Epidemiology Managment Issues

1
Virginia Department of Health
Office of Epidemiology Carl W. Armstrong, M.D.,
Director carl.armstrong_at_vdh.state.va.us
2
Virginia Department of Health Office of
Epidemiology
3
Office of Epidemiology Spending - 58M per year
79 (46M) Federal / 21 (12M) State.
4
Virginia Department of HealthDivision of
Surveillance and Investigation
Diane Woolard, Ph.D., M.P.H. Director dwoolard_at_vd
h.state.va.us
5
Vignette
Richmond City HD is investigating two cases of
acute hepatitis B (IgM) diagnosed in two
residents of a residential adult care center.
Both patients are diabetic, using the same
glucometer. There are a total of 20 diabetics in
the home and we don't know the total number of
residents. There are a total of 4 shared
glucometers. Lack of adherence to standard
precautions and failure to implement
long-standing recommendations against sharing
fingerstick devices are well described in the
public health literature as placing LTC residents
at risk for acquiring infections from bloodborne
pathogens such as HBV. For situations like this,
we have typically offered testing for hepatitis B
for all the diabetic residents.
6
Service Area Description

• This service area focuses on approximately 50
  different diseases of public health importance,
  including diarrheal diseases, hepatitis,
  meningitis. There are four main categories
• Disease surveillance
• Disease consultation and policy development
• Outbreak investigations
• Monitoring for and responding to emerging
  infections and terrorism-related illnesses

7
Statutory Authority

• 32.1-35 of the Code of Virginia requires the
  Board of Health to establish a list of diseases
  that must be reported to the health department.
• 32.1-36 and 32.1-37 require physicians,
  laboratories, and persons in charge of medical
  care facilities, school, or summer camps to
  report diseases to the health department.
• 32.1-39 requires the Department to provide for
  surveillance and investigation of preventable
  diseases and epidemics, including outbreak
  investigations.
• Articles 3, 3.01, and 3.1 of that Chapter address
  disease control measures that may be implemented,
  including quarantine, isolation of persons with
  communicable diseases, and control of rabies.

8
Functions

• Disease Surveillance
• Disease Control
• Outbreak Investigations
• Emergency Preparedness Response

9
Key Products

• Regulations for Disease Reporting and Control
• Virginia Disease Control Manual
• Virginia Epidemiology Bulletin
• Virginia Disease Surveillance Annual Report
• Web site

10
Objectives Measures

• Objective 01 Provide timely and appropriate
  coordination of disease investigation and control
  activities statewide
• Measure 01.01. Number of disease-specific plans
  and guidance documents added or updated each year
  and made available on the agencys internal web
  site
• Measure 01.02. Number of training programs
  provided for agency staff on the public health
  response to diseases and emergencies.

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Objectives Measures (cont.)

• Objective 02 Conduct comprehensive surveillance
  for communicable diseases of public health
  significance
• Measure 02.01 Number of agency staff regularly
  using the National Electronic Disease
  Surveillance System (NEDSS) to manage data on the
  occurrence of reportable diseases
• Measure 02.02 Number of hospitals submitting
  data to the Electronic Surveillance System for
  the Early Notification of Community-based
  Epidemics (ESSENCE) system daily
• Measure 02.03 Number of viable surveillance
  systems for environmental vehicles and non-human
  vectors of disease.

12
Objectives Measures (cont.)

• Objective 03 Communicate timely and appropriate
  information about the occurrence of disease and
  ways to minimize disease occurrence
• Measure 03.01 Number of issues of the Virginia
  Epidemiology Bulletin (VEB) produced
• Measure 03.02. Number of months the statistics
  available on the web site are updated

