Download Impact of Electronic Laboratory Reporting on Hepatitis A

Impact of Electronic Laboratory Reporting on
Hepatitis A Surveillance in New York City
Kristen M. Moore, Vasudha Reddy, Deborah Kapell, and Sharon Balter
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Background: The New York City Department of Health and
Mental Hygiene (DOHMH) coordinates the administration of
timely postexposure prophylaxis (PEP) to contacts of hepatitis A
cases, making prompt disease reporting especially valuable.
Electronic laboratory reporting (ELR) has been shown to improve
timeliness of infectious disease reporting, and DOHMH began
receiving hepatitis A reports via ELR in 2002. Objectives: (1) to
quantify the increase in the proportion of hepatitis A reports
received electronically, (2) to assess how implementation of ELR
affected the reporting time of hepatitis A, and (3) to assess how
changes in reporting time impacted the ability to offer timely
prophylaxis to contacts. Methods: We evaluated the proportion
of reports received via ELR and the annual reporting time of all
hepatitis A reports and quantified the individuals who received
PEP from 2000 to 2006. The specific impact of ELR on
laboratory reporting time was assessed for nine laboratories
certified as of July 2006. Results: The proportion of hepatitis A
reports received via ELR increased during the study period to 35
percent in 2006. Electronic laboratory reporting improved the
reporting time for most of the laboratories certified to report
electronically, with a median decrease of 17 days. In 2006,
DOHMH administered PEP to 299 individuals; a fourfold increase
from 2000. Conclusions: Electronic laboratory reporting
provides timely disease data to health departments. Increased
utilization of ELR can have a remarkable impact on public health
surveillance and response.
rate. Although a large, culturally diverse population
with frequent international travel can facilitate the
spread of the disease, it is often difficult to identify the
source of a hepatitis A infection. However, when an exposure is identified, such as close contact with an acute
case, transmission of hepatitis A can be interrupted by
administration of immune globulin (IG) within 14 days
of the exposure.1,2 Postexposure prophylaxis (PEP) has
been shown to be effective in interrupting transmission
in community-wide outbreaks,3,4 including a large outbreak in Pennsylvania in 2003.5 The responsibility to
identify and distribute IG to close contacts of cases falls
primarily on the health department, making prompt
reporting of hepatitis A infections especially important.
Through routine surveillance, hepatitis A cases are
reported to the NYC Department of Health and Mental
Hygiene (DOHMH). Acute hepatitis A infections are
identified by positive laboratory results, giving testing laboratories the first opportunity to report cases
to the health department. Infectious disease surveillance and response are closely related to prompt notification. Electronic laboratory reporting (ELR) can
KEY WORDS: electronic laboratory reporting, hepatitis A,
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surveillance
Over the past 5 years, rates of hepatitis A in New
York City (NYC) have been more than twice the national
The authors thank the New York City Department of Health and Mental Hygiene
hepatitis A surveillance unit: C. Addei-Maanu, L. Amoroso, S. Anderson, M.
Antwi, A. Baptiste-Norville, A. Colon-Serrant, S. Dada, P. Del Rosso, C. Dentinger,
R. Fernandez, A. Fireteanu, H. Hanson, M. Haroon, M. Iftekharuddin, T. Keller,
L. Kidoguchi, E. Lumeng, A. Murray, J. Poy, C. Roman, A. Smorodina, R. Sunkara,
and K. Turner.
Corresponding Author: Kristen M. Moore, MPH, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health
Care, 133 Brookline Ave, 6th floor, Boston, MA 02215 (kristen moore@
harvardpilgrim.org).
Kristen M. Moore, MPH, is a Research Analyst, Department of Ambulatory Care and
Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston,
Massachusetts.
Vasudha Reddy, MPH, is the Foodborne Disease Investigations Coordinator, Bureau
of Communicable Disease, NYC Department of Health and Mental Hygiene, New York.
Deborah Kapell, MPH, is a Data Analyst, Bureau of Communicable Disease, NYC
Department of Health and Mental Hygiene, New York.
J Public Health Management Practice, 2008, 14(5), 437–441
Copyright C 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sharon Balter, MD, is the Medical Director of the Waterborne and Hepatitis Unit,
NYC Department of Health and Mental Hygiene, New York.
