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With SARS, countless media reports and company press releases
promoting information and communication technology (ICT) solutions
appeared. Examples for eHealth solutions offered during the SARS crisis
include:
• Healthcarelink (http://www.healthcarelink.md) has developed a
monitoring
program that claims to detect severe acute respiratory syndrome before
symptoms occur and which—by aggregating data from a large number of
patients—also promises to detect bioterror outbreaks. Patients take
their
temperature daily in the morning and report the results by phone, fax,
or
Internet. The company publishes the graphs on the Internet for patients
and physicians to review. The data, along with information on a person’s travel history, can alert health workers to potential SARS patients
and
bioterrorist attacks. One of the open questions is, of course, how to
motivate a large number of people to measure their temperature daily and to voluntarily enter this information into a Web form.
• A very similar approach is behind the idea of Swedish company
MedDay (http://www.medday.com ), which proposes that people enter symptoms into PDAs or smart phones, which would wirelessly transmit the information
to
a
health or infectious-disease center, which could aggregate and monitor
these data. The company claims that the system can be used as an early
warning system for a nationwide outbreak of infectious diseases,
chemical
attack, or other disease. The company is surfing the bioterrorism wave
as
it simply rebranded its PharmaPoint software, originally developed for
remote patient monitoring by physicians, into RegPoint, hoping that it
will be used by governments to keep track of the health of populations.
There are open questions about the sensitivity of the system to detect
outbreaks against a “background noise” as well as about privacy issues.
• Sunday Communications, a Hong Kong mobile phone operator,
launched a
mobile phone service that promised to alert subscribers if they are near infected buildings. Those opting for the service had their phones
tracked,
and would be warned by SMS (short message service) whenever they strayed within a kilometer of a building where there had been instances of
SARS
infections. It is unknown whether this system prevented a single new
SARS
case.
• In Singapore, health officials tested electronic tracking
systems that
monitor the movements of every person who enters a public hospital.
Staff
and visitors wear credit card-sized RFID (radio frequency
identification)
tags around their neck to communicate their location to sensors hidden
in
the hospital ceilings, thereby enabling officials to track all
encounters
with other persons. Hospitals will save movement records for 20
days—twice
the incubation period for SARS. If one person turns out to be infected,
the database allows rapid identification of all encounters—health
officials say it is 10 times faster than traditional methods of asking
infected people whom they had contact with.
Apparently, some technology firms attempted to turn lemons
into
lemonade by using the crisis to bring their ICT products and services
into
the media and to public attention. As the number of new SARS cases
declines and the dust settles, it is time to ask critical questions,
including which of these tools and technologies have proven useful or
should be further developed and evaluated in order to be prepared for
the
next public health emergency.
The public health and infectious disease research
community widely
praised the role of ICT in early detection as well as in fostering
global
collaboration and information exchange during the SARS epidemic.
On March 17, 2003, WHO called upon 11 laboratories in 9 countries to
join
a collaborative multi-center research project on SARS diagnosis. The
network took advantage of e-mail and a secure WHO Web site to share
outcomes of investigations of clinical samples, electron-microscope
pictures of viruses, sequences of genetic material for virus
identification and characterization, and postmortem tissues from SARS
cases in real time [1].
Individual departments of affected hospitals
also
used Web sites and e-mail to rapidly disseminate clinical findings to
health professionals [2].
"This is a form of early warning and communication that would not have
been possible if the SARS Virus had appeared ten years ago," notes Dr.
Kimball of the APEC Emerging Infections Network [3], and Julie
Gerberding,
director of the US Centers for Disease Control and Prevention, writes in an editorial in the New England Journal of Medicine that “use of the
Internet has sped information exchange and helped overcome the problems
presented by asynchrony in the activities of investigators in many time
zones” [4].
Journal editors celebrated themselves and the Internet for being able to publish articles about SARS at the speed of electrons [5]. However,
the
role of journals—even if with electronic preprint versions and fast
track
peer-review—dwarfs compared with the role of the Internet in information dissemination of SARS.
As of June 30, 2003, PubMed lists 881 articles containing the search words ["severe acute respiratory syndrome" OR
SARS].
In contrast, Google finds 358000 pages with the phrase “severe acute
respiratory syndrome” (not counting non-English pages or pages which
contain only the abbreviations SARS or SRAS for “syndrome respiratoire
aigu sévère”).
