Direct Laboratory Notification of Communicable Diseases

3.3 Clinicians’ continuing legal obligations

The new legislation does not affect existing legislation relating to clinician obligations. It is most important that clinicians continue to notify all notifiable diseases to their local Medical Officer of Health, for the following reasons.

1. Notification from the diagnosing clinician is still a legal requirement under the current Health Act.

2. Clinician notifications contain valuable personal information that will not be available from laboratory notifications. The laboratory notifications will essentially be limited to a person’s name and date of birth, and may have no patient contact details.

3. Clinicians may have information not available to laboratories (eg, associated cases in an outbreak situation, the diagnosis of AIDS, or the clinical cases where consecutive serology is needed for confirmation).

4. The clinician may suspect that a patient has a notifiable disease on clinical grounds prior to laboratory confirmation: this clinical suspicion is sufficient for notification and to trigger public health action, and in some situations such early action could be vital.

5. The Medical Officer of Health will not receive clinical aspects of the case via a laboratory notification.

6. Some notifiable diseases are clinical syndromes, and there is no diagnostic laboratory test.

3.4 Timeframe for adding new notifiable diseases to the Schedule

The recently completed review of notifiable diseases and conditions was conducted to update the existing schedules to the Health Act and to provide a list of diseases and conditions to be made notifiable under the new Public Health Bill once enacted.
Proposed changes include the addition of:

• 
  botulism
  
• 
  noroviral gastroenteritis
  
• 
  toxic shellfish poisoning
  
• 
  verotoxin-producing Escherichia coli (VTEC)
  
• 
  chlamydia
  
• 
  gonorrhoea
  
• 
  hepatitis D
  
• 
  hepatitis E
  
• 
  HIV
  
• 
  invasive pneumococcal disease
  
• 
  Q fever
  
• 
  smallpox
  
• 
  syphilis
  
• 
  tularaemia.
  

Note that the sexually transmitted diseases chlamydia, gonorrhoea and syphilis will be unnamed notifications, but will still contain a National Health Index (NHI) number. HIV notifications will be anonymous. Notifications for HIV should not be sent or entered onto Episurv.

It is expected that the proposed amendments will be sent to the Minister/Cabinet for approval in late 2007 or early 2008. Once the amendments have been approved by Cabinet, changes to the schedules are expected to be in force before April 2008.
Laboratory notification flowcharts have already been developed for verotoxin-producing Escherichia coli (VTEC), hepatitis D and hepatitis E (see Appendix 2). The rest of the additional communicable diseases will have flowcharts developed in early 2008, before the new schedule comes into force.

4 Laboratory Notification Flowcharts

4.1 Purpose

The notification flowcharts have been designed to provide clinical laboratories with guidance on which laboratory results, at a minimum, should trigger a notification to the Medical Officer of Health. These flowcharts do not attempt to qualify results as suggestive or definitive evidence of a notifiable disease, but rather to include all results that indicate a person may be infected with a notifiable disease. Subsequent clinical information or additional laboratory results may result in de-notification of the case.
These flowcharts also aim to strike a balance between fulfilling legal obligations and inundating PHUs with information that is unlikely to indicate a notifiable illness. The flowcharts are provided in Appendix 2.

4.2 How to use the flowcharts

The flowcharts have been modelled on the e-notification flowcharts used in New South Wales (NSW), although, as stated in 4.1, without providing levels of evidence. The range of laboratory methods that are currently used or may be used more commonly in the future have been included, whenever possible. More than one method can often be chosen when testing for an infectious agent, and these flowcharts should not be interpreted as recommending one method over another, or that multiple methods need to be performed.
The flowcharts signal which result or results should trigger notification to the appropriate Medical Officer of Health.

4.3 Timing and process for updating

The flowcharts are new and yet to be tested, so they will be reviewed twice in 2008. The first review will be in March, and will coincide with the addition of new communicable diseases to those listed in the legislation. A second review will occur late in 2008. If only minor adjustments are required at this time, we will move to annual reviews of the flowcharts.
A four-member clinical committee will be used to review the flowcharts (two clinical microbiologists and two Medical Officers of Health). They will review the flowcharts and work with the sector to agree on any changes. The committee’s recommendations will then be submitted to the Director of Public Health for his/her final approval. All changes will be notified on the Ministry of Health website.
Any changes made to the flowcharts will not come into force for six months, to allow laboratories to make the necessary changes to IT systems (unless the Director of Public Health indicates that the changes are urgent).

5 National Electronic Notification System

The Ministry of Health has identified the impending change to the Health Act as an important issue and a good opportunity to be involved with ensuring a nationally consistent approach to direct laboratory notification that is low-cost, efficient and simple.
A number of other jurisdictions have or are in the process of implementing electronic notification systems. NSW is a good example, where they have had paper- and phone-based laboratory notification since 1991. A significant amount of work has been conducted since 2004 as part of the NSW e-Notification project, including work on notification algorithms (trigger points), standardised message content and structure, and the secure communication of data.
The Ministry has developed a national electronic solution in consultation with the Direct Laboratory Notification Advisory Committee, which acknowledges the sector’s current electronic capability and looks to build a new national electronic solution over several phases that aligns with other IT investment initiatives.
As well as providing a fast and efficient way for laboratories to notify their local Medical Officer of Health, the national electronic solution will provide a centralised database for receiving electronic information and real-time access to notification data. The centralised database will incorporate functionality to enable notification data to be used in a number of ways, including providing a way for public health officials to identify problems rapidly and take action to prevent the further spread of disease.
The national electronic system will provide a base set of functions and tools, including electronic and manual data capture, recording of cases of notifiable disease and subsequent investigation details, recording of outbreak information with links to individual cases, data analysis, and reporting. Section 6 of this document discusses in more detail the functions that will be provided by the national electronic system.
The national electronic system is intended to be able to coexist with local PHU systems that are used to support more advanced requirements for notifiable disease case management, contact tracing and management, and outbreak and emergency response. It will provide interfaces through which data can be exchanged electronically.