Completeness of Measles Case Reporting: Review of Estimates for the United States

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1 SUPPLEMENT ARTICLE Completeness of Measles Case Reporting: Review of Estimates for the United States Rafael Harpaz Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia Measles surveillance is complex: the patient must seek health care, the diagnosis must be recognized by the physician, and the case must be reported to health departments. The portion of total (incident) measles cases that is reported to health departments is termed completeness of reporting. Few studies describe this measure of the quality of surveillance in the United States; these studies use different methods, but they are all limited because the actual number of measles cases needed to derive completeness of reporting could not be determined. Estimates of completeness of reporting from the 1980s and 1990s vary widely, from 3% to 58%. One study suggests that 85% of patients with measles sought health care, the proportion of compatible illnesses for which measles was considered varied from 13% to 75%, and the proportion of suspected cases that were reported varied from 22% to 67%. Few cases were laboratory-confirmed, but all were reported. Surveillance in the United States is responsive, and its sensitivity likely increases when measles is circulating. Continued efforts to reinforce the clinical recognition and reporting of measles cases are warranted. In its most common form, passive measles surveillance in the United States consists of several steps: The person with measles must seek health care, the health care provider must consider the diagnosis of measles and test the patient accordingly, and the health care provider must report the case to the local or state health department. The sensitivity of measles surveillance depends on each of these components. All disease-reporting requirements derive from state laws and regulations. Although specific reporting requirements vary, measles is a reportable condition in all states. A clinical case definition has been adopted by the Council of State and Territorial Epidemiologists (CSTE), along with national criteria for classifying possible measles cases into categories of suspected, probable, and confirmed cases on the basis of the likelihood that the patient actually has disease due to measles virus infection [1]. The following case definition measles was adopted by the CSTE: an illness characterized by a generalized rash lasting for 3 days; a temperature of Reprints or correspondence: Dr. Rafael Harpaz, National Immunization Program, Mailstop E-61, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA (rzh6@cdc.gov). The Journal of Infectious Diseases 2004; 189 (Suppl 1): This article is in the public domain, and no copyright is claimed /2004/18909S C; and cough, coryza, or conjunctivitis. The following case classifications were added: suspected, a case that includes febrile illness accompanied by generalized maculopapular rash; probable, a case that meets the clinical case definition, has noncontributory or no serological or virological testing, and is not epidemiologically linked to a confirmed case; confirmed, a case that is laboratory-confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed case (a laboratory-confirmed case does not need to meet the clinical case definition). However, state requirements are not consistent with regard to which of these categories is reportable and when reporting should occur during the diagnostic process. In particular, state regulations often do not define whether notification is required on the basis of the clinical manifestations of the illness or, instead, on an often unspecified degree of clinical suspicion of measles by the health care provider (i.e., independent of symptoms and case definitions). All states require physicians to report measles to public health authorities, and all but 5 states require laboratories to report confirmed cases as well [2, 3]. Some states require hospital infection-control nurses, school nurses, day care staff, or even the general public to report measles cases. It is clear, however, that physicians play the key role in measles reporting, because notifi- Completeness of Measles Reporting JID 2004:189 (Suppl 1) S185

