874
Electronic influenza surveillance SIR,-Since 1984 Valleron and colleagues have been developing computerised surveillance system for communicable diseases in France. The five infectious diseases selected for monitoring include influenza-like syndrome, and the results have been promising.1-3 Influenza is a leading cause of death from infectious disease in the developing world, and the losses to the economy are considerable. a
In the Netherlands, influenza induces sudden outbreaks with considerable morbidity, lasting two to three months, which makes it an explosive epidemic agent. An effective influenza surveillance system is important but a major obstacle is how to define the illness under scrutiny. The differential diagnosis of influenza-like syndromes is very difficult on clinical grounds alone.4 Identification of the agent responsible is needed, and without that the significance of morbidity indices will be uncertain whatever the system of data collection. The measurement of epidemiological indices and the identification of viruses have to be done at the same time on the same population, so close cooperation between epidemiologists and virologists is required. Electronic communication can be important in detecting the beginning of an epidemic of influenza and predicting its impact,s and the distribution of such information could make general practitioners (GPs) more aware of the risks of an epidemic. The National Influenza Centre of the Netherlands set up a project on electronic influenza surveillance, the first goal being to find out how willing GPs are to use a computer as a means of communication. A health-care network (Medimatica), already in place, was used for this purpose. This network permits several health-care institutions to communicate via a central computer, and since 1985 Medimatica has offered two services to doctors, an electronic mail service and a medical database service. In February, 1992, Medimatica had about 4700 subscribers. The subscription fee is low and the first 500 electronic mail messages in a year are free. Subscribers include about 1300 pharmacists, 1700 medical specialists, and 1300 GPs. Every week 30% or so of subscribers consult one or more of the sixty databases, containing literature indices, information for patients, continuing medical education, and current information on various topics. 30-40% of the 6500 Dutch GPs have a personal computer. In October, 1991, the influenza database was set up. Its ten items include the current influenza situation in the Netherlands and other countries, information on vaccination, technical laboratory information, and influenza news. The new database was recommended to subscribers by a highlighted issue on the menu screen, and the accompanying Medimatica journal drew attention to it. The database was updated weekly with information from GPs, from the Netherlands Institute of Primary Health Care, and from bulletins of other national influenza centres and EURO-GROG.6 GPs could ask questions and request reprints. They were also asked to report outbreaks of influenza-like illness to the influenza centre, after which samples for viral diagnosis could be taken. During the current influenza season the database achieved an average monthly consultation rate of 210 (figure). The influenza database ranked 16 out of the 60 databases by frequency of consultation. (The index of Nederlands Tijdschrift voor
Geneeskunde, available since December, 1992, was the most frequently consulted at 614 per month but we do not know how many of these contacts were from GPs.) Few people requested reprints, only 2 people posed a question, and there was no response to our request that GPs contact us if they suspected an influenza epidemic in their practice. It seems that subscribers neither frequently consulted the influenza database nor participated in supplying information to it. If every Medimatica subscriber had consulted this database weekly, consultations would have averaged 18 000 per month. This is disappointing because the weekly updates are time-consuming and demand discipline. Voluntary contact with an electronic network for the collection of sentinel data does not seem to be as effective as having a coordinator make individual contact with participants by telephone. In such systems (eg, GROG surveillance in France) 85-100% response rates are readily obtained every week; the representativity and stability of the sample are much improved; and the size of the panel can be either reduced or kept the same with an increase in accuracy.’ In France, computer networks can be satisfactory as a communication medium but our experience with the influenza database suggests that Dutch physicians are not spontaneously enthusiastic about the computer as a means of communication. Perhaps if electronic data communication becomes better established such surveillance systems will be more realistic but we conclude that surveillance systems should not be based on electronic networks alone. National Influenza Centre, Department of Virology, Erasmus University, PO Box 1738, 3000DR Rotterdam, Netherlands
MARC J. W. SPRENGER BRIGITTE M. KEMPEN
National Influenza Reference Centre, Institut Pasteur, Paris, France
CLAUDE HANNOUN
National Influenza Centre, Rotterdam
NIC MASUREL
1.
