POPS Chapter 8 – HIV/STD Surveillance

Subchapters

8.1 General Information for All Health Care Professionals

8.2 HIV Infection Reporting

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8.3 Specific Information for Surveillance Authorities

8.4 Client Confidentiality

8.5 Congenital Syphilis Surveillance

8.6 Completing and Routing HIV Infection or AIDS Case Report Forms

8.7 Non-HIV/STD Clinic Health Providers

8.8 Community Based Organizations

8.9 Prioritization for Case Follow-Up

8.10 Interstate Communication Control Record (ICCR) Process

8.11 Investigations Involving Texas Department of Criminal Justice

8.12 Data Management, Review, Quality and Analysis

8.13 Surveillance Program Leadership and Management Guidelines

8.14 Minimum Standards for HIV/STD Surveillance

8.1 General Information for All Health Care Professionals

8.1.1 Definitions

Sexually transmitted disease (STD): any disease, with or without symptoms, that is transmitted primarily through sexual activities. The STDs that are required by Texas law to be reported include:

• AIDS
• Chancroid
• Chlamydia
• Gonorrhea
• HIV infection
• Syphilis

STDs that are voluntarily reportable include:

• Genital warts
• Granuloma inguinale
• Herpes
• Lymphogranuloma venereum
• Molluscum contagiosum
• Mucopurulent cervicitis
• Non-gonococcal urethritis

Surveillance case definitions are consistent with those set by the Centers for Disease Control and Prevention (CDC) and are listed in the CDC Case Definitions.

Violation: Failure to report a reportable disease is a Class B misdemeanor under Health and Safety Code, §81.049.

8.2 HIV Infection Reporting

Beginning January 1, 1999, HIV infection in adults (clients 13 years of age or older) became reportable by name. All HIV positive test results from HIV testing are being reported to the local surveillance authority. HIV infection reports that have a test date prior to the implementation of named HIV infection reporting will not be accepted into the DSHS database as morbidity. There was no change in the procedure for CD4 test result reporting – all CD4 T lymphocyte counts of <200 cells/microliter or <14% remain reportable to local surveillance authorities. Pediatric reporting of HIV infection has been reportable by name for children <13 years of age since 1994.

Effective January 1, 2000, the CDC made a change in the case definition for HIV disease. The CDC case definition considers a single viral load test (HIV RNA with detectable viral load) to be a reportable event. Beginning January 1, 2000, all individuals meeting the case definition of HIV infection (positive HIV test after January 1, 1999, OR any detectable viral load test performed after January 1, 2000) should be reported by name to the local surveillance authorities.

The implementation of HIV reporting by name did not affect the availability of anonymous HIV testing in Texas.

8.2.1 Enhanced Pediatric HIV Infection Surveillance

Pediatric HIV infection surveillance is currently conducted comprehensively with the HIV/AIDS case surveillance program, due in part to the named pediatric HIV infection provision included in the revision to the rules and regulations on March 16, 1994. These rules were revised in 1999 to include named reporting for adult/adolescent HIV infection cases. This revision allowed for more comprehensive reporting with regard to mother/baby pairs on HIV exposed pediatric cases. With additional data collected about perinatally exposed infants, the ability to characterize and target the utilization of available pediatric medical and social support services in Texas will be strengthened.

Infants born in Texas to mothers who have test results indicative of HIV infection are to be reported to the local surveillance authority as “exposed” pediatric cases.

Infants born in Texas since January 1, 1999, to an HIV infected mother will be required to have an Enhanced HIV/AIDS Surveillance to Maximally Reduce Perinatal HIV Transmission, form CDC 50.132 completed as an expansion of the standard pediatric HIV/AIDS morbidity report form.

8.2.2 Reason for Reporting

Case statistics are used in planning for HIV/STD prevention, education, counseling, testing, medical and social services. Accurate and reliable information about the diseases can be used in defining the broad range of clinical conditions and manifestations associated with HIV infection and other STDs. Additionally, funding for HIV/STD services is tied to the number of cases reported.

The accurate identification and timely reporting of STDs, including HIV infection, is an integral part of successful disease control that enables the health department to provide epidemiological follow-up or disease intervention without delay.

8.2.3 Who Should Report

• A physician or dentist, the chief administrative officer of a hospital, medical facility, or a penal institution must report each patient who has or is suspected of having any STD (see section on Definitions). An employee of the physician, clinic, or hospital may be designated to serve as the reporting officer
• Any person in charge of a laboratory, blood bank, mobile unit, or other facility in which a laboratory examination of a blood specimen or any specimen derived from a human body that yields microscopic, cultural, serologic, or any other evidence of any STD (see section on Definitions) must also report

8.2.4 How Cases Should be Reported

Disease reports can be reported on either the DSHS STD-27, Confidential Report of Sexually Transmitted Disease, by telephone, through a laboratory report or on any other mechanism that provides the information necessary to begin a case investigation. Laboratories should report on the DSHS for STD-28, Notification of Laboratory Test Findings Indicating Presence of Chlamydia Trachomatis, Gonorrhea, Syphilis, Chancroid, HIV Infections or Suppressed CD4 Counts, or its equivalent.

The existing CDC 50.42A, Adult HIV/AIDS Confidential Case Report form should be used as the official case report form for HIV infections by the surveillance personnel for adult infections and the existing CDC 50.42B, Pediatric HIV/AIDS Confidential Case Report form should be used for reporting infections in individuals <13 years old.

The following information is required when completing the report: patient’s name, address, city, county of residence, date of birth, sex, race/ethnicity, stage of diagnosis (syphilis only), type of test(s) performed, result of the test(s), date test(s) were performed, treatment provided, physician’s name, physician’s/clinic’s address, and telephone number.

The STD-28, STD-27, CDC 50.42A, and CDC 50.42B forms are available from local health departments and DSHS Regional offices.

Disease reports can also be made by calling 800-705-8868.

8.2.5 Where To Report

Reporting forms and/or information from all entities required to report diseases should be sent to the local health department serving the area where the physician’s office, hospital, laboratory, or medical facility is located. To locate a local reporting authority, use the HARS-STD Maps included in the forms section. If there is no local health department, the reports should be sent to the regional office of the Texas Department of State Health Services (DSHS) in the region where the physician’s office, hospital, laboratory, or medical facility is located.