2 cation whether by the physicians themselves, by laboratory personnel, or by infection-control staff is possible only if the physicians possess the clinical judgment to first consider the diagnosis of measles and to order confirmatory laboratory testing [3]. In general, states do not impose penalties for failure to report. Furthermore, notification is a passive process initiated by the reporter. Reporting of communicable diseases has thus often been found to be incomplete, with the degree of underreporting varying by disease on the basis of awareness of reporting requirements, disease severity, perceived public health importance, associated social stigma, and other factors [4 10]. Little information exists regarding notification practices for measles in the United States. Evaluating completeness of reporting of measles cases is difficult because the true number of measles cases in the population is not known. Although multiple methods of estimating the true number of cases have been used [11 14], it is difficult to assess the accuracy of these estimates, and often these methods do not provide sufficient information to properly classify the cases. In this article, available data relating to the completeness of reporting of measles are reviewed. These data are summarized in table 1. METHODS To identify relevant literature, the MEDLINE database for 1966 through 2002 was searched for the terms surveillance, notification, reporting, and case finding, together with the term measles. References from the studies thereby identified were also searched to find additional relevant articles. Data from a study published elsewhere in this supplement issue were also included [21]. Finally, a managed care data set was analyzed to obtain additional information regarding completeness of measles reporting. RESULTS National surveillance compared with inferred prevaccine incidence. Before licensure of measles vaccine in 1963, multiple surveys indicated that virtually all persons experienced measles by adulthood [22]. In steady-state conditions, 1 birth cohort should therefore have had measles annually during the immediate prevaccine era. This would have been 4 million cases per year in the decade preceding measles vaccine licensure. However, 400, ,000 cases of measles were reported to the Centers for Disease Control and Prevention (CDC) annually during these years, suggesting that completeness of reporting was 10% [11]. Before vaccine licensure, health care seeking and disease reporting for measles were possibly low because of the common nature of the illness and the limited treatment or prevention options available. Community-based study, Maryland, During , community-based canvassing that included questions about measles was conducted every 6 8 weeks in Hagerstown, Maryland, a city of 30,000 persons served by 37 general practitioners [15, 16]. Medical record reviews were not conducted, and the case definition for measles was simple parental diagnosis. Respondents noted 568 episodes of measles among 8587 persons during 16,517 person-years of observation; 64% of these patients sought medical attention, of which 40% (i.e., 26% of all children with measles, based on parental diagnosis and recall) were reported to the health department. Community-based study, St. Louis, During a measles epidemic in St. Louis, physicians were contacted and encouraged to report cases [17]. There were 745 measles cases with 6 deaths reported by physicians during the outbreak. Questionnaires were also sent to parents of 10,000 children enrolled in 56 city and county schools and day care centers inquiring about measles history. Response rate was 43%. By extrapolating attack rate among respondents to the entire population, the authors estimated that 10,000 children in the metropolitan area experienced measles during the outbreak. Thus, despite physician prompting, completeness of reporting was 7% (745/10,000). The study contained potential sampling biases: Parents of children with measles may have preferentially responded to the survey; furthermore, the authors extrapolated from school and day care settings, where measles is typically most likely to circulate. Community-based study, Los Angeles, A community-based survey was conducted in Los Angeles during the measles epidemic that swept through the United States [18]. Cluster-sample techniques were used to select parents of 947 children!5 years of age. The parents were visited and asked whether their children had ever been ill with measles; they were asked details regarding dates and symptoms of these episodes and whether their children received medical care. On the basis of parental responses, providers were contacted for those children with illnesses meeting CSTE criteria for probable measles. Public health authorities were notified of 10 (29%) of 35 children with probable measles. Information regarding healthseeking behavior was available for 33 of the 35 children: 5 (15%) children did not obtain medical care and 1 (20%) of these 5 cases was reported to the health department by a school nurse; of the 28 children (85%) who did obtain medical care, 9 (32%) were reported to the health department by their health care providers. Medical records were not available for review for 7 children obtaining medical care; 1 of these cases had been reported to the health department. Of the 21 children with available records, 5 had presented to their private physicians before rash onset, and none of these cases were reported to the health department. A diagnosis of measles was documented for 12 S186 JID 2004:189 (Suppl 1) Harpaz

