Virginia Department Of Health Research Articles

Setting PFAS-Based Fish Consumption Advisories for Virginia Waterways

This policy memo is intended for the Commissioner of Health at the Virginia Department of Health (VDH). The memo provides recommendations when assessing the need for per- and polyfluoroalkyl substances (PFAS)-based fish consumption advisories in Virginia waterways. High-frequency fish consumers and sensitive populations face a greater risk of negative health effects from exposure to PFAS through eating local freshwater fishes. By performing state-wide fish screening assessments for relevant PFAS, the VDH can determine if the nutritional benefits from eating fish outweigh the health risks from PFAS exposure. The following memo recommends that VDH update their PFAS fish tissue screening assessment to include PFUnA and PFDA and release final fish tissue screening recommendations for PFOA and PFOS.

Data-driven mechanistic framework with stratified immunity and effective transmissibility for COVID-19 scenario projections

Scenario-based modeling frameworks have been widely used to support policy-making at state and federal levels in the United States during the COVID-19 response. While custom-built models can be used to support one-off studies, sustained updates to projections under changing pandemic conditions requires a robust, integrated, and adaptive framework. In this paper, we describe one such framework, UVA-adaptive, that was built to support the CDC-aligned Scenario Modeling Hub (SMH) across multiple rounds, as well as weekly/biweekly projections to Virginia Department of Health (VDH) and US Department of Defense during the COVID-19 response. Building upon an existing metapopulation framework, PatchSim, UVA-adaptive uses a calibration mechanism relying on adjustable effective transmissibility as a basis for scenario definition while also incorporating real-time datasets on case incidence, seroprevalence, variant characteristics, and vaccine uptake. Through the pandemic, our framework evolved by incorporating available data sources and was extended to capture complexities of multiple strains and heterogeneous immunity of the population. Here we present the version of the model that was used for the recent projections for SMH and VDH, describe the calibration and projection framework, and demonstrate that the calibrated transmissibility correlates with the evolution of the pathogen as well as associated societal dynamics.

Monitoring and Characteristics of Mpox Contacts, Virginia, USA, May-November 2022.

During 2022, a global outbreak of mpox resulted primarily from human-to-human contact. The Virginia Department of Health (Richmond, VA, USA) implemented a contact tracing and symptom monitoring system for residents exposed to monkeypox virus, assessed their risk for infection, and offered interventions as needed. Among 991 contacts identified during May 1-November 1, 2022, import records were complete for 943 (95.2%), but 99 (10.0%) were not available for follow-up during symptom monitoring. Mpox developed in 28 (2.8%) persons; none were healthcare workers exposed at work (n = 275). Exposure risk category and likelihood of developing mpox were strongly associated. A total of 333 persons received >1 dose of JYENNOS (Bavarian Nordic, https://www.bavarian-nordic.com) vaccine, most (n = 295) administered after virus exposure. Median time from exposure to vaccination was 8 days. Those data tools provided crucial real-time information for public health responses and can be used as a framework for other emerging diseases.

The Effect of the COVID-19 Pandemic and Lockdown on Operative Traumatic Brain Injury in Northern Virginia.

COVID-19 is a disease that causes flu-like symptoms and difficulty breathing. Emerging in 2019, the COVID-19 pandemic has affected the entire world through restrictions and lockdowns. Multiple studies have compared the effects of COVID-19 on different types of head trauma, with each one producing different results. The goal of this study was to use state and hospital data to determine whether the COVID-19 pandemic had a significant impact on surgeries for traumatic brain injury (TBI). Public state data on COVID-19 incidence, sourced from the Virginia Department of Health, was compared to hospital data of 352 patients receiving surgeries for TBI from a single major level-one trauma hospital in Northern Virginia. We used data from the three years before COVID-19 and the two years during the pandemic, using t-tests and Pearson correlation to analyze the data. This is a retrospective case review study on the number and age of patients receiving TBI surgery from March 2017 through February 2022 at Inova Fairfax Hospital in Northern Virginia to determine the impact of the COVID-19 pandemic on these factors. When comparing the data, there was a 60% reduction in cases of operative TBI during the peak months of COVID-19 compared to the same months in previous years (p<0.005). Comparing data on the number of Virginia and Northern Virginia COVID-19 cases and data on the age of individuals undergoing TBI surgery four weeks later showed a statistically significant negative correlation (p<0.05) in which the average age of individuals undergoing TBI surgery was lower in the four-week block following a four-week block of increased COVID-19 incidence. Our findings indicate a correlation between the period of decreased activity from COVID-19 restrictions in Virginia and a decline in both the number of TBI surgeries and the age of individuals undergoing these surgeries.