8.2.6 Confidentiality

State law protects STD case report information, including HIV infection and AIDS case report information. No names are ever released to the public. Individual morbidity case reports received by the DSHS are confidential records and not public records.

More detailed legal information on the reporting of STDs, including HIV infection, may be found in Title 25, Texas Administrative Code, Part I, Chapter 97, Communicable Diseases, Subchapter F, Sexually Transmitted Diseases Including Acquired Immunodeficiency Syndrome (AIDS) And Human Immunodeficiency Virus (HIV), §§97.132, 97.134, and 97.135. Copies may be obtained online at: Texas Administrative Code.

8.3 Specific Information for Surveillance Authorities

8.3.1 Record Searching a Disease Report

Once received by either the local or regional health department, the disease report should be handled in the following manner:

1. The local surveillance authorities will establish a mechanism to ensure that all STD disease reports, including HIV infection and AIDS case reports, are record searched to ensure that the following steps are taken:
   1. To determine whether or not the infection has been previously reported;
   2. To determine which surveillance personnel will be responsible for completing the case report; and
   3. To ensure that all STD infection reports, including HIV infections and AIDS cases, are referred for appropriate follow-up
2. Methods can be developed to perform registry matches between the STD and HIV/AIDS surveillance systems to ensure that databases used for record searching are consistent. These registry matches should be done no less than twice a year at the local level and on a monthly basis at the HIV/STD Epidemiology Division, Surveillance Branch (Central Office Surveillance Branch)
3. Local surveillance authorities should have written protocol and procedure for accomplishing registry matching and record searching activities

The designated personnel will record search the STD disease report, AIDS case report, HIV infection report or the viral load test result to determine if this is a previously known infection report.

1. If the specific laboratory results or case report is found during the record search, the report will be considered a duplicate and administratively closed
2. If the case is determined to be a “previously known” STD or HIV infection, surveillance staff should update any information on the STD*MIS or HARS database that has changed (i.e., home address, earliest recorded viral load result, etc.). If the information indicates ongoing risky behavior (i.e., new STD diagnosis or pregnancy), then the case should be referred to the appropriate staff for follow-up
3. If the case report or laboratory result is not found during the record search process and is determined to be a new report, the report will be forwarded to the appropriate staff for follow-up. In order to be considered a new case for HIV infection, the HIV laboratory results must have a test date after the implementation of the reporting rule changes (January 1, 1999) or be a detectable viral load test result performed after the effective date of the case definition change (January 1, 2000)

The report should be entered into either the STD*MIS or HARS system as morbidity. In addition, the appropriate portions of the STD*MIS system need to be completed. This should include the morbidity section, the patient information section, laboratory information, treatment information and the field record and/or interview record, as appropriate.

Disease reports and follow-up information should be entered in either the STD*MIS or the HARS system on a daily basis.

The electronic data should be cleaned and checked for completeness before it is transmitted electronically to the HIV/STD Epi & Surveillance Branch.

The electronic data transmission to Central Office Surveillance Branch should be performed no less than once each week.

8.3.2 Case Report Follow-up

Additional follow-up to the initial disease report may be needed to:

• Gather information needed for the case report form;
• Inform client or gain permission to follow-up with the client; or,
• Confirm information that was received.

Follow-up required to inform the patient of a positive test result for STDs, including HIV infection, to offer partner services and referral services must be done by public health staff who have completed the full course of DIS training.

Follow-up of newly reported infections for HIV and syphilis should be started within 24 hours of the receipt of the report.

All follow-up of HIV/STD infection reports should be done in accordance with Chapter 9, Performance Standards for Disease Intervention Specialists.

In the follow-up of case reports and positive laboratory findings for HIV/STD infection reports, the public health staff member must contact the responsible health provider in order to inform the provider that the client will be contacted or to assist the provider in obtaining public health services for their client.

1. When there is a standing agreement with the health provider to follow-up clients, then the investigation can begin immediately
2. Staff are encouraged to establish written agreements with providers in their area, both with those providers who will routinely request assistance and those providers who will routinely decline assistance

The staff performing the HIV/STD follow-up should elicit from the health provider or their designee the information required to provide services to the client and to complete the appropriate DSHS morbidity report (either the STD-27 or the appropriate CDC case report form). The information should also be entered into the STD*MIS or HARS databases, as appropriate.

Staff should determine through discussion with the health provider whether or not:

1. The patient has been informed of his/her HIV positive status or other STD diagnosis
2. Partner elicitation/notification services are needed
3. Additional referral services are needed

The health provider should be informed of the need to provide disease intervention and referral services to the client if they have not already been provided.

If the health provider denies permission for an interview with their client, staff will tactfully conclude the discussion with the health provider, document the refusal and consult with her/his supervisor.

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The supervisor will determine if additional follow-up with the provider is needed (e.g., an in-service on health department services that are available).

For viral load tests that lead to newly discovered AIDS cases, follow-up should be done to locate and record the viral load test result that occurred nearest the date of diagnosis of AIDS.

8.3.3 Confidentiality in Surveillance Situations

The Epidemiology and Surveillance Unit of the HIV/STD Section takes proactive steps to protect the security and confidentiality of HIV/STD case reports, the contents of registries, and potentially identifying surveillance data. The unit requires specific security and confidentiality measures from its contractors and local surveillance authorities. Law requires local and regional health departments to maintain strict confidentiality and security measures.

More detailed legal information on the reporting of STDs, including HIV infection, may be found in Title 25, Texas Administrative Code, Part I, Chapter 97, Communicable Diseases, Subchapter F, Sexually Transmitted Diseases Including Acquired Immunodeficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV), §§97.132, and 97.134. Copies may be obtained online at the Texas Secretary of State website.