13
Financial Summary
This service area receives state general fund
dollars for general epidemiologic services and
for terrorism preparedness. In addition, federal
funds are awarded from the Centers for Disease
Control and Preventions Epidemiology and
Laboratory Capacity Program and Expanding
Existing Surveillance to include Pfiesteria,
Other Harmful Algal Blooms, and Marine Toxins.
The Environmental Protection Agency also supplies
federal funds from the Beach Monitoring and
Notification program.
14
Virginia Department of Health Division of HIV,
STD, and Pharmacy Services
Casey Riley Director criley_at_vdh.state.va.us
15
Vignette
The Suffolk Health Department is working with the
Virginia Department of Healths (VDH) Virginia
Epidemiology Response Team (VERT) to address the
rise in syphilis infections in Suffolk. VDH
deployed VERT, an outbreak response team, to
assist the Suffolk Health Department in
conducting community syphilis screenings and
partner notification. The team also is
responsible for heightening awareness and
education in the local community about the risk
factors for syphilis. VERT is a tremendous
resource, said Casey W. Riley, director of VDHs
Division of HIV, STD, and Pharmacy Services. The
team is trained to monitor infections, counsel
clients on testing and treatment services, and
strengthen community involvement and
partnerships. VDH has been closely following
the syphilis infection rates in Suffolk. Syphilis
is being seen in both men and women.
Additionally, the disease can be passed on by
pregnant women to their unborn children, who are
placed at risk of developing congenital syphilis.
Congenital syphilis can result in blindness or
death of a baby.
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(No Transcript)
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VERT assists NOVA and DC health depts. with
syphilis (1 yr)
VERT provides temporary staff to Richmond and
Henrico
Syphilis outbreak response (1 yr) in Danville.
VERT borrows DIS from LHDs
VERT provides temporary staff to Lynchburg,
Crater, Fredericksburg, Norfolk, and Peninsula
VERT assists with Anthrax surveillance
2000
2001
2002
2003
2004
2005
VERT begins syphilis response (1 yr) in Norfolk
VERT assists with TB and food borne outbreaks
Syphilis outbreak response in Suffolk
VERT assists Richmond (2 yrs) with
gonorrhea and chlamydia problem
VERT assists with TB outbreak in Chesapeake
Outbreak Response Unit created
18
Service Area Description

• Provides for the prevention and control of
  morbidity and mortality associated with sexually
  transmitted diseases (STD) and their
  complications, including assistance to local
  health departments and community organizations
• Identifies populations at greatest risk for
  becoming infected with HIV, provides services to
  prevent new HIV infections among individuals at
  risk, tracks the epidemic, links infected
  individuals into care, and provides
  treatment/medication to individuals who would
  otherwise be unable to access care.

19
Statutory Authority

• 32.1-36 requires physicians to report persons
  with STD to the local health department
• 32.1-39 provides for STD surveillance,
  investigation of reports, and conducting
  counseling and contact tracing (partner
  notification)
• 32.1-57 through 32.1-60 requires STD
  examination, testing, and treatment
• 32.1-64 requires treatment for opthalmia
  neonatorum.

20
Statutory Authority (cont.)

• 32.1-36.1, 32.1-37.2, and 32.1-55.1 of the Code
  of Virginia respectively establish mandatory
  confidentiality of testing, counseling
  requirements for HIV testing, and the
  establishment of additional anonymous testing
  sites
• 32.1-11.2 established the AIDS Services and
  Education Grants program which provides outreach,
  education and support services to high-risk
  populations
• 32.1-36 allows for the voluntary reporting of
  additional information at the request of the
  Virginia Department of Health for special
  surveillance or epidemiological studies
• 32.1-37.2 requires that partner notification
  services (partner counseling and referral
  services) be offered to individuals who test
  positive for HIV
• 32.1-11.2 established pilot treatment centers
  and regional AIDS resource and consultation
  centers

21
Key Products of DHIV/STD

• HIV/STD Operations Manual
• HIV/STD/Viral Hepatitis Hotline
• HIV/STD Annual Statistics Report
• HIV/STD Quarterly Surveillance Report
• Monthly HIV/STD e-Bulletin
• Numerous HIV/STD Educational materials
• HIV/STD Web site

22
Objectives Measures

• Objective 01 Reduce the incidence of Sexually
  Transmitted Diseases (STD) among Virginias
  citizens
• Measure 01.01 Primary/Secondary Syphilis
  morbidity reports and incidence rates
• Measure 01.02 Gonorrhea morbidity reports and
  incidence rates
• Measure 01.03 Chlamydia morbidity reports and
  incidence rates
• Measure 01.04 Other Reportable STD morbidity
  reports and incidence rates

23
Objectives Measures (cont.)

• Objective 02 Ensure that HIV-infected
  individuals receive optimal health care services
  that prolong length and quality of life
• Measure 02.01 Five-Year HIV Survival Rate
• Measure 02.02 Percent of HIV-Infected Persons
  Receiving Optimal Drug Therapy

