Emerging Infections

Marjorie Lazoff, MD
Emergency Medicine
Philadelphia, Pennsylvania
Medical Editor
Medical Computing Today

accepted for publication in Medical Computing Today February 1998
partial update April 2000
Originally published in edited form February 1998 in Medical Software Reviews.

Online Resources - Organizations - Government - Journals - Education/Research - List of Lists

With the increased spread of local disease from one region to another and unknown infections from foreign lands infecting native populations, the epidemiology of infectious diseases has become global in ways unthinkable 20 years ago. Advances in transportation technology, the increased speed and popularity of world travel, and the development of tourism in remote areas of the world have resulted in more casual travel within our daily lives, greater access to the world's marketplace, and new travel to previously inaccessible regions of the world. (More on Travel and the Emergence of Infectious Diseases in the April 1995 issue of Emerging Infectious Diseases). Relatively new infections such as AIDS, Lyme disease, and Toxic Shock Syndrome have quickly entered mainstream medicine. Recent media reports on hantavirus syndrome, Ebola virus, "flesh-eating" streptococcus, food borne infections, Mad Cow disease, and all the biochemical warfare and doomsday scenarios portrayed in the news, books like The Last Plague and films such as Outbreak, have fueled public concern.
World organizations, governments, and professional groups have responded by creating special departments and collaborations within this new discipline. Emerging Infections (EI) is classically defined as the study of any infection that has appeared or reappeared over the past 20 years or one that is likely to spread in the near future. Most experts include infections with partial or full resistance to antibiotics and other therapies. Some of them emphasize the urgent nature of these previously unrecognized or underappreciated infections rather than newness or rediscovery, and so prefer the name Emergent Infections.
EI is innovative in that it takes as much from public health and epidemiology as it does from specialties of medicine, pediatrics, and infectious diseases. The result is a collaboration that nevertheless remains true to the original focus of each discipline, so that both the public's and the individual's needs are medically represented; world organizations and government agencies look after the public's interest, while practicing physicians address individual needs by reporting suspicious outbreaks and educating themselves and their patients about new infections, new treatment, and prevention if possible.
A recent editorial in New England Journal of Medicine underscores the growing relationship between leaders in the medical community, industry, and government. Emerging Infections -- Another Warning, an editorial by Michael T. Osterholm, PhD, MPH, chairman and CEO of ican, Inc., describes the four EI-related articles in its April 27, 2000 issue, and suggests they may provide "powerful and convincing evidence" for an upcoming Congressional bill to amend the Public Health Service Act.
If ever a medical discipline was tailor-made for the Web, it is Emerging Infections. The Internet, a communications conduit largely unimpeded by time or distance, allows for EI's efficient collecting and maintaining data on disease outbreaks, exchange of research information, and warnings and alerts sent throughout the international medical community. Emerging Infections is not only one of the hottest new medical specialties, but it is also one of the best reasons for physicians and other health professionals to become familiar with the Web and the rest of the Internet.
Sections Online Resources
One of the best primary resources on line is the Centers for Disease Control and Prevention (CDC) landmark report, Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States. Written in the mid-90s in partnership with local, state and federal agencies; professional and public service associations, and infectious disease experts, it defines present U.S. public health issues and outlines concrete plans to accomplish its four goals: surveillance and response, applied research, prevention and control, and infrastructure. Physicians looking for a succinct introduction to EI will appreciate the Background section.
Outbreak (previously The Ebola Page) is an all-volunteer "on-line information service" on general and disease-specific EI articles and links. The content-rich site is also one of the best designed -- not by accident, since its creator uses his own Web publishing software as low-key promotion, and to good effect. Outbreak's content is easily accessible, its interface is clean and makes for easy navigation from any one page to another, and push features such as the Outbreak Channel (available at present only for Internet Explorer 4.0) places this site in the vanguard of Web technology. Those who register (free), even if using a dummy name, will benefit by having a browser-specific site and additional information and links. For those who appreciate excellent Web sites from both a content and presentation perspective, Outbreak is a real find. (HMS Beagle Web site reviewer Pamela Gannon, in her February 1998 Review of Outbreak, agrees.)
South Africa enjoys an international expert in virology, as showcased in the University of Cape Town's dated but scholarly and well-written Emerging and Re-Emerging Viruses: An Essay. Scroll down the University of Wisconsin Bock Laboratories site's Tutorial page for other articles on emerging and re-emerging viral diseases.
For Something Completely Different, Plaguescape is described as a "digital rendition of an epidemiological analysis of the biblical 10 plagues of Egypt." This unusual nonmedical site is thought provoking and well referenced but spooky in more ways than one: for example, the left frame sometimes scrolls all by itself to mid-page, showcasing a quotation from a new book available on this site's bookstore.
Sections Organizations
The heart of the World Health Organization (WHO)'s Emerging and Other Communicable Diseases Surveillance and Control (EMC) online information is found under News, where listings of disease outbreak reports are summarized and old bulletins are a link away -- unfortunately, stored as one very long scrollable page. The home page lists many EI fields; for other diseases use the search engine located at the bottom of the page. Users will return a high percentage of press releases and, inexplicably, duplicate reports with identical text but different formatting. Other resources from this page include the Weekly Epidemiological Record (see below), and the International Travel and Health section. This section needs updating, and at least some of the information isn't cross-referenced. Overall, this site contains lots of information but its all-text format belies a less-than-user-friendly and accessible resource.