Additionally, DSHS surveillance contracts require contractors and local surveillance authorities to uphold the following standards of security:

• Staff maintain paper copies of data collection forms containing potentially identifying information in a locked file cabinet located in a locked file room.
• Contractors and local surveillance authorities protect software used to access confidential HIV/STD data with passwords. Users change passwords monthly. Computer networks where contractors and local surveillance authorities house HIV/STD confidential data remain in areas accessible only to program personnel.
• Staff store case files and computer discs containing patient information in a locked file cabinet when not in use. Contractors and local surveillance authorities keep the file cabinet and surveillance computer in a locked room with limited, controlled access.
• Contractors and local surveillance authorities restrict access to areas where they store computers and files containing confidential information using locks on doors. In addition, they keep a log of visitors who enter and leave the secure area.
• Staff conduct telephone conversations in secure areas with doors closed when using or discussing patient identifiers or other confidential information.
• Staff carrying paper copies or computer discs keep them in locked briefcases, which the staff member keeps with them until they can secure the items in a locked cabinet in a secure environment.
• State or local presentations of data, oral or written, include only aggregate data.
• HIV/STD staff, contractors, and local surveillance authorities receive a copy of the Texas Communicable Disease Prevention and Control Act, which addresses confidentiality and penalties for breaches of confidentiality.
• Contractors and local surveillance authorities require HIV/STD personnel to read and sign a confidentiality agreement form stating they have read and understand the provisions of the Act and the penalties, including dismissal for any violation of confidentiality.

8.3.4 Medical and Laboratory Information

Custody and management of medical and laboratory records is the legal responsibility of the local health officer/authority (or of the individual health provider). When accessing these records in the course of daily activities, it will be done in a manner that serves to protect the confidentiality of the records.

• The existence of any individual’s medical or laboratory records is not to be acknowledged except to authorized persons whose identity is confirmed
• The removal of confidential records from designated storage areas and facilities is done only in accordance with established policies of operation. The removal of confidential records from an agency/provider facility is only done after approval has been given by the facility supervisor or by other persons in authority
• Copies of confidential records are made only with express permission or when allowed by operational policy. Copies of records or originals are not to be used in any unauthorized manner
• Confidential records (and copies) are not to be left unattended in any place or area to which unauthorized persons may reasonably gain access

8.4 Client Confidentiality

The HIV/STD staff safeguards the privacy of all persons served by the health department and of those who become involved in the disease intervention process by observing strict confidentiality of information. The HIV/STD staff shares information only with authorized persons on a need-to-know basis. In this case, authorized persons are health professionals who are bound by medical/professional rules of confidentiality and who are involved in providing health services to the individual in question. Attempts by any others to obtain records or information will be reported by the HIV/STD staff person to the supervisor.

• The sharing of specific information about individuals with an authorized person will be done according to local policies and only after taking reasonable precautions to confirm the identity of the authorized person
• The HIV/STD staff will not divulge the specific nature of his/her professional capacity to unauthorized persons in the course of surveillance activities
• Information gained in the course of work activity will not be divulged to unauthorized persons in any manner that may be construed to link an individual with a communicable disease
• The HIV/STD staff will handle each situation in a professional manner that safeguards the privacy of individuals

8.4.1 Electronic Data Security

Electronic data will be managed in accordance with the DSHS policy on confidentiality, including the following specifics:

• Electronic media containing confidential information will be secured with electronic password protection
• Access to confidential information via computer terminal will be limited to only those staff with a need to know. Staff with access to this information will secure their workstation when not in use
• Electronic media containing confidential information will not leave the secured work area, unless it is necessary to transport them for a specific purpose and then it will be carried in a way to insure against display or loss
• Electronic media which contain confidential data and are being shipped, delivered, or transported to any site outside the secured work area will be encrypted, logged, and confirmed to properly account for all transported items
• Data diskettes containing confidential data will be stored when not in use in a locking desk drawer, briefcase, or file cabinet
• Cellular or cordless phones will not be used to transmit confidential information

8.4.2 Policy for Release of Information

Data on individuals with STDs, including HIV infection, can be released only in aggregate statistical format. Only staff directly involved with HIV/STD surveillance, disease intervention or case management activities should have access to complete patient registries. Statistical data can be released to such entities as local health agencies, community planning partners, health care providers and the general public in aggregate format.

8.5 Congenital Syphilis Surveillance

The Infant Syphilis Reactor Control Record (ISRCR) is a dual-purpose form for field-based case investigation and surveillance unit morbidity reporting of congenital syphilis. It is intended to provide:

• Statewide standardization of congenital syphilis case determination
• A two tier quality control system
• Streamlined reporting of congenital cases
• A practical system for both large and small programs

8.5.1 Direct Service Provider Instructions

The investigator uses the ISRCR form to provide follow-up for all mothers and infants who test positive for syphilis. The investigator completes the ISRCR form and makes a case determination supported by the information from the worksheet.

The investigator’s supervisor or program manager reviews the ISRCR form and closes the investigation by signing the completed form in the Supervisor’s Approval block.

All completed forms, regardless of closure, are provided to and maintained by central office surveillance (filed by month reported) for a minimum of one year. They will serve to provide a method of quality control by providing the information used in making a case determination. The total ISRCR form count will provide DSHS with a better “picture” of the amount of effort committed to investigating reactive mothers and infants.

All babies with evidence of syphilis or born to mothers who show any evidence of syphilis during pregnancy are to be written up on the ISRCR form and entered into STD*MIS (this includes those infants determined to be “no case”). Each program should maintain a copy of each ISRCR form completed and submitted.

Forms should be mailed to: HIV/STD Epidemiology and Surveillance Branch Post Office Box 149347, MC 1873 Austin, Texas 78714

8.5.2 Central Office Surveillance Branch ISRCR Process

ISRCR forms received in the Central Office Surveillance Branch will be reviewed for completeness and accuracy. Any questions or concerns will be addressed by contacting the originating program manager or point of contact by phone. Significant concerns not addressed satisfactorily in a phone call will be referred to the Field Operations Branch for follow-up. Significant concerns would include incomplete, or inadequate treatment regimens for infants, and partial investigations.

After reviewing all ISRCR forms received, final case determinations will be reviewed and confirmed. All “No Case,” “Confirmed,” and “Presumptive” cases will be checked to see if they have been entered into STD*MIS by the investigating agency. (“No Case” reports do not export out of STD*MIS. They are entered in order for the Central Office Surveillance Branch to be able to determine the amount of effort being devoted to congenital syphilis investigation.)

Names are stripped and sent via the NETSS export in STD*MIS. They are then transmitted electronically to CDC weekly.

The CDC reviews the information they receive and contacts the Central Office Surveillance Branch with corrections or questions about the data. CDC gathers and generates reports using the infant’s date of birth. Therefore, the Central Office Surveillance Branch number of reported cases, done by date of report, and the CDC number of reported cases may not match.