The World Health Organization (WHO) also praised the role of GPHIN
(Global
Public Health Intelligence Network) for early detection of SARS,
claiming
that “GPHIN provided some of the earliest alerts to the November
outbreak
in China” [6]. GPHIN is part of WHOs Global Outbreak Alert and Response
Network [7]; it was developed and is operated by Health Canada’s Centre
for Emergency Preparedness and Response. It is essentially an Internet
crawler specialized in detecting news articles indicating unusual events relevant to public health: GPHIN continually scans more than 400
international sources for news of any outbreaks of 31 communicable
diseases, as well as articles about natural disasters and drug-resistant pathogens, rather than relying on “official” reports from government
sources (which may be reluctant to report disease outbreaks to avoid
economic disruptions). The approach is obviously insufficient when
disease
outbreaks occur in developing countries where little information finds
its
way into news media and the Internet, or in countries where the media a
controlled by the government. GPHIN seems to be stretched to its limits
(when the author requested access to the system the reply was “we have
now
reached our limit on the number of users that can have access to the
system”). GPHIN is currently being upgraded to include more languages,
including Chinese (which during the SARS crisis was not yet
implemented).
eHealth, consumer health informatics, and public health
informatics are emerging fields that have a clear public health aspect, in that
they include technologies that can be used to improve the health of entire
populations, not just individuals. Population health technology is a
recent umbrella term subsuming applications of technologies such as the
Internet, wireless devices, mobile phones, smart appliances, or smart
homes (domotics) that have a population focus and the potential to
improve
public health. In principle, all sorts of home-monitoring devices, from
digital fever thermometers to asthma-monitoring devices, could be
modified
to function as early detection systems, ie, to transmit data—wirelessly
or
through the Internet—to central data-mining facilities, which may detect emerging patterns indicating disease outbreaks.
Among the challenges
of
all of these systems are ethical and privacy concerns—it is a difficult
balance between gathering data from thousands of people with being able
to
track down infected individuals on the one hand, and protecting the
privacy of people on the other hand. Hospitals and pharmacies of
tomorrow
may also feed data into such central data-mining systems. In addition,
there may be a role for detecting patterns of information and
communication flows on the Internet. At the Centre for Global eHealth
Innovation we have been experimenting with monitoring search requests
people enter into search engines, to evaluate whether it is possible to
detect increases or changes in health-related requests using automatic
methods [8]. The sensitivity of such methods for detecting disease
outbreaks or bioterrorism attacks remains to be evaluated—in our search
term experiment it did not seem to be sensitive enough in the case of
SARS.
In the last week of June, Ontario presented Ottawa with a
breakdown of $945 million (Canadian) in SARS-related costs. Those include $395
million for hospitals and health-care institutions for extra staff
expenses, protective gear, clinics, and isolation rooms. Another $330
million went to replace lost wages for quarantined health-care workers.
Even more serious may be the consequences of the SARS-related “epidemic
of
fear” [9]. Millions of dollars were lost due to missed business—tourists and business travelers staying away from the hot spots.
Worse, as in
this
particular incident hospitals were the hubs of the outbreaks, patients
postponed or delayed important hospital visits. It is difficult to
estimate how many patients have been harmed by avoiding hospitals—at
least
outside of China these may be more than those actually killed by the
disease. Kelly MacDonald, a University of Toronto infectious-disease
expert, estimates that four times as many Ontarians will die from lack
of
medical attention caused by the SARS outbreak as will die from the
disease
itself [10].
To understand the epidemiology of fear in the context of population
health
technology is important for at least two reasons.
First, some ICT applications that have been advocated sometimes played a role as a psychological “duct tape of the war against fear.” Indeed,
Bruce
Hicks, group managing director of Sunday Communications, the operator
that
launched the mobile phone service that alerts subscribers when they are
near infected buildings (see above), was quoted as describing his
service
with these words: "With the dial of a few digits, subscribers can
quickly
get the peace of mind they need to go about their everyday
lives."—speaking to the fact that it is not primarily the spread of SARS but the fear that is addressed by this service.
