studies have shown that vaccinating close contacts of persons chronically infected with HBV (that is, ring vaccination) is cost-effective (Hutton et al., 2007). The strategy remains cost-effective even in populations in which the prevalence of chronic HBV infection is as low as 2%. However, without funding and staffing for surveillance and identification of new cases of HBV, ring vaccination is not a public-health activity that is typically supported by most health departments.

CDC has funded seven enhanced projects through the Viral Hepatitis Surveillance Emerging Infections Programs (EIPs). The projects began in 2004 and were scheduled to end in 2009. CDC plans to extend the program for 2 more years (personal communication, J. Efird, CDC, May 18, 2009). They are in Colorado, Connecticut, Minnesota, New York state, New York City, Oregon, and San Francisco. Although the projects focus on surveillance for hepatitis A, hepatitis B, and hepatitis C, they all take different approaches, including multiple approaches in individual jurisdictions. Project funding supports epidemiologic and data-entry staffing. Methods used in the seven programs include verification of diagnoses with medical providers, chart review, followup calls to infected persons that focus on education or data collection, educational mailings (for example, letters and booklets), followup with persons that are household or close contacts (especially acute HBV cases), sampling for followup of cases of chronic HBV and HCV, review of all data, and matching with HIV and STD programs. There is no uniform evaluation of the projects.

In February and March 2009, staff of the National Alliance of State and Territorial AIDS Directors (NASTAD) interviewed the coordinators of the seven EIPs. From those interviews, staff identified additional programmatic issues that affect reporting. They include resource issues, such as the varied capacity of county and city health departments (which leads to inconsistencies in data collection and data systems, in some instances in the same state); the staffing requirements needed to collect, process, and manage data; and the staff and time needed to investigate health-care–related outbreaks adequately. Other issues are the need to educate medical providers better on which laboratory tests are needed for appropriate diagnosis (also noted by Fleming et al., [2006]), and the difficulty that staff face in obtaining demographic data (including data on race, ethnicity, and country of origin) and data on risk history (Klevens et al., 2009; NASTAD, 2009).

Funding Sources

Funding for hepatitis surveillance is highly fragmented. No federal funds are dedicated to chronic-hepatitis surveillance except for the seven jurisdictions that receive funds from CDC’s DVH to perform enhanced surveillance activities. State, territorial, or city health-department viral-



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