services, anonymous HIV testing, STD treatment, STD surveillance, case reporting, technical assistance, consultation, training and quality assurance for local health districts, including special programs for Chlamydia prevention and viral hepatitis. HIV PREVENTION COUNSELING, TESTING, REFERRAL, AND PARTNER SERVICES All publicly funded sites conducted 75,837 HIV tests (serum, oral, and rapid) in 2006. The positivity rate was 0.7%. Of the persons tested, 39,093 (51.5%) were post test counseled and received their test results. Of the 547 new positive individuals, 210 (38%) were post test counseled and received their results. There were a total of 42,776 STD clinic patients tested for HIV in 2006. Of these, 187 (0.4%) tested positive for HIV. First time testers in the STD clinic were 10,821 with 36 (0.3%) being positive for HIV. Eighteen anonymous testing sites (ATS) provided services across Virginia in 2006. ATS receive federal and state funds to provide free HIV client-centered prevention counseling and HIV testing services. The ATS provided 2,406 HIV tests which resulted in identifying 25 (1.0%) new positives. Family planning (FP) clinics conducted 2509 HIV tests, with no positive tests identified.
SEXUALLY TRANSMITTED DISEASE PREVENTION PROGRAM 2006 showed increases in reported cases of chlamydia and syphilis. The 24,072 chlamydia cases represent an increase of 6% when compared to 2005. The continued increase of reported chlamydia infections most likely reflects an increase in screening and the use of more sensitive screening tests. Early syphilis cases increased 21%, from 291 cases in 2005 to 353 cases in 2006. This increase mirrors the national trends and is partially attributed to increases among men who have sex with men. Gonorrhea cases have been declining since 2001 and the 2006 gonorrhea case reports of 6,468 is a 2% decrease compared to 2005. The Division sponsored a statewide conference in Natural Bridge, Virginia, in December 2006. Attendees included STD/HIV health counselors and TB outreach workers from each of Virginia’s health districts. The conference, entitled “Joining Forces – The STD, HIV, and TB collaborative”, represented a joint planning effort involving various units within the Division (Field Services, Community Services, Outbreak Response, HIV Surveillance, and TB control). Presentations addressed a wide array of STD, HIV and TB topics, including hepatitis, laboratory interpretation, testing technology, and case
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management protocol, along with topical issues such as motivational interviewing, burnout, team, building and customer service. CHLAMYDIA PREVENTION PROGRAM In 2006, 94,074 clients were screened for chlamydia. The Chlamydia Prevention Program conducts screening services in all STD, family planning and prenatal clinics utilizing age-based screening criteria. In an effort to optimize program resources, the Division modified the screening criteria in 2006 to target resources toward populations at highest-risk. These criteria include: Females under the age of 25 in family planning clinics. Women age 25 and over should only be tested for diagnostic reasons i.e. pre-insertion of IUD, new patient who never had a pelvic exam, or patient that has three or more sex partners in a year. All females in STD clinics All prenatal clinic patients Male partners of chlamydia infected females Asymptomatic males in STD clinics Males visiting STD clinics that cannot perform gram stain testing The Chlamydia Prevention Program, in collaboration with Training 3, provided Improving Clinic Efficiency, Patient Flow Analysis, A Paradigm for Connecting with Males in Clinical Settings, Gen-Probe Specimen Collection Techniques, and Family Planning Update audio conferences/workshops for clinical staff.
VIRAL HEPATITIS PREVENTION PROGRAM The Viral Hepatitis program piloted hepatitis C (HCV) testing in four health districts. The pilot consisted of two parts: offering testing to patients in STD clinics who are high-risk for HCV as well as vaccination for hepatitis A and B viruses and notifying Virginia residents who test HCV-positive through commercial laboratories of their status. All residents who are notified are encouraged to visit their local health department for follow-up vaccine. In 2006 the Division notified 312 clients of their HCV-positive status; began vaccinations on 72 clients; and tested 64 clients with a positivity proportion of nearly 50%.
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The program developed and printed an educational guide for the pilot sites. The Guide allows users to record viral hepatitis information on testing, results, follow-up HCV testing and vaccination all in one small and discreet record. In 2006 over 1,000 of these guides were distributed to individual Virginia residents. The Hepatitis program collaborated with the Charlottesville Health Department in an initiative to provide HCV testing to approximately 200 high-risk local residents. The three main sites covered include: drug treatment centers; community service centers; and methadone clinics.
