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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
×

MICROBIAL THREATS TO HEALTH

EMERGENCE, DETECTION, AND RESPONSE

Mark S. Smolinski, Margaret A. Hamburg, and Joshua Lederberg, Editors

Committee on Emerging Microbial Threats to Health in the 21st Century

Board on Global Health

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

Support for this project was provided by the Centers for Disease Control and Prevention’s National Center for Infectious Diseases (Contract No. H75/CCH311468, TO#8), the U.S. Department of Defense (Contract No. DAMD17-01-2-0040), the U.S. Agency for International Development (Contract No. HRN-A-00-00-00012-00), the U.S. Department of Agriculture’s Food Safety and Inspection Service (Contract No. 590-0790-1-188), the National Institutes of Health’s National Institute of Allergy and Infectious Diseases, the National Institutes of Health’s Fogarty International Center, the Ellison Medical Foundation, the U.S. Food and Drug Administration, and the U.S. Joint Institute for Food Safety Research. The views presented in this report are those of the Institute of Medicine Committee on Emerging Microbial Threats to Health in the 21st Century and are not necessarily those of the funding agencies.

Library of Congress Cataloging-in-Publication Data

Microbial threats to health : emergence, detection, and response / Mark S. Smolinski, Margaret A. Hamburg, and Joshua Lederberg, editor(s) ; Committee on Emerging Microbial Threats to Health in the 21st Century, Board on Global Health.

p. ; cm.

Includes bibliographical references.

ISBN 0-309-08864-X (hardcover) — ISBN 0-309-50730-8 (PDF)

1. Communicable diseases—United States. 2. Public health—United States.

[DNLM: 1. Communicable Diseases, Emerging—epidemiology. 2. Communicable Diseases, Emerging—prevention & control. 3. Communicable Disease Control. WA 110 M626 2003] I. Smolinski, Mark S. II. Hamburg, Margaret A. III. Lederberg, Joshua. IV. Institute of Medicine (U.S.). Committe on Emerging Microbial Threats to Health in the 21st Century.

RA643.5.M53 2003

614.5′7—dc21

2003008754

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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“Knowing is not enough; we must apply. Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

Shaping the Future for Health

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.

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www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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COMMITTEE ON MICROBIAL THREATS TO HEALTH IN THE 21ST CENTURY

MARGARET A. HAMBURG (Co-chair), Vice President for Biological Programs,

Nuclear Threat Initiative

JOSHUA LEDERBERG (Co-chair), Professor Emeritus and Sackler Foundation Scholar,

The Rockefeller University

BARRY BEATY, Professor of Microbiology,

Colorado State University

RUTH BERKELMAN, Professor,

Department of Epidemiology, Rollins School of Public Health, Emory University

DONALD BURKE, Professor,

Departments of International Health and Epidemiology, Bloomberg School of Public Health, Johns Hopkins University

GAIL CASSELL, Vice President of Scientific Affairs and Distinguished Research Scholar in Infectious Diseases,

Eli Lilly and Company

JIM YONG KIM, Co-director of program in Infectious Disease and Social Change,

Department of Medicine, Harvard University

KEITH KLUGMAN, Professor of International Health,

Department of International Health, Rollins School of Public Health;

Professor of Medicine,

Division of Infectious Diseases, School of Medicine, Emory University

ADEL MAHMOUD, President,

Merck Vaccines, Merck and Co, Inc.

LINDA MEARNS, Scientist and Deputy Director,

Environmental and Societal Impacts Group, National Center for Atmospheric Research

FREDERICK MURPHY, Professor,

Schools of Veterinary Medicine and Medicine, University of California, Davis

MICHAEL OSTERHOLM, Director,

Center for Infectious Disease Research and Public Policy,

Professor,

School of Public Health, University of Minnesota

CLARENCE PETERS, Professor,

Departments of Microbiology and Immunology and Pathology, University of Texas Medical Branch

PATRICIA QUINLISK, Iowa State Epidemiologist,

Iowa Department of Public Health

FREDERICK SPARLING, Professor of Medicine and Microbiology and Immunology,

University of North Carolina, Chapel Hill

ROBERT WEBSTER, Professor,

Virology Division, Department of Infectious Diseases,

Rose Marie Thomas Chair,

St. Jude Children’s Research Hospital

MARK WILSON, Director, Global Health Program, Associate Professor of Epidemiology,