Early human judgment forecasts of human monkeypox, May 2022

Early human judgment forecasts of human monkeypox, May 2022

Identifying bright spot communities: Socioecological, workforce, and healthcare delivery factors influencing opioid mortality.

There were 50,000 U.S. opioid overdose deaths in 2019. Millions suffer from opioid addiction. Identifying protective factors for low community opioid mortality may have important implications for addressing the opioid epidemic. This study was funded through the Virginia (VA) Department of Medical Assistance Services (DMAS) through a SUPPORT Act Grant. To identify "Bright Spot" communities in Virginia with protective factors associated with reduced opioid mortality and morbidity. Ecologic study. Virginia All Payer Claims Database (APCD), Virginia Department of Health (VDH) statewide medical examiner registry, and American Community Survey (ACS). 2016-2019; 2019 data cited here. APCD includes VA residents with medical claims through commercial, Medicaid, and Medicare coverage. VDH data includes fatal drug overdoses. ACS surveys all VA residents. Primary outcome: fatal opioid overdoses. Secondary outcomes: emergency room visits for overdoses and opioid-related diagnoses, outpatient diagnoses for opioid-related disorder, prescription rate for opioids, and prescription rate for buprenorphine. Opioid mortality was associated with higher rates of community poverty (r=.38, p<.0001) and disability (r=.52, r<.0001). Opioid mortality was associated with inequality, with higher Gini index associated with higher opioid mortality (r=.23, p<.0001). A higher percentage of black residents was associated with increased fatal opioid overdoses (r=.37, p<.0001) and ED visits for overdoses (r=.30, p<.0001). A higher percentage of white residents correlated with increased outpatient visits for opioid use disorder (r=.24, p<.0001) and higher rates of buprenorphine (r=.34, p<.0001) and opioid prescriptions (r=.31, p <.0001). These findings suggest significant racial disparities in opioid outcomes. Communities with a higher percentage of black residents are more likely to have higher opioid mortality and a lower rate of outpatient treatment. This association may be affected by the time period used in the analysis (2015-2019), as nationally there has been an increasing rate of synthetic opioid deaths in Black communities. These measures have been incorporated into a multivariate analysis to identify Bright Spot communities, which will be discussed during the presentation.

Abstract P178: Social Determinants Of Health And Preventable Hospitalization For Hypertension

Introduction: Social determinants of health (SDH) can have a significant impact on the risk of hypertension related hospitalization. Understanding the drivers of potentially preventable hospitalizations for hypertension improves health outcomes and reduce associated costs. Identifying place and associated SDH has implications for tailored interventions to address disparities for high burden population for preventable hypertension hospitalization as hypertension and associated cardiovascular disease. Methods: County level preventable hospitalization rates for hypertension for Virginia was obtained using prevention quality indicators published by the Agency for Healthcare Research and Quality. The Health Opportunity Index (HOI), developed by the Virginia Department of Health to identify vulnerable populations is a multivariate tool that uses complex SDH indicators of a community and comprises of 13 indices - affordability, income inequality, Townsend/Material deprivation, job participation, employment access, education, air quality, segregation, food accessibility, population density, population churning, walkability, and access to care. Principal component analysis was used to develop the composite HOI and further aggregated into simple quintiles at the county level. Step-wise multiple regression analysis was performed to explore SDH and preventable hospitalization for hypertension. Results: Material deprivation index ( r = -.44), affordability index ( r = -.42) and air quality index ( r = -.23) were found to be significantly associated with preventable hospitalization rate for hypertension. Together the model accounted for 23% of the variability in the preventable hypertension hospitalization rate ( p &gt; 0.05). Conclusions: Findings indicate that neighborhoods that spend most on housing and transportation and that are materially deprived of goods, services, amenities and resources and physical environment have higher rates of preventable hospitalization for hypertension. Areas with higher air pollution may result in hypertension. Addressing these disparities by targeted approach is one possible approach to reducing the burden of preventable hospitalization for hypertension in Virginia.

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

Stay-at-Home Orders, Mobility Patterns, and Spread of COVID-19.

