Reporting Requirements for Infectious Diseases

The U.S. Centers for Disease Control and Prevention (CDC) is widely accepted as the principal source of accurate information about disease prevalence, signs and symptoms of diseases or disorders, and methods of treatment and prevention in the U.S. In order to provide health care professionals, researchers and the public with these data, the CDC must collect and analyze information from a network of local, state and territorial health departments.

Fast and accurate data sharing and reporting are essential in cases of infectious diseases that can quickly spiral into epidemics and pandemics. This article will detail the process of infectious disease information gathering by the CDC and local and state health departments. It will also explain the difference between “notifiable” and “reportable” diseases and conditions, and the types of notifications required. Finally, it will provide examples of specific notifiable infectious diseases, and the rationale for underreporting or nonreporting of infectious diseases.

A notifiable infectious disease or condition necessitates regular, frequent and timely information about individual cases in order to prevent and control the disease.¹ Based on the emergence of new pathogens, the list of nationally notifiable infectious diseases and conditions is periodically revised. The Zika virus and congenital infection, for example, were recently added to this list as the epidemic progressed and cases were identified in the U.S.² A disease can also be removed from the list if its incidence declines. The list of nationally notifiable diseases is developed collaboratively by the Council of State and Territorial Epidemiologists (CSTE), local and state health departments and the CDC. Table 1 lists the objectives of the case notification of nationally notifiable infectious diseases and conditions.¹

The CDC has been responsible for collecting data on nationally notifiable diseases and conditions since 1961.¹ Beginning in 1990, the data that were previously reported to the CDC as cumulative counts are captured electronically as individual cases, although personal identifiers are not provided. In 2001, the National Electronic Disease Surveillance System (NEDSS) was established to improve the accuracy, completeness and timeliness of reporting at the local, state, territorial and national levels. A major advantage of NEDSS is its ability to capture health information contained within electronic forms, such as laboratory test results needed for case confirmation. All 50 state health departments are using NEDSS-compatible systems to transmit their data to the CDC, making the process quick, accurate and efficient.¹

National surveillance data are compiled by the CDC from case notification reports of the nationally notifiable infectious diseases and conditions submitted by the 57 reporting jurisdictions, including 50 state, five territorial, and the New York City and District of Columbia health departments. Because each jurisdiction is subject to appropriate legislation, regulations and rules, reportable conditions may vary by jurisdiction. Some infectious diseases designated as nationally notifiable by the CSTE, for example, might not be included in the list of reportable diseases by a local or state jurisdiction.¹ This variability can make data aggregation difficult or impossible, and results in a fragmented national surveillance approach.³ In 2005, approximately 128 CDC-assigned codes for reportable diseases were in place — or approximately one-third of the 373 diseases reportable in at least one jurisdiction — presenting a substantial barrier to the reporting process.³ The increasing use of electronic medical records should help improve this situation.

An important distinction between reporting an infectious disease to local/state/territorial health departments and their subsequent notification of the CDC is that the former is mandated and the latter is voluntary.¹ This means health care providers, hospitals and laboratories are required to report cases to their appropriate health departments. The information identifies the patient, but is confidential. Proper identification (while ensuring confidentiality according to the Health Insurance Portability and Accountability Act) is necessary at the local and state levels to ensure adequate protection of public health by providing treatment to those who are already ill. It also allows tracing of contacts who might need vaccines, treatment, quarantine or education. In addition, it facilitates the investigation needed to stop disease outbreaks, eliminate environmental hazards, and close premises where disease transmission may be occuring.¹

In contrast, the information submitted to the CDC doesn’t include patient identification, although age, sex and location are reported. The CDC also collects data on the disease or condition, case status (confirmed, probable or suspected), and the earliest event date (exposure or disease onset, diagnosis date, laboratory test or result date, or the date of report to the public health system).⁴ Table 2 summarizes the chief differences between infectious diseases/conditions reportable to local and state health departments, and nationally notifiable diseases/conditions reported to the CDC.

TYPES OF NOTIFICATIONS

Depending on the nature of the infectious agent, danger to the public, and the likelihood that it will develop into an epidemic, nationally notifiable infectious diseases are listed as extremely urgent, urgent or standard when reported to the CDC.^4,5 According to the stage in infectious disease diagnosis, cases are classified as suspected, probable or confirmed. The infectious agent and possibility of its intentional release determine the following notification:

1. All cases prior to classification, such as possible bioterrorism or especially dangerous infectious agents, such as anthrax, botulism, plague, tularemia, severe acute respiratory syndrome (SARS), diphtheria, Haemophilus influenzae, tetanus and trichinellosis
2. Confirmed, probable or suspect cases (e.g., Lyme disease or malaria)
3. Confirmed and probable cases (e.g., chronic hepatitis B, hepatitis C, mumps or salmonellosis) must be reported to the CDC, according to their urgency classification
4. Only confirmed cases (e.g., cholera, rubella, rabies or measles) must be reported to the CDC, according to their urgency classification⁵

