Syndromic Surveillance of Acute Gastroenteritis Based on Drug Consumption
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Epidemiol. Infect. (2011), 139, 1388–1395. f Cambridge University Press 2010 doi:10.1017/S095026881000261X Syndromic surveillance of acute gastroenteritis based on drug consumption F. BOUNOURE1*, P. BEAUDEAU2,D.MOULY2,M.SKIBA1 AND M. LAHIANI-SKIBA 1 1 Laboratoire de Pharmacie Gale´nique, LAGEP UMR CNRS 5007, Faculte´ de Me´decine Pharmacie, Rouen, France 2 Institut de Veille Sanitaire, Saint-Maurice, France (Accepted 20 October 2010; first published online 26 November 2010) SUMMARY Since 1998, the French Health Insurance (NHI) system had established a national database in order to reimburse drug prescriptions. These electronical data are a considerable potential source for syndromic surveillance because of their exhaustive and regular updates. The aim of this study was to develop a method to identify acute gastroenteritis (AG) cases from drug reimbursements of the NHI database. The algorithm aimed at discriminating AG from other pathologies was determined from a sample of 206 AG prescriptions and 351 non-AG prescriptions collected in five pharmacies. The AG case identification was mainly based on the lag time between the prescription and delivery day, the occurrence of non-AG case-specific drugs, AG case-specific drug associations and treatment duration. The discriminant algorithm led to a sensitive and specific indicator of medically treated cases of AG with a time–spatial resolution power which met the need for waterborne AG surveillance. Key words: Acute gastroenteritis, drug prescription, France, NHI database, syndromic surveillance. INTRODUCTION establish baseline disease burdens, and the ability to delineate the geographical reach of an outbreak [1]. The U.S. Center for Disease Control and Prevention The French National Health Insurance (NHI) data- (CDC) describes syndromic surveillance as ‘an in- base is a potential data source for syndromic surveil- vestigational approach where health department staff, lance [2]. All individuals residing in France must assisted by automated data acquisition and gener- be registered with the French Social Security System. ation of statistical alerts, monitor disease indicators This registration provides access to social protection in real-time or near real-time to detect outbreaks of which includes reimbursement of expenses for health- disease earlier than would otherwise be possible with care and drugs. The NHI is responsible for these traditional public health methods’. Theoretical ben- reimbursements. Since 1998, NHI has developed a efits of syndromic surveillance include potential database used for medical consultations and drug re- timeliness, increased response capacity, the ability to funds. The NHI database contains information on patients and drug refunds which is useful for epi- * Author for correspondence: Dr F. Bounoure, Laboratoire de demiological studies (Table 1). In this database, drugs Pharmacie Gale´nique, 22 bd Gambetta, 76183 Rouen Cedex, France. are referred by the code of the ‘Inter Pharmaceutical (Email: [email protected]) Club’ (CIP) which corresponds to the product Downloaded from https://www.cambridge.org/core. IP address: 170.106.40.219, on 30 Sep 2021 at 12:55:25, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S095026881000261X Acute gastroenteritis surveillance 1389 Table 1. Database of French National Health lacks specificity related to the use of these drugs Insurance on drug prescription (ERASME, in the treatment of non-targeted pathology. Specific SNIIR-AM) methods have been proposed to deal with these problems in asthma epidemiology [14, 15] but no Information Utility methods are available for AG epidemiology. Policy holder AG results from an inflammation of the gastro- HI number intestinal tract, most commonly following an infec- Location tion. Due to its high incidence, AG represents a Address significant cost in developed countries [16, 17] and is a Post code Geographical location useful index for surveillance of diseases due to faecal Beneficiary Gender pathogens. AG is characterized by rapid onset of Birthdate diarrhoea with or without vomiting, nausea, fever, and abdominal pain. Occasionally patients may present File initially with vomiting alone, with the onset of diar- Code Information key rhoea following later. In children, the symptoms Pharmacy reference Identification of patients + might be less specific and confused by respiratory post code living outside study area GP’s reference+ Identification of patients symptoms. An AG case is clinically defined as diar- post code living outside study area rhoea and/or vomiting at least three times per day Dispensation date with recent onset [18]. Medical