A Review of Notifiable Diseases and Conditions

A Review of Notifiable Diseases and Conditions

Discussion Document April 2003

Published in May 2003 by the Ministry of Health

PO Box 5013, Wellington, New Zealand

ISBN 0-478-25615-9 (Book) ISBN 0-478-25616-7 (Internet)

HP 3614

This document is available on the Ministry of Health’s website: http://www.moh.govt.nz/cd

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Foreword Infectious diseases significantly affect the health and wellbeing of New Zealanders. Disease surveillance is a systematic way of collecting information on the incidence of diseases in order to prevent and control the spread of such diseases. The resulting public health measures arising from information about the incidence of disease provide opportunities to promote and provide improved health outcomes for all. This information can be collected in a number of ways, including periodic health surveys, direct case reporting from health clinics, and notification of diseases. Notification of diseases and conditions, a legal requirement under the Health Act 1956, plays a major role in ensuring that information on disease cases is available to those involved in controlling or preventing disease in the community. Notification is often characterised by a rapid public health response at a local level. At a national level it provides data identifying disease trends. Such data is useful for developing new programmes and health services to control and prevent diseases. Notification, like wider disease surveillance, can be thought of as ‘information for action’. The objectives of the Notifiable Diseases and Conditions project are:

• to review and update the lists of notifiable diseases and conditions contained in the first and second schedules of the Health Act 1956, which can then be carried over into new public health legislation.

• to ensure that information on notifiable diseases and conditions is collected in an accurate and timely manner and provides relevant and accessible information to all end users.

The review is also an opportunity to ensure that the notification system meets our needs, and that systems are efficient, cost-effective and flexible. The burden of notification should be as small as possible, while maintaining a high degree of information accuracy and quality. This discussion document reviews and makes recommendations on the lists of notifiable diseases and conditions and the current notification system. It is your opportunity to ensure that our notification system is responsive to all New Zealanders, and I invite your feedback on the proposals outlined. Dr Don Matheson Deputy Director-General Public Health Directorate

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Notifiable Diseases and Conditions: Discussion Document v

Contents

Foreword iii

Contents v

How to make a submission vi

Executive Summary vii

1 Introduction and Project Outline 1 1.1 Project outline 1 1.2 Link with public health legislation review 1 1.3 Limitations of this discussion document 2 1.4 Project team and reference group 2 1.5 Consultation 3 1.6 Project outputs and timing 3 1.7 Structure of the discussion document 3

2 Background 5

2.1 Surveillance in public health 5 2.2 Notification of diseases: a literature review 7 2.3 Legal and strategic framework for notification 13 2.4 Surveillance and notification in New Zealand 15 2.5 Summary 18

3 Review of Notifiable Diseases and Conditions Schedules 19

3.1 Current list of notifiable diseases and conditions 19 3.2 Review of the Notifiable Disease Schedules 21 3.3 Organisation of the list of notifiable diseases and conditions 42 3.4 Conclusions 44

4 Notification System Options 45

4.1 Introduction 45 4.2 Outline of the New Zealand’s current notification system 46 4.3 Weaknesses of the current system 47 4.4 Notification systems options 50 4.5 Comparison of options 59

Appendices 63

Glossary 73

References 76

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How to make a submission We welcome any feedback on the topics covered in this discussion document. Your submissions on the proposals outlined in this paper will help shape the list of notifiable diseases and the future system for notification. This discussion document is also available online at (www.moh.govt.nz/cd). Further hard copies of the discussion document are available from the address given below. You can make a submission by writing your comments as a letter or an email. Send your comments to: Nicola Chapple Public Health Directorate Ministry of Health PO Box 5013 Wellington Phone: (04) 495 4426 Facsimile: (04) 495 4479 Email: [email protected]

The closing date for written submissions is 30 June 2003 Questions to guide submissions are included throughout in the text, and a full list is given in Appendix 2. To assist with analysis of the submissions please indicate, where possible, the specific question number to which you are replying. Please also include relevant evidence to support your views. We welcome submissions from both individuals and organisations. When sent on behalf of an organisation, please include details of the organisation. All submissions will be available to the public. Any information that you do not wish to be made public should be clearly marked CONFIDENTIAL. Any request for confidentiality will be subject to the Official Information Act 1982.

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Executive Summary A review of the notifiable diseases and conditions schedules and systems is being undertaken to:

• provide a core list of notifiable diseases and conditions that can be carried over into new public health legislation

• ensure that the lists of notifiable diseases and conditions enable the collection of information on trends that is accurate, timely, relevant and accessible to all end users.

This project is linked to the review of public health legislation and the development of the Public Health Bill. New Zealand’s surveillance system includes the legal requirement, under the Health Act 1956, for some diseases and conditions to be notified to medical officers of health and territorial local authorities. The information collected is used for disease control and prevent the spread of disease, for surveillance of disease trends, and for planning and developing services to improve health status in the longer term. This document seeks submissions on two key areas: • the examination of the current notifiable diseases and conditions schedules, with

options for retention, addition, or removal of diseases or conditions; and

• the review of the systems for notifying diseases and conditions, with five options for improvement.

Review of notifiable diseases and conditions schedules Periodic review of the list of notifiable diseases and conditions is required to ensure that the list is relevant, reflects disease trends, and is responsive to changes, such as the emergence of new diseases and conditions. A number of issues were considered during the evaluation of the list of diseases. Major issues included whether swift public health action is necessary to control or prevent the spread of the disease, and the most appropriate surveillance method for collecting information about the disease.

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The following diseases have been recommended for retention on the schedules of notifiable diseases: • anthrax • arboviral diseases • brucellosis • cholera • Creutzfeldt-Jakob disease

(and other spongiform encephalopathies)

• cryptosporidiosis • cysticercosis • diphtheria • giardiasis • Haemophilus influenzae

b • hepatitis A • hepatitis B • hepatitis (viral) not

otherwise specified • hydatid disease

• lead absorption equal to or over 15 µg/dl of blood

• legionellosis • leprosy • leptospirosis • listeriosis • malaria • measles • meningoencephalitis -

primary amoebic • mumps • Neisseria meningitidis

invasive disease • pertussis • poisoning arising from

chemical contamination of the environment

• plague

• poliomyelitis • rabies • rheumatic fever • rickettsial disease • rubella • salmonellosis • severe acute respiratory

syndrome (SARS) • shigellosis • taeniasis • tetanus • trichinosis • tuberculosis • typhoid / paratyphoid fever • viral haemorrhagic fevers • yellow fever • yersiniosis

The following diseases are recommended for inclusion in the list of notifiable diseases: • adverse reactions to

vaccines • botulism

• hazardous and other substances injuries

• smallpox

• verotoxin-producing Escherichia coli (VTEC)

Decompression sickness is recommended for removal from the list of notifiable diseases. There are a number of diseases which require additional sector debate before a recommendation to add to or remove from the notifiable disease schedules can be made. These diseases are: • acute gastroenteritis • acquired

immunodeficiency syndrome

• campylobacteriosis • hepatitis C • human

immunodeficiency virus

• sexually transmitted infections

The organisation of schedules of notifiable diseases is also discussed. Notification systems options Information collected via notification is most useful when it is timely and complete. In order for notifications to be processed, confirmed and acted upon in the shortest possible time, systems supporting notification need to be efficient, user-friendly, and flexible.

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Such systems should be designed to ensure that the burden of notification is as small as possible, while maintaining a high degree of information accuracy and quality. Amendments to the current notification system are limited by the Health Act 1956. While some improvements can be made to the current system, wide-ranging changes – including the introduction of laboratory-based notification – would require legislative amendment. Amendments to the system are also likely to have varying financial and resource implications. Given the limited resources available, cost considerations will play an important role when considering which option is most suitable for New Zealand’s purposes. General costs associated with compliance, implementation, and maintenance have been identified. Five notification systems options are presented:

• the status quo – attending medical practitioners notify medical officers of health of cases of notifiable diseases

• improved status quo – the current system is maintained, but measures are

introduced to improve the proportion of cases notified, and the quality and timeliness of data

• an incremental process of updating the system to include extensive use of

laboratory-based notification (based on the status quo)

• electronic notification to a centralised database

• removal of the legal requirement to notify diseases from the legislation (other than those subject to international legal obligations).

This discussion document does not make any recommendations on notification systems options at this stage. A final report to the Ministry of Health will, however, identify those options that will improve the current notification system and ensure that information is collected in an efficient, cost-effective, appropriate, and timely manner. There are a number of questions throughout the text to guide your submissions. A full list of questions can be found in Appendix 2.

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Notifiable Diseases and Conditions: Discussion Document 1

1 Introduction and Project Outline 1.1 Project outline The main aim of the Notifiable Diseases project is to review and update the first and second schedules of the Health Act 1956, and to examine options for improving New Zealand’s disease notification systems. The project provides an opportunity to:

• assess the current schedules of notifiable diseases to ensure their relevance, including the identification of diseases and non-communicable conditions that could be added to, or deleted from, the schedules

• assess the current arrangement of the schedules in terms of categories and

classification of diseases and conditions

• identify and examine potential changes to enhance public health surveillance via the systems by which diseases are notified

• identify and assess the balance between the benefits and costs associated with

changes to the schedules and supporting systems. This discussion document sets out what changes are possible and desirable under current legislation, and assesses options for changes to systems that would be enabled by new public health legislation, currently under development. 1.2 Link with the public health legislation review This project is linked to the review of the Health Act 1956, a project that is being managed by the Ministry of Health’s Public Health Legislation Review team. Enabling legislation is necessary to allow significant changes to the current surveillance system specified in the Health Act. Some of the issues covered in this discussion document are also linked to the recent publication Public Health Legislation: Promoting public health, preventing ill health and managing communicable diseases (Ministry of Health 2002c). The Notifiable Diseases project aims to provide detail in the area of public health surveillance to fit into the more general framework being developed by the Public Health Legislation Review team. Submissions made to the Review team on the subject of public health surveillance will also be considered by the project team managing this project.


1.3 Limitations of this discussion document This discussion document will not discuss or make recommendations in the following areas:

• case definitions for particular diseases or conditions • the treatment of affected individuals and/or communities • specific recommendations on information technology requirements • details of service contracts to implement the notification system(s) • implementation plans for proposed options • detailed costs for proposed additions or removals of diseases from the schedules,

or specific costings for proposed systems options. The Communicable Diseases Control Manual is being revised by the Ministry of Health. This will contain information regarding laboratory case definitions and notification procedures. While information technology (IT) plays a critical part in the current surveillance system and will be central to any future systems, IT experts are best placed to make decisions on specific software applications and platforms. The recommendations of this report will help to decide which IT solutions are the most likely to support an effective notification system. Similarly, while this project may deliver broad recommendations concerning future contractual matters associated with the notifiable diseases system(s), the detail of contracts will be a matter for the Ministry of Health and providers to decide. As broad options are being proposed, the costs associated with implementation, compliance or ongoing maintenance and the likely magnitude of these costs are identified in the document where relevant. However, there is no detailed discussion of costs or implementation strategy. A separate costs report providing more detail on the options presented is being prepared and will be incorporated in the final report. 1.4 Project team and reference group The project is being managed by Allen & Clarke Policy and Regulatory Specialists, on behalf of the Ministry of Health. A project team has been formed that includes public health specialists and practitioners, policy analysts, a solicitor and an economist. An expert reference group has also been formed to advise on the Notifiable Diseases project. The group includes representatives from various health sector agencies and interest groups. A data management sub-group, including Māori representation, will assess data and information-handling issues (eg, privacy and data ownership concerns). The project team and reference group membership is set out in Appendix 1.


1.5 Consultation The Notifiable Diseases project will be informed by the views expressed as feedback on this discussion document as well as by a variety of other contacts and meetings. All those interested in this project are invited to contact the Ministry of Health by way of written submissions, or by telephone, fax or email (see ‘How to make a submission’). 1.6 Project outputs and timing The project team has been asked by the Ministry of Health to provide it with a report that:

• summarises the literature on the advantages and disadvantages of various notification systems

• assesses options for amendments to the current schedules of the Health Act 1956 • assesses options for amendments to the way in which diseases and conditions are

notified • identifies broad areas of cost • presents the results of consultation on all these issues.

The project team has also been asked to carry out an assessment of the likely costs of the various options, a privacy assessment. It will also make recommendations on implementation. The Ministry of Health expects the project team to provide final advice on the project by early July 2003. This advice will be used to inform future changes to the notifiable diseases and conditions schedules in the Health Act and, ultimately, legislative and/or administrative changes to the systems for the notification of diseases and conditions. 1.7 Structure of the discussion document This discussion document is divided into three main sections:

• section 2: Background • section 3: Review of Notifiable Diseases and Conditions Schedules • section 4: Notification Systems Options.

Section 2 provides an overview of the rationale for notification of particular diseases, as well as providing a broad summary of the current system and the legislative and strategic frameworks in which notification in New Zealand sits. Sections 3 and 4 discuss the diseases to be retained, added, removed, or amended, and the systems needed to do this. A systematic disease-by-disease approach guides discussion on the lists of notifiable diseases in section 3, and section 4 sets out options for different systems approaches. Questions to help stimulate feedback are included in each section. A full list of these questions is provided in Appendix 2.


2 Background The World Health Organisation defines surveillance as the: … ongoing systematic collection, collation, analysis and interpretation of data; and the dissemination of information to those who need to know in order that action may be taken.1 Notification is one method of collecting information for disease surveillance. 2.1 Surveillance in public health The focus of public health is on promoting and protecting the health of communities, with the primary goal of controlling and preventing disease. The Centers for Disease Control (2001) notes that disease surveillance was developed to address a public health need, including guiding immediate action to control or prevent disease, measuring and monitoring the burden of disease, and guiding the planning and implementation of programmes to prevent and control disease. Disease surveillance is a broad description of the methods and systems used to collect information, in this case, health-related information to inform public health action. Surveillance encompasses a wide range of techniques to gather information, including studies, surveys, and reports of cases (by either voluntary or mandatory notification). Generally the process and purpose of surveillance:

... uses methods distinguished by their practicality, uniformity and frequently their rapidity, rather than by complete accuracy. Its main purpose is to detect changes in trend or distribution in order to initiate investigative or control measures (Last 1998).

These definitions highlight the often-used expression that surveillance is ‘information for action’. In the public health arena, surveillance can therefore be described as an action that aims to identify changes in the health status or disease burden of the population (or communities within it). This information can then be used to inform an appropriate public health response.

1 World Health Organization, http://www.who.int/emc-documents. Accessed 14 March 2002.


2.1.1 Use of information collected via notification Notification is one part of the wider disease surveillance framework. The World Health Organization (WHO) defines notification as: ‘the processes by which cases or outbreaks are brought to the knowledge of the health authorities’.2 There are two main reasons for notification in public health:

• collection of information to inform a public health response to an individual person or a group who are experiencing an illness or condition that threatens their health and, potentially or actually, the health of others around them

• collection of information that informs a policy response to changing patterns of

disease in a community and contributes to the development and promotion of health interventions and health promotion campaigns designed to prevent outbreaks of diseases by informing the public and encouraging safer behaviours.

Personal information is usually required urgently for public health actions to be effective. Aggregated data is sufficient for informing policy responses designed to control threats to the public health and developing and promoting other health interventions. Epidemiological surveillance tracks trends of diseases, including incidence by ‘time, person and place’, and includes the analysis and interpretation of reports. Such surveillance keeps a watching brief on the patterns of disease and may contribute to a public health response. Examples include using mathematical models to predict measles and pertussis epidemics using previously collected data. These two functions overlap. Information for immediate public health action may be used by other agencies where necessary, just as information that informs a policy response may also inform epidemiological research into the area in question. Information collected via notification must balance the need for the information in terms of its ability to be used for the public’s benefit, against the costs associated with notification, while maintaining a sufficient degree of privacy for the individual concerned.

