KA.S ● PUBLIC INTEREST REPORT

Journal of tie Federation of American Scientists (FAS)

Volme 49. No. 6 November/December 1996

The Need for a Global Program To Monitor Emerging DiseasesThe FAS project to promote the establishment of a

global Program for Monitoring Emerging Diseases(ProMED) was initiated at an international conference in1993. Since then it has launched a system of worldwide e-mail reporting that now reaches 6000 people in 128 coun-tries with a dozen or more bulletins daily on infectiousdiseases—notjust human diseases, but those ofanimals andplants as well. Through a partnership with SatelLlfe,ProMED-mail extends its reach into remote areas via low-earth-orbit satellites. ProMED has also designed a widelypraised plan (soon to be published in Health Policv) for a

demonstration program of sentinel surveillance centerswhere new diseases are likely to emerge.

This newsletter report on ProMED’s status reveals amajor and ingenious FAS effort to head off low-probabil-

ip—but high risk—pandemics, as well as to provide earlywarning of the ongoing emergence of infectious diseasesthat could thwart our efforts to assure global securi~.ProMED illustrates how NGOS can, in some cases,

efficiently accomplish what large, bureaucratically bur-dened institutions cannot even begin.

The Growing Threat of Disease

Numerous recent episodes of emerging andreemerging infections, including the global AIDSpandemic, the continuing spread of dengue viruses,the now-frequent appearance of hitherto unrecognizeddiseases such as the hemorrhagic fevers, the resur-gence of old scourges like tuberculosis and cholera innew, more severe forms, and the economic andenvironmental dangers of similar occurrences inanimals and plants, attest to our continuing vulnerabil-ity to infectious diseases throughout the world. Thereis reason to believe that the number and incidence ofemerging infectious diseases and the risk ofreemerging diseases are all increasing. Factorsresponsible for the increase include such social factorsas mass population movements, rural-to-urban migra-tion and accelerated urbanization, population growth,

The Home Team (1 to r): Stephen S. Morse, ColumbiaUniversi@ School ofPublic Health (ProMED Chair); DorothyPreslar, FAS Washington ProMED O@cer; Program O@cer,

ProMED-AHEAD); Jack Woodall, NY State Department ofHealth (Chair, ProMED-mail Policy Committee); Barbara

Hatch Ro.renberg, State Universi~ ofNZ Purchase (ProgramCoordinator).

rapid transport, global trade, new food technologies,and changing life styles, as well as environmentalchanges, such as climate change, altered land usepatterns and irrigation.

These are global problems. A new infection mayfirst come to light in a circumscribed area, but insuitable circumstances the infection can span entirecontinents within days or weeks, as influe- periodi-cally demonstrates.

Many experts, both within and outside govern-ments, have warned of the need to improve capabili-ties for dealing with emerging infectious diseases.Invariably, a prim~ recommendation has been thedevelopment of an effective, worldwide infectiousdisease surveillance system. A global program aimedat recognizing unusual outbreaks at an early stage, inorder to prevent their spread, would pay enormous

(Continued on page 3)

Page 2 November/December 1996

1996 Public Service Award

On October 26, 1996, the FAS Public ServiceAwad was presented to Sally Lilienthd, at theFAS armud meeting, for her work in conceivingand creating Ploughshares and guiding its workover 15 years. The plaque read:

Sally Lihenthal

Phikmthropist for Peace

Ingenious in the Invention of a ProcessCapable in the Creation of an InstitutionResourceful in the Raising of FundsStatesmanlike in the Supplying of GrazztsAcute in the Assessing of Accomplishments

The citation is reprinted on page 12

Stanley Goldberg

We are sorry to report that Stanley Goldberg, aphysicist, historian, educator and friend of the Federa-tion died in October after a sudden illness.

Dr. Goldberg was the author of a well regardedtext, “Understanding Relativity: Origin and Impact ofa Scientific Revolution,” mong many other publica-tions, and was working on a new biography of Gen-eral Leslie Groves of the Manhattan Project.

Stanley Goldberg was also a prominent advocateof declassification of Cold War historical records, andhelped to motivate and guide declassification effortsat the Department of Energy. His efforts will bemissed. We were honored and grateful to learn thatDr. Goldberg’s family asked that contributions in hismemory be made to the Federation’s Secrecy &Government Bulletin.

For more information about FAS, its projects andactivities, please visit our web site at:

http://www.fas.org/

cThe FAS Pubric lntere,yr Reporr (USPS 188-J 00) is pubrished bi.monfhly at 307 Mass. Ave., NE, Washr”gton, D.C. 20002. A“”ualsubscription 525/year. Copyr~ght 01996 by the Federation of AmerI.

POSTMASTER: Send address changes to FAS, Public Interest Rep.,307 Massachusetts Ave..., NE, Washington, D.C. 20002.

FAS Chairman:CARLK.,,,.

Vice Chairman: ROBERTM. ADAMSPre.,ident: JE.EUYJ, Sm.BSec,etaV: A,. D,”Y..Tr<a,vurer: c“..,- C, PR,CE

The Federation of America” Scientists (FAS), fo.”ded October31,1945 as the Federation of Atomic Scientists by Ma”hat&” Rejectscientists, engaScs i“ research and advocacy on science- a“d-society issues, especiaOy glohtl security.

Cunent wm and peace issues range from ““crear war to ethnicconflict and from nuclear disarmament to ~ms sales; s“stainablcdevelopment issues i“cl”de disease s“rveilla”ce, crimate modifica-tion, povefly, food security a“d environment. FAS arso works o“h“ma” rights of scientists and on rd”ctio”s i“ secrecy.