Objectives. To understand how stay-at-home orders changed mobility patterns and influenced the spread of COVID-19.Methods. I merged 2020 data from the Virginia Department of Health, Google Mobility Reports, and the US Census to estimate a series of 2-way fixed-effect event-study regression models.Results. A stay-at-home order caused people to increase the amount of time spent at home by 12 percentage points and decrease the time the spent at work by 30 percentage points, retail and recreation venues by 40 percentage points, and grocery stores and pharmacies by 10 percentage points. People did not sustain changes in mobility and gradually returned to prepandemic levels before the stay-at-home order was lifted. In areas where people spent the most time at indoor locations, there was a large increase in COVID-19.Conclusions. A more robust and stricter policy response coordinated at the national level combined with a strong economic response from policymakers could have increased the effectiveness of the stay-at-home order.

Understanding and Advancing Organizational Health Literacy Within a Public Health Setting.

Background:Organizational health literacy (OHL) within the public health setting is lacking.Objective:The aim of this study was to form a health literacy (HL) improvement team consisting of university researchers and Virginia Department of Health (VDH) district directors and staff to assess and improve OHL practices of VDH staff in four medically underserved health districts in southwest Virginia.Methods:The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit guided this mixed-methods needs assessment and improvement plan. VDH staff completed a 44-item survey adapted from this Toolkit and a roundtable discussion to indicate their perceptions of current OHL practices. VDH clients completed a survey including seven items measuring perceptions of staff OHL practices and three items measuring subjective HL.Key Results:About one-half of VDH staff (n = 252, 88% female, average age 49 ± 12 years, 23% ≤ high school education [HS]) reported “doing well” across all OHL domains. Staff survey and roundtable discussion revealed the need to strengthen the written communication domain. Among 185 VDH clients (82% female, average age 33 ± 14 years, 40% ≤ HS), perceptions of staff OHL practices were high, ranging from 3.07 to 3.64 (scale of 1–4). Client HL status was significantly positively correlated (p < .01–.05) with 5 of 7 OHL practices. Findings aided development and initial implementation of an OHL improvement plan, including e-newsletters and in-person workshops. On average, 60% of staff opened quarterly e-newsletters. Staff ratings of the Clear Communication Index workshop were high in terms of utility and applicability of content.Conclusions:Results reflected notable strengths and weaknesses in current OHL practices from staff and client perspectives, with the greatest need identified in written communication. E-newsletter series and in-person workshops on the Clear Communication Index helped lay groundwork for additional HL improvement activities for VDH staff. Limitations and future recommendations for public health settings are discussed. [HLRP: Health Literacy Research and Practice. 2021;5(1):e35–e48.]Plain Language Summary:This study describes use of the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit to conduct an organizational health literacy needs assessment and improvement plan in a public health setting, the Virginia Department of Health. Assessment of staff and clients revealed strengths and weaknesses in organizational health literacy practices. Feedback guided efforts to improve organizational health literacy capacity.

Salmonellosis Outbreak After a Large-Scale Food Event in Virginia, 2017.

The Virginia Department of Health (VDH) identified an outbreak of Salmonella serotype Javiana infections in Virginia after a chili and chowder cook-off with 11 competitors and about 2500 attendees on September 30, 2017. The objectives of this study were to assess the extent of the outbreak and identify the most likely source of exposure. To identify people with suspected Salmonella infection, VDH used press releases and social media posts to recruit event attendees to take an online survey about foods eaten at the cook-off and any gastrointestinal (GI) symptoms experienced. VDH defined a case as reported GI illness that occurred within 1 week after eating food from the cook-off. Confirmed cases required a clinical specimen culture positive for Salmonella. Probable cases reported diarrhea or related clinical symptoms. "Not ill" people did not report GI illness. Investigators calculated unadjusted relative risks of illness and performed stratified analysis to address potential confounding. Available food samples were tested for Salmonella. Environmental health specialists interviewed food handlers and inspected restaurants where 3 competitors had prepared food. Of 438 survey responses, 171 (39%) met the case definition. Of all chilies and chowders consumed, Chowder A was associated with the highest relative risk of illness (8.9; 95% CI, 5.7-13.7). A Chowder A sample tested positive for Salmonella serotype Javiana. The environmental investigation did not identify an original contamination source but did find deficiencies in maintaining safe cooking temperatures. Epidemiologic and laboratory findings indicated that Chowder A was the most likely cause of outbreak. Recommendations to prevent future outbreaks include preparation of all food on-site to ensure safe temperatures during food preparation and service.

