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Additional Information and Resources
- Classifying Hepatitis C as Acute or Chronic in People with Hepatitis A
- Transmitting Multiple Viral Hepatitis Condition Notifications to NNDSS
- Guidance for Reporting Outbreak Source for Hepatitis A Cases to NNDSS
- Optional Data Sources to Supplement Viral Hepatitis Surveillance Systems
- CDC Training Resources for Disease Investigation Specialists
- CDC DVH Technical Assistance for Viral Hepatitis Surveillance
- NASTAD HepTAC: Online TA and Capacity Building Center
Classifying Hepatitis C as Acute or Chronic in People with Hepatitis A
Background and Rationale
During person-to-person hepatitis A outbreaks, jurisdictions may receive reports of people with evidence of coinfection of hepatitis A with hepatitis B and hepatitis C. Classification of cases of hepatitis B that are coinfected with hepatitis A is clear because a laboratory marker exists for acute hepatitis B (i.e., anti-HBc IgM); however, for cases of hepatitis C that are coinfected with hepatitis A, it is not always apparent if the HCV infection should be classified as acute or chronic.
The CDC/CSTE hepatitis A case definition, implemented in 2019 (PS 18-ID-07) (116), and the acute and chronic hepatitis C case definitions, implemented in 2020 (PS 19-ID-06) (14), do not explicitly address case classification of hepatitis C in cases associated with hepatitis A coinfection. Because viral hepatitis coinfections occur regardless of whether they are associated with a hepatitis A outbreak, long-term guidance is needed to standardize classification and notification of these cases.
Problem and Next Step
Guidance for determining whether a case with documented clinical information is caused by hepatitis A or acute hepatitis C (or both) is not explicitly included in the CDC/CSTE position statements (1, 2). The following guidance is to be used for cases reported in the 2020 MMWR year and beyond.
Considerations for Hepatitis C Case Classification and Notification
Documented HCV Test Conversion
As per the 2020 CDC/ CSTE case definition (107), any documentation of an HCV test conversion from negative to positive within 12 months should be classified as acute hepatitis C, irrespective of signs, symptoms, and other clinical information. An HCV test conversion can either be an anti-HCV test conversion or an HCV detection test conversion. Test conversion definitions are listed in Table 4-2.
Laboratory Results Indicating Early Acute Hepatitis C
Anti-HCV tests have about an 8–11-week window period from HCV exposure to detection of HCV antibodies. HCV RNA is detectable approximately 1–2 weeks after HCV exposure. If HCV RNA is detectable and anti-HCV is undetectable on the same specimen, this could indicate early acute hepatitis C; anti-HCV testing was performed during the window period. This scenario might be more common in settings where HCV testing is regularly performed (e.g., SSP providers and blood or plasma donation centers). In people who are immunocompromised, development of HCV antibodies might be delayed. In immunocompromised people at risk for HCV infection, HCV RNA testing should always be performed to determine current infection, even when the anti-HCV result is negative.
Documentation of Recent IDU Initiation
In the absence of a documented HCV test conversion or other laboratory indicators of acute hepatitis C, cases among co-infected people documented as having recently initiated IDU should be classified as acute. In this context, “recent” is defined as initiating IDU for the first time within 12 months of the first report to public health. This is an optional activity that could be considered for a special project.
Presence of Clinical Criteria in the Absence of Acute Hepatitis C Considerations
Most adults with hepatitis A have signs and symptoms of acute liver injury (117), whereas a much lower percentage (15%–25%) of people with acute hepatitis C present with signs and symptoms (98, 99, 118). In the absence of evidence to support acute hepatitis C classification, clinical signs and symptoms might be attributed to hepatitis A in the presence of previously undiagnosed chronic hepatitis C. This rationale is consistent with the 2020 acute hepatitis C case definition, which removes the discrete onset of symptoms as a requirement for classification of acute hepatitis C cases.
