Objective. To assess the level of underreporting and overreporting of hepatitis B infection at a tertiary hospital.Design. Retrospective record review.Setting. King Edward VIII Hospital, Durban.Main outcome measures. Hepatitis B notification was assessed. Underreporting was ascertained on the basis of the proportion of hepatitis B-positive laboratory results that were not notified. Overreporting was indicated by duplication of notifications and the reporting of patients who have not tested positive for hepatitis B.Results. 83.7% (95% confidence interval 79.4 - 88.0%) of patients with hepatitis B virus infection were not reported. no hospital outpatients were reported and 6% (95% confidence interval 0 - 12.6%) of the reported hepatitis B cases were not hepatitis B.Conclusion. Underreporting of hepatitis B virus infection is the result of an inadequate notification system at a health institution level. A new, user-friendly system of surveillance that actively monitors the reporting rate is recommended to improve the reporting rate and thus generates useful information

Karim, Salim S. Abdool

Rustomjee, Roxana

English

AJOL - African Journals Online

le acomplex set of factors influences vulnerability to HIV~lton, particularly among migrant workers, in the shortthe need to utilise every opportunity for management of5 and thereby impact on the HIV epidemic cannot beiciently underscored.,le thank Ms S Sewambar for assistance with the statisticalIj515; the staff at the workplace-based clinics surveyed forrparticipation and open sharing of information; and theous roleplayers and stakeholders who have committedselves to improved management of STDs in the workplacewaZulu-Natal. This study was funded by the Medicalearch Council and supported by the Fogarty International11re, NIH (grant TWO-0231).ilENCES'~cool Kanm ss. Challenges to Ihe control of sexually transmlHed d,seases tn"rea (Editorial). Am J Public Hea/rh 1994; 84: 1891-1893.~mcn M. Hoosen AA. Mooaley J, Moodley S. Urogenital traCt tnfeclions in'~nancy at K,ng Edward VUI Hospilal. Durban. South Africa. Gemrourm Med5S2 68: 39-41.~a"ell N. Hoesen A. Kharsany ABM. van den Ende J. Sexually transmjtted21"ogens In pregnant women In a rural South African commumty. Gemrounn Med';9 65: 276-280."!~eus A, PlOt P. Provls,on 01 serv,ces for sexually transm'Ued diseases In".e:o~Jtng counlnes. In: Onel JO. Hams JAW. eds. Recenr Advances m Sexually"'lmlf/ed Diseases. New Yorll: Churchill Livmgstone. 1992: 261-271.~panment of Health. Sixth oal,onal HIV survey 01 women attendmg antenatal'·cs of me public health services m the Republic of South Africa,c:Ooer{November 1995. Epidemiological Comments 1996: 23(1): 2-16.·'~~s...unn H. Mosha F, Toad J. el aL Impact of ,mprovea treatment of sexually'3 r sm'1I!!d d,seases 0" HIV ,0fecl,on m rural Tanzania: random,sed controlled'i1 lancet 1995: 346: 530·536."'-elson K. Mothlbedi M. Leger JP. Human Immunodefic,ency virus and m'9rant'DOur ,,, South Africa. 1nl J Healrh Setv 1991: 21: 151·173.~~ool Karlm a. Abdool Kaflm SS. S",gh B. Snon A. Ngxongo S. Seroprevalence'''IV ,nfectlon m rural South AITlca. AIDS 1992; 6: 1535-1539.• nlan DJ, Moodley J. Kharsany ABM. Vat! den Enoe J. Sexually transmJlled,'"agens In acute pelVIC mllammatory disease. S Afr Med J 1989; 16: 251-254..bopanaar D. Hoosen AA. Mooaley J. Tait DA, Moodley C. Human-r-unodetiClency virus. sypnll,s ana mucopurulent CervICitiS In gynaecology.:~al'ent cliniC allenders. Soutnern Afflcan Journal of Ep,demlology and-'f:llo,., 1993; 8: 74-76_• 'es W. HOlmes KK. Sexually Ifansmitted diseases. 10: Mallcy-Rosenau. ed._o"c Healrh and PreventIve Medicme. 13th ed. Norwalk. Conn.: Appleto,.,-e~:ury-Crolts, 1991; 99-114.:ted 18 Dec 1996.SAMJPUBLIC HEALTHUnderreporting andoverreporting of hepatitis Bat a tertiary hospitalRoxana Rustomjee, Salim S Abdool KarimObjective_ To assess the level of underreporting andoverreporting of hepatitis B infection at a tertiary hospital.Design. Retrospective record review.Setting. King Edward VIII Hospital, Durban.Main outcome measures. Hepatitis B notification wasassessed. Underreporting was ascertained on the basis ofthe proportion of hepatitis B-positive laboratory resultsthat were not notified. Overreporting was indicated byduplication of notifications and the reporting of patientswho have not tested positive for hepatitis B.Results. 83.7o/~ (95% confidence interval 79.4 - 88.0%)of patients with hepatitis B virus infection were notreported. no hospital outpatients were reported and 6%(95% confidence interval 0 - 12.6%) of the reportedhepatitis B cases were not hepatitis B.Conclusion. Underreporting of hepatitis B virus infectionis the result of an inadequate notification system at ahealth institution level. A new, user-friendly system ofsurveillance that active!