To report an infectious disease case that requires extremely urgent notification, representatives of public health agencies must call the CDC Emergency Operations Center at 770-448-7100 within four hours, and submit an electronic case notification report the next business day.^4,5 The CDC strongly encourages early communication, which should not be delayed if information is missing or not yet verified.⁴ The CDC will follow up on the extremely urgent notification within an hour. In some situations, clinicians call the CDC directly — bypassing their local or state health departments — to report an infectious disease on the immediately notifiable list. In such cases, the CDC immediately informs the local or state health department.⁴ As of January 2016, infectious diseases that require extremely urgent notification include anthrax, botulism, plague, paralytic poliomyelitis, SARS, smallpox, tularemia and viral hemorrhagic fever.⁵

For infectious disease cases that require urgent notification, a representative of the public agency must call the CDC within 24 hours of receiving the report. The CDC will return such calls within four hours. Again, information must also be sent to the CDC electronically by the next business day.^4,5 Brucellosis, diphtheria, initial detection of novel influenza A virus infections, measles, nonparalytic poliovirus infection, rabies, rubella and yellow fever are infectious diseases that require urgent notification.⁵

All other nationally notifiable infectious diseases and conditions require standard notification. Diseases in this category are also known as routinely notifiable, and include foodborne disease outbreaks, hepatitis A, B or C, human immunodeficiency virus (HIV) infection, mumps and tuberculosis.⁵ Standard notifications do not require a phone call to the CDC, but they must be submitted electronically within the next weekly reporting cycle.^5,8

The following examples of nationally notifiable infectious diseases and conditions were selected due to the Zika virus epidemic and presence of disease signs in the oral cavity and head or neck area, such as HIV infection/acquired immune deficiency syndrome (AIDS) and mumps.

INFECTION CONTROL CONSIDERATIONS^6,7

All patients should be treated as though they have an infectious disease. As such, patients with diagnosed infectious conditions do not need special accommodations. Rather, universal precautions must be implemented when treating all patients. Here are a few guidelines for safe treatment.

• Follow the U.S. Centers for Disease Control and Prevention’s (CDC) Guidelines for Infection Control in Dental Health-Care Settings — 2003; the CDC’s recently published Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care; and the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard
• Prevent occupational exposure to blood by donning personal protective equipment, such as masks, gloves, eyewear and a protective garment; limiting the use of fingers for retracting tissue; recapping needles; and implementing devices, such as instrument cassettes, to avoid sharps injuries
• Keep all immunizations up to date
• Ensure the office has an exposure control plan
• Remain up to date on infection control standards; the CDC and the Organization for Safety, Asepsis and Prevention (OSAP.org) are excellent resources

ZIKA VIRUS

Up-to-date information about the Zika virus epidemic is available at CDC.gov. It includes disease statistics, geography, transmission, signs and symptoms, complications, association with microcephaly and birth defects, and methods of disease prevention.⁹ Information for health care personnel is also provided, including resources for clinical guidance, evaluation, diagnostic testing and special populations, including pregnant women and patients with comorbidities, such as HIV. As a developing epidemic, Zika virus infection was not included in the list of the nationally notifiable conditions approved by the CSTE in June 2015,⁵ but it was added in February 2016 as a routinely notifiable condition with a standard reporting timeline.¹⁰ The CSTE recommended that states and territories enact laws and regulations to make Zika disease reportable in their jurisdictions. Health care providers are encouraged to report suspected cases of Zika infection to local or state health departments, which can notify the CDC after the infection is confirmed by laboratory testing.¹⁰

Because patients with active Zika disease are unlikely to seek routine dental treatment, the role of oral health professionals may be limited to conducting a thorough medical history and travel history (where appropriate), referring when applicable, and providing information about the disease and its prevention.¹¹ If Zika virus infection is suspected, the patient should be referred to his or her primary care provider for further assessment and for diagnostic testing at an appropriate laboratory.¹⁰

HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNE DEFICIENCY SYNDROME

The first cases of HIV infection and AIDS (Stage 3 HIV infection) were reported in 1981. Since then, advances in diagnostic testing have led to revisions in surveillance case definitions.^1,12 By 2008, all 57 reporting jurisdictions introduced regulations that required confidential, name-based reporting for HIV infection and AIDS, which must be confirmed by laboratory testing.¹ The latest HIV surveillance case definition was published by the CDC in 2014; it is intended to help monitor the HIV infection burden and assist prevention and care efforts on a population level.¹² Local and state health departments notify the CDC of confirmed cases of HIV infection according to the standard timelines for reporting.⁵