In addition, the 2020 acute hepatitis C case definition of the CSTE Hepatitis C Position Statement (PS 19-ID-06) includes a clause under the clinical criteria that states that a more likely diagnosis, such as another viral hepatitis infection (e.g., hepatitis A), should be considered a possible explanation for the presence of clinical criteria before considering that the clinical criteria for acute hepatitis C is met.
Scenarios for Hepatitis C Case Classification and Notification
Table 5-1 describes hepatitis C case classification and notification scenarios when a concurrent hepatitis A diagnosis is present. Because laboratory markers of acute viral hepatitis infection (e.g., anti-HAV IgM, HAV RNA, total bilirubin levels ≥ 3.0 mg/dL, and peak ALT levels >200 IU/L) can change within a narrow timeframe, the term “concurrently” in this context refers to hepatitis A and hepatitis C-associated laboratory results that were performed on the same specimen or at least within a few days.
Table 5-1. Classification of hepatitis C cases diagnosed concurrently with hepatitis A
| Scenario Confirmed hepatitis A* AND… |
Classification | Rationale |
|---|---|---|
|
Confirmed acute hepatitis C | Documented HCV test conversion.† Clinical criteria not required to be met for acute hepatitis C case classification. However, because the patient has confirmed hepatitis A, clinical criteria are present.* |
|
|
Confirmed acute hepatitis C | For the first 8 weeks following exposure to HCV, anti-HCV tests might not detect HCV antibodies.‡,§ HCV RNA is likely detectable ~1–2 weeks after HCV exposure.‡ If HCV RNA is detectable and anti-HCV is not detectable in the same specimen, this could indicate early acute HCV infection.‡ This scenario might be more common in settings where HCV testing is regularly performed (e.g., syringe services providers and blood donation centers). |
|
Confirmed acute hepatitis C | The risk of HCV infection associated with injection drug use is strong following onset of injection. However, in the absence of information about recent initiation of injection drug use, this case would be classified as confirmed chronic hepatitis C. See below scenario. |
|
Confirmed chronic hepatitis C | The 2020 acute hepatitis C case definition, under clinical criteria, states that a more likely diagnosis, such as another viral hepatitis infection (e.g., hepatitis A), should be considered as a possible explanation for the presence of clinical criteria before considering that the clinical criteria for acute hepatitis C is met. |
|
Probable chronic hepatitis C | The 2020 acute hepatitis C case definition, under clinical criteria, states that a more likely diagnosis, such as another viral hepatitis infection (e.g., hepatitis A), should be considered as a possible explanation for the presence of clinical criteria before considering that the clinical criteria for acute hepatitis C is met. |
*A case of confirmed hepatitis A, in this context, has evidence of
- acute hepatitis symptoms (i.e., the abrupt onset of symptoms consistent with acute viral hepatitis [e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal pain, or dark urine]), AND
- acute hepatitis signs or laboratory abnormalities (defined as a report of jaundice or peak elevated total bilirubin levels ≥3.0 mg/dL or peak ALT levels >200 IU/L), AND
- anti-HAV IgM positive and/or HAV RNA positive.
†Anti-HCV test conversion: 1) documented negative HCV antibody (anti-HCV) test followed by a positive HCV antibody test within 12 months or 2) documented negative HCV detection test followed by a positive anti-HCV test within 12 months.
HCV detection test conversion: 1) documented negative anti-HCV test followed by a positive HCV detection test within 12 months or 2) documented negative HCV detection test in someone without a prior diagnosis of hepatitis C followed by a positive HCV detection test within 12 months.
‡Source of information: https://www.aphl.org/aboutAPHL/publications/Documents/ID-2019Jan-HCV-Test-Result-Interpretation-Guide.pdf [PDF – 4 pages]
§In people who are immunocompromised, development of HCV antibodies might not occur or be delayed. In people who have risks for HCV infection, HCV detection testing, regardless of HCV antibody status, should always be performed to determine presence or absence of infection.
