April 16, 2003 4:00 AM PDT

Doctors log on to fight SARS outbreak

Read more about SARS
WASHINGTON--Some of the starkest early reports about the deadly SARS pneumonia came not from health authorities, but from Internet discussions in which emergency-room physicians swapped details about the start of the epidemic.

An intensive-care specialist at a hospital in Hong Kong, a community virtually shuttered by the virus, riveted his colleagues with dispatches from the SARS, or severe acute respiratory syndrome, front lines.

"There are now 145 confirmed cases in the Prince of Wales Hospital," Tom Buckley wrote in an e-mail message last month. "New cases (first contact) tend to bring their families (second contact). Close family contacts seem to have a very high rate of infectivity. The outbreak within the hospital appears to have been contained, but it has put an enormous strain on the system."

At a time when the world was paying far more attention to the war on Iraq than to a still-mysterious disease, these notes stand out as a prescient warning about the risks of SARS, a contagious lung infection with a fatality rate of about 5 percent. "This pneumonia is out there in the community. The numbers are increasing daily, and a third hospital is being prepared for the influx. How big this is going to get is anyone's guess," Buckley wrote on March 24.

As of that date, Hong Kong authorities had reported more than 260 cases of SARS, including 10 deaths. By this week, Hong Kong's total had ballooned to 1,232 cases and 56 deaths. Meanwhile, economists lopped a few percentage points off their Asia GDP forecasts, Intel and Hewlett-Packard temporarily closed their Hong Kong offices, and business and tourist travel to the area has plummeted.

Buckley's dispatches, which helped to place the worldwide medical community on alert, are part of a broader trend of SARS researchers using e-mail and the Web to exchange information and collaborate in a way that would not have been possible a decade ago.

The venerable New England Journal of Medicine, which is published weekly, typically has an eight-week lead time before articles appear in the printed journal. To respond to the SARS outbreak, the publication placed seven articles on its Web site during the past month. Karen Pedersen, a spokeswoman for the Journal, said the publication takes that sort of a step "when articles are very important."

SARS resources online

From Hong Kong to Toronto and Atlanta, medical researchers and practitioners are sharing information through Web sites and discussion lists. Here's a sample of some early responses to the outbreak.

World Health Organization
Page with epidemiological maps, case counts, updates on the development of SARS tests and information on a SARS conference to be held in Geneva in June.

Centers for Disease Control and Prevention
Page with links to the SARS virus genome sequencing, case counts, travel advisories and treatment and prevention information.

New England Journal of Medicine
Early releases of papers detailing various SARS outbreaks.

Critical Care Medicine List
Online forum where David W. Crippen, MD, posted some of Hong Kong intensive care specialist Tom Buckley's early online dispatches about SARS.

Health Canada
Federal department site with information for the public, including alerts, case counts, travel advisories, advice for the food industry and frequently asked questions.

Health Canada
Site by health officials across Canada for health professionals, that includes lab-testing recommendations, infection control measures, and case counts and definitions.

Government of Hong Kong Department of Health
Site with news, frequently asked questions, local buildings with SARS outbreaks, health advice and hotlines.

The World Health Organization has responded to the threat of SARS by using its Web site to publish daily updates about the number of worldwide cases--which has allowed analysts to graph the progress of the outbreak.

In the United States, the Centers for Disease Control (CDC) has posted dozens of fact sheets, travel advisories and a breakdown of domestic cases by state on its site.

In Toronto, perhaps the hardest-hit city outside of Asia with 13 SARS deaths documented so far, the public health department credits the Web with giving it a low-cost way of reaching thousands of people, as well as providing a speedier medium for getting information on a global problem.

Unprecedented speed
"In terms of pulling information from the WHO and the CDC, it's been very useful to get those updates because this is an international disease, and we're able to access those very quickly," said Mary Margaret Crapper, a representative for the Toronto public health department. "We have information about what's going on in China that would otherwise take us a long time to get. In terms of reaching the public, we are able to share that information on the Web site. It's a far less expensive way to reach our public. And in municipal government, we don't have big advertising budgets."

The Net has helped spread word of the disease and of preventive techniques, such as those found in guidelines from the Center for Disease control, which recommend, among other things, that SARS patients wear surgical masks while in close contact with uninfected people.

Equally if not more significantly, online resources have created an unprecedented collaborative network devoted to understanding the disease and developing a treatment, some researchers said.

"I've never seen people scoop up data and opinions so fast in my life," said Kathryn Holmes, professor of microbiology at the University of Colorado Health Sciences Center in Denver. "They are using every bit of expertise they can harness from around the world. Of course it is a tremendous emergency."

