Roush S, Birkhead G, Koo D, Cobb A, Fleming D. Mandatory Reporting of Diseases and Conditions by Health Care Professionals
and Laboratories. JAMA. 1999;282(2):164-170. doi:10.1001/jama.282.2.164
Context Surveillance is a key component of the core public health function of
health assessment. Systematic reporting by health care professionals and laboratories,
which may vary by state law, statute, or regulation, continues to provide
essential data for assessing public health.
Objective To describe the state and territorial reporting requirements for diseases
and conditions recommended for national public health surveillance.
Design, Setting, and Participants Between May and August 1997, the state and territorial epidemiologists
from all 50 states, in addition to New York City, Puerto Rico, and Guam, completed
questionnaires indicating which diseases and conditions were reportable by
health care professionals and laboratories in their jurisdictions. The surveys
were subsequently updated to reflect reporting requirements current as of
January 1, 1999. The overall response rate for the survey was 100% for US
states and 90% overall, including the territories.
Main Outcome Measure State and territorial reporting requirements for diseases and conditions
of public health concern.
Results Of the 58 diseases and conditions recommended for national reporting,
35 (60%) were reportable in greater than 90% of the states and territories,
15 (26%) were reportable in 75% to 90%, and 8 (14%) were reportable in less
than 75%. Nineteen of the infectious diseases were reportable in all of the
states and territories that responded.
Conclusions Required reporting varies substantially by state or territory. Health
care professionals are integral to public health efforts at the local, state,
and national levels.
Public health surveillance is defined as the ongoing and systematic
collection, analysis, and interpretation of outcome-specific data for use
in the planning, implementation, and evaluation of public health practice.
A surveillance system includes the functional capacity for data collection
and analysis as well as the timely dissemination of these data to persons
who can undertake effective prevention and control activities.1
Public health surveillance systems in the United States were designed for
the reporting of infectious diseases of public health interest, and health
care professionals (usually physicians and nurses) have been the primary source
of disease reporting.2- 4
Recently, laboratories have also become an important source of reporting for
public health surveillance.5- 7
Together, health care provider reporting and laboratory reporting may ensure
more complete and timely reporting for diseases and conditions recommended
to be under national surveillance.
The list of diseases and conditions that are recommended for national
surveillance is designed to reflect the current needs and priorities for public
health surveillance at any given time.
Table 1 shows selected changes in the list of diseases under national
surveillance that occurred between 1989 and 1996, illustrating the dynamic
nature of the list of diseases under national surveillance. Public health
officials at state health departments and the Centers for Disease Control
and Prevention (CDC) collaborate in determining which diseases should be under
national surveillance; the Council of State and Territorial Epidemiologists
(CSTE), in conjunction with CDC, makes annual recommendations for additions
and deletions to the list of diseases under national surveillance.2,8 For example, in 1994, CSTE recommended
that 10 diseases or conditions be deleted from the list of diseases or conditions
under national surveillance2,9;
in addition, 9 diseases or conditions were added (
Table 1). In 1995 and 1996, CSTE and CDC again responded to changes
in public health priorities and expanded the list of diseases and conditions
under national surveillance beyond the traditional list of infectious diseases,
recommending that elevated blood lead levels,10
silicosis,11 tobacco use,12
and acute pesticide poisoning13 be added.
The list of diseases and conditions under national surveillance is published
each year in the annual MMWR Summary of Notifiable Diseases
8; however, the list of what is reportable
within each state or territory may vary.3,5,8
This article describes the state and territorial public health reporting requirements
for health care professionals and laboratories for those diseases and conditions
that are recommended for national surveillance.
In May 1997, a survey questionnaire was mailed to the individual at
each state or territorial health department designated the state epidemiologist.
(New York City is bound by New York State reporting requirements, but, as
is true with other local areas, may have additional reporting requirements.
New York City was included in the survey because its population is greater
than that of many states.) Responses were received between May and August
1997. States and territories that did not initially complete the survey received
follow-up telephone calls requesting their participation in the survey. The
results of the survey were subsequently reviewed by the state and territorial
epidemiologists and updated to reflect reporting requirements current as of
January 1, 1999.
Each of the 52 infectious diseases and 4 conditions
(acute pesticide poisoning, silicosis, elevated blood lead levels, tobacco
use) recommended by CSTE and CDC for national surveillance was included as
a single response item on the survey, with 4 exceptions: (1) Hepatitis C/non-A,
non-B on the national list was separated into hepatitis C and hepatitis non-A,
non-B on the survey. (2) Adult human immunodeficiency virus infection was
included, in addition to pediatric human immunodeficiency virus infection.