Downloads of this table: PDF | PPT
Transmitting Multiple Viral Hepatitis Condition Notifications to NNDSS
Background and Rationale
Different scenarios may lead to reports of multiple viral hepatitis condition notifications in the same person. Jurisdictions might receive laboratory reports indicating hepatitis coinfections; additionally, people with perinatal or acute hepatitis B or hepatitis C can develop chronic infection. Capturing these events through surveillance is critical to accurately measure the national burden of hepatitis A, hepatitis B (acute, chronic, and perinatal), and hepatitis C (acute, chronic, and perinatal) and characterize cases. See Table 1-2 for the complete list of viral hepatitis conditions that are notifiable to CDC.
For jurisdictions using a person-level data transmission mechanism to transmit case-report data (e.g., NBS or HL7), a unique person-specific ID should be transmitted along with each case notification. The same unique person ID should be submitted for all conditions associated with the patient across reporting years. Submission of data in this manner allows for people who have more than one condition notification across time from the same jurisdiction to be grouped together for analyses. Please note that this guidance does not pertain to jurisdictions that are transmitting viral hepatitis cases to NNDSS solely via NETSS, because NETSS is not a person-level system.
Transmission of Multiple Viral Hepatitis Condition Notifications to NNDSS via NBS
Table 5-2 describes the variables that are recommended for transmitting multiple viral hepatitis condition notifications on a person via NBS.
Table 5-2. Person and case identification variables in the National Electronic Disease Surveillance System Base System (NBS)
| CDC Variable ID | CDC Variable Name | CDC Variable Type | CDC Question/Variable Description |
|---|---|---|---|
| DEM197 | Person_ local_id | Alphanumeric (<200 characters) | The local ID of the subject/entity of the case. This is the ID that the state NBS application assigned to the subject when it was entered into NBS. |
| INV168 | Case_local_id | Alphanumeric (<200 characters) | State-assigned expanded case ID/local record ID in source NBS Master Message. |
| NOT109/nbsStateCode | NND_Reporting_State_Cd | Alphanumeric (<20 characters) | NBS reporting state code. |
Downloads of this table: PDF | PPT
To transmit multiple viral hepatitis condition notifications on a person via NBS, use the same person local ID (DEM197) for all associated case investigations (INV168). Make sure that all cases are de-duplicated before transmitting to NNDSS.
Transmission of Multiple Viral Hepatitis Condition Notifications to NNDSS via HL7 Case Notification
Table 5-3 describes variables that are recommended for transmitting multiple viral hepatitis condition notifications on a person via HL7 case notification.
Table 5-3. Person and case identification variables via Health Level Seven (HL7) case notification
| PHIN Variable | Variable Type | Data Element | Data Element Description |
|---|---|---|---|
| DEM197 | Text | Local subject ID | The person local ID associated with the case. |
| INV168 | Text (Alphanumeric <200 characters) | Local record ID | Sending system-assigned local ID of the case with which the subject is associated. |
| NOT116 | Coded value (Alphanumeric <20 characters) |
77968-6 National Reporting Jurisdiction |
National jurisdiction reporting the notification to CDC. |
Downloads of this table: PDF | PPT
To transmit multiple viral hepatitis condition notifications on a person via HL7 case notification, use the same person local ID (DEM197) for all associated case investigations (INV168). Make sure that all cases are de-duplicated before transmitting to NNDSS.
Guidance for Reporting Outbreak Source for Hepatitis A Cases to NNDSS
When transmitting cases of outbreak-associated hepatitis A to NNDSS, it is important to differentiate between cases associated with a common-source (i.e., foodborne or waterborne) versus person-to-person outbreaks.
Data Elements Defining Outbreak Source
Specific reporting fields enable jurisdictions to report outbreak status on hepatitis A cases notified to NNDSS. To indicate that a case of hepatitis A is associated with a person-to-person outbreak (rather than a common source), HDs should use the outbreak variable in the core section. To indicate that a case of hepatitis A is part of a common-source outbreak, HDs are advised to use both the outbreak variable located in the core section and the outbreak variable(s) found in the hepatitis A condition-specific section.
