The underreporting of disease and physicians' knowledge of reporting requirements

Previous studies of underreporting of disease have mainly addressed the attitudes of physicians toward reporting of communicable disease to public health agencies and have not examined adequately the physicians' knowledge of the reporting system as a cause of underreporting. To investigate, the authors designed a questionnaire and distributed it to 345 physicians at two hospitals. One hundred and sixty-nine questionnaires, which examined knowledge of reporting requirements and reasons for not complying with those requirements during 1978-81, were returned (a 49 percent response rate). Most of the respondents knew that reporting is required, but their knowledge in specific areas, such as which diseases are reportable, varied greatly. The number of physicians who knew which diseases they are required to report ranged from a low of 63 physicians (37 percent) for trachoma to 163 (96 percent) for syphilis. Of the 169 physicians, only 50 believed they knew how to report reportable diseases, and only 40 of them knew the correct procedures. Thirty-six percent of the 169 physicians indicated that they had not reported any cases at all during 1978-81. On the average, physicians recalled reporting 28 percent of their reportable cases. When they indicated why they had not complied with reporting requirements, the physicians chose reasons that reflected a lack of knowledge of the reporting system. The most common reasons were "did not know how to report" and "did not know it was a reportable disease." The results suggest that a major factor in physician underreporting is a lack of knowledge of the morbidity reporting system.     

Lyme disease incidence in Wisconsin: a comparison of state-reported rates and rates from a population-based cohort

Few studies have assessed the accuracy and completeness of Lyme disease surveillance systems. Lyme disease cases were identified through review of medical records for residents of the Marshfield Epidemiologic Study Area (MESA), a population-based cohort of nearly 80,000 in north-central Wisconsin for which comprehensive medical care data are available through the Marshfield Clinic. These cases were compared with cases reported to the Wisconsin Division of Public Health to estimate the completeness of reporting. Annual incidence rates were calculated for MESA using the cases identified from chart review. Division of Public Health data were used to calculate statewide reported incidence rates, as well as rates for an eight-county region that surrounds and includes the MESA region. Of Lyme disease cases meeting the national case definition identified in MESA, 34% were reported to the state. The average incidence of Lyme disease (1992-1998) was 19.1 per 100,000 per year in MESA, 17.0 in the surrounding eight-county region, and 9.0 statewide. Trends in reported incidence across time, gender, and age in the surrounding eight-county region were generally comparable with those observed in MESA. These findings suggest that the passive surveillance system monitored trends in Lyme disease incidence reasonably well despite underreporting of cases.     

Lyme disease knowledge,beliefs, and practices of New Hampshire primary care physicians

BACKGROUND: Lyme disease is the most commonly reported vectorborne illness in the United States and is endemic in many counties in the Northeast, including counties in New Hampshire. Previous studies conducted elsewhere on Lyme disease have indicated substantial differences between physician practices and published consensus guidelines for diagnosis and treatment. METHODS: During 1999, we mailed a 21-item questionnaire to 600 randomly selected family practice physicians, internists, and pediatricians in New Hampshire. RESULTS: Respondents answered a median of 10 (76.9%) of 13 knowledge items correctly. Most physicians (73.6%) underestimated the incidence of erythema migrans among Lyme disease patients, and 41.2% would either test or offer treatment to an asymptomatic patient with deer-tick bite. When surveyed, most respondents (72.4%) planned to recommend Lyme disease vaccine to high-risk persons. Approximately one half (44.8%) reported giving empiric antibiotic treatment of Lyme disease solely because of patient concern. CONCLUSIONS: New Hampshire primary care physicians indicated good knowledge about Lyme disease. Lack of awareness about Lyme disease diagnostic criteria, however, could contribute to misdiagnosis through overreliance on laboratory testing. Lyme disease vaccine appeared to be well accepted by physicians, although the vaccine has since been withdrawn from the US market. Both inappropriate management of tick bite and empiric treatment of unsubstantiated Lyme disease diagnoses were common.     

Physician and infection control practitioner HIV/AIDS reporting characteristics.

We surveyed a random sample of South Carolina physicians and infection control practitioners about the reporting of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) cases. Of physicians surveyed, 79% indicated that HIV infection as well as AIDS should be reported by name. The following characteristics were associated with those physicians who do not report AIDS cases: not feeling responsible for reporting, not reporting a case perceived to have been reported in another state, believing that information required for reporting is not on the chart, and residing in an urban setting. Targeted education can address these underreporting factors.     