Thermal-imaging
scanners set up at airports to screen travelers for signs of SARS may have had
a
similar role: to assure people that “something is being done,” and to
prevent economic damages. In fact, there is limited evidence on the
sensitivity and specificity of this technology to identify passengers
with
fever. Information and communication technology can also help to keep
the
health care system accessible in cases of disease (or fear) outbreaks.
For
example, Singapore General Hospital, introduced during the SARS crisis
an
online physiotherapy program allowing physical therapists to remotely
monitor patients in their homes. Using a webcam, patients can
communicate
with their therapists, who can in turn show their patients new exercises and give them feedback on their progress [11].
The second reason why we need to understand the epidemiology of fear in
the context of population health technology is that some technologies
used
as early warning system may not be able to discriminate between a true
biological epidemic and an epidemic of fear. This is especially true for systems relying on users entering symptoms, systems designed to
detect
changes in patterns of health care utilization or other databases, or
systems analyzing information and communication patterns on the Internet or in news media. Such early-warning systems may pick up changes in
collective behavior triggered by a mere epidemic of fear. For example,
thousands of New Yorkers buying duct tape did not indicate a
bioterrorism
attack, but a fear epidemic. Similarly, runs on doctors or pharmacies
may
either indicate mass hysteria (a highly-prevalent phenomenon in our
society), or a bioterrorism attack (a far less prevalent event). The
predictive value of such early warning systems is thus inherently low.
False positive warnings lead to media reports, and lead to further
changes
in the public’s behavior—a potentially-devastating positive-feedback
loop.
The recent SARS outbreak provides an opportunity to
analyze and
study
the use of population health technology, and to learn lessons for future public health emergencies, including acts of bioterrorism. Most
importantly, it should be a stimulus to critically evaluate these
technologies and to provide directions for further research and
development. Population health technology clearly has a vast potential
to
increase our preparedness for the next public-health emergency, but it
also raises many questions related to ethics, libertarian values, and
privacy, and has the potential to fuel an epidemic of fear and
collective
mass hysteria.
References
1.World Health Organization. WHO collaborative multi-
centre
research project on Severe Acute Respiratory Syndrome (SARS) diagnosis.
2003. URL: http://www.who.int/csr/sars/project/en/ [accessed 2003 Jun
28]
2.Griffith J, Antonio G, Ahuja A. SARS and the modern day pony
express
(the World Wide Web) [letter]. AJR Am J Roentgenol. 2003
Jun;180(6):1736.
4.Gerberding JL. Faster... but fast enough? Responding to the
epidemic
of severe acute respiratory syndrome [editorial]. N Engl J Med. 2003 May 15;348(20):2030-2031. Epub 2003 Apr 02.
5.Drazen JM, Campion EW. SARS, the Internet, and the Journal
[editorial]. N Engl J Med. 2003 May 15;348(20):2029.
6.World Health Organization. Severe acute respiratory syndrome
(SARS):
status of the outbreak and lessons for the immediate future. 2003 May
20.
URL: www.who.int/csr/media/sars_wha.pdf [accessed 2003 Jun 28]
7.Heymann DL, Rodier GR; WHO Operational Support Team to the
Global
Outbreak Alert and Response Network. Hot spots in a wired world: WHO
surveillance of emerging and re-emerging infectious diseases. Lancet
Infect Dis. 2001 Dec;1(5):345-353.
8.Eysenbach G, Kohler C. What is the prevalence of health-related searches on the World Wide Web? Qualitative and quantitative analysis
of search engine queries on the Internet. Proc AMIA Annu Fall Symp 2003
(in press).
9.Furedi F. Epidemic of fear. Spiked 2002. URL: http://www.spiked-
online.com/Articles/00000002D46C.htm [accessed 2003 Jun 28]
10.SARS fight impeded care for other patients: MD. Toronto Star.
2003
May 8.
Competing interests:
None declared
Competing interests:
No competing interests
17 July 2003
Gunther Eysenbach
Senior Scientist, Centre for Global eHealth Innovation
I am a doctor in the frontier of SARS in China. I do not see so many
death,and even a little panic in the area where SARS is spread. In
Tangshan, a middle city apart from Peking about 150 Km, which hold about
7,000,000 people, I do not see any special situation in the epidemic peak(
we find 4 cases daily,last for 3 days).
There is only one death in 52 SARS patients.
