Global Health Ideas

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Safety Net – ProMED mail, SARS and H5N1

ProMED – mail is a global electronic reporting system for emerging infections. It was created over a decade ago when personal email was new and the list-serv was the latest word.  The virtues of  ProMED is that it is fast, low-tech, egalitarian, bottom-up, open and transparent.  It is modern disease surveillance that delivers facts to those who need to know.  It began, according to current editor, Larry Madoff, MD, as an idea “Wouldn’t it be great if people who had access to the Internet in far-flung places, and were seeing something unusual, could send an email to this list?  We wouldn’t have to wait for a public health laboratory to notify the Under Minister of ..Health, who would notify the Minister, who would notify the World Health Organization.  We would all know at once.”  Email messages to the list are selected into a few posts each day, which are moderated and commented on by a panel of experts and then sent around the world.

Don’t underestimate simplicity – ProMED alerted the world to the SARS epidemic.

Safety Net – by Madeline Drexler
On February 9, 2003, Catherine Strommen, an elementary school teacher in California, took one last look at her favorite chat room,, before going to bed.  One of the posts came from China, from “Ben” who described an illness that began like a cold, but killed people in days.  Several people he knew had died, and hospital doors were locked.

Alarmed, Strommen emailed an old neighbor and friend, Stephen Cunnion, MD, a retired Navy physician and epidemiologist who now lived in Maryland.  A practical, no-nonsense man, Cunnion started searching the web.  With no success, he tried a new tack – sending an email to ProMED-mail.  After quoting Strommen’s missive, he asked: “Does anyone know anything about this problem?”

The tiny ProMED staff conducted its own web search.  It, too, came up empty handed.  On February 10, it sent out to tens of thousands of subscribers a posting headed: “PNEUMONIA – CHINA (GUANGDONG): Request for Information.”

Thus did the world first learn of SARS, the new and deadly infection that had begun in November 2002, and would kill 774 people and infect 8,000 in 27 countries.  The next day the World Health Organization issued a belated bulletin on the raging epidemic…

Read more of Madeline Drexler’s article here.

Now we’re in the age of H5N1, and as of Monday, ProMED-mail has decided to report suspect human cases of H5N1 from Indonesia.

Here are a few excerpts from the many responses from readers:

I write in support of reporting H5N1 cases, even if unconfirmed by
the relevant authorities. The best example of [the benefit of] such a
policy is that of SARS [severe acute respiratory syndrome], which was picked up by ProMED-mail before official acknowledgement, and which many believe played a significant role in the subsequent efforts leading to its containment. Further, as a matter of consistency, ProMED-mail does not wait for official word before reporting on any of many other outbreaks elsewhere in the world.
– —
Henry Huang
Dept. of Molecular Microbiology
Washington U. School of Medicine
St Louis, MO, USA

If ProMED-mail continues this policy of not reporting suspect cases
of infectious disease when a country is in flagrant violation of the
IHR (and basic common sense public health), then ProMED will be of
little use. Such a policy merely encourages other miscreants to do the same.

– —
Len Peruski, PhD
Associate Professor (Adjunct)
Microbiology and Immunology
Indiana University School of Medicine, Northwest Center

The last thing we need is to play ostrich and delaying tactics games
with HPAI [highly pathogenic avian influenza] outbreaks in any part
of the world. Experts should be trusted with enough pre-confirmatory judgment to alert cases of suspected HPAI, rather than play a waiting game that could cost the world millions of lives if we fail to prepare and take precautionary actions. Waiting games could be costly. A report indicating a new strain of HPAI in Nigeria is worrying enough, but not galvanizing steps to stop or slow down the spread of the virus anywhere in the world is like sitting on an atomic bomb waiting for the right trigger.

– —
Babatunde Bello
Lagos, Nigeria

I was so disappointed in your recent decision on suspect bird flu
cases in Indonesia. We are not getting any valuable information from Indonesia and very, very little from [elsewhere]. ProMED-mail has always been an excellent source of news on disease outbreaks, and you have always marked them as suspect until confirmation, so why do you want to treat something as deadly as the H5N1 virus any differently?
I ask you to reconsider your decision. It is the RIGHT thing to do.

– —
Carol Owens

In my opinion you are definitely NOT creating alarm and despondency.  Suspected cases are, as a rule, looked up and followed by experienced ProMED ‘watchers’ who can weigh the information and be alert if necessary. Being alert is quite different from being alarmed. The disclaimer of ProMED-mail is clear enough about the intent to be as truthful as possible, and holding the reader responsible and implicitly capable of taking the risk resulting from reading the posts.

I am in favor of ProMED-mail posting on all known and suspected cases of human H5N1 or other types of human ‘bird’ flu.

– —
Dr. T. Veenema
The Netherlands

And now, the official decision from ProMED moderators:

ProMED’s motive in seeking to screen out unsubstantiated reports of suspected human cases of H5N1 avian influenza from Indonesia was simply to avoid creating alarm and despondency.

ProMED-mail has now decided to report all suspected human cases of H5N1 from Indonesia because the usual flow of information – first suspect and then confirmation — is disrupted there because of their public health policy.

In countries where the standard flow is working properly, it is counterproductive to report suspects because many of them will not be confirmed as positive, thereby causing undue alarm. Over time, this could have the effect of “crying wolf” (repeated false alarms leading to a true alarm being ignored).

ProMED – mail is an effort of the International Society of Infectious Diseases


Written by farzaneh

August 20, 2008 at 4:08 am

Posted in Global Health

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