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The rabies information system — A model for a common information system in human and veterinary medicine
Computer Programs in Biomedicine 7 (1977) 211-217 © Elsevier/North-Holland Biomedical Press
THE RABIES INFORMATION SYSTEM SYSTEM IN HUMAN AND VETERINARY
21l
A MODEL FOR A COMMON INFORMATION MEDICINE
H. SINNECKER, L. APITZSCH, G. DEMSKI, G. RASCH, R. SINNECKER and U. VOIGT EpMemiological Center of The State Hygiene Inspection, Prof. Dr. H. Sinnecker, Tornowstr. 21/22, 15 Potsdam, GDR An information system is described in the field of rabies, which realizes the integration of information streams from human medicine as well as from veterinary medicine by help of computers. This rabies information system is based on a homogeneous and coordinated system of surveillance in connection with prophylaxis and control of rabies. It includes a modification of the case record, suggested by the WHO-Expert-Committee on Rabies. The aims of this rabies information system are: to make obvious the epizootiological situation with formation and change of loci, to show the epidemiological importance of special animals and to recognize the epidemiological situation. All this has to be fulfilled in an integrated system. Furthermore optimal treatment is guaranteed by express diagnostics and earliest possible special treatment of high-risk groups by the co-operation of human and veterinary medicine. The rabies information system was generally introduced in the GDR in 1970. It has proved to be practicable and effective especially by standardization of diagnostics, recording exposure of the patient, his treatment and partly automated evaluations of situation records and documentation of efficiency. Rabies
Information system
1. Introduction
The development of a computerized information system is necessary because of the abundance o f data, their steady increase and the difficulty of the epidemiological process. The development of a computerized information system is also necessary for the integration of information streams from human and veterinary medicine with the aim to optimize leading of prophylaxis and control of rabies. Fundamental to the rabies information system is a homogeneous and coordinated system of prophylaxis and control, including the co-operation o f first-attending physicians, veterinary medical institutions, epidemiological and epizootiological services, antirabic vaccination points and central services o f human and veterinary medicine. A description o f such a developed and homogeneous rabies information system, realized in the GDR since 1970, and deduction of some principles for the development of information systems in general, integrating information streams from human and veterinary medicine, follow. This system is built up according to the recommendations o f the WHO-Expert-Committee on Rabies.
2. Methods of planning and pilot studies After analysis of the mode in control and prophylaxis of rabies an optimization model was developed by considering the system of theoretical orientation on the development o f epidemiological and ecological surveillance (Sinnecker [4] ). In this model the improvement of existing services in human and veterinary health and of the mode was provided. After development of the model and the first design of a data carrier a discussion with some teams from human and veterinary services was carried out and also a follow-up study referring to the practicability. After that a conference was organized, based on the tested recommendations. Participants in the conference were all vaccinators and all veterinarians dealing with rabies diagnosis. The results and the recommendations of this conference caused the Ministry of Health of the GDR to introduce the developed system for the whole GDR in 1970. In routine conferences with the users of the project further evaluations and improvements were undertaken, especially directed by mistakes found and backward information and their form of presentation.
212
H. Sinnecker et al., The Rabies Information System
3. Description of the system Aims and activities of the epidemiological and ecological surveillance of rabies are summarized in table 1. The information system is directed on the aim to
show in an integrated system the epizootiological situation with formation and change of foci, the epidemiological importance of species and the epidemiological situation. Aims and activities are furthermore directed by the
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Epldemio|oglsches Zentrum der Staatlldlen Hygieneinspektlon Abt. ffir Immunepidemiologie und Referenzlabor for Tollwut 108 Bedln, Clara-Zetkin-Stra~e 96 Name Be.~d~reibung des Vorfalls: Geburtsname
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H. Sinnecker et al., The Rabies Information System ~,q~ositionsobiekt
.~hlSlseI-Nr. ]NI 1. Fuchs 2, Dachs 3. Marder 4. 11tis
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der Exposition
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mlt Berufst6tigke[t
32 w e i t e r e K o n t a k t p e r s o n e n 33 A r t I = 3~ 5= 7~
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der Exposltien indlrekter Kontakt, 2 ~ Kontakt - unvedetzte Haut, Kontakt . verletzte Hout, 4 ~ Kontokt - unverletzte Sd~lelmhout. Kontakt - vedetzte SchleimhQut. 6 ~ Krotlverletzung, Bil~verletzung - lelcht, 8 ~ BiBverletzung - sdlwer
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1-6 N u m m e r d e r E l n r l c h t u n g 7-14 I m p f s t e I l e ( $ c h l ~ s s e I - N r , ) , J a h r P a t i e n t e n n u m m e r
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43 B s f u n d z u r Z e l t d e r E x p o s i t i o n ollgemelner Befund: 1 = entlaufen, 2 = unter Beobochtung, 3 = verendet, 4 = ~ ;t6tet 44 klinischer Befund: 1 = tollw0tlg, 2 ~ tollwutverdSchtig. 3 = kelne Zeidlen van W u t
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45 B e f u n d i m w e i t e r e n V e d o u f klinischer Be?und: 1 = Tollwut, 2 = keine Tollwut, 3 = unbekonnt 46-46 Laborbefund: 1 = positlv, 2 = verdSchtig. 3 ~ negatTv, 4 = nicht ouswertbor, 5 = nicht durdlgef0hrt 49 B e h o n d l u n g
1 = ambulant, 2 = stationer, 3 ~ nicht e~orderlich
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50 Iokale Versorgung, chirurgisch: 1 ~ io, 2 = neln 51 wlrksame OesinFektion: 1 ~ ja, 2 = nein. 3 ~ ungenaue A n g a b e n
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Fig. 1. Case record for human rabies exposure.