SPONSORS

“SidnqAl,mln (B!,)),,8Y) %!sc,lla McM,ll,n (Hi,t”cy),,”,. Ames (B ,,>cb.m,stv) Rc>y Men.ing.r (ky.hia*zy),Ph,li, W. .ndcrs”o (Physic, ) R“tir, Me,,,>” (s,,.; <,1”,,).Ke”neth J Am”. (=”n”m!cs) Matthnw S, Mesc,w” (B,”chcmi,o)‘l.),”, Axe]r”d (Biwhcmis,q) NC., E. M,!,., (Psy.h”,<>gy,.D””id Bl],im”,e (B,.ch,mi, w,) ,h,,,p M“r,,m. (Pbysi.s)Paul B..?”. (Mcdic3nc) step,.. s. M“,,, <V,”,”gy]*H,”, A. Beth= (Wysic,) ‘Dsnic! Nmtbm, (B; ”themi, try)*K,,nrId B]!>ch (Chemistry) Frankfi” A, N,,, (Mcd,c;DeI.N”rman E, B“,],us wh..,) ,M,rsh,ll N,mnk,g (B i,,chem,stry)A... Pi,,, cum, @“n,, mic,) -A,.” A. P.nz, as (Ast,”.”my).0..” chamber,,,. (Pb,,ic,) *M.,,!” L. P.,] (Wysics)Abram Chay.s (Law) GcrArd 8.1 (S.! Pubtishe?)M<>ris C,>h<m e“~inccting) P,,”) P!,””.y (m”.”m{.s)Mi)drcd C,>bn (B i“.bem?suy] M,,,k P,.sh”. (M”,m”v., K,”>,>gy]‘U,,” N. C<,!,mr (Physics) ‘Edw,!d M, ,urcc,, (physi c,)PJ”l B. C,>r”cl, (M4icine) George Rathjc”s V“l iticnl Science)Carl Djersssi (Or&a”iC Chem.) .F{d.,ick R.i”., (Physics)‘Rc”$!” Du,b,u” (M,c,,,h,”,,,gy) ‘B”,,”” Richter (Physic, )1,>,”,, Ed,.,, (6,”1,,,,> DJV:4 Ri.smao, 1,. (Smi,>i”gy)Pa., R. .hrt$.h (Bi”,”gy) VCr”,>” Rut,,” (A8r,eult”,e)Ge,>,,e field (Astr”phy,ics) J. ff,ey Sachs (a”n<>mi<,]‘V.! L. Rtch (Physic, ) C.,! Sagm (Asm”o”my))ecc>m. D, Fr,”k (Ps,ch”)”Ey) ‘A!thur Schaw,”w (Physics). . . Caf)e t<>. G.jd”sek (Medicine) ‘J, R,,bezt Schr!c~.r (PbysicsI,,,,” Kc””.,, Ga,brsith {~”””mi.,) ‘Cl.”” T. Scab!,rg Chtm,,try)‘ WIltcr Gilhr, (Bioch em; stry) Andrew M. Scsslcr (Physics)Edwsd L, G,”.,.” (agin..,in,) .Ph,,,i, A. Shsrp (B,,,,,,gy)“D””old Glas.r (,, ,s,c,.B ,“,<>gy] S[an!ey K. Sh.inbaum (Ec”o”m,c,),Sbc, d,,” L. G,,,,,,. (Physic,) Ge,>rgt A. S1”., (Mcd,c!oc]M.w,” L, G,,,ikrg.r (Physics) ‘Herbert A. Sim,,n (Psy.h,>l”gy).D”dle, R. Herschbacb (Chtm. Physics) Nc<l Smcls.r (S”ci”l”gy].Alfrcd D. Hershey (B i,,l,,gy) Afic. K,mb,,, Sm;,b {H,s,,,w)Fr.mk ,,,” MPPCI (Pby,,.s) . . . . . . Taube (Cl,emis,,y)‘R,\ald H,, ffm.mn (Chcmlsvy) ‘iJIme, T“b, m (fi,,n,,mics)J,!h” P, H,,ldren (E”ec~y/&m, C,,”,) ‘ChJr)es H, T,,wns, (Pbys, c,)‘Jtr,,mc KJ, Ic (Physical Chcmi,t] .G.”cgt w8,d (B,”,,,gyINJtl,”n Keyfi= (Dcm”g,aDhy) M,rc>” E. Wccma” (Med~c,”c)‘H, G,, ti”d Kh,,rJ”a (Mmh. misxy) R,,bc,r A. Wc:nkrE (Bic>!”gyI.Arth. r K<!rnberg (Biochcmis.y) Vict”r F, Weissk”pF (Physics>‘W,lhs E. L,mb, ,,, (Pby,ic,I R,>&r, R. W,],,>” (Physics].,.,. Ledtrmd” (Physics) C.S. W. (Physics). Wlss!l y w. k,l.,,,f (m,,” ”mi., ) A,’xd Y,”kaut, (Mcc,ci.c)‘Wlk,,m N. Up,c<>mb (C,.”,,, ”,) Herb.” F. Yc,rk (Ph,,;cs)

‘N,, btl L, U,GJ,C

.AT,ONAL cow.,, MW,,,s (C,m,cd)

Ruth S. Adams (SCi. Etiti,>E) M,>,,,,. HnlPcri” (P,>,; tic,, Science)R<,%mary Chalk (P<,fit(ca, S<! . ...] DJni.I K.mm.n (physic,)S,... Pc,,., (Phys(cs) Rob.,, S“,”,”. (E”gi”eer,”g)*V.! Fl,ch (Physics) I“h” S. T,,)%(Physic,)L,”+, G,,ttf,.ds,>n (3<>ci”lc,zy) Ie,c”,y P. Wdlctiti (Mcticin<].1”,, .. f,m.is,.r (physics) BUr”, w,s,,,” (,..,”.,’””8, u,.)

