An Early Warning System for Disease Outbreaks

One of the biggest public health challenges is to identify new infectious disease outbreaks as soon as possible. Lawrence Madoff., editor of ProMed Mail, talks about how incidents are reported. Madoff is an associate physician in the Infectious Disease Division and the Channing Laboratory, at Brigham and Women's Hospital in Boston.

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JOE PALCA, host:

Well, you just mentioned viruses, and I want to use that as the bridge to talking with our next guest, because obviously there are a great many concerns that viral infections will spring up. I mean, we're talking now about being on the guard for a new influenza that might bring a pandemic with tremendous loss of human life. And the question has always been, you know, how do you become aware of this? I mean, if something springs up in Ulan Bator, can you be sure that the public health officials either will let other people know elsewhere, or in a timely fashion, or will recognize it, or what have you.

And there is an interesting service that is intended at least in some way to be that early warning system. It's called ProMED-mail. And Lawrence Madoff is the editor of ProMED-mail. He's an associate physician in the Infectious Disease Division and the Channing Laboratory at Brigham and Women's Hospital in Boston. He's also associate professor of medicine at Harvard Medical School, and he joins us by phone from there. Thanks for talking with us today.

Dr. LAWRENCE MADOFF (Infectious Disease Division, Brigham and Women's Hospital): Thanks for having me.

PALCA: So did I characterize ProMED-mail accurately? Is it really an early warning system?

Dr. MADOFF: Well, that's our intention. ProMED is a system based on the Internet where we try to gather and distribute information about new and emerging disease threats around the world. And it's the largest publicly accessible system that's out there. It's freely available to anyone. I'd encourage your listeners to look at our Web site, which is www.promedmail.org. And we currently have about 40,000 participants all over the world who subscribe to our service and who receive our messages sent by e-mail or on the Web, and who also send us information and participate in the service.

PALCA: And who are - I mean, who generates material? Is it physicians? Is it doctors? I mean, is it public health people? Who's contributing?

Dr. MADOFF: Lots of different kinds of people. One of the things which distinguishes ProMED is that it's open to all sources of information, and so we receive information from our subscribers who send us firsthand reports sometimes. We have reports that are generated by what we call the astute clinician, a doctor in a clinic or an office somewhere who notices something unusual and sends us a report about it, or notices an outbreak of something and sends us a firsthand report about it.

We also actively search for information about disease outbreaks and we look at several different kinds of sources of information, including the news media. We actively look on Web sites of local, national, international news sources. And we also look for official sources of information, for example, from WHO or from ministries of health in different countries and from our own CDC.

PALCA: And who's responsible for vetting this information. I'm sure that things flood in all the time, but how do you know what you're getting is reliable or trustworthy?

Dr. MADOFF: Right. And that's I think one of the most important things we do is to act as a filter for the information. And there is lots and lots of information out there, we get, as you can imagine, hundreds of e-mails a day. And part of what we do is try to authenticate and verify the information that we get, and everything that we receive and send out is subject to scrutiny by a team of experts. We have about 30 people now who participate, who work for ProMED, who are part of our staff. They are located in, I think, now 13 countries around the world.

And these are - we have an expert in viral diseases, an expert in bacterial diseases, an expert in parasitic and fungal infections. We have experts in insects that carry diseases, so called entomologist - medical entomologist - parasitologist, as I say. And we also have a team of veterinarians, because infections in animals are very important source of emerging diseases and also important to our food supply.

PALCA: So can you give a sense of, you know, for example, this week, what kinds of things have been on the site or on the service?

Dr. MADOFF: Yeah. It's been a typical week in many ways. There were all kinds of things. There's an ongoing - several ongoing stories, I guess. One of which you've mentioned already is avian influenza, a story that's been going on for several years now. Really since avian influenza emerged in Hong Kong in 1997, and then has recurred several years ago and has now traveled around the world both in birds and in people.