guarantee of an optimal post-expositional treatment by express diagnosis and earliest possible special treatment of high-risk groups, enabled by the co-operation of human and veterinary services. Finally all institutions for hunting and human and veterinary medicine should co-operate in a national
programme, connecting measures of surveillance, warning and control with the measurement of ef(lciency in control and prophylaxis measures. According to the aims, a coordinated system was realized, especially including the central epidemiological service, diagnostic standards with general applica-
H. Sinnecker et al., The Rabies Information System
214
Table 1 Aims and activities of epidemiological and ecological surveillance of rabies. Aim
Activity .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1. Data gathering and surveillance of morbidity and mortality of animals and of the exposure of man by
1.1 Express information - For recognition of dangers and for guarantee of an optimal control of rabies in animal - For guarantee of an optimal early treatment of highrisk groups
.
.
.
.
.
1. Further development of data gathering, storage and data evaluation of epizootiological and epidemiological data by a central data bank, special vaccination points and diagnostic institutions 1.1 Data gathering of - Case-diagnostics with standardized express diagnostic methods and with special immediate report of accumulations and problem strains - Exposure of man with special immediate report of high-risk groups and accumulations
1.2 Information on corrected computer-fitting documentations for objectivation and rationalization of the leading and of documentation of efficiency
1.2 Data gathering and partly computerized data evaluation of the situation and the trends with corrected computerfitting documents and partly computerized elaboration of epizootiological and epidemiological reports and of documentation of efficiency
1.3 Trend decision
1.3 Development of quantitative models for processing of the information and for the prognosis
2. Data gathering and surveillance of high-risk areas with investigation of change of foci and viruses and of high-risk groups for prevention of cases of death in man with the aim of
2. Development of epidemiological and ecological surveillance with a central data bank and an ecological, epidemiological and epizootiological measuring-point programme
2.1 Early recognition of dangers and for the control of epizootiological developments
2.1 Data gathering of circulation and characterization of viruses and special problem strains in relationship to the ecological situation
2.2 Prevention of vaccination failures by early and special treatment of high-risk groups with probably short incubation period
2.2 Immediate registration and optimal treatment of highrisk groups with probably short incubation periods in special vaccination points
Serological-virological surveillance of post-expositional treatment for
3. Development of serological -virological surveillance in
3.1 Preventing vaccination failures by interference of antibody stimulation caused by serum and vaccine in combined treatments
3.1 Combined treatments with serological exclusion of interferences in the antibody stimulation
3.2 Reduction and early recognition of complications in vaccinations
3.2 Persons who are endangered by complications in vaccination (previous rabies vaccine treatment, combined treatments or diseases of CNS) for the early recognition of complications
4. Control of rabies in animal by control and prophylaxis Connection of warning and control with measurements of the efficiency of measures
4. Improvement of prophylaxis and control with rational cooperation of all institutions in human and veterinary medicine and in hunting within a national programme
215
H. Sinnecker et al. / The Rabies Information System
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Fig. 2. Data flow and organization chart. tion of express diagnostic methods in the veterinarymedical field and surveillance in connection with control measures. The data gathering is carried out without forms by the first-attending physicians, by the veterinarians and by the epidemiological services, but in the vaccination points a so-called 'Case record for human rabies exposure' is filled in (fig. 1). The new original record replaces all usual, not unitary, documentations used in the vaccination points up to this time. It includes personal information on the patient, the description of the event, the results of veterinary examination and a documentation on therapeutic measures, on the front page. The reverse contains all adequate encoded information. The data flow and organization chart is given in fig. 2. Explanations according to fig. 2: (1) Immediate record - according to the direction of registration. (2) Weekly record of the county. ] Exposures with increases and high(3) Weekly record of the district, risk groups.