FAS The Fedcratio” of America” Scientise F.”d, fo””ded

FUNDin 1971,is the 501 (.)(3) tz.ded”ctibrc rescxch mdcd.cation xm of PAS,

Frank ..” Hippel, Chairman Jeremy J. Sto”c, President

BOARD OF TRUS~ES

David Armi ngton Pete, RenterAnn D,uyam R.,ymo”d S, SczudloM,!rvi,, L. Go) dberger Margartt R. Span.]Murk A.R. Kleiwan M;>rti. St.”.Richard Mull,, Roben WeinbergWi!lk,m Rcvc)le Herb.. F. York

(Continued@om page 1)dividends for the entire world as well as for theimmediately affected areas.

There is presently no functional system anywherefor monitoring emerging diseases on a global basis.Current surveillance capabilities are fragmentary, lackcoordination, and are geared toward establisheddiseases. Moreover, they have mostly fallen intoneglect, both at the national and international levels.

In January 1996, 36 medical journals worldwidedevoted their issues to emerging and reemergingglobal microbial threats. Over 200 articles documentthe occurrence, causes, and consequences of thesediseases, leading the Journal of the American MedicalAssociation to conclude that “world health is indivisi-ble, we cannot satisfy our most parochial needswithout attending to the health conditions of all theglobe. We have never been more vulnerable; thisvulnerability must be matched against the extraordi-nary sophistication of the science that we are, inprinciple, able to pit against the threats.”

Development of the ProMED Proposal

At its founding conference in 1993, attended by 60prominent health experts from all parts of the world,ProMED established working groups and began toelaborate plans to promote the establishment of aglobal Program for Monitoring Emerging Diseases.Planning continued at subsequent meetings, consulta-tions and through mailings. Based on the outcome, aWorld Bank official encouraged and guided a sub-group of the Steering Committee in the drtiing of adesign for a demonstration program. The drafi wascirculated for comment to more than 300 expertsaround the world, includlng dl those who had partici-pated in ProMED activities.

In a document incorporating many of the sugges-tions made by the reviewers, ProMED proposes aresearch program to demonstrate the feasibility of anetwork of centers to monitor emerging diseasesdirectly through clinical surveillance for selectedsyndromes, coupled with effective laboratory backup.Whh financial resources in short supply, a smallnetwork of strategically located sentinel centers withcapability for surveillance of both endemic andemerging diseases may be the most effective way, inthe neti term, not only to test the concept but to beginproviding early warning of serious epidemics.

The ProMED project has compiled information onmedical centers around the world and identified likelycandidate centers for the network. Representatives ofsome of these centers came together in February 1996in Bellagio to exchange information at an interna-tional conference on Enhancing Infectious DiseaseMonitoring and Response, organized by ProMEDmembers at the request of tie Rockefeller Foundation.

Overview of the ProMED Proposal: Outhne fora Demonstration Program on Human Diseases

As things now stand, given the current dearth ofresources, what can be foreseen is a painfully slowevolution of disparate national and regional elementstowards the distant goal of a unified global system formonitoring emerging diseases, For more rapid prog-ress, significant investment will be needed for coordi-nation and development of relevant capabilities ininstitutions in the developing world, particularly inthose environments where diseases are most likely toemerge. In the human disease arena, ProMED recom-mends making a modest start on the faster track byprioritizing a small number of strategically situatedThird World institutions, mainly those least in need of

upgrading, for development as sentinel centers. Inthis way, a functional, although limited, networkcould be rapidly established at minimal cost. Thesystem would serve as an experimental model pro-gram for future expansion.

The centers would start by monitoring the emer-gence of a limited munber of defined syndromes,through broadly-based local clinical outreach fromeach center. Each center would develop laboratorycapabilities for identifying the likely agents for thetargeted syndromes, as well as for the well-knowncosmopolitan and locally-endemic diseases. Indeveloping countries the latter will generally over-shadow emerging diseases and will therefore be themain focus of concern and the incentive for undertak-ing the program.

The goal would be to achieve full competence ateach center witiln, at most, five yems, and then beginto expand the number of syndromes monitored. Ifsuccessful, the number of centers could be increased,as resources permit, to cover more seas of the world.

Concentration on a small number of strategicallylocated medical facilities in developing countries tocreate comprehensive centers of excellence would

,,,

Page 4 November/December 1996

Infectious Disease Information on the Internet

● Global Information (current)

WHO - Week~ Epidemiological Record WER

~Onet *

OIE - Disease Information(List A mimal diseases)NGO - ProMED-mail

-TravelMedicineNeNorks-ISTMH/ACCTMT*- Outbreak

ComercialMASTA(BritishTravelersAdvisory)

- newswiresfmedia WWW pages

. Global Information (reviews and updates)

WHO - EmergingDiseaseProgmmme(EMC) Repofls

OIE HandiStatus (downloadable mimal diseasedatabase)

FAO - Threats to food production

CDC Emerging Infectious Diseases (quarterly)

NGO - Yale Univ Emerging Infections InformationNetwork- FAS ProMED Page

. Regional Information (current)

Europe - Eurosuneillance (on Sentiweb)

- SaIm-Net * (Salmmrellosis nework)- EPPO’s Reporting Semite (plants)

Americas - PAHO’S Polio and Measles

SumeillanceAsia - Japan’s National Zrrstitute of Animal

Health Reports

. National Information (examples)

USA CDC Morb;di@ & Mortali@ WeeklyReport

Canada - Canadian Communicable DiseaseReport

France - Sentiweb

Mexico Boletin Epidemiologic

UK Communicable Disease Report Weekly

Spain - MedicinaPreventivee Saude Public

* Not open to the public

establish regional nuclei in mess critical for monitor-ing emergi~g diseases, without waiting for miversdprogress. The centers would reach out to otherinstitutions in their regions, providing medlcd infor-mation and training.

