The economic impact of pandemic influenza
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4888 (Published 20 November 2009) Cite this as: BMJ 2009;339:b4888
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Benford's Law to evaluate the detection and reporting of cases during the A(H1N1) influenza outbreak
Benford's Law to evaluate the detection and reporting of cases during
the A(H1N1) influenza outbreak
Since the beginning of the A(H1N1) pandemic, a question concerning both
the general population as well as the scientific community is whether the
health systems are adequately responding to this worldwide challenge. It
is argued that the question is not easily answered because there are no
established criteria for making an adequate evaluation. Fortunately,
Benford’s Law, also called the “Law of Anomalous Numbers” and the “First-
digit Law,” is a method that can help overcome this obstacle. This law
states that for a determined set of numbers, those whose leading digit is
the number 1 will appear more frequently than those numbers that begin
with other digits; the other digits appear with decreasing frequency. This
can be expressed formally as P(d) = log[1+(1/d)] d= {1,2,…, 9}, where for
a series of numbers, P(d) is the probability that a digit will be the
leading number.1,2 While Benford’s Law has been shown to be useful to a
variety of topics,1,2 one of the most frequent current applications is for
the detection of financial fraud.3
In the case of the A(H1N1) influenza outbreak, the number of
laboratory-confirmed cases can be of use to discover whether or not the
detection and reporting processes performed well. If the daily incidence
follows the distribution described by Benford’s Law, there is evidence of
good performance. As a preliminary empirical test, data reported to WHO
by 135 countries until July 6, 2009 were analyzed (see Figure 1). Note the
similarity between the observed and theoretical data. These data suggest
that the system for detecting and reporting cases functions well.
Benchmarking among countries using this simple method will enable the
identification of certain patterns which, with information from other
sources, will help answer the question regarding the performance levels of
health systems.
References
1. Benford F. The law of anomalous numbers. Proc Am Philos Soc
1938;78:551-572.
2. Hill TP. The first digit phenomenon. Amer Sci 1998;86:358-363.
3. Durtschi C, Hillison W, Pacini C. The effective use of Benford’s
law to assist in detecting fraud in accounting data. J Forensic Account
2004;5:17-34.
Competing interests:
None declared
.gif)
Figure 1. First digits frequencies for the Benford distribution and the world incidence of A(H1N1) influenza until July 6, 2009.
Competing interests: No competing interests
Flu Bedside Diagnosis and Differential Diagnosis.
from:
Sergio Stagnaro MD
Via Erasmo Piaggio 23/8
16039 Riva Trigoso (Genoa) Italy
Founder of Quantum Biophysical Semeiotics
Who's Who in the World (and America)
since 1996 to 2009
Ph 0039-0185-42315
Cell. 3338631439
www.semeioticabiofisica.it
dottsergio@semeioticabiofisica.it
Sirs,
in a number of Arch.Intern.Med. Authors have suprisingly stated that flu
diverse type can be diagnosed with sophisticated semeiotics, certainly not
apllicable on very large scale (Impact of Rapid Diagnosis on Management of
Adults Hospitalized With Influenza. Ann R. Falsey, MD; Yoshihiko Murata,
MD, PhD; Edward E. Walsh, MD Arch Intern Med.
2007;167,doi:10.1001/archinte.167.4.ioi60207).
In my opinion, intriguing articles, like that just mentioned, are not
updated, since authors unfortunately either ignore or overlook Quantum
Biophysical Semeiotics (www.semeioticabiofisica.it).
In fact, nowadays it is very difficult to know the real nature of an
infectious disorder at both the bed-side and ER or hospital, as well as to
recognize a lot of cases such as those described in the article, not to
speak of disorders recognizable by means of the academic, orthodox,
physical semeiotics, as allows me to state a 53-year-long clinical
experience. In fact, I am filled with wonder at reading that there are
doctors who are sharing the uncertainty of the value of antibiotics for
acute tonsillitis, pharingitis, bronchitis in the form of written and
verbal advice, although I do not know if these physicians are skill at
performing the advancement in the field of physical examination (1). For
space reasons, I underscore here merely the possibility of recognizing
easily and quickly the “chronic” antibodies synthesis in the spleen during
flu, as well as the spleen “small” antibody production, in case of Gram-
negative bacteria (Esch.coli, HP, a.s.o.), which play a pivotal role in
bed-side diagnosis of virus or Gram-negative infections (1). Moreover,
interestingly doctor can now-a-day observe clinically, and in a
“quantitative”way, the so-called Reticulo- Endothelial-System-Hperfunction
Syndrome (RESH), which parallels with ESR and Proteins Electrophoresis,
but it is “more” sensitive and specific than both (2-3). Certainly, most
adults, and childrens, of course, with acute bronchitis who consult their
general practitioner (as well as University Professors...) will receive
antibiotics, although in many cases antibiotics do not modify the natural
course of the disorder, at all. In my mind, the real problem is to
recognize “clinically” both the nature of infectious disorder and the
actual patient's defence , including antibody and PCR synthesis (in above-
cited website): first, the “ethyological” , complete diagnose, starting
from bedside recognizing all constitutions (ibidem; 4) and, then, the
proper therapy. Nowadays, we can solve such as problem, and a lot of
others…if we are determined to be “open-minded” physicians, Referees and
peer-review's Editors.
As regards differential diagnosis between different types of flu,
parameters values play a central role. In fact, e.g., in the seasonal flu,
latency time of BALT-Gastric Aspecific Reflex is 4-5 sec. (NN = 6 sec.),
intensity less than 3 cm., duration 4 sec. followed by characteristic
tonic Gastric Contraction.