TRAINING UNIT The Training unit continued to provide trainings on rapid (OraQuick) and non-invasive (OraSure) HIV antibody testing. The unit coordinated one OraQuick training for contracting community-based organizations (CBOs), and health departments. In addition, the unit conducted two OraSure trainings for CBOs. Training unit staff assisted Instructional Design Specialists in the development of the Virginia Epidemiology Response Team (VERT) Certification modules. The unit continued to provide technical assistance and collaborate with other agencies and work units in the provision of training. The unit also collaborated with the state and local labs in their trainings. During 2006, the unit continued to serve on the VDH Distance Learning Committee, assisting in the development of technologies that will serve all of VDH. The unit continued to work with CDC and the regional training centers in providing the “Introduction to STD Intervention (ISTDI)”, “Advanced STD Intervention (ASTDI)”, and the “STD Intensive” clinical training. In addition, the Training unit continued to serve as liaison between the Division and local health department nursing staff. In 2006, health counselors and public health nurses attended two “ISTDI”, one “ASTDI,” and a “Fundaments of STD Intervention” course. Finally, one “STD Intensive” course was delivered in Virginia through collaboration with the Region III STD/HIV Prevention Training Center and Virginia’s HIV/AIDS Resource and Consultation Center.
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H E A LT H C A R E S E RV I C E S
Health Care Services (HCS) coordinates statewide HIV health and support services and manages the Ryan White (RW) Part B (formerly Title II) program which includes the AIDS Drug Assistance Program (ADAP), consortia-based and Emerging Communities (EC) services, and Minority AIDS Initiative (MAI) services. In addition, HCS contracts for and manages the State Pharmaceutical Assistance Program (SPAP), early intervention services and health care provider education. HEALTH CARE PLANNING In the autumn of 2006, VDH held five public hearings across the state to gain further input into the planning process and to provide an update on activities related to Statewide Comprehensive Plan (SCP) implementation. One hundred and forty-one people attended, a significant increase from 75 attendees in 2005 and only 16 attendees in 2004. As was done the previous year, the public hearings were held in conjunction with the Community Services unit and were conducted in all five regions of the state. VDH worked closely with regional consortia in planning the date, time, and location of each public hearing to make them accessible for consumers. In 2006, the Health Care Planner drafted a modification to the current memorandum of agreement between the Department of Medical Assistance Services (DMAS) and VDH in order to obtain the client information necessary for the unmet need estimate. This agreement marked the first successful HIV data sharing agreement with DMAS.
AIDS DRUG ASSISTANCE PROGRAM (ADAP) ADAP is supported through a combination of state and federal RW funding. Patients access medications through local health departments and the Virginia Commonwealth University Health System. In 2006, the formulary covered 69 medications. In 2006, 3,332 clients received 54,796 prescriptions through ADAP. In addition, ADAP assisted 84 newly released HIV-positive inmates with access to medications and primary care through the Seamless Transition Program. Client demographics are described below:
0-12 13-19 20-44 45> GENDER MALE FEMALE UNKNOWN
Age
%
RACE
0.5
BLACK
0.1
51.7
WHITE
47.4
HISPANIC ASIAN/PACIFIC ISLANDER
%
69.6
29.6
0.8
UNKNOWN
AMERICAN INDIAN / ALEUTIAN/NATIVE ALASKAN ESKIMO
%
54.9
28.5
7.1
0.8
0.5
8.2
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STATE PHARMACEUTICAL ASSISTANCE PROGRAM (SPAP) With funding appropriated by the General Assembly on July 1, 2006, VDH established a SPAP for individuals participating in ADAP who hold a Medicare Part D policy, and who have an income between 135% and 300% of the federal poverty level. Initial services consisted of providing Medicare Part D premium assistance. Ultimately, to the extent funding allows, SPAP will provide all aspects of Part D cost-sharing assistance including deductibles and medication copayments/coinsurance. Coverage under the SPAP results in two advantages. Clients will be able to obtain all medications under their Medicare Part D policy with SPAP financial assistance and will no longer access medications through ADAP, thereby conserving this resource. Additionally, because the SPAP is funded only with state dollars, this assistance will apply toward true out of pocket (TrOOP) costs under Medicare Part D and will help clients reach the catastrophic (maximum) level of coverage. Fewer dollars will be spent on obtaining medications than if these clients continued to get their medications through ADAP. Within the first six months of the SPAP, a system was developed to enroll clients and provide premium payments, a statewide training was conducted to introduce providers to the program, and a Request for Proposals was developed to identify a contractor able to fully implement the coordination of benefits with the Centers for Medicare and Medicaid Services (CMS) so that cost-sharing assistance could be provided. Initial estimates predict that at least 115 citizens will be eligible for the SPAP, with available benefits determined by state allocations. RYAN WHITE (RW) PART B-FUNDED SERVICES RW Part B funding provides regional consortia-based services administered through lead agencies. The consortia and lead agencies in 2006 were: o Central Virginia HIV Care Consortium: Virginia Commonwealth University, Community Health Research Initiative o Eastern Regional HIV Care Consortium: Eastern Regional AIDS Resource and Consultation Center o Northwest HIV Care Consortium: James Madison University, Institute for Innovation in Health and Human Services o Northern Virginia HIV Consortium: Northern Virginia Regional Commission o Southwest/Piedmont HIV Care Consortium: Council of Community Services The Central Consortium also receives EC funding to provide additional HIV services. During 2006, a total of 43 subcontractors provided primary medical care and support services to 3,060 clients in Virginia. Two minority CBOs were funded to provide outreach and case-finding. These CBOs used innovative strategies to find persons who know their HIV-positive status but are not currently receiving health care in order re-engage and retain them in care.