Perhaps the most impressive way in which technology has aided research into SARS is in helping to analyze the virus' complete genetic code, which two teams announced over the weekend, and then making the results available. This week the CDC placed on its Web site the entire nucleotide sequence of the virus suspected to be responsible for SARS.

Henry Niman, a Harvard University instructor in surgery at Massachusetts General Hospital in Boston who has studied retroviruses, says the process normally would have taken researchers at least months. "The fact that the virus has been sequenced in two weeks by two groups--that's pretty quick," Niman said. "That's unprecedented speed. You would probably not have had two groups going simultaneously if you didn't have this information out there. The exchange of information has sped things up."

Niman started two mailing lists this month to share SARS-related information with his colleagues: One for highlighting news reports and the other for scientific discussions.

"Putting together a list like this could have been done 10 years ago, but it would have been hard," Niman said, because so few of his colleagues had e-mail accounts at the time. "The idea was to get the news out to a elected group rather than a broad group. If there was a Web site, it would probably reach more people than a listserv. But with a listserv it's easier to focus it."

Another physician who's been active in distributing information about SARS is David Crippen, a clinical professor at the University of Pittsburgh Medical Center who's also the "Listgruppenmeister" (list group master) of the Critical Care Medicine List. Crippen started the CCM-L discussion list in 1994, for intensive care physicians, and it boasts more than 1,000 subscribers. (Excerpt from the Web site: "What's New on CCM-L this month: The technique for bedside percutaneous tracheostomy.")

CCM-L is where Buckley, the Hong Kong physician, posted his widely disseminated reports from the intensive care unit of the Prince of Wales Hospital. "We might very well be the first leak of all this to an international group of about a thousand people on the list," Crippen said. "The interesting thing was that a physician in an area where something really different was happening got that information out to a bunch of people all around the world who started sniffing around. And then when it hit Toronto?The word got out so quick not from the press but via the Internet."

The first Internet-age epidemic
Crippen says SARS is the first Internet-age epidemic. "At the CDC they've always pretty much relied on written words," Crippen said. "If something happens, the next time you hear about is when you get a bulletin. They're two iterations behind?Those organizations have epidemiologists who are trying to figure out what's going on. What's going on here is that the primary physicians who are in charge--you're getting way in front of the major organizations?You're way ahead of the WHO or the CDC."

Dean Dobbert, an emergency-room doctor in a community hospital in Delaware and the medical director for the Kent County EMS system, agreed that Internet channels like mailing lists were scooping more established information sources online.

"SARS is different because of the Internet," Dobbert said. "The Internet has been great, especially hearing the posts from the doctor in Hong Kong right there on the front line, giving his observations. The other information on the CDC and WHO Web sites has for the most part just reflected what we heard already on the Internet."

For the CDC's part, Karen Hunter, a senior press officer with the organization, says the agency has been distributing "a wealth of information including frequently asked questions as well as CDC's guidelines and recommendations for a variety of audiences."

The WHO did not immediately respond to a request for comment but has published almost daily reports on the progress of the disease.

The agency published its first SARS-related advisory on Feb. 11, citing an unconfirmed report from Chinese authorities of an outbreak of deadly atypical pneumonia in Guangdong province. An update to that report the following day, which disclosed 305 cases and 5 deaths from Nov. 16 through Feb. 11, said that Chinese authorities were reporting that the outbreak was coming under control.

By March 12, the WHO had confirmed cases in Vietnam and Hong Kong, and issued a global alert warning that hospital staff could be at risk. Three days later, WHO Director General Dr. Gro Harlem Brundtland declared SARS "a worldwide health threat" in an emergency travel advisory posted on the group's Web site. In the same statement, he urged that the "world needs to work together to find its cause, cure the sick and stop its spread."

Virologist Holmes praised the WHO's work, noting that the agency has harnessed the efforts of about a dozen different labs and hospitals to track the progress of respiratory outbreaks in hopes of preventing something like the influenza pandemic that killed between 20 million and 50 million people worldwide in 1918.

"They have had a private site on the Internet where about 12 labs coordinated by WHO have shared their data every single day," Holmes said.

Holmes said the degree of sharing contrasted vividly with the competitive atmosphere that clouded early research on the AIDS virus 20 years ago.

"AIDS came around in the early '80s, when there was a lot less openness and sharing of data," Holmes said. "And the global community has understood from recent events how important it is to work together for the good of all. It's very encouraging to me that that has been achieved."

 

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