ARCHIVED - Suboptimal reporting of notifiable diseases in Canadian emergency departments: A survey of emergency physician knowledge, practices, and perceived barriers

 

Canada Communicable Disease Report

1 September 2006

Volume 32
Number 17

SM Friedman, MD, MPH (1), L-A Sommersall, MD, BSc (2), MGardam, MD, MSc (3), T Arenovich, MSc, BSc (4)

  1. Assistant Director (Research), Emergency Medicine, University Health Network,
    Toronto and Assistant Professor, Faculty of Medicine, University of Toronto

  2. Resident, Faculty of Medicine, University of Toronto

  3. Director, Infection Prevention and Control, University Health Network and
    Assistant Professor, University of Toronto

  4. Statistician, University Health Network, University of Toronto

Introduction

Reporting of infectious diseases is integral to the detection of common-source outbreaks (such as food or waterborne outbreaks), provision of appropriate medical therapy, and the planning and evaluation of prevention and control programs1. The re-emergence of “old” infectious diseases, such as tuberculosis, the appearance of new pathogens, for instance, the one giving rise to SARS (severe acute respiratory syndrome), and the deliberate introduction of infectious diseases through bioterrorism highlight the need for effective disease surveillance2,3. Ashford et al. argue that the most critical component for bioterrorism outbreak detection and reporting is the front-line health care profession and local health departments4.

Physician compliance with respect to mandatory reporting of common notifiable diseases has reportedly varied between 6% and 90%5. Failure in mandatory public health reporting by physicians has been attributed to lack of knowledge regarding the components of notification, including the requirement to report6, which diseases are reportable7,8, and how or to whom to report9. Poor compliance has also been attributed to physician assumption that someone else will report, concerns regarding the effort required for reporting10, insufficient compensation for doing so, and a view that no useful action is taken on notifications11. Physicians cite poor accessibility and complexity of notification forms, lack of motivation secondary to poor feedback, and a perception that reporting these diseases is a useless endeavor12.

Few studies have examined the reporting practices and barriers to reporting by emergency physicians (EPs), and none has specifically examined EPs practising in Canada. The goal of this study was to assess Canadian EP knowledge about public health reporting requirements as well as their self-reported practices and perceptions regarding barriers to compliance. A secondary goal was to identify potential improvements for facilitating timely and complete infectious disease reporting from Canadian emergency departments.

Methods

The survey instrument consisted of 14 multiple choice and short-answer questions, and seven questions regarding respondent demographics. The survey was piloted among 20 EPs for clarity and validity before study launch.

A cover letter and electronic link to a Web-based survey was e-mailed to all 1,176 members of the Canadian Association of Emergency Physicians (CAEP) who had furnished an e-mail address to the organization and indicated a willingness to be contacted in this manner. CAEP is a professional body representing Canadian EPs13. Membership is open to all physicians practising full- or part-time emergency medicine, residents engaged in postgraduate training in emergency medicine, and medical students. At the time of the survey, the CAEP membership numbered 1,725 paying members (CAEP administrator: personal communication, 2004).

A modified Dillman methodology was used14,15, and subjects were sent by e-mail an electronic letter describing the study and a link to an on-line survey, and then three weekly reminder e-mails with a link to the survey. Data were collected for 8 weeks from the first mass e-mail.

Correlations were sought between physician knowledge and demographic variables, nature of practice, and self-rating of knowledge. Chi square tests and analysis of covariance were performed using Excel and SPSS. This study was approved by the hospital Research Ethics Board. External funding was provided by Roche Canada.

Results

Of the 1,176 CAEP members solicited for participation, five responded that they were not practising emergency medicine, nine e-mail addresses consistently generated an automatic response indicating that the respondent was away, and 21 unique e-mails were invalid. Overall, 386 CAEP members completed part or all of the survey, representing 33.8% of surveys sent to 1,141 EPs with functioning e-mail addresses and no vacation alert. Their responses are shown in Table 1. The minimum number of respondents per question was 373 (32.7%).

Respondents represented all provinces/territories and a broad array of certifications and years in practice. The geographic and sex distribution of respondents was proportional to that of all those surveyed. Respondents were primarily from Ontario (44%), British Columbia (15.1%), and Alberta (14.3%).