437
438 ❘ Journal of Public Health Management and Practice
facilitate more timely and complete reports than conventional methods,6–9 therefore, playing an essential
role in successful public health control measures, intervention strategies, rapid outbreak response, and detection of potential bioterrorist events.10–12 The DOHMH
began receiving electronic laboratory reports through
the New York State Electronic Clinical Laboratory Reporting System in 2002. Shortly thereafter, the NYC
Board of Health passed an electronic reporting mandate
requiring all 96 commercial and hospital-based laboratories serving NYC to report electronically by July 1,
2006.13
We evaluated the impact of electronic reporting on
hepatitis A surveillance and response, including distribution of IG, in NYC. The specific objectives of this
research were to (1) quantify the increase in the proportion of hepatitis A reports received electronically
by DOHMH, (2) assess how implementation of ELR affected the reporting time of hepatitis A, and (3) assess
how changes in reporting time impacted the ability to
offer timely prophylaxis to contacts of cases.
● Methods
Hepatitis A reports were received by DOHMH from
many sources (eg, clinicians, hospital infection control
personnel, laboratories), by mail, phone, fax, and electronic data transfer. As all of these sources were required to report a suspected case of hepatitis A, multiple reports were often received for an individual case
of hepatitis A. For this study, if the first report received
by DOHMH was an electronic laboratory result, then
the report was defined as being electronically reported.
Only the first report received for each case was included
in the analysis. Reporting time was defined as the period from diagnosis to the date the report was first received and the data were entered at DOHMH, and was
measured to assess report timeliness. If this period was
greater than 365 days or a negative number, it was assumed that data were entered incorrectly and the report
was excluded from the timeliness analysis.14
Although certification was required for laboratories
to report exclusively electronically, electronic reports
were received from all laboratories, regardless of their
certification status. Noncertified laboratories were required to submit duplicate paper reports to ensure data
quality. Electronic reporting from noncertified laboratories was inconsistent; therefore, only those certified
were included in the analysis to assess impact of ELR
on laboratory reporting times.
The surveillance case definition used by DOHMH
changed during the study period, decreasing the proportion of reports counted as confirmed cases. Until
July 2005, all positive laboratory reports were classified
as a confirmed case unless a case investigation was conducted. During this time, investigations were focused
on providing PEP to close contacts (eg, household, sexual, day care center–associated, restaurant-associated)
and were only conducted on reports received within 10
days of diagnosis. With additional funding available,
DOHMH began investigating every report of hepatitis
A in July 2005. Since then, the CDC case definition for
acute hepatitis A was used, which required both laboratory and clinical criteria.15
Data analysis was performed using the SAS System
(version 9.1; Cary, North Carolina). We analyzed electronic reporting over time, compared reporting time of
certified laboratories both before and after certification,
and quantified individuals who received PEP both before and after ELR implementation (2000 vs 2006). Statistical significance was considered to be at P < .05.
● Results
Electronic reporting of hepatitis A began in 2002. From
this time to 2006, the proportion of hepatitis A reports
received electronically increased significantly from 1
percent to 35 percent (P < .001) (Figure 1). The proportion of electronic reports increased steadily during
the study period, with an exception in 2004 when a substantial increase in electronic reporting occurred. From
2000 to 2006, the median reporting time of hepatitis A
reports received by DOHMH, including those electronically and nonelectronically reported, decreased significantly from 27 days to 6 days (P < .001). This decrease
was also steady during this time, except 2001 when
the median reporting time increased dramatically to
53 days, with an interquartile range of 20 to 165 days.
However, median reporting time returned to prior levels after this year.
To assess the impact of ELR on reporting times for
hepatitis A, we compared the median reporting times
both before and after certification for the nine laboratories certified to report exclusively through electronic
data transfer as of July 1, 2006. Approximately 20 percent of all hepatitis A reports received annually during
the study period were from these laboratories. Of these,
eight had a decrease in their reporting time, with a median decrease of 17 days (mean decrease of 28 days)
(Table 1). One hospital-based laboratory (Lab E) had a
nonsignificant increase in reporting time of 14 days.
In 2006, 76 (61%) case patients with acute hepatitis A
had a close contact identified within 2 weeks of diagnosis for whom PEP was indicated (Table 2). The DOHMH
recommended that 398 individuals receive IG, whereas
administration was confirmed in 299 of them. During
the study period, the number of individuals who received IG increased more than fourfold from 73 to 299.
Impact of Electronic Laboratory Reporting
❘ 439
FIGURE 1 ● Proportion of Hepatitis A Reports Received Electronically and Median Reporting Time for First
Received Reports, New York City, 2000–2006.
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With the exception of 2003, the ratio of the number of
contacts who received IG per acute case reported to
DOHMH rose steadily and increased sixfold during the
study period.