24
Objectives Measures (cont.)

• Objective 03 Decrease new HIV infections among
  Virginias citizens
• Measure 03.01 HIV infection case rate
• Measure 03.02 Percentage of individuals with
  newly-diagnosed HIV infection who receive their
  HIV test results

25
Federal Funds

• Ryan White CARE Act Title II
• HIV/AIDS Surveillance
• STD Prevention
• Syphilis Elimination
• Chlamydia Prevention
• Viral Hepatitis Integration Project
• Community Services
• HIV Counseling and Testing Services
• OASIS Project

26
Federal Funds (cont.)

• Linkages to Care Demonstration Project
• Morbidity Monitoring Project

27
Division of HIV, STD, and Pharmacy
ServicesBudget by Funding Type
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Financial Summary
The chief source of funding for Sexually
Transmitted Disease Prevention and Control is
federal funds from the Centers for Disease
Control and Prevention. Federal funds are
intended to supplement (not replace or supplant)
state and local resources but matching of these
funds is not required. The service area also
receives some general funds. Within the general
fund, 75 of the funds are used for central
office personnel and the remaining 25 supports
STD testing and travel.
29
Financial Summary (cont.)
HIV prevention services, including HIV counseling
and testing, are supported through state and
federal funds. The U.S. Centers for Disease
Control and Prevention provides the majority of
these funds with approximately 5,000,000
annually. HIV treatment services receive both
federal and state funding. The largest portion of
funding for these services, approximately 22.7
million annually, is provided by Title II of the
Ryan White Comprehensive AIDS Resources Emergency
(CARE) Act, which is administered federally by
the Health Resources and Services
Administration. The Surveillance program receives
approximately 1.24 million federal dollars
annually from the U.S. Centers for Disease
Control and Prevention to support multi-faceted
programs essential to measuring the effectiveness
of HIV prevention activities.
30
Virginia Department of Health Division of
Tuberculosis Control
Margaret Tipple, M.D. Director mtipple_at_vdh.state.
va.us
31
Vignette
A 70 yo female day care worker with a history of
pneumonia, PPD for 40 years, has one positive
AFB smear and a positive MTB probe. The day care
serves members of the news media. LHD is working
with the daycare to obtain list of all staff and
children from daycare who are currently in
daycare or who have left since 9/14/04 when case
first went to volunteer. The day care will
assemble most of the parents and staff so LHD can
provide risk communication with recommendations
based on CDC guidelines. LHD is offering PPD
testing in cooperation with the daycare and
giving written materials to families and staff.
32
Service Area Description

• The purpose of this service area is to control,
  prevent, and eventually eliminate tuberculosis
  (TB) from the Commonwealth
• Strives to detect every case of TB, assure the
  adequacy and completeness of treatment, and
  prevent further disease transmission
• Includes the Newcomer Health Program (NHP, which
  focuses on the health needs of refugees newly
  resettled in Virginia

33
Statutory Authority

• 32.1-49 of the Code of Virginia specifically
  directs the Board of Health to include
  tuberculosis in the list of diseases required to
  be reported in 32.1-35.
• 32.1-48.02 D allows the Commissioner to issue
  an Emergency Detention Order for diseases of
  public health significance caused by an airborne
  microorganism.
• 32.1-50 of the Code of Virginia relates to the
  examination of persons suspected of having active
  tuberculosis disease, including authority for
  examination, report forms report schedule
  laboratory reports and required samples.
• 32.1-50.1 relates to the development of
  treatment plans for patient undergoing treatment
  for tuberculosis, submission of plans for health
  director review and mediation of disagreements
  concerning the plan. This section also provides
  a definition for the determination of cure.

34
Functions

• Disease Surveillance
• Disease Control
• Outbreak Investigations
• Emergency Preparedness Response
• Education
• Refugee and Immigrant Health Program

35
Key Products

• Regulations for Disease Reporting and Control
• Virginia Disease Control Manual
• Refugee and Immigrant Health Manual
• Virginia Epidemiology Bulletin
• Virginia Disease Surveillance Annual Report
• Web sites

36
Objectives Measures

• Objective 01 Reduce the occurrence of TB disease
  among Virginia residents
• Measure 01.01 The proportion of patients who
  complete an adequate and appropriate course of
  treatment within 12 months of treatment
  initiation
• Measure 01.02 Increase the percentage of
  infected contacts of infectious TB that are
  placed on treatment for latent TB infection
  (LTBI) and complete that treatment regimen