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Demographics of Patients Served
GENDER MALE FEMALE TRANSGENDER AGE 0-12 13-24 25-44 45 >
%
62.6
RACE/ ETHNICITY
36.7
0.4
%
1.8
ASIAN/ PACIFIC ISLANDER
4.1
NATIVE AMERICAN
51.2
OTHER/ UNKNOWN
43.0
CAUCASIAN
BLACK
HISPANIC
% 28.3% 58.1% (Clients may report >1 racial/ethnic category)
6.2%
0.5 %
0.9%
14.6%
Service Categories*
MEDICAL CARE DENTAL CARE MENTAL HEALTH CASE MGMT TRANSPORTATION OUTREACH FOOD BANK/ NUTRI-TION CLIENT ADVOCACY MEDICATION COPAYS TREATMENT ADHERENCE
49.7%
13.0%
4.0%
44.3%
10.5%
3.8%
3.7%
17.6%
22.3%
5.9%
*Represents percentage of clients requesting specific services, and multiple services could have been provided to the same client. This does not include all services available.
EARLY INTERVENTION SERVICES Early diagnosis and treatment helps prevent the spread of HIV/AIDS in the general population. Additional support services are provided to empower clients with knowledge, self-care and support skills to reach their maximum level of functioning and well-being. In 2006, services were provided at two existing sites: the Central Virginia Health District, located in Lynchburg and the Arthur Ashe Clinic, located in Richmond at the Hayes E. Willis Health Center.
VIRGINIA HIV/AIDS RESOURCE AND CONSULTATION CENTER (VHARCC) VHARCC received funding to educate health care providers in all aspects of HIV/AIDS, hepatitis and sexually transmitted diseases through consultation, education and clinical training sessions. During 2006, the VHARCC provided training to a wide variety of agencies including correctional facilities. Training focused on HIV prevention counseling skills, case management standards, and U.S. Public Health Service HIV Treatment Guidelines. Clinical training was offered by VHARCC in collaboration with the Pennsylvania MidAtlantic AIDS Education and Training Center. Physicians and nurses attending these programs were able to earn continuing education credit. A total of 2,495 individuals received training through the VHARCC.
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H E A LT H
AND
R E S E A RC H I N FO R M AT I C S
The mission of the Health & Research Informatics (HRI) unit is to enhance epidemiologic and program capacity through the use of innovative methods and resources, with an emphasis towards advancing communicable disease knowledge, quality of care assessments, and program performance. Primary functions include epidemiologic/statistical analyses, data quality management and enhanced STD surveillance initiatives. Advancements in the use of information science and technology are employed to provide innovative and enhanced approaches to focal areas such as survey research, descriptive and analytic epidemiology, geospatial analysis, health economics, and imaging informatics. The Division's data-related reports are generated in HRI, as well as geographic information systems (GIS) initiatives such as geocoding services, mapping and spatial analyses. HRI staff provides all services listed above within the Division, as well as reports and mapping/geocoding for local health departments, the media, health care providers, CBOs, legislators, grant applicants, students and other agencies. The Division’s web-presence, security and confidentiality guidelines, as well as data matching and transfers, are all conducted or maintained by HRI. An emphasis on analytic proficiency through the use of SAS and data visualization techniques is ongoing. 2006 HIGHLIGHTS • HRI staff authored or co-authored eight abstracts accepted to the 2006 National STD Prevention Conference. Topics included: • • • • • • • • Aberration Detection in STD Surveillance The Effect of Mailing Cost Reimbursements on Reporting Timeliness of Sexually Transmitted Diseases HIV among African-born Persons in the U.S.: A Hidden Epidemic? Enhancing Gonorrhea Surveillance to Guide Program and Policy Use of Tablet PCs in Enhanced Gonorrhea Surveillance Suppression of Sexually Transmitted Disease (STD) Data to Protect Confidentiality: At What Cost? Geographic and Spatial Regression Analysis of Sexually Transmitted Diseases in Richmond, VA Who’s Using Geographic Information Systems (GIS): A Survey of STD Programs
To read all of the Division’s abstracts written in 2006 for the National STD Prevention Conference, please visit our “Reports and Publications” page at http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/reportsandpubs.htm • HRI staff presented Informatics-related activities during the 4th Annual Public Health Information Network (PHIN) Conference in Atlanta, GA. Presentations included an oral presentation entitled Strategic Aberration Monitoring (SAM): Using AVR Mechanisms to
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Improve STD Surveillance, as well as a poster presentation related to the utility of geographic information systems (GIS) within state public health STD programs. • HRI staff taught the “GIS and Public Health” component of an introductory public health course at Virginia Commonwealth University by invitation of the School of Nursing. HRI staff helped the Division become one of only three sites funded by CDC to examine the linkages of HIV/AIDS surveillance data with geographic information systems (GIS). In December 2006, a manuscript, authored by two HRI staff members, was accepted for publication to the Journal of Public Health Management and Practice. The paper was a nation-wide examination of the way in which sexually transmitted disease (STD) programs release data to protect patient confidentiality. In June 2006, an HRI staff member attended, through a competitive screening process, training on health disparity analysis at the Harvard School of Public Health. HRI fully automated and launched a web-based version of the Division’s Quarterly Surveillance Report. This report can be viewed at:
http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/DAta/
•
•
•
•
•
HRI staff automated an internal weekly report for HIV Incidence and Resistance Surveillance
CAPACITY BUILDING FOR HIV SURVEILLANCE This funding supports development of epidemiologic profiles and other reports that meet the needs of CDC HIV prevention planning and HRSA HIV health care programs, and augments surveillance program capacity through personnel training, resource allocation and program evaluation. • An HRI staff member helped develop a new method for prioritizing populations for HIV planning. This process utilized eight indicators, including five quantitative and three qualitative sources of data. These indicators included five-year averages of HIV/AIDS prevalence, HIV and AIDS incidence, population size, hazard distribution, available resources, type of risk, and social indicators. HRI staff implemented methods to calculate age-standardized rates, confidence intervals and incidence rate ratios for diagnosed cases of HIV/AIDS, total early syphilis, gonorrhea and chlamydia by poverty level. This information can be utilized to address programmatic needs for data that incorporates socioeconomic status. The Health Commissioner appointed an HRI staff member to the Virginia Department of Health’s Institutional Review Board (IRB).
•
•
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•
An HRI staff member implemented the use of new data visualization techniques into the Division’s Quarterly Surveillance Report for which she was recognized by VDH.
LINKING HIV/AIDS SURVEILLANCE DATA WITH GEOGRAPHIC INFORMATION SYSTEMS (GIS) This funding is used to demonstrate and evaluate methods for spatially linking existing HIV/AIDS surveillance data with other datasets to enhance epidemiologic capacity. The main goal of this project is to develop procedures and guidelines that allow the use of GIS in analyses while safeguarding security and confidentiality. • In September 2006, the Division was awarded a competitive grant from CDC to examine the use of GIS with HIV/AIDS surveillance data. For additional information, please visit the project website at http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/Programs/GIS/index.htm
•
STD SURVEILLANCE NETWORK (SSuN) This funding is used to obtain a more comprehensive picture of the STD population. Demographic and behavioral risk data is being captured via a self-administered questionnaire given to all STD clinic attendees in Chesterfield County, Henrico County and Richmond City. Future activities include enhanced gonorrhea surveillance outside of public health department settings, as well as initial data collection and surveillance for genital warts. • HRI staff worked closely with STD clinic staff in the three local health departments to integrate enhanced surveillance questions into routine STD clinic procedures. HRI staff began sharing SSuN project results, through a new reporting mechanism, with the three local health departments. HRI staff worked collectively with the other 5 SSuN sites and CDC to determine data collection protocols for county level gonorrhea surveillance, as well as genital warts surveillance.
•
•
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HIV/AIDS S U RV E I L L A N C E P RO G R A M
The Virginia HIV/AIDS Surveillance Program (VSP) functions as the central repository for reports of all adults and children diagnosed with or exposed to HIV/AIDS in Virginia. VSP encourages the ongoing and systematic collection of HIV/AIDS reporting from public and private providers and laboratories across the state. The primary functions of Virginia’s HIV/AIDS Surveillance Programs are 1) to provide accurate epidemiologic data to monitor the incidence and prevalence of HIV infection and AIDS-related morbidity and mortality, and 2) to use these data trends to assist in public health planning, education, and treatment for those Virginians infected with HIV/AIDS. The following HIV surveillance programs work together towards achieving these goals: CORE HIV/AIDS SURVEILLANCE The VSP utilizes standardized CDC guidelines for collecting accurate, timely, high-quality data on individuals who are infected with HIV/AIDS and for infants perinatally exposed to HIV infection. In addition to gathering data critical to planning efforts and funding allocation, surveillance activities include evaluating the completeness of HIV/AIDS reporting in Virginia, investigating modes of transmission, and conducting follow-up investigations. Routine surveillance activities for 2006 include: Active & Passive Surveillance for both adults and perinatal exposures Routine Interstate De-Duplication Review (RIDR) Registry matches for Virginia’s AIDS Drugs Assistance Program (ADAP) and TB Death Certificate reviews for Cause of Death (COD) Staffing for HIV information booths at relevant statewide meetings and conferences Assessment of Cases of Public Health Interest (COPHI).