2.1.2 Surveillance methods used in New Zealand Public health surveillance, as defined above, is a broad term covering collection of ‘information for action.’ There are a number of different ways surveillance is undertaken in New Zealand:

• Notification: health practitioners are legally obliged under the Health Act 1956 to report cases of diseases specified in legislation, including named patient information.

2 World Health Organization, http://www.who.int/emc-documents. Accessed 10 March 2002.


• Reporting: this refers to reports of diseases that are not legally required to be

notified, but which are under surveillance. Reporting can be continuous or periodic, and can use a variety of different data sources, for example laboratories as well as medical and other health practitioners.

• Periodic Surveys: this includes surveys on the health of New Zealanders such as

Taking the Pulse – the 1996/97 New Zealand Health Survey (Ministry of Health 1999). In future, Ministry of Health surveys (in conjunction will other providers) will be coordinated under the New Zealand Health Monitor (Ministry of Health 2002d), which will include general health surveys every two years.

• Other methods: interviews, focus groups and other forms of research studies

contribute information to the general picture of disease trends that surveillance attempts to capture. These methods do not usually include reports of individual cases, but rather the experiences of groups within the population.

2.2 Notification of diseases: a literature review This section provides an overview of the literature on the notification of diseases and conditions. It places an emphasis on New Zealand-specific research, while also drawing on international literature. A search of reputable databases, and health strategies, agencies and statutes of other nations, sets the basis for this search. This section is divided into six thematic areas, which cover some of the key issues surrounding the notification of diseases and the systems used to do this. The areas are:

• the value of surveillance and notification • what information is necessary to fulfil the public health functions • identifying appropriate systems to facilitate disease notification:

who should have responsibility for collecting information rates of reporting notification systems

• information technology • privacy and notification • diseases notified in other nations.

2.2.1 The value of surveillance and notification While there are a number of articles detailing the advantages and disadvantages of surveillance, much less work has been done on the value of notification. However, the

Question 1: Do you consider notification an appropriate method for collecting information on disease for the purposes of disease prevention and control? If not, why not?


fact that most nations have some form of statutory notification provides support for notification in some form. The Department of Health, United Kingdom, (2002) has set out two broad functions of notification:

• to provide current, accurate information to public health officials responsible for the control and prevention of disease at a local level

• to provide information at a national level to identify disease trends and patterns,

and to inform policy and health services.3

Notification in New Zealand, as set out in the Communicable Disease Control Manual (Ministry of Health 1998), echoes these purposes, and notification is seen as a key strategy for preventing communicable disease. Weir et al (2001) also state that notification systems form the foundation of communicable disease control. Dickinson (1991) acknowledges that while a certain level of complacency has risen around infectious disease reporting over the previous 20 years, notification remains a vital tool for understanding disease burden in a community. Controlling or preventing the transmission of disease, assessing the progress of a disease, and assessment of control measures stand as primary reasons for maintaining notification systems for communicable diseases. Bryan et al (1994) note that strengthened notification systems must still be flexible enough to include emerging diseases as well as providing rapid response capability to detect, contain and prevent emerging diseases. Notification also plays an important role in initiating the prevention of international infectious disease threats (Bartlett and Gill 1993). There is little evidence of the financial benefits of notification, although the costs of investigating and testing suspected cases of a notifiable disease, costs associated with health care, and costs to the family and society of notifiable diseases have been estimated by Roberts et al (1989) in response to an outbreak of salmonellosis in the United Kingdom. This study concluded that public sector savings created by public health interventions were worthwhile for this specific outbreak.

2.2.2 What information is necessary to fulfil public health functions? The type of information collected via notification depends to some extent on the reason the information is required. If a public health response is required, personal details would usually be needed, whereas aggregate and/or anonymised data would be sufficient for analysis of disease trends or programme development.

3 Peate (1999) also notes this second function.


Data usefulness is often compromised by lack of data completeness (Dickinson 1991; Durrheim and Thomas 1994; Verity and Nicoll 2002). It has been suggested that additional data on ethnicity could be collected in order to help develop programmes addressing the communicable health needs of different ethnic groups in the community (Centre for Disease Control, 1999). Weir et al (2001) note that consistent diagnosis and reporting can contribute to the elimination of bias in notifications data. This could be assisted by more precise definitions of notifiable diseases. Improving the quality of existing data collections, especially the quality of ethnicity data, is one of the priorities for the WAVE Project (Ministry of Health 2001b). It is also a core project of He Korowai Oranga (Māori Health Strategy (Ministry of Health 2002b) and Reducing Inequalities in Health (Ministry of Health 2002e). The improved ability to analyse and compare ethnicity data for health needs, healthcare service delivery, and outcomes monitoring will allow the development of more appropriate services. The Ministry of Health is also currently undertaking an Ethnicity Data Improvement Project, to assist in the standardised collection of ethnicity data (a standard will apply from June 2003).

2.2.3 Identifying appropriate systems for disease notification Notification systems around the world vary in terms of design, type and capacity, yet the success of each system ultimately relies on the timely collection of appropriate data and the swift and appropriate dissemination of this data. This section details literature covering the collection and dissemination of information, particularly relating to who should have responsibility for collecting information, what information must be collected to fulfil a public health function, rates of reporting, and laboratory-based notification. Who should have responsibility for notification? Studies identify a number of agents who could take responsibility for notifying public health authorities of cases of notifiable diseases. While medical practitioners currently have a statutory duty to perform this role in many nations, a number of other health practitioners or providers have been identified. Simmons et al (2002) and Weir et al (2001) have noted that practice nurses in some general practices in New Zealand are delegated the task of notifying the medical officer of health. Both groups of authors suggest that this practice could be extended. In an international context, hospital staff or nurses have been identified as filling the notification function (Abdool Karim and Ditraj 1996; Peate 1999). Medical practitioners have expressed some confusion regarding who has responsibility to notify in areas where laboratory-based notification is used (Allen and Ferson 2000; Rushworth et al 1991; Schramm et al 1991). Vogt et al (1983) noted that laboratories should be responsible for reporting any cases diagnosed by them. This concurs with Rushworth et al’s conclusions. They also discuss providing a mechanism allowing


laboratories to report of provisional results if a disease requires urgent public health action. Collection of information – rates of reporting The literature suggests that completeness of information and notification rates are highly variable. Some nations in Europe report the variation in reporting completeness as ranging between 10% and 90% for different diseases (Desenclos et al 1993). Vogt et al (1983) noted that under-reporting is more likely in passive surveillance systems that rely on reporting by health-care providers. Allen and Ferson (2000) conducted an audit of notifications reported by medical practitioners and laboratories in Australia. The findings were that 40 pertussis cases were notified by medical practitioners compared to 66 notifications received from laboratories. Rushworth et al (1991) also noted significant variation in the reporting of diseases when this was undertaken by laboratories (75%) and medical practitioners (20.2%). Simmons et al (2002) note that New Zealand has a relatively high reporting average for particular gastrointestinal illnesses (76% of laboratory-based campylobacteriosis; 82% of salmonellosis; and 88% of shigellosis). New Zealand general practitioners (GPs) have identified a number of barriers to reporting cases of notifiable diseases. These include forgetting to notify (13% of GPs), lack of time (7%); confidentiality concerns (3%) (Weir et al, 2001). Medical practitioners in New Zealand suggest emphasising the benefits of notification to GPs and patients, reminders on laboratory forms and direct laboratory notification as ways to improve notification (Weir et al, 2001). These authors also discuss providing incentives for notification: 62% of respondents to Weir et al’s questionnaire considered reimbursement would facilitate notification, in fact there is little evidence to show that this would result. A British study undertaken by McCormick (1987) notes that providing incentives did not lead to an increase in notification rates. A number of studies based in other nations detail issues likely to contribute to the under-reporting of notifiable diseases, including attitude to notification and motivation (Abdool Karim and Ditraj 1996; Durrheim and Thomas 1994; Voss 1992), physician awareness (Abdool Karim and Ditraj 1996; Allen and Ferson 2000; Durrheim et al 1994; Peate 1999; Squires et al 1998; Weiss et al 1998), poor feedback from public health authorities (Abdool Karim and Ditraj 1996; Allen and Ferson 2000; Rushworth et al 1991; Squires et al 1998), and unclear communication channels (Allen and Ferson 2000; Rushworth et al 1991; Schramm et al 1991). Options for increasing reporting rates focus on providing self-addressed stamped envelopes and easy-to-understand forms, memory aids, a 24-hour telephone line, more training on notification procedures, and publishing regular bulletins. These studies did not consider financial costs of various options. Notification systems Schramm et al (1991) note that while laboratories can make a significant contribution to disease surveillance, multiple sources of information will need to work collaboratively to


create a comprehensive surveillance system. This theme is picked up in a number of articles, including that by Dickson (1991). Automatic and direct reporting from physicians, and from private and public laboratories increases the timeliness of notifications received by public health units (Bryan et al 1994). Dickinson (1991) and Durrheim et al (2000) note the usefulness of considering diseases according to the reasons they are notified; for example, public health authorities need to know about cases of some diseases quickly. While public health action requires named patient data, Pinner et al (2000) note that personal data does not need to be collected at a national level. Laboratory-based notification systems require standard test names and standards for results (Pinner et al 2000). Weir et al (2001) also recommends that medical practitioners request laboratory confirmation of all suspected cases to ensure that all cases of a disease are picked-up and counted under laboratory-based notification. While laboratory-based notification is itself timely, there may be a delay between a patient presenting with an illness and the laboratory diagnosis being made. Simmons et al (2002) record delays of up to 2 days for VTEC and up to 224 days for campylobacteriosis. Secure networks, capable infrastructure, and effective communication links are necessary to developing good laboratory-based systems (Bryan et al 1994). Standardised messaging formats need to be developed (Jernigan 2001). Doyle et al (2002) also note that ongoing maintenance and monitoring are important features of surveillance systems, allowing for useful and complete data to be collected.

2.2.4 Information technology The WAVE Project (Ministry of Health 2001b) sets the development of health information technology in New Zealand, with a primary goal of integrated health information systems that consider privacy issues. Increased access to technology will contribute to the development of this. Studies identifying levels of computer use among GPs have been conducted in New Zealand. Thakurdas et al (1996) found that 84% of GPs used a computer for an unspecified task (or tasks), and:

• 75% considered it useful to have electronic display of laboratory results (16% of GPs had this capability)

• 74% considered it useful to have modem transfer of laboratory results (14% of GPs had this capability)

• 58% considered it useful to have the ability to print laboratory request forms (9% of GPs had this ability).

Given the age of the data, there is likely to have been some change to the figures presented above. More recent studies on computer use have been undertaken,


particularly regarding access to the Internet. Cullen (2002) notes that 36.3% of GPs have office access to the Internet (Kerse et al 2001 put the figure at 40%). Rural and urban practices have similar levels of access to the Internet (Kerse et al 2001).

2.2.5 Privacy and notification The collection, use, storage, and dissemination of health data, particularly if it contains information identifying an individual, can be a sensitive issue, particularly if privacy concerns for individuals compete with the potential benefits to public health as a whole. New Zealand has a national health information service which transfers personal data across a wide network of health service providers. Buchan and Paul (1992) question whether sharing health information for research or the control of disease spread should take precedence over an individual’s right to privacy. Most notable is Buchan and Paul’s observation that society does not consider that a person has an absolute right to control information about themselves. Seeking informed consent from an individual may result in delays to getting information to those who need it, thus delaying any public health action required to prevent the spread of the disease. Data sensitivity, particularly that of aggregated data used for analysing disease trends, may also be compromised if a person withholds consent (Buchan and Paul 1992; Verity and Nicoll 2002). Thirty-three percent of doctors responding to a questionnaire from Thakurdas et al (1996) did not consider that electronic exchange of data had adequate security capabilities. Options suggested for addressing privacy issues associated with notification included ensuring that systems for sharing data offer adequate protection (Buchan and Paul 1992) and informing the public about the need to collect such data (Verity and Nicoll 2002). (See section 2.2.2 for a discussion of the kinds of information that needs to be collected for notification to be effective.)

2.2.6 Diseases notified in other nations A survey of statutes shows that most nations require a variety of diseases to be notified4, and a number of national surveillance centres and committees have also provided information.5 A wide variety of diseases are notified, reflecting differing public health priorities, concerns about particular diseases, and different endemic diseases. Serious infectious diseases requiring a rapid response to prevent or control spread (eg, cholera, hepatitis A, plague, tuberculosis, and yellow fever), and vaccine-preventable illnesses such as diphtheria, measles, and poliomyelitis are notifiable in many nations. Australia, Canada, Sweden and the United States of America require the notification of common sexually transmitted diseases such as chlamydia, gonorrhea, and syphilis.

4 Inventory of Infectious Diseases Resources in Europe. http://iride.cincea.org/. Accessed 14 February 2003. 5 The Communicable Disease Network in Australia, the Advisory Committee on Epidemiology in Canada, and the Centre for Communicable Disease in the United States.


Carrier status for hepatitis C and hepatitis B is notifiable in some states of Australia. Other nations do not require the notification of chronic infections, with the exception of Human Immunodeficiency Virus (HIV) (notifiable in Canada, Sweden, and the United States). Antibiotic resistance, and in particular, methicillin-resistant Staphylococci aureus (MRSA), Streptococcus pneumoniae with decreased resistance to penicillin, and vancomycin-resistant Enterococcus, are notifiable in Sweden. Pneumococci drug resistance is also notifiable in the United States. A number of nations, including Australia, Canada and the United States, have a designated national body or committee charged with amending the lists of diseases under national notification. Such committees provide a mechanism for regularly updating notifiable disease schedules. New Zealand’s system is more ad hoc, utilising advisory groups for this purpose. The WHO (2002), looking more broadly at notification, has indicated that reporting of all public health emergencies of international concern is a priority over requiring reporting of particular disease lists. Desenclos et al (1993) note that while mandatory notification is in place in several European countries, there is a trend towards voluntary systems. Notification is voluntary at a federal level in Canada and the United States however most states and territories in these countries require some degree of mandatory notification. Further discussion on notification systems used in other countries can be found in section 4.1.1. 2.3 Legal and strategic framework for notification National and international legal obligations require that certain diseases be notified. New Zealand’s legal framework also sets out who should notify what and to whom, what information can be collected, and how that information should be managed. As well as legal requirements, a number of strategic frameworks cover the planning, development and delivery of health services, and provide a stated direction for health services in New Zealand. Several of these strategies have direct relevance to surveillance (including notification) of diseases and conditions.

2.3.1 International Legal Obligations The International Health Regulations 1966 provide for cross-border surveillance of infectious diseases considered to be of international importance. Member nations must report any incidence of cholera, plague, or yellow fever. The WHO is revising the International Health Regulations 1966 and has signalled that it is likely to move away from requiring notification of particular diseases to requiring notification of outbreaks of diseases of international significance (WHO 2002). Other international and regional obligations allow the WHO to request information about outbreaks of a variety of diseases considered important for international control and


surveillance. Various WHO projects require robust data and timely reports of any cases, including the Polio Eradication Initiative; the Stop TB partnership, leprosy, and the WHO’s antimicrobial resistance surveillance programme.

2.3.2 The Health Act 1956 and Tuberculosis Act 1948 Section 2 of the Health Act 1956 defines communicable disease as including ‘any infectious disease, tuberculosis, venereal disease, and any other disease declared by the Governor-General, by Order in Council, to be a communicable disease for the purposes of this Act’. Infectious disease is defined as ‘any disease for the time being specified in Part 1 or Part 2 of the Schedule 1 to this Act’. The legal requirement to notify diseases is set out in the Health Act 1956. The first and second schedules of the Act set out the diseases that must be notified. The Act also includes provisions relating to notifications where individuals are found to be suffering from a notifiable disease. Section 74 of the Act requires that medical practitioners give notice of cases of notifiable diseases to the medical officer of health and/or the territorial local authority. Funeral directors and veterinarians are also required to notify cases (sections 85 and 87(a) respectively). Section 19 of the Education Act 1989 requires school principals to notify the medical officer of health if a student is excluded from school on the grounds of having a communicable disease. Cases of tuberculosis are notifiable under the Tuberculosis Act 1948. This Act also provides for contact tracing of those who are at risk of developing the disease, and for information regarding cases to be provided to the medical officer of health.