}' monitors the reporting rate isrecommended to impr'f'e the reporting rate and thusgenerates useful information.S Afr Med J 1997; 87; 249-251.Hepatitis B virus infection is a notifiable condition in SouthAfrica. Nationally, this is undertaken by a process of passivesurveillance. While notification is required by law, theprocess needs the voluntary participation of health workersto initiate the process. The Department of Health collatesthese data nationally.Since this information is intended for planning f:1urposes, itis important that it should provide an estimate of theincidence rate of hepatitis B that is reasonably accurate.However, it has been found that the incidence rate ofhepatitis B is at least 7-fold greater than that calculated fromnotification data. IThis seriousty alters the quality of health information in thecountry and has the consequence of misdirecting healthplanning and interventions. Further, the ExpandedProgramme on Immunisation vaccination schedule,2introduced on 28 February 1995, includes hepatrtis BCentre for Epidemiological Research in Southern Africa. MedicalResearch Council, DurbanRoxana Rustomjee. MS 016Salim 5 Abdool Karim. MB 018. MS (Epl. Dip o.ta. MMeo lCHl. FFOi lSA.lProfessor K Klugman was the guest editor responsible for editorialdecisions regarding this~.SAMJ Volume 87 No.2 February 1997~accination, making reliable information essential formonitoring the effectiveness of this proposed policy.Since tertiary hospitals are a major source of hepatitis BnotIfications, this study set out to determine the accuracy ofratification of hepatitis B at the regional tertiary hospital ofKI·.alulu-Natal. King Edward VIII Hospital (KEH).MethodsThe reporting of hepatitis B for the 6-month period Julyi993 - December 1993 was investigated at KEH, a tertiaryfaierral centre with a considerable outpatient care facility.At KEH, the reporting process for notifiable conditions issometimes initiated by doctors who complete notificationiorms after receiving laboratory evidence of hepatitis B virusInfection. In addition, clerks in the medical registry section ofIhe hospital sometimes identify evidence of hepatitis B virusmfection in inpatient charts, and refer these to the hospital'snotification clerk who then proceeds to complete anotification form. These notification forms, together with thehospital records, are forwarded via the medical registry tome medical superintendent for verification. Thereafterconfirmed notifications are entered into the hospitalnotification register and submitted to the Local HealthAuthority.Three sets of data were obtained from these sources, viz.notification data from the hepatitis 8 notification register,aboratory data from hepatitis B laboratory test results andd'scharge data on hepatitis B from medical registrycomputer records.Hospital inpatient charts of patients notified for hepatitis 8as wetl as patients with a discharge diagnosis of hepatitis awere retrieved and examined for corresponding hepatitis Blaboratory test results, clinical evidence of hepatitis B virusInfection and evidence of previous notification.An underreporting rate was calculated from the proportionof hepatitis a-positive laboratory results that exceeded theotifications. Overreporting was assessed on the basis ofduplication of notifications and the proportion of reportedpatlents who had not tested positive for hepatitis 8.The Ethics and Higher Degrees Committee of theUniversity of Natal approved this study.Resultslaboratory data showed that of the 1 904 hepatitis Baboratory tests performed for KEH patients from July 1993to December 1993, 288 were HBsAg-positive. Notificationdata revealed only 50 (17.4%) notifications during thisl'eriod.The underreporting rate was 83.7%. There were 47correct notifications, making the calculated notification ratea mere 16.3% (47/288) (95% confidence interval 12.0-20.6%). Of these 47,17 (36.2%) were children.Three notified patients did not test positive for hepatitis Band were incorrectly notified, thus giving an overreportingrate of 6% (3150) (95% confidence interval 0 - 12.6%). ThereWas no duplication of notifications.There were no notifications for the hospital outpatientswith hepatitis B-positive laboratO!)' results, desprte a larger• Volumt' 87 No. 2 Ft'brvo.ry 1997 SA-M}proportion of positive laboratory results in this group.Discharge data revealed that the admission rate for currenthepatitis B infection was low, estimated at 21 %. Of theinpatients with a discharge diagnosis of hepatitis a. 75.4%were correctly notified.DiscussionThe current system for the reporting of hepatitis B at KEH isinadequate because 83% of patients with hepatitis B virusinfection were not reported, no hospital outpatients werereported and 6% of the reported hepatitis B cases were nothepatitis B.Effective surveillance of hepatitis a, through notificatlon.can only be achieved if the purposes of surveillance' arebeing achieved, viz. to identify disease trends and high-riskgroups, institute preventive measures and evaluate theeffectiveness of intervention programmes. While it might beargued that complete reporting is not essential to satISfy theaims of surveiJIance,~the high rates of hepatitis 8 infection,the complications and the potential for primary preventlonsupport a need for vigilant surveillance.Moreover with the launch of a national immumsationprogramme that includes hepatitis B vaccine, surveillance