1. FROM SARS TO BIO ATTACK: DEVELOPING A COORDINATED RESPONSE TO THE UNEXPECTED -- THE ROLE OF AN INTERNET BASED EARLY WARNING SYSTEM A.K.A. “THE INFORMAL SECTOR” Marjorie P. Pollack, MD Associate Editor Epidemiology & Surveillance Moderator ProMED-mail, International Society for Infectious Diseases <http://www.promedmail.org>

2. The global electronic reporting system for outbreaks of emerging infectious diseases and toxins, open to all sources • http://www.promedmail.org

3. About ProMED-mail • The global Program for Monitoring Emerging Diseases:A program of the International Society for Infectious Diseases • The ProMED-mail electronic outbreak reporting system was inaugurated on the Internet in August 1994 to monitor emerging infectious diseases globally. • It is the only outbreak rapid reporting system open to all sources and free of political restraints. • All reports are screened by expert Moderators before posting. Source: ProMED-mail http://www.promedmail.org

5. Disease Focus • Plant • food security • Animal • veterinary, zoonotics • Human • infectious and acute toxic

6. Sources of information • Official reports from National and International Public Health Authorities • ProMED-mail subscribers • Lay press reports

7. Constraints to sources of information • Official reports from National and International Public Health Authorities • require confirmation from reporting unit • (federal needs state, state needs county) • ProMED-mail subscribers • is the source reliable? Is there a political agenda? • Lay press reports • is the source reliable? Is there a political agenda?

8. INFORMATION SOURCES USED BY WHO Global Public Health Information Network • Intelligence • Real time gathering of information related to outbreak events from Multiple sources • GPHIN 39% • WHO System 33% • PRO-MED 6% • Others (labs, NGOs.) 22% Source: WHO Ray Arthur Presentation ICEID 26 Mar 2002

9. PNEUMONIA - CHINA (GUANGDONG): RFI******************************************** Date: 10 Feb 2003 From: Stephen O. Cunnion, MD, PhD, MPH International Consultants in Health, Inc Member ASTM&H, ISTM This morning I received this e-mail and then searched your archives and found nothing that pertained to it. Does anyone know anything about this problem? "Have you heard of an epidemic in Guangzhou? An acquaintance of mine from a teacher's chat room lives there and reports that the hospitals there have been closed and people are dying." Source: ProMED-mail archives -- edited

10. PNEUMONIA - CHINA (GUANGDONG): RFI (2)******************************************** Date: 10 Feb 2003 Moderator comment: • [ProMED-mail appreciates the preliminary information above and would be grateful for any additional information. The etiology and extent of this apparent outbreak of pneumonia are unclear, as is whether the outbreak is secondary to influenza. - Mod. LM] Source: ProMED-mail archives -- edited

11. PNEUMONIA - CHINA (GUANGDONG) (07)******************************************* Date: Fri 21 Feb 2003 Source: British Medical Journal, 326, 416, Sat 22 Feb 2003 [edited] <http://bmj.com/cgi/content/full/326/7386/416?etoc> Pneumonia in Guangdong Province ----------------------- The past 2 weeks have seen the province of Guangdong in southern China become victim to a serious pneumonia epidemic that seized its people with fear and caused major temporary economic damage, but that eventually turned out to have relatively slight medical impact. By last week, there had been 8 deaths. However, considerable anxiety was created by an "epidemic of rumours." During the first week of February 2003 the public became aware of a mysterious respiratory illness which apparently had a very high mortality and caused death within hours. Symptoms included cough, fever, and breathing difficulty. Source: ProMED-mail archives -- edited

12. PNEUMONIA - CHINA (GUANGDONG) (07) part 2******************************************* Rumours abounded about the source of the infection…... People spread their fears and new-found information by telephone, mobile phone, text messages, email, and word of mouth. In the absence of public statements and official information the media communicated very little. The rumour spread that many of the victims of the illness were hospital staff and that a number of them had died. As a result outpatient departments almost emptied. It was not until Tue 11 Feb 2003 that an official statement was made by the Guangdong Department of Health. In the interim it had been very difficult for doctors and other health professionals to respond to the barrage of inquiries. The officials announced that the first case had occurred in November 2002, but as it was common for influenza-like infections to afflict the community in the winter months, there had been no undue concern. Source: ProMED-mail archives -- edited

