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Impact of Electronic Laboratory Reporting on Hepatitis A Surveillance in New York City Kristen M. Moore, Vasudha Reddy, Deborah Kapell, and Sharon Balter rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr 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, qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq 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. qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq 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 qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq 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 qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq 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. 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