37
Financial Summary
Tuberculosis Prevention and Control is supported
by both general funds and federal funds. The
Federal funds come through a categorical
cooperative agreement from the Centers for
Disease Control and Prevention and are intended
to supplement (not replace or supplant) state and
local resources.
38
Virginia Department of HealthDivision of Health
Hazards Control
Khizar Wasti, Ph.D. Director kwasti_at_vdh.state.va.
us
39
Virginia Department of Health Division of
Zoonotic and Environmental Epidemiology
Susan Fischer Davis, M.D. Acting
Director susan.davis_at_vdh.state.va.us
40
Vignette
In May 2005 there was an outbreak of lymphocytic
choriomeningitis (LCM) among organ recipients
(not in Virginia) that was associated with a
donor who had purchased a hamster from a pet
store. A trace back led to a hamster distributor
in Ohio where about 3 of sampled animals were
positive. DZEE was called this morning by CDC to
inform us that some of the rodents from the
implicated distributor appear to have ended up in
Virginia--at small, independent pet shops. CDC is
planning to publish a public advisory. They will
not be recalling the animals, just asking for
stores to stop selling them and giving advice to
pet owners. Because this organism can be found in
wild rodents, it is difficult to require a recall
and depopulation.
41
Service Area Description

• Develop/distribute written information for human
  animal medical professionals and the public
• To respond to inquiries from private/public
  health professionals local/state/federal
  governments researchers and the public
• To collect, maintain, analyze and interpret data
  and to distribute findings to appropriate
  audiences
• To obtain grants to further public health lab
  programs and oversee distribution of these funds

42
Objectives

• To prevent and control diseases of humans
  resulting from environmental exposures
  infections from animals.
• To conduct appropriate surveillance, outbreak
  investigations, and environmental public health
  monitoring and tracking.

43
Federal Funds

• Expanding Existing Surveillance to include
  Pfiesteria, Other Harmful Algal Blooms, and
  Marine Toxins
• State of Virginia Beach Monitoring and
  Notification

44
Virginia Department of Health Division of
Immunization (DIMM)

• James Farrell
• Director
• jfarrell_at_vdh.state.va.us
• www.vdh.virginia.gov/imm

45
Vignette
As media attention to a possible influenza
pandemic continues, citizens are asking their
physicians to prescribe oseltamivir (Tamiflu) for
personal stockpiles for possible later use during
an influenza pandemic. VDH is not encouraging the
practice of writing such prescriptions or the
establishment of personal stockpiles. However,
since physicians may wish to consider the special
circumstances of individual patients before
making a decision about whether to honor these
requests, VDH has developed guidance regarding
the advantages and disadvantages of such
prescribing.
46
Statutory Authority

• Code of Virginia, Sections 32.1-46 and
  22.1-271.2
• Mandates immunization of children against certain
  diseases
• Authorizes sharing immunization records and
  establishment of a statewide registry
• Requires health departments to administer
  mandated vaccines without charge
• Code of Virginia, Section 23-7.5
• Mandates higher education immunization
  requirements

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Programs

• Vaccine Supply
• Quality Assurance
• Vaccines for Children (Federal Entitlement
  Program)
• Perinatal Hepatitis B Prevention
• Epidemiology
• Immunization Registry
• Assessment

48
Objectives Measures

• Objective 01 Achieve and maintain maximum
  immunization coverage rates in Virginias
  children and adults
• Measure 01.01 Immunization coverage rates of
  children at 2 years of age
• Measure 01.02 Immunization coverage rates of
  children at school entry

49
Objectives Measures (cont.)

• Objective 02 Improve influenza and pneumococcal
  coverage rates in persons 65 years of age
• Measure 02.01 Influenza vaccination coverage
  rates in persons 65 years of age
• Measure 02.02 Pneumococcal vaccination coverage
  rates in persons 65 years of age

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Funding Sources

• Federal Funds
• 85 of Division funding
• Immunizations and Vaccines for Children
  Categorical Grant
• Authorized by Section 317 of the Public Health
  Service Act
• State Funds
• 15 of Division funding

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Financial Summary
The total budget for the service area has two
funding streams consisting of general and
non-general funds. Nongeneral funds are received
in a federal, categorical, cooperative agreement
from the Centers for Disease Control and
Prevention.
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Questions?