This article is the first in a series of two on the importance of the health care provider in public health.

Centuries ago, it was recognized that certain diseases might be spread from person to person, and since then, numerous attempts to control and prevent the spread of infectious diseases have been undertaken. Although the governmental use of quarantine as a method to stop the spread of infectious diseases was recorded in Europe as early as the 14th century, the modern concept of public health surveillance as a tool for controlling disease outbreaks began in the mid 1800s in England. And while communicable diseases now, in general, are not the scourge they once were, old diseases that are re-emerging, new emerging diseases, and the threat of bioterrorism have made public health surveillance as relevant as ever. Thus, the ongoing systematic collection and analysis of health data remains an essential first step to protecting the health of the population.

Health care provider reporting of notifiable diseases remains one of the foundations of public health surveillance and control activities. The providers, always on the front lines diagnosing and treating the ill, are the eyes and ears for the local health department, who after examining all the reports that come in, make a determination about whether public health intervention is necessary. Each report that comes in is very important to the local health department, and each is examined carefully by a disease investigator or epidemiologist.

Unfortunately, reporting notifiable conditions has gained a reputation as being a useless tool. Whether it’s the fear that volunteering patient information could potentially violate confidentiality, or the fear that data provided to the health department will be thrown into a black box, never to be looked at again, there are many reasons providers do not report notifiable conditions. Surprisingly, the results of a survey of primary care residents in King County, conducted between March and June of this year, indicated that the biggest barrier to timely reporting of notifiable disease was unfamiliarity with reporting requirements, including which diseases were notifiable, how soon a condition should be reported, and the specific laboratory or clinical data required when reporting. In order to clear up misunderstandings regarding reporting, and to make reporting as simple and hassle-free as possible, we have listed a few of the most frequently asked questions regarding notifiable condition reporting in the following section:

What are the reporting requirements Health Advisories & Resources?

To help you understand the reporting requirements we have enclosed a pocket-sized laminated notifiable disease card with this issue for you to treasure and carry with you. One side of the card lists conditions notifiable to the local health jurisdiction, along with the timeframes for reporting. The reverse side lists conditions notifiable directly to the Washington State Department of health, as well as our contact numbers and additional internet resources. You can also find a list of notifiable conditions here: www.metrokc.gov/health/providers/epidemiology/reporting.htm#list

What information should I include about the patient when I report a case to Public Health?

Please provide as much of the following information as possible: the patient’s notifiable condition, name, address, phone number, sex, race and ethnicity, your name and phone number, relevant clinical and laboratory data (for example, liver enzyme test results for patients with hepatitis), risk factors/suspect exposure sources (for example, a history of intravenous drug use for chronic hepatitis B or C), a travel history, information on family members or other contacts that are ill, and any other information you think will help the investigation. Finally, if the patient is not yet aware of the diagnosis, please indicate how long we should wait before attempting to interview the patient.

How do I report a case?

Refer to the enclosed card – it has our contact information (or see the “Disease Reporting” section on the reverse). Having demographic, clinical, and relevant laboratory data on hand at the time of the call will help prevent unneeded subsequent requests for information from us.

If a notifiable condition is reportable by the laboratory, does that relieve providers from reporting?

No. Laboratories don’t provide clinical or epidemiologic data, which is just as important for the investigation. They also don’t report suspected cases, cases for which a clinical diagnosis is relevant, or case clusters of non-laboratory confirmed disease.

Should I await laboratory confirmation before reporting to public health?

Not necessarily. The Washington State Administrative Code (the “WAC”) states that “Health care providers shall notify the local health department…regarding cases or suspected cases of notifiable conditions specified…”

Some diseases, such as hemolytic-uremic syndrome, or clusters of foodborne or waterborne diseases are diagnoses based on a combination of clinical, epidemiologic and/or laboratory data and no one laboratory test is sufficient to confirm a disease. Immediately notifiable conditions, such as tuberculosis, measles, meningococcal disease, and all cases of suspected bioterrorism, should be reported as soon as they are suspected, without awaiting laboratory confirmation, preferably while the patient is still present. Whether or not to await laboratory confirmation depends upon several factors, including strength of clinical suspicion, length of time required to obtain a diagnosis, or the potential threat the disease is to public health. The general rule is, “If in Doubt, Report it Out.”

If I am not the patient’s primary care provider, does that relieve me of the reporting obligation?

Unfortunately, no. Per the WAC, “Other health care providers in attendance shall notify public health…unless the condition notification has already been made.” This regulation was written to ensure that notification will be made by a provider. In this era of patients with numerous subspecialists, along with ER providers, it saves a lot of precious time if the provider who diagnoses the condition does the reporting.

Are only notifiable conditions that are specifically listed reportable to public health?

No. Notifiable conditions reportable also include “unexplained critical illness or death”, “rare diseases of public health significance”, and disease clusters of suspected foodborne or waterborne origin. For example, a single sporadic case of gastroenteritis due to norovirus is not reportable, but a troupe of 25 ill boy scouts with vomiting and diarrhea returning from a camping trip would be.

Does HIPAA change the obligation to report?

No. Although that would have been nice, eh? HIPAA rules (in the US Code of Federal Regulations) state that “Nothing in [HIPAA] shall be construed to invalidate or limit the authority, power, or procedures established under any law providing for the reporting of disease or injury, child abuse, birth, or death, public health surveillance, or public health investigation or intervention.”

How can I remember what disease are notifiable?

No one is expected to memorize the list of reportable conditions, so just refer to the enclosed card.

Please note: since our cards were initially printed in December 2003, a change has already been made to the content of the notifiable disease list. The rule adds “arboviral diseases” and deletes “encephalitis-viral.” This reflects new, national case definitions for disease caused by the bites of certain insects, and includes West Nile Virus, St. Louis encephalitis, western equine encephalitis, and others. It also expands the new case definitions to identify the variety of symptoms that accompany all arboviral diseases, including fever, meningitis, acute flaccid paralysis, and other serious brain and nerve disorders.

For those of you would like to read the WAC at your leisure, please refer to www.doh.wa.gov/notify/other/legal.htm. In the second part of our series, we will discuss a particular issue that has vexed providers, especially in the context of outbreaks: what is the role providers play in giving prophylaxis to contacts?