Representing cases from each of the five health-planning regions, 1,502 total new HIV/AIDS cases were added to Virginia’s HIV/AIDS Reporting System (HARS). HIV INCIDENCE AND RESISTANCE PROGRAMS Virginia is one of 34 national jurisdictions funded by CDC to implement HIV incidence and resistance (I/R) testing. The primary goals of the HIV/AIDS incidence and resistance surveillance programs are to detect, at a population-based level, the rate of Virginians who are newly infected with HIV within the last year, and determine their rate of transmission of a drug resistant form of HIV. This testing allows the Division to distinguish for the first time if a person newly diagnosed with HIV was infected recently, and also for the first time, to collect information to identify active transmission of antiretroviral drug resistant virus and other atypical strains (subtypes) of HIV. I/R highlights for 2006 include:
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By January of 2006, the new testing programs were expanded to all 55 public health departments, and 100% of all public health department sites successfully submitted samples eligible for incidence and resistance testing. This activity was accomplished through the Division’s cooperative agreement with the state lab, the Division of Consolidated Laboratory Services (DCLS), and CDC designated laboratories. I/R program expansion to the private sector was initiated in 2006. These efforts involved collaboration with CDC, state and national laboratories, and several Virginia medical facilities. In late 2006, the Division hired two new I/R staff -- an I/R Epidemiology Consultant and a Laboratory Liaison -- to assist with meeting new CDC program expansion goals. By the end of 2006, local health department field staff received training for completing “Testing/Treatment History (TTH)” information; data which is critical towards accurately calculating incidence rates.
HIV BEHAVIORAL SURVEILLANCE The National HIV Behavioral Surveillance (NHBS) is a response to the CDC-led coalition that identified the need for a national HIV/AIDS prevention plan in 2001. Based on surveillance data, CDC has identified three behavioral groups that are at high risk for becoming infected with HIV: men who have sex with men (MSM), injecting drug users (IDU), and high-risk heterosexuals (HET). As one of 24 nationally funded sites, the program is conducted in the Norfolk Metropolitan Statistical Area (MSA) and will be conducted over three 12 or 18-month cycles, utilizing different sampling methodologies for each project cycle. Highlights for 2006 include: In cooperation with its research partner, Virginia Commonwealth University Community Health Research Initiative (VCU CHRI), the Division and VCU CHRI successfully conducted the NHBS IDU cycle. Data cleaning and analysis for this population is on-going and will be utilized to improve prevention planning and education efforts. In the summer and fall, formative research, ethnographic analyses, and extensive planning activities were conducted for the next 18-month “HET cycle”. In 2006, Virginia was also funded to conduct a supplemental Heterosexual “Partner study” that is to be conducted in conjunction with the HET project. The resulting NHBS data will be utilized for improved planning, prevention, and education efforts targeted at Virginians who are at high-risk of becoming HIV infected. MEDICAL MONITORING PROJECT The Medical Monitoring Project (MMP) is a surveillance system that collects behavioral and clinical data from an annual probability sample of persons in care for HIV infection in the United States. Virginia is one of 26 national sites randomly selected to participate in MMP.
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The goal of MMP is to provide nationally representative estimates of clinical and behavioral outcomes among persons living with HIV infection. Clinical outcomes include quality of care, access to care, and use of HIV care and treatment. Behavioral outcomes include use of prevention services, medication adherence, and levels of ongoing risk behaviors. To improve the quality and usefulness of data, MMP will increase the representativeness of data compared to legacy systems; increase the relevance of data for use at the local level (e.g., for Ryan White Comprehensive AIDS Resources Emergency [CARE] and HIV prevention planning groups); and collect data from people through both interview and medical record review. Highlights for 2006 include: VSP successfully constructed their facility sampling frame consisting of 157 HIV care providers in the state who met the MMP definition as determined by CDC. CDC, in conjunction with the RAND Corporation, randomly selected a sample of 46 Virginia facilities to participate in the first round of data collection. VSP received VDH Institutional Review Board (IRB) approval to conduct MMP activities in the state. Facility recruitment activities were initiated with all sampled facilities. A Virginia Community Advisory Board (VACAB) was created fashioned after the national MMP Community Advisory Board (CAB). The VACAB has representatives from different regions of the state and is representative of demographically diverse Virginians. The VACAB consists of six members and serves to advise program staff about community perception of MMP.
CAPACITY BUILDING VSP also continues to be funded to conduct HIV Capacity Building, which is described in the Health Research Informatics section.