2.3.3 Other domestic legislation Many New Zealand statutes either require or provide for information to be gathered for public health purposes, or to enable action to protect the public health. Examples include the:

• Biosecurity Act 1992 • Education Act 1989 • Hazardous Substances and New Organisms Act 1996 • The Health and Disability Services (Safety) Act 2001 • Health and Safety in Employment Act 1992 • New Zealand Bill of Rights Act 1990 • Privacy Act 1993 • Venereal Disease Regulations 1982.

2.3.4 Strategies for the health sector A number of health sector, and wider government, strategies have particular relevance to public health-related disease surveillance, including the:

• New Zealand Health Strategy


• New Zealand Disability Strategy • An Integrated Approach to Infectious Disease: Priorities for Action 2003–2006

(Ministry of Health 2001a) • He Korowai Oranga (Māori Health Strategy) • Pacific Health and Disability Action Plan • Primary Health Care Strategy • Reducing Inequalities in Health • Sexual and Reproductive Health Strategy • Working to Add Value through E-Information (the WAVE project).

Consideration given to the content of the schedules of notifiable diseases and conditions, to the systems surrounding and supporting notification, or to how data is used, needs to take into account the strategic goals set out in these strategies.

2.3.5 The Treaty of Waitangi Through the principles of the Treaty of Waitangi, the Government seeks to improve Māori health and reduce inequalities. The principles also include the need to protect Māori cultural and belief systems, and to involve Māori in decision-making at all levels. Health information shows that Māori suffer disproportionately from the incidence of infectious disease, particularly rheumatic fever and meningococcal disease (Ministry of Health 2001a). The Treaty principles of partnership, participation and protection obligate the Crown to work with Māori to reduce the incidence and impact of infectious diseases. Māori provider programmes and service delivery that is culturally appropriate are important approaches. Notification provides information on diseases that can be used to inform programmes specifically addressing the issues around communicable disease among Māori. However, systems must respect the fact that, for Māori, personal information and data have cultural and spiritual value. Consultation, collaboration and co-operation are required to ensure that data is sensitively and appropriately handled and used to benefit Māori while respecting cultural practices and values. 2.4 Surveillance and notification in New Zealand New Zealand has a passive notification system based on provider-initiated notifications rather than active seeking of cases of notifiable diseases. This is provided under the Health Act 1956 and Tuberculosis Act 1948 (see section 2.3.2). Surveillance in general is more active, with case reporting and (from time to time), surveys providing additional information on the health of the population or specific groups within it. A more detailed examination of the systems of surveillance in New Zealand, including the strengths and weaknesses of the current system and proposed options, is provided in section 4.


2.4.1 The notification process The Institute of Environmental Science and Research’s Centre for Disease Control (ESR: CDC) is the agency that collects, stores, analyses and disseminates most of the information regarding notifiable diseases and conditions in New Zealand. This is managed through the EpiSurv software programme. Diagnosing physicians must report all cases of notifiable diseases to the local medical officer of health. Surveillance co-ordinators enter case information onto EpiSurv.6 At this stage, the medical officer of health may also undertake direct action, as necessary, to deal with any threat posed by the case(s) in question. Specific action for individual cases is usually undertaken via staff at the local public health service, and/or the territorial local authority. Physicians may also notify suspected cases of some diseases. The physician will subsequently inform the public health service once a case is confirmed or ruled out, so that EpiSurv records can be updated, and the public health unit undertakes appropriate action. Most notifiable diseases require laboratory confirmation to be counted as a true case. At present, the legal framework does not allow direct notification from a laboratory to a medical officer of health, though this is not the case for some non-notifiable diseases (see below). ESR undertakes data matching and integration to minimise duplication of data, and to ensure that case reports are as complete as possible. At times, confirming cases and collecting important case information is done manually by ESR staff to achieve the best possible data set for cases of significant diseases. ESR produces weekly reports to medical officers of health, as well as regular disease-specific reports and the New Zealand Public Health Report, which details the incidence of notifiable diseases and diseases under other forms of surveillance. All stakeholders involved in disease notification incur a variety of costs associated with notification, including time and opportunity costs, compliance costs, and systems maintenance costs. Costs can create barriers to notification rates and therefore must be carefully balanced against the benefits of collecting and using the information. The costs associated with notification need to be as small as possible, while maintaining a high degree of information accuracy and quality.

6 Processes and instructions for filling out case report forms on EpiSurv are contained in the Manual for Public Health Surveillance in New Zealand, published by the Ministry of Health.


2.4.2 Other data collection systems A number of diseases and conditions are under surveillance in New Zealand, using methods other than notification. ESR runs a number of programmes that collect data on, for example, sexually transmitted infections, hospital-acquired infections, invasive pathogens, and spraydrift incidents. Where possible and appropriate, laboratory-based surveillance is used for these diseases and conditions. A number of other agencies also collect data on disease trends in New Zealand, for both notifiable and non-notifiable diseases, including the following: AIDS Epidemiology Group This group collects data on incident HIV cases as well as notifications of Acquired Immunodeficiency Syndrome (AIDS), with particular reference to the source of infection. The information is anonymous and is collected from the diagnosing physician. New Zealand Paediatric Surveillance Unit This group collects information on childhood diseases, including acute flaccid paralysis and vertical transmission of HIV. Questionnaires sent to diagnosing paediatricians elicit anonymised case details. Ministry of Health The Ministry contracts or undertakes health surveys to determine the health status of the population. The Ministry of Health is also involved in the Water Information New Zealand database, which looks at water quality, and it previously administered the FoodNet database, onto which cases of food-borne illnesses were reported. The Public Health Intelligence branch of the Ministry undertakes surveys, including general health surveys conducted every two years (Ministry of Health 2002d).

• New Zealand Health Information Service (NZHIS), Ministry of Health The NZHIS collects hospital discharge and cause-of-death data that can be used as a measure of the incidence of some diseases.

National Poisons Centre A key role is to provide information to the public and health professionals regarding the management of poisoning cases. However, records kept by the Centre indicate which products are most commonly involved in accidental and intentional poisonings, and some information on which population groups are most at risk. Other government agencies A number of other government agencies collect information that directly or indirectly relates to public health. These include (but are not limited to):

• Occupational Safety and Health Service (OSH) • Accident Compensation Corporation (ACC) • Environmental Risk Management Authority (ERMA)


• New Zealand Food Safety Authority • Department of Immigration • Pharmaceutical Management Agency (PHARMAC) • Ministry of Education • Ministry of Foreign Affairs and Trade • Ministry of Agriculture and Forestry (MAF).

Not all this information is shared between agencies. Some duplication is likely, and there are gaps in knowledge in other areas. Information sharing between government agencies, including implications for the protection of personal information, is addressed in section 4. 2.5 Summary Disease surveillance in New Zealand provides information that informs public health response. In particular, notification allows for the identification of diseases of public health significance for which a specific public health action may exist to control or prevent the spread of the disease. Notification data may also be used for surveillance of disease trends and longer-term tracking of disease trends, planning of services, and policy development. Mandatory notification of certain diseases and conditions is a part of this wider surveillance programme. Notification may be expensive, with costs to those involved in the notification processes, and to the personal privacy of people with notifiable diseases. Careful consideration of the risks and benefits must be undertaken as part of the process of making diseases notifiable, or removing diseases from the schedules. To be effective and useful, a notification system needs to produce information that is fit for the purposes for which it is collected, while fulfilling the requirements of national and international law.


3 Review of Notifiable Diseases and Conditions Schedules

This section examines the current schedules of notifiable diseases and conditions with a view to making recommendations on which diseases should remain on the schedules, which should be removed, and possible additions to the schedules. The list of notifiable diseases in the Health Act was last reviewed in 1996. Periodic reviews of the lists have taken place to ensure that the Health Act requires notification of diseases that are of current (or expected future) public health significance. Evaluation of the schedules, including identification of diseases and conditions considered for addition and deletion, was initially undertaken by the project team, and was subsequently discussed with the reference group advising this project. Information about diseases notified in other nations is contained in section 2.2.6. Adding or removing a disease from the requirement to notify will result in additional or reduced costs, depending on the volume of cases. For example, adding a disease with one case a year will have less impact on resources than adding a disease for which 100 cases are notified. There will also be some regulatory costs associated with changing the schedules. Costs associated with suggested additions or removals have not been analysed for this report. 3.1 Current list of notifiable diseases and conditions The current list of notifiable diseases and conditions is set out in schedules 1 and 2 of the Health Act. Tuberculosis is separately notifiable under the Tuberculosis Act 1948. The current schedules to the Health Act are split into sections, depending on who cases must be notified to.


Schedule 1, Part 1 Section A: Infectious diseases notifiable to the medical officer of health and the local authority:

acute gastroenteritis7 campylobacteriosis cholera cryptosporidiosis giardiasis hepatitis A legionellosis

listeriosis meningoencephalitis (primary amoebic) salmonellosis shigellosis typhoid / paratyphoid fever yersiniosis.

Section B: Infectious diseases notifiable to medical officer of health: acquired immunodeficiency syndrome anthrax arboviral diseases8 brucellosis Creutzfeldt-Jakob Disease (and other spongiform encephalopathies) diphtheria Haemophilus influenzae b hepatitis B hepatitis C hepatitis (viral) not otherwise specified hydatid disease leprosy leptospirosis

malaria measles mumps Neisseria meningitidis invasive disease pertussis plague poliomyelitis rabies rheumatic fever rickettsial diseases9 rubella tetanus viral haemorrhagic fevers10 yellow fever.

Schedule 2

Section A: Diseases notifiable to the medical officer of health, other than infectious notifiable diseases:

cysticercosis decompression sickness lead absorption equal to or in excess of 15µg/dl

poisoning from chemical contamination of the environment

taeniasis trichinosis.

7 This category includes acute gastroenteritis in 2 or more linked persons (common food or water source); an affected person in a high-risk occupation (eg, food handling); or single cases of botulism, chemical poisoning or verotoxin-producing infections, particularly E-coli 0157. 8 Arboviral diseases are sorted according to virus group: alphavirus group (Ross River fever); flavivirus group (Dengue fever); and Murray River encephalitis. 9 Rickettsial diseases include endemic and murine typhus, and other tick- and mite- borne rickettsial diseases, for example Q fever. 10 Viral haemorrhagic fevers include diseases such as Ebola and Marburg viruses, and Lassa fever.


Schedule 1, Part 2 to the Health Act includes a list of diseases of public health importance but which are not notifiable. Medical officers of health are able to take action to control the spread of these diseases. Included in this section are:

chancroid gonorrhoeal infection influenza impetigo contagiosa herpes simplex non-specific urethritis

pediculosis scabies streptococcal infection Group A syphilis venereal granuloma varicella-zoster infection.

3.2 Review of the Notifiable Disease Schedules The current review is taking place to:

• ensure that the lists of notifiable diseases and conditions enable the collection of information on trends that is accurate, timely, relevant and accessible to all end users

• provide a core list of notifiable diseases and conditions that can be carried over into new public health legislation.

Section 3.2.1 outlines the method used for this review, and sets out the criteria used when assessing individual diseases and conditions. Detailed discussion of each disease begins at section 3.2.2. For a summary of the recommendations made regarding diseases and conditions to be retained, added, or removed from the schedules, please see section 3.2.8. This section also contains a number of diseases requiring additional sector debate before a recommendation can be made.

3.2.1 Method To ensure that the list of notifiable diseases was assessed and reconfigured appropriately, a number of steps were followed by the project team. The first step involved the identifying those diseases that must stay on the notifiable diseases list due to international reporting requirements and/or due to their inclusion on the current National Childhood Immunisation Schedule. These diseases are listed in section 3.2.2. The remaining (currently scheduled) diseases were then examined by using specified criteria to guide evaluation of each disease and condition and then checking the list for internal consistency. Given that public health action and ongoing surveillance are the main reasons diseases and conditions are notifiable, these two issues were the primary criteria. Other criteria


were considered in assessing each disease and condition, though it should be noted that not all criteria are relevant to each disease or condition. The other criteria considered were (in no particular priority order):

• outbreak potential and ease of transmission • severity of disease or condition • whether effective public health interventions are available • whether effective personal health interventions are available • whether a relevant vaccine is available • public perception of the risk posed by the disease or condition • cost of each case, to the individual, community and the health system • the vector, in particular whether the disease can be acquired from animals • whether other agencies have an interest in, or dependence on, the information • whether the disease is emergent, or if there are strong trends either toward fewer

or a greater number of cases • whether environmental factors contribute to incidence • how common the disease or condition is in the general population, or within

discrete populations • whether the disease or condition contributes to or creates inequalities in health.

This process identified those diseases that should remain notifiable, and a group that might be considered for removal from the list. These are discussed in sections 3.2.3 and 3.2.6 respectively. A table of the criteria assessment is included in Appendix 3. Subsequently, consideration was given to identifying other diseases that should be considered for inclusion due to emergent disease trends, the National Childhood Immunisation Schedule, vector establishment, or because information collected through notification could improve the ability to control the disease. These are set out in section 3.2.4 (recommended for addition to the notifiable disease schedules). A number of diseases require additional sector debate before a firm recommendation for inclusion or otherwise can be made. These are set out in section 3.2.5. Finally, the project group assessed the way that diseases are categorised on the list with a view to ensuring that the list is as clear as possible to those who use it for notification, and that it encourages the submission of timely and complete notifications. These matters are discussed in section 3.3. The project team’s assessments were subsequently reviewed by the reference group to determine if they were appropriate. The advice of the reference group was built into the final recommendations included in this discussion document.


3.2.2 Diseases to be automatically retained on the list There are a number of diseases on the current list that the project team and reference group considered should automatically remain notifiable. These are:

a) diseases that New Zealand is required to monitor under the International Health

Regulations 1966:

• cholera • plague • yellow fever

b) diseases that are vaccine-preventable, and which are on New Zealand’s current

National Childhood Immunisation Schedule:

• diphtheria • Haemophilus influenzae b • hepatitis B11 • measles • mumps • pertussis • poliomyelitis • rubella • tetanus.12

Vaccine-preventable diseases included on the National Childhood Immunisation Schedule were first added to the notifiable diseases list in 1996. The addition was designed to improve surveillance of these diseases by gauging the effectiveness of immunisation (particularly among children), allowing for more accurate and responsive service planning, and mapping disease trends to help predict and plan for outbreaks. After removing these 12 diseases from consideration, analysis focused on those remaining, and on diseases considered for addition to the list.

11 At the present time, only acute cases of hepatitis B are notifiable. 12 Influenza is also included on the National Childhood Immunisation Schedule. However, it is not included in the list of notifiable diseases and is not considered here as the vaccine is available only to those meeting the chronic medical condition criteria or high risk individuals or groups. Tuberculosis (for which a BCG vaccine for under-16 high risk individuals or groups is available on the National Childhood Immunisation Schedule) is considered under section 3.2.3.