Reporting Outbreak Source to NNDSS via NETSS
Table 5-4 describes the options for indicating the outbreak source for hepatitis A cases notified to NNDSS via NETSS.
Table 5-4. Variables indicating outbreak source for hepatitis A cases notified to the National Notifiable Diseases Surveillance System (NNDSS) via the National Electronic Telecommunications System for Surveillance
| CDC Variable Name | Position (Column/Length) | Description | Coding for Transmission to NNDSS |
|---|---|---|---|
|
Outbr (Core Data) |
55/1 | Outbreak-associated |
Indicates whether the case-report was associated with an outbreak. 1 = Case is outbreak-associated 2 = Case is not outbreak-associated 9 = Unknown |
| Outbreak (Hepatitis-Specific Data) | 82/1 | Common source outbreak |
Was the patient suspected as being part of a common-source outbreak? 1 = Yes 2 = No 9 = Unknown |
Downloads of this table: PDF | PPT
To indicate that a hepatitis A case was associated with a person-to-person outbreak, use the following selections:
- Outbreak-associated (core data) = Yes AND
- Common-source outbreak (hepatitis A-specific data) = No
To indicate that a hepatitis A case was associated with a common-source (e.g., foodborne or waterborne) outbreak, use the following selections:
- Outbreak-associated (core data) = Yes AND
- Common-source outbreak (hepatitis A-specific data) = Yes
Reporting Outbreak Source to NNDSS via NBS
Table 5-5 describes the options for indicating the outbreak source for hepatitis A cases notified to NNDSS via NBS.
Table 5-5. Variables indicating outbreak source for hepatitis A cases notified to the National Notifiable Diseases Surveillance System (NNDSS) via the National Electronic Disease Surveillance System Base System (NBS)
| NBS ID | NBS Label | Description | Coding for Transmission to NNDSS |
|---|---|---|---|
| INV150 | OUTBREAK | Outbreak-associated |
Indicates whether the case-report was associated with an outbreak. 1 = Case is outbreak-associated 2 = Case is not outbreak-associated 9 = Unknown |
| HEP143 | AOUTBREAK | Common-source outbreak |
Was the patient suspected as being part of a common-source foodborne or water borne outbreak? 1 = Yes 2 = No |
Downloads of this table: PDF | PPT
To indicate that a hepatitis A case was associated with a person-to-person outbreak, use the following selections:
- INV150 = Yes AND
- HEP143 = No
To indicate that a hepatitis A case was associated with a common-source (e.g., foodborne or waterborne) outbreak, use the following selections:
- INV150 = Yes AND
- HEP143 = Yes
Reporting Outbreak Status to NNDSS via HL7 Case Notification
Table 5-6 describes the options for indicating the outbreak source for hepatitis A cases notified to NNDSS via HL7 case notification.
Table 5-6. Variables indicating outbreak source for hepatitis A cases notified to the National Notifiable Diseases Surveillance System via Health Level Seven case notification
| PHIN Variable | OBX 3.1 Identifier | Data Element Name | Data Element Description |
|---|---|---|---|
| INV150 |
77980-1
|
Case outbreak indicator | Indicates whether the case report was associated with an outbreak. |
|
INV618
|
INV618
|
Common-source outbreak | Is the subject suspected as being part of a common-source outbreak? |
|
INV609
|
INV609
|
Foodborne outbreak; infected food handler | If yes, was the outbreak associated with an infected food handler? |
|
INV610
|
INV610
|
Foodborne outbreak; not an infected food handler | If yes, was the outbreak not associated with an infected food handler? |
|
INV612
|
INV612
|
Waterborne outbreak | If yes, was the outbreak waterborne? |
Downloads of this table: PDF | PPT
Table 5-7 describes the selections that should be used to indicate the outbreak source for hepatitis A cases notified to NNDSS via HL7 case notification.
