Computer Program for Diagnosing and Teaching Geographic Me dic ine Stephen A. Berger and Uri Blackman One of the unique aspects of infectious disease is its neighboring countries and previous years when neces- wide variety, both in time and place.The specialist prac- sary (Table 1). In cases where the accuracy of disease ticing in India may have little or no expertise in Peru- reporting was suspect (e.g.,AIDS in Africa), more real- vian disease.A colleague in NewYork may be called upon istic published estimates were used. to diagnose and treat conditions originating in Africa,Asia, The data base is limited to infectious diseases South America, Fiji and Papua, New Guinea. At the (Table 2). It does not include slow viral illnesses and a same time, this colleague must be familiar with the number of self-defined and obvious conditions such as pathogens that originate in Texas, Hawaii, and Canada. otitis externa and furunculosis.As the program is designed Indeed, even the full-time infectious diseases specialist may to diagnose clinically apparent disease, data regarding not be conversant in diseases such as lagochilascariasis, asymptomatic carriage or infestation were adjusted louping ill, and lobomycosis. War, famine, education, accordingly. Figures regarding the incidence of signs and immigration, and business travel have contributed to the symptoms within each specific disease were derived advent of specialists in Geographic Medicine and Empo- from standard textbooks and reviews. Clinical and epi- riatrics, otherwise known as Travel medicine. demiologic data are updated on a continous basis. The “art” of diagnosis is largely an ability (albeit sub- The program user is first requested to indicate the conscious) to rank probabilities based on the incidences country of disease origin and is then presented with a of likely diseases and the chance of encountering given list of 22 basic clinical parameters, which are grouped clinical features within each disease. In theory, Bayesian according to body system.A + or - response to each of analysis could be employed to diagnose disease accurately the latter is indicated by using any of a variety of com- when given proper input.A multicenter study was under- puter keystr0kes.A + response automatically opens a com- taken to test a comprehensive computer driven-soft- puter window that requests further details.Thus, if the ware program that incorporates worldwide epidemiologic user indicates that a rash is present, he will be asked to and clinical parameters. further define the nature and distribution of the skin lesions. An additional window is available for the entry Materials and Methods of laboratory test results (hematologic, cerebrospin, hepatic, or renal) if available. Computer Program Design User input is processed by a Bayesian matrix, and Interactive data bases that represent rates and clin- compatible diagnoses are presented in order of probability ical probabilities were constructed for 308 diseases; 127 in a bar graph and numerical format.Ancillary clues for symptoms, signs, and laboratory findings; and 205 coun- all listed diseases are accessed by specified key strokes as tries. Reported statistics published by the World Health follows: incubation period, clinical hints, geographic dis- Organization and national health ministries were used tribution, vector, vehicle, reservoir, etc.Additionally,drugs where available.These were supplemented by data for of choice and dosages for adult or pediatric therapy are 1isted.The diagnosis list is accompanied by an ancillary screen, which indicates rare (albeit compatible) clinical findings in each disease listed for the patient in question. Stephen A. Berger, MD, The Infectious Diseases Division, An additional interactive screen lists all additional clin- Tel-Aviv Sourasky Medical Center, and Uri Blackman, BS, The Department of Computer Science, University of Tel-Aviv, ical findings that could improve diagnostic specificity. Tel-Aviv, Israel Separate computer modules allow the user to study Participating study institutions: Soroka Medical Center, Beer specific diseases and antiinfective agents without regard Sheva [Pediatrics and Internal Medicine]; Edith Wolfson to a specific patient.The user may, for example, request Medical Center, Holon; Haemek Hospital, Afula; Chaim a listing for all parasitic diseases acquired in Togo from Sheba Medical Center, Tel Hashomer; Carmel Hospital, Haifa the bites of mosquitoes; or of all drugs which interact with Reprint requests: Stephen A. Berger, MD, Dept. of alcohol. In addition to the epidemiologic and clinical para- Microbiology, Tel Aviv Medical Center, 6 Weitzman Street, meters outlined above, screens are available that outline Tel Aviv 64239, Israel the worldwide distribution of