3.2.3 Diseases recommended for retention The following section outlines the diseases and conditions recommended for retention on the schedule of notifiable diseases. Anthrax Anthrax is a very rare but serious disease, requiring immediate public health action to identify how the case acquired the disease and to secure the source. In the case of deliberate spread of anthrax spores, the public health response would include advice on decontamination and prophylactic treatment. The last human case of anthrax was reported in New Zealand in the early 1900s. Given the rarity of anthrax in New Zealand, notification is the only method of surveillance. Arboviral diseases Arboviral diseases are carried by insects. Of most interest in New Zealand are mosquito-borne diseases, particularly given recently established populations of mosquito species associated with arboviral diseases, such as Ross River fever and dengue fever. Cases of arboviral diseases must be notified early to exclude or identify local sources of infection. Prompt action, including securing the source would be essential in controlling the spread of the disease. While there have not been any notified cases of locally-acquired arboviral diseases, surveillance is important in determining trends in imported cases, given that vectors for arboviral diseases now exist in this country. Surveillance would be critical in responding appropriately to an outbreak. Brucellosis Brucellosis is a potentially serious disease. It is not transmitted from person to person, so the public health response to notification would be limited to identifying and securing the source to prevent others becoming infected. A very small number of returning travellers have been found to be acutely ill with brucellosis. As bovine brucellosis has been eradicated in New Zealand, locally acquired cases may indicate infection in the animal herd. This would have significant implications for the export of New Zealand meat products. Surveillance is therefore important for both health and agricultural reasons. Creutzfeldt-Jakob Disease (CJD) and other spongiform encephalopathies CJD is very rare in New Zealand. The detection of cases linked to acquisition in New Zealand would have serious implications for both the health and agricultural sectors. While there is no specific public health response to an individual case of CJD, thorough investigation is required to assess the route of transmission and to assure public safety.


Cryptosporidiosis This is a water-borne disease that can cause severe illness, particularly in immuno-compromised people. It has a high outbreak potential, and public health action centres on identifying and controlling the source of infection, such as closing swimming pools and advising symptomatic people not to use public swimming pools. Recent outbreaks have been linked to public swimming pools and other common water sources. Surveillance of cryptosporidiosis identifies trends in disease patterns and helps identify outbreaks, although is it unlikely that the majority of cases of cryptosporidiosis are notified. Cysticercosis and taeniasis Cysticercosis and taeniasis are transmitted via raw or undercooked beef and pork products or occasionally person-to-person. While most cases of cysticercosis and taeniasis are imported, infection acquired in New Zealand would require a public health response to prevent the spread of infection, as well as to identify and control the source. A locally acquired case of either cysticercosis or taeniasis would have implications for New Zealand’s agricultural industry. Giardiasis Giardia is now endemic in New Zealand waterways. A single infected water source could potentially be responsible for an outbreak of giardiasis. Public health action stemming from notification centres on identifying and controlling the source of infection, and excluding people in high-risk occupations (eg, healthcare workers, early childhood teachers), or children from attending early childhood care while symptomatic. Surveillance of giardiasis shows the spread of the disease and disease patterns. It can be useful for identifying outbreaks, particularly multiple outbreaks linked to a single source. Given the relatively mild nature of the illness in most people, it is unlikely that the majority of giardiasis cases are notified. Hepatitis A Hepatitis A can be spread through faecal-oral contact, and can be transmitted through food handling and person-to-person contact. It is a potentially serious illness, and requires a public health response to identify and control the source of infection, and to exclude symptomatic people from high-risk occupations such as food-handling, childcare and healthcare.

Hepatitis (viral, not otherwise specified) Hepatitis D (always concurrent with hepatitis B infection) and hepatitis E (blood-borne and faecal-oral transmission) are currently rare in New Zealand. Continued surveillance will highlight changes in incidence. Though unlikely, outbreaks of hepatitis E are possible and would require a public health response to identify and control the source, particularly if the infection is linked to food-handling practices, healthcare or childcare workers.


Hydatid disease Incident or active cases of hydatid disease are now very rare in New Zealand, and are found almost exclusively in new migrants and returning travellers. Most cases of hydatid disease relate to infections acquired many years ago, with the results of the infection (eg, calcified cysts) found during investigation for other health issues. Active cases are those in which the cysts associated with hydatid disease are found to be actively developing. Ongoing surveillance provides important information on the source of infection. New cases of hydatid infection in patients unlikely to have been exposed prior to the control of hydatid disease (ie, young children) would alert the Ministry of Health and MAF of re-infection among livestock and/or dogs. Lead absorption Lead absorption is currently notifiable if the concentration is equal to or over 15 µg/dl of blood. Lead was a common ingredient in paint until the 1980s. Lead absorption notification is more likely to involve householders exposed to lead paint while renovating, or children eating or chewing on items containing lead (eg, rails of old cots decorated with lead-based paint). Public health action arising from a notification concentrates on identifying and controlling the source of the lead. Health promotion campaigns designed to alert home renovators to the risks associated with lead-based paint are another current public health intervention.

Ongoing surveillance is justified given the potentially large number of people, particularly children, exposed to lead-based paint, usually during house renovations. Lead is persistent in the environment, so it is unlikely that notifications will drop significantly for some time. Surveillance also helps gauge the success of health promotion campaigns designed to raise awareness and limit exposure to lead in the household environment.

Legionellosis Legionellosis can cause outbreaks involving a large number of people, normally linked to air-conditioning systems in buildings, garden products and a number of other potential sources. It is a potentially serious disease that requires a rapid public health response to contain outbreaks, and surveillance to identify patterns (including sources) of disease. Rapid public health action is required to ensure that the source of the infection is identified and controlled, and that people exposed to the bacteria are traced and treated appropriately. Surveillance of legionellosis can help to identify clusters of disease associated with a particular place or product, and provides information on trends of the disease which can inform other public health interventions (eg, an increase in building-associated cases may warrant action aimed at building owners and maintainers). Leprosy Leprosy is rare in New Zealand, occurring mainly in new migrants and, less commonly, in returning travellers. Public health action is limited to contact tracing related to active cases. Surveillance of leprosy is limited to tracking disease trends, and fulfilling the


WHO’s request that cases of leprosy be reported to them to provide an international overview of leprosy infection. Leptospirosis Leptospirosis is a serious zoonotic disease which requires a rapid public health response to enable identification and control of the source, and identification and management of contacts exposed to that source. Surveillance provides information for identifying outbreaks, as well as longer-term information on disease trends. Since routine vaccination of dairy herds, leptospirosis most commonly occurs among meat workers. A small number of cases involve people who live on or have visited farms or similar places but who are not occupationally exposed.

Listeriosis Listeriosis is a food-borne disease. It is a potentially serious disease, and can cause miscarriage in pregnant women, and serious illness in the elderly, very young, or immuno-compromised individuals. Rapid identification and control of the source is important, as are initiatives to prevent contamination of food sources. Malaria Malaria is a serious illness spread by mosquitoes. At present there is no vector for malaria in New Zealand, but the disease is endemic in most parts of the Asia-Pacific region. All cases in New Zealand are currently imported, but surveillance remains important for international surveillance programmes run by the WHO, and for travel advice. An imported case of malaria would not elicit any specific public health action, although an immediate response would be required to a notification of locally acquired case, in order to identify and control the vector. Meningoencephalitis – primary amoebic Meningoencephalitis (primary amoebic) is a rare disease, most commonly caught from untreated thermal pools. An affected source could potentially cause infection in a number of people, requiring a rapid public health response to find and prevent further exposure to the source of infection, to trace and treat other people exposed, and to provide advice to the public. Surveillance of this disease is used to identify outbreaks. Neisseria meningitidis invasive disease New Zealand is currently experiencing an epidemic of meningococcal disease, particularly group B. Māori and Pacific peoples are disproportionately affected. Meningococcal disease is a serious disease, occurring as single cases (or, more rarely, as outbreaks) with a high case fatality rate. Immediate public health action is required to control the spread of the disease, while surveillance provides important information on the disease trends and patterns. An immunisation campaign for group B meningococcal disease is currently being developed. Sensitive surveillance, aided by notification, is an important part of assessing the impact of vaccination.


Poisoning resulting from chemical contamination of the environment This broad category is intended to include poisoning resulting from chemical contamination of the environment that is a threat to the public health. It could include, for example, chemical contamination of waterways, foodstuffs, the air (spraydrift or chemical discharge into the air), or of land that is used by people for recreation. Given that cases of chemical contamination of the environment could identify a source that might affect a large number of people, notifications could trigger public health action. Surveillance of chemical injury could help to determine what agents and situations may account for the majority of notifications, allowing health promotion campaigns and related action by other authorities. Rabies New Zealand is officially rabies-free, so all detected cases will be imported. Rabies is an extremely serious disease that is widespread around the world. Some of the vectors for rabies, including dogs and bats, are present in this country. A case acquired in New Zealand would have a significant public health impact as well as serious consequences for agriculture. Imported cases in returning travellers do not require any public health action. For completeness, bat lyssa virus (found in Australian bats) should be specified under the rabies heading. Rheumatic fever Rheumatic fever is a serious disease with long-term consequences. It can cause cardiac problems particularly in children aged 3 to 15. Rheumatic fever follows infection with streptococcal group A infections of the upper respiratory tract. It is rare in most developed countries, with the exception of New Zealand, where rheumatic fever affects a disproportionately high proportion of Māori and Pacific children. Once diagnosed, a patient requires monthly penicillin injections for up to 10 years to prevent long-term health problems. Notification allows for prompt and appropriate follow-up; for example, providing treatment to the patient and prophylactic treatment and advice to contacts. Ongoing surveillance provides information on patterns of the disease, and an indication of the efficacy of programmes designed to lower the incidence of rheumatic fever in New Zealand. Rickettsial diseases Rickettsial diseases are not currently considered endemic in New Zealand, but there is potential for them to become established. Returning travellers account for the majority of cases, but locally-acquired infections require a rapid public health response to identify and contain the source of infection. Rickettsial disease should be retained as a heading, with the diseases of interest specified. These will include Q fever, endemic and murine typhus, Queensland tick typhus, and Rocky Mountain spotted fever.


Salmonellosis This is a significant cause of food-borne illness. Notification helps to identify and control of the source of infection, such as excluding affected food-handlers, healthcare workers and childcare workers from work to prevent the spread of the disease. Surveillance can provide a general overview of disease patterns, although due to the nature of the illness, it is unlikely that the majority of cases of salmonellosis are notified. Severe acute respiratory syndrome (SARS) SARS is a syndrome and not a specific diagnosis. It was added to the list of notifiable diseases in April 2003. SARS is usually associated with close contact with another case, abrupt onset of fever and systemic symptoms with a respiratory component, which progresses. Although there have been no confirmed cases in New Zealand to date, with international travel there is risk that a traveller could bring the syndrome into the country. Shigellosis Shigellosis is a significant cause of food-borne illness and should remain notifiable for the purposes of surveillance and control. As with other food-borne infections, food-handlers and other high-risk occupational groups should be excluded from work while they are infected. Trichinosis Trichinosis is rare in New Zealand, but has been recorded in pig herds as recently as the late 1990s. Cases of human infection are usually found in returning travellers; cases acquired in New Zealand are rarer still. Trichinosis can cause serious disease. It is usually transmitted by eating infected pork products. While it cannot be transmitted person-to-person, an infected pig herd could potentially cause an outbreak. This is of particular concern given the relatively common practice of backyard slaughtering and pig hunting in parts of New Zealand. Tuberculosis (currently notifiable under the Tuberculosis Act 1948) Tuberculosis rates in New Zealand have remained stable since the late 1980s. Control of tuberculosis involves tracing of close and casual contacts, meaning that its status as a notifiable disease enables better management as well as enhanced surveillance. Tuberculosis should continue to be notifiable under the current legislative framework (ie, under the Tuberculosis Act). Duty to notify cases of tuberculosis should fall under any new public health legislation. Typhoid and paratyphoid fever Most cases of typhoid and paratyphoid are imported, although there may be chronic carriers in the community. Typhoid is a serious and treatable disease. Reported cases are subject to detailed investigation to identify and control the source of infection.

Typhoid and paratyphoid can be food-borne, and have been reported in contaminated shellfish and fruit overseas. These diseases have a relatively high outbreak potential and should remain notifiable.


Viral haemorrhagic fevers This category includes Marburg and Ebola viruses, and Lassa fever. Although no cases have been reported in New Zealand, these diseases would pose a significant threat if found here.

A rapid and comprehensive public health response and sensitive surveillance would be warranted if a case or outbreak of a viral haemorrhagic fever was reported. Yersiniosis Yersiniosis is a significant cause of food-borne illness, which requires investigation to identify and control the source of infection. Occupational restrictions may be required to prevent the spread of the disease from food-handlers, early childhood and healthcare workers.

Question 2: Do you agree that these diseases and conditions should be retained on the schedule of notifiable diseases? Question 3: If not, which diseases or conditions should be removed, and why? Question 4: Are there any significant resource issues for you or your agency with respect to retaining of these diseases and conditions on the schedule? If so, what are they?

3.2.4 Diseases and conditions recommended for addition to the list The diseases and conditions discussed in this section were considered for inclusion in the schedules due to emerging public health concerns, updated means of monitoring particular diseases, and responses to changing legislation. Adverse reactions to vaccines It is proposed that adverse reactions to vaccines be added to the schedule of notifiable diseases. Immunisation plays an important role in protecting the community from potentially harmful diseases. Adverse reactions to vaccines do occur, ranging from acute anaphylactic reactions that are rare but life threatening, to mild or moderate reactions around the site of the injection. Notification of adverse reactions to vaccines is important for a number of reasons. Fear of adverse reactions is a common reason for children not to be immunised. More complete information on adverse reactions may provide a basis for more informed discussion on the relative risks and benefits of immunisation. Adverse reactions may pinpoint problems within the ‘cold chain’ – the process that preserves vaccines throughout their manufacture, transport and storage. Finally, adverse reactions


notifications may indicate that certain vaccines are not well tolerated in the population, suggesting that alternative vaccines may need to be found. The Centre for Adverse Reactions Monitoring (CARM) collects information on adverse reactions to all pharmaceuticals, including vaccines. The system is currently voluntary. Notification may encourage more complete reporting of adverse reactions to common vaccines.

Botulism Botulism is currently notified under the broad acute gastroenteritis category. It is proposed to list botulism separately on the list of notifiable diseases. Botulism is very rare in New Zealand, but is a serious disease that has outbreak potential. Notified cases require a response covering identification and control of the source of infection. Surveillance would identify outbreaks, as well as providing longer-term information on incidence trends.

Hazardous and other substance injuries It is proposed to add hazardous and other substance injuries to the list of notifiable diseases. Poisonings were notifiable under the Toxic Substances Act 1981, but this Act was repealed during the introduction of the Hazardous Substances and New Organisms Act 1996 (HSNO). The Toxic Substances Act required notification of all poisonings regardless of the source, and included accidental and deliberate exposure that resulted in admission to hospital. When the requirement for notification of toxic substances injuries was transferred to HSNO, the category was broadened to include all injuries (ie, inhalation, corrosive burns) but did not include foods, medicines or other materials that do not trigger the HSNO definitions of a hazardous substance. The proposal to make a broader range of injuries notifiable under health legislation requires no change to HSNO requirements, as it includes injuries caused by substances defined in HSNO as hazardous, as well as those caused by other substances. Reports of hazardous substances injuries that require hospital admission would continue to be notifiable under HSNO. This proposal would therefore not change that situation, as information on admissions is available to public health from ERMA. The collection of information on hazardous and other substances injury may result in some dual reporting

Question 6: Do you agree that botulism should be made notifiable separately, rather than under acute gastroenteritis? If not, why not?

Question 5: Do you agree that adverse reactions to vaccines should be made notifiable? If not, why not?


of cases, particularly in those cases requiring hospitalisation. However it would capture the potentially large number of hazardous substances injuries that are not seen in hospital. Hazardous substances injuries are of public health importance for a number of reasons. Exposure to some hazardous substances can cause or contribute to health problems, acute and chronic. Reports of such injuries can also highlight issues such as the unsafe use, storage and transport of hazardous substances that cause illness and that may put others at risk. Reports of hazardous substances injuries could also identify materials that are being sold or made available outside normal restrictions; for example non-occupational injuries related to chemicals that should not be available to the general public. Poisonings are the second most common reason for hospitalisation of children under 14 years, accounting for approximately 500 admissions per year. Although death is a rare outcome (approximately one death per year in the 0–14 years age group), there are serious consequences from poisonings with some substances. Almost all childhood poisonings are preventable. Although information is currently collected using hospital discharge data and reports from the National Poisons Centre, it is likely that making this condition notifiable would provide a more complete picture.