The Health Wagon Partners with the Virginia Department of Health to Provide COVID-19 Testing in Rural Southwest Virginia.

The Health Wagon has been providing care for the rural population of southwest Virginia for the past 40 years. The mission of the Health Wagon is to provide quality health care to the medically underserved people in the mountains of Appalachia. It has expanded to two stationary clinics, three mobile units, and a mobile dental unit, logging over 19,000 patients encounters in the past year.

Outbreak of Severe Hypoglycemia After Ingestion of a Male Enhancement Supplement - Virginia, August-November 2019.

In August 2019, the Virginia Poison Center (VPC) and the Blue Ridge Poison Center (BRPC) were contacted concerning patients experiencing repeated episodes of marked hypoglycemia following ingestion of a male enhancement supplement tablet marketed as "V8" in convenience stores in central Virginia. Over the following 3 months, the Virginia Department of Agriculture and Consumer Services (VDACS) and the Virginia Department of Health (VDH) conducted an investigation and identified 17 patients meeting the case definition (severe hypoglycemia within 48 hours of consuming an over-the-counter male enhancement supplement in a man with no history of use of insulin or other medication used to control blood glucose). Analysis of the V8 tablets revealed that most contained glyburide, a sulfonylurea oral hypoglycemic used in the treatment of diabetes and associated with prolonged hypoglycemia following overdose (1). To stem this outbreak, V8 was removed from stores when found, and public service announcements were released. The public health implications of V8 use include the potential for substantial morbidity from hypoglycemic episodes and the potential for mortality if health care services are not accessed in a timely manner when hypoglycemia occurs. The presence of V8 in the market poses a serious threat to public health because of its potentially life-threatening adverse effects.

Antecedents of Suicide Among Active Military, Veteran, and Nonmilitary Residents of the Commonwealth of Virginia: The Role of Intimate Partner Problems

Objective Intimate partner problems increase suicide risk, particularly among active service members and veterans. Age, marital status and military service status may modify the role of intimate partner problems in suicide. Methods Participants included 6255 men who died by suicide at 18 years of age and older and who actively, previously, or never served in the military. Reports of intimate partner problems prior to suicide were documented by the Virginia Department of Health. Results Unmarried active service members, above middle age, were more likely than veterans and individuals without prior military service to have associated reports of intimate partner problems. Conclusion Life stages and relationship context may influence the role of intimate partner problems as a risk factor for suicide.

Lessons Learned from a DoD and Virginia Data Sharing Pilot using NSSP ESSENCE

ObjectiveThis panel will focus on the experiences from the Department of Defense (DoD) and Virginia Department of Health (VDH) data sharing project using the National Syndromic Surveillance Program (NSSP) ESSENCE and will discuss lessons learned, challenges, and recommendations within the following areas: 1) data sharing authority, 2) coordination and implementation of data sharing with a focus on personnel, training, and managing access and 3) communication between local, state, and federal agencies.IntroductionThe DoD and VDH both maintain local ESSENCE installations to monitor the health status of their military and civilian populations, respectively, and submit syndromic surveillance data to the NSSP ESSENCE to foster data sharing and collaborative initiatives among public health entities. Military Treatment Facilities (MTFs), housed on DoD installations, provide healthcare to all service members and their beneficiaries stationed in the area. Service members and their beneficiaries represent a substantial portion of the local community and interact with the civilian population throughout daily activities. Sharing syndromic surveillance data between DoD and public health jurisdictions can provide public health situational awareness among both civilian and military populations to support disease surveillance. DoD and VDH engaged in a pilot project to develop processes and procedures for data sharing, data access, and communication with the aim they can serve as best practices for other jurisdictions seeking to share syndromic surveillance data with DoD.DescriptionThe pilot project began in June 2018 with the Centers for Disease Control and Prevention (CDC) NSSP team providing technical support. NSSP ESSENCE users from the VDH state and local health departments across nine Virginia city/counties participated in the project. VDH shared syndromic surveillance data from 34 healthcare facilities (17 urgent cares, 3 emergency care centers, and 14 hospitals) with DoD, which shared syndromic surveillance data from 18 MTFs (16 clinics and 2 hospitals) in Virginia. To standardize the analysis of syndromic surveillance data and use of NSSP ESSENCE across project participants, myESSENCE tabs were created and shared by between VDH and DoD. The goal was to facilitate and enhance communication between local public health departments and their DoD counterparts through the sharing of syndromic surveillance data.How the Moderator Intends to Engage the Audience in Discussions on the TopicThe moderator will solicit feedback from the audience regarding their data sharing experiences with other entities or agencies, data sharing practices, and ideas for use cases when sharing syndromic surveillance data with DoD.

