TCS Daily

Listening for the Hoofbeats of Zebras

By Jeffrey Trent - June 25, 2003 12:00 AM

On May 22, 2003, 3-year-old Schyan Kautzer of Dorchester, Wisconsin, was admitted to the hospital with skin lesions and a 103-degree temperature. According to the Wausau Daily Herald, doctors "didn't know what they were dealing with...They considered everything from herpes to anthrax." According to Dr. Kurt Reed, an infectious disease pathologist, "Doctors looked for any possible explanations..." Added Dr. John Melski, a Marshfield Clinic dermatologist, "One of the most important things for any physician to learn is to know what you don't know...When you don't know things, you keep working." By now, the world knows that the girl was exposed to a rare African virus called Monkeypox, which she picked up from her pet prairie dog, who picked up the disease from a Gambian giant rat.

Doctors in training are traditionally taught that the most common diseases occur most commonly. In other words, they are taught that "When you hear hoof beats, think of horses, not zebras." But what happens as doctors in our global village are increasingly working in the darkness of the unknown, and it is more difficult to distinguish the hoof beats of the horses from the zebras and whatever else is out there?

We live in a world where illnesses now travel just as easily as we do. Monkeypox and other rare diseases like West Nile virus are appearing in local headlines with increasing regularity. Combine these with additional infectious fears like sudden acute respiratory syndrome (SARS), HIV and others (not to mention potential bioterrorism agents such as anthrax), and it is easy to see why today's medical professionals need to be empowered with the latest technologies to distinguish monkeypox from chickenpox. Even some of the most common diseases can baffle physicians and researchers, making them wonder whether they are about to encounter a new plague or just another strain of the common cold.

Without an early and accurate diagnosis, patients could be harboring and spreading an unfamiliar medical time bomb. In a worst-case scenario, hundreds or thousands of people could die before anyone knows what caused the deaths. With the monkeypox outbreak, the Washington Post reported that at least 19 people in three states were infected with the virus by the time federal health officials released their nationwide alert. Dr. Melksi's comments speak to the heart of the challenge when dealing with the increasingly complex issue of bio threats and rare virus outbreaks. It is up to the physicians and primary care providers to "learn to know what they don't know" and they must do so quickly.

The good news is that the technology already exists, and an early warning system can be put together that will make use of all kinds of biological information, including DNA and other genetic testing, to educate doctors so they can provide faster and more efficient solutions to new and more insidious medical dilemmas and biological threats. If this early warning system were in place when Schyan Kautzer arrived at the hospital with her unusual symptoms, a quick blood test, matched up with an enormous genomics database, integrated with a national healthcare and national defense systems, could have identified the rare monkeypox virus in a matter of moments and the proper protocol of care and quarantine approaches downloaded to the hospital for immediate implementation. Her disease could have been identified up to three weeks earlier, and the first few patients could have been quarantined soon after the first signs of danger.

Faster detection and identification of diseases will limit the number of individuals exposed and ensure a chain reaction of better outcomes whenever a biothreat appears. Healthcare professionals will be better able to distinguish between infected and uninfected individuals, allowing for better allocation of drugs and vaccines, as well as better management of public alerts and fears. Ultimately, a more detailed analysis of infectious agents and pathogens, from the earliest point of discovery, will also provide the best forensic material needed to determine the origins of the disease and how it can be prevented, curtailed, contained or eliminated.

With diseases such as monkeypox and SARS still on our minds, not to mention the fear of whatever new biological threats we will undoubtedly face in the future, we cannot afford to wait. While the global village we live in is becoming increasingly complex, the public is growing tired of listening for mysterious hoof beats in the distance, and physicians are waiting for the best technology to give us the best answers.

Dr. Jeffrey Trent heads the Translational Genomics Institute (TGen) in Phoenix. Dr. Paul Keim is an expert in anthrax and microbial forensics at Northern Arizona University. George Poste is Director of the Arizona Biodesign Institute at Arizona State University. The authors are part of a consortium whose mission is to develop a network of sophisticated diagnostic tests to create an "end-to-end solution" that will immediately distinguish infections caused by bio threat agents from those routinely found in patients.

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