Smallpox It is proposed that smallpox be added to the list of notifiable diseases. Smallpox is of concern due to publicity about the possibility of the virus being used as an agent of bioterrorism. Smallpox has been officially eradicated, although stocks are known to be held in two laboratories worldwide, with possible storage in other facilities. Vaccination against smallpox is currently being conducted in Europe and North America due to a perceived threat of the virus being used maliciously. If smallpox were released, cases could be imported into New Zealand. Any cases of suspected smallpox would require an immediate public health response, and highly sensitive surveillance to track any outbreaks.

VTEC (verotoxin-producing Escherichia coli) VTEC is currently captured under the broad acute gastroenteritis category. It is proposed to list VTEC separately on the list of notifiable diseases. Given VTEC’s increase in incidence and the potentially serious nature of the disease, it is recommended that VTEC become notifiable in itself. VTEC has emerged since 1993 and

Question 8: Do you think smallpox should be made notifiable? If not, why not?

Question 7: Do you think hazardous and other substance injuries should be made notifiable? If not, why not?


is becoming increasingly common. It is a relatively serious disease and as such should be monitored separately from other forms of acute gastroenteritis.

3.2.5 Diseases requiring sector input regarding inclusion or removal from the schedules of notifiable diseases

The following diseases require additional sector input before recommendations can be made. Acute gastroenteritis The purpose of the category is to collect notifications of diseases that present with acute gastrointestinal symptoms (vomiting and diarrhoea). The category currently includes acute gastroenteritis in two or more linked persons (common food or water source); an affected person in a high-risk occupation (eg, food-handlers); or single cases of botulism, chemical poisoning or verotoxin-producing infections (eg, E-coli 0157). In practice, reports from clinicians and public health units suggest that this category is not widely used, and that awareness of the fact that acute gastroenteritis is notifiable varies among practitioners. It is therefore likely that notified cases of acute gastroenteritis do not represent anything like the total number of cases presenting for treatment. The data collected via notification does allow for outbreaks to be identified and control measures to be initiated on notification, rather than awaiting laboratory confirmation of the causative pathogen. The intention is that once cases are confirmed as being caused by a specific disease, those cases will be counted under individual disease headings (ie, cryptosporidiosis, shigellosis), if the causative pathogen is notifiable. Effective retention of the acute gastroenteritis category would require an emphasis on awareness of the notifiable status of the diseases covered, a requirements for timely notification, and the rapid transfer of cases from acute gastroenteritis to specific disease headings as soon as the pathogen is confirmed (where appropriate).

Question 9: Do you agree that VTEC should be made notifiable individually rather than under the heading of acute gastroenteritis? If not, why not?

Considering all the diseases and conditions considered for inclusion: Question 10: If these diseases and conditions were added to the schedule of notifiable diseases and conditions, would there be resource implications (either positive or negative) for you or your agency? If so, what would they be? Please give details for each disease or condition.


Campylobacteriosis This a food- and water-borne disease. The route of transmission is usually animal to human, via food, contaminated water or other direct contact with the faeces of an infected animal. Person-to-person infection is possible, but not common. For some time, the incidence of campylobacteriosis has risen steadily, to the point where New Zealand has the highest reported rate of notifications per 100,000 people in the developed world: 10,148 cases were notified in 2001 (accounting for approximately 48% of all notifiable disease cases) (ESR 2002). There is no clear reason for the high rate of reported incidence in New Zealand. Studies using notification data are being undertaken to define the aetiology of campylobacteriosis. There have been a number of large outbreaks from common sources (such as the 187 cases of waterborne campylobacteriosis that occurred in Te Aute College in May 2001), however, sporadic cases make up the majority of notified cases. Campylobacteriosis is of concern due to the number of people who can be infected from a single source (eg, a communal water supply or food source). In most otherwise-healthy people, campylobacteriosis causes stomach cramps, diarrhoea, fever and vomiting. It can be a serious disease, particularly among the very young, elderly, or immuno-compromised individuals. Notification of campylobacteriosis can inform public health action, in particular where notification identifies an outbreak with a common source. Public health measures to control the source and limit further infections can be taken. Investigation of sporadic cases is more difficult, and does not often result in identification of a source of infection. Due to the number of cases of campylobacteriosis that are notified, and the likelihood that notifications will not often result in public health action, campylobacteriosis cases are not routinely investigated in some areas. For example, central and north-west Auckland accounted for 576 notifications in 2001, however Auckland public health services do not investigate campylobacteriosis cases unless they are linked (two or more from the same source), or affect high-risk groups, including childcare workers and attendees, healthcare workers and food-handlers. This measure concentrates resources where they are most likely to have an affect on disease patterns. From a surveillance perspective, point prevalence surveys and, in the future, laboratory-based surveillance (potentially including laboratory-based notification) may be more efficient and appropriate means of tracking the trends of campylobacteriosis infection. Requiring laboratory-based reporting or notification would also provide a mechanism for alerting public health authorities to potential outbreaks without relying on timely notifications to be received by public health services. If necessary, laboratory-based notification could provide named patient information used for individual follow-up.

Question 11: Do you think that acute gastroenteritis should be removed from the schedule of notifiable diseases? If not, why not?


These measures may represent a more appropriate and timely way of monitoring trends in campylobacteriosis then notifications.

Hepatitis C Hepatitis C is a viral disease. It is most commonly spread through shared use of equipment for intravenous drug use. Hepatitis C infection was previously associated with blood products, but routine testing of donated blood and blood products now prevents the spread of the disease to blood product recipients. Reports of hepatitis C are relatively rare – notified cases gave a rate of 1.6 per 100,000 in 2001 (ESR 2002). It is likely that this figure greatly underestimates the true rate of incidence (Ministry of Health 2002a). There is no vaccine for hepatitis C. Acute hepatitis C infection is most commonly asymptomatic, with a small proportion of patients presenting with acute symptoms after contracting the disease. Chronic carriage of hepatitis C is common among those who contract the disease; chronic carriers remain infectious. Hepatitis C may progress to cirrhosis over time. Acute cases of hepatitis C are currently notifiable in New Zealand; chronic infection is not notifiable. Public health action may result from notifications of acute hepatitis C infection, for example, cases that may be linked to healthcare facilities where identifications and control of the source can prevent further cases. However, there is no specific public health response for most notifications of acute hepatitis C and notifications of acute cases are of limited value for surveillance purposes. Notification catches a small proportion of people affected and does not provide reliable information on the burden of chronic disease. Chronic hepatitis C is not notifiable. If chronic hepatitis C infection was made notifiable, a more complete picture of disease patterns may be presented. However since no routine screening for hepatitis C is carried out, notified cases would comprise those patients who were either known by their health practitioners to be high-risk for the disease, or those presenting with symptoms that suggested hepatitis (this is an unknown quantity). As such, notification of chronic hepatitis C, like acute hepatitis C, is likely to be of limited value for surveillance. Interventions to control the disease, including advice to the patient on limiting behaviour that could spread the disease, is most appropriately given by the patients’ doctor. It is unlikely that notifications of chronic carriage of hepatitis C would add significantly to knowledge of the disease patterns, nor would it result in more effective public health action.

Question 12: Do you think that campylobacteriosis should be retained or removed from the schedule of notifiable diseases? Why? Question 13: Do you think is it feasible to limit notifications of campylobacteriosis to high-risk cases (childcare and healthcare workers, linked cases, food-handlers) only? Why, or why not?


Other options for surveillance of hepatitis C may be more appropriate than notification, and could include focused screening studies of at-risk populations or the general population, to provide more accurate and complete information on the prevalence of hepatitis C.

HIV and AIDS HIV is the virus that causes AIDS, a disease that primarily affects the immune system. HIV is transmitted through blood and bodily fluids, and is most commonly transmitted sexually. There is no vaccine against HIV, although recent advances in treatment regimes mean that HIV is now treated as a chronic infection rather than an invariably fatal disease. Many people live with the HIV virus for many years before (or if) they develop AIDS. Although HIV/AIDS cases do not usually require public health interventions, surveillance of these diseases is important. HIV/AIDS is a severe and sometimes fatal disease, currently causing a worldwide pandemic. The costs associated with HIV/AIDS can be considerable, both to the health sector and, more importantly, to affected individuals and communities, with particular communities bearing a disproportionate burden of disease. A large sector of the population is potentially at risk of contracting HIV/AIDS, underlining the importance of ongoing public health programmes to increase awareness, and educate people on preventive strategies. At present, AIDS is a notifiable disease. The rate of AIDS notified in the New Zealand population is relatively stable at 0.7 cases per 100,000 (ESR 2002). In contrast, infection with the HIV virus is not notifiable in New Zealand. Information on HIV infection is collected, using anonymised information about people found to be infected with the virus (confirmed by a Western Blot antibody test through reference laboratories). Since 1996, the AIDS Epidemiology Group has requested additional information from the clinician who organised the test, including the age, sex, ethnicity and likely mode of infection. This current system allows comprehensive epidemiological surveillance of HIV. Viral load testing picks up cases who may not have been diagnosed in New Zealand. When HIV testing was first available in New Zealand in 1985, little medical intervention could be offered to those infected. One reason for HIV not being made notifiable at that time was that it was felt this might deter people from being tested. While individuals can now be offered effective treatment, there is still a stigma around the diagnosis, especially in certain communities. Making HIV notifiable may still deter some people from seeking testing.

Question 14: Do you think that hepatitis C should be removed from or retained on the schedule of notifiable diseases? If not, why not?


There are a number of options for collecting information on HIV/AIDS in New Zealand, including making HIV and AIDS notifiable; removing AIDS from the list of notifiable diseases (immediately or in the future); making HIV notifiable; or retaining the status quo. Given that the current surveillance system is comprehensive, it may be also be appropriate to consider not notifying AIDS or HIV. The rationale for removing AIDS from the list of notifiable conditions is that AIDS notifications provide limited information on the spread of HIV. Given that the time between infection with HIV and development of AIDS is currently lengthening as a result of treatment advances, AIDS notifications will relate to HIV infections that took place some time ago. The delay between infection and the development of AIDS means that any action in response to changing disease patterns will not relate to recent HIV epidemiology. Notification of AIDS has the following benefits.

• International comparisons can be made. • AIDS incidence is more likely to be complete than HIV incidence because it is

less dependent on testing patterns. • Trends in AIDS may provide some information on the overall effectiveness of

controlling the progression of HIV to AIDS. While personal information regarding any disease must be handled sensitively and confidentially, it is recognised that HIV/AIDS carries a very significant stigma among some communities. Any surveillance (including notification) of HIV should continue to use an anonymised code, such as the code currently used for AIDS notifications, respecting concerns for confidentiality and limiting the potential for surveillance methods (including notification) to act as deterrents against testing.

Sexually transmitted infections (STIs) A number of STIs are referred to under schedule 1, part 2, of the Health Act 1956. These diseases are, however, not notifiable (see section 3.2.7 for discussion of this part of the schedule). The discussion below refers specifically to chlamydia, gonorrhoea, and syphilis. Chancroid, non-specific urethritis, and venereal granuloma are also considered. HIV is discussed separately (see above).

Question 15: Do you think that HIV should be made notifiable? Why, or why not? Question 16: Should AIDS remain notifiable? Why, or why not? Question 17: Should both AIDS and HIV be notifiable? Why, or why not? Question 18: what other approaches to HIV/AIDS notification should be considered? Please give details.


A number of STIs are common in New Zealand.

• Chlamydia: 3238 cases were reported in 2001 (ESR 2002). The population rate is significantly higher than reported rates in Australia or Canada.13 New Zealand’s reported rate of chlamydia increased by 90% between 1996 and 2000.

• Gonorrhoea: 533 cases of gonorrhoea were reported in 2001 (ESR 2002). This rate is twice as high as Australia.

• Syphilis: 18 cases were reported in 2001. • No cases of chancroid, granuloma inguinale, or lymphogranuloma venereum

were reported. Data on non-specific urethritis is collected for men only (1054 cases in 2001) (ESR 2002).

If left untreated, a number of these STIs have serious sequelae, including infertility in men and women, pelvic inflammatory disease, ectopic pregnancy, and damage to the central nervous system. A number of cases may also be asymptomatic, increasing the risk of serious health problems. There is often no need for public health action or for cases to be followed up on a named-patient basis. GPs or specialist staff from sexual health clinics may undertake contact tracing on a patient’s behalf in some circumstances, although patients are encouraged to contact their partners(s) directly. Public health units are not usually involved in contact tracing. There are currently two sentinel surveillance systems for STIs:

• clinic-based (from sexual health clinics, youth health clinics and family planning clinics)

• laboratory-based. Both systems have limitations. Cases seen by GPs, hospital physicians, and private specialists are not captured by the clinic-based system. The laboratory-based system, which covers chlamydia and gonorrhoea, is currently limited to Auckland and the Bay of Plenty. STIs may be well-suited to anonymised laboratory-based notification. As with all notifiable diseases, undiagnosed STIs will be missed. Data collected on STIs is incomplete. The Ministry of Health’s Sexual and Reproductive Health Strategy (Ministry of Health 2001c) indicates that better reporting of STIs is necessary to ensure the good sexual health of New Zealanders. Although the option of physician notification is not discussed in this Strategy, notification could provide more comprehensive data to assess trends and variations in STI incidence by age, gender, and ethnicity. Information on incidence continues to be important in the planning and targeting of health promotion campaigns, in service provision, and to gauge the

13 Direct comparison of population rates of diseases between countries is difficult due to differences between surveillance reporting rates and accuracy of data. This issue is more likely to affect STI data due to sensitivity of information, as patients may be less likely to provide complete data


effectiveness of interventions. Laboratory-based notification may enable more complete data collection. There are potentially negative consequences of making STIs notifiable. Given that STIs involve highly personal and often sensitive issues that require trust and confidentiality, notification may deter patients from seeking help if doctors were required to provide information to the medical officer of health. Many STIs can have serious health effects for patients if left untreated. Thus potentially negative effects could outweigh the benefits of more detailed information that may be collected through notification. It is debatable whether making some or all STIs notifiable will increase the amount and quality of data collected and this issue requires discussion within the sector to determine the most appropriate approach.

3.2.6 Condition recommended for removal from the notifiable diseases schedules

The following condition is recommended for removal from the schedules of notifiable diseases and conditions: Decompression sickness Primarily involving divers (recreational and professional), cases of decompression sickness require no public health response, and overall have little impact on the public health. Clusters of cases involving divers from particular areas or involved with particular operations would be more appropriately reported to, and handled by OSH.

Question 19: Do you think that STIs should be made notifiable or not? Why, or why not? Question 20: If yes, which STIs should be made notifiable?

Question 23: Do you agree that decompression sickness be removed from the list of notifiable diseases and conditions? If not, why not? Question 24: If decompression sickness were removed from the schedule of notifiable diseases and conditions, would there be resource implications (either positive or negative) for you or your agency? What would these be?

Question 21: Do you agree with the proposals outlined in this section? If not, why not? Please specify the disease under discussion. Question 22: If these diseases were removed or added to the schedule of notifiable diseases and conditions, would there be resource implications (either positive or negative) for you or your agency? What would these be?


3.2.7 Diseases contained in Schedule 1; part 2 At present, a range of diseases of public health importance are identified in schedule 1, part 2 of the Health Act. These diseases are mainly STIs, and diseases of importance to children, such as varicella-zoster infection, streptococcal group A infection, pediculosis, and scabies. These diseases are not notifiable. Medical officers of health can use powers within the Health Act to control these diseases, if required, although this is very rarely used. For example, under the Education Act 1989, school principals are able to exclude students from attending school if they have a communicable disease (as defined under the Health Act and subsequently by the inclusion of diseases in part 2 of the first schedule of the Health Act). Diseases contained in this part of Schedule need to be considered in light of other relevant legislation. It is recommended that these diseases remain in legislation to facilitate the prevention and control of disease, and to retain consistency with other legislation and with powers contained within the Health Act.

