Implementation of automated electronic systems can greatly increase the speed with which cases can be identified (LaPorte et al., 2008), but they are not available in most states. The second problem involves a lack of resources to follow up on all potential and known cases and their contacts in a timely manner. Followup of an infant can take up to 2 years. In addition, a substantial number of HBsAg-positive mothers are not identified in time to ensure the required followup of the mothers and their infants (see Chapter 4).
Repeat testing in high-risk populations can confuse the number of suspected acute versus chronic infections. Members of some populations, such as IDUs, may repeatedly incur HCV infection that resolves spontaneously without ever becoming chronic (Mehta et al., 2002). Those cases could mistakenly be classified as chronic infections based on antibody results alone.
Many of the people affected by hepatitis B and hepatitis C have limited access to health care (for example, active IDUs, homeless people, some Pacific Islanders, legal immigrants living in poverty, and undocumented immigrants) and are less likely to be diagnosed appropriately, to provide complete and accurate demographic and behavioral information, or to access followup care. Structural and political barriers, stigma, and fear of legal repercussions contribute to the limitations on their access. Each HBV-infected or HCV-infected person who does not enter into appropriate medical care represents a missed opportunity for secondary prevention and may contribute to the collection of inaccurate and less detailed surveillance data. Finding ways to ensure that patients receive comprehensive and culturally appropriate care and referrals not only would increase the likelihood of improving their health outcomes but is likely to affect surveillance-data collection favorably.
Finally, because of the chronic nature of viral hepatitis, it is important that surveillance staff communicate well between jurisdictions. Persons with chronic disease can be misclassified as having acute cases if earlier diagnoses made in other jurisdictions are not identified. Not infrequently, a previous diagnosis has been reported in another state or jurisdiction. The ability of state and local surveillance-program staff to track cases across jurisdictions is hampered by various factors, including inadequacy of staff resources, nonstandardized surveillance software systems, and the lack of a national database that could be used to identify potential matches in other jurisdictions.