EP knowledge of diseases and requirements

Test of physician knowledge: EPs were presented with a list of 16 diseases and asked to identify which are reportable. Seven diseases on the list (chlamydia, giardiaisis, hepatitis A, hepatitis B, HIV/AIDS, malaria, and mumps) are reportable in every Canadian province and territory; performance on this subset was considered for comparison across regions.

The mean score (by province/territory) for identifying reportable disease was 70.9% (range 0% to 85.7%); 36.7% of EPs could only identify four or fewer of the seven diseases, and 21 % identified three diseases or fewer. EPs were most likely to correctly identify chlamydia (88.3%) and HIV (81.1 %) as notifiable diseases, and least likely to identify mumps (59.1%) and giardiasis (47%). EP performance was not correlated with years in practice, sex, certification, practice setting (urban, community, or rural), affiliation with teaching hospital, or emergency department workload (see Table 2).

Self-rating of knowledge: Overall, 80.5% of EPs estimated their knowledge of notifiable disease reporting requirements as “fair” or “poor”. This subjective rating of self-knowledge was associated with the objective test of knowledge (p < 0.001) (Table 1).

Reporting prior to positive confirmation: Only 12.9% of EPs correctly identified the requirement to report suspected diseases before laboratory confirmation. Approximately two-thirds of subjects indicated that they relied on the laboratory to report positive results to the local health authorities (Table 1).

EP practice and compliance

Approximately two-thirds of EPs reported knowing where the telephone number of the local public health unit is posted in their emergency department, but only approximately one-third indicated knowing where a list of notifiable diseases was posted. Knowledge of where this list was posted was positively associated with performance on the objective test of knowledge (p = 0.0072).

Approximately half of EPs reported that they never consulted a list of reportable diseases, and almost half indicated reporting 40% or fewer of notifiable diseases.

EPs indicated that notification of public health was initiated by emergency department staff (including physician, nurse, and clerical staff) approximately 40% of the time and by laboratory or infection control staff approximately 40% of the time. When EPs were asked who should do the reporting, their responses did not change significantly.

There was no significant association between province/territory and estimated proportion of diseases reported. However, province/ territory was associated with knowledge of the location of the notifiable diseases list in the emergency department (p = 0.0006), ranging from 0.0% (Northwest Territories and Yukon Territories) to 100% (Nunavut).

Ontario, the single province not divided into regional health systems, performed close to the median of other provinces in tests of physician knowledge and compliance.

Perceived barriers to compliance

Most EPs indicated that the reporting process takes too much time. The major barriers to reporting that were most frequently identified included time required for notification, lack of knowledge regarding which diseases are reportable, and a belief that many notifiable diseases are too common or unimportant to merit the effort of reporting (29.0%).

EPs were asked how they would improve public health reporting in Canada, and 161 (42% of respondents) provided a free text answer. The majority of responses focused on educating physicians and streamlining the process of reporting. Proposals for enhancing EP knowledge included mounting notifiable disease lists with contact information in emergency departments, use of concise mailings, and continuing education. There were numerous comments on the heavy workload of emergency department clinicians, with suggestions for streamlining the reporting process, shifting the notification responsibility to third parties (such as laboratory or infection control), and implementing remuneration for reporting. Advocates of automation proposed reporting on-line, use of voice mail-boxes, and pads of standardized sheets that could be faxed to the local authorities. Less frequent suggestions included shortening the list of notifiable diseases and enforcing sanctions against physicians for poor compliance.

Discussion

Public health surveillance systems typically include both a case-detection and diagnosis component, and a disease reporting component2. Legislation requiring physicians to report notifiable diseases is commonplace around the world. In the United States, the authority to require notification of cases resides in state legislatures, and reporting requirements vary substantially by state or territory1,16. In Canada, the reporting or notifying of diseases is mandated by provincial legislation, and the list of notifiable diseases differs by province/territory. Prior to 1990, each jurisdiction had its own set of case definitions, and comparability across jurisdictions was difficult. In March 1991, the Laboratory Centre for Disease Control (LCDC), in conjunction with the provincial and territorial epidemiologists, published disease-specific case definitions for diseases under national surveillance. Canadian physicians diagnosing a case of a specific (notifiable) disease are directed to report their clinical diagnosis, with or without laboratory confirmation, to local health authorities. These authorities are responsible for determining that the case meets the surveillance case definition before they officially report the case. The local health authority reporting the case collects all necessary epidemiologic data on it17.

