Virginia Department of Health

1. Virginia Department of Health Office of Epidemiology Carl W. Armstrong, M.D., Director carl.armstrong@vdh.state.va.us

2. Office of Epidemiology Carl W. Armstrong, M.D., Director Division of Disease Surveillance and Investigation Diane Woolard, PhD Director Division of Health Hazards Control Khizar Wasti, Ph.D. Director Division Of Zoonotic and Environmental Epidemiology Susan Fischer Davis, MD Acting Director Division of HIV/STD Casey Riley Director Division of Immunization James Farrell Director Division of Tuberculosis Control Margaret Tipple, M.D. Director 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@vdh.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 agency’s internal web site • Measure 01.02. Number of training programs provided for agency staff on the public health response to diseases and emergencies.

11. 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 Prevention’s 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@vdh.state.va.us

15. Vignette The Suffolk Health Department is working with the Virginia Department of Health’s (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 VDH’s 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.

17. 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 Virginia’s 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 Virginia’s 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

28. 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@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@vdh.state.va.us

39. Virginia Department of Health Division of Zoonotic and Environmental Epidemiology Susan Fischer Davis, M.D. Acting Director susan.davis@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@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

47. 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 Virginia’s 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

50. 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