Importance of notifying febrile rash illnesses from a private hospital to the Regional Epidemiological Unit: a qualitative study
Keywords:
epidemiological surveillance, febrile rash illness, measles, disease notification, private sector, qualitative researchAbstract
Introduction: febrile rash illnesses (FRI) are the operational core of integrated measles and rubella surveillance. In Paraguay, reporting is mandatory and immediate within twenty-four hours of suspicion for every notifying unit, including private facilities, which must report to their corresponding Regional Epidemiological Unit (UER). Nevertheless, the literature consistently documents lower compliance in the private sector than in the public subsector, and little evidence exists on the meanings, practices and tensions underlying that gap. Objective: to understand the meaning that health professionals of a private hospital attribute to FRI notification to the UER, together with the practices, barriers and facilitators that shape this process. Methods: qualitative research with a hermeneutic-phenomenological design. Twenty-one informants were selected through purposive criterion and snowball sampling: eighteen hospital staff members (physicians, nurses, biochemists, administrative personnel and managers) and three UER professionals. In-depth semi-structured interviews, two focus groups and documentary review of notification forms and institutional protocols were carried out between August 2025 and March 2026. Analysis followed Braun and Clarke reflexive thematic procedure, supported by ATLAS.ti 23, with triangulation of sources, techniques and researchers. Reporting adheres to COREQ criteria. Results: six categories emerged: (1) clinical suspicion as a fragile first link; (2) notification between legal duty and bureaucratic burden; (3) formal circuits, informal shortcuts and dependence on key individuals; (4) tension between private-sector logic and public health responsibility; (5) from perceived inspection to constructed collaboration; and (6) proposals emerging from the actors themselves. Conclusions: FRI notification does not operate as an isolated administrative act but as a situated social practice, conditioned by clinical competence to suspect, the quality of the relationship with the UER, and the existence of institutionalised circuits that do not depend on the goodwill of specific individuals. Strengthening epidemiological feedback, formalising the surveillance focal point role and embedding notification within the clinical workflow emerge as priority interventions.
References
Asociación Médica Mundial. (2013). Declaración de Helsinki: principios éticos para las investigaciones médicas en seres humanos (64.ª Asamblea General). JAMA, 310(20), 2191–2194.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.
Calba, C., Goutard, F. L., Hoinville, L., Hendrikx, P., Lindberg, A., Saegerman, C., & Peyre, M. (2015). Surveillance systems evaluation: A systematic review of the existing approaches. BMC Public Health, 15, 448.
Centers for Disease Control and Prevention. (2001). Updated guidelines for evaluating public health surveillance systems: Recommendations from the Guidelines Working Group. MMWR Recommendations and Reports, 50(RR-13), 1–35.
Consejo de Organizaciones Internacionales de las Ciencias Médicas. (2016). Pautas éticas internacionales para la investigación relacionada con la salud con seres humanos (4.ª ed.). CIOMS.
Dirección General de Vigilancia de la Salud. (2024). Red Nacional de Vigilancia Epidemiológica. Ministerio de Salud Pública y Bienestar Social. https://dgvs.mspbs.gov.py/red-nacional-de-vigilancia-epidemiologica/
Dirección General de Vigilancia de la Salud. (2025a). Alerta epidemiológica por riesgo de dispersión de sarampión en el país, ante casos confirmados relacionados a importación. Ministerio de Salud Pública y Bienestar Social.
Dirección General de Vigilancia de la Salud. (2025b). Boletín Epidemiológico Semanal, Semana Epidemiológica 26. Ministerio de Salud Pública y Bienestar Social.
Doyle, T. J., Glynn, M. K., & Groseclose, S. L. (2002). Completeness of notifiable infectious disease reporting in the United States: An analytical literature review. American Journal of Epidemiology, 155(9), 866–874.
Friedman, S. M., Sommersall, L. A., Gardam, M., & Arenovich, T. (2006). Suboptimal reporting of notifiable diseases in Canadian emergency departments: A survey of emergency physician practices following the SARS outbreak. Canadian Journal of Public Health, 97(2), 101–104.