Question 25: Should schedule 1 part 2 remain in the Health Act? Why, or why not? Question 26: Should any diseases in schedule 1 part 2 be considered for inclusion on the list of notifiable diseases? If so, which diseases, and why? Question 27: Are there other diseases that should be included in schedule 1 part 2 of the Health Act? If so, which diseases, and why?


3.2.8 Summary of recommendations for diseases The following tables summarise, in full, the recommendations of the project team and reference group.

Diseases recommended for retention on the list of notifiable diseases

Anthrax Meningoencephalitis – primary amoebic Arboviral diseases (specifying diseases of interest)

Mumps

Brucellosis Neisseria meningitidis invasive disease Cholera Pertussis Creutzfeldt-Jakob disease and other spongiform encephalopathies

Poisoning arising from chemical contamination of the environment

Cysticercosis and taeniasis Plague Cryptosporidiosis Poliomyelitis Diphtheria Rabies Giardiasis Rheumatic fever Haemophilus influenzae B Rickettsial diseases Hepatitis A Rubella Hepatitis B Salmonellosis Hepatitis (Viral other, specifying D, E, F and G)

Severe acute respiratory syndrome (SARS)

Hydatid disease Shigellosis Lead absorption equal to or over 15µg/dl

Tetanus

Legionellosis Trichinosis Leprosy Tuberculosis Leptospirosis Typhoid and paratyphoid fever Listeriosis Viral haemorrhagic fevers (specify

diseases of interest) Malaria Yellow fever Measles Yersiniosis

Diseases recommended for addition to the schedule of notifiable diseases

Adverse reactions to vaccines Smallpox Botulism Verotoxin-producing Escherichia coli Hazardous and substances injuries Diseases requiring sector input regarding inclusion or removal

from the schedules of notifiable disease Acute gastroenteritis HIV and AIDS Campylobacteriosis Sexually transmitted infections Hepatitis C


Condition recommended for removal from the schedules of notifiable diseases

Decompression sickness

Question 28: Are there any other diseases or conditions that should be notifiable? Why?

Question 29: What costs, if any, would the proposed changes have for your

organisation? Please include staff time costs. 3.3 Organisation of the list of notifiable diseases and

conditions Amendments to the list of notifiable diseases would require amendment of the Health Act. If and when such amendments are made, this could be a prudent time to alter the scheduling and classification of notifiable diseases to make the list easier to follow and more logical in its groupings and layout. In addition this section proposes assigning a recommended notification timeframe for each notifiable disease and condition to promote more timely notification, including notification on suspicion, where required.

3.3.1 Options for grouping notifiable diseases and conditions At present, the list of notifiable diseases is divided into schedules depending largely on reporting lines: who notifies what to whom. The project team’s initial analysis indicates that the current grouping of diseases and conditions by notification lines is of limited value. There are other listing options that would be more logical, and easier to follow for those notifying diseases. These are described below. Option 1: Current list of diseases and conditions using categories of disease This option retains the current headings of diseases, simply removing the division of diseases along reporting lines. The schedules have a number of categories covering more than one disease or condition:

• arboviral diseases • acute gastroenteritis • rickettsial diseases • viral haemorrhagic fevers • hepatitis (viral non-specified) • poisoning resulting from chemical contamination of the environment.


With the exception of acute gastroenteritis, the current categories could be retained, with all diseases and conditions not covered by a category being listed separately. This option has the advantage of familiarity, and is not tied to particular groupings used in other documents or legislation. Option 2: Communicable Disease Control Manual groupings The Communicable Disease Control Manual (Ministry of Health 1998) is separated into several sections that make for easy navigation through the list of diseases. The headings used are:

• vaccine-preventable • food- and water- borne diseases • rare diseases • other notifiable diseases.

Adding a heading ‘Notifiable conditions (lead poisoning, poisoning from chemical contamination of the environment)’ would complete the list of notifiable diseases. Grouping diseases under headings related to disease type would represent a significant change in the way the schedules are currently arranged. The advantages would be a more logical grouping of diseases, easier navigation of the schedules, and easier placement of any diseases or conditions added to the schedules in future. Option 3: Grouping diseases by recommended notification timeframe Effective public health action often relies on rapid notification to identify and control the source of disease to limit the spread of infection. Other diseases do not require an immediate public health response, and regular routine notification may be appropriate for surveillance purposes. The list of notifiable diseases and conditions could be grouped according to how urgent notification is, as follows:

• immediate notification required – as soon as possible (would almost always require notification on suspicion) (eg, viral haemorrhagic fevers, plague, meningococcal disease)

• urgent notification required – within 24 hours (eg, arboviral disease, legionellosis, measles)

• weekly notification (eg, brucellosis, tetanus, trichinosis) • routine monthly notification (data could be notified anonymously) (eg, AIDS,

CJD, hepatitis C).

Appendix 4 comprises a table listing diseases and conditions and estimated notification timeframes. Option 4: Alphabetical listing Under this option all diseases are listed alphabetically. There is no grouping of diseases.


It is possible that a combination of options could be used. For example, each disease under a heading is assigned a recommended notification timeframe, with some diseases being notified via anonymous data.

3.4 Conclusions Following the 1996 revisions to the list of notifiable diseases, this initial review by the project team and reference group has concluded that the majority of diseases on the list remain relevant and important in the context of protecting public health. Some changes are recommended, and the views of health agencies, individuals working in the sector and members of the public are valued. The options for grouping diseases give approaches that could be used within the current legislative framework and transferred into new legislation, or they could be implemented when the new public health legislation is drafted. Final decisions on the make-up of the list of notifiable diseases and the categories under which they are listed will be informed by this consultation process. The processes and options outlined in this document are intended to provide a guide for discussion in the sector.

Question 30: Do you agree that the grouping within the schedules of notifiable diseases and conditions should be revised? If so, which option do you prefer? Question 31: What other options are there for grouping notifiable diseases and conditions?


4 Notification System Options This section examines the current notification system, with a brief analysis of its strengths and weaknesses. Several options amending the system are proposed. These proposed options fall under two broad headings:

• changes possible under the current legislative framework; and • options that could be implemented under proposed new legislation (the Public

Health Bill, currently under development). The timing of legislative development and implementation means that a staged approach to updating the notification system is likely to be the most realistic. For that reason, options for notification systems are presented as components that can be developed and established over time, as legislative changes and resources allow. 4.1 Introduction The WHO has identified an effective surveillance system as one that:

• considers diseases of high public health importance • provides timely, sensitive and representative data that is useful in terms of

preventing the spread of disease • facilitates the smooth flow of information from source to dissemination • is administratively simple and flexible enough to consider differing requirements

for different diseases • co-ordinates data collection systems and reduces duplication in collection of data; • provides easy access to information for those who need it • is cost effective • builds on existing resources and response capabilities • promotes the most effective use of health resources (material and human) • provides quality assurance • is supported by strong legislative frameworks • weighs individual privacy concerns with the disclosure of information for the

public good. A surveillance system can provide information that enables action and surveillance of identified diseases. Notification, as a component of an effective surveillance system, can provide this information effectively, efficiently, and responsively.

4.1.1 Notification systems in other countries Notification is an essential component of a number of disease surveillance systems throughout the world. These systems range from complete online notification by physicians and laboratories, to a central database (as with the SMInet system in Sweden),


14 to requiring physicians to report to appropriate public health authorities by certificate, telephone, fax, or email (as in England)15. A combination of laboratory-based notification and physician reporting is used in Australia,16 Canada,17 Ireland, Scotland,18 Sweden, and the United States of America. Notably, Ireland is currently developing Computerised Infectious Disease Reporting, an electronic system designed to integrate multiple clinical epidemiology and laboratory databases.19 Electronic dissemination of information from a designated central agency is also used in a number of countries, including Australia, Canada, Ireland, Scotland, and Sweden. This is either via an electronic weekly report, or via information on national disease surveillance websites. The literature review in (section 2.2.6) contains further discussion on the diseases notified in other nations. 4.2 Outline of New Zealand’s current notification system New Zealand has a passive notification system in which health providers send information to public health authorities. Notification of diseases involves a number of different organisations and individuals. Those directly involved and their roles are:

• clinicians – responsible for notifying cases of diseases and conditions that are notifiable under the Health Act, and other legislation.

• medical officers of health / public health services – receive information on cases of notifiable diseases; may seek additional information from GPs; investigate cases of disease where appropriate; initiate appropriate public health action; and load the case information onto EpiSurv (the central surveillance database).

• clinical laboratories – provide confirmation of cases of notifiable diseases and

conditions, where required.

• Institute of Environmental Science and Research (ESR) – manage and maintain EpiSurv; analyse and disseminate data on notifiable diseases; provide specialist reference laboratory facilities.

14 Swedish Institute for Infectious Disease Control, http://www.smittskyddsinstitutet.se. Accessed 14 February 2003. 15 PHLS Communicable Disease Surveillance Centre, April 2000 16 Communicable Diseases Network Australia, http://www.health.gov.au/pubhlth/cdi/nndss/nndss1.htm. Accessed 14 February 2003. 17 See Case Definitions for Diseases Under National Surveillance; Health Canada; 2000. 18 Inventory of Infectious Disease Resources in Europe, http://iride.cincea.org/. Accessed 17 February 2003. 19 Ibid.


• territorial local authorities – in some districts, investigate outbreaks of food- or water- borne diseases, and other diseases or conditions, as appropriate and in conjunction with public health services.

• Other notifiers including veterinarians, funeral directors, and pathologists – notify

cases of specified diseases and conditions, as required by the Health Act 1956. Figure 1 illustrates the components of the current notification system. Figure 1 Current notification system

Follow-up investigation of some diseases

Public health action

Return results Notifications

Specimens

Lab reports

Reports Data Specimens Reports EpiSurv

Epidemiological information disseminated

4.3 Weaknesses in the current system A notification system needs to collect information that is as complete, accurate, and timely as possible on each individual case of every specified disease and condition, to enable public health action and surveillance to take place. The current New Zealand system operates with some limitations that are common to most notification systems, and

Patient presents

Medical practitioner Territorial local

authorities

Medical officers

of health

Clinical laboratories

ESR Reference laboratory and data collection


which provide a guide for areas that require attention to improve the rate and quality of notifications, and the resulting information for action.

4.3.1 Completeness of notification and data quality Information provided to allow for public health action to be undertaken varies according to the disease. However, in general, complete information means providing:

• personal identifying details such as name, address, date of birth, National Health Index (NHI) number, ethnicity

• disease • source of disease • attending physician • date reported • occupation (where relevant).

As noted in the literature review, studies show that a (quite often large) proportion of notifiable disease cases are not notified at all, while others cases are notified but with incomplete information. This is why raising awareness of which diseases and conditions are notifiable is important. The notification system must provide the most efficient and user-friendly process possible to encourage notification, including required data fields such as ethnicity or NHI number. For example, ESR data shows that while the inclusion of NHI numbers (a unique personal identifier) is increasingly supplied with notifications, only 20.3% of notifications included an NHI number in 2002.

4.3.2 Timeliness To be most useful, information on cases of notifiable diseases needs to be received quickly. This is especially true for some cases of highly contagious diseases, to allow effective contact tracing, where there may be a common source, and for diseases where exposed people can be treated to prevent illness. Notifications of diseases may reach public health units too late for effective action to be taken. This may be due to practitioners notifying after laboratory confirmation rather than on suspicion, which is appropriate practice for some but not all notifiable diseases. There are also anecdotal reports of practitioners only notifying once they have a number of cases to process. Workloads, barriers within the system, the need for greater awareness of the rationale for notification, and costs associated with notification (eg, resourcing or staff time), may be causal factors in delayed notification. Costs, including those relating to staff time, have been mentioned as being barriers to timely notification. Timeliness is also an issue with the confirmation of cases. In some circumstances, the ESR reference laboratory may confirm a case. The reference laboratory then has to report confirmation to the community laboratory, which in turn reports to the referring doctor. The doctor is then required to confirm the case with the public health service.


The number of links in the chain means that there are delays in cases being notified and/or confirmed.

4.3.3 Legislative restrictions The Health Act 1956 does not reflect current practices and concerns around notification. Most notably, it does not allow laboratories to make notifications directly to medical officers of health. Amendments to the schedules to the Health Act involve a time consuming process, meaning that the schedules of notifiable diseases and conditions are not easily updated to reflect emerging disease patterns. In New Zealand there are now legislative precedents for implementing more rapid changes to schedules in statutes. For example, the provisions to amend the controlled drug schedules in Misuse of Drugs Act 1975. Under this Act, amendments to schedules can now be made by way of Orders in Council, on the recommendation of the Minister of Health and after consideration by an expert advisory committee.

4.3.4 Technological advancements Using the right information technology can greatly improve the efficiency and user-friendliness of a notification system. IT systems have the potential to reduce costs related to time spent notifying and in following up and investigating cases, as well as providing more complete and timely data to add to the overall surveillance picture. Technology is constantly changing. It is unreasonable to expect that a notification system would be updated to keep pace with all new innovations. A notification system should, however, be flexible and current enough to interface with other systems that are feeding in and analysing data.

4.3.5 Privacy Most notifications currently require the collection and use of named patient data for public health action. Named patient data is not required to identify disease trends or to inform policy. While there appears to no concerns regarding the privacy of information in the current system, any amendments to the notification system must be made with a view to ensuring that personal information is protected, and that it is safely and appropriately collected, transferred, stored and used.

The Health Act was enacted long before the Human Rights Act 1989, the New Zealand Bill of Rights Act 1990 and the Privacy Act 1993. Careful consideration therefore needs to be given to how the obligations under the Privacy Act, the Human Rights Act and the New Zealand Bill of Rights Act can be met while allowing for notification to proceed.


While the current system – like any notification system – has weaknesses, it does provide a working basis for the development of options for the development and implementation of a more advanced and more effective notification system.

4.3.6 Reporting lines: who reports to whom? At present some diseases, primarily food- and water- borne diseases, are notifiable to the relevant territorial local authority (TLA) and the medical officer of health. The diseases involved are those commonly stemming from sources over which TLAs have a regulatory function, such as swimming pools, food premises and water supplies. TLAs report that this line of direct reporting is very rarely used, and that most practitioners report directly to the public health service, which involves the TLAs where appropriate. TLA involvement in disease investigation varies considerably across the country.

Question 32: What other weaknesses or deficiencies are there in the current notification system? Question 33: What are the potential approaches to remedying these weaknesses or deficiencies?

4.4 Notification systems options This paper identifies five options for the notification of diseases and conditions systems. These options are broad rather than focussing on implementation details. These are:

1. the status quo – attending medical practitioners notify medical officers of health of cases of notifiable diseases

2. improved status quo – the current system is maintained but measures to

improve the proportion of cases notified, and the quality and timeliness of data, are introduced

3. based on the status quo, an incremental process of updating the system to

include extensive use of laboratory-based notification 4. complete electronic notification to a centralised national surveillance unit 5. removal of the requirement to notify diseases (other than those subject to

international legal obligations).

Options 2, 3, and 4 are not mutually exclusive. Using a staged implementation process, option 2 provides a base for the development of option 3, and option 3 a base for option 4.


Under the current legislative framework there is limited scope for broad improvements to the system. Option 1 (retaining the status quo) represents a legislatively neutral option. The scope of the Health Act 1956 does not currently allow for the implementation of options 3 and 4. A number of amendments listed under option 2 may also be restricted by the current legislative framework. The review of the Health Act and the development of the Public Health Bill provide an opportunity to create a legislative framework that supports extended or different approaches to notification systems. Major areas of costs and the expected magnitude of costs have been indicated for each option although these costs are not detailed. Given limited resources in the health sector, progressing with any of the proposed options will require further consideration.

4.4.1 Option 1: Status Quo – attending medical practitioners notify medical officers of health of cases of notifiable diseases

The current system of notification has been outlined above. It provides information for public health response and surveillance. There are recognised weaknesses inherent in the system, primarily concerning data quality and the timeliness of both notification and data flow back to public health services and other notifiers. While option 1 may appear to be fiscally neutral, several issues need to be taken into account, including the increasing costs of information management, data collection and dissemination of information. In addition, subsequent changes to the schedule of notifiable diseases and conditions, as anticipated in section 3 of this discussion document, could lead to increases or decreases in the numbers of cases notified, and associated costs or savings.