Identification and Assessment of Repeat Drug Overdose Visits at EDs in Virginia

ObjectiveTo identify and assess the characteristics of individuals with repeated emergency department (ED) visits for unintentional opioid overdose, including heroin, and how they differ from individuals with a single overdose ED visit.IntroductionThe Virginia Department of Health (VDH) utilizes syndromic surveillance ED data to measure morbidity associated with opioid and heroin overdoses among Virginia residents. Understanding which individuals within a population use ED services for repeated drug overdose events may help guide the use of limited resources towards the most effective treatment and prevention efforts.MethodsVDH classified syndromic surveillance visits received from 98 EDs (82 hospitals and 16 emergency care centers) between January 2015 and July 2018. An unintentional opioid overdose, which included heroin, was classified based on the chief complaint and/or discharge diagnosis (ICD-9 and ICD-10) using Microsoft SQL Server Management Studio. ED visits were categorized as either a single or a repeat visit, where a repeat visit was defined as two or more separate ED visit records from the same individual. ED visit records were matched to individuals using medical record number. Each match represented a repeat visit for one person. RStudio was used to conduct Pearson’s chi-square tests for sex, race, and 10-year age groups among both visit groups and to assess visit frequency among the repeat visit group.ResultsBetween January 2015 and July 2018, 9,869 ED visits for opioid overdose were identified, of which 734 (7.4%) were repeat visits among 597 individuals occurring among 57 EDs. The proportion of individuals with repeated opioid overdose visits was significantly different compared to the proportion of individuals with a single opioid overdose visit by sex (male 66% vs. 61%) and age group (20-29 years 34% vs 30%) (p &lt; 0.05). No significant difference was found by race. EDs had an average of 10 individuals who had repeated opioid overdose visits, with a range from 1 to 62 individuals. Individuals with repeated opioid overdose visits made on average 2.2 visits to EDs, with a range of 2 to 6 visits. The overdose visit rate among EDs ranged from 0.6 to 51.3 opioid overdoses per 100,000 ED visits, with four EDs having a rate greater than 40 opioid overdose visits per 100,000 ED visits.ConclusionsApproximately 7% of ED visits during the study period for opioid overdose were identified as repeat visits using the medical record number. Individuals with repeated opioid overdose visits differed from those with a single opioid overdose visit with respect to sex and age. Repeated opioid overdose visits were disproportionately higher for males and individuals aged 20-29. Hospital utilization by individuals with repeated opioid overdose visits can provide information on which EDs or communities that may require further attention. Some limitations of this study are that the method utilized to identify individuals may result in an underestimation of repeat visits because limited personally identifying information was used to match visit records, and repeat visits that occurred before and after the study period would not be captured.

Using Syndromic Surveillance and Climatic Data to Detect High Intensity HFMD Seasons

Using Syndromic Surveillance and Climatic Data to Detect High Intensity HFMD Seasons

Access to Allogeneic Hematopoietic Cell Transplantation (HCT) for Patients with Acute Myeloid Leukemia (AML) in the State of Virginia

Background While HCT provides the best chance for cure for eligible patients with AML, barriers limit the number able to receive HCT. Virginia (VA) has some of the wealthiest and poorest counties in the country. We hypothesize that there are geographic variations in the rate and estimated unmet need of HCT for patients with AML in VA. Understanding geographic differences may help improve access to HCT. Methods All patients aged 20-74 years diagnosed with AML in 2013-2015 were identified by the VA Department of Health and classified by residence into 8 regions: Southwest, Southside, Valley, Central, Northern, Richmond, Eastern, and Hampton Roads. Socioeconomic (SES) factors including sex, age, race, marital status, education, employment, income, and health insurance were examined by region. Number of patients receiving first HCT by region were obtained from CIBMTR data. Unmet need was calculated by estimating the number of potential patients for HCT and subtracting the actual number of HCTs (Besse et al., 2015). Results 690 patients were diagnosed with AML in VA between 2013 and 2015; 153 first HCTs were reported to CIBMTR during the same time period. The rate of HCT and unmet need varied among the different geographic regions (Figure 1). The only SES factor that correlated with HCT rate was race/ethnicity (P=0.0334). The Southside, which had a higher percentage of non-Hispanic Black or African American population (31%), had a lower HCT rate (8%) compared to the Northern region, which had a Black or African American population of 12%, but a HCT rate of 29% (Figure 2). The Northern region had the highest median income ($105,000) and one of the highest rates of proceeding to HCT (29%) (Figure 3). In contrast, the Southside, which had the lowest median income ($40,000), had only 8% of patients proceeding to HCT and an estimated unmet need of 88%. Private vs public insurance, marital status, education, and gender did not correlate with HCT rates. Conclusions There are geographic differences in rates of HCT for patients with AML in VA. Regions with a higher non-Hispanic Black or African American population had lower rates of receiving HCT. Further study is needed to determine if the decreased rates in regions with a higher non-Hispanic Black or African American population are related to donor availability or SES barriers. Future steps to eliminate these SES barriers will be vital to increase the access of patients receiving a potentially curative HCT in VA.