University of Michigan

MARY WILSON, Associate Professor of Medicine,

Harvard Medical School,

Associate Professor of Population and International Health,

Harvard School of Public Health

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Staff

MARK S. SMOLINSKI, Study Director

PATRICIA A. CUFF, Research Associate

KATHERINE A. OBERHOLTZER, Project Assistant

RICHARD MILLER, Director,

Medical Follow-up Agency

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

John G. Bartlett, The Johns Hopkins University, Baltimore, Maryland

Michael G. Groves, Louisiana State University, Baton Rouge, Louisiana

Marcelle C. Layton, New York City Department of Health, New York, New York

Lord Robert May, University of Oxford, Oxford, United Kingdom

Mark Nichter, University of Arizona, Tucson, Arizona

Jonathan Patz, The Johns Hopkins University, Baltimore, Maryland

Regina Rabinovich, Malaria Vaccine Initiative, Rockville, Maryland

Bill Roper, University of North Carolina, Chapel Hill, North Carolina

Robert Shope, University of Texas, Galveston, Texas

Andrew Spielman, Harvard University, Boston, Massachusetts

Robert A. Weinstein, Cook County Hospital, Chicago, Illinois

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Ronald W. Estabrook, the University of Texas Southwestern, Dallas, Texas, and Samuel L. Katz, Duke University, Durham, North Carolina. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Cover Artwork

INFLUENZA*

The global nature of influenza and the aqueous environment needed for virus spread are depicted by the world viewed from space and its aqueous environs (blue globe). Gulls and wild ducks are the natural host of all known influenza A viruses. During evolution these viruses adapted to migratory birds that travel long distances and spread virus by transmission to mammals (lines of migration and interspecies spread). Pigs act as intermediate hosts with receptors for avian and mammalian influenza viruses and occasionally transmit the viruses to humans.

There are 15 different subtypes of influenza A viruses (different shades of virus particles) that vary in shape and size. After transmission to mammalian hosts influenza viruses evolve rapidly. The segmented RNA genomes (8 segments per virion) permit related viruses to reassort (virus particle with 14 genes—should be 16—artistic license). In mammalian hosts

*  

A stained glass window 21 × 56” depicting the natural history of influenza viruses and zoonotic exchange in the emergence of new strains is shown in reduced size on the back cover of this report. A detailed section of the image was used to design the front cover. Based on the work done at St. Jude Children’s Research Hospital supported by American Lebanese Syrian Associated Charities (ALSAC) and the National Institute of Allergy and Infectious Diseases (NIAID).

Artist: Jenny Hammond, Highgreenleycleugh, Northumberland, England

Commissioned by Rob and Marjorie Webster.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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the ever-changing spike glycoproteins (spike-like fringe on particles) permit the virus to evade the immune response resulting in annual disease outbreaks. At irregular intervals the reassortment of viruses gives rise to pandemic strains with the potential of devastating disease. The yearly outbreaks of influenza and occasional pandemics cause high fever (red) and excess mortality.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Preface

As we enter the twenty-first century, infectious diseases continue to burden populations around the world. Both naturally occurring and intentionally introduced biological threats hold increasing potential to cause disease, disability, and death. And beyond disease itself, the ability of infectious agents to destabilize populations, economies, and governments is fast becoming a sad fact of life. The prevention and control of infectious diseases are fundamental to individual, national, and global health and security; failure to recognize—and act on—this essential truth will surely lead to disaster. Over the past decade, the United States has taken important steps to strengthen its capacity to address the threats posed by these diseases. However, we must do more to improve our ability to detect, prevent, and control emerging and resurging diseases if we are to be better prepared for future microbial threats to health.

In 1992, the Institute of Medicine published a landmark report, Emerging Infections: Microbial Threats to Health in the United States, which pointed to major challenges for the public health and medical care communities in detecting and managing infectious disease outbreaks and monitoring the prevalence of endemic diseases. Completed just about a decade ago, it reflected the consensus of a wide-ranging group of specialists that America needed a wake-up call, that infectious diseases remained a tangible threat to our security, and that the comfort and complacency that overtook us in the 1960s with the advent of wonder drugs and vaccines might be short-lived. That report was a stimulus for numerous other studies and policy actions, many in response to the harsh realities of the spread of HIV/AIDS, the

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
×

emergence of new or previously unrecognized diseases, the resurgence of old diseases, and the looming failure of technological innovation in antimicrobial drugs to keep up with the constant evolution of microbial resistance.

