A Review of Provider Sexually Transmitted Infection Reporting Requirements Across the US: Identification of the Need for Standardization

To the Editor:

Reported cases of sexually transmitted infections (STIs) have been rising steadily for more than a decade. ¹ The escalating STI epidemic has not been borne equally but has disproportionately impacted communities of color, adolescents/young adults, and men who have sex with men, necessitating a disease surveillance system with sufficient case detail for monitoring trends among subpopulations to ensure equitable delivery of monitoring. ² STI surveillance is predominantly passive, relying on manual and voluntary submission of case reports to public health authorities. Passive surveillance contributes to underreporting via inconsistencies in reporting practices across states and jurisdictions. STI reporting challenges were further exacerbated based on the diversion of resources from testing, reporting, and treatment during the COVID-19 pandemic. ³

Establishing notifiable STI-reporting requirements safeguards population-level health by guaranteeing the identification and follow-up of cases, as well as monitoring trends in disease to inform outbreak response. Nonetheless, STI reporting is mandated only at the local and state level, leading to variations in the reported diseases, case definitions, demographic information collected, and the means by which reporting is required. ⁴ Statutes differ in the types of administrators required to report cases to state health departments (e.g., medical professionals, school principals, prison wardens), the information included in case reports, the timing and route of notification, and the repercussions for noncompliance, leading to limited data comparability across states. ⁵ Further complicating the public health issue is that the US reporting system largely relies on hospitals, laboratories, and/or clinicians reporting to the local or state health departments, and data standardization does not exist at the federal level.

To better understand differences in health care providers reporting requirements across each US state, we comprehensively reviewed the STI section of the state health department website to determine which STIs are reportable, the sociodemographic information collected on each case report form, and the reporting timeframe for each STI. We identified 10 STIs that are reportable in at least one US state. Delaware, New York, Florida, and Washington State are the states with the most (n = 8) reportable STIs. The average number of reportable STIs in each state is six. New Hampshire, Vermont, Tennessee, Iowa, and North Dakota only have four reportable STIs, which is the lowest number of any state, and all five states require reporting of HIV/AIDS, syphilis, Chlamydia, and gonorrhea. Table 1 shows the number of states that require each STI to be reported. All states and Washington, DC, require HIV/AIDS, syphilis, and Gonorrhea diagnoses to be reported. Nearly all states require reporting of chlamydia except California. Trichomoniasis is only reportable in humans in one state—Arkansas.

Further, we compared sociodemographic categories that are collected by at least 1 state. Table 2 shows the number of states that collect these sociodemographic variables: age, sex, gender, sexual orientation, race, ethnicity, occupation, primary language, physical address, and partner’s sociodemographic. Sex and gender information are not collected in all states. Montana is the only state that does not require reporting ethnicity. Three states, Hawaii, Connecticut, and Alabama, collect insurance status/patient’s payer source information. The Indiana reporting form collects whether patients have insurance but not the payer source. No states collect information on housing status, education level, or income information of patients.

Reporting methods also varied widely across states. Thirty states and Washington, DC, have a specific STI report form; 18 states have a general disease report form, and Montana and Idaho do not have a standardized form. The majority (n = 36) of states use fax for reporting new STIs. Twenty-three states developed their own secure online report portal for reporting, and 22 states allow for reporting via the United States Postal Service. Eight states use electronic case reporting, which is the automated generation and transmission of case reports from electronic health records (eHours) to public health agencies.

Untreated STIs can have severe health consequences, including pelvic inflammatory disease, infertility, miscarriage or newborn death, increased risk of HIV infection, genital and oral cancers, and neurological and rheumatological effects. The consequences extend beyond the individual level, with the increased rates of STI cases in the US exacerbating the public health significance of this crisis. Our review identified inconsistencies in requirements for STI reporting by health providers at the state and local level, in the timeframe and method (i.e., mail, fax) for reporting STIs to the health departments, the requirements of reporting between local health departments and their “parent” state, and what is included in the list of notifiable diseases and conditions.

This review demonstrates that although reporting of infectious diseases has evolved over more than a century, standardization has not been achieved across the US. Reporting of STIs, even most communicable diseases, depends on having laboratory diagnoses and reports to health departments and plays an increasingly valuable role in disease surveillance. ⁶ Nonetheless, dual reporting by the laboratory and health care providers is a widespread requirement, which is a persistent challenge, especially in the context of evidence that health care providers are notoriously poor at reporting infectious diseases. For instance, Wisconsin has dual STI reporting laws requiring that both laboratories and health care providers must submit a report. ⁷ Similarly, Iowa requires STI data to be reported by the laboratory and provider; however, treatment information is only included in the provider report. ⁸

While disease control may be improved by simplified, semi-automated reporting of notifiable diseases to public health authorities, these findings suggest that US state and local health departments have not consolidated or standardized the STI reporting process for providers. Importantly, the lack of data standardization among states and cohesion between state and federal practices can lead to a stunted understanding of the STI burden and an inability to control disease. For instance, states and localities within states differ considerably in their collection of types of STIs. Further lack of standardization can lead to inconsistent reporting of sociodemographic data, such as race/ethnicity, sex, and gender, which compromises the understanding and mitigation of STI disparities. ⁹ Inconsistent reporting of sociodemographic variables that describe the impact of the populations is critically important so that health departments know where to direct resources for prevention activities. Notably, language and occupation are collected in very few states, despite evidence that these are related to STI incidence. ¹⁰ Critically, income, education, and housing status are not collected on any STI reporting forms, even though income inequality and homelessness are well documented as being correlated with STI prevalence. ^11,12

In summary, our review of the health care providers’ STI reporting requirements across states and local governments demonstrates the fragmented reporting system and the downstream challenges of data consolidation given the unstandardized approach to reporting STIs in the US. Most state and local governments expect reporting of diseases to be initiated by hospital, laboratory, or clinic staff through passive approaches such as fax, the United States Postal Service, or an online portal. The current reporting approaches are known to be burdensome for reporting staff and produce incomplete data that can delay outbreak identification. ¹³ Thus, our review identified the current gaps in the reporting system and inconsistencies across states’ STI reporting practices, demonstrating the need for standardization and collection of sociodemographic information to better address the mounting public health crisis of rising rates of reported STI cases in the US.