● Discussion
During the study period, ELR of hepatitis A to DOHMH
increased to 35 percent in 2006. Reporting times decreased; by 2006 reports from all sources were received
by the department in a median of 6 days, 20 days faster
than in 2000. Data presented here suggest that prompt
reporting through increased utilization of ELR had a
direct impact on the ability of the health department
to administer PEP to contacts of hepatitis A cases. In
2006, IG was provided to 299 persons, representing a
fourfold increase from 2000.
Infectious disease surveillance at health departments is dynamic and is affected by several factors. At
times, varying public health priorities must compete
for limited resources. For example, in Fall 2001 routine disease surveillance was disrupted by the public
health response to the World Trade Center attack and
the anthrax-contaminated mail investigation. Many resources were diverted to support the surveillance and
epidemiologic activities associated with these emergencies. This was a substantial contributor to the large
TABLE 1 ● Effect of electronic laboratory reporting certification on timeliness of first report received by DOHMH, from
nine laboratories certified to transmit hepatitis A data electronically, New York City, 2000–2006
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Laboratory
A
B
C
D
E
F
G
H
I
a indicates
Before certification
(certification date–January 1, 2000)
After certification
(certification date–December 31, 2006)
No. of
reports
Median reporting
Time (d)
No. of
reports
Median reporting
Time, d
Difference in
reporting Time, d
42
58
42
92
7
15
30
42
28
78.5
70.5
24
21.5
12
13
24
21
21
32
182
23
29
4
21
24
28
6
6
6
6
7
26
6
7
4.5
5.5
(−) 72.5a
(−) 64.5a
(−) 18a
(−) 14.5a
(+) 14
(−) 7
(−) 17.5a
(−) 16.5a
(−) 15.5a
statistically significant result; P < .05.
440 ❘ Journal of Public Health Management and Practice
TABLE 2 ● Postexposure prophylaxis with immune globulin
to contacts of acute hepatitis A cases, New York City,
2000–2006
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Y
2000
2001
2002
2003
2004
2005
2006
Acute
casesa
Individuals who
received IG
Ratio of individuals
who received IG
per acute case
741
709
529
454
354
288
124
73
121
208
154
354
541
299
0.1
0.2
0.4
0.3
1.0
1.9
2.4
a Prior
to July 2005, case investigations were conducted only on reports received
within 10 days of diagnosis; noninvestigated reports meeting laboratory criteria were
classified as acute cases; IG = Immune globulin.
increase in reporting time seen in 2001, an increase of
27 days from the previous year (Figure 1).
Ongoing communication and collaboration between
laboratory staff, their information technology departments, and the health department is essential for successfully implementing and maintaining ELR.9 Without these, the certification process can be laborious and
lengthy, and laboratories could be required to revert
to paper reporting to uphold quality assurance standards. This was a likely cause of the surge of electronic
reports in 2004 (48% of all hepatitis A reports), when
many laboratories first began the certification process,
followed by a decline to 24 percent the following year
(Figure 1).
Concurrent utilization of ELR and reporting via fax
can account for decreases in reporting times with relatively small increases in ELR. It was difficult to determine the effect of faxed reports using these data because mailed and faxed reports were indistinguishable.
Even so, the impact of electronic reporting on individual laboratories was clearly demonstrated. With one
exception, all laboratories certified to report hepatitis
A electronically substantially decreased their reporting
time (Table 1). It is unknown why Lab E had an increase
in reporting time; however, its ability to transmit data
electronically was likely interrupted.
Prompt disease reporting facilitates successful public health interventions. After ELR implementation,
eight of nine laboratories had a median reporting time
of less than 7 days, allowing for timely distribution of
IG. In 2006, DOHMH provided IG to 299 contacts of
hepatitis A cases and the ratio of individuals who received IG per acute case increased sixfold during the
study period (Table 2). Immune globin should be administered within 14 days of exposure; therefore, it is essential that acute cases are promptly reported to health
departments. Even with timely reporting, the ability for
a prompt investigation is limited by the period from
symptom onset to diagnosis, which was not measured
in this study.
The early proponents of electronic laboratory-based
reporting systems envisioned that such systems would
have a positive impact on infectious disease surveillance and enhance early detection of bioterrorist
events.6,7,16,17 Although ELR provides timely data to
health departments, it can never completely replace
traditional reporting methods. Phone calls from alert
clinicians continue to play a critical role in disease reporting and outbreak and bioterrorist event detection.
Electronic laboratory reporting requires additional resources to manage and check electronic data and to respond to timely reports, such as arranging PEP. Implementation of an ELR system and transformation from
conventional to electronic data create new challenges.
However, when coupled with traditional public health
resources, ELR strengthens public health infrastructure,
improves data quality, and enhances prevention efforts.
Data presented here suggest that increased utilization
of ELR can have a remarkable impact on public health
surveillance and response.
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