8.5.3 Enhanced Pediatric HIV Infection Surveillance

Infants born in Texas to mothers who have test results indicative of HIV infection are to be reported to the local surveillance authority as “exposed” pediatric cases. The Pediatric HIV/AIDS Confidential Case Report, CDC 50.42B is to be completed at the time of birth and updated regularly as additional laboratory tests on the infant are completed. Once a final determination of infection status is made for the infant, the case report form and the HARS database should be updated to reflect the final infection status.

Infants born in Texas since January 1, 1999, to an HIV infected mother will be required to have a CDC 50.132 form completed as an expansion of the standard pediatric HIV/AIDS morbidity report form. The following recommendations should be followed:

• At the delivery hospital, locate and review both the mother and the infant medical records
• If the delivery hospital did not also provide the prenatal care, identify the prenatal provider/facility and review the prenatal care medical record
• If postpartum care was not provided through the delivery hospital, identify the postpartum provider/facility and review the mother and child’s medical record

Although data abstraction will primarily require review of medical records, contact staff at the central office surveillance program if a review of the following ancillary data sets could assist with enhanced surveillance form completion for each pediatric HIV exposed case reported:

• Birth certificate, including the electronic download of medical information found on each birth certificate record
• HIV Medication Program registry to review for availability of information on antiviral therapy usage
• Pediatric Spectrum of Disease (PSD) initial and follow-up forms and PSD electronic database
• Out-of-state medical care providers

The surveillance report form of record for pediatric HIV/AIDS case reporting will continue to be form CDC 50.42B.

8.6 Completing and Routing HIV Infection or AIDS Case Report Forms

Every HIV infection or AIDS case must have a case report form completed (Adult, CDC 50.42A or Pediatric, CDC 50.42B). The case report form is the mechanism used to enter the case into the HARS system (the official surveillance database for HIV/AIDS cases).

• In areas with a HARS site, the responsibility for completing the form usually lies with the person responsible for AIDS surveillance
• In areas without a HARS installation, the ultimate responsibility for completing the case report forms lies with the central office surveillance staff person responsible for HARS in “Cactus” Texas (those parts of the state without HARS installations)

The reporting system is most efficient and timely when the reporting providers (whether it is an STD clinic site, private physician, hospital infection control personnel) complete the case report and submit it to the local surveillance authority.

DSHS encourages all local and regional health departments to establish working relationships with local providers and reporting sources to facilitate the form completion by a reporting provider.

The reporting rules and regulations do not REQUIRE anyone reporting an HIV infection or AIDS case to submit anything more than the basic morbidity information.

There is no legal method to require infection control nurses or any other reporting source to complete the case report form. These arrangements are made strictly through negotiations at the local level and require cooperation to ensure the form submission gets accomplished.

8.6.1 HIV/AIDS Case Reporting

In areas with local HARS installations:

1. A case is reported to the local surveillance authority
2. The person accepting the disease report forwards it to the HIV/AIDS surveillance person
3. The HIV/AIDS surveillance person record searches the disease report in the local HARS database and with the statewide HARS database to ensure that it is not a duplicate
   1. If it is new disease report, the surveillance person contacts the provider, completes the HIV/AIDS case report form, and informs the provider that they will be contacting the patient to provide partner services, additional public health assistance, etc.
   2. If it is a duplicate disease report, the surveillance person should update any new information on the HARS database

The surveillance person notifies the STD program that there is an HIV/AIDS case that needs follow-up for either test result notification, partner elicitation or referral for other public health services.

The surveillance person then enters the case into the local HARS installation and forwards the electronic copy of the data and a copy of the case report form to central office during the weekly data submissions.

In areas WITHOUT a local HARS installation:

1. A case is reported to the local surveillance authority (usually the regional office or the local health department)
2. The regional office or local health department record searches the disease report to ensure that it is not a duplicate (record search should be done through STD*MIS at the local area and by calling central office DSHS for a statewide HARS record search)
   1. If the disease report is determined to be a new report, the regional office or local health department contacts the provider and informs them that they will be contacting the patient and providing public health services
   2. If the local relationships are established, the HIV/AIDS case report form may be completed at this time Note: Any case report forms received by a regional office or local health department without a HARS installation need to be copied and forwarded to central office surveillance branch for entry into the statewide system.
3. The information on the field record/interview record/lab report/morbidity report is entered into STD*MIS and submitted during the weekly data uploads through STD*MIS.

At the Central Office, HIV/AIDS cases reported through STD*MIS are handled by the surveillance staff as outlined below:

1. On a monthly basis, the data contained in STD*MIS for HIV infections/AIDS cases is electronically compared to the HARS statewide dataset
2. Any cases that do not “match” (i.e., cases that are in STD*MIS but not in HARS) are sent back out to the local HIV/AIDS surveillance person (in areas with local HARS installations) or are given to the central office staff responsible for “Cactus,” Texas, for completion of the HIV/AIDS case report form (see HARS-STD Maps)
3. The HIV/AIDS case report forms should then be submitted to the Central Office Surveillance Branch with the electronic update of the HARS database

In summary:

• Any provider or reporting source MAY complete the HIV/AIDS case report form
• Only HIV/AIDS surveillance personnel are REQUIRED to complete the case report form
• Any HIV/AIDS case report forms that are received by a local or regional health department should be forwarded to the local HIV/AIDS surveillance personnel (if there is a local HARS installation) or to the Regional HIV/AIDS Coordinator (who will then forward the case report to the DSHS central office surveillance person responsible for “Cactus” Texas)
• It is beneficial to the local areas that the HIV/AIDS case report form be completed by the reporting providers – this increases the efficiency of the reporting system and decreases the time it takes for a case to be reported into HARS. Local and regional health departments are encouraged to work with local providers to get this accomplished

8.6.2 Completed HIV Infection Case Reports

After all information is gathered to complete the HIV infection case report, the HARS and/or STD*MIS systems should be updated and the case report forwarded to the Central Office Surveillance Branch. In order to be considered a complete case report (and not just a morbidity report) the case report information must include all items required for morbidity:

• Patient’s name
• Patient’s address (including city and county of residence)
• Date of birth
• Sex
• Race/ethnicity
• Stage of diagnosis (syphilis only)
• Type of test(s) performed
• Result of the test(s)
• Date test(s) were performed
• Treatment provided
• Physician’s name
• Physician’s/clinic’s address
• Physician’s telephone number

as well as:

• Information on whether or not the patient has been informed of his/her HIV infection
• How the patient’s partners will be notified about their HIV exposure
• Whether or not the patient has been referred for additional services
• Patient History/Risk Information (see Transmission Mode Tracking Sheet)
• Is patient pregnant/ recent pregnancy history

Case reports received at the Central Office Surveillance Branch without the above information documented will be returned to the local surveillance authority to complete the follow-up.

