Improving notification rates for tuberculosis
BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6985.974 (Published 15 April 1995) Cite this as: BMJ 1995;310:974
- J S Brown, registrar in thoracic medicinea,
- F Wells, medical audit facilitatora,
- G Duckworth, consultantb,
- E A Paul, lecturer in medical statisticsc,
- N C Barnes, consultant thoracic physiciana
- a East London Tuberculosis Centre, London Chest Hospital, London E2 9JX
- b Communicable Disease Control for East London and the City Health Authority, Royal London Hospital, London E1 1BB
- c Department of Epidemiology and Medical Statistics, Royal London Hospital Medical College, London E1 2AD
- Correspondence to: Dr Barnes.
- Accepted 15 March 1995
Notification of cases of tuberculosis is a legal requirement to permit calculation of accurate incidence figures and efficient contact tracing. We previously found considerable undernotification of cases at our hospitals.1 To improve the percentage of cases notified several changes have been instigated. All consultants are encouraged to refer cases of tuberculosis to a chest physician; copies of reports of smears or cultures positive for Mycobacterium tuberculosis and histology suggestive of tuberculosis are sent to a consultant in communicable disease control (GD); and the pharmacy informs the consultant of patients prescribed isoniazid. When unnotified cases are identified during these procedures the consultant in communicable disease control contacts the consultant in charge of the patient as a reminder to notify.
We report an audit of the percentage notification rates of cases of tuberculosis diagnosed at our hospitals two years after making these changes.
Patients, methods, and results
As in our previous study,1 we identified retrospectively all cases of tuberculosis diagnosed from 1 January 1992 to 31 December 1993 at the Royal London and London Chest Hospitals in patients aged 16 years or over. We identified cases from statutory notifications; microbiology reports of smears or cultures positive for M tuberculosis; histology reports suggestive of tuberculosis; hospital activity data; necropsy and coroners' reports; and pharmacy lists of patients prescribed antituberculous drugs. Notified cases were identified from the notification records kept by the consultant in communicable disease control. Tuberculosis was confirmed by review of notes in cases identified from histology reports, those with a clinical diagnosis alone, and those that had not been notified. We compared the data with those from our original study of notifications for 1985-9 using χ2 tests for contingency tables and 95% confidence intervals.
Notification rates according to specialty of consultant in charge of patients
During 1992-3, 252 new cases of adult tuberculosis were diagnosed. Of these, 235 (93%) were notified, an increase of 20% (95% confidence interval 15% to 25%) over the percentage notified in the 1985-9 study (73%). Only one case with a sputum smear positive for acid fast bacilli was not notified. The table shows the improvement in notification rates according to the specialty of the physician in charge of the case.
The mean age of patients was 46 years (range 16 to 96), and 149 were men. The proportion of African patients increased from 15 out of 580 (3%) in the original study to 29 out of 252 (12%), 18 of them being Somalis. Patients from the Indian subcontinent remained the commonest ethnic group affected (108/252 (43%)). Fourteen patients (5.5%) were positive for HIV infection in the 1992-3 cohort compared with four patients (0.7%) in our original study.
Comment
Tuberculosis is undernotified,1 2 which may hinder disease control and makes accurate assessment of incidence difficult. Since the introduction of new mechanisms for notifying cases of tuberculosis we have found that a fifth more cases were notified from our hospitals, which are in an area of high incidence. Cases with positive sputum smears are the main risk to public health,3 4 and in 1992-3 only one such case was not notified.
The local referral pattern of patients with tuberculosis has not changed enough to affect notification statistics. The recent resurgence of interest in tuberculosis may have independently made notification more likely. The large improvement in the percentage of cases notified suggests, however, that introducing systems of cross checking pathology reports, prescriptions for antituberculous drugs, and notifications by a consultant in communicable disease control is at least partially responsible. If accurate information on tuberculosis is to be available similar systems should be initiated nationally, especially for hospitals in areas where the incidence of the disease is high.