(4) Monthly record on situation and measures. (5) Records on epidemiological and ecological situation and documentations of efficiency. (a) Remittance to the antirabic vaccination point. (b) Record of diagnostic findings in animal, suspicious after exposures of man. (c) Record on exposed persons, their treatment and on injured animals. (d) Monthly record on positive findings in animals suffering from rabies, and on problem strains. The data processing takes place according to the aims shown in table 1 and is directed on main points: Epizootiological situation, epidemiological situation and also high-risk persons, needing a special treatment, as well as a survey on all attended people. According to the law medical advice is also accepted to be treatment. According to the aims the following da~ groups and the adequate information tables mean: (1) Occurrence of rabies in animals in relationship to
216
H. Sinnecker et al. / The Rabies Information System
begins within hours after exposure. The report by telephone is the base of a fast survey on especially problematic cases of exposure and it also helps prepare optimal treatment in connection with immunological controls. A general survey on the frequency of kinds of exposures, classified into the species of animals, is given in register 3 in the programme.
exposures, classified into district, month, species, group of diagnosis (+, +, 6) and exposures by injuries and contacts. (Register 2 and 6 in the programme.) This sample is completed by the general survey on rabies in animals, based on the reports of veterinary examination offices which register all cases, also those without contact to man. From this general survey result the surveys on the epizootiological situation in all districts and on species of epidemiological importance, necessary for decisions on treatment. (2) Exposures and post-expositional treatments of man, classified into district of exposure, season, age and sex in relationship to the diagnosis in animals and the kind of exposure (bite, contact). (Register 1 in the programme.) Also vaccinations in spite of negative findings in animals must be included in the programme. It also has to contain all advice with the result that a vaccination was not necessary, because according to the law all medical advice is also treatment. From this the surveys on the epidemiological situation and for documentation of efficiency, necessary for quarterly, annual and other records, result. (3) Kind of exposure and high-risk groups, needing a special treatment because of a probably short incubation period. Of decisive importance are: the localization and the severity of the injury (injuries in danger area I: multiple injuries, injuries in head and neck) the species (wildlife carnivores) and the time of retardation between injury and beginning of the treatment (in cases of more than 4 days). All these points have to be seen in relation to the findings in the animals. According to the decisive data, in order to characterize high-risk groups, a combined serum-vaccine treatment can be recommehded. This only can be carried out in special vaccination points. Children are always high-risk persons, but combined treatments cannot be carried out in every case. It must be guaranteed that the treatment of children
(4)
High-risk persons with a supposed higher probability for the occurrence of complications after vaccination (re-vaccinations, combined treatments, previous diseases of the CNS). The report by telephone is the base of a fast survey on patients with increased danger of a vaccination encephalitis and it shall help to organize an optimal treatment in connection with immunological controls.
(5) Survey on used vaccine and immunoglobulin charges, also side reactions and complications and data presentation of all persons, treated in the vaccination point. In supplements the side reactions and complications after combined treatments and in case of re-vaccinations are separately outlined. (Register 4 in the programme.) From this the analysis of used preparations and debit of vaccinations with reactions and complications results. This information is necessary for quarterly, annual and other reports. (6) Survey on the activity of the vaccination points with presentation of treatment, of epidemiological characteristics of treated persons, of reactions and of applied preparations. (Register 5 in the programme.) The data processing takes place over the R 300 after the data flow chart, outlined in fig. 3. Altogether there are necessary about 10 computer hours per annum. Based on this programme the records on the epidemiological situation and reports on the efficiency are produced partly automated.