each disease, as well as the J Travel Med 1995; 2199-203 current status ofAIDS, malaria, tuberculosis,yellow fever, 199 200 Journal of Travel Medicine, Volume 2, Number 3 Table 1 Sources Used in Maintaining The Epidemiologic Database Official Health Ministry Reports Archives of Internal Medicine Bericht Uber dat Gesundheitswesen in Osterreich British Melcal Journal [Austria] Bulletin of the World Health Organization Boletin Epidemiologico de Chile Clinical Infectious Diseases Boletin Epidemiologico Nacional [Argentina] Clinical Microbiology Reviews Boletin Epidemiologico y Microbiologico [Spain] European journal of Microbiology and Infectious Boletin lnformativo [Bolivia] Diseases Bulletin Epidemiologique Hebdomadaire [France] Harefuah Canada Communicable Disease Report [Canada] Infectious Disease Clinics CDR Weekly [United Kingdom] Infectious Disease Clinics of North America Choroby Zakazne I Zatrucia W Polsce [Poland] International Journal of Systematic Bacteriology Communicable Diseases Intelligence [Australia] Israel Journal of Medical Sciences Community Health & Disease Surveillance News Letter JAMA [Oman] journal of Antimicrobial Chemotherapy Comportamiento de Patologias Immunoprevenibles journal of Clinical Microbiology [Argentina] Journal of Clinical Pathology Daten des Gesundheitswesens [Germany] Journal of Hospital Infection EpidAktuellt [Sweden] Journal of Internal Medicine Epidemiology Bulletin [Taiwan] Journal of Infectious Diseases EPI-NYT [Denmark] Journal of Pediatrics Heilbrigdisskyrslur [Iceland] Journal ofTravel Medicine IASR Uapan] Lancet Health Statistics Ireland [Ireland] Medical Journal of Australia Monthly Epidemiological Bulletin [Israel] Medicine Morbidity and Mortality Weekly Report [USA] Morbidity and Mortality Weekly Report (CDC) MSIS-rapport [Norway] New England Journal of Medicine Notiziario dell’Instituto Superiore de Sanita [Italy] Pediatric Clinics of North America Terveys [Finland] The Pediatric Infectious Disease Journal Weekly Epidemiological Record [WHO] Pediatrics Journals and Periodicals Reviews of Infectious Diseases AIDS Scandinavian Journal of Infectious Diseases American Journal of Clinical Pathology South African Medical Journal American Journal of Diseases of Children Southern Medical Journal American Journal of Epidemiology The Medical Letter American Journal of Medicine Transactions of the Royal Society ofTropical Medicine American Journal of Public Health and Hygiene American Journal ofTropical Medicine and Hygiene Tubercle Annals of Internal Medicine World Health Statistics Quarterly Antimicrobial Agents and Chemotherapy Applied Microbiology and cholera. The therapeutic spectrum, toxicity, dosage results were collated and entered into a data base (dBase and other characteristics of anti-infective agents and III+) prior to to review of the clinical diagnoses. vaccines are also available. Statistical analysis employed the chi-square test for unpaired proportions. Multicenter Study Questionnaires reflecting the computer input screen Results were distributed to six senior full-time infectious dis- ease specialists. (The authors’ own institution was Four hundred ninety and five of 513 cases submit- excluded). Participants were requested to record all pos- ted were suitable for analysis (Table 3). Ninety four itive and negative clinical data for consecutive patients individual infectious diseases were represented among with established diagnoses. Since the majority of cases these cases (Table 2).The computer program accurately were anticipated to represent disease acquired in the study identified the clinical diagnosis in 75.3% of actual cases country (Israel) a similar number 0f“hypothetical” cases and in 64.0% of hypothetical cases (p = .009).The clin- acquired abroad was also elicited. Questionnaires were ical diagnosis was included in the computer differential assigned code numbers and submitted in a blinded fash- diagnosis list in 94.7%. The accuracy of diagnosis was ion, with diagnoses recorded on a separate sheet.AU highest for parasitic disease (p = .04) and diseases acquired Berger and Blackman, Computer Program for Diagnosing & Teaching Geographic Medicine 201 Table 2 Diseases and Pathogens Included in the Data Base Abscess, intraabdominal* Cutaneous larva migrans" Herpes simplex infection* Mycobacteriosis - M. Actinomycosis Cutaneous leishmaniasis* Herpes simplex encephalitis* ulcerans Adenovirus infection Cyclospora infection Herpesvirus simiae infection Mycobacteriosis - systemic* Aeromonas & marine Cysticercosis* Herpes zoster* Mycoplasma pneunioniae Vibrio infx. Cytomegalovirus infection* Heterophyiasis infec.* Myiasis* AIDS* Dengue* Histoplasmosis* Nanophyetiasis Amebiasis* Derniatophytosis Histoplasmosis - African Necrotizing skidsoft tissue Amoeba - free