4.4.2 Option 2: Improved status quo – current system is maintained but measures to improve the proportion of cases notified, and the quality and timeliness of data introduced

A number of amendments could be made to the current systems framework to streamline processes and ensure that data is collected, used, stored and disseminated in the most effective manner. While some minor amendments to the Health Act would be required, changes suggested in option 2 are primarily administrative and do not require extensive legislative change. A number of these options will facilitate the operation of the broader systems options presented in options 3 and 4. This option could therefore be a starting point for wider notification system changes prior to the introduction of new legislation.


The changes under this option come under the following broad headings:

1. reduce barriers to notification: a. allow flexibility in method of notification: fax, email, phone or post b. review the case report forms to ensure that they are as clear and concise as

possible c. investigate providing financial incentives to notify in a complete and

timely manner

2. improve awareness of the schedules of notifiable diseases and conditions: a. initiate an awareness-raising campaign for health professionals,

particularly around any changes to the schedules of notifiable diseases and conditions, and the purposes of notification

b. identify methods for providing feedback and access to information on notifiable disease and conditions trends and results of notifications

3. expand the range of practitioners who can notify to include nurse practitioners,

midwives and other allied health professionals, as appropriate

4. provide for more rapid and responsive updating of the notifiable diseases and conditions schedules

5. address data quality issues:

a. raise awareness of reasons for notification b. encourage use of nationally consistent case report forms where possible,

including NHI numbers c. encourage consistent use of case definitions, updating where necessary to

take account of new techniques d. review case report forms to ensure that ethnicity is updated to reflect the

Ministry of Health’s standard (due for publication in June 2003)

6. remove the requirement for notifiers to notify some diseases to local authorities 7. provide guidelines and information for notifiers and patients regarding the

collection, transfer, storage and use of named patient information. A number of these options would have some financial implications which would be borne by different parts of the health sector. The main costs would be generated by educative and awareness raising campaigns, subsidy payments for notification, regulatory costs, and the development of privacy guidelines. Compliance costs for health practitioners may be higher than in the current system. A number of savings could also be generated by encouraging complete data collection when a case is first notified. As noted in option 1, the list of notifiable diseases will affect the costs associated with any of these proposals.


4.4.3 Option 3: Based on the status quo – an incremental process of updating the system to include extensive use of laboratory-based notification

This option builds on the current system by providing a new mechanism allowing medical officers of health to receive notifications directly from laboratories as well as from medical practitioners. Medical practitioners will retain the ability to notify a disease on suspicion. Public health services would retain responsibility for updating EpiSurv, including updating any cases notified on suspicion. Care will be needed to minimise duplication of records. Designated staff within public health services would have read-only access to notifications from other regions to allow immediate comparison of disease rates where necessary (at present, public health services can see only data from their own area). The minimum required dataset would depend on the disease and the purpose for which it is notified. Identifying information is likely to be necessary for diseases requiring public health action. Anonymised data or aggregate data would suffice for diseases for which there is no public health action taken (eg, CJD). Information about the incidence of STIs and other diseases that are not notifiable but remain important for surveillance purposes could be reported directly from laboratories. All data on these cases would need to be anonymous. The benefits of expanded laboratory-based notification include timely notification to the public health service, capture of more cases of notifiable diseases and conditions referred for laboratory confirmation, and the removal of a number of steps in the current notification process.

Question 34: Do you agree that these improvements would be useful? Why not? Question 35: Do you agree that the requirement for practitioners to notify TLAs should be removed? If not, why not and what role would the TLA play in the notification process? Question 36: Given that health dollars are scarce, which of the above proposals do you consider to be the most important to implement? Question 37: What other systems improvements and related activities would you suggest, that work within the current legislative framework? Question 38: Would there be major resource implications (either positive or negative) for you or your agency from implementing these measures? What would these be?


A number of amendments proposed under option would facilitate the smooth implementation of a formalisation and expansion of laboratory-based notification; for example, addressing data quality issues and providing guidelines and information for notifiers and patients regarding the collection, transfer, storage and use of named patient information. Critical to the success of this option would be the ability of the system to provide information to the referring practitioner at the same time as information is provided to the medical officer of health. The relationship between doctor and patient must be preserved for the patient to have ongoing medical support where necessary for recovery, and to have a single point of contact for information on the illness. It is not appropriate for patients to be told of their diagnosis by a person other than the referring physician or the patient’s GP. Best practice guidelines could be developed to address this concern. Other risks include cases not being referred for laboratory testing and therefore not being picked up and the need to develop clear case definitions and laboratory test standards. Option 3 is neither fiscally or legislatively neutral. While costs to GPs (as primary notifiers) are reduced, implementation and compliance costs for others involved in the notification process are likely to increase. The main costs are associated with initial outlay and ongoing maintenance costs of IT systems changes to accommodate electronic links with laboratories, public health services and health practitioners, and payments for laboratory services. Regulatory costs would be incurred because legislative amendment is required to allow laboratories to notify cases directly to a medical officer of health, or to confirm cases on EpiSurv. These costs will vary depending on the number of diseases contained on the notifiable disease schedules. Figure 2 describes a system that could be used for diseases and conditions that require public health action, and those that do not. Figure 3 describes a possible adjunct system for diseases and conditions that do not require a public health service response.


Figure 2 Option 3: Notification of all diseases and conditions

requiring public health action


Shall notify on suspicion

Lab Results Specimens

Direct notification

Data Specimens EpiSurv

Epidemiological information disseminated (paper and electronic means)

Medical Officers

of Health

Health Practitioner

Hospital and community laboratories


Territorial Local Authorities

Medical Officers

of Health


Patient presents with illness


Figure 3 Option 3: Alternative option for notification of diseases that do not require public health action (only)

Notification on lab confirmation or clinical diagnosis

Lab Reports Specimens

Data Specimens EpiSurv

Epidemiological information disseminated (paper and electronic means)

Question 39: Under option 3 (and option 4), laboratories would notify some cases of diseases directly to the medical officer of health, instead of GPs being responsible. Do you agree/disagree with this approach? Why? Why not? Question 40: Under option 3 (and option 4), the Health Act would be amended to state that territorial local authorities would no longer need to be notified of cases of diseases or conditions (note that current arrangements relating to investigation of cases and outbreaks are not affected). Do you agree/disagree? Why?

Question 41: Do you agree that there should be a different process for diseases and conditions that do not require a public health response (removing direct notification of these cases)? Question 42: Would there be financial/resource implications (either positive or negative) for you or your agency from implementation of option 3? What would these be?

Medical Officers

of Health

Health Practitioner





4.4.4 Option 4: Complete electronic notification to a centralised national surveillance unit

This option describes a completely electronic notification system with information accessed via a web-based system. Hospital and community laboratories, with support from ESR reference laboratories, would notify all cases of notifiable diseases to the medical officer of health at the public health unit. The health practitioner requesting the test would receive the result at the same time as the local medical officer of health. The result would include identifying information to allow the medical officer of health to undertake public health action as appropriate. As with option 3, the patient–health practitioner relationship must be preserved, with the patient having a single point of contact for the duration of their illness. Health practitioners would retain the ability to notify a medical officer of health on suspicion of diagnosis of a disease requiring immediate public health action. Health practitioners would not otherwise initiate the notification process. Laboratories would also send details of confirmed cases to a central consolidated database. This database would be maintained by one organisation – either ESR or another designated central agency. The designated agency would be responsible for data matching and integration. Conceivably, a variety of organisations may add information to the database, including government departments such as OSH and MAF. Amendments proposed under options 2 and 3 would ensure that privacy issues are taken into consideration. For national surveillance purposes, information would be loaded onto a secure web-based system. Aggregated or anonymised data (only) would be stored on the database. Varying levels of access to information would be granted to users, ranging from full access to information for medical officers of health to limited access to aggregated data for researchers, policy makers and related government departments. Option 4 could be based on the platform created by options 2 and 3, or implemented from the status quo, if supporting legislation was introduced. While a long-term option, some steps in previous options would be redundant if option 4 was implemented as one phase. The development of a completely electronic system has significant associated costs. A number of other amendments could be introduced before the development of this system, so there may also be significant variation in implementation costs, depending on timing (ie, high costs if established now, lower cost if established after some of the proposals noted in option 3 are implemented). The main costs associated with this option are implementation costs for IT systems and the establishment of a centralised database, as well as ongoing maintenance costs. There may be some variation in these costs, depending on the number of diseases contained within the notifiable diseases schedules. Figure 4 describes option 4.


Diagram 4.4 Option 4: Complete electronic notification to a centralised national surveillance unit


Notify on suspicion Lab reports Specimens

Direct notification

Dissemination of Information to end users

Question 43: Would there be financial/resource implications (either positive or negative) for you or your agency from implementation of Option 4? What would these be?

4.4.5 Option 5: Removal of the requirement to notify diseases from the legislation (other than those subject to international legal obligations)

This option would require legislative amendment to remove mandatory reporting of any diseases other than those for which New Zealand has international reporting obligations. Information on the incidence of disease would be collected using voluntary reporting (laboratory-based and other methods such as collection of information from sentinel practitioners or clinics), various forms of epidemiological studies and periodic surveys, and data sharing between organisations and agencies. This option would significantly reduce compliance costs, and would simplify the process of information collection. However, data quality and completeness would probably be affected, as would the ability of public health services to respond to local and national public health incidents involving infectious diseases and other conditions.


Medical Officers

of Health

Health Practitioner

Clinical laboratories

Central database at central disease

surveillance centre

ESR

Territorial Local Authorities


This option may require some form of laboratory-based reporting to ensure that adequate information was gathered to inform service planning, evaluation and policy-making.

Question 44: Would there be financial/resource implications (either positive or negative) for you or your agency from implementation of Option 5? What would these be?

4.5 Comparison of options The advantages and disadvantages for each option are assessed below. Proposed administrative amendments have not been included in this discussion. Areas covered by this table include:

• the collection, use and storage of data • timeliness • access to and dissemination of data • resourcing • implementation • fulfilment of a public health function.

Advantages Disadvantages Option 1 Status quo

• Fulfils public health function and contributes to the prevention and control of disease in the community adequately

• Legislatively neutral – does not require legislative amendment in order to be implemented

• Is familiar to notifiers and users of the data

• Fiscally neutral (based on the current list of diseases, rates of notification, and technology costs)

• Does not always provide timely and accurate information to those who need it

• Significant under-reporting of some diseases

• Duplication of information collected by a number of different agencies

• Poor data-sharing abilities between the public health service

• Does not take into consideration recent technological advances

• Privacy issues are not fully addressed


Advantages Disadvantages Option 2 Improved status quo – the current system is maintained but measures to improve the proportion of cases notified, and the quality and timeliness of data, are introduced

• Provides improved data to fulfil the notification function, including improved rates of notification, improved data quality and heightened awareness of notification requirements

• Improved responsiveness to concerns about privacy

• Could be used as a first step toward implementing a more comprehensive system

• Legislation can be brought into line with current practice (eg, the role of TLAs)

• As for option 1; plus: • Unknown benefits from

interventions designed to change notifier behaviour

• Some suggested amendments would require legislative change

• Some proposed amendments may have significant implementation and compliance costs

Option 3 Updating the status quo – an incremental process of updating the system to include extensive use of laboratory-based notification

• Provides timely and accurate advice and information to the medical officers of health, allowing for swifter control and prevention of disease

• Potential increase in rate of notification

• Allows for anonymised, aggregate data to be collected for some diseases

• Rapid dissemination of information to those who need it

• Points of contact in the system are reduced, reducing the potential for data error

• Increased data sharing capabilities, including anonymised data

• Takes advantage of recent advances in technology

• Increased data quality better informs public health responses and surveillance data

• Software to monitor data quality could be developed

• May be less work for GPs

• Cases may not get picked up if laboratory tests are not requested or if a case is not notified on suspicion, meaning public health authorities may not be able to fulfil their public health duty

• Need safeguards to protect against the risk that a patient will get information from someone other than the attending health practitioner

• Data must be secure • Will have initial set-up costs

and additional ongoing maintenance costs

• Laboratories in some areas may not be resourced to handle the additional workload

• Requires implementation of the Public Health Bill as the legislative vehicle for change


Advantages Disadvantages Option 4 Complete electronic notification to a centralised national surveillance unit

• Provides timely and accurate advice and information to the medical officers of health, allowing for swifter control and prevention of disease

• Less time-consuming for medical practitioners, as not involved in reporting

• Notification can become part of administrative processes

• Consistent set of recorders, including case definition

• High rate of notification • High-quality data collected,

better informing public health responses and surveillance data

• Rapid dissemination of information to those who need it

• Access to aggregate information for other users

• Clear lines of responsibility for the collection, storage and dissemination of information

• Capable of collecting data on a wide range of diseases or conditions

• Automated evaluation could be built in

• Laboratory testing required for all suspected cases of notifiable disease

• Laboratories in some areas may not be resourced to handle the additional workload

• High initial establishment costs, and may have significant ongoing maintenance costs

• May be costly for laboratories, public health units, ESR or a central agency with a dedicated data collation function

• May take some time to develop appropriate software and systems

• Requires implementation of the Public Health Bill as the legislative vehicle for change

Option 5 Removal of the requirement to notify diseases from the legislation (other than those subject to international legal obligations)

• List of diseases does not need to be updated

• Reduces the burden of compliance for notifiers

• Capable of collecting data on a wide range of diseases or conditions

• Follows WHO trend to notify incidents of importance rather than specific diseases

• Will not provide timely, accurate information to prevent and control the spread of infectious disease

• Only depends on laboratory data • Many agencies involved in the

collection of information • May not provide adequate and

timely data to allow public health authorities to do their job

• Would only collect information on very specific incidents of disease

• Data may be patchy • Will not fulfil the objectives of

notification • Requires major legislative

amendments


Question 45: On balance, which systems option or combination of options do you prefer? Why? Question 46: Are there any further advantages or disadvantages to any of the options set out in this document? What are they? Question 47: What other systems options would you suggest? Please give details on the advantages and disadvantages of alternative approaches. Question 48: Are there any other either positive or negative financial or resource implications for you or your agency arising from any of the options set out in this document? What are they?


Appendix 1: Membership of Project Team and Reference Group

Project team members Matthew Allen Brigid Borlase David Clarke Mike Copeland Dr Nigel Dickson Anna Gribble Dr Phil Shoemack Bella Tuau

Project Manager Lead Analyst Solicitor Economist Technical Advisor Policy Analyst Public Health Medicine Specialist Health Protection Officer (Māori Health).