Valleron AJ, Bouvet E, Garnerin Ph, et al. A computer network for the surveillance of communicable diseases. the French experiment. Am J Publ Health 1986; 76:
1289-92. 2. Valleron AJ, Garrat F, Garnerin Ph. Early detection of epidemic influenza. Lancet 1992; 339: 57-58. 3. Costagliola D, Flahault A, Galinac D, Garnerin Ph, Menares J, Valleron AJ. A routine tool for detection and assessment of epidemics of influenza-like syndrome m France. Am J Publ Health 1991, 81: 97-99. 4. Hannoun C, Dab W, Cohen JM. A new influenza surveillance system in France: the Ile-de-France "GROG" I: principles and methodology. Eur J Epidemiol 1989; 5: 285-93. 5. Sprenger MJW, Mulder PGH, Beyer WEP, Masurel N. Influenza. relation of
mortality to morbidity parameters: Netherlands, 1970-1989. Int J Epidemiol 1991; 20: 1118-24. 6. Hannoun C. Bull Eurogrog (European Network for Specific Surveillance of Epidemic
Influenza). 1991-92, weekly. W, Quenel P, Cohen JM, Hannoun C. A new influenza surveillance system in France: the Ile-de-France ’GROG" II: validity of indicators (1984-89). Eur J Epidemiol 1991; 7: 579-87.
7. Dab
Epoetin and the right to prescribe SIR,-ln the UK, recombinant human erythropoietin (epoenn,
rhEPO) is licensed for use only in patients with chronic renal failure, giving health authorities an excuse to withhold financial support if it is prescribed for any other condition. However, as Erslevl pointed out, some patients with non-renal anaemia and raised endogenous EPO levels benefit from treatment with rhEPO. While it would be difficult to make a case for extending the licence for use in patients with incurable malignancy, it would be a different matter if there were a disorder in which rhEPO proved potentially curative. Pure red cell aplasia (PRCA) may be one such disorder. Although treatment with steroids or immunosuppressive agents may be effective in PRCA, these drugs have unpleasant long-term side-effects and are rarely curative. Two recent reports document partiaP and complete3responses to rhEPO in, respectively, primary and secondary PRCA. This report is of yet another complete response.
A 20-year-old man had PRCA with no obvious underlying cause. His endogenous immunoreactive EPO level was 48 IU/l (normal 5-22). Although the haematological response to prednisolone 60 mg daily was excellent, a psychosis developed with muscular pain and
Electronic influenza surveillance SIR,-Since 1984 Valleron and colleagues have been developing computerised surveillance system for communicable diseases in France. The five infectious diseases selected for monitoring include influenza-like syndrome, and the results have been promising.1-3 Influenza is a leading cause of death from infectious disease in the developing world, and the losses to the economy are considerable. a
In the Netherlands, influenza induces sudden outbreaks with considerable morbidity, lasting two to three months, which makes it an explosive epidemic agent. An effective influenza surveillance system is important but a major obstacle is how to define the illness under scrutiny. The differential diagnosis of influenza-like syndromes is very difficult on clinical grounds alone.4 Identification of the agent responsible is needed, and without that the significance of morbidity indices will be uncertain whatever the system of data collection. The measurement of epidemiological indices and the identification of viruses have to be done at the same time on the same population, so close cooperation between epidemiologists and virologists is required. Electronic communication can be important in detecting the beginning of an epidemic of influenza and predicting its impact,s and the distribution of such information could make general practitioners (GPs) more aware of the risks of an epidemic. The National Influenza Centre of the Netherlands set up a project on electronic influenza surveillance, the first goal being to find out how willing GPs are to use a computer as a means of communication. A health-care network (Medimatica), already in place, was used for this purpose. This network permits several health-care institutions to communicate via a central computer, and since 1985 Medimatica has offered two services to doctors, an electronic mail service and a medical database service. In February, 1992, Medimatica had about 4700 subscribers. The subscription fee is low and the first 500 electronic mail messages in a year are free. Subscribers include about 1300 pharmacists, 1700 medical specialists, and 1300 GPs. Every week 30% or so of subscribers consult one or more of the sixty databases, containing literature indices, information for patients, continuing medical education, and current information on various topics. 