The plan calls for the formation of a network

consisting of, roughly, ten of the most adequatelyprepmed medical facilities in different regions of thedeveloping world. A center might consist of a groupof nemby, closely-collaborating institutions. Agree-ment and cooperation of the government would beessential, in each case. Each center would develop itsow local/regional network includlng existing clinics,hospitals, health cme providers, academic centers,government agencies and voluntary organizationstith which it wotid cooperate md exchange informa-tion, The centers would collect clinical data mddiagnostic smples with the help of these regionalnetworks. The centers and their networks would beassisted in developing expertise in recognition mddiagnosis of the specified syndromes, and would haveaccess to designated specialized reference laborato-ries.

The process would be coordinated by a programoffice, which could be located at one of the centers orat a sepmate location. The program office, in collabo-ration with v~ious programs at WHO, would main-tain the networks level of competence through aquality asswance progmrn, md provide diagnosticmaterials and equipment where needed, as well astmining activities and regular meetings. The programoffice would also solicit and help to raise financialsuppoti for individual centers to cover other needs.The centers would be linked to the program officewith m electronic commmications system, throughwhich surveillance information would be reported ina timely manner and relayed to other centers andinterested institutions. The network would coordinatewith existing networks such as WHONET (a globalrepotiing system for antibiotic resistance) and otherWHO electronic reporting systems that may beestablished, tith the goal of forming a unified globalcommunications system on infectious disease sweil-lance that will inco~orate data from existing andfutme international, regional, national, and localsuweilhmce efforts.

WHO’s international mmdate may make it diffi-cult to inco~orate a limited, trial program such asthis, especially in view of carrent resoarce limitations.Alternatively, a demonstration program could perhapsbe established outside ~0 as a research projectwhich, if successful, would eventurdly expand mdmerge with other sweillance activities at WHO.

—Barbara Hatch Rosenberg and Stephen S. Morse

November~ecember 1996 Page 5

ProMED-mail: Global Communication of Infectious Disease Outbreaks

by Jack Woodall, Ph. D., Chair, P?oMED-mail Policy Committee

The Internet and disease sumeillance

A truly global system of communications fordisease smeillmce does not yet exist. But we aregetting there, thanks to elecfionic mail md theInternet. Several initiatives using the Internet fordisease sumeillance have begun ~’What’s on theInternet”, page 4). Worldwide reporting of emergingdiseases is provided by only one service:ProMED-mail. Moreover, this sewice is publiclyaccessible ad free.

The ProMED-mail Electronic Conference

In August 1994, the FAS ProMED project launch-ed the ProMED-mail electronic conference, withSatelLife providing the technical semices. Bothorganizations we non-profit entities that have theirroots in peace md international security issues.ProMED-mail was inaugurated with 40 subscribersfrom seven countries. Two yenrs later, it has grown toover 6000 participmts in 128 countries, with newsubscribers joining at the rate of 500 per month.

Many more receive ProMED-mail reports throughsecond~ distribution (e.g., subscribers to HealthNetin 16 cormtiies, physicians subscribing to DocNet inSweden, and the faculty md students of the Aga KhanUniversity in Kmachl, Pakistan), or by selective re-posting of ProMED-mtil reports on other e-mail lists(e.g., Wildlife Ecology Digest, WildlifeHealth,WlldlifeRehab md EpiVet) and by accessing WWWsites set up by FAS, HealthNet, Medscape and DavidOmstein’s Outbreak Page. (See “World Coverage”, p.6).

As m exmple of ProMED-mail’s effectiveness asa tool of international information, the State epidemi-ologist of Sweden reported a cluster of EHEC (entero-hemorrhagic e. coli) cases that appeared therein lateSeptember 1995, unusually late in the season. Theywere suspected of having a meat origin, but were alsopossibly associated with dogs. Within a few days hereceived replies from health deptiment officialsrepofiing recent unseasonable EHEC outbre~s inCmada md the US (in Id&o, Kmsas, Ohio ad Ut*)

+ases probably linked to contaminated salad—redalso numerous references to finding the organism indogs.

Last December, a Chinese parent sent m aimailletter to ProMED-mail’s chief moderator describingthe symptoms of his daughter, who is suffering froman apparently untreatable disease. He had obviouslyheard of the successful diagnoses made over theInternet of other Chinese patients, notably one whohad suffered from thdliurn poisoning, and was confi-dent that he could receive help by the same mems. Ittook a matter of minutes to scan the letter into thecomputer in New York, post it to ProMED-mail, andreceive from Tel Aviv, almost by return, a list ofdifferential diagnoses from the developer of thediagnostic software package GIDEON. The resultswere available to ProMED-mail’s subscribers inChina within hours of receipt of the letter. If repofisof new outbre~s come in from any country, even byordin~ mail, similarly rapid responses could beorgnnized, since ProMED-mail subscribers includeWHO and the agencies concerned with disease

Web Addressesfor Infectious Disease Information

WHO http:llwww.who.cW

OIE http:ll~.oie.orgl

FAO http:llwww.fao. orgl

PAHO http: //paho.org/US-CDC http:ll~.cdc.govlCanada http:llhpbl .hwc.cdhpbllcdclFrance http: //www.b3e.jussieu. fr/sentiweblMexico http: //cenids.ssa.gob. mtiUK http: /lwww.open.gov. uticdsc/Spain http: //mrsplx2.use.es/

ProMED-policy http: //www.fas.org/prome&

ProMED-mail http:/Aealthnet. org/progrus/premed.html/

Outbreak http:lwww.outbred. orglCABI http:ll~.cabi.orglwhatsnewiMedscape http: //www5.medscape. cotiHome/

Medscape-ID/Medscape-ID/mhtml/

November~ecember 1996

swveillance and control in many countries (See“Institutions”, p. 10).