Once the Central Office Surveillance Branch receives a completed case report form, the statewide HARS database will be reviewed to determine if the case report is a “duplicate” of an already known case.

• If this is a unique case, it will be entered into the statewide HARS database
• If it is not a unique case, the local surveillance unit will be contacted and the case will be removed from the local database as a “case”

Monthly, the contents of the statewide database is stripped of client identifiers (name, address) and sent to the CDC.

The HARS system will continue to be the database of record for HIV/AIDS morbidity.

8.6.3 Anonymous HIV Positive Test Results

The implementation of HIV reporting by name did not affect the availability of anonymous HIV testing in Texas. When a positive HIV test result is received at the local surveillance authority, the surveillance personnel will contact the provider for follow-up information.

If the determination is made at that time that the positive HIV test was performed anonymously, the local surveillance personnel should retain the anonymous test result information in a separate, secure file and in accordance with the record retention policies for retaining positive laboratory reports.

8.6.4 Communication with Reporting Sources

All reporting sources need to be provided information about the HIV/STD reporting rules. Reporting materials need to be distributed to local health clinics, public and private hospitals, private physicians, laboratories and other reporting sources in the local surveillance areas.

Annual site visits to the major reporting sources to personally inform them of the reporting requirements, provide reporting materials, review the spousal notification rules and reinforce the need to report STDs, including HIV, are also recommended.

8.6.5 Laboratory Visits

Non-health department laboratories comprise a crucial component in HIV/STD surveillance, both through their reporting practices and through their influence on the levels of testing throughout the medical community. Laboratories should be visited in order to:

• Establish or improve reporting practices
• Offer health department services; and
• Maintain existing cooperative-relationships

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These visits should be documented on the forms provided in the HIV and STD Program Operating Procedures and Standards manual.

8.7 Non-HIV/STD Clinic Health Providers

Non-HIV/STD clinic health providers who offer HIV/STD services can make critical contributions to the public health system in the areas of surveillance, treatment services, and client education.

All PCPE contractors are required to have a memorandum of understanding with their local or regional STD Program regarding reporting, contact elicitation and notification.

Providers should be visited in order to:

• Establish or improve reporting behaviors
• Solicit active participation in client education; or
• Offer health department services

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These visits should be documented on the forms provided in the HIV and STD Program Operating Procedures and Standards manual.

8.8 Community Based Organizations

Community-based organizations (CBOs) are extremely important to a well-functioning HIV/STD reporting system. It is crucial that the local surveillance personnel establish a good working relationship with the CBOs in their areas. Surveillance staff should be encouraged to work with personnel in the CBOs to establish a trusting professional relationship. The following suggestions can improve communication between the local surveillance program and the CBOs.

• Local health department surveillance personnel and DIS can participate in staffing meetings with the CBOs to provide collaboration and cooperation in offering services to the clients
• Local health department personnel involved in surveillance and DIS activities should participate in community meetings, such as community planning groups and Title I and II meetings to familiarize the meeting participants with the public health duties
• Local surveillance personnel can offer to provide educational presentations to CBO staff about the nature of surveillance and details about how surveillance functions in their local areas. Often this information can assist in breaking down any barriers to reporting that may exist
• Educate the CBO staff about how the partnership with surveillance and STD DIS personnel can assist them with their client duties
• Offer information to the CBO staff about how surveillance data is used and what benefits the community can derive from accurate morbidity information
• Offer CBO staff the opportunity to participate in surveillance and STD staff meetings

8.9 Prioritization for Case Follow-Up

It is crucial that each local program reviews its existing interview and follow-up priorities and adjusts them accordingly to ensure that:

• All program objectives continue to be met
• Employee efforts are targeted to the highest priority diseases for investigation and follow-up
• Clerical and administrative duties are shared between HIV/AIDS Surveillance and STD Program staff, rather than duplicated

Priorities for interview should follow the hierarchy below:

1. All new HIV positives, any previous HIV positive with STD involvement, all early syphilis cases or syphilis cases of unknown duration and/or those who are pregnant
2. Gonorrhea and Chlamydia (options exist in interviewing priority)
   1. Verify treatment and interview all positives
   2. Verify treatment on all positives and interview only male positives
   3. Verify treatment on all positives and interview only male, adolescent positives
   4. Verify treatment on all positives and no interviewing
3. Interview all STD complications among STD clinic clients, including PID (pelvic inflammatory disease), DGI (disseminated gonococcal infection)
4. Interview STD complications as requested by private providers (PID, DGI)
5. Interview other HIV positive clients (long-term HIV positive clients or AIDS diagnosed clients in care and newly reported through viral load process) AND late syphilis cases to determine steady or last partner

Field follow-up activities will also be impacted by changes in morbidity. Program priorities for field follow up may also need to be adjusted to deal with additional follow-up activities. The following field follow-up priorities should be used:

1. Prenatal HIV infections and congenital syphilis cases, as well as follow-up of infants exposed to HIV
2. New HIV positives and untreated and/or un-interviewed early syphilis and syphilis reactors
3. All contacts to HIV and syphilis
4. All contacts to gonorrhea and chlamydia
5. Untreated positive gonorrhea and chlamydia STD clinic patients
6. Untreated positive gonorrhea and chlamydia patients referred from screening sites or selected providers.
7. Low titer syphilis reactors, in accordance with the decision tree
8. Long-term HIV positive clients or AIDS diagnosed clients in care and newly reported through viral load process

Other adjustments in field activities can include:

• Reducing or eliminating field follow-up done on hepatitis B vaccination programs
• Referring STD educational presentation requests to CBOs
• Reducing the number of private physician educational visits that are performed

8.10 Interstate Communication Control Record (ICCR) Process

When notification of a client contact is received from out-of-state, the Field Record, CDC form 73.2936S, is to be filled out as completely as possible by the Interstate Communication Control Record (ICCR) Clerk within the Central Office Surveillance Branch. For diseases with high priority for follow-up (new HIV infections, new syphilis infections, pregnant client):

1. Within one day of receiving enough information to create a Field Record, the Central Office ICCR Clerk will make a telephone call to the ICCR Clerk or Disease Intervention Specialist (DIS) in the local area where the client is believed to be
2. The ICCR clerk MUST call all information on syphilis contacts, suspects and associates, HIV contacts, suspects and associates, and syphilis reactors with 1:8 or greater titers to the local health department for follow-up within 24 hours of the receipt of the information. Local health departments with information needs on the above patients from out of state are also required to call the Central Office ICCR clerk with 24 hours of the determination of the need for the information
3. The local ICCR clerk should take down all the information available and ensure that the information is initiated for DIS follow-up.
4. A due date should be calculated from the date of initiation recorded on the Field Record. This due date is the target date for a disposition to be provided to the Central Office ICCR clerk.

