E-Health and the Surveillance and

Management of Infectious Diseases

By: Francisco I. Bastos. Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil, at francisco.inacio.bastos@hotmail.com

The inter-relationships between e-health and

infectious diseases are multifarious and far from

linear or unidirectional.

1. Virtual models as tools for better understanding

the dynamic of infectious diseases

The very understanding of the dynamic of infectious

diseases has evolved in recent years from the so-called

“vat model” (apud Duncan Watts[1]), according which

susceptibles and infected individuals interact in the

same haphazard way molecules (for instance, of a

gaseous substance) do (i.e. depending on their

respective orders of magnitude, but without any

underlying structure).

[1] Watts D. “Six Degrees: The Science of a Connected Age”

Vat model

New, interactive, agent-based models assess such interactions taking in account their underlying structure. i.e. the geographic, social and cultural characteristics that shape their networks.

In this sense, virtual worlds that emulate the characteristics and dynamics of real world situations became a fundamental tool of such renewed modeling strategies.

The now famous plague affecting the game “World of Warcraft”, as described by Ran Balicer (Epidemiology2007;18:260-261) showed that:

“(…) agent-based modeling and similar simulations are limited in their potential to account for changes in human behaviors during epidemics. This has led to searches for novel methods to simulate human daily interactions. One possibility lies in existing Internet role-playing games.”

“A serious epidemic of an infectious disease recently erupted among the virtual characters in „World of Warcraft‟”

World of Warcraft

“The outbreak began on September 2005 when the “World of Warcraft” game administrators introduced a new virtual creature that had the ability to cast a disease (“corrupted blood”) on its opponents.”

“In addition to inflicting severe damage on the target character, the disease “infected” close contacts who could spread the disease to others in close proximity. Game administrators presumably believed that the short period of infectivity (several seconds), as well as its highly lethal effect, would render the disease self-limiting. This proved not to be the case.”

“Unlike previous “virtual plagues” that had been officially planned, this was a local effect that went out of control - a naturally occurring virtual outbreak.”

“(…) the plague ravaged the population. Game administrators were

baffled. As they scrambled to quarantine areas of the game world,

the disease quickly spread beyond their control. Partially to blame

was the game‟s feature that allows players to teleport from one

area to another, and which made it possible for the plague to

rapidly reach the most distant regions of the map.”

… any similarity between teleport properties and

Francisco Bastos itinerary to deliver this lecture today?

BASTOS/FRANCISCO INACIO

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IB 6764 MADRID - BARCELONA

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IB 6755 BARCELONA - MADRID

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MADRID - RIO DE JANEIRO RJ

CAMBIO DE AVION: AIRBUS INDUSTRIE A340-200

“ (…) several epidemiologic attributes enabled this

uncontrolled dissemination of the disease. One was the

lack of residual immunity following convalescence. This

enabled characters to be reinfected and re-enter the

transmission cycle.”

“The second characteristic was its infectivity to the

virtual animals (“pets”). While pets were relatively

resistant to the lethal effects of the disease, they were

infective to other pets and humans, thus serving as a

disease reservoir.”

What about our own pets as

reservoirs of different zoonosis?

“An increasing number of people suffer from immunodeficiencies. Environmental- and climatic conditions cause a change in distribution of vectors in need of special climatic conditions to establish. Exotic species are also to an increasing extent introduced as family pets, which may contribute to a wider panorama of infections.”

“However, the traditional zoonotic diseases are still the most important. Vaccination, proper hygiene measurements and knowledge of preventive measures restrict the risk of transmittance of infections from companion animals. The most significant risk of companion animals in Norway are mostly related to dog and cat bites or other physical injuries.”

So… why do we have pets?

“In total the benefit and pleasure of this type of

animal husbandry is more important than the

fear of zoonotic diseases.”

(J. Grøndalen, B. Sævik, H. Sørum, first published in

the Norwegian Veterinary Journal 11/2004).

Avalon Bastos

“once the plague reached the cities, it did not

just infect other players but also the nonplayer

characters of the city, providing a large

“bystander” population that also spread the

disease.”

What about our cities?

Rio

Rio

Unger A, Riley LW, 2007 Slum Health: From

Understanding to Action. PLoS Med 4(10): e295.

“In 2002, the UN operationally defined slums as those

communities characterized by: insecure residential

status, poor structural quality of housing, overcrowding,

and inadequate access to safe water, sanitation, and

other infrastructure”

“Slum locations may be unused or undesirable because

of their hazardous geography, such as landslide- or

flood-prone areas, or unsafe or polluted environments.

Moreover, their residential status limits their ability to

fight for the right to a safe environment.”