30-40% of the 6500 Dutch GPs have a personal computer. In October, 1991, the influenza database was set up. Its ten items include the current influenza situation in the Netherlands and other countries, information on vaccination, technical laboratory information, and influenza news. The new database was recommended to subscribers by a highlighted issue on the menu screen, and the accompanying Medimatica journal drew attention to it. The database was updated weekly with information from GPs, from the Netherlands Institute of Primary Health Care, and from bulletins of other national influenza centres and EURO-GROG.6 GPs could ask questions and request reprints. They were also asked to report outbreaks of influenza-like illness to the influenza centre, after which samples for viral diagnosis could be taken. During the current influenza season the database achieved an average monthly consultation rate of 210 (figure). The influenza database ranked 16 out of the 60 databases by frequency of consultation. (The index of Nederlands Tijdschrift voor
Geneeskunde, available since December, 1992, was the most frequently consulted at 614 per month but we do not know how many of these contacts were from GPs.) Few people requested reprints, only 2 people posed a question, and there was no response to our request that GPs contact us if they suspected an influenza epidemic in their practice. It seems that subscribers neither frequently consulted the influenza database nor participated in supplying information to it. If every Medimatica subscriber had consulted this database weekly, consultations would have averaged 18 000 per month. This is disappointing because the weekly updates are time-consuming and demand discipline. Voluntary contact with an electronic network for the collection of sentinel data does not seem to be as effective as having a coordinator make individual contact with participants by telephone. In such systems (eg, GROG surveillance in France) 85-100% response rates are readily obtained every week; the representativity and stability of the sample are much improved; and the size of the panel can be either reduced or kept the same with an increase in accuracy.’ In France, computer networks can be satisfactory as a communication medium but our experience with the influenza database suggests that Dutch physicians are not spontaneously enthusiastic about the computer as a means of communication. Perhaps if electronic data communication becomes better established such surveillance systems will be more realistic but we conclude that surveillance systems should not be based on electronic networks alone. National Influenza Centre, Department of Virology, Erasmus University, PO Box 1738, 3000DR Rotterdam, Netherlands
MARC J. W. SPRENGER BRIGITTE M. KEMPEN
National Influenza Reference Centre, Institut Pasteur, Paris, France
CLAUDE HANNOUN
National Influenza Centre, Rotterdam
NIC MASUREL
1.
Valleron AJ, Bouvet E, Garnerin Ph, et al. A computer network for the surveillance of communicable diseases. the French experiment. Am J Publ Health 1986; 76:
1289-92. 2. Valleron AJ, Garrat F, Garnerin Ph. Early detection of epidemic influenza. Lancet 1992; 339: 57-58. 3. Costagliola D, Flahault A, Galinac D, Garnerin Ph, Menares J, Valleron AJ. A routine tool for detection and assessment of epidemics of influenza-like syndrome m France. Am J Publ Health 1991, 81: 97-99. 4. Hannoun C, Dab W, Cohen JM. A new influenza surveillance system in France: the Ile-de-France "GROG" I: principles and methodology. Eur J Epidemiol 1989; 5: 285-93. 5. Sprenger MJW, Mulder PGH, Beyer WEP, Masurel N. Influenza. relation of
mortality to morbidity parameters: Netherlands, 1970-1989. Int J Epidemiol 1991; 20: 1118-24. 6. Hannoun C. Bull Eurogrog (European Network for Specific Surveillance of Epidemic
Influenza). 1991-92, weekly. W, Quenel P, Cohen JM, Hannoun C. A new influenza surveillance system in France: the Ile-de-France ’GROG" II: validity of indicators (1984-89). Eur J Epidemiol 1991; 7: 579-87.
7. Dab
Epoetin and the right to prescribe SIR,-ln the UK, recombinant human erythropoietin (epoenn,
rhEPO) is licensed for use only in patients with chronic renal failure, giving health authorities an excuse to withhold financial support if it is prescribed for any other condition. However, as Erslevl pointed out, some patients with non-renal anaemia and raised endogenous EPO levels benefit from treatment with rhEPO. While it would be difficult to make a case for extending the licence for use in patients with incurable malignancy, it would be a different matter if there were a disorder in which rhEPO proved potentially curative. Pure red cell aplasia (PRCA) may be one such disorder. Although treatment with steroids or immunosuppressive agents may be effective in PRCA, these drugs have unpleasant long-term side-effects and are rarely curative. Two recent reports document partiaP and complete3responses to rhEPO in, respectively, primary and secondary PRCA. This report is of yet another complete response.
A 20-year-old man had PRCA with no obvious underlying cause. His endogenous immunoreactive EPO level was 48 IU/l (normal 5-22). Although the haematological response to prednisolone 60 mg daily was excellent, a psychosis developed with muscular pain and