3 Table 1. Data relating to completeness of measles reporting to public health authorities, United States. Study design and location Community-based study Period of study Mode of ascertainment for measles Hagerstown, MD Household survey: entire population of city sector Measles case definition used for study No. of persons meeting study case definition No. (%) meeting study case definition who sought medical care No. (%) seeking medical care who were given diagnosis of measles No. (%) of cases diagnosed by physicians that were reported No. (%) meeting case definition that were reported Parental diagnosis 586 a (64) a Unknown Unknown (26) a 15, 16 St. Louis, MO Mailed survey: parents of 10,000 children b Parental diagnosis 10,000 c Unknown Unknown Unknown (7) d 17 Los Angeles, CA Cluster survey of households Parental recall; CSTE case definition d 35 28/33 (85) 12/16 (75) e 8/12 (67) f 10/35 (29) 18 Hospital-based capture-recapture analysis Los Angeles, CA 1986, 1991 Citywide data on hospital discharges g Physician diagnosis NA NA 898 h 461/898 (51) i 19 New York, NY 1991 Logs, billing and infection-control records: ambulatory and inpatient units of 12 hospitals Managed care-based study Minneapolis St. Paul, MN Electronic search: administrative data, electronic records, and laboratory data Physician diagnosis NA NA 1487 j 664/1487 (45) 20 Modified CSTE case definition (rash duration not specified) d 68 Unknown 9/68 (13) k 2/9 (22) k 2/68 (3) 21 CA, WA, OR Administrative data Physician diagnosis Unknown Unknown 8 0/8 NA Unpublished NOTE. CSTE, Council of State and Territorial Epidemiologists. NA, not applicable a Parental diagnosis only; medical charts were not reviewed. Proportion seeking medical care and reported with measles were derived from aggregate data and not individual analysis. b Sampled from city and county day care centers and schools; sample frame was not reported. c Total cases was derived by applying survey attack rate to the entire population of children!10 years of age. d See [1]. e Excludes 5 children who presented for medical care before rash onset. Of children presenting to hospitals and emergency departments and with available records, 11/12 were given diagnosis; of those presenting to private physicians, 1 of 4 were given diagnosis. f Proportion with measles diagnoses that were reported, by site: 2 of 2 from hospitals; 6 of 9 from emergency departments; 0 of 1 from private physicians. g Validity of discharge data was not assessed. h Total physician-diagnosed measles hospitalizations estimated via capture-recapture analysis: 26 cases (95% confidence interval, cases) in 1986; 872 cases (95% confidence interval, cases) in i 58% of cases reported in 1986 and 53% in j Total number of physician-diagnosed measles hospitalizations estimated via capture-recapture analysis (95% confidence interval, hospitalizations). k Measles explicitly considered, not necessarily the final diagnosis; 2 reported and remaining 7 cases were given alternative final diagnoses. Reference

4 (75%) of the 16 children presenting for care after rash onset (11 [92%] of 12 for patients seen in hospitals and 1 [25%] of 4 for patients seen by private physicians). Three (25%) of these 12 case patients underwent measles IgM testing, yielding positive results, and 8 (67%), including the 3 with confirmed measles, were reported. Notification varied by source of care: In addition to the case reported by the school nurse, the 10 reported cases included both hospitalized patients, 7 of 11 case patients seen in emergency departments, 0 of 3 case patients seen in county public health clinics, 0 of 12 case patients seen by private physicians (Fisher s exact test, P p.001). Hospital-based study, Los Angeles, 1986 and Capture-recapture analysis was used to assess measles reporting by hospitals in Los Angeles before and during the measles epidemic [19]. Data on patients discharged from area hospitals with a diagnosis of measles were matched with data on patients hospitalized whose cases were reported to the health department. Measles diagnoses were not laboratory-confirmed for the hospitalized case patients. Completeness of reporting was 58% in 1986 and 51% in There was no improvement in response to increased awareness generated by the measles epidemic in Hospital-based study, New York, A capture-recapture analysis was conducted in New York City during the measles epidemic [20]. Twelve city hospitals were selected for study. Logs, billing records, and infection-control records were used to detect measles diagnoses among hospitalized and ambulatory (i.e., clinic and emergency room) patients!19 years of age; measles diagnoses for these cases were not laboratory-confirmed. The data were matched with cases reported to the city health department. Completeness of reporting among the sites was 45% (range, 19% 83%). Data were not presented in this study regarding the