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N E WCO M E R (R E F U G E E
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I M M I G R A N T ) H E A LT H
The mission of the Newcomer Health Program (NHP) is to protect the public’s health by empowering local health districts to provide thorough initial health assessments to all new refugees entering Virginia. The Department of Social Services, Office of Newcomer Services (ONS), administers federal Refugee Medical Assistance (RMA) funds in Virginia. ONS works through NHP to coordinate, facilitate, and monitor the provisions of initial health assessment services to newly arriving immigrants with a refugee or asylum status. Virginia’s local health districts are encouraged to orient refugees to our health care system and provide referrals for follow-up of health problems identified during the comprehensive health assessment. Providing quick and appropriate treatment for health problems, such as TB disease and latent TB infection, ensure better health for the refugee, and protects the public’s health. Virginia continued to experience a steady flow of refugee arrivals during the 2006 SFY (July 1, 2005-June 30, 2006), with 1,963 persons with refugee status entering the Commonwealth. Of these, 239 claimed Somalia as their country of origin. Other countries of origin included: Ethiopia (230), Uzbekistan (191), Cuba (183), Russia (148), Sierra Leone (123), Liberia (90), Sudan (89), Iran (84), and Burma (58). The remaining 528 hailed from another 49 different countries. During the 2006 SFY, 17 local health districts provided initial health assessments to new refugees. These assessments were provided on average of 48 days from the time of arrival into the U.S. Health districts reported that 1,495 refugees received Level I (TB skin test, follow-up chest x-ray and treatment if warranted) of the initial health assessment, which is the minimum required by NHP. Of the 1,495 refugees screened, 1,364 are reported to have received Level II (evaluation of health history and immunization status) of the screening, 956 (67%) received Level III (examination of the heart and lungs & evaluation for anemia and/or sexually transmitted diseases) and 1,386 received Level IV (referrals for follow-up of health problems identified & case management).
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OUTBREAK RESPONSE
The Virginia Epidemiology Response Team (VERT) was created by the Division of Disease Prevention to work with local health departments in the event of a disease outbreak. OUTBREAKS The syphilis outbreak that began in 2005 in Suffolk was averted. There were only 34 cases in 2005 followed by a sharp drop in 2006. Had the outbreak not been stopped, history suggests that more than 250 cases would have occurred in a 12 month period. The response was a collaborative effort between VERT, Western Tidewater Health District, community leaders, the media, and several CBOs. Also contributing resources to the effort were the Health Districts of Portsmouth, Peninsula, Hampton, Virginia Beach, and Chesapeake. In the fall of 2006, surveillance monitoring detected increases in the number of early syphilis cases in Virginia Beach, Portsmouth and Chesapeake resulting in VERT activation into assessment mode. Several VERT members were deployed to those cities and Suffolk to help reduce and manage the number of syphilis cases. Due to VERT’s extended stay in the Eastern region and the overall number of cases, it was determined that it would be more cost effective to open a satellite office in the Eastern Region and permanently staff it with VERT members. The new VERT satellite office opened in January 2007.
CUTTING EDGE The annual Certification process developed for VERT staff concluded its first year in August 2006. Addressing more than 50 different skills, the process is designed to ensure they maintain a high degree of proficiency. A statistical comparison between certified staff and non-certified staff showed significant differences in which the higher achievements were made by the staff that completed their certification in 2006. As a result, Certification was made available to other Health Counselors in Virginia. All participating staff must be recertified every year. At the national STD conference in Jacksonville (May 2006), Outbreak Response staff made two presentations. One was comparing the two successfully averted syphilis outbreaks (Danville 2000, Suffolk 2006), and the other was on the Certification process described above. The Division developed a protocol for partner notification services via the internet in response to the increase in anonymous sex arranged through web sites and chat rooms. Any Health Counselor in the state who gets an e-mail address as a contact sends the address to the Assistant Director of Outbreak Response who attempts to contact the
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person either in a chat room or by sending an e-mail. Numerous sex partners met through the internet were contacted in 2006 and several received treatment as a result. SCREENING EVENTS The new VERT testing van was designed with the ability to test several people simultaneously and still maintain confidentiality. The van was used at several screening events in conjunction with local health departments and CBOs. Working with the Richmond Health Department, an outreach and screening event was conducted at the Hispanic Festival in Richmond to test persons for syphilis and HIV. Other testing events VERT prepares for a community screening throughout the Commonwealth in 2006 resulted in more than 500 people being screened for syphilis and HIV. All outreach events have targeted high-risk populations at specific venues. The areas were selected based on epi intelligence analyzed using SAM (Strategic Aberration Monitoring), a computer program that can detect outbreaks early on and pinpoint areas with high morbidity. Outreach screenings to test men who have sex with men (MSM) for syphilis and HIV occurred in Richmond and Norfolk. Outreach screenings were conducted at three MSM bars in Richmond in collaboration with a local CBO. They were conducted from 10 pm until 5 am. In Norfolk, a screening at an MSM bar was conducted in collaboration with a local CBO. A screening was also held specifically targeting Transsexual prostitutes in which several people were tested.