examination Like other countries, the French Ministry of Health date first built enteric disease surveillance on compulsory Product reporting of specific infections, e.g. cholera, sal- Drug code (CIP) monellosis, or collective food poisonings, by both Name ATC code Extraction by therapeutic general practitioners (GPs) and laboratories [19]. The class ‘Sentinelle GPs’ network’ supplemented the system EPhMRA code Extraction by therapeutic in 1990, providing an estimate of the weekly number class of AG consultations in the 20 regions of France [20]. Number of boxes The specific usefulness of the ecological (i.e. non- dispensed individual) data depends on both their sensitivity CIP, Inter Pharmaceutical Club; ATC, Anatomical Thera- and their time–space resolution power. The Sentinelle peutic Classification; EPhMRA, European Pharmaceutical GPs’ network provides the public health stakeholders Marketing Research Association. with data, with a 1-week delay, regarding the spread of winter viral AG outbreaks throughout France. However, with a GP participation rate of about packaging. Drugs may also be extracted by homo- 1/1000 and a GP consultation rate for AG represent- genous classes of the ‘Anatomical Therapeutic ing 0.08/person per year, this database cannot sup- Classification’ (ATC) of the World Health Organiz- port local investigations, particularly for waterborne ation [3] or ‘European Pharmaceutical Marketing AG outbreaks. The quasi-completeness of the NHI Research Association’ (EPhMRA) nomenclatures. database dramatically increases the possibilities for Drug consumption data are already used to esti- local investigations and studies. mate the prevalence of chronic diseases like asthma The aim of this study was to develop a method to [4], diabetes [5–8], or cardiovascular diseases [9]. identify cases of AG from drug-reimbursement data These data are used less frequently to estimate the in the NHI database. The performance of this method incidence of diseases such as acute gastroenteritis was evaluated and its use for an AG surveillance (AG) [10] and acute respiratory diseases [11–13]. The system was discussed. incidence or prevalence of these diseases is generally estimated by the annual drug sales divided by the av- MATERIALS AND METHODS erage daily dose, and by average treatment duration. However, the conversion of sales into cases remains The definition of a medically treated AG case is based inaccurate because of the variation in drug dosage on the typology of GP prescriptions, which we ob- and drug associations. Furthermore, this indicator tained according to the following design. Downloaded from https://www.cambridge.org/core. IP address: 170.106.40.219, on 30 Sep 2021 at 12:55:25, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S095026881000261X 1390 F. Bounoure and others Table 2. Drug used for the treatment of acute gastroenteritis (data provided by NHI) Therapeutic classes ATC Trademark Drug Intestinal antispamodics* A03A Spasfon1 Phloroglucinol Duspatalin1 Mebeverine Dicetel1 Pinaverium Debridat1 Trimebutine Meteospamyl1 Alverine Meteoxane1 Simeticone Anti-emetics A04A Vogalene1 Metopimazine A03F Motilium1 Domperidone Peridys1 Metoclopramide Primperan1 Probiotic antidiarrhoeals A07F Ultralevure1 Saccharomyces boulardii Lacteol1 S. cerevisiae Intestinal antipropulsive A07D Imodium1 Loperamide Arestal1 A07X Tiorfan1 Racecadotril 1 Intestinal absorbents A07B Carbolevure Activated charcoal+S. cerevisiae No ATC code Carbosylane1 Activated charcoal A02X Bedelix1 Montmorillonite Smecta1 Diosmectite Intestinal anti-infectious A07A Ercefuryl1 Nifuroxazide agents Lumifurex1 Panfurex1 Oral rehydration salts Medical devices Adiaril1 Alhydrate1 Fanolyte1 Ges 451 Hydrogoz1 Picolite1 Viatol1 ATC, Anatomical Therapeutic Classification. * Not used for the extraction of refund data from NHI database. Pharmacy survey nor was a new drug launched. Additionally, no sig- nificant changes in prescription patterns were vali- A list of drugs currently used in the treatment of AG in dated by the pharmacists participating in the study. France was released by GPs and pharmacists. Drugs The five pharmacies were located in three major cities used for treating AG were divided into six therapeutic and two small villages of the same region. A consent classes which roughly matched the A07 ATC sub- form was obtained verbally from each patient prior to classes but required some adaptations from day- enrolling in the study. The patients were asked about to-day prescription practice (Table 2). A retrospective their medical history (e.g. presence of AG vs. other investigation was conducted in pharmacies to obtain a diseases, labelled as non-AG), age, gender and post sample of prescriptions associated with the diagnosis. code. The selection bias