Introduction
In
the modern era, media remains an important source of infectious disease event
reporting. “Global epidemic
intelligence” in the near-real time operational setting has, since the
mid-1990s, relied on computer automated online media harvesting capabilities
that may or may not include human supervision of translated output. Examples include the Canadian Global
Public Health Intelligence Network (GPHIN)1, ProMED2, and
HealthMap3. Media
reports that reach the attention of the World Health Organization (WHO) and the
WHO-facilitated Global Outbreak Alert and Response Network (GOARN) are
evaluated against the International Health Regulations. Should criteria be met, then
verification that may include an epidemiological investigation or laboratory
confirmation is facilitated through communication with GOARN partners that may
include subject matter experts deploying to the site in question to obtain
samples for laboratory confirmation and conduct an epidemiological
investigation. 4
Those
that monitor global media use interpretive techniques more akin to open source
intelligence than classic epidemiology.
Key limitations to the use of media include diagnostic ambiguity in the
information, experience and credibility of the media source, official
government control of media outlets, and contextualization of the information
within indigenous cultural baseline.
An ability to gather information across multiple data sources such as
human ground networks is essential for signal interpretation, enhancement of
credibility, and ultimately, ability to act on the information. Key to this process is an ability to
communicate within a trusted network of professionals to evaluate warning
information of varying levels of ambiguity and credibility. 5,6
Until
recently, there was little recognition of the need for a professional
discipline that utilizes near-real time multi-source information to detect,
track, and issue notification of infectious disease events of potential
international importance. Here we
present the efforts of multi-lingual analysts at the Veratect Corporation who
participated in warning of unusual respiratory disease in April 2009 in Mexico,
later discovered through laboratory confirmation to be the first recognized
area in the world with rapidly transmitting novel swine influenza (H1N1), that
evolved into the first pandemic since 1968, now known as pandemic (H1N1) 2009.
Methods
Veratect
Corporation currently maintains two operations centers staffed with
multi-lingual analysts who collect raw information in 28 native vernacular
languages and are highly trained in culturally sensitive interpretation of
reporting behavior and social responses to infectious disease events, crises,
and disasters. These analysts draw
upon multiple sources of near-real time information that includes online media
harvesting. For signal validation
purposes, Veratect is confidentially partnered with more than 14 organizations
that provide direct ground observations in 238 countries. The model of event detection and
verification follows that of the WHO GOARN. 5
In
the interpretation of raw information, analysts are trained on proprietary
grounded taxonomies7 that map the socio-cultural context of an
infectious disease event. As
analysts evaluate information in the native vernacular language, they assess
the described event for whether it is associated with indicators of a routine
occurrence of disease (an “event”); whether time-sensitive, non-routine
organized decision making is occurring in response to disease where such
decisions may affect a local community’s activities of daily living (a
“crisis”) 8-10; or whether perceived failure of crisis mode decision
making has occurred with subsequent indicators of community disintegration (a
“disaster”) 11-16.
Analysts working with different cultures have become accustomed to
locally-relevant nuances in reporting behavior, and changes in both the
behavior in reporting as well as reported social reactions to an infectious
disease event are passed internally through a warning notification protocol
inspired by the meteorological and natural disaster communities. 6
An
online web portal containing Veratect’s up to the minute global infectious
disease event detection, tracking, and notification information was provided
pro bono to the United States Centers for Disease Control and Prevention (CDC),
the World Health Organization (WHO), and the Pan American Health Organization
(PAHO, the WHO Regional Office of the Americas) several months prior to the
worldwide acknowledgment of pandemic (H1N1) 2009 in Mexico. Additionally, an email user alert
system was created in collaboration with the Global Disease
Detection Operations Center (GDDOC) at CDC that provided alert for 1) any infectious
disease event assessed by the analyst to have evolved to a crisis or disaster
that was 2) within 300 km of an international airport connected to the United
States by direct, non-stop air traffic. This algorithm typically presents
approximately 1 to 3% (2 to 6 event reports) of our daily operational output
for the world to CDC in the form of an email push.