COMMUNITY OUTREACH During 2006, the Division funded two CBOs, two syphilis elimination coalitions, and one health department to provide ongoing prevention education to at-risk populations. These organizations provided street and community outreach and made 1,853 contacts. They established rapport with the community, distributed condoms, literature and other prevention materials, and recruited high-risk persons into more intensive interventions. CBOs also implemented interventions with scientific evidence of effectiveness, including those endorsed by CDC and the Academy for Educational Development (AED). Interventions implemented include; 1) The SISTA Project, a five-session group-level, gender-and culturally-relevant intervention, designed to increase condom use with African American women; 2) Many Men Many Voices, a seven-session, group level STD/HIV prevention intervention for gay men of color. The intervention addresses behavioral influencing factors specific to gay men of color, including cultural/social
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norms, sexual relationship dynamics, and the social influences of racism and homophobia; 3) VOICES, a single-session video-based intervention designed to increase condom use among heterosexual African American and Latino men and women who visit STD clinics; 4) Becoming A Responsible Teen (BART), an eight-session group level for youth. The intervention is based on social learning theory and stresses attention to participants’ informational needs, motivational influences, and behavior. CBOs also conducted STD 101 presentations that discussed common STDs, transmission, prevention and treatment. Numerous community events occurred to increase awareness of syphilis.CBOs in Eastern Virginia participated in several health fairs. The fairs specifically targeted MSM and African American women. The Danville Community Health Coalition coordinated three major community events. These were Community Health Day, Men’s Empowerment, and Women’s Empowerment. The Community Health Day consisted of a health fair with free syphilis and HIV testing, a community basketball tournament, games, free food, door prizes and local entertainment. Approximately 300 community residents participated. A coalition composed of several community groups and individuals was developed in Suffolk as a result of the syphilis outbreak in 2005. The coalition calls itself PUSH, Public Unity for Safety and Health. The coalition organized a large community event that included a health fair. There were 81 people tested for syphilis and HIV at the event. Because of funding shortages, the Community Coordinator position was abolished when it became vacant. The Assistant Director for Outbreak Response has assumed some of the duties, however, information on community activities are not being entered into the database.
PUBLIC INFORMATION A media campaign that included posters, bus signs, and TV and radio commercials that targeted high risk MSM behavior, and men on the “down-low”, was developed. The campaign was approved for production and implementation in May 2007.
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P H A R M AC Y S E RV I C E S
Pharmacy Services support the Department of Health in its public health mission by the provision of pharmaceuticals, vaccines and pharmaceutical services to other divisions within the Department of Health and to local health departments. Pharmacy Services provides support services to the Department of Health in many and various ways. Pharmacy Services supports the AIDS Drug Assistance Program by the purchasing of pharmaceuticals, storage and subsequent distribution of over 45,000 prescriptions annually to underserved HIV infected citizens of the commonwealth at a cost of approximately $18,000,000. Support is provided to the Division of Immunization by the storage and distribution of over $6,700,000 in vaccines to local health departments through the Virginia Vaccines for Children Program. Pharmacy Services supports the Tuberculosis Control and Prevention Program by the filling of prescriptions sent in statewide from local health departments for primarily underserved citizens of the commonwealth with tuberculosis. The support for Tuberculosis Control was expanded in 2006 with the creation of a separate funding and distribution process for patients that have been identified as having multiple drug resistant tuberculosis as well as the creation of cache of TB drugs to be used in case of a disaster. The purpose of this drug cache is to be able to provide uninterrupted medication to displaced TB patients until which time they can access their medications via normal methods. Pharmacy Services support of the Emergency Preparedness and Response Program for Virginia expanded greatly in this past year. Pharmacy Services worked in cooperation with EP and R staff and the Commissioner of Health to procure the funding, arrange the purchase, and contract with a suitable vendor for the storage of approximately 800,000 courses of antivirals as preparation for a possible pandemic influenza outbreak. In addition, Pharmacy Services is working with EP and R in the development of an antiviral distribution plan to be able to efficiently distribute the state’s antiviral cache to the citizens of the Commonwealth. The development of this plan involves the coordinating of a network of over 500 dispensing sites that are situated both geographically and demographically across the state. Pharmacy Services also supports the mission of the Department of Health by the dispensing of pharmaceutical products to over 130 local health department sites for the provision of mandated services. Other means by which Pharmacy Services provides support to the Department of Health are: Purchasing, storage and distribution of influenza vaccine in support of Operation FLUEX 06 for the Emergency Preparedness and Response Program
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Purchasing, storage and distribution of Medroxyprogesterone Acetate as well as an assortment of oral contraceptives and alternative contraceptive products to local health departments for the Office of Family Health Services The establishment of the necessary vendor purchasing processes in cooperation with Dr. Suttle for the purchase and distribution of IUD contraceptive devices for the Office of Family Health Services. The dispensing of over 120,000 doses of flu vaccine to local health departments in the fall in response to seasonal flu. The filling and dispensing of prescriptions for the Chesapeake Health Department in support of their medical clinic. Storage of pharmaceuticals for response to a bioterror event for the Richmond district of the United States Postal Service. Dispensing of prescriptions in support of the Care Connection for Children Project, Newborn Screening Project and VCUHS Hemophilia Project.