The period from incident to admission is about 4 days and all the
patients are admissioned in hospital as soon as they are sepected for
SARS. After 14 days clinical treat ment, nearly all of them can be
discharged from hospital.
No scare, no social disturb. This is the real situation in Tangshan,
and in other cities in north China
SARS, the Internet, and Population Health Technology
With SARS, countless media reports and company press releases
promoting information and communication technology (ICT) solutions
appeared. Examples for eHealth solutions offered during the SARS crisis
include:
• Healthcarelink (http://www.healthcarelink.md) has developed a
monitoring
program that claims to detect severe acute respiratory syndrome before
symptoms occur and which—by aggregating data from a large number of
patients—also promises to detect bioterror outbreaks. Patients take
their
temperature daily in the morning and report the results by phone, fax,
or
Internet. The company publishes the graphs on the Internet for patients
and physicians to review. The data, along with information on a person’s travel history, can alert health workers to potential SARS patients
and
bioterrorist attacks. One of the open questions is, of course, how to
motivate a large number of people to measure their temperature daily and to voluntarily enter this information into a Web form.
• A very similar approach is behind the idea of Swedish company
MedDay (http://www.medday.com ), which proposes that people enter symptoms into PDAs or smart phones, which would wirelessly transmit the information
to
a
health or infectious-disease center, which could aggregate and monitor
these data. The company claims that the system can be used as an early
warning system for a nationwide outbreak of infectious diseases,
chemical
attack, or other disease. The company is surfing the bioterrorism wave
as
it simply rebranded its PharmaPoint software, originally developed for
remote patient monitoring by physicians, into RegPoint, hoping that it
will be used by governments to keep track of the health of populations.
There are open questions about the sensitivity of the system to detect
outbreaks against a “background noise” as well as about privacy issues.
• Sunday Communications, a Hong Kong mobile phone operator,
launched a
mobile phone service that promised to alert subscribers if they are near infected buildings. Those opting for the service had their phones
tracked,
and would be warned by SMS (short message service) whenever they strayed within a kilometer of a building where there had been instances of
SARS
infections. It is unknown whether this system prevented a single new
SARS
case.
• In Singapore, health officials tested electronic tracking
systems that
monitor the movements of every person who enters a public hospital.
Staff
and visitors wear credit card-sized RFID (radio frequency
identification)
tags around their neck to communicate their location to sensors hidden
in
the hospital ceilings, thereby enabling officials to track all
encounters
with other persons. Hospitals will save movement records for 20
days—twice
the incubation period for SARS. If one person turns out to be infected,
the database allows rapid identification of all encounters—health
officials say it is 10 times faster than traditional methods of asking
infected people whom they had contact with.
Apparently, some technology firms attempted to turn lemons
into
lemonade by using the crisis to bring their ICT products and services
into
the media and to public attention. As the number of new SARS cases
declines and the dust settles, it is time to ask critical questions,
including which of these tools and technologies have proven useful or
should be further developed and evaluated in order to be prepared for
the
next public health emergency.
The public health and infectious disease research
community widely
praised the role of ICT in early detection as well as in fostering
global
collaboration and information exchange during the SARS epidemic.
On March 17, 2003, WHO called upon 11 laboratories in 9 countries to
join
a collaborative multi-center research project on SARS diagnosis. The
network took advantage of e-mail and a secure WHO Web site to share
outcomes of investigations of clinical samples, electron-microscope
pictures of viruses, sequences of genetic material for virus
identification and characterization, and postmortem tissues from SARS
cases in real time [1].
Individual departments of affected hospitals
also
used Web sites and e-mail to rapidly disseminate clinical findings to
health professionals [2].
"This is a form of early warning and communication that would not have
been possible if the SARS Virus had appeared ten years ago," notes Dr.
Kimball of the APEC Emerging Infections Network [3], and Julie
Gerberding,
director of the US Centers for Disease Control and Prevention, writes in an editorial in the New England Journal of Medicine that “use of the
Internet has sped information exchange and helped overcome the problems
presented by asynchrony in the activities of investigators in many time
zones” [4].
Journal editors celebrated themselves and the Internet for being able to publish articles about SARS at the speed of electrons [5]. However,
the
role of journals—even if with electronic preprint versions and fast
track
peer-review—dwarfs compared with the role of the Internet in information dissemination of SARS.