(3) Streptococcus pneumoniae, drug-resistant invasive
disease (from the national list) was separated into 2 categories,
S pneumoniae-invasive and S pneumoniae–drug-resistant.
(4) Surveillance for tobacco use does not rely on reporting by health care
professionals or laboratories and therefore was not included in this survey.
For laboratory reporting, epidemiologists were to consider any specific laboratory
test indicative of the disease or condition.
In addition to the
diseases and conditions under national public health surveillance, 84 others
also were included on the survey to assess as completely as possible the reporting
requirements for any diseases and conditions that may have had local or state
public health importance. Respondents were also asked to write in any additional
diseases or conditions for which their state or territory had mandated reporting.
Respondents were asked to indicate whether each disease or condition was reportable
by health care provider, laboratory, both provider and laboratory, or neither
provider nor laboratory. For diseases or conditions included on the survey
that were considered by the state to be reportable but under some other name
or heading (eg, Eastern equine encephalitis, reportable in the category of
"Encephalitis, all types"), the disease or condition was coded by the authors
as reportable for that state, although the specific term or name given on
the survey was not the same as that used for reporting in the state or territory.
Epidemiologists from each of the 50 states and from New York City, Puerto
Rico, and Guam responded to the survey (100% response rate for US states and
90% overall, including the territories). Table 2 displays the state and territorial requirements for reporting
of diseases and conditions recommended for national surveillance as of January
1, 1999, and shows conditions and diseases reportable only by health care
provider, those reportable by laboratory only, those reportable by both health
care provider and laboratory, and those for which neither the health care
provider nor laboratory are required to report.
Table 3 summarizes the reporting requirements for each of the diseases
and conditions under national surveillance. Of the 58 diseases and conditions
recommended for national reporting, 35 (60%) were reportable in greater than
90% of the states and territories, 15 (26%) were reportable in 75% to 90%
of the states and territories, and 8 (14%) were reportable in less than 75%
of the states and territories. Nineteen of the infectious diseases (acquired
immunodeficiency syndrome, botulism, cholera, diphtheria, gonorrhea, hepatitis
A, hepatitis B, malaria, measles, pertussis, poliomyelitis [paralytic], human
rabies, rubella, salmonella, shigella, syphilis, tetanus, tuberculosis, and
typhoid fever) were reportable in all of the states and territories that responded
to this survey.
The information presented in Table 2 is also available on the Internet
(http://www.cste.org). However, public health reporting requirements
change often; readers should contact their public health departments for the
most current information on reporting requirements. The reporting requirements
for diseases and conditions that are not under national surveillance but for
which at least 10 states or territories mandated reporting by health care
professionals, laboratories, or both are not included in this article but
are available online (http://www.cste.org).
Several factors may affect whether a disease or condition on the list
for national surveillance is reportable within a specific state or territory
at any given time. In this survey, only 19 (33%) of the 58 diseases and conditions
on the list for national surveillance were actually reportable in each of
the 53 responding states and territories. Time needed to enact a requirement,
available resources, and competing public health priorities each affect a
state's list of reportable diseases and conditions.
to the national list may only be reportable in fewer states if there has been
insufficient time for the legislative and other processes needed within the
state to make the disease or condition reportable by law, statute, or regulation.
For example, acute pesticide poisoning (reportable in 20 [38%] states and
territories) and silicosis (reportable in 24 [45%] states and territories)
were added to the national list relatively recently (1996). In addition, surveillance
data may be difficult to capture, and the state or territory may not have
the resources to implement reporting programs or systems for that disease
or condition. The relatively low level of mandatory reporting for drug-resistant S pneumoniae (reportable in 28 [53%] states and territories),
may illustrate the reluctance of states and territories to require reporting
for diseases and conditions for which surveillance data (eg, antimicrobial
susceptibility patterns) are difficult to capture. Also, not all diseases
and conditions on the list for national surveillance have equal relevance
to each state or territory, and reporting requirements for these diseases
and conditions may be affected by regional or other factors. For example,
hantavirus and coccidioidomycosis are reportable in only 34 (64%) and 10 (19%)
of the states and territories, respectively, because these conditions usually
cause public health problems only in certain regions of the United States.