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T U B E RC U LO S I S C O N T RO L
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PREVENTION
The purpose of the Tuberculosis Control and Prevention Program is to control, prevent and eventually eliminate tuberculosis (TB) from the Commonwealth of Virginia. The program does this through a variety of strategies aimed at detecting every case of TB that occurs in Virginia, assuring that every case is adequately and completely treated and preventing additional transmission of the disease in communities. The TB Control and Prevention Program provides services to local health districts, health professionals in the private sector, laboratories and individuals impacted by TB in the Commonwealth. CONSULTATION AND TECHNICAL ASSISTANCE The program provides consultation and technical support through case conferences with local districts; review and audits of records; clinical consultation and phone availability 24/7 to local health directors and other health department staff. The program also provides clinical consultation and phone availability to other physicians and health facilities throughout the Commonwealth. Consultation may include advice and assistance on diagnosis, treatment, case management, contact investigation, and discharge planning. The program develops policies and technical guidance to standardize care and case management.
DISEASE SURVEILLANCE In 2006, 332 cases of TB were reported in Virginia, for a case rate of 4.3 per hundred thousand. Tuberculosis cases were found in all regions of the state, with 60% of the cases reported from the Northern Region. Cases among US-born persons decreased 22% from 130 in 2005 to 101 cases in 2006. Foreign-born cases represented 43 different countries of origin and spoke 18 languages other than English. The 2006 Tuberculosis Surveillance Report is located at http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/Programs/Tuberculosis/ Epidemiology/
DIRECT ASSISTANCE Program staff provide direct assistance to local health districts and health care facilities in the management of complex cases and contact investigations. In 2006, direct assistance was provided in the management of individual cases and contact investigations at work places, health care facilities, detention centers and schools throughout Virginia.
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In addition in 2006, an additional nurse consultant position was created to enhance consultation for long-term care and corrections facilities.
EDUCATION AND TRAINING The videoconference education program was continued in 2006 with six sessions held during the year. Topics included Targeted Testing and Treatment of Latent TB Infections, Diagnosis and Treatment of Tuberculosis, Contact Investigations, Case Management and Infection Control. A total of 20 sites can be accommodated by the videoconference system and routinely all 20 slots were utilized by the local health districts. VHS and DVD copies of the programs were made available to health departments upon request. TB Control continues to partner with Healthy Roads Media to create multimedia health education material on TB-related topics using VDH developed patient education pamphlets. Materials developed by Healthy Roads media include a multi-media presentation, an audio-only version and a printable version of all seven of the VDH pamphlets. Five additional languages were added in 2006 including: Russian, Tagalog, Arabic, French and Korean. Six individuals from Virginia health districts attended the Comprehensive Training Program at the Southeastern National Tuberculosis Center in Lantana, Florida. The group included two health directors, two TB clinicians, and two TB Nurse Coordinators. Two Outreach Worker Trainings were held, one in May and one in December. Topics included XDR/MDR TB, Contact Investigation Guidelines, Performance Measures and Case Discussions. The December training included cross-training with other staff in the Division. The 4th annual TB and Newcomer Health Nurse Retreat was held in March of 2006. This retreat is a critical opportunity for nurses to further their professional development. The program included topics such as New CDC Contact Investigation Guidelines, Issues in Screening Newcomers, Radiographic Manifestation of Tuberculosis and Prevention of Transmission of TB in Healthcare Facilities. Staff worked with the American Lung Association to implement skin testing training courses throughout the state. Various onsite trainings were conducted at local health departments. Case conferences were conducted throughout the state either by polycom or in person. The case conferences allow for medical consultation and discussion with local health departments about difficult TB cases.
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COLLABORATION WITH THE DIVISION OF CONSOLIDATED LABORAOTRY SERVICES (DCLS) Virginia continues to participate in the national genotyping program in order to identify patterns of disease transmission and clustering of cases. Information obtained through the genotyping project is used to improve case and contact investigations. The program worked closely with DCLS to implement the STARTLIMS system for TB lab results and data transfer.
HOMELESS INCENTIVE PROGRAM The goal of the homeless incentive program is to improve compliance and completion of therapy. Individuals are provided with housing and food assistance as needed and in compliance with eligibility requirements to ensure they comply with isolation restrictions and medication and treatment regimens.
DRUG FUNDING The TB Control program administers funding to assist individuals diagnosed with active TB disease obtain necessary TB medications required to ensure a complete course of treatment. Separate funds are available to assist patients and local districts in the purchase of more expensive second line drugs for those who are resistant to one or more of the first line medications used to treat active TB disease.
OTHER ACCOMPLISHMENTS In 2006, staff presented three posters at the annual National Tuberculosis Controllers Association (NTCA): “The Flexibility of Using Memoranda of Agreement,” “The Impact of Population Trends in a Medium Incidence State: Virginia, 1995-2005,” and “Partnering to Improve Patient Understanding.” Staff presented “Virginia’s Human Resource Plan” at the State TB Education Focal Points meeting, Atlanta Georgia, August 2006. Staff presented "Update to the Southeastern TB Controllers - The Virginia Report," September 2006. The TB Nurse Consultant served as President of the National TB Nurse Coalition (NTNC) from January- December 2006.
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