H. Sinnecker et al., The Rabies Information System
217
human and veterinary medicine could be developed by consideration of the following principles: 1. A homogeneous system of prophylaxis and control with normatives worked out commonly is the fundamental which is necessary for a common system. Therefore the first step on the way to develop an integrated system has to be the development of an optimization model of control and prophylaxis for characterizing aims, tasks and structures, and for planning the development of the existing services, • "~
~k A
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. The epidemiological and epizootiological conception of a developed system has to be tested concerning practicability, efficiency and expense within a small group of participators in several successive steps. The improvement and evaluation, commonly worked out. is the fundamental of a preliminary conference in which all partners, working in the realization, take part. This conference must close the study as a fundamental for computerization.
References
Fig. 3. Data flow chart for the rabies information system.
The information system has proved its practicability and efficiency during an application over 5 years, especially by standardization of diagnostics and recording of patients exposure and treatment. This information system for information from
[ 1 ] WHO-Expert-Committee on Rabies, Fifth report, World Health Organization Technical Report Series (1970) No. 322. [2] WHO-Expert-Committee on Rabies, Sixth report, World Health Organization Technical Report Series (1973) No. 523. [3] World Health Organization, Regional Office for Europe (1969): Communicable Diseases - Methods of Surveillance. Report on a Seminar. [4] H. Sinnecker, Stan d und Perspektive des Infektionsschutzes in der DDR, Z. Ges. Hyg. 10 (1974) 699.
THE RABIES INFORMATION SYSTEM SYSTEM IN HUMAN AND VETERINARY
21l
A MODEL FOR A COMMON INFORMATION MEDICINE
H. SINNECKER, L. APITZSCH, G. DEMSKI, G. RASCH, R. SINNECKER and U. VOIGT EpMemiological Center of The State Hygiene Inspection, Prof. Dr. H. Sinnecker, Tornowstr. 21/22, 15 Potsdam, GDR An information system is described in the field of rabies, which realizes the integration of information streams from human medicine as well as from veterinary medicine by help of computers. This rabies information system is based on a homogeneous and coordinated system of surveillance in connection with prophylaxis and control of rabies. It includes a modification of the case record, suggested by the WHO-Expert-Committee on Rabies. The aims of this rabies information system are: to make obvious the epizootiological situation with formation and change of loci, to show the epidemiological importance of special animals and to recognize the epidemiological situation. All this has to be fulfilled in an integrated system. Furthermore optimal treatment is guaranteed by express diagnostics and earliest possible special treatment of high-risk groups by the co-operation of human and veterinary medicine. The rabies information system was generally introduced in the GDR in 1970. It has proved to be practicable and effective especially by standardization of diagnostics, recording exposure of the patient, his treatment and partly automated evaluations of situation records and documentation of efficiency. Rabies
Information system
1. Introduction
The development of a computerized information system is necessary because of the abundance o f data, their steady increase and the difficulty of the epidemiological process. The development of a computerized information system is also necessary for the integration of information streams from human and veterinary medicine with the aim to optimize leading of prophylaxis and control of rabies. Fundamental to the rabies information system is a homogeneous and coordinated system of prophylaxis and control, including the co-operation o f first-attending physicians, veterinary medical institutions, epidemiological and epizootiological services, antirabic vaccination points and central services o f human and veterinary medicine. A description o f such a developed and homogeneous rabies information system, realized in the GDR since 1970, and deduction of some principles for the development of information systems in general, integrating information streams from human and veterinary medicine, follow. This system is built up according to the recommendations o f the WHO-Expert-Committee on Rabies.
2. Methods of planning and pilot studies After analysis of the mode in control and prophylaxis of rabies an optimization model was developed by considering the system of theoretical orientation on the development o f epidemiological and ecological surveillance (Sinnecker [4] ). In this model the improvement of existing services in human and veterinary health and of the mode was provided. After development of the model and the first design of a data carrier a discussion with some teams from human and veterinary services was carried out and also a follow-up study referring to the practicability. After that a conference was organized, based on the tested recommendations. Participants in the conference were all vaccinators and all veterinarians dealing with rabies diagnosis. The results and the recommendations of this conference caused the Ministry of Health of the GDR to introduce the developed system for the whole GDR in 1970. In routine conferences with the users of the project further evaluations and improvements were undertaken, especially directed by mistakes found and backward information and their form of presentation.
