Introduction

The Internet is revolutionizing biosurveillance.1 It is already the electronic network over which people and biosurveillance systems located anywhere on the planet communicate and exchange data. Modern biosurveillance systems (e.g., RealTime Outbreak and Disease Surveillance [RODS], National Retail Data Monitor [NRDM], web-based disease reporting systems, BOSSS, ESSENCE, and BioSense) would not be possible without the Internet. Hospitals, laboratories, schools, retailers, and individuals contribute data to these systems via the Internet, and end users log in to these systems using Internet browsers. The Internet has made it possible not only to conceive of biosurveillance systems of global scope, but also to construct them, and to do so quickly.

The Internet facilitates communication among the many individuals involved in biosurveillance. Like the telegraph (1844) and telephone (1876), the Internet quickly and profoundly changed how professionals communicate (Kravitz, 1969). Colleagues use e-mail to exchange text, images, video, sound and (password-protected and encrypted) data. Newsgroups, blogs, and chat rooms support more structured or topical communication among self-defining communities of individuals. These communications, although inherently asynchronous, have become nearly synchronous due to the use of wireless devices such as BlackBerry® handheld computers. Increasingly, the Internet supports synchronous communication such as telephony, conference calls, video conferencing, instant messaging, telemedicine, and remote diagnosis.

The Internet has become a real-time encyclopedia for epidemiologists, infection control practitioners, researchers, and outbreak investigators. These individuals quickly "Google" to journal articles, technical reports, newspapers, books, and video. They find both highly reliable information (e.g., peer-reviewed papers, technical reports, books, ProMED-mail items, treatment guidelines, World Health Organization [WHO] alerts), and less reliable but still useful information such as newswire stories, unmoderated e-mail lists, chat rooms, and online newspapers.2

The Internet provides new tools for outbreak investigators. An investigator need only type an address into an internet browser to see a map, satellite image, or both of the location of an outbreak or a building of interest (Figure 26.1). When shoe-leather epidemiology is required, the same website can provide driving directions to the location. An investigator may use a search engine to obtain a restaurant's menu (e.g., when investigating a Salmonella outbreak) or use Internet-based "people locators'' such as http://www.anywho.com to obtain contact information for individuals with communicable disease or their contacts.

Perhaps of greatest importance, the massive amount of information on the Internet represents a new form of biosurveillance data. A newswire story, for example, is input data for computer programs such as those operated by the Global Public Health Intelligence Network (GPHIN), which we discuss in detail in this chapter. These programs use search engines and text-filtering programs to bring information from websites, newswires, and other Internet resources to the attention of analysts. The idea that computers could search and filter large document collections was conceived soon after the birth of digital computers (Luhn, 1958, Luhn, 1961, Connor, 1967, IBM, 1962); but its application in biosurveillance required the invention of the Internet.

1 Many people use the term Internet loosely to refer not only to the physical network (what an information technologist would consider the Internet), but also the information that is available on the World Wide Web and applications such as email that utilize the network. In this chapter, we also use the term Internet loosely.

2 We note that the Internet has become an important means for public health education. The Center for Disease Control and Prevention's Public Health Training Network http://www2a.cdc.gov/phtnonline/, and the Supercourse, http://www.pitt.edu/~super1/ are just two of the many examples of readily available free training.

figure 26.1 MSN Virtual Earth hybrid map. Visual inspection of this map may suggest hypotheses about the cause of illness (e.g., proximity to vegetation, industrial plants, and special events) that a more conventional map might not suggest. The oblong object is the stadium at the University of Pittsburgh. Microsoft product screen shot reprinted with permission from Microsoft Corporation.

figure 26.1 MSN Virtual Earth hybrid map. Visual inspection of this map may suggest hypotheses about the cause of illness (e.g., proximity to vegetation, industrial plants, and special events) that a more conventional map might not suggest. The oblong object is the stadium at the University of Pittsburgh. Microsoft product screen shot reprinted with permission from Microsoft Corporation.

In this chapter, we focus on the Internet as a source of biosurveillance data and begin with a discussion of ProMED-mail—a worldwide biosurveillance system crafted from standard e-mail-list software. We then provide a brief primer on the Internet as background for the subsequent discussion of GPHIN—a system that automatically analyzes newswire and other resources available on the Internet—and futuristic biosurveillance systems that may search spatial and temporal patterns of Internet utilization that may provide an early indication of an outbreak.

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