As of June 30, 2003, PubMed lists 881 articles containing the search words ["severe acute respiratory syndrome" OR
SARS].
In contrast, Google finds 358000 pages with the phrase “severe acute
respiratory syndrome” (not counting non-English pages or pages which
contain only the abbreviations SARS or SRAS for “syndrome respiratoire
aigu sévère”).
The World Health Organization (WHO) also praised the role of GPHIN
(Global
Public Health Intelligence Network) for early detection of SARS,
claiming
that “GPHIN provided some of the earliest alerts to the November
outbreak
in China” [6]. GPHIN is part of WHOs Global Outbreak Alert and Response
Network [7]; it was developed and is operated by Health Canada’s Centre
for Emergency Preparedness and Response. It is essentially an Internet
crawler specialized in detecting news articles indicating unusual events relevant to public health: GPHIN continually scans more than 400
international sources for news of any outbreaks of 31 communicable
diseases, as well as articles about natural disasters and drug-resistant pathogens, rather than relying on “official” reports from government
sources (which may be reluctant to report disease outbreaks to avoid
economic disruptions). The approach is obviously insufficient when
disease
outbreaks occur in developing countries where little information finds
its
way into news media and the Internet, or in countries where the media a
controlled by the government. GPHIN seems to be stretched to its limits
(when the author requested access to the system the reply was “we have
now
reached our limit on the number of users that can have access to the
system”). GPHIN is currently being upgraded to include more languages,
including Chinese (which during the SARS crisis was not yet
implemented).
eHealth, consumer health informatics, and public health
informatics are emerging fields that have a clear public health aspect, in that
they include technologies that can be used to improve the health of entire
populations, not just individuals. Population health technology is a
recent umbrella term subsuming applications of technologies such as the
Internet, wireless devices, mobile phones, smart appliances, or smart
homes (domotics) that have a population focus and the potential to
improve
public health. In principle, all sorts of home-monitoring devices, from
digital fever thermometers to asthma-monitoring devices, could be
modified
to function as early detection systems, ie, to transmit data—wirelessly
or
through the Internet—to central data-mining facilities, which may detect emerging patterns indicating disease outbreaks.
Among the challenges
of
all of these systems are ethical and privacy concerns—it is a difficult
balance between gathering data from thousands of people with being able
to
track down infected individuals on the one hand, and protecting the
privacy of people on the other hand. Hospitals and pharmacies of
tomorrow
may also feed data into such central data-mining systems. In addition,
there may be a role for detecting patterns of information and
communication flows on the Internet. At the Centre for Global eHealth
Innovation we have been experimenting with monitoring search requests
people enter into search engines, to evaluate whether it is possible to
detect increases or changes in health-related requests using automatic
methods [8]. The sensitivity of such methods for detecting disease
outbreaks or bioterrorism attacks remains to be evaluated—in our search
term experiment it did not seem to be sensitive enough in the case of
SARS.
In the last week of June, Ontario presented Ottawa with a
breakdown of $945 million (Canadian) in SARS-related costs. Those include $395
million for hospitals and health-care institutions for extra staff
expenses, protective gear, clinics, and isolation rooms. Another $330
million went to replace lost wages for quarantined health-care workers.
Even more serious may be the consequences of the SARS-related “epidemic
of
fear” [9]. Millions of dollars were lost due to missed business—tourists and business travelers staying away from the hot spots.
Worse, as in
this
particular incident hospitals were the hubs of the outbreaks, patients
postponed or delayed important hospital visits. It is difficult to
estimate how many patients have been harmed by avoiding hospitals—at
least
outside of China these may be more than those actually killed by the
disease. Kelly MacDonald, a University of Toronto infectious-disease
expert, estimates that four times as many Ontarians will die from lack
of
medical attention caused by the SARS outbreak as will die from the
disease
itself [10].
To understand the epidemiology of fear in the context of population
health
technology is important for at least two reasons.
First, some ICT applications that have been advocated sometimes played a role as a psychological “duct tape of the war against fear.” Indeed,
Bruce
Hicks, group managing director of Sunday Communications, the operator
that
launched the mobile phone service that alerts subscribers when they are
near infected buildings (see above), was quoted as describing his
service
with these words: "With the dial of a few digits, subscribers can
quickly
get the peace of mind they need to go about their everyday
lives."—speaking to the fact that it is not primarily the spread of SARS but the fear that is addressed by this service.