212
H. Sinnecker et al., The Rabies Information System
3. Description of the system Aims and activities of the epidemiological and ecological surveillance of rabies are summarized in table 1. The information system is directed on the aim to
show in an integrated system the epizootiological situation with formation and change of foci, the epidemiological importance of species and the epidemiological situation. Aims and activities are furthermore directed by the
Meldebogen
..... I
I
bei
Tollwutexposilion
Epldemio|oglsches Zentrum der Staatlldlen Hygieneinspektlon Abt. ffir Immunepidemiologie und Referenzlabor for Tollwut 108 Bedln, Clara-Zetkin-Stra~e 96 Name Be.~d~reibung des Vorfalls: Geburtsname
'9
20
21
22
23
24
IIIIIII
:.!,: °£
Vomame geb. a m
I o_.
in
Beruf jetzige T~ttgkeit links
IIII1[
Wohnsi~ TierbesFczer
Name: Anschrift :
FA
Aufforderung zur Untersuchung des Tieres am:
im NotfaII zu verst6ndigen
Negrl
Datum
Untersuchu ngsergebnis
dutch: Bemerkungen
1. Untersucfiung :
IIIIIli
2, Untersudlung : 0berwiesen
durch 3, Untersuchung :
W,l~er Aa: Datum der Oberweisung a
63
64
~
IIIIIII ]~
~
Angaben aus Anamnese und Status des Patlenten, die einen verSnderten Vedauf Immunislerung e~vorten [assen:
der
Datum der Aufnahme verslchert bel
Wel~er Art: Behandlung
,IDotur.~,~I.
ImmunglobulLn . . . . . . . . . .
-~
:~ i~
w.l~,, ^.= /u .....
. . . . . . . .
Impfstoff
M~ng~ I Unterschrlft
I
-
-
.
i
-_
Boosterungen Datum Menge
I I
i I
U.te,sd~
I
!
~S2 Ag ~07/73 Reg.-Nr. Ikl51/6~7 30 20
. . . . . . . . . .
Teta nusprophy~oxe : WunddesinfekUonsmlttel :
I J'
213
H. Sinnecker et al., The Rabies Information System ~,q~ositionsobiekt
.~hlSlseI-Nr. ]NI 1. Fuchs 2, Dachs 3. Marder 4. 11tis
5. Wiesel Eich hSrnchen Ratte Maus Bisamratte
6. 7. 8. 9. I~
lie
I. 2. 3. 4. 5. 6. 7. 8. 9.
Rehw[Id Rotwild Schwa rzwild Hose Wild~ahindnen Hamster Iqel Maulwurf Biber
1. Fledermaus 2. V6gel 3.
7. g.
412
18Wohnsitz 19-24Datum
17 (3eso~leo~t
! 1 ~ rnEmnli~ 2 =~ welblich
'i ........ I"l" I ....... I°..I I ......
1 ~ Stadt, ~ber 10000 ETnwohner 2 = Land, unter 10000 Einwohner
der Exposition
I..... i
19-20=Tog, 21-22~Monot, 23 - 24 ~ Jahr
25-30 E x p o s i t l o n s o r t (5chliJsseI-Nr.) 31 Z u s a m m e n h a n g
mlt Berufst6tigke[t
32 w e i t e r e K o n t a k t p e r s o n e n 33 A r t I = 3~ 5= 7~
1 = ja, 2 ~ nein
IIIIII
1 = ja, 2 = neTn, 3 ~ unbekonnt
der Exposltien indlrekter Kontakt, 2 ~ Kontakt - unvedetzte Haut, Kontakt . verletzte Hout, 4 ~ Kontokt - unverletzte Sd~lelmhout. Kontakt - vedetzte SchleimhQut. 6 ~ Krotlverletzung, Bil~verletzung - lelcht, 8 ~ BiBverletzung - sdlwer
34 L o k a f i s o t l o n d e r V e r l e t z u n g
1 ~ Kopf, 2 = H e l l , 3 ~ Rumpf
l;nks
37 Art d e s E~po~itionsob}ektes 1 = Wildtier, 2 = Hausfier, 3 = Iondw, Nutzt;er, 4 = Labort[er, 5 = Zootier. 6 = unbekonn!es Tier, 7 ~ Mensch, 8 = Sonstiges
8.
1. H u n d 2, Kotze 3. Rind
~. 5. 6. 7. 8.
15-16 v o l l e n d e t e L e b e n s j ( : h r e
35-36 1 = Finger, 2 = H~inde, 3 = Unterorme, 4 = Oberarme, 5 ~ FQ6e, 6 = Unterschenkel, 7 ~ Oberschenkel
4.