The greatest potential of ProMED-mail lies in itsaccessibility by the public. Most official and gover-

nment electronic conferences are restricted, such asCDC’S nationwide Public Health Laboratory Informat-ion System (PHLIS) and the 13-state InformationNetwork for Public Healti Officials (INPHO). Incontrast, anyone ca read about a case and follow anoutbreak on ProMED-mail,and can research past databy accessing the archivesmaintained by SatelLife.

Further, almost anyonecan post a disease repofi onProMED-mail, the res@ic-tions being that the personmust provide an e-mail ad-dress in case verification isneeded, must supply thesource of the informationand must understand thatthe repofi is published at thediscretion of the modera-tors, through whose handsall items must pass. Re-pofis sent to the moderatorsfrom official sources some-times contain requests thatthe information, consideredsensitive, not be posted onProMED-mail until furthernotice, and sometimes notbe posted at all. While thisindicates a considerable de-gree of confidence in themoderators, it does placethem in the same invidiousposition for which we criti-cize some governments and

tempted abuse of ProMED-mail, and only one inwhich a report has had to be refracted. It concernedan erroneous report of an outbreak of a rash disease oncollege campuses in the US. In that case, electroniccommunications demonstrated an impofiant advan-tage over print media. Whereas in the newspapers aretraction is ofien relegated to an inside page in smallprint, au Internet comection gets exactly the same playas the original item, so that it is difficult to miss. And

World Coverage by ProMED-mail

●

●

●

●

{, ,.,,.mail: 128

Number of subscribers: 5600USA addresses: * 3900Nmr-USA addresses: 1700

Number reached directly each day by email:5600

Number reached by seconda~ distributionRegularly: 500+Selectively: 2000+

Number of accesses to sites on WWW per monthSatelLife’s ProMED-mail Archives: 28,000FAS’S ProMED page: 300+Medscape’s ProMED-mail digests: 850Outbreak’s ProMED links: ?

* some “USN addresses actually seine overseaslocations

international organizations -suppressing informationrelevant to the public health. And it contradictsexperience: ProMED-mail’s principal veterin~moderator Dr. Martin Hugh-Jones of Louisiana StateUniversity, has observed that those Chief VeterinaryOfficers who are most transparent about livestockdisease outbreaks in their jurisdictions receive themost positive support for remedial action.

There have been remarkably few cases of at-

there is usually no morethan a few hours delay be-fore someone posts a cor-rection or clarification, sothat the system is largelyself-comecting.

Two anaJyses have beenmade of first repotis of dis-ease outbreaks (first reportsonly and not follow-upitems or discussions) thathave been posted onProMED-mail. Results ofthe most recent of theseanalyses are presented in“Source of First Repofis” onpage 9. In contrast to theprevious analysis, the num-ber of repotis posted by sub-scribers, rather thanProMED-mail staff andmoderators, rose signif-icmtly. Thus, ProMED-mailtaps a considerableresource—the interestedprofessional who does nototherwise feed into a na-tional or international dis-ease reporting system.

The unique value ofProMED-mail is that it can

provide people in remote mess and developing couu-tries who may have only e-mail access, current infor-mation of fluid disease situations on a sustainablebasis, free of charge. But to reach ProMED-mail’sobjective of rapidly collecting reliable informationabout emerging disease outbreaks in human, animaland plant populations from these people, and li~lngthose who need it with sowces of further informationon diagnosis, control and prevention, will require

November/December 1996

financial suppofi over and above what is needed tosuppofl an e-mail “list”.

Public Participation in Disease Surveillance

Emerging diseases me most likely to emerge inplaces where disease suweillance is absent or mini-mal. In countries such as Siema Leone, Somalia,

Sudan and Zaire, the collapse of their central govern-ments, or their inability to control all their temito~,means that little or no disease repotiing occurs. InHaiti, 90% of the health services are provided byforeign NGOS and religious missions, and there is nocentralized disease repotiing. Such coun@ies oftensuffer as well from lack of telecommunications withremote regions within their borders.

Official sources of disease information havelimitations. On occasion, WHO has either not beentold of an outbreak, or has been asked not to publishthe information. For example, for years cholera hasbeen endemic in Egypt and Bangladesh, yet has neverbeen admitted publicly by those governments for fearof adverse effects on their food expofis. Saudi &abiadoes not want it spread abroad that there is dengue inJeddah, for few of affecting the annual pilgrimage toMecc~ yet it brms pilgrims horn Nigeria because thatcount~ has, ve~ properly, repofied a severe epidemicof meningitis. Serbia has appmently asked WHO notto repofi cases of Congo-Crimean hemomhagic feveroccuming in Kosovo. Nofih Korea is said to haverecently suffered a severe cholera epidemic, which ithas denied. Episodes of repofi suppression haveoccumed in the case of animal and plant diseaseoutbreaks also.