The 1990s also saw a revolution in globalization in all spheres: political, economic, cultural, technological, and informational. This revolution included the breakdown of cold war politics and the ever broader engagement of the United States in every geographic region; the progressive breakdown of national barriers to trade and migration and the emergence of a global economy; and the wonders of information technology, especially Internet access to ideas and information. These developments offered new opportunities and exigent challenges as infectious agents piggybacked on the internationalization of people and goods. More recently, the new global environment has brought home our vulnerability to malicious attacks on our homeland, including events that have led the words “anthrax” and “smallpox” to appear in banner headlines. All this has occurred in an era that has seen us identify the complete genomic codes not merely for mice and humans, but also for a host of their parasites.

As we conclude our work for the current study, we must continue to trumpet the message of urgency and concern, but our more demanding task is to take stock of existing preventive and remedial measures, and to consider what further investments of fiscal and political capital are needed if we are to keep pace with our microbial competitors. We need no longer limit our concern to the United States as the venue for microbial threats to health, as it is now widely understood that our borders offer trivial impediment to such threats. Nor need we have an exclusive focus on emerging diseases when we have so far to go in dealing globally with tuberculosis, malaria, and HIV/AIDS, which emerge and reemerge with violent fluctuations of intensity in different parts of the world.

This report is entitled Microbial Threats to Health with the tacit understanding that the phrase embraces all of the above. Information resources such as the Internet, with content provided by a multitude of governmental and academic sources (most notably Medline and PromedMail), obviate the need to catalogue the details of the thousand or so microbial agents of most urgent concern, especially with information on new threats appearing monthly. Yet we have included important narratives to illustrate the complexity of disease and the intertwining of the biological, environmental, ecological, social, and political factors that must all be taken into account to understand the threats that confront us, and to define meaningful and sustainable solutions.

We must also note that soon after the work of this committee began, the world was rocked by the attacks of September 11, 2001, and the subsequent dissemination of anthrax as a biological weapon through the mail. In

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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the wake of these tragic events, a new imperative animated our discussions and reinvigorated our work. Suddenly a spotlight was cast on the serious and frightening reality of the intentional use of a microbial agent. With this heightened awareness came increased conviction that the best defense against any disease outbreak is a robust public health science and practice, underscoring the need to devote markedly greater attention and resources to meeting this critical need.

Of course, it is often easier to delineate problems than to design and execute remedies, though the former is obviously an obligatory first step. In the triad of Emergence, Detection, and Response, the last decade has seen important improvements—perhaps most dramatically in technologies that enable us to detect previously unknown pathogens. The most problematic need is perhaps for incentives for the necessary investments in preventive and therapeutic technologies (i.e., vaccines and antimicrobials) to bring them from the laboratory to public use. While there was consensus among the committee members that the nation is well into a crisis with regard to microbial threats to health, our most contentious discussions concerned the precise details of how the enormous power (and political sensitivity) of government can be applied in partnership with the private sector to meet public needs.

The next decade will surely see a broader range of further scientific advances in our fundamental understanding of pathogenesis, host–parasite co-evolution, and intertwined genomics and physiology. Comparable leaps of political will and public understanding will be required to enable these fruits of scientific endeavor to benefit a humankind that still suffers many burdens whose alleviation is scandalously within our technical grasp.

Margaret A. Hamburg

Joshua Lederberg

Co-chairs

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Acknowledgments

The committee is indebted to the researchers, administrators, and public health professionals who presented informative talks to the committee and participated in lively discussions at the open meetings, including James Hughes, Carol Heilman, Gerald Keusch, Richard Sprott, Stephanie James, Murray Trostle, Patrick Kelley, Michael Zeilinger, Kaye Wachsmuth, Walter Hill, Jerry Gillespie, Jessie Goodman, Byron Wood, Alexandra Levitt, Ray Arthur, Mary Gilchrist, Julie Gerberding, Douglas Hamilton, Joel Breman, Claude Earl Fox, Richard Wansley, and Bob England (see Appendix A for affiliations and discussion topics). The committee is also grateful to Jo Ivey Boufford, John Edman, Bruce Eldridge, and Stanley Oaks who graciously made themselves available for consultation and technical reviews.