Comparison of nurses' smoking habits: the 1975 DHEW survey and Connecticut nurses, 1981

In a 1975 study conducted by the Centers for Disease Control, Department of Health, Education, and Welfare, 38.9 percent of the nurses surveyed were smokers--a substantially higher percentage than among women in the general U.S. population and higher than among other groups of health professionals. In a 1981 study of a 3-percent random sample of Connecticut nurses, only 25.5 percent of the nurses reported that they smoked. There are limitations to comparisons of the two studies. The 1975 sample was a national population, and the Connecticut study was limited to nurses in one State and may not reflect the habits and attitudes of this occupational group throughout the country. In the more recent study, however, there appear to be several differences in nurses' smoking habits. A trend toward a decrease in smoking seems to be emerging among nurses. The percentage of smokers among the Connecticut nurses resembles the prevalence in two other recent surveys: 25.8 percent in the American Cancer Society, Rhode Island Division study, and 23.6 percent in the University of Michigan Hospital survey. In the U.S. female population, 29.4 percent of the women are smokers. The percentage of former smokers in both the U.S. and this Connecticut population seems to be rising, and there appears to be a trend toward increasingly larger percentages of former smokers in each successive age group. Smoking more (25 or more cigarettes per day) was reported by 28 percent of the Connecticut nurses compared with 16 percent in the earlier study. Compared with the 1975 sample, significantly fewer Connecticut nurses who smoked agreed that a nurse should set a good example by not smoking and that most cigarette smokers can stop if they want to.     

Antibiotic therapy for Lyme disease in Maryland.

The recommended treatment of Lyme disease is evolving and important questions remain unanswered, such as (a) Are inexpensive oral regimens effective in curing acute illness and preventing arthritic, neurologic, and cardiac manifestations or are much more costly, and potentially toxic, intravenous antibiotics required? (b) Are relatively short 2- to 3-week courses of antibiotics sufficient or are prolonged regimens of a month, or more, better? This study reviews antibiotic therapy prescribed by Maryland physicians for the 283 cases reported in 1991 that meet the Centers for Disease Control and Prevention''s case definition for Lyme disease. The purpose of the review was to obtain baseline information on the antibiotics being used by physicians in practice to treat patients that they believe have Lyme disease. The most frequently prescribed antibiotics for either the 60 percent of patients presenting with erythema migrans or the 40 percent with arthritic, neurologic, or cardiac manifestations were oral doxycycline (47 percent), tetracycline (11 percent), and amoxicillin (13 percent). Seventy-one percent of therapeutic courses were for 2 to 3 weeks. Amoxicillin was used in two-thirds of children younger than 8 years. Sixty (21 percent) received intravenous therapy, of which ceftriaxone, with or without other antibiotics, was almost always (95 percent) used. Intravenous therapy was more frequently given to those with arthritic, neurologic, and cardiac manifestations than to those with erythema migrans (odds ratio = 3.7) and to those with these systemic symptoms along with erythema migrans than to those with erythema migrans alone (odds ratio = 3.8).(ABSTRACT TRUNCATED AT 250 WORDS)     

Sterilization of infant formula: current practices and recommendations

Home sterilization of infant formula became a standard of well-baby care in the 1940s. Its purpose was to eliminate bacterial pathogens that could contaminate water and bottles. Public water supplies are now rarely contaminated, and studies have confirmed that sterilization is no longer necessary. Connecticut family physicians and Connecticut mothers were polled and it was found that 48 percent of physicians recommend sterilization and that 54 percent of mothers (using public water supplies) sterilize formula. Formula sterilization recommendations by physicians and sterilization practices by mothers need to be updated.     

Patterns of Lyme disease diagnosis and treatment by family physicians in a southeastern state

This study examined how often physicians in Georgia diagnose and treat Lyme disease as well as the criteria they use to reach a diagnosis of Lyme disease. A survey was sent to 1,331 family physicians in Georgia concerning how many cases of Lyme disease the physicians diagnosed, and the criteria used to make the diagnosis, during the preceding 12 months. Of 710 responses, 167 physicians treated 316 cases of Lyme disease without a firm diagnosis. In addition, 125 physicians diagnosed 262 cases of Lyme disease, 130 without serologic testing and 132 with serologic testing. Family Physicians in Georgia diagnose Lyme disease at a rate 40 times greater than the surveillance case rate reported in Georgia.     

