PLANNING A TRIP to Vancouver Island? You might want to know that Cryptococcus gattii, a pathogenic fungus that invades the central nervous systems of humans and other animals, has recently infected about 100 people there, six of whom have died. Do you know that at least 10 Egyptians have died of avian flu since Christmas Eve? Or that 50 people in central Russia have contracted a deadly form of hemorrhagic fever? Closer to home in Minnesota, could your child's extreme itching last summer have been caused by cercaria, the immature stage of a blood fluke found in some of the state's seemingly pristine lakes?
For the germ-obsessed, there is no more terrifying reading than the daily reports focusing on outbreaks of mysterious illnesses or emerging infectious diseases around the globe on the website known as ProMED, short for the Program for Monitoring Emerging Diseases (www.promedmail.org.) Now in its 12th year, ProMED has become one of the most powerful, if underappreciated, surveillance tools for protecting public health.
Both the U.S. government-funded Centers for Disease Control and Prevention in Atlanta and the World Health Organization in Geneva operate excellent disease surveillance systems. But absent an obvious health emergency, unverified reports of suspected outbreaks are normally circulated only internally or to closed lists of fellow health professionals. ProMED is free, decentralized and available to anyone with Internet access — the Wikipedia of disease surveillance. And, unlike the CDC and WHO, it tracks plant and animal as well as human diseases. Finally, the CDC and WHO are ultimately beholden to governments, which means they can be affected by official pressure to delay the public reporting of a potentially embarrassing or economically costly outbreak. In an era in which rapid public reporting of suspicious diseases can save thousands, if not hundreds of thousands, of lives, ProMED fills a vital gap in monitoring infectious illnesses.
Each day, ProMED's editor, Lawrence C. Madoff, an infectious disease specialist at Harvard Medical School, assisted by five associates and about 25 scientific experts, cull through the dozens of e-mailed reports of mysterious outbreaks sent in from experts and amateur disease watchers throughout the world. Scanning newspapers and health department alerts, government reports and other sources of information for threats to public health that official surveillance systems may not yet be circulating, they post reports that moderators deem credible. The site gets roughly 10,000 hits a day and is distributed without a fee to 37,000 e-mail subscribers in about 160 countries.
In 2003, ProMED was first to report the disease that turned out to be severe acute respiratory syndrome, or SARS. Though China initially tried to squelch news of the mysterious outbreak, Madoff says, ProMED tracked the spread of the disease. When ProMED fans at a Toronto hospital began seeing symptoms similar to what they were reading on-line, they isolated suspect patients and took other steps now credited with having limited its spread.
Late last year, ProMED's reporting on a cattle die-off in northeastern Kenya led scientists to conclude they were seeing the first outbreak there in nearly a decade of Rift Valley fever, a hemorrhagic fever that spreads from cattle to their caretakers and kills both unless treatment is prompt and intensive. The prompt reporting enabled officials to contain the virus.
STATES OFTEN want to suppress reports of outbreaks to avoid frightening away tourists, being forced to destroy plants and animals that are a key source of income and jeopardizing hard currency from farm exports, says Stephen S. Morse, a ProMED founder at Columbia University's School of Public Health.
ProMED, with a budget under $500,000 a year and no full-time staff, has no such concerns. It has nevertheless come a long way since 1993, when Morse and Barbara Hatch Rosenberg, an expert on the treaty banning germ weapons who was then at the Federation of American Scientists, convened a meeting to discuss how to improve the detection of naturally or unnaturally-inspired diseases. A year later, ProMED was born. It had 40 subscribers.
"Most doctors and scientists didn't even have e-mail in those days," said Jack Woodall, a Brazilian-based virologist and former WHO official who co-founded the service. But in 1995, when Ebola erupted in Zaire, people desperate for reliable information about the outbreak discovered ProMED. By year's end, ProMED had 3,000 subscribers.
The service also won fans in October 2001 during the anthrax letter attacks that killed five, infected 17 and put more than 20,000 frightened Americans on antibiotics. D.A. Henderson, the scientist who led the successful campaign to eradicate smallpox and who was then a key advisor to the secretary of Health and Human Services, said CNN and ProMED had been the government's most reliable sources of information.
Occasionally, ProMED has made mistakes. Among the most infamous was a 1999 posting that quoted a local newspaper in Connecticut as saying that the West Nile virus had probably killed several cows there. Woodall, who knew that the bird-killing West Nile was not known to have killed cows, investigated. The error, it turned out, was a typo: the letter "r" had been dropped. West Nile had indeed been found in Connecticut, but in dead crows, not cows. A correction was promptly posted.
Such insistence on transparency, rapid reporting and universal access has caused friction with some at the CDC and the WHO.
"They have accused us of spreading unfounded rumors and posting reports that have had no peer review," said Charles H. Calisher, one of ProMED's first moderators. "But we're just reporting what is being said or published…. We tell health officials, you might as well report this, because you'll be reading it on ProMED tomorrow."
ProMED's democratic, decentralized approach to disease surveillance, though not always perfect, seems indispensable in a globalized world where germs travel the planet as fast as e-mail messages and respect no borders.