Of particular note, the following individuals directly contributed to the report by drafting commissioned papers in their areas of expertise. Aaron Shakow, Paul Farmer, and William Rodriguez contributed to a review of the social and economic determinants of infectious disease that made a substantial contribution to the report. A paper by Kelly Henning provided important background on syndromic surveillance (see Appendix B), and another by David Relman provided insight to modern methods of pathogen discovery, detection, and diagnostics (see Appendix C). Thanks also to Lawrence Gostin for his contributions on public health law, which were replicated in that section of the report.

The committee would like to thank the staff and members of the Institute of Medicine’s Forum on Emerging Infections for their support in conducting three workshops over the course of the study that served to inform-

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
×

the committee’s deliberations on assessing the science and response capabilities regarding the intentional use of biological agents, the growing threat of antimicrobial resistance, and the impact of globalization on emerging infectious diseases (see Appendix D for Forum membership and list of publications).

The committee wishes to express its sincere appreciation to the devoted project staff. As study director, Mark Smolinski ensured the success of this project through his dedication, diligence, creativity, and leadership. This study would not have been possible without Dr. Smolinski’s oversight and coordination of the work of the committee and his insightful and careful drafting of the report. Additional praise goes to Patricia Cuff for her analytic proficiency and perseverance in completing the daunting task of reviewing the literature, verifying references, and drafting text. Pat’s contributions were instrumental to the evidence-based rigor of the report. Katherine Oberholtzer was outstanding in her meticulous attention to detail, great finesse in the organizational work of the committee, and numerous contributions to supporting the research and editing of the report.

Many other individuals within the Institute of Medicine and the National Academies were instrumental in seeing the project to completion. A special note of appreciation goes to Judith Bale for her continuous encouragement, Dick Miller for his leadership and guidance, and Stacey Knobler for her invaluable assistance through her work with the Forum on Emerging Infections. Thanks also to Clyde Behney, Andrea Cohen, Bronwyn Schrecker, Jennifer Otten, Jennifer Bitticks, Carlos Orr, Marjan Najafi, Lois Joellenbeck, Janice Mehler, and the NAP production staff. Thanks are also due to writing and editorial consultants Leslie Pray, Beth Gyorgy, and especially Rona Briere who helped polish brass into gold.

The committee would like to thank the following agencies and organizations who generously provided funding for this study: the Centers for Disease Control and Prevention’s National Center for Infectious Diseases, the National Institutes of Health’s National Institute of Allergy and Infectious Diseases, the National Institutes of Health’s Fogarty International Center, the Ellison Medical Foundation, the U.S. Agency for International Development, the U.S. Department of Defense, the U.S. Department of Agriculture’s Food Safety and Inspection Service, the U.S. Food and Drug Administration, and the U.S. Joint Institute for Food Safety Research. Finally, the committee would like to acknowledge the support of the Board on Global Health (see Appendix D) as part of its continuing pursuit to improve the health of the global community.

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Synopsis

Infectious diseases continue to be a serious burden around the world, in developing and industrialized countries alike. Whether naturally occurring or intentionally inflicted, microbial agents can cause illness, disability, and death in individuals while disrupting entire populations, economies, and governments. In the highly interconnected and readily traversed “global village” of our time, one nation’s problem soon becomes every nation’s problem as geographical and political boundaries offer trivial impediments to such threats. The United States has shown leadership in the past by strengthening its own and others’ capacities to deal with infectious diseases, but the present reality is that the public health, veterinary, and medical-care communities are inadequately prepared. We must do more to improve our ability to prevent, detect, and control microbial threats to health.

We must understand that pathogens are endlessly resourceful in adapting to and breaching our defenses. We must also recognize that factors relating to society, the environment, and our increasing global interconnectedness actually enhance the likelihood of disease emergence and spread. Moreover, it is a sad reality that today we must also grapple with the intentional use of biological agents to do harm, human against human. In fact, thirteen individual factors—some reflecting the ways of nature, most of them reflecting our ways of life—account for the emergence of infectious disease. Any of these factors alone can trigger problems, but their convergence creates especially high-risk environments where infectious diseases may readily emerge, or re-emerge.