Table 5-7. Selections for variables indicating outbreak source for hepatitis A cases notified to the National Notifiable Diseases Surveillance System via Health Level Seven case notification
| Hepatitis A Outbreak Scenario | Variable Selections | ||||
|---|---|---|---|---|---|
| 77980-1 | INV618 | INV609 | INV610 | INV612 | |
| Person-to-person outbreak | Yes | No | No | No | No |
| Foodborne outbreak, infected food handler | Yes | Yes | Yes | No | No |
| Foodborne outbreak, not infected food handler | Yes | Yes | No | Yes | No |
| Waterborne outbreak | Yes | Yes | No | No | Yes |
Optional Data Sources to Supplement Viral Hepatitis Surveillance Systems
Supplementary data sources can be used to augment case surveillance data. For example, certain sources can provide information on progression of chronic infection to advanced liver disease or cancer; births to people of childbearing age with childbearing potential with HBV and HCV infection; deaths among patients; and data for missing demographic, risk, and vaccination status needed for completing case reports.
Even without linkage to case reports, supplementary data sources can be used to assess the extent of disease burden associated with viral hepatitis; track trends in risk behaviors or exposures and awareness of infection, and access to treatment; and monitor the impact of prevention and control programs or elimination plans. Some supplementary data sources provide information at the jurisdiction level, others provide only national level data*, and some provide both. Cost to jurisdictions also varies, with some data sources being free or low cost and others requiring substantial investment or a licensing fee, particularly data previously collected or compiled from multiple data providing organizations. Collaborations with universities, public health institutes, and other partners with capacity and experience in using these other data sources can be advantageous when a HD’s resources are insufficient to support in-house use of one or more of these data sources.
Each type of data source and each specific source has unique strengths and limitations, making each one more suitable for certain uses and less suitable for others. None is a perfect substitute for another, so they should be viewed as a portfolio that can be used to provide a more complete overview of the burden of viral hepatitis in a jurisdiction. Awareness of these data sources and their uses is especially important before deciding to undertake additional data collection efforts and for prioritizing use of other supplementary data sources.
Table 5-8 lists some data sources that might be helpful in improving the understanding of the viral hepatitis burden in a jurisdiction.
Table 5-8. Supplementary data sources
| Data Source | Representativeness | May Be Able to Link to Surveillance Data? |
Additional Information |
|---|---|---|---|
| Registry/Surveillance System Data | |||
| Accurint/LexisNexis | Jurisdiction-specific | No | https://www.accurint.com |
| Birth Certificates | National-level and jurisdiction-specific | Yes | https://www.cdc.gov/nchs/nvss/births.htm |
| Birth Defects Registry | Jurisdiction-specific | Yes | https://www.cdc.gov/ncbddd/birthdefects/data.html |
| Cancer Registry | National-level and jurisdiction-specific | Yes | https://www.cdc.gov/cancer/npcr/index.htm |
| Commercial Laboratory | US population-based | No (standalone system) |
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6606113/ |
| Death Certificates | National-level and jurisdiction-specific | Yes | https://www.cdc.gov/nchs/nvss/deaths.htm |
| Enhanced HIV/AIDS Reporting System (eHARS) | National-level and jurisdiction-specific | Yes | https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html |
| Immunization Registry | Jurisdiction-specific | Yes | https://www.cdc.gov/vaccines/programs/iis/index.html |
| National Death Index (NDI) | National-level and jurisdiction-specific | Yes | https://www.cdc.gov/nchs/ndi/index.htm |
| Ryan White Eligibility System (RWES) | National-level and jurisdiction-specific | Yes | https://hab.hrsa.gov/data/data-reports |
| Jurisdiction-specific Infectious Disease Surveillance Databases (e.g., HIV, STI, Tuberculosis Case Surveillance) | Jurisdiction-specific | Yes | |
| Jurisdiction-specific Non-infectious Disease Surveillance Databases (e.g., Cancer Registry and Injury Prevention) | Jurisdiction-specific | Yes | |