Gibbons, C. L., Mangen, M. J., Plass, D., Havelaar, A. H., Brooke, R. J., Kramarz, P., Peterson, K. L., Stuurman, A. L., Cassini, A., Fèvre, E. M., & Kretzschmar, M. E. (2014). Measuring underreporting and under-ascertainment in infectious disease datasets: A comparison of methods. BMC Public Health, 14, 147.
Groseclose, S. L., & Buckeridge, D. L. (2017). Public health surveillance systems: Recent advances in their use and evaluation. Annual Review of Public Health, 38, 57–79.
Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. En N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 105–117). Sage.
Guerra, F. M., Bolotin, S., Lim, G., Heffernan, J., Deeks, S. L., Li, Y., & Crowcroft, N. S. (2017). The basic reproduction number (R0) of measles: A systematic review. The Lancet Infectious Diseases, 17(12), e420–e428.
Hernández-Sampieri, R., & Mendoza Torres, C. P. (2018). Metodología de la investigación: Las rutas cuantitativa, cualitativa y mixta. McGraw-Hill Interamericana.
Krause, G., Ropers, G., & Stark, K. (2005). Notifiable disease surveillance and practicing physicians. Emerging Infectious Diseases, 11(3), 442–445.
Ley N.º 836/1980. Código Sanitario de la República del Paraguay. Poder Legislativo.
Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research, 26(13), 1753–1760.
Nsubuga, P., White, M. E., Thacker, S. B., Anderson, M. A., Blount, S. B., Broome, C. V., Chiller, T. M., Espitia, V., Imtiaz, R., Sosin, D., Stroup, D. F., Tauxe, R. V., Vijayaraghavan, M., & Trostle, M. (2006). Public health surveillance: A tool for targeting and monitoring interventions. En D. T. Jamison et al. (Eds.), Disease control priorities in developing countries (2.ª ed., pp. 997–1015). Banco Mundial y Oxford University Press.
Organización Mundial de la Salud. (2016). Reglamento Sanitario Internacional (2005) (3.ª ed.). OMS.
Organización Mundial de la Salud. (2018). Measles and rubella surveillance standards. En WHO vaccine-preventable diseases surveillance standards. OMS.
Organización Panamericana de la Salud. (2007). Eliminación del sarampión: Guía práctica (2.ª ed., Publicación Científica y Técnica N.º 605). OPS.
Organización Panamericana de la Salud. (2018). Plan de acción para la sostenibilidad de la eliminación del sarampión, la rubéola y el síndrome de rubéola congénita en las Américas 2018-2023 (CD56/9). OPS.
Organización Panamericana de la Salud. (2026a). Brote multipaís de sarampión: Evaluación de riesgo y situación regional. OPS. https://www.paho.org/es/brote-multi-pais-sarampion-2026
Organización Panamericana de la Salud. (2026b). Informe de situación: Sarampión en la Región de las Américas. OPS.
Patel, M. K., Goodson, J. L., Alexander, J. P., Kretsinger, K., Sodha, S. V., Steulet, C., Gacic-Dobo, M., Rota, P. A., McFarland, J., Menning, L., Mulders, M. N., & Crowcroft, N. S. (2020). Progress toward regional measles elimination — Worldwide, 2000–2019. MMWR Morbidity and Mortality Weekly Report, 69(45), 1700–1705.
Silk, B. J., & Berkelman, R. L. (2005). A review of strategies for enhancing the completeness of notifiable disease reporting. Journal of Public Health Management and Practice, 11(3), 191–200.
Strauss, A., & Corbin, J. (2002). Bases de la investigación cualitativa: Técnicas y procedimientos para desarrollar la teoría fundamentada. Editorial Universidad de Antioquia.
Tan, H. F., Yeh, C. Y., Chang, H. W., Chang, C. K., & Tseng, H. F. (2009). Private doctors’ practices, knowledge, and attitude to reporting of communicable diseases: A national survey in Taiwan. BMC Infectious Diseases, 9, 11.
Thacker, S. B., & Berkelman, R. L. (1988). Public health surveillance in the United States. Epidemiologic Reviews, 10, 164–190.
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357.
Vandenbroucke, J. P. (2008). Observational research, randomised trials, and two views of medical science. PLoS Medicine, 5(3), e67.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Cynthia Carolina Vazquez Rolón (Autor/a)
This work is licensed under a Creative Commons Attribution 4.0 International License.
