Role of epidemiologic information system in sudden death prevention among Croatia's haemodialysis patients.

The main aim of Croatia's epidemiological information system is to enable the monitoring of infectious diseases as well as to enable necessary interventions. Its 24-hour epidemiologic alert mechanism made it possible for initial reports of sudden death clusters in haemodialysis units to reach epidemiologists on the night of 12 October 2001. The alert about the sudden deaths among haemodialysis patients in two hospitals has prompted us to do an epidemiological inquiry during that night and early the next morning. It looked at suspicions of a possible link between Baxter Plivadial P-15 lot 2001F075 dialyser and these deaths. As the suspicion was based on a small amount of data, it needed confirmation from a countrywide inquiry involving the other 40 haemodialysis units. A phone inquiry showed that 23 haemodialysis deaths occurred on 8-13 October 2001. It suggested that also dialyser of a different type and lot (P-18 2001B17R) should be incriminated. During the inquiry (October 13), all haemodialysis units were informed of the suspicions regarding incriminated dialysers, and of the necessity of temporary withdrawal of these from use. The withdrawal on 13 October of incriminated dialysers stopped the deaths among haemodialysis patients. No more such sudden deaths have been recorded since that could be linked either to the described period or to this clinical picture.