| Social Security Death Master File (SSDMF) | National-level and jurisdiction-specific | Yes | https://dmf.ntis.gov |
| Jurisdictional Corrections Information Systems | Jurisdiction-specific | Yes | |
| Health Care Systems Data | |||
| AIDS Drug Assistance Programs (ADAP) | Jurisdiction-specific | Yes | https://adap.directory |
| All-payers/Insurance Claims | Jurisdiction-specific | Yes |
https://www.ahrq.gov/data/apcd/index.html
https://www.cms.gov/OpenPayments/Explore-the-Data/Data-Overview |
| Electronic Medical Records (EMR) or Electronic Health Records (EHR) | Jurisdiction-specific | Yes | https://www.cancer.gov/publications/dictionaries/cancer-terms/def/electronic-medical-record |
| Electronic Case Reporting (eCR) | Jurisdiction-specific pilot study | Yes | https://www.cdc.gov/ecr/index.html |
| Hospital Discharge Databases | Jurisdiction-specific | Yes | https://www.cdc.gov/nchs/nhds/index.htm |
| Healthcare Cost and Utilization Project (HCUP) | National-level | No, standalone system | https://www.hcup-us.ahrq.gov/overview.jsp |
| Pharmacy Claims | US-population-based | Yes | https://www.ajmc.com/journals/supplement/2019/burden-chronic-hepatitis-c/assessing-burden-illness-chronic-hepatitis-impact-antiviral-healthcare-costs-medicaid |
| Syndromic Surveillance for Injection Drug-Related Complaints, Non-Fatal Drug Overdoses | Jurisdiction-specific | Dependent on capabilities of surveillance system | https://www.cdc.gov/nssp/overview.html |
| Survey Data | |||
| Behavioral Risk Factor Surveillance System (BRFSS) | Jurisdiction-specific | No, standalone system | https://www.cdc.gov/brfss/index.html |
| Medical Monitoring Project (MMP) (e.g., HCV in medical chart review portion) | Jurisdiction-specific | Yes | https://www.cdc.gov/hiv/statistics/systems/mmp/index.html |
| National Health and Nutrition Examination Survey (NHANES) | National-level | No, standalone system | https://www.cdc.gov/nchs/nhanes/index.htm |
| National HIV Behavioral Surveillance (HCV testing during IDU cycle) | Jurisdiction-specific | No, standalone system | https://www.cdc.gov/hiv/statistics/systems/nhbs/index.html |
| National Health Interview Survey | National-level | No, standalone system | https://www.cdc.gov/nchs/nhis/index.htm |
Downloads of this table: PDF | PPT
Table 5-9 describes the usefulness of select data sources that might supplement case ascertainment, investigation, characterization, and for monitoring of infection trends and disease-related outcomes. Some data sources are more useful for certain purposes than others.
Table 5-9. Use of supplementary data sources for case ascertainment, investigation, characterization, and for monitoring of infection trends and disease-related outcomes
| Data Source | Usefulness |
|---|---|
| Birth Certificates | Birth certificate data can be matched with surveillance data to identify infants born to gestational parents who are positive for hepatitis B and hepatitis C. Some jurisdictions’ birth certificates also have indicators of a history of maternal hepatitis B and hepatitis C, which can help identify unreported cases, although the quality of these variables should be validated prior to use for case ascertainment. For hepatitis B, matching birth certificates to gestational parent-infant pairs in the Perinatal Hepatitis B Prevention Program and/or hepatitis B registry or database may be used to assess appropriate hepatitis B testing, and the administration of hepatitis B immunoglobulin and hepatitis B vaccine. |
| Death Certificates | Death certificate data can be used to identify people reported with viral hepatitis as the underlying or contributing cause of death. This information is stored in both text form and in ICD-10 codes. Though viral hepatitis infections are often underreported on death certificates, crossmatches between viral hepatitis surveillance data and death certificates can identify deaths among people known to have viral hepatitis and can characterize trends in mortality among affected populations. |