On the contrary, in A flu, intensity is greatest (5 cm,) as well as
duration.
1) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica
Biofisica. Il Terreno oncologico”. Ed. Travel Factory SRL., Roma, 2004.
www.travelfactory.it
2) Stagnaro-Neri M., Stagnaro S., Appendicite. Min. Med. 87, 183,
1996[MEDLINE]
3) Stagnaro S., Sindrome percusso-ascoltatoria di Iperfunzione del Sistema
Reticolo-Istiocitario Min. Med. 74, 479, 1983 [MEDLINE].
4) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-
Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la
definizione della Single Patient Based Medicine. Travel Factory, Roma,
2004.
5) Stagnaro S., Stagnaro-Neri M. Single Patient Based Medicine.La Medicina
Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Ed.
Travel Factory, Roma, 2005.
6) Stagnaro Sergio. Bedside Diagnosis of Flu. October, 2009.
http://doc2doc.bmj.com/forums.html LINK
7) . Stagnaro Sergio. Subjects at Inherited Real Risk of A/H1N1 broncho-
pneumonitis. MedicalPage, 4 November, 2009
http://www.medpagetoday.com/tbindex.cfm?tbid=16786#ayk
8) Stagnaro Sergio. Quantum-Biophysical-Semeiotic Bedside Diagnosis of
Flu, since its earliest stage. 30 October, 2009. CMAJ 2009; 181: E195-
196E. http://www.cmaj.ca/cgi/eletters/181/9/E195#228652
Competing interests:
None declared
Competing interests: No competing interests
End of reason in the pandemic season - mislabelling of potentially life threatening infections requiring timely antimicrobials as “swine flu”
Houlihan C(1), Patel S(2), Price A(1), Valappil M(3), Schwab U(1)
1.Department of Infectious Diseases and Tropical Diseases, Newcastle
Upon Tyne Hospitals NHS Trust, NE1 4LP
2.Department of Paediatric Infectious Diseases/Immunology Newcastle
Upon Tyne Hospitals NHS Trust, NE4 6BE
3.Health Protection Agency, Regional Laboratory, Westgate Road, NE4
6BE
Diagnostic uncertainties in patients presenting with febrile
illnesses are not infrequent. The use of algorithms to remotely diagnose
and issue antiviral drugs is indispensable during a pandemic where the
case burden threatens to paralyse the healthcare system and helps to
reduce nosocomial spread. The National Pandemic Flu Service (NPFS) has
issued antiviral drugs to patients with an influenza-like illness who call
or log onto the internet site without direct clinical assessment or
virological evidence of infection with novel H1N1 (1). Applying such an
approach to both high and low prevalence areas is controversial and the
lack of specificity in the use of the algorithm has been highlighted (2
3).
We reviewed cases admitted to the Newcastle infection services with
potentially life threatening conditions, where the diagnosis and
management were delayed because of an initial, incorrect diagnosis of
“swine flu” over a six week period (01.07.09-15.08.09). During this
period, rates of novel H1N1 swab positivity (n=22/336) suggested a local
prevalence of patients presenting to hospital with a flu like illness of
6.5%(4) and 11.8% throughout England according to sentinel surveillance
(5). 6 adults and 2 children were admitted with potentially life
threatening infection requiring timely antimicrobials, where the incorrect
“swine flu label” resulted in an average diagnostic delay of 3 days. The
misdiagnosis included cases of meningococcal meningitis, severe (11%
parasitaemia) and mild (0.2%) Plasmodium falciparum malaria complicated by
renal failure, acute myeloblastic leukaemia presenting with febrile
pancytopoenia, Campylobacter gastroenteritis with renal failure,
Haemophilus influenzae respiratory tract infection in bone marrow
transplant recipient, complicated soft tissue infection and a fatal
Staphylococcus aureus bacteraemia with multiorganfailure.
The North-East of England had the lowest case burden of H1N1 in
England during this study period (5), both in the community and amongst
hospital admissions with fever and flu-like-symptoms. However, the NPFS
algorithm, which is used universally across the UK, irrespective of up to
date local epidemiological data, resulted in significant delay in reaching
the correct diagnosis and appropriate antimicrobial treatment of
potentially life threatening infections. Enhanced surveillance of cases
misdiagnosed as flu is required, which has been initiated locally in
collaboration with the regional HPA, currently on a voluntary basis.
It is imperative that content of algorithms and their implementation
are critically evaluated in order to optimise any future response to a
pandemic, and it should be ensured that a concise history covers prior
travel history, immunosuppression and drug exposure comprehensively.
Striking the right balance between public health response and ensuring
optimal individual case management will remain challenging. Up to date
local epidemiological data should influence the interpretation and
application of algorithms which should not replace comprehensive history-
taking, clinical acumen, laboratory-support and above all, common sense.
1. https://www.pandemicflu.direct.gov.uk/.
2. Payne R, Darton TC, Greig JM. Systematic telephone triage of
possible 'swine' influenza leads to potentially serious misdiagnosis of
infectious diseases. J Infect 2009;59(5):371-2.
3. Federation of Infection Societies Birmingham 11-13th Nov 2009.
Houlihan C et al Clinical Lesson; Rampling T el al Abstract P84, Thomas S
et al Abstract P111, Habibi M et al Abstract P218, Trainor E et al
Abstract P223.
4. Personal communication Dr M. Valappil Consultant Virologist; North
East England Regional Laboratory, Health Protection Agency.
5. HPA Weekly National Influenza Report 20 August 2009 (Week 34).
Health Protection Agency 2009.
Competing interests:
None declared
Competing interests: No competing interests