Underreporting of notifiable diseases may distort trends observed in the incidence of diseases, distort attributable risk estimates for disease acquisition, prevent accurate assessment of the potential benefits or impact of control programs, prevent timely identification of disease outbreaks, and undermine the success of prevention and control programs1. This study suggests that Canadian emergency physician knowledge, motivation, and compliance regarding infection disease reporting requirements is deficient.

Durrheim and Thomas reported that differences in knowledge were not associated with physician sex, years of practice, or the number of partners in a particular practice8. Our findings are consistent with these past reports.We postulate that the high recognition by EPs of chlamydia and HIV as notifiable diseases relates to the public health education regarding sexually transmitted infections in earlier medical training, disproportionate to that for other notifiable diseases. Doyle et al. observed that in the United States, reporting completeness for AIDS, tuberculosis, and sexually transmitted diseases has been significantly greater than for all other notifiable diseases combined2.

Two primary barriers to reporting were identified: not knowing what diseases are reportable, and the perception that the reporting process requires too much time and effort. EPs currently struggle with increasing patient volumes, emergency department overcrowding, and deteriorating performance on such quality benchmarks as door-to-needle time for thrombolysis of ST-elevation myocardial infarction(18). A human factors approach to complex system failure would focus not solely on the physician but also on the system in which the EP operates19. Prominent posting of notifiable disease lists and a streamlined reporting process might improve EP knowledge and compliance. Improvement in completeness and expediency of reporting has been observed with the institution of automated reporting systems20,21. Appointment of a nurse charged with compliance has been shown to improve notification rates22. Bek et al. propose that feedback to doctors, showing them that preventive action is taken as a result of notification, may be an effective way to improve notification practices23.

Several limitations to this study are identified. First, the response rate (approximately one-third of those surveyed) was low, hence our results may not be generalizable to EPs as a whole. Second, there is the potential of selection bias, as the study selected EPs who were members of CAEP, had Internet access, and were motivated to participate in a voluntary study. Nonetheless, selection bias and response potentially add concern to the counterintuitive results at hand. We argue that respondents to the study were likely to have been among the more motivated EPs, who view public health reporting as a concern.

Conclusions

EP knowledge, motivation, and compliance regarding notifiable disease reporting requirements merits improvement. Much planning for future infectious disease crises, such as bioterrorism events or emerging infectious disease epidemics, relies on surveillance by front-line health care workers to detect cases. Our study, with others, has shown that the current system is not particularly reliable. Respondents to our survey suggested that improved physician education, posting of notifiable disease lists in emergency departments, and streamlining the reporting process may improve performance. We concur and recommend that public health units wishing to improve reportable disease surveillance should discuss the barriers to reporting with front-line health care workers and include them in devising solutions to improve compliance.

Table 1. Canada-wide survey of emergency physicians (n = 1,141)

1) Which of the following diseases must be reported to public health as required by Health Canada? (n = 386, 33.8%)

Disease*

Yes

(%)

No

(%)

Chickenpox (varicella)

87

(23)

298

(77)

Chlamydia (genital)

340

(88)

45

(12)

Cryptosporidiosis

229

(59)

156

(41)

Cytomegalovirus

98

(25)

287

(75)

Epstein-Barr virus

27

(7)

358

(93)

Giardiasis

181

(47)

204

(53)

Hepatitis A

294

(76)

91

(24)

Hepatitis B

297

(77)

88

(23)

Atypical mycobacteria

166

(43)

219

(57)

Herpes simplex virus 2

92

(24)

294

(76)

HIV/AIDS

313

(81)

73

(19)

Influenza

167

(43)

219

(57)

Invasive group B Streptococcus

203

(53)

183

(47)

Malaria

260

(67)

126

(33)

Mumps

228

(59)

158

(41)

Mycoplasma

24

(6)

362

(94)

*Diseases in bold are reportable in each province and territory.