13. PNEUMONIA - CHINA (GUANGDONG) (07) part 3******************************************* Date: 21 Feb 2003 Moderator comment: [This article mentions a total of 345 cases in 8 cities throughout Guangdong with an associated 7 deaths…. What this article also mentions is the power of rumor-mongering that goes along with "unknown" etiology outbreaks. The statement "In the absence of public statements and official information the media communicated very little" may refer to the local media, but on the international level, the media were rife with articles on the outbreak, many of which would be better characterized as rumor mongering than real information exchange. This is a reminder of the need for official sources to report information on outbreaks and findings of outbreak investigations sooner rather than later. In today's environment, with increased telecommunications worldwide, combined with heightened concerns about bioterrorism, news of disease outbreaks travels much faster and more widely than in the past. - Mod.MPP] Source: ProMED-mail archives -- edited

14. CHRONOLOGY OF REPORTS • 10-Feb-03 Pneumonia - China (Guangdong): RFI • 19-Feb-03 Influenza, H5N1, human cases - China (Hong Kong) • 21-Feb-03 Pneumonia - China (Guangdong) (07) • 11-Mar-03 Undiagnosed illness - Vietnam (Hanoi): RFI • 12-Mar-03 Acute respiratory syndrome - China (HK), VietNam • 13-Mar-03 Acute respiratory syndrome - China (HK), VietNam (02) • 13-Mar-03 Acute respiratory syndrome - China (HK), VietNam (03) • 14-Mar-03 Acute respiratory syndrome - East Asia • 14-Mar-03 Acute respiratory syndrome - Canada (Ontario) • 15-Mar-03 Severe acute respiratory syndrome - Worldwide • 25-Mar-03 SARS - worldwide (04): etiology • 06-Jul-03 SARS - worldwide (162): the end? Source: ProMED-mail archives

15. Severe Acute Respiratory Syndrome: The U.S. Experience February 10 --A report posted on ProMED describes a problem of pneumonia in China’s Guangdong Province --CDC receives a call from a U.S. medical missionary who described reports of 400 deaths due to “pneumonic plague” in Guangdong; CDC contacts colleagues at WHO March 5-11 -- CDC learns of spread of the disease to large numbers of HCWs in Hong Kong and Vietnam following alert to WHO from Dr. Urbani March 12 -- WHO issues global alert about cases of severe atypical pneumonia in Hong Kong and Vietnam Source: Presentation by James M. Hughes, M.D. Director, National Center for Infectious Diseases Director, National Center for Infectious Diseases Centers for Disease Control and Prevention Centers for Disease Control and Prevention, Global SARS conference 17 Jun 2003

16. Sequence of events • 10 Feb2003 - Reports of atypical pneumonia in Guangdong China -- from ProMED subscriber, plus newswire report (Chinese language) • 19 Feb 2003 - Reports of H5N1 (avian influenza) human cases in Hong Kong with history of travel from Fujian Province to Hong Kong - from newswire RED HERRING • 11 Mar 2003 -Reports of undiagnosed respiratory illness in hospital in Hanoi VietNam - from newswire report Source: ProMED-mail archives

17. Sequence of events • 14 Mar 2003 - Reports of atypical pneumonia in East Asia -- Hong Kong, VietNam,Singapore, China (Guangdong Province), Taiwan -- official sources, newswires • 14 Mar 2003 -- Reports of acute respiratory syndrome Ontario Canada -- official sources, newswire reports • 15 Mar 2003 -- Reports of severe acute respiratory syndrome worldwide -- WHO advisory/alert following Singaporean MD ill on flight from USA to Singapore with stop in Germany Source: ProMED-mail archives

18. Source: WHO/CSR <http://www.who.int/csr/sars/epicurve/epiindex/en/index1.html>

19. Source: WHO/CSR <http://www.who.int/csr/sars/epicurve/epiindex/en/index2.html>

20. LESSONS LEARNED We live in a global village No single institution has the complete capacity to address all needs and cover all bases with respect to disease surveillance Early alerts important and valuable -- prevents rumors, speculations Encourages reporting on the part of partners