The Federation of American Scientists (FAS) is a privately funded nonprofit policy organization founded in 1945 by members of the Manhattan Project who are presently engaged in analysis and advocacy on science, technology, and public policy for global security. Since August 1994 its Program for Monitoring Emerging Diseases (ProMED) has sponsored a well-regarded e-mail list ProMED-mail, an open discussion group for EI experts and interdisciplinary network for communicating and sharing information concerning emerging diseases; two years later the management of ProMED-mail was assumed by SatelLife, the communications arm of the International Physicians for the Prevention of Nuclear War. ProMED-mail is only one of several SatelLife's HealthNet projects; see too its Program for Collaboration Against AIDS and Related Epidemics (ProCAARE).
Two online sites feature ProMED-mail. FAS links to Medscape, which offers About ProMED, a summary of the project and online subscription instructions, and ProMED List, which posts present and past digest versions as scrollable text only. More sophisticated technology is available on SatelLife's Web site, which permits online subscription to ProMED-mail, and access to present and past posts via monthly archives, retrievable by date or thread. There is also a WebGlimpse search engine for this database.
The Infectious Disease Society of America's Emerging Infections Network (EIN) was created in conjunction with the CDC as a provider-based EI sentinel network. The site is largely administrative, but does offer several published reports that not only provide general information and statistics but also future plans for monitoring and/or intervention.Readers who follow NetView will appreciate a December 1997 summary of reported cases of presumed viral meningoencephalitis during the winter months 1996-7.
As a professional organization involved in EI, the Council of State and Territorial Epidemiologists, has posted 1997 position statements on a number of EI-related topics, including the National Public Health Surveillance System and a Local-State-Federal Outbreak Investigation Coordination. The American Society for Microbiology is another professional organization with a Web presence.
Sections Government
The CDC's National Center for Infectious Diseases (NCID) includes information for both physicians and the public on the full spectrum of infectious disease, but its emphasis on EI is clear from its site's table of contents. Those interested in browsing will find new and other major articles under What's New, most of which concern new or re-emerging infections. To investigate a specific infection, the home page's buggy search engine is unfortunately the best way to navigate. The Diseases section has a fairly comprehensive alphabetical listing written for the public including most major EI, but inexplicably excludes HIV+ and TB, and the Traveler's Health section is a huge practical resource with a list of recent outbreaks under its Yellow Pages and the section table of contents. The home page also provides direct access to the agency's peer-reviewed EI journal, as described below.
In late 1994, the CDC awarded five year grants to Minnesota, California, Oregon, and Connecticut, to develop emerging infection programs. The Minnesota Department of Health presents parts of its Emerging Infection Program on line.
Sections Online Journals
January 1998 starts the fourth year for the CDC's popular quarterly Emerging Infectious Diseases. (EID) All issues are available on line, with full text articles with charts presented in traditional Web format (charts and text on same screen, links to references at the end of the scroll). The content is scholarly and fully reflects the international and epidemiologic scope of the discipline. Technical problems with its search engine aside, EID is a good example of how a paper journal can put its content on line in a straightforward and readable manner, for dissemination to a worldwide medical audience. Note too that EID's first issue contains Emerging Infections: Getting Ahead of the Curve by David Satcher, MD, PhD, head of the CDC and our new Surgeon General.
WHO's bilingual Weekly Epidemiological Record contains epidemiological information on cases and outbreaks of diseases under the International Health Regulations, other communicable diseases of public health importance, including the newly emerging or re-emerging infections, noncommunicable diseases, and other health problems. It is accessible online as PDF files or as a weekly e-mail digest.
EuroSurveillance is a monthly European public health publication wholly accessible online. It publishes data from European surveillance networks, such as results of outbreak investigations and approaches to communicable disease prevention. The articles are particularly well-formatted; .pdf versions for downloading are also available. EuroSurveillance Weekly, with different articles and a more practical and relaxed perspective from its monthly sister, is available as an e-mail digest with links for those who register (free).
Surprisingly, the major medical journals do not have much on EI in general, although readers may have greater success searching under specific diseases. JAMA's editorial on Infectious Diseases A Global Approach to A Global Problem ends with a link to a bibliography of international EI articles published in 1996. The January 1, 1997, issue of Annals of Internal Medicine has an Update on Infectious Diseases, which devotes a number of sections to general and specific emerging infections. One of the few scholarly articles on Tropical Medicine comes from British Medical Journal, September 1, 1995.
Sections Education & Research
Yale University's wonderful Emerging Infection Information Network was founded with support from WHO, UNESCO, and several private corporations. In both 1996 and 1997 it offered a series of one-way teleconferencing seminars on EI topics to anyone with a modem and $75. These lectures are now available free for downloading, most in a variety of formats: full multimedia, slides, audio, or written transcripts. The forums section didn't take off, but hopefully the funding for the resource materials will continue in 1998. Medivision offers a free online simulcast (using RealAudio Player) and slide show of a 1996 lecture, Therapeutic Responses to Emerging Resistance with Gram Positive Aerobic Infections, for 1.5 CME credits.
Only a few of the 20-odd slide lectures under University of Pittsburgh's Supercourses: Epidemiology, The Internet and Global Health are germane to EI, but this site is recommended for its solid content, interface, its clever interactivity and linking to outside sites, and for its feedback. (Unrelated to EI, those who follow NetView may enjoy the lecture on the epidemiology of Multiple Sclerosis.) Unfortunately, this site does not offer CME credit.
A summary of a January 1997 panel discussion on the Surveillance of Emerging Infectious Diseases, part of University of Washington's graduate level course in Emerging Infections in International Public Health, provides a readable overview of EI from a national, state, and local perspective. The course syllabus includes a good reading list of scholarly articles up to around 1996.
Sections List of Lists
A number of excellent EI lists link not only to general EI sites but to specific infections and diseases a huge reservoir of Web content wholly ignored in this review. Among these lists ASM's Government Agencies and Scientific Organizations and Newsgroups, and ProMED's Links on Infectious Diseases stand out.

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