2) Rate your knowledge regarding which diseases are reportable.
(n = 384, 33.7%, nonrespondents: 2)

 

n

%

95% confidence interval (CI)

Poor

91

23.6

19.4, 28.0

Fair

218

56.7

51.8, 61.7

Good

69

18.0

14.1, 21.8

Very Good

3

0.8

0.0, 1.7

Excellent

3

0.8

0.0, 1.7


3) Do you know where a list of notifiable diseases is posted in your
emergency department?
(n = 384, 33.7%, nonrespondents: 2)

 

n

%

95% (CI)

Yes

117

30.5

25.9, 35.1

No

196

51.0

46.0, 56.0

Uncertain

71

18.5

14.6, 22.4


4) Do you know where the telephone number of the local public
health unit is posted in your emergency department? (n = 383, 33.6%,
nonrespondents: 3)

 

n

%

95% (CI)

Yes

243

63.4

58.6, 68.3

No

96

25.1

20.7, 29.4

Uncertain

44

11.5

8.3, 14.7


5) When is the last time you consulted a list of notifiable diseases
that is posted in your emergency department? (n = 383, 33.6%,
nonrespondents: 3)

 

n

%

95% (CI)

Less than 1 week ago

8

2.1

0.7, 3.5

Less than 1 month ago

31

8.1

5.4, 10.8

Less than 6 months ago

80

20.9

16.8, 25.0

Less than 1 year ago

79

20.6

16.6, 24.7

Never

185

48.3

43.3, 53.3


6) What proportion of notifiable diseases diagnosed in the emergency
department do you report (or direct your staff to report)? (n = 373, 32.7%, nonrespondents: 3)

 

n

%

95% (CI)

< 20%

139

37.3

32.4, 42.2

20% -40%

32

8.6

5.7, 11.4

41% -60%

66

17.7

13.8, 21.6

61% -80%

53

14.2

10.7, 17.8

> 80%

83

22.3

18.0, 26.5


7) Who in your emergency department USUALLY notifies public health
about notifiable diseases? (n = 373, 32.7%, nonrespondents: 3)

 

n

%

95% (CI)

Emergency physician

88

23.6

19.3, 27.9

Intern/resident

2

0.5

0.0, 1.3

Emergency department nurse

35

9.4

6.4, 12.3

Clerical staff

19

5.1

2.9, 7.3

Laboratory

105

28.2

23.6, 32.7

Patient's family physician

3

0.8

0.0, 1.7

Patient/family member

0

0.0

0.0, 0.0

Infection control

48

12.9

9.5, 16.3

Nobody (typically do not notify)

5

1.3

0.2, 2.5

Uncertain

60

16.1

12.4, 19.8

Other (please specify)

8

2.1

0.7, 3.6


8) Who in your emergency department SHOULD notify public health
about notifiable diseases?
(n = 373, 32.7%, nonrespondents: 3)

 

n

%

95% (CI)

Emergency physician

128

34.3

29.5, 39.1

Intern/resident

1

0.3

0.0, 0.8

Emergency department nurse

26

7.0

4.4, 9.6

Clerical staff

10

2.7

1.0, 4.3

Laboratory

85

22.8

18.5, 27.0

Patient's family physician

3

0.8

0.0, 1.7

Patient/family member

0

0.0

0.0, 0.0

Infection control

66

17.7

13.8, 21.6

Nobody (typically do not notify)

1

0.3

0.0, 0.8

Uncertain

36

9.7

6.7, 12.6

Other (please specify)

17

4.6

2.4, 6.7


9) Is it a requirement to report suspected diseases that are diagnosed
clinically before laboratory confirmation? (n = 373, 32.7%, nonrespondents: 3)

 

n

%

95% (CI)

Yes

48

12.9

9.5, 16.3

No

72

19.3

15.3, 23.3

Sometimes

136

36.5

31.6, 41.3

Uncertain

117

31.4

26.7, 36.1


10) If you send a specimen to the laboratory for confirmation do you
rely on the laboratory to report any positive results to the local
health unit rather than reporting them yourself?
(n = 373) (nonrespondents: 3)

 

n

%

95% (CI)

Yes

245

65.7

60.9, 70.5

No

67

18.0

14.1, 21.9

Sometimes

61

16.4

12.6, 20.1


11) Does the reporting process take too much time? (n = 373, 32.7%,
nonrespondents: 3)

 

n

%

95% (CI)

Yes

205

55.0

49.9, 60.0

No

168

45.0

40.0, 50.1


12) Do ethical concerns (i.e. patient confidentiality) impact on your
compliance with public health reporting requirements?
(n = 373, nonrespondents: 3)

 

n

%

95% (CI)

Frequently

12

3.2

1.4, 5.0

Sometimes

122

32.7

27.9, 37.5

Never

239

64.1

59.2, 68.9


13) What do you see as the major barriers to reporting notifiable
diseases from the emergency department?
(n = 373, 32.7%, nonrespondents: 3)