Smoking cessation during pregnancy: strategies used by Michigan family physicians

This study reports the attitudes and strategies of members of the Michigan Academy of Family Physicians about their antismoking interventions for pregnant smokers. Of the 978 physicians surveyed, 607 (62 percent) returned completed questionnaires. Three hundred twenty-three (53 percent) were not practicing obstetrics. The remaining 284 physicians currently practicing obstetrics constituted the study group. Ninety-four percent of these physicians routinely assessed smoking status at the first prenatal visit. Ninety-eight percent advised pregnant smokers to quit smoking during pregnancy. The most frequently used method of intervention was personal counseling (97 percent), followed by referral to smoking cessation clinics (40 percent), and behavior modification (20 percent). Fifty-seven percent of the physicians reported using antismoking pamphlets, and 30 percent used antismoking posters designed for pregnant women. Only 11 percent of the physicians surveyed were generally satisfied with the effectiveness of their current methods. Nonetheless, 97 percent were convinced that the benefits of smoking cessation during pregnancy merited their efforts. The physicians in this sample consistently have advised their pregnant smokers to quit, but most believe there is a need for more effective smoking cessation methods.     

Lyme disease--United States, 2003-2005

Lyme disease is caused by the spirochete Borrelia burgdorferi and is transmitted to humans by the bite of infected blacklegged ticks (Ixodes spp.). Early manifestations of infection include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. Left untreated, late manifestations involving the joints, heart, and nervous system can occur. A Healthy People 2010 objective (14-8) is to reduce the annual incidence of Lyme disease to 9.7 new cases per 100,000 population in 10 reference states where the disease is endemic (Connecticut, Delaware, Maryland, Massachusetts, Minnesota, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin). This report summarizes surveillance data for 64,382 Lyme disease cases reported to CDC during 2003-2005, of which 59,770 cases (93%) were reported from the 10 reference states. The average annual rate in these 10 reference states for the 3-year period (29.2 cases per 100,000 population) was approximately three times the Healthy People 2010 target. Persons living in Lyme disease--endemic areas can take steps to reduce their risk for infection, including daily self-examination for ticks, selective use of acaricides and tick repellents, use of landscaping practices that reduce tick populations in yards and play areas, and avoidance of tick-infested areas.     

Acceptance and self-reported use of national occupational medicine practice guidelines

The authors conducted a survey to ascertain post-training attitudes and self-reported use of the American College of Occupational and Environmental Medicine occupational medicine practice guidelines. Trainees were surveyed 3 to 4 months after completing a case-based practice ACOEM occupational practice guidelines seminar. Of 96 physician respondents, 95% reported that the guidelines improved their practice in some manner. Fifty-two percent of physicians thought that guideline use decreased medical costs. Seventy-one percent reported that their care complied with the guidelines in 70% or more of their cases; however, "actually considering the guidelines in particular cases" was reported by only 47%. Discussion of cases was frequent (92%) and involved physicians, patients, and other health care providers. We concluded that physicians' attitudes toward the guidelines are positive and that reported compliance is high. Guidelines are discussed frequently.     

Estimating underreported pesticide poisonings in Nicaragua

We undertook to estimate the degree of underreporting to a regional pesticide poisoning registry, and to estimate the true incidence of poisoning in an agricultural region of Nicaragua. We surveyed 633 workers at 25 of 33 agricultural cooperatives and any nearby private farms in a area geographically convenient to the regional health headquarters with a short structured interview about pesticide poisonings. Eighty-three percent of workers described current use of pesticides. Twenty-five percent described a pesticide poisoning in the preceding 12 months, and almost one-half (48%) described having been made ill by pesticides at some point in time. Sixty-nine (11%) described a poisoning in the preceding month, 23 of whom had received medical attention. The names of the medically treated were sought in the Regional Pesticide Poisoning Registry for the survey year of 1988. Only 8 of the 23 subjects were found reported to the registry when a total of 1,143 human pesticide poisonings were reported in the entire region. Using 65% as an estimate of underreporting to the registry, we calculate that 3,300 (95% Cl 2100–7500) poisonings had received treatment in the region in 1988, of whom more than 2,100 remained unreported. Based on the ratio of total poisonings (treated and untreated) to registry-reported poisonings among our survey respondents, we estimate that 6,700 (95% Cl 4100–18000) systemic poisonings, occurred in 1988 in the region. Underreporting of pesticide poisonings disguises the enormity of the problem in developing countries. Even in a region with a strong emphasis on illness reporting for targeted conditions, underreporting is substantial. This method for estimating underreporting is easily applied and provides a rough estimate of registry underreporting and actual incidence for conditions identifiable by a community-applied questionnaire. © 1996 Wiley-Liss, Inc.     

