eHealth Resources for Controling AIDS in Brazil. Bastos F. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. 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

2. 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

3. 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”

4. Vat model

5. 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.

6. The now famous plague affecting the game “World of
Warcraft”, as described by Ran Balicer (Epidemiology
2007;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‟”

7. World of Warcraft

8. “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.”

9. “(…) 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?

10. BASTOS/FRANCISCO INACIO
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11. “ (…) 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.”

12. 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.”

13. 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).

14. Avalon Bastos

15. “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?

16. Rio

17. Rio

18. 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.”

19. “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.”

20. “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.”

21. 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?

22. 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)

23. San Francisco AIDS Foundation

24. 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.”

25. Grassroots Alliance for
Community Education

26. 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.”

27. APUA

28. “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

29. 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/

30. Pig news

32. 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.

33. The bad side of the internet:
• Misinformation
• Dissemination of racism, prejudice, spam,
viruses etc.
• Networks and/or communities of
pedophiles, warmongers, hooligans etc.

34. 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!

35. Thank you! Muchas gracias! Grácies!
Miró