Notifiable infections can be and often are transmitted sexually and the process of notification often does not work well in the GUM setting. It is the statutory duty of medical practitioners to report notifiable infections, but there are a number of barriers to reporting in sexual health, in particular concerns that notification may breach confidentiality. In this article, we hope to explain the reporting process and aim to highlight why we need to report and what health protection teams do with the information provided. We hope to make the process simple so that GUM clinics can fulfil their public health obligations and enable timely and appropriate public health action to be taken.
- Genitourinary Medicine
- Notification of Communicable Diseases
- Public Health
- Sexual Health
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Communicable diseases can and often are transmitted sexually. Although Genitourinary Medicine (GUM) clinics deal mainly with sexually transmitted infections, patients with other notifiable diseases (Notifiable Infectious Disease (NOIDs)) can present from time to time1 and the process of notification often does not work well in this setting.
The 2010 Health Protection (Notification) Regulations2 state that it is the statutory duty of medical practitioners in England to report notifiable infections. There are similar arrangements in Scotland, Wales and Northern Ireland, although the specific list of notifiable infections varies slightly. However, a number of barriers to notification remain; lack of knowledge of which infections are notifiable, and lack of understanding of why notification is important and how this information is used. In GUM, there are also concerns that notification may breach confidentiality.
Notification has two aims: for surveillance (monitoring disease by time, person and place) and to enable public health action to prevent onward transmission of infectious diseases. It underpins disease control, providing information to help target intervention. R0,3 the case reproduction number, is used to describe the average number of secondary cases of an infection generated by one case, over the course of its infectious period, in a susceptible population. For HIV, it is difficult to calculate but has been estimated at 2.5–6;4 however, for measles it is 12–16.5 It is affected by the number of contacts an individual has; therefore, for highly transmissible diseases such as measles, ‘early reporting’ (within 24 h) is vital for effective outbreak control. Public health actions for measles include isolating exposed individuals and administering live virus vaccine or immunoglobulin to exposed and susceptible contacts within 72 h. If reporting delays occur, for example, due to confusion about confidentiality, preventable onward transmissions can occur. For example, if hepatitis A-positive, food handler contacts need to be identified. Hepatitis B household contacts would be offered vaccination.
Notifications require sharing of patient information to enable effective public health action. This can seem at odds with our usual code of confidentiality in GUM/HIV. For many years, we were guided by the Venereal Diseases act (1974)6 stating “information capable of identifying an individual… shall not be disclosed except (a) for the purpose of communicating that information to a medical practitioner… and (b) for the purpose of such treatment or prevention”.
It can be difficult to untangle what we should be doing when we encounter notifiable infections in clinic, but the General Medical Council (GMC) and Department of Health (DoH) are clear: our public health responsibility outweighs the duty of confidentiality in this context. This is supported by advice from the medical defence organisations (MDU, MPS, MDDUS).7–9
Why do we need to report notifiable infections?
The Notification of Infectious Diseases (NOIDs) regulations2 set out a list of notifiable diseases (see table 1). These are infections or clinical situations in which we have a duty as medical practitioners to report to ‘the Proper Officer’ (the local Health Protection Team (HPT)). This list should be consulted whenever a notifiable infection is suspected or a laboratory result confirming infection is received. It is the legal responsibility of the medical practitioner seeing the patient to notify and should not, strictly, be done by a third party (such as a health advisor or specialist nurse), although in practice could be delegated if unavoidable to enable more rapid public health action.2 The laboratory also has a duty to report. This may result in notification from both sources, but is preferable to no notification and processes are in place to prevent double counting of cases. You should not receive a result and assume the laboratory has notified. The HPT only receives limited information from the laboratory and will need further clinical information and patient details to act. Equally, you should not wait for laboratory confirmation: your responsibility is to notify on suspicion, an important distinction to allow for timely public health action.
Which notifiable infections might present to sexual health?
All notifiable infections could present to GUM/HIV but some are more likely to (see table 2). The likelihood for many is low while the presentations are likely to differ between the HIV clinic and the GUM clinic, for example, Corynebacterium diphtheriae may be detected on a pharyngeal swab in GUM, whereas malaria may present in a returning traveller attending the HIV clinic. Men who have sex with men are at risk of Shigellosis and may present to either setting with infectious bloody diarrhoea. Acute infectious hepatitis could present to either clinic; 589 cases of acute hepatitis B infection were reported in England in 2011 with sexual transmission implicated in almost 80%.10 The risk of onward transmission is high, and acute infectious hepatitis should be notified immediately where clinical suspicion is high or within the differential diagnosis. Atypical presentations can also occur, as highlighted by a recent case report of urethral C diphtheriae.1
What details do I need to pass on to the HPT?