The effect of underreporting on the apparent incidence and epidemiology of acute viral hepatitis

To determine if passively reported cases of acute viral hepatitis are representative of the affected population, an active surveillance system was set up that identified all persons in Pierce County, Washington, who had been diagnosed by a physician as having acute viral hepatitis in the period March 1 through August 31, 1984. In this county, this was part of an ongoing epidemiologic study of viral hepatitis that had previously included some stimulation of reporting. The active surveillance system covered all primary sources of medical care, including all private physicians who were most likely to see persons with hepatitis. Secondary sources, those that did not provide direct medical care but might be aware of new cases, were also surveyed. The results of active surveillance showed that passive reporting was about 65% complete in Pierce County. No change occurred in the number of hepatitis A cases reported, but hepatitis B cases increased by 50%, and non-A, non-B hepatitis cases increased by 138%. Most of the increase was a result of enhanced reporting from private physicians. The two risk groups most affected by underreporting were homosexual men with hepatitis B and blood transfusion recipients with non-A, non-B hepatitis. During active surveillance, the proportion of persons with hepatitis B who reported homosexual activity was 52% compared with 20% from passive surveillance. Transfusion recipients represented 24% of the non-A, non-B hepatitis reported from active surveillance compared with 9% reported from passive surveillance. Although Pierce County may not be representative of all counties in the United States, persons responsible for public health prevention programs should recognize that data acquired through passive surveillance may not accurately reflect the magnitude of the risk for specific populations or the amount of disease that can be prevented.     

Predisposing factors for individuals' Lyme disease prevention practices: Connecticut, Maine, and Montana.

OBJECTIVES: This study examined factors that predispose individuals to protect against Lyme disease. METHODS: Knowledge, attitude, and practice questions concerning Lyme disease prevention were included in the Behavioral Risk Factor Surveillance surveys in Connecticut, Maine, and Montana. A total of 4246 persons were interviewed. RESULTS: Perceived risk of acquiring Lyme disease, knowing anyone with Lyme disease, knowledge about Lyme disease, and believing Lyme disease to be a common problem were significantly associated with prevention practices. CONCLUSIONS: Predisposing factors differ substantially between states and appear related to disease incidence. Personal risk, knowing someone with Lyme disease, and cognizance about Lyme disease and acting on this information are consistent with social learning theories.     

Lyme disease and preventive behaviors in residents of Nantucket Island, Massachusetts

BACKGROUND: To determine the age-specific prevalence of Lyme disease and whether preventive behaviors on Nantucket Island correlate with Lyme disease, we surveyed island residents. METHODS: A survey with questions on Lyme disease symptoms, history, and preventive behaviors was mailed to all residents. Respondents were stratified by likelihood of having had Lyme disease. A subsample was selected for examination, and then classified according to the Lyme disease national surveillance case definition. RESULTS: The overall lifetime prevalence of Lyme disease for Nantucket residents was 15% (CI, 10%-19.8%): 19% among females, and 11% among males. The prevalence was highest among age groups 0-16 and 30-49 years. Overall, 86% of the population practiced at least one behavior. The most frequently reported preventive behavior was checking oneself for ticks (80%), followed by wearing protective clothing (53%), avoiding tick areas (34%), and using tick repellent (11%). Younger individuals practiced fewer preventive behaviors than older individuals (p=0.001). Although males reported greater tick exposure than females, females uniformly practiced preventive behaviors more frequently (p=0.001). The practice of preventive behaviors was not associated with a history of Lyme disease, but finding more than 5 ticks per year on oneself was (p=0.001). CONCLUSION: Lyme disease is highly prevalent on Nantucket Island. Young people are particularly at risk and health education should emphasize preventive behaviors less frequently practiced: using tick repellent, avoiding tick areas, and wearing protective clothing.     