 

n

%

95% (CI)

Too much time required

200

53.6

48.6, 58.7

I do not know what number to call

95

25.5

21.0, 29.9

Too difficult to reach the right public health person

134

35.9

31.1, 40.8

Many diseases too common or too unimportant to merit effort of reporting

108

29.0

24.4, 33.6

I do not know what diseases are reportable

195

52.3

47.2, 57.3

Ethical considerations

38

10.2

7.1, 13.3

Not my job

45

12.1

8.8, 15.4

Not compensated for my time

90

24.1

19.8, 28.5

There are no barriers to reporting

37

9.9

6.9, 13.0

Others

49

13.1

9.7, 16.6


14) How would you improve public health reporting in Canada?
(n = 161, 14.1%
[see Discussion])

 

Table 2. Demographic characteristics and practice

1) Years in clinical practice (n = 370, 32.4%, nonrespondents: 16)

 

n

Proportion

95% (CI)

0-5

138

37.3

32.4, 42.2

6-10

59

15.9

12.2, 19.7

11-15

66

17.8

13.9, 21.7

16-20

46

12.4

9.1, 15.8

21+

61

16.5

12.7, 20.3


2) Gender ( n = 368, 32.3%, nonrespondents: 18)

 

n

Proportion

95% (CI)

Male

270

73.4

68.9, 77.9

Female

98

26.6

22.1, 31.1


3) Where do you currently practice? ( n = 371, 32.5%, nonrespondents: 15)

 

n

Proportion

95% (CI)

Alberta

53

14.3

10.7, 17.8

British Columbia

56

15.1

11.5, 18.7

Manitoba

14

3.8

1.8, 5.7

New Brunswick

10

2.7

1.0, 4.3

Newfoundland and Labrador

5

1.3

0.2, 2.5

Northwest Territories

3

0.8

0.0, 1.7

Nova Scotia

28

7.5

4.9, 10.2

Nunavut

1

0.3

0.0, 0.8

Ontario

164

44.2

39.2, 49.3

Prince Edward Island

4

1.1

0.0, 2.1

Quebec

22

5.9

3.5, 8.3

Saskatchewan

10

2.7

1.0, 4.3

Yukon

1

0.3

0.0, 0.8


4) Certification* ( n = 368, 32.3%, nonrespondents: 18)

 

n

Proportion

95% (CI)

None

33

9.0

6.0, 11.9

CCFP

51

13.0

10.3, 17.4

CCFP(EM)

156

42.4

37.3, 47.4

FRCP (EM)

83

22.6

18.3, 26.8

FRCP (Other)

14

3.8

1.8, 5.8

DABEM

8

2.2

0.7, 3.7

Other (please specify)

23

6.2

 

*CCFlP = certificant of the College of Family Physicians; FRCP = Fellow of the Royal College of Physicians; DABEM = Diplomate of the American Board of Emergency Medicine

5) Which best describes your primary emergency medicine practice setting?
( n = 371, nonrespondents: 15)

 

n

Proportion

95% (CI)

Urban

243

65.5

60.7, 70.3

Community

98

26.4

21.9, 30.9

Rural

30

8.1

5.3, 10.9


6) Is this practice setting a teaching hospital? ( n = 371, nonrespondents: 15)

 

n

Proportion

95% (CI)

Yes

244

65.8

60.9, 70.6

No

127

34.2

29.4, 39.1


7) Number of shifts worked per month in emergency department ( n = 371, nonrespondents: 15)

 

n

Proportion

95% (CI)

0-4

19

5.1

2.9, 7.4

5-9

77

20.8

16.6, 24.9

10-14

161

43..4

38.4, 48.4

15-19

105

28.3

23.7, 32.9

20 +

9

2.4

0.9, 4.0


Table 3. Performance on test of knowledge of notifiable diseases (by province/territory)

Province/territory

Score

Standard error

Nunavut

85.7

+/-0.0

Northwest Territory

80.9

+/-4.8

New Brunswick

78.6

+/-6.8

Ontario

78.3

+/-1.7

Saskatchewan

74.3

+/-7.9

Quebec

71.4

+/-6.0

Alberta

69.8

+/-2.6

Newfoundland

68.6

+/-14.6

Nova Scotia

67.9

+/-5.3

Prince Edward Island

67.9

+/-15.8

Manitoba

67.3

+/-5.3

British Columbia

52.3

+/-3.2

Yukon

0.0

+/-0.