8.10.1 Disposition Due Dates

1. Dispositions on HIV cases are due in four weeks
2. All other case dispositions are due in two weeks
3. If the date falls on a weekend, the following business day is given
4. Due dates may vary for information requested from other states
5. The process for following up on overdue investigations will be:
   1. The ICCR clerk will call the local area on the due date
      1. If no disposition is available, the ICCR clerk will make a second call to the local area at one week past the due date
      2. If there continues to be no disposition at two weeks past the original due date, the ICCR clerk will turn the field record over to the supervisor for resolution

8.10.2 Interstate Information

All information on positive test results or contact follow-up for patients residing outside the state of Texas must be communicated through the ICCR desk.

Local arrangements for communicating to a “border” state (i.e., Oklahoma, Louisiana, or New Mexico) can be made to hasten patient notification, treatment or contact notification. These local arrangements do not negate the requirement to report the information through the DSHS ICCR desk for communication through official channels to the other state health departments.

• The exceptions to this policy are the areas of Dallas and Houston. These local areas will call their ICCR information directly to other out-of-state programs

8.10.3 Intrastate Information

Local and regional health departments should communicate information on Texas residents across jurisdictions without reporting them through the DSHS ICCR desk using the steps outlined in section 9.10 Interstate Communication Control Record (ICCR) Process.

NOTE: The DSHS ICCR Clerk is NOT involved in Intrastate sharing of information except when information needs to be communicated to the Texas Department of Criminal Justice (TDCJ) contacts. Any type of contact information for TDCJ must come through the Central Office ICCR desk. This process is requested by TDCJ in Huntsville so that they have only one public health entity to deal with in the state regarding HIV/STD infections.

8.10.4 ICCR Process for Low-Priority Disease Reports

Diseases that have low priority for follow-up are gonorrhea, chlamydia, and chancroid. These do not need a disposition and are mailed to the central office ICCR clerk unless the client is pregnant, a minor, or the DIS worker made a special request to expedite the process by telephoning the information.

8.11 Investigations Involving Texas Department of Criminal Justice

Local and regional public health department surveillance programs are to follow-up on case reports on individuals residing in a TDCJ facility. In order to accomplish the communication of information between the local surveillance programs and the TDCJ medical units, the following process has been established:

• All sex partner/cluster information, treatment history for syphilis, and information regarding reporting of cases within the TDCJ prison system should be called to the ICCR desk at the Central Office Surveillance Branch. The ICCR staff will contact the TDCJ staff in Huntsville with the need for information
• Local/Regional STD programs will be working with local TDCJ facilities for follow-up on HIV/STD cases just as they would with any medical provider to see if the inmate has been adequately treated and disease intervention services have been offered. Any contacts elicited that are in the prison system need to be communicated to Huntsville through the DSHS ICCR desk
• TDCJ Huntsville, not the local unit, handles the reporting of cases to the health department. TDCJ has asked that the local or regional local health department staff remind and encourage the local TDCJ unit medical personnel to report HIV/STD cases to their Huntsville personnel. It is important to be very clear with the units that they ALWAYS report to TDCJ Huntsville. TDCJ in Huntsville will then officially report the morbidity to the Central Office Surveillance Branch
• All local and regional health department HIV/STD programs are encouraged to establish good working relationships with the local TDCJ facilities. This relationship will assist health department personnel in doing interviews on individuals within the prison system. However, please be aware that the local TDCJ wardens are the final arbiter for access into their facility and may not allow public health employees access to inmates for interview purposes

See Forms Chapter of the HIV and STD Program Operating Procedures and Standards manual for a copy of the Department of Criminal Justice – Letter encouraging the local TDCJ facilities to cooperate and work with the local health department in their area.

8.12 Data Management, Review, Quality and Analysis

Good data management is crucial to a well-functioning surveillance system. All local and regional health departments should maintain the following standards to ensure that their surveillance data is useful and accurate.

• All case report and case follow-up information should be entered into the HARS and STD*MIS data systems on a daily basis. “Batching” of data entry at month-end or quarter-end time frames should only be done in emergency situations and for a short period of time. If the local surveillance authority needs assistance in entering data, please contact the Central Office Surveillance Branch for help before the decision to “batch” enter cases is made
• Syphilis morbidity should be entered when a case is identified (e.g., at date of treatment, diagnosis, or interview). Do not wait until the interview record is closed to enter morbidity into STD*MIS. The case may need to be reclassified at closure
• All data entered into the HARS and STD*MIS systems should be as complete and accurate as possible. Local and regional surveillance staff should strive to have at least 85% completeness on required morbidity data elements (i.e., name, date of birth, address, city, state, race/ethnicity, gender, diagnosis, treatment, test date, test result, provider name and address). Data element completeness can be assessed through frequency analyses in EpiInfo or through management reports in STD*MIS
• Electronic data submission to the Central Office Surveillance Branch staff should be done no less that once each week. These submissions are due to DSHS central office by Thursday of each week
• Data uploaded through the STD*MIS system should have all appropriate program management reports run and data cleaned for errors and duplicates prior to its submission to Central Office Surveillance Branch (see STD*MIS System Maintenance Recommendations).

Data analysis and interpretation are necessary to ensure accurate case reporting and to provide insight into needed disease intervention activities. State and local surveillance programs should perform the following analyses of surveillance data to monitor disease trends.