Dramatic advances in science, technology, and medicine have enabled

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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us to make great strides forward in our struggle to prevent and control infectious diseases, yet we cannot fall prey to an illusory complacency. The magnitude of the problem requires renewed commitment. As we look at our prospects, it is clear that a robust public health system—in its science, capacity, practice, and through its collaborations with clinical and veterinary medicine, academia, industry, and other public and private partners— is the best defense against any microbial threat.

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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Breakdown of Public Health Measures,

 

107

   

Poverty and Social Inequality,

 

121

   

War and Famine,

 

125

   

Lack of Political Will,

 

127

   

Intent to Harm,

 

130

   

A Case in Point: Influenza—We Are Unprepared,

 

136

4

 

ADDRESSING THE THREATS: CONCLUSIONS AND RECOMMENDATIONS

 

149

   

Enhancing Global Response Capacity,

 

149

   

Improving Global Infectious Disease Surveillance,

 

154

   

Rebuilding Domestic Public Health Capacity,

 

159

   

Improving Domestic Surveillance Through Better Disease Reporting,

 

163

   

Exploring Innovative Systems of Surveillance,

 

170

   

Developing and Using Diagnostics,

 

174

   

Educating and Training the Microbial Threat Workforce,

 

181

   

Vaccine Development and Production,

 

184

   

Need for New Antimicrobial Drugs,

 

190

   

Inappropriate Use of Antimicrobials,

 

204

   

Vector-borne and Zoonotic Disease Control,

 

209

   

Comprehensive Infectious Disease Research Agenda,

 

220

   

Interdisciplinary Infectious Disease Centers,

 

222

 

 

EPILOGUE

 

227

 

 

GLOSSARY

 

231

 

 

REFERENCES

 

241

 

 

APPENDIXES

 

 

A

 

Microbial Threats to Health Public Committee Meeting Agendas

 

277

B

 

Syndromic Surveillance

 

281

C

 

Pathogen Discovery, Detection, and Diagnostics

 

313

D

 

Forum on Emerging Infections Membership and Publications, Board on Global Health

 

331

E

 

Computational Modeling and Simulation of Epidemic Infectious Diseases

 

335

F

 

Committee and Staff Biographies

 

343

 

 

INDEX

 

353

Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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List of Figures, Tables, and Boxes

FIGURES

ES-1

 

The Convergence Model,

 

5

2-1

 

The first two decades of HIV/AIDS,

 

27

2-2

 

Examples of recent emerging and re-emerging infectious diseases,

 

33

2-3

 

Fluoroquinolone prescriptions per capita and frequency of pneumococci with reduced susceptibility to fluoroquinolones in Canada,

 

40

2-4

 

Percentage of fluoroquinolone-resistant Neisseria gonorrhoeae,

 

41

3-1

 

The Convergence Model,

 

55

3-2

 

New world hantaviruses and their rodent reservoirs,

 

75

3-3

 

The human population explosion,

 

80

3-4

 

The world’s populations by age and sex: 1950, 1990, and projections for the year 2030,

 

82

3-5

 

Estimated life expectancy at birth in years: 1900–2000, United States,

 

83

3-6

 

World urbanization trends, 1950–2030,

 

84

3-7

 

International tourist arrivals, 1950–2020,

 

102

3-8

 

International agriculture trade, 1961–2000,

 

103

3-9

 

Reported diptheria cases in the Soviet Union and the Newly Independent States,

 

116

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Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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3-10

 

Diagram of influenza virus,

 

140

3-11

 

The reservoir of influenza A viruses,

 

141

3-12

 

Direct transmission of avian influenza viruses to humans,

 

142

4-1

 

Global surveillance of communicable diseases: a network of networks,

 

155

4-2

 

Three-year treatment with indinavir, zidovudine, and lamivudine,

 

200

B-1

 

EMS respiratory call syndrome 99 percent threshold precedes influenza sentinel physician surveillance by 2–3 weeks, 1999– 2001,

 

296

B-2

 

Gastroenteritis syndrome count, ESSENCE, San Diego, 2002,

 

306

E-1

 

Continuous wavelet transform decomposition of 1928–1964 Baltimore measles time series data,

 

337

E-2

 

Visual display of a two-dimensional agent-based model,

 

338

E-3

 

Internet routing map (80,000 nodes),

 