41
1-6 N u m m e r d e r E l n r l c h t u n g 7-14 I m p f s t e I l e ( $ c h l ~ s s e I - N r , ) , J a h r P a t i e n t e n n u m m e r
P(erd Zieqe Sc]lo f ~chwein Oefl~gel
1. LobormoteHol 2. Sektionsmatedol 3. 4.
7. 8. 9.
38-42 T i e r a r t -
Expositionsobjekt
lllill
(Erkl6rungen siehe Rand Ik)
43 B s f u n d z u r Z e l t d e r E x p o s i t i o n ollgemelner Befund: 1 = entlaufen, 2 = unter Beobochtung, 3 = verendet, 4 = ~ ;t6tet 44 klinischer Befund: 1 = tollw0tlg, 2 ~ tollwutverdSchtig. 3 = kelne Zeidlen van W u t
@8Q_
45 B e f u n d i m w e i t e r e n V e d o u f klinischer Be?und: 1 = Tollwut, 2 = keine Tollwut, 3 = unbekonnt 46-46 Laborbefund: 1 = positlv, 2 = verdSchtig. 3 ~ negatTv, 4 = nicht ouswertbor, 5 = nicht durdlgef0hrt 49 B e h o n d l u n g
1 = ambulant, 2 = stationer, 3 ~ nicht e~orderlich
llll[lt
50 Iokale Versorgung, chirurgisch: 1 ~ io, 2 = neln 51 wlrksame OesinFektion: 1 ~ ja, 2 = nein. 3 ~ ungenaue A n g a b e n
Befundgruppen ~2 1 = ImmtJnglobulln, 2 ~ Impfstoff, 3 ~ Immung!obulin -~- Impfstoft So~ ff;sseI-Nr. 53-58 I m m u n g l o b u l i n c h a r g e (Nummer) 76 1. Tollwut nachgew. (Lobor oder klln, 59-60 insgesomt verabreichte Immunglobullnmenge in ml Bi!d u~d Labor) 2. To!'.wut nachgew. 61 t m m u n g l o b u [ i n r e a k t i c n e n 1 = ja, 2 ~ neln (kGn. Bild) 3. vorl~utiqer Toffwut62-67 I m p f s t o H c h o rge (Nummer) verdocht (kl6rbor Ermitt unqen, Unter58-69 I n s g e s a r n t v e r o b r e i c h t e I m p f s t o f f m e n g e i n rnl suchunqen slnd cnqesefzt) 70 Impfverl~Juf 4. Tollwutverdacht (night kl~rbar, "~ier I = Patient hot dle verordneten Injektionen erhalten, 2 ~ ImDfunq bzw. Material nicht 5rztlicherselts abgebrochen, 3 ~ impfung gegen ~rztlidlen Rat zuqSngfich nlcht obgebrochen 4 = Impfung obgelehnt bewertbar) 71 w i e v l e l t e T o l I w u t s c h u t z i m p ~ u n g 5. Tollwu~verdacht t'nw~ hrschelnllch 1 = erste, 2 = zweite, 3 ~ dritte, etc. (kl~rb~r. Ermlttl., UntersucT~unqen 72 I m p f r e o k t i o n e n 1 = keine, 2 ~ Iokale, 3 ~ allgemelne nnqesetzt) 6 kc';n Tol!wutverdacht 73 I m o f l : o m p l l k o t l o n e n I : ia, 2 : neln (a~sl~hr[ichen Bericht senden noch telefonlsdler Sofortmeldung) 7"/ i , Taqwut nachqew. (Lqbor cder klff~. 74-75ZeitDun~.t der ersten 1njektlon van Immunglobulin oder B;td und Lab~r) Impfstof| {A~g~be in Togen nach dot Exposition) 2, Tollwut nachqew. (k)in. Bild} 76 [ ~ e f u n d g r u p p e b e i d e r A u f n o h m e 3, Tollwutverdod'~t (n}cht klSrbor, Tier bzw. Material nicht zuq~natich, nlcht bewertbar) 4. kein Tollwutverdachl
77 B e f u n d g r u p p e
nod~ A b s c h l u ~ d e r E r r n i t t l u n g e n
44
4S
F'T" I I I I I
]
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Fig. 1. Case record for human rabies exposure.
guarantee of an optimal post-expositional treatment by express diagnosis and earliest possible special treatment of high-risk groups, enabled by the co-operation of human and veterinary services. Finally all institutions for hunting and human and veterinary medicine should co-operate in a national
programme, connecting measures of surveillance, warning and control with the measurement of ef(lciency in control and prophylaxis measures. According to the aims, a coordinated system was realized, especially including the central epidemiological service, diagnostic standards with general applica-
H. Sinnecker et al., The Rabies Information System
214
Table 1 Aims and activities of epidemiological and ecological surveillance of rabies. Aim
Activity .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1. Data gathering and surveillance of morbidity and mortality of animals and of the exposure of man by
1.1 Express information - For recognition of dangers and for guarantee of an optimal control of rabies in animal - For guarantee of an optimal early treatment of highrisk groups
.