And so that's something that we have reports on almost every day, outbreaks both in birds and in humans. And certainly we follow every human reported illness. So that's been a major story that we've been covering. There have been some interesting diseases that have come up recently. And more recently, there's a disease called chikungunya, which is a viral infection that's a little bit like dengue - a viral infection that's spread by mosquitoes.

And this has been spreading around the world recently, starting in East Africa and through the Indian Ocean, now into India and beginning to occur in Southeast Asia. There have been not only thousands of cases in these regions, but also people from other parts of the world who traveled to these regions and then returned to their home countries with a mysterious infection which has turned out to be this chikungunya virus.

PALCA: We're talking with Larry Madoff. He's the editor of ProMED-mail. Also with us is Gerry Callahan, author of "Infection: The Uninvited Universe." I'm Joe Palca and this is TALK OF THE NATION from NPR News.

And Gerry, if I can turn back to you for a second - I mean, Larry just talked about influenza as sort of this long-playing issue since it first, this new H5N1 I guess it is form of the virus that mostly infects chickens at the moment, or fowl anyway, or birds. But you think that influenza is the one to watch in terms of the next big thing, don't you?

Professor GERALD CALLAHAN (Pathology, English, Colorado State University): I do think that. And part of it is that based on the epidemiology of the 1918 flu, the Spanish flu, which actually originated in the U.S. That's a flu that had a relatively low kill rate. But within a year or so - in part certainly because of troops being shipped out for the war and other things - but circled the globe, infected nearly 50 percent of the world's population without jet planes, without fast boats, without any of the sort of high-speed delivery systems we have now.

Influenza, especially an influenza that can be spread from human to human, is the sort of disease that could really change the phase of this planet.

PALCA: Larry, I just - and coming back to that, I mean, how - do you - does it make you nervous at all to be the early warning system for what could be a global pandemic, you know? What if you get it wrong? What if you miss it? What if you don't identify it soon enough? You know, that does give you pause?

Dr. MADOFF: Yes. Of course, it's a big responsibility. And we're very aware of that responsibility. It's - of course we don't do it alone, and I don't mean to imply that we're the only warning system out there, that we are solely responsible for doing this. There are numerous official and unofficial types of disease surveillance systems of which ProMED is just part of the system, I hope. And we're very, very attuned to that. And we have to be very careful. We realize that we certainly don't want to spread false information or cause undue alarm or panic.

Part of our job is trying to keep concern at the appropriate level, to keep people aware of what's going on and to make people understand the threats there out there but not to certainly cause panic or undue alarm.

PALCA: Are you anxious? I mean, are you anxious for members of the general public to actually read this, or do you think that they would have a hard time understanding the context to put it in?

Dr. MADOFF: Well, we try to - it's hard to answer that question. I guess. We aim our material towards the public health community, and that certainly our goal is to keep the public health community and physicians in tune, and veterinarians and other people who are involved directly in healthcare. And that's where we aim our material. But we also welcome people from the general public, and I would encourage them to read it. I think it's a way of staying informed.

Certainly there are many members of the general public, many journalists who subscribe and read our reports. And I think that that's an important source of information. It's a way of getting the information in a more firsthand way. And all of the information that we send out is what we call moderated. We subject it to review by one of these experts who also provide some commentary and context regarding the disease or the outbreak. For example, we'll explain the type of disease. We'll explain how it's spread. We'll talk about past outbreaks. We provide links to our own Web site that have reports on previous outbreaks of the same disease.

PALCA: OK. Larry…

Dr. MADOFF: …outside literature.

PALCA: Larry, I'm sorry I have to cut you off there. I'm afraid we've run out of time. But thanks very much for coming on and telling us about ProMED.

Dr. MADOFF: Thank you, Joe.

PALCA: Larry Madoff is the editor of ProMED-Mail and is also an associate professor and physician in Infectious Disease Division at Brigham and Women's Hospital. I also - my other guest this hour was Gerry Callahan. He's the author of "Infection: The Uninvited Universe" from St. Martin's Press. Gerry, thanks for being on.

Prof. CALLAHAN: Thank you, Joe. It was delightful.

PALCA: And next we'll be talking about the latest in cancer research. So stay with us.

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