When official suppoti for a suweillance programdries up, the repotiing often falls to zero. This hap-pened when WHO could no longer subsidize themonkeypox reporting system in West Africa. Here isa classic case of a potentially emerging disease thathas disappeared off the rad~ screen of global smeil-lance, yet is cefiainly still there, and still causinghuman disease, In most countries, if a disease is noton the list of officially repofible diseases, it does notget reported. This results in a vicious circle; rmediseases are dropped from the list, so there is nolonger a mechanism for noting any sudden increase inthe number of cases. Even in countiies with a com-prehensive epidemiological s~eillance system onpaper, the paper may be left blank or filled out incor

Page 7

Problems With Existing Disease

Reporting

COVEWGE

o Absence of some national systems- government collapse- civil wm- NGOS and religious missions operatehealth services

(e.g. Haiti, Siena Leone, Somalia, Sudan, Zaire)

B Official secrecy -policy or fear of adverseimpact on

- trade- tourism

(e.g. Bangladesh, Egypt, Saudi Arabia,Notih Korea)

● Poor communications with interior(e.g. Southern Sudan, Zaire)

UONTENT

P Inadequacy ofsome national systems- intermittent, incomplete or missingrepofis- incomect diagnoses- inappropriate lists of reportable diseases

rectly, andrarely fowmded tothehealth ministry intime to be of any use.

The bweaucratic notification process is often slow—not to mention the outright blocking of repofismentioned abov+aud public health may not be wellserved by delay. While it is impotiant to avoidharming trade and tourism by making provisionalannouncements that may have to be retracted later, itis equally impo~t that the public avoid a suspectedsowce of serious infection until a clean bill of healthhas been given. Ifpeople aretobe persuaded nottoflee an epidemic, as they did in India dining theplague episode in 1994, but to stay and take preven-tive measures, they must have confidence that infor-mationon outbreaks will not be withheld. Nowadaysthe public increasingly demands participation in

Page 8 November~ecember 1996

matters affecting health and accountability from is needed in the way of a non-govemrnentaJ ewly-public health authorities—and not only in the devel-

oped countries. The public hates cover-ups. That iswhy a non-governmental source of disease informa-tion has an important place in the system.

It could be argued that the media provide all that

WHY PLANTS ON THEProMED-mail CONFE~NCE?

A significant factor contributing to humanllness and death is protein-calorie malnutrition.Malnourished hosts have increased vulnerability tonfectious diseases. The Conference on Hungermd Poverty estimates that over 800 million peoplen the world are conically hungry. And, in 1994,umger and diseases related to malnutrition claimed:he lives of 10 to 12 million children under five.

The cwent movement towmds production ofIon-tradhional agricul~al export crops hasdramatically changed agricultural systems inDeveloping countries. Not only rae these changes~ndermining the production of staple food crops,but the pathogen outbreaks that accompany theinhoduction of new, foreign gemplasm ae a direct;ause of the devastating new and emergingiiseases of both export and staple food crops.Emerging plant diseases have led to theabandonment of over 2 million hectares previouslyplanted to tiaditiond food crops in Latin America.

The agricultumJ changes that have taken placein developing countries have contributed to theglobrd emergence or resurgence of hmrm diseaseand human epidemics. The loss of crops and thehigher production costs that result from increasingdisease incidence, and the pesticide use to contiolnew diseases, tmnslates into decreased footavailability and increased malnutrition. At thtsame time, the failure to maintain economically-viable and sustainable agricultwasystems in the Tropics, has displaced poor freer:into maginal environments - tropical forests 01savanuahs or urban slums - where they encounte:new pathogens (Ebola, AIDS, VHF, choleradengue), and become the initial foci for spread o:new and emerging dise~es.

— Dr. Pamela Anderson, CIA T Cali, Colombil

warning system of new outbreaks md emergingdiseases. Health authorities often hear first about auepidemic from the media. Those stories, however,may appear only in obscwe local newspapers, or maybe broadcast on local radio and in-couut~ televisionand never make it to the attention of the major inter-national wire sewices. Or just the reverse mayoccur—repotis reach Ewope and Japan but not thevillages in the country of outbreak. Thus, au adequatenetwork needs people who are on the scene or haveaccess to local print and broadcast media, rmd who areprepmed to repofi what they see and hear to a centralcleming place.

It is expensive to setup and equip multiple officialdisease surveillance centers. But there is akeady ahuge installed base of personal computers in healthinstitutions, universities, homes and offices in thedeveloped areas of the world, used by people who areinterested in the subject of emerging diseases andeager to ptiicipate as sentinels on the lookout for newoutbreaks. Their enthusiasm can be harnessed atminimal expense. The situation is, however, quitedifferent in the developing world. In many countriesthere are no telephone lines reaching into the interiorand no dependable somces of electricity in remotevillages.

In June, US Vice President Al Gore announced anew Mite House policy for combating infectiousdiseases that includes a $15 million effort, though theUS Agency for Intemationrd Development, to connect20 Afilcau countries to the Internet, and thence tohealth centers around the world. ~lle this seems ahandsome sum, it is likely to cover only the costs oflinking major cities in all 20 countries with the USand Europe, far from what it will take to lifi all areasof these countries with the capitals and each other.

The Challenges Faced by a Global DiseaseSurveillance Network

Plans for developing global communications formonitoring and responding to infectious disease mebeing formulated by a number of institutions, includ-ing WO, OIE, CDC, LCDC Canada, and ProMED-mail itself. The Ewoperm Union-United States JointAction Plan signed in Madrid in December 1995envisages an “effective global ealy warning systemand response network for communicable diseases”. In

November~ecember 1996 Page 9

response to a crdl by CDC for the creation ofpractitioner-based Emerging Infections SentinelNetworks, proposals have been submitted by theInfectious Disease Society of America, a consortiumof emergency rooms, and the International Society ofTravel Medicine. They propose to collect at a central

site key demographic data on potential emerginginfections from general infectious disease practices,emergency rooms, and travel clinics worldwide.