Thermal-imaging
scanners set up at airports to screen travelers for signs of SARS may have had
a
similar role: to assure people that “something is being done,” and to
prevent economic damages. In fact, there is limited evidence on the
sensitivity and specificity of this technology to identify passengers
with
fever. Information and communication technology can also help to keep
the
health care system accessible in cases of disease (or fear) outbreaks.
For
example, Singapore General Hospital, introduced during the SARS crisis
an
online physiotherapy program allowing physical therapists to remotely
monitor patients in their homes. Using a webcam, patients can
communicate
with their therapists, who can in turn show their patients new exercises and give them feedback on their progress [11].
The second reason why we need to understand the epidemiology of fear in
the context of population health technology is that some technologies
used
as early warning system may not be able to discriminate between a true
biological epidemic and an epidemic of fear. This is especially true for systems relying on users entering symptoms, systems designed to
detect
changes in patterns of health care utilization or other databases, or
systems analyzing information and communication patterns on the Internet or in news media. Such early-warning systems may pick up changes in
collective behavior triggered by a mere epidemic of fear. For example,
thousands of New Yorkers buying duct tape did not indicate a
bioterrorism
attack, but a fear epidemic. Similarly, runs on doctors or pharmacies
may
either indicate mass hysteria (a highly-prevalent phenomenon in our
society), or a bioterrorism attack (a far less prevalent event). The
predictive value of such early warning systems is thus inherently low.
False positive warnings lead to media reports, and lead to further
changes
in the public’s behavior—a potentially-devastating positive-feedback
loop.
The recent SARS outbreak provides an opportunity to
analyze and
study
the use of population health technology, and to learn lessons for future public health emergencies, including acts of bioterrorism. Most
importantly, it should be a stimulus to critically evaluate these
technologies and to provide directions for further research and
development. Population health technology clearly has a vast potential
to
increase our preparedness for the next public-health emergency, but it
also raises many questions related to ethics, libertarian values, and
privacy, and has the potential to fuel an epidemic of fear and
collective
mass hysteria.
References
1.World Health Organization. WHO collaborative multi-
centre
research project on Severe Acute Respiratory Syndrome (SARS) diagnosis.
2003. URL: http://www.who.int/csr/sars/project/en/ [accessed 2003 Jun
28]
2.Griffith J, Antonio G, Ahuja A. SARS and the modern day pony
express
(the World Wide Web) [letter]. AJR Am J Roentgenol. 2003
Jun;180(6):1736.
3.Kimball AM, Pautler NF. Lessons of SARS: The APEC/EINet
Experience.
2003 May 6. URL: http://apec.org/infectious/SARS_Lessons.pdf [accessed
2003 Jun 28]
4.Gerberding JL. Faster... but fast enough? Responding to the
epidemic
of severe acute respiratory syndrome [editorial]. N Engl J Med. 2003 May 15;348(20):2030-2031. Epub 2003 Apr 02.
5.Drazen JM, Campion EW. SARS, the Internet, and the Journal
[editorial]. N Engl J Med. 2003 May 15;348(20):2029.
6.World Health Organization. Severe acute respiratory syndrome
(SARS):
status of the outbreak and lessons for the immediate future. 2003 May
20.
URL: www.who.int/csr/media/sars_wha.pdf [accessed 2003 Jun 28]
7.Heymann DL, Rodier GR; WHO Operational Support Team to the
Global
Outbreak Alert and Response Network. Hot spots in a wired world: WHO
surveillance of emerging and re-emerging infectious diseases. Lancet
Infect Dis. 2001 Dec;1(5):345-353.
8.Eysenbach G, Kohler C. What is the prevalence of health-related searches on the World Wide Web? Qualitative and quantitative analysis
of search engine queries on the Internet. Proc AMIA Annu Fall Symp 2003
(in press).
9.Furedi F. Epidemic of fear. Spiked 2002. URL:
http://www.spiked-
online.com/Articles/00000002D46C.htm [accessed 2003 Jun 28]
10.SARS fight impeded care for other patients: MD. Toronto Star.
2003
May 8.
Competing interests:
None declared
Competing interests: No competing interests