Industry-sponsored infectious disease surveillance--an idea whose time has come?

Influenza virus infections result in 200,000 hospitalizations and 38,000 deaths per year in the United States, despite widely available information about influenza and influenza prevention efforts via vaccination programs. The Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Reports provide abundant data on the status of influenza-like illnesses in the United States. A description of the FluStar Surveillance System, an industry-sponsored approach to influenza surveillance, appears in this issue of the Journal by Aull et al. FluSTAR surveillance information is routinely distributed via the internet. Roche Laboratories, Inc., the primary sponsor of the FluSTAR surveillance system, has taken on a noble mission to provide influenza surveillance information for the US, through a timely surveillance system among a voluntary network of physicians across the country. In 2001, the CDC published guidelines used to evaluate public health surveillance systems. The CDC guidelines suggested that surveillance systems be evaluated on the basis of simplicity, flexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability. In this editorial, we evaluated the strengths and weaknesses of the FluSTAR system, using the CDC guidelines as criteria. First, the FluSTAR system was highly simplistic. During the 2005 to 2006 influenza season, 395 physicians volunteered, in the course of their office practices, to evaluate and test patients in-office for influenza via a rapid antigen test. A case report form was completed for each patient tested and submitted twice a week to Surveillance Data, Inc., The FluSTAR system was flexible, with simple case report forms and taking full advantage of internet communications and reporting. Data quality was difficult to judge, as the article by Aull et al did not address issues such as missing data and completeness of data. Proof of the program’s acceptability was that 396 physicians participated in the program, and the program has continued through the 2006 to 2007 flu season. Most of the sensitivity factors, such as patient selection, sample collection, and rapid antigen test kit sensitivity, appeared to be acceptable. Predictive value positive was the FluSTAR system’s greatest advancement over the CDC’s Influenza-Like Illness (ILI) sentinel site surveillance system. The FluSTAR reported patients who tested positive for influenza, whereas the CDC ILI system reported patients with a temperature 100.0°F ( 37.8°C), oral or equivalent, and cough and/or sore throat in the absence of a known cause other than influenza, as positive. One limitation of the FluSTAR system was that the rapid influenza test utilized did not differentiate Influenza A from Influenza B, only noting that one was present. Therefore, it was of limited value in assessing whether current circulating strains were Influenza A or B. In contrast, the CDC’s National Respiratory and Enteric Virus Surveillance System (NREVSS) isolated a percentage of influenza viruses and reported the proportions of circulating type A and B influenza. Another feature missing in the FluSTAR system compared with the CDC’s influenza surveillance was the ability to estimate the severity of illness among patients with influenza. The CDC estimated the severity of influenza in the population with three surveillances: Pneumonia and Influenza Mortality Surveillance for 122 U.S. cities, Influenza-associated Pediatric Mortality, and Influenza-associated Pediatric Hospitalizations. The FluSTAR System’s representativeness was less than the CDC’s influenza surveillance. FluSTAR had 396 physicians reporting, whereas the CDC had approximately 1,200 provider sites reporting. One limitation of the FluSTAR system was that it did not report a representative number of children 12 months of age, with only 15 children 12 months of age out of 17,247 total patients. The latter occurred despite the observation that children 1 year of age were particularly vulnerable during the 2003 to 2004 influenza season, prompting the CDC to request reporting of influenza deaths among children. The FluSTAR system claimed to cover approximately 80% of the From the Departments of Safety and Infection Control, Pitt County Memorial Hospital, and The Brody School of Medicine at East Carolina University, Greenville, NC.