Results
The detection timeline and notification actions for the H1N1 crisis in Mexico are provided in Table 1 and online data supplement that accompanies this manuscript. Documentation of the timeline begins with first report of “unusual” respiratory disease (as described by local communities in Mexico) and is carried through to the point of CDC and WHO’s first public announcement of the crisis.
Table 1. Evolution of Veratect Corporation’s awareness and notification of the Mexico crisis.
Laboratory
confirmation of unusual respiratory disease in Mexico was not known until
eighteen days into the timeline.
Alerting and notification was based primarily on judgment that asserted
local community behavior was unusual both in reactions to the events themselves
and how the events were reported by local media. Specific examples of this include reference to “unusual”
respiratory disease, use of the phrase “atypical pneumonia” and reports of an
attempted diagnostic rule-out for SARS. “Atypical pneumonia” was a phrase used
during the early days of the emergence of SARS in southern Asia in 2002 and
2003 and thus considered a key indicator of interest.
Notification
protocols were escalated during the timeline, which reflected not only a change
in the content of the disseminated warning information but the communication
mode. The first level was posting
to an online website in a “pull” model, where viewing of the information
depends on the user. The second
level was an automated user alert email that did not provide a listing of all
infectious disease crises and disasters throughout the world but rather those
within proximity to an international airport connected to the United States by
direct, non-stop air traffic. In
this case, the email alert generated on April 16 and 17th to CDC was
due to event proximity to Oaxaca airport, which was located approximately 150
miles from Reforma and connected by direct, non-stop air traffic to Houston,
Texas.
Notification
by phone to CDC was initiated due to awareness of an international request for
diagnostic assistance by Mexican authorities, along with reports of possible
more widespread involvement of Mexico with “unusual” respiratory disease. During the conversation, information
was presented in terms of what was and was not known. It was emphasized that while claims of SARS was unlikely,
the level of non-routine social concern and disruption and knowledge of an
international request for assistance demanded immediate attention.
Figure
1a displays the volume of respiratory disease event reporting by Veratect for
Mexico and the United States.
Figure 1b displays the volume of respiratory disease event reports in
Mexico where the events were in proximity to an airport connected to the United
States by direct, non-stop air traffic.
Escalation in the notification protocol was activated before an overt
increase in the volume of source reporting of the events in Mexico. The April 6th report,
available on the Veratect web portal, was derived from 6 sources of
information. The April 16th
report, which was sent by email, was derived from 2 sources of information. The April 20th phone call
was triggered by communication with a highly trusted individual.
[a]
[b]
Figure 1.
Respiratory disease reports issued by Veratect during emergence of the
H1N1 pandemic. Notification of
unusual respiratory disease in Mexico began on April 6. Figure 1a displays all Veratect
respiratory and influenza reporting for Mexico and US. Figure 1b displays Veratect reporting
for Mexico filtered by proximity to international airports connected to the US
by direct, non-stop air traffic; all respiratory disease and influenza
reporting for the US also shown.
Steps
were taken to disseminate information to other organizations and governments
due to the realization of a potentially serious, rapidly evolving international
public health crisis occurring in proximity to multiple international
airports. None of the domestic
U.S. authorities Veratect contacted indicated awareness of these events at the
time of notification and requested access to situational awareness.
At
the suggestion of Colorado state officials, Veratect activated a Twitter
account on April 24th to distribute all real-time updates of the
evolving crisis. The intent was to
freely provide situational awareness until official public health organizations
had an opportunity to inform the public. By April 29, the Veratect Twitter
account was the second most retweeted (reposted) source of information on
Twitter.com under the #swineflu trend group behind CDC’s CDCEmergency Twitter
account. 17 Figure 2
displays the increase of public followers of the Veratect Twitter feed, an
indicator of public demand for information. Veratect ceased distribution of information through its
Twitter account at 2000 Eastern Standard Time on May 15, 2009.