The "No Wrong Door" Approach to HIV Testing: Results From a Statewide Retail Pharmacy-Based HIV Testing Program in Virginia, 2014-2016.

As part of the Care and Prevention in the United States Demonstration Project (2012-2016), which aimed to reduce HIV-related morbidity and mortality among racial/ethnic minority groups in 8 states, the Virginia Department of Health (VDH) funded Walgreens to provide HIV testing in retail pharmacies in areas with large racial/ethnic minority communities and high rates of poverty. We describe this program and summarize its outcomes. We hypothesized that (1) offering walk-in HIV testing outside of traditional business hours and alongside other point-of-care tests in retail pharmacies would increase rates of first-time testers and (2) using data on social determinants of health associated with higher rates of HIV infection to locate test sites would increase the identification of people who were previously undiagnosed. Using 2010 US Census data and 2007-2011 five-year population estimates from the American Community Survey, VDH selected 32 Walgreens stores located in census tracts where at least 30% of the population was black and/or Hispanic/Latino and/or where at least 20% of the population was living at or below the federal poverty level. Pharmacists administered the INSTI HIV-1/HIV-2 Rapid Antibody Test. Clients with a reactive test result were linked to confirmatory testing and medical care. Between June 1, 2014, and September 29, 2016, Walgreens pharmacists performed HIV tests on 3630 clients, of whom 1668 (46.0%) had either never been tested or were unsure if they had been tested. Of all clients tested, 30 (0.8%) had a reactive test result. Of 26 clients who also had positive confirmatory testing, 22 (84.6%) were linked to care. The mean cost per person tested was $41.79, and the mean cost per reactive result was $5057. Retail pharmacies may be an effective venue for those who have never been tested for HIV to access HIV testing, particularly if the pharmacies are located in priority areas or where community-based organizations are unable to operate.

Missing information in statewide and national cancer databases: Correlation with health risk factors, geographic disparities, and outcomes

ObjectiveThe objectives of this study were to analyze factors associated with outcomes and missing data in women with epithelial ovarian cancer using institutional, state and national databases. MethodsData were abstracted from the University of Virginia cancer registry, Virginia Department of Health (VDH) database, and Surveillance, Epidemiology, and End Results (SEER) Program and analyzed for correlations with demographics, cancer characteristics, and outcomes. Statewide spatial associations between health risk factors such as smoking, obesity, and missing grade/stage were evaluated using bivariate LiSA in Geoda. ResultsThere were 524 institutional, 3544 VDH, and 44,464 SEER cases of epithelial ovarian cancer. Institutional cases were younger, most often of white race, had increased grade 1, and decreased unknown grade and stage (all p < 0.001). Significant predictors of unknown grade were non-white race, older age, no surgery, unknown stage/stage IV, and unknown histology/adenocarcinoma. Unknown grade correlated with a significant survival disadvantage. Missing stage and grade correlated with county-level obesity and smoking, as rural regions in Southwest and Southside Virginia had high rates of health risk factors and missing stage/grade compared to urban, affluent regions in Northern Virginia. ConclusionsOver a third of nationally reported cases have an unknown grade and 10–20% have an unknown stage which correlates with the worst survival. Predictors of unknown grade include insurance, age, race, smoking status, obesity, and rural setting. Missing data may represent geographical differences or disparities in cancer care available as significantly fewer cases had an unknown grade/stage at a tertiary academic medical center compared to VDH and SEER.