Significant differences in knowledge scores exist across provinces (Chi-sq = 181.7, df = 84,
p
< 0.0001). Additional testing revealed that B.C. scores were significantly different than Alberta
(p = 0.0195), New Brunswick (p = 0.0286), Ontario (p < 0.0001), Quebec (p = 0.0170), and Yukon scores (p = 0.0106). Ontario scores were also found to be significantly different from Alberta
(p = 0.0315), Manitoba (p = 0.0352) and Yukon scores (p < 0.0001). Yukon scores were significantly different than Alberta (p < 0.0001) and Manitoba scores (p =0.0104).

Acknowledgements

This study was supported by a grant from Roche Canada.

References

  1. Centers for Disease Control. Mandatory reporting of infectious diseases by clinicians. MMWR 1990;39(RR-9):1-11, 16-17.

  2. Doyle TJ, Glynn MK, Groseclose SL. Completeness of notifiable disease reporting in the United States: An analytical literature review. Am J Epidemiol 2002;155(9):866-74.

  3. Green MS, Kaufman Z. Surveillance for early detection and monitoring of infectious disease outbreaks associated with bioterrorism. Isr Med Assoc J 2002;4(7):503-6.

  4. Ashford DA, Kaiser RM, Bales ME et al. Planning against biological terrorism: Lessons from outbreak investigations. Emerg Infect Dis 2003;9(5):515-9.

  5. Thacker SB, Berkelman RL. Public health surveillance in the United States. Epidemiol Rev 1998;10:164-90.

  6. Sepdding RL, Jenkins MG, O'Reilly SA. Notification of infectious disease by junior doctors in accident and emergency departments. J Accid Emerg Med 1998;15(2):102-4.

  7. Konowitz PM, Petrossian GA, Rose DN. The underreporting of disease and physicians' knowledge of reporting requirements. Public Health Rep 1984;99:31-5.

  8. Durrheim DN, Thomas J. General practice awareness of notifiable infectious diseases. Public Health 1994;108(4):273-8.

  9. Harvey I. Infectious disease notification - a neglected legal requirement. Health Trends 1991;23(2):73-4.

  10. Abdool Karim SS, Dilraj A. Reasons for under-reporting of notifiable conditions. S Afr Med J 1996;86(7):834-36.

  11. Seneviratne SL, Gunatilake SB, de Silva HJ. Reporting notifiable diseases: Methods for improvement, attitudes and community outcome. Trans R Soc Trop Med Hyg 1997;91(2):135-7.

  12. Schramm MM, Vogt RL, Mamolen M. The surveillance of communicable disease in Vermont: Who reports? Public Health Reports 1991;106(1): 95-7.

  13. About CAEP. URL: <http://caep.ca/001.welcome/001-02.about.htm>.

  14. Dillman DA. Mail and Internet surveys: the tailored design method. New York: JohnWiley and Sons, 2000.

  15. Dillman D, Tortora RL, Bowker D. Principles for constructing Web surveys. Presented at the Joint Meetings of the American Statistical Association, Dallas, Texas, August 1998.

  16. Roush S, Birkhead G, Koo D et al. Mandatory reporting of diseases and conditions by health care professionals and laboratories. JAMA 1999;282:164-70.

  17. Health Canada. Case definitions for diseases under national surveillance. CCDR 2000;26S3:1-133.

  18. Schull M, Vermeulen M, Slaughter G et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004;44(6):577-85.

  19. Reason J. Human error: models and management. Br Med J 2000;320:768-70.

  20. Effler P, Ching-Lee M, Bogard A et al. Statewide system of electronic notifiable disease reporting from clinical laboratories. JAMA 1999;282:1845-50.

  21. Ward M, Brandsema P, Van Sraten E et al. Electronic reporting improves timeliness and completeness of infectious disease notification, The Netherlands, 2003. Eurosurveillance Monthly 2005;10(1):7-8.

  22. Seneviratne SL, Gunatilake SB, de Silva HJ. Reporting notifiable diseases: Methods for improvement, attitudes and community outcome. Trans R Soc Trop Med Hyg 1997;91(2):135-7.

  23. Bek MD, Lonie CE, Levy MH. Notification of infectious diseases by general practitioners in new South Wales. Survey before and after the introduction of the Public Health Act 1991 (NSW). Med J Aust 1994;161(9):538-41.


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