proportion of patients who were ambulatory. Managed care based study, Minnesota, Completeness of reporting in ambulatory settings was recently evaluated in a large health maintenance organization (HMO) in Minnesota [21]. Administrative data, electronic clinic notes, and laboratory data were searched to ascertain measleslike presentations during ; the filtered records were then reviewed by 2 physicians to determine whether symptoms recorded in the medical record met the study case definition for measles (a generalized maculopapular rash with simultaneous fever [by history or C on examination], and either cough, coryza, or conjunctivitis). Six million patient encounters occurred during the study period, and 68 records were identified that met the case definition. A measles diagnosis was considered for 9 (13%) of 68 presentations: 2 underwent confirmatory measles IgM testing and 1 of these was confirmed; 3 were ultimately identified as reactions to recently administered measles vaccine; 2 were thought to be due to streptococcal pharyngitis; 1 was thought to be a drug reaction; and 1 had no diagnostic plan documented. The diagnoses for the remaining illnesses were based on clinical judgment and were generally listed as unspecified viral rashes. The health department was notified about 2 (3%) of the 68 cases, those being the patients who had measles IgM testing, and about an additional patient who did not meet the study case definition. Managed care based study, California, Oregon, and Washington, To further explore reporting behavior in ambulatory, managed care settings, an evaluation was conducted during 2000 at the Vaccine Safety Datalink (VSD) sites [23]. VSD is a coalition of 4 HMOs that have formed partnership with the CDC to assess vaccine safety issues. The HMOs are located in Washington, Oregon, and California, with combined enrollment of almost 6 million persons. Administrative data at the sites were searched by use of ICD-9 (International Classification of Diseases, 9th edition) codes for measles, and the identified records were abstracted manually. During , there were 24 patient encounters coded as measles. However, only 8 (33%) of these patients had a recorded diagnosis relating to measles, serving as a reminder that administrative data may require validation before they are used for surveillance. Only 2 (25%) of 8 patients with measles diagnoses met the CSTE clinical case definition for measles. Measles IgM testing was conducted for 2 (25%) of these 8 patients, including 1 who met the case definition; both test results were negative. The health department had no records that any of the 8 cases of measles had been reported; it is possible they had been reported but that the records had not been retained because measles was ruled out during investigation. DISCUSSION AND CONCLUSIONS Measles reporting depends on effective case recognition and subsequent notification. The reviewed studies provide insights relating to these processes and to the completeness of measles reporting in the United States. First, in the Los Angeles community-based study, 85% of children with probable measles sought medical care, suggesting that in recent times and in a relevant setting, most patients with measles are evaluated clinically, providing opportunity for diagnosis and reporting to occur. Of note, 1 case was reported by a school nurse, although the patient had not sought medical care, demonstrating that schools can play a partnership role in disease notification [24 26], Once patients with measleslike illnesses present for medical care, the diagnostic performance of their providers is difficult to assess. In the Los Angeles community-based study, the classification of probable measles was established by parental recollection of symptoms, and the diagnostic performance of providers was evaluated on the basis of that classification. It is S188 JID 2004:189 (Suppl 1) Harpaz

5 quite possible that parental recall was faulty. Nonetheless, providers did diagnose measles for 75% of children with probable measles who presented after rash onset. In the Minnesota study, measles was considered for 13% of cases meeting the study case definition. However, although cases were classified on the basis of findings from the medical records, the study case definition differed from the CSTE case definition for measles. Furthermore, even for cases that meet the formal CSTE case definition, it is possible that physicians consider the diagnosis of measles but rule out the possibility on the basis of clinical considerations that lead to alternative diagnoses; unfortunately, these diagnostic considerations are often not recorded in the medical chart, making it difficult to evaluate the physician s diagnostic process. State reporting requirements are generally based on the premise of suspicion of measles rather than on compatibility with a specific case definition. Nonetheless, the data reviewed here