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Web Can Quickly Spot Disease Outbreaks

E-mail networks can sound the call before the government knows

WEDNESDAY, Dec. 7, 2004 (HealthDayNews) -- For Dr. Eric Granowitz and others, the ability of the Internet to serve as a sentry against emerging disease outbreaks recently made its power known in a mundane yet strange fashion: with a forwarded e-mail about a sickness caused by a tummy tuck.

Last spring, Granowitz had asked a colleague for advice in treating a patient with a rare bacterial infection.

The colleague forwarded an e-mail she had received from Emerging Infections Network (EIN), which is a subscription-only Internet network called a listserv. Attached to the bottom of the e-mail was yet another e-mail from a doctor in New York City, detailing what looked to be a strikingly similar case.

"I was obviously suspicious, so I phoned the doctor [at Columbia in New York City] and he contacted his patient, and indeed it was a match," related Granowitz, who is an assistant professor of medicine at Baystate-Tufts School of Medicine in Springfield, Mass.

Both patients, it turned out, had had recent tummy tucks performed at the same clinic in the Dominican Republic. Both patients had become seriously infected with Mycobacterium abscessus.

A quick check into Columbia's system found three more cases linked to the same clinic. At that point, Granowitz and the second doctor, Neville D. Clynes, contacted the New York City Department of Health and the U.S. Centers for Disease Control and Prevention. Only 24 hours had elapsed since their first telephone conversation.

The CDC then posted a case definition on EIN and on another listserv, ProMed. By early October, 16 potential cases had been identified in Massachusetts, New York, Rhode Island, North Carolina and Puerto Rico. When health authorities were first notified, the clinic was still performing procedures.

The electronic grapevine of the 21st century had worked to astonishing effect, and quite a bit better than official governmental systems set up to do the same thing.

"It demonstrates the incredible power of the Internet. One wonders how many more people would have gotten infected if the listserv hadn't been there," said Granowitz, who details the story in a letter to the editor in the Dec. 9 issue of the New England Journal of Medicine. "It's kind of a grassroots MMWR," he said, referring to the CDC publication Morbidity and Mortality Weekly Report, which outlines reports from state health departments.

"The Internet is an incredible, powerful vehicle that has been underutilized so far," added Dr. Luciana Borio, a senior fellow at the Center for Biosecurity at the University of Pittsburgh.

EIN and ProMed are the two best known listservs in this category; EIN has 945 participants from all 50 states and 36 foreign countries, while ProMed is where many of the initial SARS outbreaks were reported, Borio said.

While this unofficial system is powerful, it may also make people uneasy because it relies so heavily on serendipity. But, Borio pointed out, the huge amounts of money being spent by the government and others on surveillance systems are hardly fail-safe. One strategy, looking at the patterns of disease going through emergency rooms, is also arbitrary and provides no way of drawing a clear line between what is normal and what is abnormal. "In the middle of an influenza season, you cannot pick up any of the diseases that would manifest as pneumonia or respiratory illnesses," Borio pointed out.

Experts believe it could also be used to sound the first clarion call of a bioterrorism attack. The anthrax scare of 2001 was picked up only because a physician was astute enough to notice something amiss, not because a well-funded surveillance system kicked into gear.

The electronic grapevine is important not just for detection but for management of an outbreak as well, Borio said. "With the 2001 anthrax outbreak, the CDC lagged behind in issuing recommendations to private physicians in local hospitals," she said. "They desperately needed protocols that were unique to them. It's difficult for an agency to predict what those needs are, but a communication system which allows physicians to share this information can be extremely powerful."

Having learned this lesson firsthand, Granowitz is now a member of EIN. Recently, he became aware of an outbreak of malaria in people from the Caribbean, so when a patient from that area came in with a fever, he knew to check that avenue. "That isn't what they turned out to have, but it raised a red flag," he said.

More information

The U.S. Centers for Disease Control and Prevention has a number of links on emerging infectious diseases, including EIN.

SOURCES: Eric Granowitz, M.D., assistant professor, medicine, Baystate-Tufts School of Medicine, Springfield, Mass.; Luciana Borio, M.D., senior fellow, Center for Biosecurity, University of Pittsburgh; Dec. 9, 2004, New England Journal of Medicine
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