Figure 2. Daily
public subscription to the Veratect Corporation Twitter account. Reporting of the H1N1 crisis on the
Veratect Twitter account began on April 24.
Discussion
A
critical aspect of warning is communication within a framework of trust. 18 This was the single most important
aspect of the warning process during the 2009 pandemic of H1N1, where an
expression of concern, level of uncertainty, and ultimately, an adjustment of
community sensitivity and orientation to a certain issue was achieved. Communication of Canadian engagement in
the Mexico crisis was an essential piece of information to drive sensitization
of the US public health and healthcare communities. Collegial communication with CDC on April 20th
occurred within this framework, and their response was an immediate attempt to
coordinate with international colleagues to understand the nature of the crisis
in Mexico. 20
The
evolution of reporting and resolution of uncertainty was similar to the time
frame observed during the 1968 influenza pandemic. In 1968, 28 days passed between initial social awareness of
respiratory disease in Hong Kong and 20 days after local recognition of unusual
event features, respectively, before laboratory confirmation of the presence of
a genetically shifted strain of influenza. 21 In the case of the 2009 pandemic of
H1N1, 18 days passed between local report of unusual respiratory disease and
publicly declared laboratory confirmation of a novel H1N1 strain. We propose poor reporting and
healthcare infrastructure in the initial areas of transmission in rural Mexico,
as well as delays in information sharing delayed diagnostic evaluation of the
situation.
It
could be argued that H1N1-positive cases identified in California and Texas was
an earlier detection point in the pandemic. However, H1N1 cases have been identified sporadically in
the past for several years.19,20 We propose the crucial missing piece of information was
evidence of rapid, sustained community transmission as observed during the
Mexico crisis to enable recognition of an international public health
emergency. Communication of
biosurveillance information in a trusted social network of biosurveillance
analysts facilitates an integrated situational awareness of public health
threats. Here the process entails
bringing together disparate lines of evidence for a fusion of actionable
information that enables decision-making.
Information pertaining to laboratory confirmation of H1N1 in California
and Texas and that produced by operational biosurveillance analysts is derived
from two different professional cultural domains. Both of these domains are distinct components of an integrated
warning system, which will be described below.
Collegial
communication among professionals in operational biosurveillance occurs through
various modes such as email and phone calls. Conversations occur to share events of concern, collectively
resolve discrepancies or ambiguity in the information, elicit different
perspectives based on experience and discipline, and ultimately, arrive at a
consensus about a particular event.
Such consensus can either be realization an event’s etiology and threat
potential is well understood to be of minimal potential consequence, an event’s
initial features warrant closer scrutiny and potential ground investigation, or
a full escalation of warning notification to multiple parties is required. The constant processing of indicators,
communication of that information, and consultation with professional
colleagues has resulted in the emergence of a novel analytic community
comprised of different disciplines, experience, and professional perspectives
that when combined has enabled realization of a new capability to process a
disparate array of biosurveillance information. This nascent community is comprised of United
Nations organizations, Non-Governmental Organizations (NGOs), foreign
governments, corporations, academia, and individuals.6
Sociologically, this is highly reminiscent of the birth of modern meteorology
as a professional discipline.22,23
There
is a cultural difference between those that provide early warning and those
that respond. For example, in
meteorology the National Weather Service focuses its efforts solely on the
detection and warning function, whereas the Federal Emergency Management Agency
(FEMA) is more concerned with what happens when and after a storm strikes. The culture of early warning, and the
people drawn to that kind of work, are very different from the response culture
of FEMA. We have found in our
experience the culture and people who work in our environment are very
different in orientation from the classic epidemiologist or public health
officer. It is similar to the
difference in personality between an emergency room physician and a
pathologist- both attract very different types of people to the job, but both
specialties are essential for patient care.