8.12.1 Weekly Analysis

1. Compare the number of case reports with the previous two weeks case reports
2. Compare the number of case reports with the same timeframe during the previous year
3. Compare the number of case reports for the week with the expected number of case reports for the week (average weekly case numbers)
4. Review the number of case reports by specific categories, when appropriate (i.e., geographic area, sex, age grouping, race/ethnicity, provider type, risk behaviors or mode of exposure)

8.12.2 Monthly Analysis

1. Compare the number of case reports with the previous two months case reports
2. Compare the number of case reports with the same quarter during the previous year
3. Compare the number of case reports for the month with the expected number of case reports for the time frame
4. Review the number of case reports by specific categories, when appropriate (i.e., geographic area, sex, age grouping, race/ethnicity, provider type, risk behaviors or mode of exposure)

8.12.3 Quarterly Analysis

1. Compare the number of case reports with the same quarter during the previous year
2. Examine the trend in the number of reported cases for the past 1-2 years, overall and by specific categories (i.e., geographic area, sex, age grouping, race/ethnicity, provider type, risk behaviors or mode of exposure)

8.12.4 Annual Analysis

1. Examine the annual number of case reports received, by category (i.e., geographic area, sex, age grouping, race/ethnicity, provider type, risk behaviors or mode of exposure)
2. Review the annual trend in comparison to trends reported for the past 1-2 years
3. Examine rates of co-infection, where appropriate
4. Examine infection rates by specific category (i.e., geographic area, sex, age grouping, race/ethnicity, provider type, risk behaviors or mode of exposure)
5. Things to consider when doing analyses include:
   1. Acute changes in reported morbidity may be real or may be the result of changes in testing or reporting practices. Any marked change in the number of reported cases should be investigated to determine the probable cause. Notify Central Office Surveillance Branch of any unusual changes in morbidity and the possible cause(s)
   2. In large jurisdictions, it is important to stratify case report information by sex, age, and race to assist in accurately determining disease trends
   3. Examination of the number of case reports by major providers and laboratories may be used to identify new providers who could benefit by a visit by the surveillance staff

Central office surveillance and epidemiology staff are available to assist local areas with the various analyses recommended.

8.12.5 Syphilis Decision Tree

Each local surveillance area is expected to utilize the decision tree listed below in order to prioritize interview and follow-up efforts. Local areas may redefine the syphilis decision tree to reflect their local morbidity trends. The local decision trees must be no more restrictive than the Central Office Surveillance Branch recommended reactor grid.

• Any local changes or revisions to the decision tree must be provided to Central Office Surveillance Branch for review and approval
• All prenatal/neonatal and STD clinic clients should be initiated for investigation regardless of the titer result
• Any morbidity that is received with a diagnosis of Primary, Secondary or Early Latent syphilis should be assigned for investigation, regardless of serology results
• A positive serology with a negative confirmatory test (i.e., TP-PA or FTA) should be initiated only with supervisory approval
• High titer serologies (>1:8) on patients over the age of 50 should be assigned for DIS investigation on a case-by-case basis with supervisory approval
• If there is no age and/or no titer listed on the laboratory report, that information must be obtained before a determination for follow-up can be made
• Previously treated primary and secondary syphilis infections that maintain a 1:8 or higher titer two years after treatment need supervisory evaluation for follow-up decisions

Syphilis Reactor Criteria

Age <=1:4 >=1:8 Confirmatory test + Only 0-30 Investigate Investigate Investigate* 31-45 Male=Admin Closure Female=Investigate Investigate Investigate* 46-50 Admin Closure Investigate Investigate* >50 Admin Closure Supervisory Approval Investigate* STD Clinic Clients Investigate Investigate Investigate* Prenatal/neonatal Clinic Clients Investigate Investigate Investigate* Syphilis reported diagnosed as primary, secondary, or early latent (710, 720, 730) Investigate Investigate Investigate

* – Reactive confirmatory tests reported without an RPR should be followed up to obtain a quantitative test result in order to determine whether or not further investigation is necessary

8.12.6 Investigate

1. Record search serology report
   1. If no previous history of reactive serology is found, contact physician for diagnosis, treatment and locating information and then interview client
   2. If client is found to have been previously treated for syphilis and there is no significant titer rise (4-fold or greater), update the STD*MIS system, if necessary and close the case
   3. If client is found to have been previously treated and the current serology report shows a titer that has gone up significantly (4 fold or greater), contact physician for diagnosis, treatment and locating information and then interview client

8.12.7 Administrative Closure

1. High titer serologies (>1:8) on patients over the age of 50 should be assigned for DIS investigation on a case-by-case basis with supervisory approval

Administrative closures should be used as a tool to prioritize investigative efforts. Unless local morbidity dictates and after performing a record search, administrative closures should be used for:

• Males, ages 31-44 with a reported serology of less than or equal to 1:4 or
• Any adults, older than 44 years of age with a reported serology of less than or equal to 1:4

8.12.8 Supervisory Approval

Items marked “Supervisory approval” should be discussed with the DIS supervisor. The supervisor will be responsible for making the follow-up decisions based on items such as who the provider is, the reason for exam, known morbidity occurring in that demographic population and other items that indicate a need for disease intervention.

8.12.9 HIV Decision Tree

(HIV Positive refers to laboratory tests that meet the reporting definition e.g., a positive ELISA/Western Blot positive or detectable viral load.)

HIV Positive Report Received

HARS Record Search – Not Found HARS Record Search – Not Found HARS Record Search – Found (case report on file) HARS Record Search – Found (case report on file) STD*MIS Record Search – Recent STD DX found STD*MIS Record Search – Recent STD DX not found STD*MIS Record Search – Recent STD DX found Contact Provider Contact Provider Contact Provider Investigate Investigate Administrative Closure Investigate

8.12.10 CD4 Test Results

CD4 T-lymphocyte test results of <200 cells/microliter should be referred to the appropriate surveillance personnel for further investigation before applying the HIV decision tree. CD4 T-lymphocyte test results without any HIV test information are not to be considered an HIV infection. CD4 T-lymphocyte test results of >200 cells/microliter are not reportable under current Texas law. They do not warrant investigation.

