The health surveillance program in Saudi Arabia began in 1933 (1353 Hijjra). The program has improved over the years and now 19 regions report 47 communicable diseases (13 are reported within 24 hours and 34 are reported weekly). Since a surveillance system cannot succeed without a continuing and reliable source of information from the reporter, this study aimed to evaluate the knowledge, attitudes and practices of those responsible for reporting communicable diseases in Makkah.
Health units were selected at random from a list of all medical facilities in the Makkah region health affairs (RHA). Self-administered questionnaires were made in English and Arabic requesting demographic and professional information. The questionnaire listed 10 diseases and asked participants to match these to the official reporting requirements. They were also asked to list four more reportable diseases. To evaluate and measure attitude towards confidentiality of data, reporting source, feedback, and training, participants were asked their opinion (strongly agree, agree, no opinion, disagree, or strongly disagree). We also asked them to mark important, no opinion or unnecessary on 14 items of information usually contain in the reporting form.
The response rate of the study was 90%, including 257 physicians, 53 non-physicians. Only 51 (17%) had attended one or more courses in public health during the past five years. These were mainly RHA (57%) and PHCC (39%).
Physicians working at RHA and PHCCs correctly identified 100% and 96% of reportable diseases compared to 70% for private clinic physicians. Correct answers of physician knowledge for the three communicable diseases (CD) reported within 24 hours, ranged as high as 99.6% for HIV to 90% for yellow fever. For six CD reported weekly, correct answered ranged as high as 95% for hepatitis B to 78% for non-pulmonary tuberculosis. For one non-reportable disease, Trachoma, 42% answered correctly.
All physicians working at RHA and other government health units (GHU) were able to list four different reportable CD, compared with 92% of physicians working at PHCCs, 73% of private hospital physicians, and 72% of MOH hospital and private clinic physicians.
Only 36% of non-physicians were able to list four CD reportable within 24 hours; five employees at RHA (100%), nine employees from PHCCs (90%), lower scores were achieved by employees in other GHU (40%), and three employees of MOH hospitals (19%). Of non-physicians, only 60% were able to list four CD reportable weekly. Again RHA (100%) and PHCC (90%) employees scored higher than GHU (67%) and MOH hospital (52%) employees.
All non-physicians identified cholera as a CD required to he reported within 24 hours and bacterial meningitis and poliomyelitis were identified correctly by 98% and 70% respectively. Of four other CD reported weekly, only 49% of them or less answered correctly. Of the three diseases which do not require reporting, 51% or less of them answered correctly as not reportable.
Of 53 non-physicians, 50 (94%) stated they had enough time to do reporting, and they spent a median of six hours (1-96 hours) weekly.
The attitude of all physician and non-physician participants was good, they agreed with the CD surveillance system, confidentiality of cases reported, feedback, and strongly agreed with demands for training. They dis agreed with reporting by telephone. They all thought information requested in the CD reporting form was important and no significant difference was found between different health units. The main motivation for reporting CD was for epidemiological investigation (61%).
The three CD reporting forms used in Makkah are similar to the one designed by RHA. There is no difficulty sending the forms to RHA (Figure 1).
None of the health units had an updated circular containing all communicable diseases required for reporting. However circulars regarding reporting of a single communicable disease are often received.
During the study period, we implemented a computerized data entry for reported CD at the department of disease prevention in Makkah RHA using Epi Info 6.02 (a microcomputer database and statistics program).
Editorial note:
The overall knowledge for reportable diseases among physicians at different health units is high for all diseases and slightly higher for diseases that require reporting within 24 hours. Physicians were more confused about non-reportable diseases, showing a tendency to report diseases which were not listed for reporting. This may be due to unavailability of an updated circular containing all CD required for reporting and/ or the special circumstances of Makkah (visitors for Hajj and Omra). A booklet, to be publish annually by the MOH listing all diseases required for reporting and contain other criteria required for reporting would help eliminate confusion and keep reporters better informed.
Daily reporting from hospitals by fax requires daily tabulation, is time consuming, and wastes resources. Monthly reporting leaves no time for the data to be examined and delays discovery of possible epidemics. Weekly reporting would give the hospitals more time to revise data, to recognize any abnormal increases in cases of specific diseases and still leave time for the RHA to follow up cases. A standard reporting form requesting all information should be used by all health units. Thus the resources and efforts of the PHCCs can be concentrated on applying prevention measures. The reporting of different diseases should be standardized for all health units according to MOH regulations.
Feedback is an important factor in improving reporting because without feedback, health workers do not know if what they report or whether they report matters. This was mentioned by all participants. A one or two page monthly newsletter could be distributed locally to all health units summarizing surveillance information and the current health situation. It would also serve as a forum for providing credit to those who have made an exceptional contribution, such as identifying an outbreak. A standardized reporting form for all health units should be used which includes all essential variables. This would eliminate the need for the PHCC to track down additional information for the cases reported from the hospitals.
Training programs for surveillance are needed and reporter participants must be encouraged to attend as only a few participants in our survey had had the opportunity to attend any public health courses.