All these plrms include electronic communicationsas an integral and essential ingredient. AUy effectiveglobal plan utilizing electronic communications fordisease monitoring, whether official or not, must havetwo basic components: it must connect with dl relatedinitiatives, and it must cater to all means ofcommunication—voice, text and video, mail, telexand fax.

The first component is essential because it isunlikely that any one initiative will be able to providecomprehensive coverage. The global WO, OIE andEC-US plans, and national systems such as the CDC’Sfor the US and France’s sentinel physician network,need to be linked together with regional and sectordsystems as they are developed, and with informationfrom the media, including such resources as the USgovernment’s Foreign Broadcast Information Service(FBIS).

When everything is interconnected, the big chall-enge will be to make sense of the wealth of data thatwill pour in. Semi-automated, intelligent systems willbe needed to help in screening and classifying thereports. Cross-checking for validity and analysis ofthe results will have to be done by a team of qualifiedpeople, and then the results will have to be dissemi-nated in, probably, two different form+ne for thegeneral public, and one with more technical detail forthe physicians and public health workers, veterinari-ans or plant pathologists who will have to deal withthe outbreaks.

Finally, there must be a rapid response capability.In the case of serious outbreaks for which externalassistance is requested, it is certain that qualifiedteams will be available, as they were under WHOleadership for the recent Ebola outbreak in Zaire, Inaddition, ProMED-mail’s subscriber base containshundreds of health professionals with internationalexperience who can advise on possible diagnoses andsuggest preventive and control measures. But morepeople trained in epidemiology, laboratory diagnosis

and public hedtb will be needed—in fact, more areneeded right now to handle the increasing load ofemerging diseases we are already seeing.

The Future of PubEc Global Disease Monitoring

ProMED-mai~s electronic conference will con-tinue to expmd in numbers of subscribers and cover-age. There are just over 170 countries with e-mailaccess, but in 30 or so of those, the service is quiteexpensive and is therefore used mainly by governmentand commercial interests. Out of the 128 countriesnow reached by ProMED-mail, a dozen, mostly inAfrica, are represented only because the subscribersare served by SatelLife’s HealthNet. The numbers ofsubscribers in a country range from about 3500 in theUS downward to less than 20 in even large coutriessuch as the ex-USSR states, India and Indonesia, toonly two in China, and to just one in each of 30 or soother countries. Other gaps in our coverage areFrancophone Africa, the Arab states and the smallerCaribbean and Pacific islands. We are, however, wellaware of the language constraints and are exploringhow to offer the service in Spanish, French andPortuguese.

Source of First Reports to ProMED-mail on Infectious Disease Outbreaks

●

●

e

●

1 Jannary- 18 August 1996

Number of reports analyzed: 115

Official information from public healthagencies 43%

- Subscribers at these agencies 33%- Other reports 1o%

Media and scientific journals 33%

Health Practioners, Researchers,Epidemiologists 17%

All other sources Iv.

Page 10 November/Dec:mber 1996

Pro-MED-mail operations are now directed andadministered by SatelLife, a non-profit organizationbased in Boston, which began as an initiative of theIntemationd Physicians for the Prevention of Nuclear

War, recipient of the 1985 Nobel Peace Prize.SatelLife was originally conceived as a symboliccounterpoint to the “Star Was” defense system—using space as a platform not for weapons of massdestruction, but for the exchange of life-savinginformation among health care workers in both thedeveloped nations and the Developed World.

The growing availability of ever-more sophisti-cated multimedia technology at au ever-decreasingprice will have au impact on the monitoring of newdiseases. To add to the already immense, installedbase of privately-owned computers worldwide, thecomputer industry is planning to introduce in the nearfuture very inexpensive computers—in the $500 rangeAedicated to Internet access. This should lead to amuch larger segment of society in industrializedcountries logging on, and to more widespread accessin developing countries. The reporting base, in termsof general public online, will expand enormously.

Public reporting of outbreaks already potentiallyexceeds official reporting capacity and at a muchlower cost. This is because private and commercialgroups such as missionary and charitable organiza-tions, petroleum and mineral exploration outfits, roadbuilders and construction companies reach the mostremote areas, taking their own telecommunicationswith them, long before government instigations. Thenumber of people scanning the media, surfing theInternet and accumulating information on matters ofherdth and disease for their own interests far exceedsthose who could be deployed by any health agencytowards the same goal. Reports from the public arenot delayed by the bureaucratic requirement to haveeverything signed off at several levels; neither are theysubject to self-censorship or embargo. And they maybe no less reliable than official reports.