In the United States, the authority to require notification of
cases of diseases resides in the respective state legislatures.14
The states exercise their authority to require reporting by enacting legislation;
some state statutes delegate the authority to enumerate the health conditions
that are reportable to state or local agencies. Subsequent reporting of morbidity
data by the state or territorial health department to CDC is voluntary.3,4
Because of each state's
autonomy with regard to morbidity reporting, the list of diseases and conditions
that are reported varies by state. In addition to the variation among states
for the conditions and diseases to be reported, the time frames for reporting,
agencies receiving reports, persons required to report, and conditions under
which reports are required also may differ among states.3
In many states, local health departments provide epidemiologic services; as
a consequence, health care professionals in many states are encouraged by
their public health officials to report diseases directly to local health
departments rather than to the state health department. Health care professionals
are encouraged to determine the specific requirements in their area by contacting
their state health department.
Standardized case definitions for
the diseases under national surveillance have been created to provide uniform
criteria for reporting cases.15,16
Although the public health case definitions are useful for surveillance, they
are not designed to influence clinical treatment or to delay the reporting
of pending case confirmation. Case definitions for the diseases under national
surveillance were first developed and approved by CDC and CSTE in 1989 and
were published in the MMWR Morbidity and Mortality Weekly
Report in 1990.15 The most recent revisions
to the case definitions were published in 199716
(available at http://www.cdc.gov/epo/phs.htm). The CDC and CSTE
also have initiated development of standardized case definitions for injury,
chronic, environmental, occupational, and other health conditions.
Historically in the United States, infectious disease surveillance has
relied primarily on case reports from physicians and other health care professionals.
Although these diseases are usually underreported (reporting is estimated
at 6%-90% for many of the diseases under national surveillance),14,17
if the reporting is consistent over time, these data are a good source of
temporal and geographic trends and characteristics of the persons experiencing
morbidity.18 For diseases or other health conditions
for which there is a substantial laboratory component included in case diagnosis
or definition, laboratory reporting is a useful mechanism to supplement reporting
by clinicians to public health authorities allows immediate public health
response, including case investigation, contact prophylaxis, and outbreak
control, other methods of surveillance are also necessary to meet the changing
needs of public health assessment. Some of these other methods are sentinel
surveillance and secondary analysis of hospital discharge or other administrative
data sets, prevalence surveys, and vital records. These methods may be used
in combination to improve the comprehensiveness of data collection and to
provide more complete information to assess local, state, or national goals
for public health.14,20 In 1994,
CSTE and CDC convened a national surveillance meeting to formalize the concept
of a comprehensive framework for surveillance to include infectious as well
as noninfectious health conditions, and CSTE proposed the concept of the National
Public Health Surveillance System.18
The CDC coordinates the states' and territories' surveillance data,
providing weekly reports in the MMWR Morbidity and Mortality
Weekly Report and annually in the MMWR Summary of
Notifiable Diseases, which are available on the Internet (http://www.cdc.gov/epo/mmwr/mmwr.html
). In addition, many states and territories provide newsletters and
epidemiologic updates of surveillance data within their jurisdictions. Surveillance
summaries for injury,21,22 hazardous
substances and emergency events,23 infant mortality,24,25 childhood lead poisonings,26 low birth weight,24
neural tube defects,27 occupational asthma,28 occupational hazards,29
silicosis,30,31 and smoking28,32,33 illustrate that other
mechanisms for surveillance and data collection must be flexible and appropriate
to the specific public health issue.
Public health surveillance
forms the basis for establishing public health priorities and monitoring trends.34 Health care professionals are key to public health
efforts. By describing the reporting requirements for various diseases and
conditions, the CSTE survey provides information on state and national priorities
for surveillance. At the local level, knowledge of surveillance priorities
can help ensure that diseases and conditions of public health concern are
investigated, that appropriate public health action is taken, and that the
disease or condition is reported to the appropriate public health authority.
At the state level, surveillance data can be summarized and communicated to
the private and public sectors to identify needed interventions and to assess
programs. Awareness of state-specific priorities and requirements for surveillance
is essential, because authority for reporting resides in each state. At the
national level, surveillance data are used to guide policy and to evaluate
Public health has expanded from its traditional base
in infectious disease control, and as the scope of public health expands,
the list of diseases and conditions of public health interest will vary between
jurisdictions and over time. In the future, greater emphasis should be placed
on gathering data electronically from existing sources, including clinical
laboratories and computerized medical records. Those concerned about public
health will increasingly be required to make the best use of limited resources
for surveillance to meet the challenges of a changing medical care system
using new information technology.