.
.
.
.
1. Further development of data gathering, storage and data evaluation of epizootiological and epidemiological data by a central data bank, special vaccination points and diagnostic institutions 1.1 Data gathering of - Case-diagnostics with standardized express diagnostic methods and with special immediate report of accumulations and problem strains - Exposure of man with special immediate report of high-risk groups and accumulations
1.2 Information on corrected computer-fitting documentations for objectivation and rationalization of the leading and of documentation of efficiency
1.2 Data gathering and partly computerized data evaluation of the situation and the trends with corrected computerfitting documents and partly computerized elaboration of epizootiological and epidemiological reports and of documentation of efficiency
1.3 Trend decision
1.3 Development of quantitative models for processing of the information and for the prognosis
2. Data gathering and surveillance of high-risk areas with investigation of change of foci and viruses and of high-risk groups for prevention of cases of death in man with the aim of
2. Development of epidemiological and ecological surveillance with a central data bank and an ecological, epidemiological and epizootiological measuring-point programme
2.1 Early recognition of dangers and for the control of epizootiological developments
2.1 Data gathering of circulation and characterization of viruses and special problem strains in relationship to the ecological situation
2.2 Prevention of vaccination failures by early and special treatment of high-risk groups with probably short incubation period
2.2 Immediate registration and optimal treatment of highrisk groups with probably short incubation periods in special vaccination points
Serological-virological surveillance of post-expositional treatment for
3. Development of serological -virological surveillance in
3.1 Preventing vaccination failures by interference of antibody stimulation caused by serum and vaccine in combined treatments
3.1 Combined treatments with serological exclusion of interferences in the antibody stimulation
3.2 Reduction and early recognition of complications in vaccinations
3.2 Persons who are endangered by complications in vaccination (previous rabies vaccine treatment, combined treatments or diseases of CNS) for the early recognition of complications
4. Control of rabies in animal by control and prophylaxis Connection of warning and control with measurements of the efficiency of measures
4. Improvement of prophylaxis and control with rational cooperation of all institutions in human and veterinary medicine and in hunting within a national programme
215
H. Sinnecker et al. / The Rabies Information System
Out-potit*cff. deportment ]
t~actitlor,ar ]
Hospltel ]
- - - - ~ 1 CountyHygiene In~ection
~1
I
I Veterlnarion]
+
~"
Oistrikt-Hyoien¢ I~t--I[ "~.' Inspect~n
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-#4&&~o~,&-1 Center
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Ministryof Heatth
MiniStryof AgricuIt. 1, ond Food-Stuff Prod.
I. l
Fig. 2. Data flow and organization chart. tion of express diagnostic methods in the veterinarymedical field and surveillance in connection with control measures. The data gathering is carried out without forms by the first-attending physicians, by the veterinarians and by the epidemiological services, but in the vaccination points a so-called 'Case record for human rabies exposure' is filled in (fig. 1). The new original record replaces all usual, not unitary, documentations used in the vaccination points up to this time. It includes personal information on the patient, the description of the event, the results of veterinary examination and a documentation on therapeutic measures, on the front page. The reverse contains all adequate encoded information. The data flow and organization chart is given in fig. 2. Explanations according to fig. 2: (1) Immediate record - according to the direction of registration. (2) Weekly record of the county. ] Exposures with increases and high(3) Weekly record of the district, risk groups.
