60 Chapter 2 a selection bias and influences by missing data are possible. Since the study is data-driven and not initiated by hypothesis it is reasonable to treat missing data as missing at random. We therefore think that these two limitations are less likely to bias our results and conclusions, but we must be careful before making final inferences. Our study still provides a novel approach, that is, data-driven modelling, to investigate the potential triggers of narcolepsy. We find that the 2009–2010 pH1N1 pandemic influenced the incidence of narcolepsy in more European countries than we knew before. The unexpected increased incidence of children/adolescent NT1 in 2013 calls for more studies to further investigate the links between infectious agents, vaccination, genes and narcolepsy in 2013. These studies will improve our knowledge of the pathophysiology of immunemediated narcolepsy and the pathological links between vaccinations and narcolepsy. Our observed increased incidence of NT1 is one more argument in favour of the immune-mediated process involved in the pathophysiology of NT1 showing a possible connection between active viral infections, attenuated forms of viruses in vaccines, and narcolepsy. Acknowledgements We thank Lucie Barateau, Carole Pesenti, Carles Gaig, Alex Iranzo, Laura LilloTriguero, Pablo Medrano-Martínez, Corina Gorban, and José Haba-Rubio who have helped to input data into EU-NN database. Authorship contribution statement Conception and design of the study: JKG, ZZ, RF, RK, GJL. Acquisition of data: JKG, RF, PA, GJL. Analysis of data: JKG, ZZ. Interpretation of results: JKG, ZZ, RF, RK, GJL. Manuscript writing and revisions: JKG, ZZ, RF, RK, GJL. Disclosure statement Financial disclosure: The EU-NN has received financial support from UCB Pharma Brussels for developing the EU-NN database. UCB Pharma Brussels has had no involvement in the design, conduct, interpretation and publication of this study. The authors have no conflicts of interest to disclose that are relevant for this manuscript. Non-financial disclosure: nothing relevant to disclose.
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