Between 30% and 80% of patients with HIV infection have oral lesions, including oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma, oral warts, herpes simplex virus ulcers, major aphthous ulcers or ulcers not otherwise specified. They may also present with HIV salivary gland disease, xerostomia or atypical gingival and periodontal diseases.^13,14 Identifying these oral manifestations in a dental setting can aid in detecting a previously unknown HIV infection. Thus, dental professionals may be the first providers to refer these patients for medical consultation and testing. Additionally, many patients already diagnosed with HIV are treated with antiretroviral therapies that have adverse oral effects, including salivary gland disease, xerostomia and human papillomavirus-related lesions.¹³

Research shows that patients¹⁵ and primary care physicians¹⁶ view chairside screening in dental settings favorably, and that oral health professionals consider such screenings important and are willing to incorporate them into practice.¹⁷ Additionally, as oral HIV rapid testing has become available, it may be well suited for dental settings — although the feasibility of such testing should be further investigated prior to implementation.¹⁸

MUMPS

Mumps is an acute communicable viral disease, but since the introduction of a vaccination program in 1967, its incidence in the U.S. has decreased by 99%.¹⁹ There are occasional outbreaks, especially in the winter/spring seasons and in close-contact settings, such as educational facilities and dormitories. As of June 6, 2016, 1272 cases of the disease have been diagnosed this year.¹⁹ An outbreak among students at Harvard University in April 2016 caused alarm.²⁰ Mumps is a nationally notifiable infectious disease, and confirmed or probable cases are reported to the CDC by local and state health departments according to standard notification timelines.⁵

Oral health professionals should be familiar with the signs and symptoms of mumps, as there is typically a bilateral involvement of parotid salivary glands (including pain, swelling or tenderness). In about 25% of mumps cases, the involvement is unilateral, and, less frequently (in approximately 10% of cases) submandibular and sublingual, as well. Therefore, this infectious disease may be initially identified in dental settings. Other, nonspecific signs of mumps include fever, headache and malaise, but the disease can be mild or asymptomatic.²¹ The possible complications are serious, however, and include viral meningitis, sensorineural hearing loss, and orchitis in men, which can, rarely, cause sterility.^21,22 A two-dose measles, mumps and rubella vaccination introduced in 1989 is 91% to 94.5% effective, although there is evidence of reduced immunity over time.²² In addition to suspecting the disease and making an appropriate referral, oral health professionals may play an important role by providing information to patients about the importance of vaccinations against mumps and other infectious diseases, as well as vaccine effectiveness and safety.

BARRIERS TO REPORTING

The public health surveillance system relies on the timely, accurate and complete reporting of notifiable infectious diseases to local and state health departments, followed by notification of the CDC, as applicable. This is especially important if the infectious disease is acute, severe and highly transmissible, has the potential to develop into an outbreak or epidemic, and poses a substantial danger to the public.⁸ Timely national data collected from multiple reporting jurisdictions may be used in identifying multistate disease outbreaks, which enables the federal public health system to help states with prevention and control measures. Due to the hierarchical structure of reporting, however, delays at each level contribute to notification delays nationally.^3,8

The variability of reporting requirements — in combination with variances in the diseases that are considered reportable among the local and state jurisdictions, and the absence of a uniform information model — presents additional barriers to timely reporting.^3,8

In order to report effectively, health care providers must be familiar with the diseases and conditions that need to be reported, understand the case-reporting criteria, and know how to submit a report when necessary. There are often minimal rewards for reporting or punitive consequences for nonreporting.³ An earlier investigation found that information for health care providers about reportable conditions was provided on all local and state health department websites, but was often not prominently displayed.³ That said, a simple web search for “reportable infectious diseases” in a given state will most likely provide a link to the information. This may be the simplest approach for health care providers who are not familiar with the reporting requirements in their states.

CONCLUSION

Oral health professionals may play a vital role in recognizing infectious diseases, including those that require reporting to local and state public health authorities and the CDC. Appropriate referral to a primary care physician or hospital is also necessary. Some communicable infectious diseases do not need to be confirmed, however, and, if suspected or probable, should be reported as soon as possible. In order to prevent an outbreak of infectious disease and to ensure the fastest response by public health officials, dental teams should be familiar with the infectious disease reporting requirements in their local and state jurisdictions, and know where to find pertinent information and resources.