From a sociological perspective, components of an integrated warning system function together as a social network based on trust.18 This is true in the biosurveillance operational environment. Figure 3 displays a schematic of an integrated warning system as it applies to current biosurveillance operations. Human subject matter experts are required to interpret, process, and communicate signals from detection subsystems such as biosensors, syndromic surveillance systems, open source information, direct clinical observations, or laboratory diagnostic findings. Fusion of that information, an assessment of credibility and potential threat represented, and consultation with biosurveillance community members are important components of the decision process to generate a given level of warning notification. Issuance of a warning implies operational sensitization and orientation to the event in question, which requires ongoing monitoring, reassessment for the need to maintain a given state of alert, and communication with biosurveillance community members who themselves may also have a role in translating warnings into response action.
Figure 3.
Integrated biosurveillance warning system, adapted from Mileti and
Sorensen (1989). 18
Here
we have documented the first instance of using Twitter-based text messaging to
warn of an international public health crisis. The speed with which the pandemic crisis unfolded demanded a
dramatically different method of disseminating warning information to a large
body of disparate, multi-disciplinary communities. The dramatic uptake of information by the public, an
indicator of confirmation behavior and demand for information was a classic
sociological hallmark of a crisis.18 Veratect analysts monitored Twitter accounts, websites, and
public broadcasts by CDC, the U.S. Department of Health and Human Services and
the World Health Organization in order to decide the appropriate time to cease
the Veratect Twitter feed. This
decision to cease “Twittering” was a specific attempt to encourage public use
of credible official sources and avoid confusion in a rapidly complicated
information environment.
In
a prior report, we emphasized rapid recognition of foreign infectious disease
threats and proactive communication of that information was key to mitigating
the potential damage sustained by communities that may be connected to that
threat by air traffic, cultural diaspora, or commerce. 21 Detection and warning activities in the
early days of the pandemic (H1N1) 2009 dramatically emphasized this point. Aside from voluminous road and foot
traffic at the border of the United States and Mexico, substantial connectivity
via direct, non-stop air traffic between the two countries was noted. Canada issued a notification to their
public on April 22nd without waiting for laboratory confirmation of
samples from Mexico. This decision
was based predominantly on media based reporting of the situation in Mexico and
the request by Mexican authorities to Canada for diagnostic assistance (D.
Skowronski, personnal communication).
As mentioned in our prior paper, Canada’s proactive use of early warning
information for public health crises and disasters represents a potential new
standard. 21
The
World Health Organization recently noted “the 2009 influenza pandemic has
spread internationally with unprecedented speed. In past pandemics, influenza
viruses have needed more than six months to spread as widely as the new H1N1
virus has spread in less than six weeks.” 24 When it comes to unusual respiratory
disease events, the global community cannot wait for laboratory confirmation to
issue public notifications due to the speed with which pathogens are able to
translocate.
The
definition of “early warning” implies time-sensitive dissemination of
actionable information. The
“early” component, by its very nature, is associated with a degree of false
positives and sensitivity that requires balance with the receiving community of
users in terms of their tolerance levels for frequency of notification and
operational resources to verify information within their own network. The “warning” component implies some
form of analytic process has occurred to bring the report in question to the
attention of a resource-constrained user community. This balance, from an
operational viewpoint, is best achieved with trained professionals serving as
intermediates between raw information and decision makers.
Conclusion
We
have suggested a robust analytic discipline is required to provide the
appropriate cultural context and experience when interpreting the complex
interaction between disease hazards and socioeconomic vulnerability and
ultimately produce warning information.
In the case of the current pandemic, warning notifications were
escalated based on a low volume of source information assessed by experienced
analysts. This is analogous to the
comparison of the “astute clinician” versus an automated syndromic surveillance
system, where the clinician is a more reliable source of relevant warning
information. 25-27 As
with the evolution of medicine and meteorology as professional disciplines,
improvements in performance over time is expected with more experience in this
new professional domain as well as encouragement of evidence-based practice and
scientific research.
Acknowledgments
This
work was supported through internal funding by the Office of the Chief
Scientist, Veratect Corporation.
The authors wish to acknowledge the assistance of Mr. Kyle Geiger and
the analysts who participated in the operational functions described in this
paper.
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