Reference group members Dr Tim Blackmore Infectious Disease Specialist Mike Fitzgerald Community Laboratories Dr Ben Gray Royal New Zealand College of General Practitioners

(nominated) Marion Guy New Zealand Nurses Organisation (nominated) Te Miringa Huriwai Māori representative Dr Jane Morgan Sexual Health Physician John Pepper New Zealand Institute of Environmental Health David Phillips Communicable Disease Centre, Institute of Environmental

Science and Research Dr Greg Simmons Medical Officer of Health, Auckland Regional Public Health. John Boyd Ministry of Health Nicola Chapple Ministry of Health Dr Douglas Lush Ministry of Health Stuart Powell Ministry of Health (DHB Service Analysis) Dean Alexander New Zealand Health Information Service


Appendix 2: Questions to guide submissions Section 2: Background 1: Do you consider notification an appropriate method for collecting information on disease for the purposes of disease prevention and control? If not, why not? (2.1.2) Section 3: Review of Notifiable Diseases and Conditions 2: Do you agree that these diseases and conditions should be retained on the schedule of notifiable diseases? (3.2.3) 3: If not, which diseases or conditions should be removed, and why? (3.2.3) 4: Are there any significant resource issues for you or your agency with respect to retaining these diseases and conditions on the schedule? If so, what are they? (3.2.3) 5: Do you agree that adverse reactions to vaccines should be made notifiable? If not, why not? (3.2.4) 6: Do you agree that botulism should be made notifiable separately, rather than under acute gastroenteritis? If not, why not? (3.2.4) 7: Do you think hazardous and other substance injuries should be made notifiable? If not, why not? (3.2.4) 8: Do you think smallpox should be made notifiable? If not, why not? (3.2.4) 9: Do you agree that VTEC should be made notifiable individually rather than under the heading of acute gastroenteritis? If not, why not? (3.2.4) Considering all the diseases and conditions considered for inclusion: 10: If these diseases and conditions were added to the schedule of notifiable diseases and conditions, would there be resource implications (either positive or negative) for you or your agency? If so, what would they be? Please give details for each disease or condition. (3.2.4) 11: Do you think that acute gastroenteritis should be removed from or retained on the schedule of notifiable diseases? If not, why not? (3.2.5) 12: Do you think that campylobacteriosis should be retained or removed from the schedule of notifiable diseases? Why? (3.2.5) 13: Do you think is it feasible to limit notifications of campylobacteriosis to high-risk cases (childcare and healthcare workers, linked cases, food-handlers) only? Why, or why not? (3.2.5)


14: Do you think that hepatitis C should be removed from or retained on the schedule of notifiable diseases? If not, why not? (3.2.5) 15: Do you think that HIV should be made notifiable? Why, or why not? (3.2.5) 16: Should AIDS remain notifiable? Why, or why not? (3.2.5) 17: Should both AIDS and HIV be notifiable? Why, or why not? (3.2.5) 18: What other approaches to HIV/AIDS notification should be considered? Please give details. (3.2.5) 19: Do you think that STIs should be made notifiable or not? Why, or why not? (3.2.5) 20: If yes, which STIs should be made notifiable? (3.2.5) 21: Do you agree with the proposals outlined in this section? If not, why not? Please specify the disease under discussion. (3.2.5) 22: If these diseases were removed or added to the schedule of notifiable diseases and conditions, would there be resource implications (either positive or negative) for you or your agency? What would these be? (3.2.5) 23: Do you agree that decompression sickness should be removed from the list of notifiable diseases and conditions? If not, why not? (3.2.6) 24: If decompression sickness were removed from the schedule of notifiable diseases and conditions, would there be resource implications (either positive or negative) for you or your agency? What would these be? (3.2.6) 25: Should schedule 1, part 2, remain in the Health Act? Why, or why not? (3.2.7) 26: Should any diseases in schedule 1, part 2, be considered for inclusion on the list of notifiable diseases? If so, which diseases, and why? (3.2.7) 27: Are there other diseases that should be included in schedule 1, part 2, of the Health Act? If so, which diseases, and why? (3.2.7) 28: Are there any other diseases or conditions that should be notifiable? Why? (3.2.8) 29: What costs, if any, would the proposed changes have for your organisation? Please include details of staff time costs (3.2.8) 30: Do you agree that the grouping within the schedules of notifiable diseases and conditions should be revised? If so, which option do you prefer? (3.3.1) 31: What other options are there for grouping notifiable diseases and conditions? (3.3.1)


Section 4: Notification systems options 32: What other weaknesses or deficiencies are there in the current notification system? (4.3.6) 33: What are the potential approaches to remedying these weaknesses or deficiencies? (4.3.6) 34: Do you agree that these improvements would be useful? If not, why not? (4.4.2) 35: Do you agree that the requirement for practitioners to notify TLAs should be removed? If not, why not and what role would the TLA play in the notification process? (4.4.2) 36: Given that health dollars are scarce, which of the above proposals do you consider to be the most important to implement? 37: What other systems improvements and related activities would you suggest, that work within the current legislative framework? (4.4.2) 38: Would there be major resource implications (either positive or negative) for you or your agency from implementing these measures? What would these be? (4.4.2) 39: Under option 3 (and option 4), laboratories would notify some cases of diseases directly to the medical officer of health, instead of GPs being responsible. Do you agree/disagree with this approach? Why? Why not? (4.4.3) 40: Under option 3 (and option 4), the Health Act would be amended to state that territorial local authorities would no longer need to be notified of cases of diseases or conditions (note that current arrangements relating to investigation of cases and outbreaks are not affected). Do you agree/disagree? Why? (4.4.3) 41: Do you agree that there should be with a different process for diseases and conditions that do not require a public health response (removing direct notification of these cases)? (4.4.3) 42: Would there be financial/resource implications (either positive or negative) for you or your agency from implementation of option 3? What would these be? (4.4.3) 43: Would there be financial/resource implications (either positive or negative) for you or your agency from implementation of option 4? What would these be? (4.4.4) 44: Would there be financial/resource implications (either positive or negative) for you or your agency from implementation of option 5? What would these be? (4.4.5) 45: On balance, which systems option or combination of options do you prefer? Why? (4.5)


46: Are there any further advantages or disadvantages to any of the options set out in this document? What are they? (4.5) 47: What other systems options would you suggest? Please give details on the advantages and disadvantages of alternative approaches. (4.5) 48: Are there any other either positive or negative financial or resource implications for you or your agency arising from any of the options set out in this document? What are they? (4.5)


Appendix 3: Disease/condition and criteria

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Acute gastroenteritis •• • • ••• ••• Z (some cases) •↓ TLA Yes •

Adverse reactions to vaccines × ••

CARM • × × ••

AIDS × ••

AIDS Epidemiology

Group

••• × × ••

Anthrax •• • ••• × × MAF ••

Arboviral diseases • •

Vector surveillance

•• • × • MAF TLA Yes •

Botulism •• • •• × × • Brucellosis • • •• • × Z MAF Yes • Campylobacteriosis • • •• ••• ••• Z

(potentially) •↑ TLA Yes •• Cholera •• • ••• • •• Yes Yes ••• Creutzfeldt-Jakob disease and other spongiform encephalopathies

× •• CJD Register

••• × × MAF •••

Cryptosporidiosis • • •• •• ••• Z TLA Yes ••

20 Public health action indicates the action that a public health unit may take around an individual case of disease. 21 All notifiable diseases are under surveillance. Some additional disease-specific surveillance systems operate at a national level in New Zealand. 22 A number of diseases disproportionately affect some groups in society. Comparative figures are not available for some diseases.


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tion

to

ineq

ualit

ies

Cysticercosis • • •• •• × Z MAF • Decompression sickness × • • × × OSH • Diphtheria •• • ••• • ••• Yes •• Giardiasis • • •• ••• ••• Z TLAs Yes ••

Haemophilus influenzae b •• •

•• (acute cases)

• • Yes •↓ •

Hazardous or other substances injuries • • •• •• ×

OSH MFE TLA

Yes ••

Hepatitis (viral) not otherwise specified •• • •• • • ••

Hepatitis A •• • •• •• ••• Yes •• Yes

Hepatitis B (acute) • • •• • •• Yes •• Yes

Hepatitis C (acute) × • • •• • ••

HIV × ••

AIDS Epidemiology

Group ••• • • ••

Hydatid disease × • •• × × Z MAF TLA •

Lead absorption equal to or over 15µg/dl blood •• • •• × × •↑ MFE

OSH Yes •••

Legionellosis •• • •• •• × Housing Yes ••

Leprosy × • •• • • Yes •••

Leptospirosis •• • •• •• × Z MAF OSH Yes •

Listeriosis •• • •• •• •• ••


Publ

ic h

ealth

act

ion

to

prev

ent d

isea

se ta

ken

by

publ

ic h

ealth

uni

t

Dis

ease

surv

eilla

nce

or

othe

r nat

iona

l sur

veill

ance

sy

stem

in p

lace

Indi

catio

n of

seve

rity

of

clin

ical

illn

ess

Out

brea

k po

tent

ial i

n N

ew Z

eala

nd

Ease

of t

rans

mis

sion

(p

erso

n-to

-per

son)

Incl

uded

on

the

Nat

iona

l C

hild

hood

Imm

unis

atio

n Sc

hedu

le

Inte

rnat

iona

l rep

ortin

g re

quire

men

ts

Zoon

otic

/ Vec

tor(

s)

esta

blis

hed

in N

ew

Zeal

and

Cha

ngin

g di

seas

e pa

ttern

Oth

er a

genc

ies i

nvol

ved

Envi

ronm

enta

l fac

tors

co

ntrib

ute

to d

isea

se

Publ

ic p

erce

ptio

n of

risk

Con

tribu

tion

to

ineq

ualit

ies

Malaria • • •• × × Yes • Yes •••

Measles •• • •• •• •• Yes •

Meningoencephalitis – primary amoebic

•• • ••• • × TLA ••

Mumps •• • • •• •• Yes •

Neisseria meningitidis invasive disease •• • ••• ••• • •↑ Yes ••• Yes

Pertussis •• • •• •• •• Yes •

Plague •• • ••• × • Yes •••

Poisoning arising from chemical contamination of the environment

•• • •• × × TLA MFE Yes ••

Poliomyelitis •• ••

Paediatric Surveillance

Unit

•• • •• Yes Yes •••

Rabies × • ••• × × Z MAF TLA •••

Rheumatic Fever •• ••

Rheumatic fever register

•• • • •↑ Yes •• Yes

Rickettsial disease • • •• • × Z TLA ••

Rubella (Congenital rubella) •• •

• •••

•• •• Yes •

Salmonellosis • • •• ••• ••• TLA Yes ••

SARS •• • ••• Not

known ••• Yes •↑ •••

Sexually transmitted infections × •• • • ••• • Yes


Publ

ic h

ealth

act

ion

to

prev

ent d

isea

se ta

ken

by

publ

ic h

ealth

uni

t

Dis

ease

surv

eilla

nce

or

othe

r nat

iona

l sur

veill

ance

sy

stem

in p

lace

Indi

catio

n of

seve

rity

of

clin

ical

illn

ess

Out

brea

k po

tent

ial i

n N

ew Z

eala

nd

Ease

of t

rans

mis

sion

(p

erso

n-to

-per

son)

Incl

uded

on

the

Nat

iona

l C

hild

hood

Imm

unis

atio

n Sc

hedu

le

Inte

rnat

iona

l rep

ortin

g re

quire

men

ts

Zoon

otic

/ Vec

tor(

s)

esta

blis

hed

in N

ew

Zeal

and

Cha

ngin

g di

seas

e pa

ttern

Oth

er a

genc

ies i

nvol

ved

Envi

ronm

enta

l fac

tors

co

ntrib

ute

to d

isea

se

Publ

ic p

erce

ptio

n of

risk

Con

tribu

tion

to

ineq

ualit

ies

Shigellosis • • •• •• •• • Smallpox •• • ••• • •• Yes ••• Taeniasis • • •• •• •• Z MAF •

Tetanus • • ••• • • Yes ••

Trichinosis • • •• •• •• Z MAF ••

Tuberculosis •• • ••• •• ••• Yes •↑ Yes ••• Yes

Typhoid/paratyphoid fever •• • •• • ••• Yes •••

Viral haemorrhagic fever •• • ••• × ••• Yes •••

VTEC •• • •• ••• ••• •↑ ••

Yellow fever •• • ••• × ••• Yes •• Yersiniosis • • •• •• •• •↑ MAF ••


× • ••

Public health unit does not respond to notification Cases may generate public health unit response Cases always generate a public health unit response

Ease of transmission

× • •• •••

Very low person-person transmission potential Low level of person-person transmission Medium level of person-person transmission High level of person-person transmission

Severity of illness

• •• •••

May cause mild illness Causes mild-serious illness Causes severe illness

Zoonotic/Vector established in New Zealand

Z •

Zoonotic Vector could become established in New Zealand

Outbreak potential in New Zealand

× • •• •••

No outbreak potential Low risk of outbreak Medium risk of outbreak High risk of outbreak

Public perception of risk

• •• •••

Low Medium High


Appendix 4: Disease notification timeframes

Cases to be notified as soon as possible (to allow for immediate action from the public health unit)

Cases to be notified within 24 hours (to allow for swift action from the public health unit)

Cases to be notified within one week (to generate case investigation if necessary)

Acute gastroenteritis Anthrax Botulism Cholera Diptheria Haemophilus influenzae b Hepatitis A Hepatitis B Listeriosis Legionellosis Measles Meningoencephalitis – primary amoebic Neisseria meningitidis Paratyphoid Plague Poliomyelitis SARS Smallpox Typhoid Viral haemorrhagic fever VTEC Yellow Fever

Arboviral diseases Campylobacteriosis Cryptosporidiosis Giardiasis Hazardous or other substances injuries Hepatitis (viral) otherwise unspecified Leptospirosis Malaria Mumps Pertussis Poisoning arising from chemical contamination of the environment Rheumatic fever Rubella Salmonellosis Shigellosis Trichinosis Tuberculosis Yersiniosis

Adverse reactions to vaccines AIDS Brucellosis CJD Decompression sickness Hepatitis C HIV Hydatid disease Lead absorption equal to or over 15µg/dl blood Leprosy Rabies Rickettsial disease Sexually transmitted infections Tetanus


Glossary

Aggregate data The sum total of individually collected data.

Chronic carriage The harbouring of a specific infectious agent by a person, who thereby serves as a source of infection over a long period of time.

Communicable See Infectious disease. disease

Contact tracing Identifying and seeking out those people who have been in contact with a person with an infectious disease, with a view to controlling spread of that disease by either diagnosing and treating further cases or providing protections such as preventative treatment or immunisation, or advice and information.

Endemic Of a disease or infectious agent: constantly present in an area.

Epidemic The occurrence of a disease in excess of expected cases.

Immunisation The National Childhood Immunisation Schedule, which is set out Schedule in the Immunisation Handbook 2002.

Incidence The number of new cases or events that occur in a given period in a specified population.

Infectious disease An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an infected person, animal, or reservoir to a susceptible host. It may be transmitted directly or indirectly through an intermediate plant or animal host, vector or the inanimate environment.

Medical officer of An officer designated to undertake public health statutory function health and to exercise the statutory powers and responsibilities attached to

that position within a specified health district.

Notifiable disease A disease that, by legal requirements under section 74 of the Health Act 1956 or under section 3 of the Tuberculosis Act 1948, must be reported to by medical practitioners to public health services.

Notification An obligation specified in law to notify a specified authority (usually the medical officer of health) in relation to information about a person with a particular disease.


Prevalence The number of instances of a given disease or other condition in a population at a given time.

Public health The health of all people in a community or a section of such people; the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society.

Public health action Swift action taken to prevent the spread of a disease in a

community. Rate The frequency with which a health event occurs in a defined

population, including the number of events, size of population at risk, and a specified time period.

Surveillance Ongoing scrutiny of all aspects of disease occurrence and spread

pertinent to disease control. Suspected case A person whose medical history and clinical symptoms suggest

s/he may have an infectious disease. Vaccine-preventable A disease that is preventable by vaccination. For example, rubella. disease Vector A living carrier which transfers an infectious agent from an

infected individual (or their waste) to another individual, their food, or their immediate surroundings.

Vertical A disease transmitted from a mother to a child, usually during transmission birth. Zoonosis An infectious disease transmissible from vertebrate animals to

humans.


Abbreviations

AIDS Acquired immunodeficiency syndrome

CARM Centre for Adverse Reactions Monitoring

CJD Creutzfeldt-Jakob disease

ERMA Environmental Risk Management Authority

ESR Institute of Environmental Science and Research

GP General practitioner

HIV Human immunodeficiency virus

HSNO Hazardous Substances and New Organisms Act 1996

IT Information technology

MAF Ministry of Agriculture and Forestry

NHI number National Health Index number

NZHIS New Zealand Health Information Service

OSH Occupational Safety and Health

STI Sexually transmitted infection

TLA Territorial local authority

VTEC Verotoxin-producing Escherichia coli

WHO World Health Organization

WINZ Water Information New Zealand


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A Review of Notifiable Diseases and Conditions

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