| All-payers/Insurance Claims | These databases have information regarding specific medical claims and reimbursements (e.g., Medicaid data). When identifiable, viral hepatitis surveillance staff can match viral hepatitis surveillance data to these data sources to identify unreported cases and learn about case-specific viral hepatitis-related health care visits or costs and prescribed medications. If the database cannot be matched to viral hepatitis surveillance data, it can be used as a standalone system to a) provide estimates of viral hepatitis-related health care visits, prescriptions, and costs and b) assist in constructing the care and cure continuum in the jurisdiction. |
| Hospital Discharge Databases | Hospital discharge databases are maintained by many jurisdictions and contain data about hospital admissions. The databases generally contain inpatient records; other types of records (e.g., emergency department visits) are available in some jurisdictions. Some conditions, like endocarditis, are suggestive of risk behaviors (e.g., injection drug use) for viral hepatitis. Identifying the distribution of such conditions, such as data regarding the prevalence of injection drug use, can be used to inform hospitals of the need to test for viral hepatitis. Matching viral hepatitis surveillance data with hospital discharge databases can also help monitor disease severity, specifics of treatment, and cost of hospitalizations among specific populations. |
| Electronic Medical and Health Records (EHRs) | EHRs can be used to obtain additional patient data for case ascertainment, investigation, and classification (e.g., review negative laboratory results to clarify infection status, test results for other types of viral and non-viral hepatitis, and collect risk history). These data can also be used for identifying unreported cases in facilities that have data mining capabilities. EHRs can also potentially be used to identify missing data elements from known cases (e.g., race/ethnicity) through electronic case reporting, although EHR data quality and completeness varies depending on how data are stored. |
| Supplementary Laboratory Data | In addition to the positive viral hepatitis laboratory results that are routinely received by jurisdictions, some jurisdictions also receive non-positive laboratory results (e.g., undetectable HBV DNA and undetectable HCV RNA results). If available, viral hepatitis surveillance staff can use these data to identify acute cases by test conversion, differentiate between acute hepatitis B and hepatitis B reactivation, identify hepatitis C reinfection, determine if a laboratory result is likely false-positive, estimate hepatitis B and hepatitis C treatment coverage in their jurisdiction, and detect the prevalence of viral suppression in certain communities. Staff can use these data to clarify whether a positive HBV DNA or HCV RNA is in a chronic case, a reinfection (hepatitis C), a reactivation (hepatitis B), or possibly represents treatment failure. In addition, pregnancy status can be added to laboratory reports to encourage timely reporting of hepatitis B and hepatitis C in pregnancy. |
| Jurisdiction-specific Infectious Disease Surveillance Databases | Viral hepatitis surveillance data can be matched to other infectious disease surveillance databases (e.g., HIV, sexually transmitted infections, and tuberculosis) to obtain additional patient data for case investigation and classification. Matching viral hepatitis surveillance data with those for other infectious diseases can also be used to monitor rates of coinfection and inform data-to-care interventions. |
| Jurisdiction-specific Non-infectious Disease Surveillance Databases | Non-infectious disease surveillance data for related conditions can also be matched to viral hepatitis databases. For example, matching hepatitis B and hepatitis C databases to cancer registries or other chronic disease surveillance databases can be used to identify the prevalence of these outcomes among patients with chronic hepatitis B and hepatitis C. Data from injury prevention records can also be used to better characterize the intersecting epidemics of infectious diseases, opioid, methamphetamine, and other drug use disorder, and to inform the development of integrated public health interventions for people who use drugs. |
Downloads of this table: PDF | PPT
If a jurisdiction decides to use medical claims or death certificate data to supplement their viral hepatitis surveillance data, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes are used in these data sources to categorize hepatitis A, hepatitis B, and hepatitis C diagnoses and causes of death. Table 5-10 lists the ICD-10 codes.