isrequired to assess the effectiveness of the programme andto identify groups in which the programme is not. having thedesired effect. At present this cannot be done given thatage-specific incidence rates based on notifications will beinaccurate because hospital outpatients are not reportedand there is gross underreporting. Although the notification~a~e based on .disc~rge d~ta was relatively high (75.4%),it IS a mechamsm 0' reportmg that will only captureinpatients. .It becomes necessary to look at reasons for theshortcomings in hepatitis B notification. The need for asystem that includes hospital outpatients is obVIOUS. Further,the possibility that hepatitis B serology is not understoodand therefore misinterpreted by medical staff as a reason forunderreporting needs to be investigated. A recent study~attributed the reasons for underreporting of notifiableconditions to poor overall knowledge about notifiableconditions by doctors at KEH.A new system of surveillance for hepatitis Ii' virus infectionat the health institution level is required. This new systemshould focus on treating the various data sources such aslaboratory results, patient notes and doctor-initiatednotification as a continuum. Each patient will need anindividual identity number such as a hospital number; thiswould access the data on that patient and form the basis foractive data tracking and notification. Using this identitynumber, all positive laboratory results should be checkedagainst the patient's discharge diagnoses and notificationreports to see if that patient has been correctly notified. Inthe event of a notification not being made, a remindershould be sent to the health care providers of the need tonotify hepatitis 8-positive patients. This will help to increasethe reporting rate and provide training for clerks, doctorsand nurses to reduce over-reporting. Correlation oflaboratory resutts with clinical diagnoses and doctor-initiatednotifications will avoid duplications and detect incorrectnotifications, thereby reducing the overreporting rate.In a study of the New York State Perinatal Hepatitis Bevention Program the use of multiple reporting sources formatal hepatitis B surveillance improved the reporting rate96% from 77 - 83% with the existing indivkfual reportingstem.6 In addition the programme identifies and ensuresCC1nation of exposed infants and thus also functions as ase management system.While the results from this study reflect the situation atHonly, this is a teaching hospital and practices at KEHE likely to be similar to or, at most, no better those in thesi of the health service. The occurrence of clinical illness is1essential for the diagnosis and notification of hepatitis BS Infection. Asymptomatic cases and cases of routinereening form part of the positive laboratory results.owever, these cases are not reflected in notification data.onclusionnoerreporting of hepatitis B virus infection is caused by an~dequate notification system at a health institution level. Aher and more accurate data tracking and notification'stem is required to improve information intended forrveillance and planning purposes.Anew system which actively monitors the reporting rate isaWed. In the proposed system, data sources should beSAMJPUBLIC HEALTHlinked and potential cases of notifiable conditions trackeduntil discharge to ensure that the patient is notified. Such asystem requires better organisation, clear procedures andnot necessarily substantial additional resources, The clearbenefit will be information that is useful for planning andmonitoring purposes.The authors would lik~ to thank Professor A N Smith andMr W Gopaul from the Department of Virology. the superintendentof King Edward VIII Hospital, Or L Dwarkapersad, and Ms C RStone from the Medical Registry for their assistance in this study.The study was funded by the South African Medical ResearchCouncil and the Fogarty International Center (grant TWO-0231).REFERENCES,. Abdool Karlm SS, AOdool Karlm O. Unal!rTl!ponlng In I'lepahlls B nolll.callon.S Afr Med J 1991: 79: 242-244.Oepanmenl 01 Healtn. Immumsal'on that Worlls! Tne Vaccmaror's Manual of rheEJl.panded Programme on Immumsatton In Sourn Afnca. EPI (SA). Pretona:Government Printer. 19953_ Brachman PS. Surveillance. 111; Evans AS. Feldman HA. eos. Bacteria/InfectIonsof Humans: EpidemIology and Control. New York: Plenum Med'cal Book Co.•1982; 50.4. Greenoerg AE, Hmdln A. Nlcholas AG. Bryan El, Thomas PA. The completeness01 AIDS case reporting In New York City. JAMA 1993. 269: 2995-3001.AOdool Kaflm SS, Ollral A. Reasons for underreponmg 01 noMlable condluons.S Afr Med J 1996; 86: 834-836. ..Ikeaa RM. Slrkhead GS. Flynn MK_ Use of muUlple reporting sources lorpeflnalalnepaUlls B surveillance ana follow·up. Am J Ep,demlol 1996; 142: 765-770.Accepted 11 Dec 1996.ISAMJ Volumt 87 No.2 February 1997

Underreporting and overreporting of hepatitis B at a tertiary hospital

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Underreporting and overreporting of hepatitis B at a tertiary hospital

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