Papanicolaou smear cell recovery techniques used by primary care physicians

Nine hundred Tennessee-based internists, family physicians, and obstetrician-gynecologists were randomly selected and surveyed to identify Papanicolaou smear cell recovery methods used in their practices. This 16-item survey also requested typical laboratory reporting procedures on Papanicolaous smears. The most frequently reported cell sampling technique was the combination cotton-tipped applicator and spatula, which was used by 47 percent of all physicians. Use of the cervical cytobrush for Papanicolaou smears, which has been shown to improve the detection of cervical dysplasia, was used alone or in combination by 19 percent of those surveyed, of whom 72 percent were gynecologists. Cervical sampling should contain cells from the transformation zone as evidenced by an adequate number of endocervical cells on the smear. Laboratories reporting the presence of endocervical cells were significantly different (P less than 0.05) among the specialties, with 26 percent of the internists', 18 percent of the family physicians', and 15 percent of the obstetricians' laboratories not providing this information in their reports. Reporting inadequate smears is a necessary first step toward improved sampling technique. Without this information, physicians risk missing pathology through reports of false-negative Papanicolaou smears.     

Prevention in primary care: variability in physician practice patterns in New York City

We conducted a telephone survey of 120 randomly selected primary care physicians in New York City. This survey, which was completed in October 1984, concerned physicians' recommendations for health promotion and disease prevention. The recommendations by these physicians were often at variance with the recommendations of nationally recognized organizations such as the American Cancer Society and the American College of Physicians. Multivariate analysis revealed that board-certified physicians, U.S. medical graduates, and younger physicians agreed more frequently with the recommendations of national organizations. The physicians surveyed agreed upon the need to include health promotion and disease prevention in their practices. Eighty-seven percent agreed with the statement, "Physicians should probably practice more preventive medicine than they presently do." Reasons given for the failure to practice more prevention included lack of time (70 percent), inadequate reimbursement (60 percent), and "unclear recommendations" (58 percent). Approximately four out of five of the physicians felt a task force was needed to "clarify recommendations" for preventive medicine. The findings of this survey suggest a need for increased physician training and education in disease prevention and health promotion.     

Self-reported HIV and AIDS experience, practices, and knowledge of Pennsylvania family physicians.

BACKGROUND: Patients with disease caused by the human immunodeficiency virus (HIV), while still more commonly treated in urban settings, are being seen in nonurban areas in numbers rapidly outstripping the local availability of specialists with expertise in HIV or acquired immunodeficiency syndrome (AIDS). METHODS: A questionnaire designed to measure self-assessed experience, practices, and knowledge regarding basic aspects of HIV was mailed in 1989 to the 2177 members of the Pennsylvania Academy of Family Physicians. RESULTS: The response rate was 72 percent. Approximately 95 percent of physicians surveyed had been asked questions by patients about AIDS, 30 percent had a patient with a confirmed positive blood test, and 27 percent had a patient with symptomatic HIV disease in their practice. CONCLUSIONS: Although most family physicians indicated that they were comfortable in recognizing persons at risk, counseling, and using tests to diagnose HIV and AIDS, more than one-half reported practice patterns at variance with published guidelines. Respondents were most uncomfortable with their knowledge and skills regarding legal issues, state and community resources, and caring for patients with AIDS. Continuing medical education courses at local hospitals and written materials were the two methods of AIDS education most likely to be used by respondents.     

Lyme disease: a search for a causative agent in ticks in south-eastern Australia.

Attempts were made to identify the causative organism of Lyme disease in Australia from possible tick vectors. Ticks were collected in coastal areas of New South Wales, Australia, from localities associated with putative human infections. The ticks were dissected; a portion of the gut contents was examined for spirochaetes by microscopy, the remaining portion inoculated into culture media. The detection of spirochaetes in culture was performed using microscopy, and immunochemical and molecular (PCR) techniques. Additionally, whole ticks were tested with PCR for spirochaetes. From 1990 to 1992, approximately 12,000 ticks were processed for spirochaetes. No evidence of Borrelia burgdorferi or any other spirochaete was recovered from or detected in likely tick vectors. Some spirochaete-like objects detected in the cultures were shown to be artifacts, probably aggregates of bacterial flagellae. There is no definitive evidence for the existence in Australia of B. burgdorferi the causative agent of true Lyme disease, or for any other tick-borne spirochaete that may be responsible for a local syndrome being reported as Lyme disease.