21. Who’s who in ProMED-mail - MODERATORS • LAWRENCE C. MADOFF Managing Editor • Associate Physician, Infectious Disease Division and Channing Laboratory, Department of Medicine, Brigham and Women's Hospital; Assistant Professor of Medicine, Harvard Medical School, Boston, MA, USA • STUART HANDYSIDESAssociate Editor • General practitioner, Buntingford, Hertfordshire, England. Former editor (based at the PHLS Communicable Disease Surveillance Centre, London) of the Communicable Disease Report, Communicable Disease and Public Health, and Eurosurveillance Weekly. • DONALD KAYEAssociate Editor, ProMED-mailProfessor of Medicine, Drexel University, College of Medicine, Philadelphia, PA, USA. Formerly Professor and Chairman, Department of Medicine, MCP Hahnemann School of Medicine. • MARJORIE P. POLLACKAssociate Editor/ProMED-mail Medical Epidemiology and Surveillance Moderator Independent consultant medical epidemiologist with a focus on developing world issues following CDC training. Former part time clinical attending, Harlem Hospital, Bellevue Hospital Emergency Rooms, New York City.

22. Who’s who in ProMED-mail - MODERATORS (2) • DANIEL S. SHAPIROAssociate Editor, • Assistant Professor of Medicine, Pathology & Laboratory Medicine, Boston University School of Medicine, Director of Clinical Microbiology Laboratory, Boston Medical Center, Boston, MA, USA • JACK WOODALLAssociate Editor • Director, Nucleus for the Investigation of Emerging Infectious Diseases, Department of Medical Biochemistry, Institute of Biomedical Sciences, Federal University of Rio de Janeiro, BRAZIL. • PETER COWENAnimal Disease Assistant ModeratorDirector, PAHO/WHO Consulting Center for Graduate and Residency Training in Veterinary Public Health, North Carolina State University, Raleigh, NC, USA • TAM GARLANDProMED-mail Animal Disease and Zoonoses ModeratorProfessor, College of Veterinary Medicine, Texas A&M University, College Station, TX, USA • RICHARD I. HAMILTONProMED-mail Plant Disease ModeratorSenior Research Scientist (Retired), Research Branch, Agriculture and Agri-Food Canada, Pacific Agriculture Research Centre, Vancouver, BC CANADA • MARTIN HUGH-JONESProMED-mail Animal Disease Assistant ModeratorDirector, WHO Collaborating Center for Reference and Training in Remote Sensing and Geographic Information Systems for Veterinary Public Health, and Coordinator, Anthrax Res. & Control Working Grp, Louisiana State University, Baton Rouge, LA, USA

23. Who’s who in ProMED-mail - MODERATORS (3) • LUIZ JACINTHO DA SILVAModerator, ProMED-PORTSUCEN, Sao Paulo - SP, BRAZIL • LARRY I. LUTWICKBacterial Disease ModeratorDirector, Infectious Diseases, VA New York Harbor Health Care System (Brooklyn Campus); Professor of Medicine, State University of New York - Downstate Medical Center. • ESKILD PETERSONParasitic Diseases ModeratorHead, Department of Mycobacterial and Parasitic Diseases, WHO National Malaria Diagnostic Reference Centre, Statens Serum Institut, Copenhagen and Director WHO/FAO International Collaborating Centre for Research and Reference on Toxoplasma. Specialist of Infectious Diseases and Tropical Medicine. • CRAIG R. PRINGLEViral Diseases ModeratorEmeritus Professor, Biological Sciences Department, University of Warwick, U.K. • ARNON SHIMSHONYAnimal Disease and Zoonoses ModeratorAssociate-Professor, Koret School of Veterinary Medicine, Hebrew University of Jerusalem • JAIME TORRESProMED-ESP ModeratorPresident, Emerging Diseases Committee, Pan American Infectious Disease Society (Asociacion Panameicana de Infectologia)