KEY TAKEAWAYS

• The U.S. public health surveillance system relies on the timely, accurate and complete reporting of notifiable infectious diseases to local and state health departments, followed by notification of the federal Centers for Disease Control and Prevention (CDC), as applicable.
• National surveillance data are compiled by the CDC from reports submitted by the 57 reporting jurisdictions, including 50 state, five territorial, and the New York City and District of Columbia health departments.
• It’s important to note that because each jurisdiction is subject to appropriate legislation, regulations and rules, reportable conditions may vary by jurisdiction.
• A key distinction between reporting an infectious disease to local/state/territorial health departments and their subsequent notification of the CDC is that the former is mandated and the latter is voluntary.¹
• In order to report effectively, health care providers must know the diseases and conditions that must be reported, maintain an understanding of the case-reporting criteria, and know how to submit a report when necessary.

REFERENCES

1. U.S. Centers for Disease Control and Prevention. Summary of notifiable infectious diseases and conditions — United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;62:1–124.
2. U.S. Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System. 2016 Nationally Notifiable Conditions. Available at: cdc.gov/nndss/conditions/notifiable/2016. Accessed August 31, 2016.
3. Doyle TJ, Ma H, Groseclose SL, Hopkins RS. PHSkb: A knowledge base to support notifiable disease surveillance. BMC Med Inform Decis Mak. 2005;5:27.
4. Council of State and Territorial Epidemiologists. Surveillance/Informatics Committee. Process statement for Immediately Nationally Notifiable Conditions. Available at: cdc.gov/nndss/document/09-SI-04.pdf. Accessed August 31, 2016.
5. U.S. Centers for Disease Control and Prevention. Protocol for Public Health Agencies to Notify CDC About the Occurrence of Nationally Notifiable Conditions, 2016. Available at: cdc.gov/nndss/document/NNC-2016-Notification-Requirements-By-Condition.pdf. Accessed August 31, 2016.
6. Garland K. How do I best protect myself? Dimensions of Dental Hygiene’s Ask the Expert online forum. Available at: dimensionsofdentalhygiene.com/asktheexpert/blog.aspx?id=18536&blogid=7259&term=universal%20precautions. Accessed August 31, 2016.
7. Garland K. Will I contract an infectious disease from a patient? Dimensions of Dental Hygiene’s Ask the Expert online forum. Available at: dimensionsofdentalhygiene.com/asktheexpert/blog.aspx?id=20599&bid=7259&blogid=7259&term=universal%20precautions. Accessed August 31, 2016.
8. Jajosky RA, Groseclose SL. Evaluation of reporting timeliness of public health surveillance systems for infectious diseases. BMC Public Health. 2004;4:1.
9. U.S. Centers for Disease Control and Prevention. Zika Virus. Available at: cdc.gov/zika/index.html. Accessed August 31, 2016.
10. Council of State and Territorial Epidemiologists. Notice to Readers: Changes in the Presentation of Zika Virus Disease, Non-Congenital Infection, and Addition of Zika Virus Congenital Infection to Notifiable Diseases and Mortality Table I. Available at: cdc.gov/mmwr/volumes/65/wr/mm6520a6.htm. Accessed August 31, 2016.
11. Matthews A, Cohen Brown G. Zika virus in the dental setting. Decisons in Dentistry. 2016;2(7):40–43.
12. Selik RM, Mokotoff ED, Branson B, Owen SM, Whitmore S, Hall HI. Revised surveillance case definition for HIV infection — United States, 2014. MMWR Recomm Rep. 2014;63:1–10.
13. Cohen Brown G. Oral Lesions and Treatment Recommendations for the HIV-Infected Patient. CME and dental-accredited self-study module. Albany Medical College and NY/NJ AIDS Education & Training Center; 2010.
14. Patton L. Oral lesions associated with human immunodeficiency virus disease. Dent Clin North Am. 2013;57:673–698.
15. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent. 2012;72:28–35.
16. Greenberg BL, Thomas PA, Glick M, Kantor ML. Physicians’ attitudes toward medical screening in a dental setting. J Public Health Dent. 2015;75:225–233.
17. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes toward chairside screening for medical conditions. J Am Dent Assoc. 2010;141:52–62.
18. Pollack HA, Pereyra M, Parish CL, et al. Dentists’ willingness to provide expanded HIV screening in oral health care settings: results from a nationally representative survey. Am J Public Health. 2014;104:872–880.
19. U.S. Centers for Disease Control and Prevention. Mumps: Cases and Outbreaks. Available at: cdc.gov/mumps/outbreaks.html. Accessed August 31, 2016.
20. Sabate I. Mumps count rises to 40, concerning HUHS director. Available at: thecrimson.com/article/2016/4/26/mumps-concerns-HUHS-director/. Accessed August 31, 2016.
21. U.S. Centers for Disease Control and Prevention. Mumps for Healthcare Providers. Available at: cdc.gov/mumps/hcp.html. Accessed August 31, 2016.
22. Dayan GH, Rubin S, Plotkin S. Mumps outbreaks in vaccinated populations: are available mumps vaccines effective enough to prevent outbreaks? Clin Infect Dis. 2008;47:1458–1467.