suggest that physicians may not always consider measles in the differential diagnosis when seeing patients with compatible findings: Measles is rare, and in recent years, most physicians have had little experience with the illness. The data from the Los Angeles community-based study suggest that hospital and emergency department physicians are more likely to consider the diagnosis of measles. Large volumes of patients are seen in such settings; hospital-based physicians may be more attuned to uncommon diseases circulating in the community, or they may have more familiarity with measles. Hospital-based physicians also have easier access to specialist consultation and laboratory testing. The next step in the reporting process involves notification of cases suspected by the health care provider to be measles. Data addressing this issue are sparse. Reporting was in the range of 45% 58% in the New York and Los Angles studies of hospital-based reporting. Because most patients with measles are not hospitalized [27], monitoring of hospital-based notification would provide only ancillary information on the quality of measles surveillance. In the Los Angeles community-based study, 12 children had a diagnosis of measles in their medical records. Of these, 8 of 11 patients hospitalized or seen in the emergency department were reported, and the 1 patient given a measles diagnosis by a private provider was not reported. In the Minnesota study, physician reported 2 of 9 patients for which a measles diagnosis was considered, including the 1 laboratory-confirmed case, and alternative final diagnoses were documented for the other 7 patients. In the VSD study, 0 of 8 cases with measles diagnoses were reported. Only 2 of these cases met the clinical case definition, and neither was confirmed. Other evidence exists that a substantial proportion of suspected measles cases may not be reported: 120,000 measles IgM tests are ordered by physicians annually, presumably, for the most part, to confirm suspected cases as measles [28]. Yet, the number of suspected measles cases reported annually to health departments is 1400 [29]. Although reporting of suspected measles appeared inadequate, reassuring data from national surveillance suggest that reporting of actual measles is considerably better: Few new unreported cases of measles are detected when health departments conduct thorough investigations in response to report of an index case [30]. Three of the studies reviewed here assessed reporting of laboratory-confirmed cases. Although there were only 4 IgM-positive results, all 4 of these cases were reported. Laboratory reporting of notifiable diseases is typically more complete than that by physicians [7, 8, 31] and could serve as a backup for notification by physicians, assuming that physicians consider the diagnosis of measles and order testing in the first place. Public health regulations usually require that any illness suspected to be measles be reported, though the degree of clinical suspicion is not generally defined. Furthermore, notification typically needs to be immediate, prior to laboratory confirmation, so that rapid intervention can prevent spread of the highly communicable disease. But with measles incidence in the United States at record low levels, the predictive value of simple clinical suspicion is correspondingly low, and few, if any, suspected measles cases are likely to be true measles. Indeed, an average of only 100 cases of measles are confirmed annually [32], despite the fact that 120,000 tests are conducted [28], directly suggesting the low predictive value of clinical suspicion alone. Although difficult to formally demonstrate, surveillance in the United States is responsive: When measles cases do occur, community awareness in increased, and diagnostic and reporting behavior are likely increased by providers. As measles incidence increases, a more sensitive, less specific system is appropriate. The surveillance system, and by implication, the current level of measles reporting, appears adequate to detect endemic measles if it were occurring [30]. Nonetheless, public health authorities need to continue to reinforce physician awareness of measles and notification requirements for vaccine-preventable diseases in general through education, health department feedback, and other measures. Assessments of measles reporting in the United States have been sparse, and outcomes have been somewhat conflicting. Additional research would clearly be helpful to better understand provider diagnosis and reporting practices for notifiable diseases, particularly those such as measles that have been targeted for elimination. Acknowledgments I thank Mary McCauley, Mark Papania, and Jane Seward from the National Immunization Program, CDC, for their editorial and scientific input. Completeness of Measles Reporting JID 2004:189 (Suppl 1) S189

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