Table 5-10. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes for hepatitis A, hepatitis B, and hepatitis C for clinical diagnosis and cause of death coding
| Condition | ICD-10 Codes |
|---|---|
| Hepatitis A | B15 |
| Hepatitis B | B16, B17.0, B18.0, and B18.1 |
| Hepatitis C | B17.1 and B18.2 |
Downloads of this table: PDF | PPT
CDC Training Resources for Disease Investigation Specialists
Passport to Partner Services is a national training program that provides education materials and resources for disease investigation specialists (DIS) and other providers of partner services at no cost to the registrant (119). This training program was developed by CDC’s Division of HIV/AIDS Prevention and Division of STD Prevention in collaboration with the National Network of STD/HIV Prevention Training Centers. The training consists of two components: self-study online modules and in-person, classroom-based training. Passport to Partner Services provides training for conducting surveillance activities, including case investigation that, although it is specific to HIV and STIs, the concepts can be applied to viral hepatitis case investigation. Staff who are interested in taking the training can register by visiting the Passport to Partner Services website and following registration instructions. DIS who perform viral hepatitis case investigations do not need to participate in the entire course, as not all material is relevant. The focus areas that are most applicable for viral hepatitis case investigation are:
- Introduction to partner services,
- Communication skills,
- Interviewing,
- Field investigation and notification, and
- Referrals and linkage to care.
CDC DVH Technical Assistance for Viral Hepatitis Surveillance
The Surveillance Team within DVH is responsible for viral hepatitis surveillance at the national level. The team works directly with viral hepatitis surveillance programs within state, territorial, and local HDs to ensure standardization of methodologies, including surveillance definitions and processes. The collaborative goal is to develop, implement, evaluate, and improve viral hepatitis surveillance to support and evaluate prevention policies and programs.
The Surveillance Team includes epidemiologists and statisticians with expertise in surveillance. Epidemiologists provide consultation in epidemiology, surveillance, study design, questionnaire design and development, data collection, epidemiologic methodology, data analyses, data interpretation, and information technology. Statisticians provide consultation in sample and study design, data standardization, data analyses, and statistical methodology. DVH’s Surveillance Team provides HDs with technical assistance (TA) to evaluate state, territorial, and local programs to highlight strengths and identify areas for improvement; to outline goals and objectives and define activities that facilitate achievement of such goals and objectives; and identify and recommend resources to help programs address areas for improvement.
The team also works with partner organizations to address surveillance-related issues. For example, the Surveillance Team collaborates with CSTE members to develop surveillance case definitions for nationally notifiable viral hepatitis conditions. Other partners work with DVH and the Surveillance Team to identify and address surveillance issues that impact specific populations (e.g., Asian Americans, African Americans, PWUD, and specific age groups).
The Epidemiology Research Team within DVH includes medical epidemiologists who work with the Surveillance Team to ensure that clinical aspects of viral hepatitis are included in all decisions. Medical epidemiologists also provide expert clinical consultation directly and indirectly to state and local programs.
TA is provided by e-mail, telephone, site visits, periodic group trainings during conferences, and webinars.
NASTAD HepTAC: Online TA and Capacity Building Center
In 2018, NASTAD was awarded funding through a CDC DVH cooperative agreement to provide TA to viral hepatitis prevention and surveillance programs within state and local HDs. In 2019, NASTAD introduced HepTAC, an online system that provides TA and capacity building for HD viral hepatitis programs (120). The primary goals of HepTAC are to build jurisdiction-level technical expertise and enhance HD capacity to support viral hepatitis prevention, control, and elimination activities (120). Goals are accomplished through collaborative activities, including conference calls, webinars, workgroups, bi-monthly newsletters, an online resource bank, and a discussion board. Success stories are shared, and mentorships and courses are offered in the following tracks:
- Hepatitis program infrastructure and workforce;
- Community engagement and strategic planning;
- Harm reduction and prevention;
- Epidemiology and surveillance;
- Testing and linkage to care;
- Care and treatment
- Stigma and health equity; and
- Elimination (120).
One-on-one viral hepatitis surveillance and prevention TA is provided by logging in to HepTAC’s Online Technical Assistance Platform (OnTAP) and submitting an inquiry (121).