Certain patient details are required for notification; name, DOB, gender, ethnicity, NHS number, current address and telephone number, and clinical information about the case (date of onset, general practitioner details). The HPT will gain additional information from the patient once contact details have been given. This provides a stumbling block to many working in GUM/HIV where confidentiality is uniquely important, and it may be necessary to explain the rationale for this to patients so that appropriate public health action can be taken. There is no legal obligation to obtain patient consent to pass on necessary details, but GMC guidance advises informing patients where practical.11 Previously, GUM clinicians have sometimes notified using a SOUNDEX code, a unique patient identifier made up of the first part of the patient's postcode and their date of birth. Recent British Association of Sexual Health and HIV (BASHH) guidance12 refers to the use of SOUNDEX codes when reporting acute hepatitis. However, SOUNDEX codes do not allow for preventative public health action as the patient is not contactable.
It is important to reassure the patient that only those details required for public health action will be passed on, that these will remain confidential and that information about their sexual history will not be included.
What do the health protection team do with the information?
Individual cases are followed up using evidence-based guidance published by Public Health England. Cases will be quickly contacted and asked for further details to enable risk assessment, which may involve a routine questionnaire about their recent activity, food history, travel and other details. Along with knowledge of local epidemiology, this information is used to determine the likelihood of the diagnosis, and of further undetected cases and onward transmission.
Risk assessment involves assessing the likely source of infection, circumstances of the individual case and potential risk to close contacts. Action will vary but may include hygiene advice, immunisation, further testing or exclusion from work for a specific period. This will be determined by the nature of the infection and the potential risk of transmission, for example, a case of foodborne infection in a healthcare worker would prompt different action to one in an office worker. The risk to contacts will be assessed, based on type and duration of contact, timing (whether the case was likely to have been infectious) and vulnerability, for example, pregnancy or immunosuppression, immunisation status or risk of transmission through occupation or other activities. Those considered at risk may be contacted and offered testing, prophylactic treatment or vaccination.
The HPT also relies on notifications to provide population-level intelligence, in conjunction with other data including population demographics and immunisation coverage. Notifications contribute to epidemiological data and can identify areas or populations at particular risk, detect outbreaks or clusters, and allow interventions and resources to be targeted appropriately. Notification data are also collated nationally to form surveillance datasets used to monitor trends in infection rates, produce epidemiological evidence for public health decision making, and develop and evaluate infection control measures. Laboratory notifications provide a valuable complementary source of information. Under-notification from either source hinders this work and makes data interpretation difficult.
What if we fail to notify or choose not to?
While there is unlikely to be General Medical Council (GMC) investigation for failure to notify, the DOH guidance makes reference to this possibility: “There is no offence in the Notification Regulations for failure by an Registered Medical Practitioner (RMP) to notify because there are other mechanisms for dealing with non-compliance with legal requirements”, referring to our GMC and individual National Health Service (NHS) contractual obligations to comply with the requirement.
Understanding the reasons for notification, the ease of the process and what is done with the information makes it simpler to report. Several studies have shown that barriers to reporting include lack of knowledge about notifiable conditions and a lack of feedback about what is done with the information.13–17 Getting to know your local HPT can facilitate two-way feedback about current clusters and outbreaks, and enable early discussions about cases of concern.
How do I notify?
Your local HPT is based at the Public Health England Centre covering your area. For England, use the postcode lookup facility on http://www.hpa.org.uk/. For Wales, use http://www.publichealth.hscni.net/directorate-public-health/health-protection. For Scotland, use http://www.hps.scot.nhs.uk/, and for Northern Ireland, http://www.publichealth.hscni.net/directorate-public-health/health-protection.
A notification certificate should be completed immediately on suspicion of a notifiable disease—don't wait for laboratory confirmation. You can notify by telephone, encrypted email or to a secure fax machine within 3 days, or report verbally within 24 h if considered urgent. See box 1 for tips and useful information.
Box 1 Tips for notification
Be aware of the NOIDS list (table 1)
Know your responsibilities–notify on suspicion–don't wait for laboratory confirmation
If urgent: by telephone within 24h
If non-urgent: within 3 days
Get ‘friendly’ with your local Health Protection Team (HPT). Take a visit, send trainees (to find your local HPT: http://www.hpa.org.uk/)
Notify by phone, encrypted email, to a secure fax machine or by post–pass on enough details so the HPT can do their job, ie, at least a name, date of birth and telephone number
Explain to the patient reasons for the statutory duty to notify–that only relevant information to enable Public Health action will be passed on, not sexual health information
The notification form can be found on this page: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/NotificationsOfInfectiousDiseases/ReportingProcedures/
Handling editor David A Lewis
Contributors SH and KH wrote the manuscript. JAC contributed to, reviewed and supervised the writing of the manuscript.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.