8.12.11 Handling High Priority Follow-up

• Record search serology report. This should include pulling any available medical records, as well as record searching surveillance databases at the state and local level
• If no previous history of positive serology is found, contact physician for diagnosis, other laboratory results, treatment and locating information. Contact physician to determine need for follow-up and interview client. Complete HIV/AIDS Case Report form and interview record
• If client is found to have been previously reported as HIV positive and does not have CD4 T-lymphocyte test result of less than 200 cells/microliter, update the HARS system, if necessary. Determine if patient is pregnant or has a recent STD diagnosis. If not, close the case
• If client is found to have been previously reported as HIV positive and now has a CD4 T-lymphocyte test result of less than 200 cells/microliter, update the HARS system diagnosis to “AIDS” and close the case

8.12.12 Handling Low Priority Follow-up

Low priority cases should be investigated and prioritized for investigative efforts as local morbidity dictates. Low Priority cases include:

• Previously reported HIV positive individuals with no recent history of unprotected sexual exposure (i.e., pregnancy or recent STD diagnosis)
• Patients with only a CD4 T-lymphocyte test result of less than 200 cells/microliter and no history of any HIV positive or detectable viral load test and with physician confirmation that the patient is not HIV positive; or
• Patients where the physician has denied the HIV/STD staff permission to interview and follow-up with the client. An HIV/AIDS case report must still be completed in this situation

8.13 Surveillance Program Leadership and Management Guidelines

Each local and regional health department should have in place written guidelines or procedures that address the questions below. The following questions, as well as other measures, will frame the requirements for contract monitoring visits.

8.13.1 System Organization

• How does data flow in and out of the local/regional surveillance unit (i.e., flow diagram by disease and source)?
• Is there a designated surveillance coordinator? If so, is the position responsible for an integrated HIV/STD surveillance system?
• What management information systems are currently in use (i.e., STD*MIS, HARS, or a local proprietary system)? Is there a written procedure for backing-up the information systems, describing how it is done, how often it is to be done and where the back-up information will be stored?
• Is the local system an integrated HIV/STD surveillance system? If not, how is follow-up on HIV infection coordinated and reported?
• What is the current staffing pattern (i.e., STD surveillance clerks, HIV surveillance staff, etc.)? Are there specific written standards describing expected performance of the surveillance staff?
• What type of data analysis is done and how often? What variables are available for analysis of case reports? What types of reports are generated and distributed and how often?

8.13.2 Case Reporting

• What are the required time frames for laboratory and provider reporting of HIV/STDs?
• What procedures are in place to identify and eliminate duplicate reports from the reporting databases?
• What procedures are in place to ensure the completeness and accuracy of data entered into the system?
• Are provider visits and laboratory visits routinely conducted to promote reporting of HIV/STDs? What is the protocol for laboratory and provider visits?
• Who is responsible for the reactor program? Is a reactor grid/decision tree in place to identify priority reactors? How and how often does the surveillance program evaluate the reactor grid/decision tree?

8.13.3 Community Organization Participation

• What kinds of community organizations and institutions work in partnership with the health department? What types of services or activities do these organizations provide? Are there formal memorandums of understanding with these community partners?
• What kinds of health care/provider organizations and institutions work in partnership with the health department? What types of services or activities do these organizations provide? Are there formal memorandums of understanding with these health care/provider partners?

8.13.4 Rapid Response

• Is there a written rapid response plan for the local/regional health department to use when addressing an unexpected increase in morbidity?
• Who is responsible for reviewing, evaluating, and updating the local rapid response plan?
• Are there locally established outbreak thresholds for HIV/STDs?

8.13.5 Security

• Is there a written procedure for both physical and electronic security at the local/regional health department?
• Who is responsible for reviewing, evaluating, and updating the local security procedures?

8.14 Minimum Standards for HIV/STD Surveillance

All local surveillance authorities will have written procedures for performing registry matching and record searching. These procedures will specify the processes and timeframes used.

No less than 90% of all new disease reports received by the local surveillance authority will be entered as morbidity into either the STD*MIS or HARS systems (as appropriate) within 24 hours of the receipt of the disease report.

Each local surveillance authority should meet the weekly electronic data transmission. Within any 6-month time frame, 85% of the weekly transmissions will be transmitted on time.

Each local area should have no less than 90% of the HIV/AIDS case reports with legitimate answers to the three questions: 1) was patient informed of HIV status or other STD diagnosis; 2) were partner services needed; and, 3) are additional referral services needed. If the percentage of case reports with these three questions complete drops below 80%, the local surveillance authority must prepare and submit a plan to the central office addressing how the completion percentage will be improved.

STD Programs must have an appropriate written security policy that addresses access to areas where confidential information is used or stored.

All computers that contain confidential patient information should be equipped with password protection and each employee who must access the information should have an individual password.

All file cabinets used for storage of confidential patient information is equipped with a working lock that is use during non-working hours, when files are not in use or left unattended.

All employees handling confidential patient information must sign statements of confidentiality within seven days of their date of employment and all employees must renew these annually.

No less than 95% of all infants born to mothers with reactive syphilis serologies will have the congenital syphilis case report and worksheet forms completed (or an approved electronic substitute) and submitted to Central Office Surveillance Branch within one month of the report of the reactive serology.

No less than 85% of all pediatric HIV/AIDS cases born after 1999 will have the CDC 50.132 form completed.

A determination of the need for public health follow up will be made on 95% of all HIV positive test results within three business days of the receipt of the test result. If no clear determination can be made within the three business days, the HIV test result should be sent to a DIS for investigation.

Once it has been determined that HIV/AIDS cases need DIS follow-up for either test result notification, partner elicitation or referral to other public health services, no less than 95% of these cases will be forwarded to the STD program within 72 hours.

No less than 95% of HIV/AIDS case report forms received by a local surveillance authority without a HARS installation will be copied and forwarded within seven days of the receipt of the case report to Central Office Surveillance Branch for entry into the statewide system.

Each area (either with or without a HARS installation) must have a written procedure on handling HIV/AIDS cases reported to them, including the process for ensuring case reports are entered into the statewide database and the process for ensuring DIS follow-up for test result notification, partner elicitation or referral to other public health services.

No less than 85% of case reports returned to the local surveillance authority for completion of case report data elements will be returned, completed, to Central Office Surveillance Branch within 30 days.

Each local surveillance authority must prepare and maintain an annual proposed schedule for provider and laboratory visits.

All local surveillance authorities will have written procedures documenting how ICCR reports are tracked and maintained.

No more than 15% of ICCR dispositions will be considered “overdue” (i.e., returned more than two weeks after the original due date) in any six-month period.

Copies of quarterly analyses reports will be maintained on file for the past two-year time frames.

Local program managers will review and monitor the use of the syphilis decision tree no less than quarterly.

Each local and regional surveillance authority should have written procedures in place that address system organization, case reporting, community organization participation, rapid response plans and security, as defined in this chapter.

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