(4) Monthly record on situation and measures. (5) Records on epidemiological and ecological situation and documentations of efficiency. (a) Remittance to the antirabic vaccination point. (b) Record of diagnostic findings in animal, suspicious after exposures of man. (c) Record on exposed persons, their treatment and on injured animals. (d) Monthly record on positive findings in animals suffering from rabies, and on problem strains. The data processing takes place according to the aims shown in table 1 and is directed on main points: Epizootiological situation, epidemiological situation and also high-risk persons, needing a special treatment, as well as a survey on all attended people. According to the law medical advice is also accepted to be treatment. According to the aims the following da~ groups and the adequate information tables mean: (1) Occurrence of rabies in animals in relationship to
216
H. Sinnecker et al. / The Rabies Information System
begins within hours after exposure. The report by telephone is the base of a fast survey on especially problematic cases of exposure and it also helps prepare optimal treatment in connection with immunological controls. A general survey on the frequency of kinds of exposures, classified into the species of animals, is given in register 3 in the programme.
exposures, classified into district, month, species, group of diagnosis (+, +, 6) and exposures by injuries and contacts. (Register 2 and 6 in the programme.) This sample is completed by the general survey on rabies in animals, based on the reports of veterinary examination offices which register all cases, also those without contact to man. From this general survey result the surveys on the epizootiological situation in all districts and on species of epidemiological importance, necessary for decisions on treatment. (2) Exposures and post-expositional treatments of man, classified into district of exposure, season, age and sex in relationship to the diagnosis in animals and the kind of exposure (bite, contact). (Register 1 in the programme.) Also vaccinations in spite of negative findings in animals must be included in the programme. It also has to contain all advice with the result that a vaccination was not necessary, because according to the law all medical advice is also treatment. From this the surveys on the epidemiological situation and for documentation of efficiency, necessary for quarterly, annual and other records, result. (3) Kind of exposure and high-risk groups, needing a special treatment because of a probably short incubation period. Of decisive importance are: the localization and the severity of the injury (injuries in danger area I: multiple injuries, injuries in head and neck) the species (wildlife carnivores) and the time of retardation between injury and beginning of the treatment (in cases of more than 4 days). All these points have to be seen in relation to the findings in the animals. According to the decisive data, in order to characterize high-risk groups, a combined serum-vaccine treatment can be recommehded. This only can be carried out in special vaccination points. Children are always high-risk persons, but combined treatments cannot be carried out in every case. It must be guaranteed that the treatment of children
(4)
High-risk persons with a supposed higher probability for the occurrence of complications after vaccination (re-vaccinations, combined treatments, previous diseases of the CNS). The report by telephone is the base of a fast survey on patients with increased danger of a vaccination encephalitis and it shall help to organize an optimal treatment in connection with immunological controls.
(5) Survey on used vaccine and immunoglobulin charges, also side reactions and complications and data presentation of all persons, treated in the vaccination point. In supplements the side reactions and complications after combined treatments and in case of re-vaccinations are separately outlined. (Register 4 in the programme.) From this the analysis of used preparations and debit of vaccinations with reactions and complications results. This information is necessary for quarterly, annual and other reports. (6) Survey on the activity of the vaccination points with presentation of treatment, of epidemiological characteristics of treated persons, of reactions and of applied preparations. (Register 5 in the programme.) The data processing takes place over the R 300 after the data flow chart, outlined in fig. 3. Altogether there are necessary about 10 computer hours per annum. Based on this programme the records on the epidemiological situation and reports on the efficiency are produced partly automated.
H. Sinnecker et al., The Rabies Information System
217
human and veterinary medicine could be developed by consideration of the following principles: 1. A homogeneous system of prophylaxis and control with normatives worked out commonly is the fundamental which is necessary for a common system. Therefore the first step on the way to develop an integrated system has to be the development of an optimization model of control and prophylaxis for characterizing aims, tasks and structures, and for planning the development of the existing services, • "~
~k A
A
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. The epidemiological and epizootiological conception of a developed system has to be tested concerning practicability, efficiency and expense within a small group of participators in several successive steps. The improvement and evaluation, commonly worked out. is the fundamental of a preliminary conference in which all partners, working in the realization, take part. This conference must close the study as a fundamental for computerization.
References
Fig. 3. Data flow chart for the rabies information system.
The information system has proved its practicability and efficiency during an application over 5 years, especially by standardization of diagnostics and recording of patients exposure and treatment. This information system for information from
[ 1 ] WHO-Expert-Committee on Rabies, Fifth report, World Health Organization Technical Report Series (1970) No. 322. [2] WHO-Expert-Committee on Rabies, Sixth report, World Health Organization Technical Report Series (1973) No. 523. [3] World Health Organization, Regional Office for Europe (1969): Communicable Diseases - Methods of Surveillance. Report on a Seminar. [4] H. Sinnecker, Stan d und Perspektive des Infektionsschutzes in der DDR, Z. Ges. Hyg. 10 (1974) 699.