Sooner than we might imagine, we will no longerhave to wait for a news wire to pick up a report of auoutbre~ in au obscure comer of the world, the reportwill appear first on the Internet, and will be seen theresimultaneously by the public on their own computers,by the media, an! by public health, animal and planthealth authorities worldwide. This is the challenge forProMED-mail.

u

Institutions represented amongProMED-mail subscribers

(selected examples)7H0[ealth CanadaAHOCDC Canada‘AO~griculture Canada)IE‘HLS - United Kingdom;SCAP~auga Hospital, ZaireAEAltate Epidemiologist, Russia, Sweden,;imbabweJNICEFVorld Bank~sian Development Bank{IH JapanJSAID3SIR0 AustraliaJSDA, APHIS:VO Australia, New Zealand;PA~ws

<IOCRUZ BrazilFDANIV South AfricaCDCMOH ArmeniaNIH, NIAIDMOH P. R. C., Nicaragua, MozambiqueU.S. State Health DeptsNASAVA HospitalsInstitut PasteurUS Army, Navy, Air Force and MarinesCAREC TrinidadIVIC VenezuelaUSAMRJIDUniversitiesScientific pressNAMRU-2> NAMRU-3, NAMMDPopular press, TV, radioAmerican Red CrossPharmaceutical companies

November/December 1996 Page 11

In order to sample ProMED-mail:

If you have access to the World Wide Web and want to sample ProMed-mail repotis, archives maybe found at<http://www.healtbnet. org/progrmns/promed.htrnl>. Daily digests may be viewed at <http://www.medscape.codHomeNedscape-ID~edscape-ID.html>, co@esy of MEDSCAPE en on-line resources of SCP Communications.

Even if you do not have access to the World Wide Web, you can still access the mchives. To retrieve a report, youwill need to know the date of posting. Send an e-mail message to <Majordomo@usa.healthuet.erg>, the text ofwhich should read “get premed topics”. You will then receive an alphabetical list of the topics for 1996; if you wanttopics from prior years, yow message should read “get premed-1995 topics” or “get premed-l 994 topics”. Fromthe list(s), select the file(s) you would like to receive and send a second message to Majordomo which reads “getpremed (the dater.

For example, to retreive the foloowing achive file listed in “topics”:Alpha-1 Antit~psin Deficiency: RFI 960809181156

you would type “get premed 960809181 15&’. There is no limit on the number of files you may request, but eachfile request must appem on a sepmate line of yow message. Do not forget to tite “end at the end of your archivesrequest message.

In order to subscribe:Send an e-mail message to: Majordomo@usa.healthnet. org

[f you want to subscribe to: The text of your message should read: You will then receive:

ProMED-mail subscribe premed <your e-mail address> all repotis (as they weend generated), including

AHEAD, EDR and Plant

ProMED Digest subscribe premed-digest <your e-mail address> a consolodatimr of allend repofis (approx. daily

according to volume);includes AHEAD Digest

ProMED-AHEAD subscribe premed-ahead <your e-mail address> animal, zoonotic, vectOr-end borne disease repofis (as

they are generated)

AHEAD Digest subscribe premed-ahead-digest <your e-mail address> a consolidation of AHEADend repofis (appmx, daily,

according to volume)

ProMED-EDR subscribe premed-edr <your e-mail address> emerging disease repofisend (new outbreaks only, as

they are repofied)

Pro-MED-Plant subscribe premed-plant <your e-mail address> plant disease repotis (asend they are generated)

Simply send the appropriate above message, andyou will be subscribed. All subscribers receive a welcome to thene~or~ as well as information on how to post reports and how to retrieve reports from the archives.

Page 12 NovemberDecember 1996

1996 Public Service Award Citation for Sally Lilienthal

The Bible says, in Matthew 5:9, “Blessed ae the effective as FAS—which is about right—Sally stillpeacemakers”. How much more blessed, then, must achieved far more than dozens of anti-nuclea activists.be those who fund great numbers of peacemakers? And how sweetly she did it, and with such an absence

And what shall we say of Sally Lilienthd who has of unnecess~ fuss, tieating her grantees with greatcreated an institution to fund, on an ongoing basis, consideration.generations of peacemakers?

In 1981, Sally conceived andcreated the Ploughshmes Funddevoted to the most seriousproblem of ow time: globalsectity in the nuclear age. In 15yews of operation, under herleadership and though herpersonal indefatigable effotis,Ploughshaes raised, and thendistributed, $15 million forprojects for peace.

At FAS we know theimpofiance of this work in aspecial existential way, becausewe know what we have actievedwith ow own Ploughshmesgrants. We worked on conven-

Elght hun&ed yas ago, MO*S Mtionides tiednine levels of chaitable ~ivin~--in accortice with the degree ofanonymity of the gift, rangingfrom donations given directly tothose given in such anonymitythat the giver and recipient meunknown to each other eliminat-ing any direct sense of gratitude.By funding projects on globalsecurity, Sally has given a gifi ofpeace anonymously to millionsof inditidtis unknom to her—agiving relationship at the top ofthe Maimonides scale.

LiIienthal receiving plaque from FAS Chairman But, in her case, theseCarl Kaysen (seepage 2fo~ text ofplaque) millions of individuals me not

even awwe that they have

tiond -s sales, on the mti-bdlistic missile system,on biological wafme and the related issue of diseasesurveillance, on chemical wmfae treaties, and oncleaning up the nucleu envirournent. We got prompt~avel grants to go to kgentina and Peru. We receivedonly about 2°/0 of that $15 million. Yet this smallfraction made m irrunense difference both to FAS andto FAS’S gods.

So imagine, by extension, how much Sally hasachieved overall. Even if the other organizationsreceiving the rest of the $15 million were one-fifth as

FAS PUBLIC INTEREST REPORT (202) 546-3300307 Mass. Ave., N.E., Washington, D.C. 20002Return Postage GuaranteedNovember~ecember 1996, Volume 49, No. 6

received a precious gifi of enhauecd prospects for peaceand sectity, so her gitig reflects a level of anonyfityabove the Maimonides scale. Moreover, because, inan uncefiain world, the results of her work—likeours—can never be asswed, she can be described asone who gives anonymously to individuals unbownto her who are unoware of her gl~t and she does so incircumstances where she herself cannot be assured thather g$ts will be eflective. This is two levels above thetop of the Maimonides scale. So Sally is some kind ofsaint.

m