“Slum housing is densely packed and poorly built with substandard or even flammable materials. Houses built against hillsides are subject to landslides during heavy rain, and inferior building standards cause many thousands of deaths from earthquakes, especially where urbanization and poverty collide”

“Slum dwellings have high occupancy rates in all-purpose rooms. Cooking, sleeping, and living with 13.4 people per 45 m2 room (…) places residents at risk of respiratory infections, meningitis, and asthma.”

“(…) children living in squatter settlements are nine times more likely than other children to have tuberculosis (TB). Epidemic-prone infections like pertussis cluster in areas of urban poverty, and overcrowding may even fuel potentially emerging epidemic diseases like SARS or influenza.”

“Poor water quality is a leading cause of morbidity and mortality worldwide and a defining danger of living in slums. Many life-threatening infectious diseases are associated with contaminated water in slums, such as cholera and hepatitis.”

“Lack of access to water also restricts water intake, sources for infant formula or cooking, bathing and personal hygiene. Infrequent bathing is associated with scabies and bacterial skin infections, a subset of which (i.e., group A streptococcus) can lead to acute glomerulonephritis”

“The lack of infrastructure affects all aspects of life, including waste collection and sewers, public transportation, policing, education, and electricity supply.”

2. Back to Games: World of

Warcraft as a research tool….

“The mixing patterns and behavior observed in the game can be precisely measured and accounted for (without the usual epidemiologic problems of incomplete ascertainment or loss to follow-up). Furthermore, the rules and environment could potentially be adjusted to allow better modeling of specific real-life scenarios.”

“The game‟s administrators eventually cured the plague with a “spell” that was distributed rapidly to players en masse. If only real life were that simple.”

What kind of spell could we disseminate?

3. The spell is to profit from the connectivity of risk networks as prevention networks, actually the very same networks, just disseminating prevention by the word-of-mouth about prevention, instead of micro-organisms…

Such spell helped to curb HIV dissemination in San Francisco:

“With no cure and no vaccine for AIDS currently available, the only way we can stop HIV is to prevent its spread. Every community has its own unique prevention needs - in San Francisco we work with populations at greatest risk for infection by focusing on individuals' overall life and health.”

“The San Francisco AIDS Foundation operates four programs for gay and bisexual men and also runs one of the nation's largest needle exchange programs” (San Francisco AIDS Foundation)

San Francisco AIDS Foundation

The big challenge ahead refers to

Sub-Saharan Africa:

“The Grassroots Alliance for Community Education works with communities in sub-Saharan Africa to mitigate the effects of HIV/AIDS. G.R.A.C.E. helps networks of African community-based organizations (CBOs), people living with AIDs (PLWAs), and youth deliver household-focused prevention and care, early childhood development, nutritional, agricultural, and economic improvements for sustainable communities.”

Grassroots Alliance for

Community Education

Another major challenge:

microbial resistance

“The Alliance for the Prudent Use of Antibiotics (APUA) was founded as a non-profit global organization in 1981 to contain antibiotic resistance and improve antibiotic effectiveness. APUA‟s mission is to strengthen society‟s defenses against infectious disease by promoting appropriate antimicrobial access and use and controlling antimicrobial resistance on a worldwide basis.”

“With affiliated chapters in over 60 countries, many in the developing world, APUA stands as the world‟s leading organization conducting antimicrobial resistance research, education, capacity building and advocacy at the global and grassroots levels.”

APUA

“Antimicrobials are uniquely societal drugs because

each individual patient use can propagate resistant

organisms affecting entire health facilities, the

environment and the community. Wide-scale

antimicrobial misuse and related drug resistance is

challenging infectious disease treatment and healthcare

budgets worldwide.”

4. E-health tools as key resources in the

management of resistance

Sites targeting both the general and

specialized audience

http://www.thepigsite.com/swinenews/22512/co

mmission-to-tackle-antimicrobial-resistance

http://www.who.int/csr/en/

Pig news

Information can be disseminated through the use of text messages to mobile phones, wherever access to the internet is rare or non-existent.

As of February 2009, Brazil topped over 152 million mobile phones, corresponding to 0.8 phone per inhabitant.

Brasil tem mais de 152 milhões de celulares em fevereiro de 2009

Por Redação do IDG Now!

Publicada em 20 de março de 2009 às 13h03

Atualizada em 20 de março de 2009 às 13h53

Destaque fica por conta da teledensidade, que cresceu 22,82% em 12 meses. Com isso, Brasil tem quase 0,8 celular por habitante.

The bad side of the internet:

• Misinformation

• Dissemination of racism, prejudice, spam, viruses etc.

• Networks and/or communities of pedophiles, warmongers, hooligans etc.

The good side of the internet

The whole presentation delivered today was

composed by material of high quality obtained

at no cost from the internet.

Including a wonderful rooster by Miró and a

mispronounced word in Catalan with the help of

an on-line translator!

Thank you! Muchas gracias! Grácies!

Miró