339

E-4

 

Representation of evolving bit strings in a fitness landscape,

 

340

TABLES

2-1

 

Leading Infectious Causes of Death Worldwide, 2001,

 

26

2-2

 

Examples of Recent Emerging and Re-Emerging Infectious Diseases,

 

34

2-3

 

Infections Associated with Chronic Conditions,

 

42

3-1

 

World Megacities, 1975, 2000, and (Projected) 2015: Population in Millions,

 

85

3-2

 

Organ Transplants Performed and Patients Awaiting Transplants in 2001,

 

96

4-1

 

Selected Sentinel Surveillance Systems for Monitoring Infectious Diseases,

 

168

4-2

 

Antibiotics and Antivirals in Development,

 

192

4-3

 

Stages of Virus Replication and Possible Targets of Action of Antiviral Agents,

 

199

4-4

 

Approved Antiretroviral Drugs,

 

201

B-1

 

Syndromic Surveillance: Characteristics, Advantages, and Disadvantages,

 

286

B-2

 

Selected Syndromic Surveillance Systems: Domestic,

 

302

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BOXES

2-1

 

The End of Infectious Diseases in the United States?,

 

24

2-2

 

Diseases/Agents of Biological Warfare,

 

47

3-1

 

Factors in Emergence,

 

54

3-2

 

The Microbiome,

 

58

3-3

 

Fungal Threats,

 

66

3-4

 

An Outbreak of Cryptosporidiosis,

 

67

3-5

 

Rift Valley Fever,

 

69

3-6

 

Nipah Virus,

 

72

3-7

 

The Changing Demographics of Child Care in the United States,

 

79

3-8

 

Sexually Transmitted Diseases,

 

89

3-9

 

A Behavior Paradox,

 

90

3-10

 

E. Coli O157:H7,

 

91

3-11

 

Neisseria meningitidis: A Sacred Peril,

 

98

3-12

 

West Nile Virus,

 

100

3-13

 

Shigella sonnei: A Garnish of Parsley?,

 

105

3-14

 

Transmissible Spongiform Encephalopathies: From Herd to Mortality,

 

108

3-15

 

Ebola Virus,

 

113

3-16

 

The Breakdown of Vector Control,

 

120

3-17

 

World Poverty Statistics,

 

123

3-18

 

Lost Windows of Opportunity,

 

128

3-19

 

Anthrax: Postmarked for Terror,

 

133

3-20

 

The 1918 Influenza Pandemic,

 

137

4-1

 

The World Health Organization Office in Lyon,

 

152

4-2

 

Global Outbreak Alert and Response Network,

 

157

4-3

 

Epidemic Information Exchange,

 

161

4-4

 

Emerging Infections Program,

 

166

4-5

 

Nationally Notifiable Infectious Diseases in the United States, 2003,

 

169

4-6

 

The Electronic Surveillance System for Early Notification of Community-Based Epidemics,

 

172

4-7

 

The Value of Autopsies,

 

178

4-8

 

Training in Foreign Animal Disease Control,

 

183

4-9

 

WHO Global Strategy for Antimicrobial Resistance,

 

210

4-10

 

Public Health Action Plan to Combat Antimicrobial Resistance,

 

212

B-1

 

Syndromic Surveillance Systems: Nomenclature,

 

284

B-2

 

Issues in Developing Syndromic Surveillance Systems,

 

290

B-3

 

Potential Data Sources for Syndromic Surveillance Systems,

 

294

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Acronyms


ABCs:

Active Bacterial Core Surveillance

AFO:

animal feeding operation

AIDS:

acquired immunodeficiency syndrome

APHIS:

Animal and Plant Health Inspection Service

APUA:

Alliance for the Prudent Use of Antibiotics

ARS:

Agricultural Research Service


BSE:

bovine spongiform encephalopathy

BSI:

blood stream infection


CAFO:

concentrated animal feeding operation

CAREC:

Caribbean Epidemiology Center

CDC:

Centers for Disease Control and Prevention

CIN:

cervical intraepithelial neoplasia

CJD:

Creutzfeldt-Jakob disease

CLIA:

Clinical Laboratory Improvement Amendments

CMV:

cytomegalovirus

CSTE:

Council of State and Territorial Epidemiologists

CWD:

chronic wasting disease


DARPA:

Defense Advanced Research Projects Agency

DHF-SS:

dengue hemorrhagic fever and shock syndrome

DNA:

deoxyribonucleic acid

DOD:

Department of Defense

Page xxvi Cite
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DOT:

directly observed therapy

DOTS:

directly observed therapy, short course

DTP:

diptheria, tetanus, and pertussis vaccine


EBV:

Epstein-Barr virus

EIP:

Emerging Infections Program

EIS:

Epidemic Intelligence Service

EMS:

Emergency Medical System

Epi-X:

Epidemic Information Exchange

ESSENCE:

Electronic Surveillance System for Early Notification of Community-Based Epidemics

EU:

European Union

EWORS:

Early Warning Outbreak Recognition System


FADDL:

Foreign Animal Disease Diagnostic Laboratory

FAO:

Food and Agriculture Organization

FDA:

Food and Drug Administration

FETP:

Field Epidemiology Training Programs

FIC:

National Institutes of Health Fogarty International Center for Advanced Study in the Health Sciences

FoodNet:

Foodborne Disease Active Surveillance Network


GAO:

General Accounting Office

GDP:

gross domestic product

GEIS:

Global Emerging Infections Surveillance

GIS:

geographic information system

GISP:

Gonococcal Isolate Surveillance Project

GOCO:

government owned, contractor operated

GPHIN:

Global Public Health Intelligence Network


HA:

hemagglutinin

HERV:

human endogenous retrovirus

HFRS:

hemorrhagic fever with renal syndrome

HHV-8:

human herpesvirus-8

HIV:

human immunodeficiency virus

HLA:

human leukocyte antigen

HMO:

health maintenance organization

HPS:

hantavirus pulmonary syndrome

HPV:

human papilloma virus

HRSA:

Health Resources and Services Administration

HSV:

herpes simplex virus

HTLV:

human T-cell lymphotropic viruses

HUS:

hemolytic uremic syndrome

Page xxvii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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ICC:

immunocytochemical

ICD-9:

International Classification of Diseases, 9th Revision

ICIDR:

International Collaborations in Infectious Disease Research

ICU:

intensive-care unit

IOM:

Institute of Medicine


KSHV:

kaposi’s sarcoma-associated herpesvirus


MDR:

multidrug-resistant

MDR-TB:

multidrug-resistant tuberculosis

MRSA:

methicillin-resistant Staphylococcus aureus


NA:

neuraminidase

NCHS:

National Center for Health Statistics

NEDSS:

National Electronic Disease Surveillance System

NETSS:

National Electronic Telecommunications System for Surveillance

NIAID:

National Institute of Allergy and Infectious Diseases

NIH:

National Institutes of Health

NNDSS:

National Notifiable Diseases Surveillance System

NNIS:

National Nosocomial Infections Surveillance System

NRC:

National Research Council

NSF:

National Science Foundation


OIE:

Office International des Epizooties


PAHO:

Pan American Health Organization

PCR:

polymerase chain reaction


QRNG:

fluoroquinolone-resistant Neisseria gonorrhoeae


rDNA:

ribosomal DNA

RNA:

ribonucleic acid

RSVP:

Rapid Syndrome Validation Program

RVF:

Rift Valley fever


SIV:

simian immunodeficiency viruses

SNV:

Sin Nombre virus

STD:

sexually transmitted disease

STI:

strategic treatment interruption

SV:

Simian virus

Page xxviii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press. doi: 10.17226/10636.
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TB:

tuberculosis

TLR:

TOLL-like receptors

TSE:

transmissible spongiform encephalopathy

TTV:

TT virus


UNAIDS:

Joint United Nations Programme on HIV/AIDS

UNICEF:

United Nations Children’s Fund

USAID:

U.S. Agency for International Development

USDA:

U.S. Department of Agriculture

UTI:

urinary tract infection


VA:

Department of Veterans Affairs

vCJD:

variant Creutzfeldt-Jakob disease


WHO:

World Health Organization

WTO:

World Tourism Organization


YF:

yellow fever

Page xxix Cite
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MICROBIAL THREATS TO HEALTH

EMERGENCE, DETECTION, AND RESPONSE

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Infectious diseases are a global hazard that puts every nation and every person at risk. The recent SARS outbreak is a prime example. Knowing neither geographic nor political borders, often arriving silently and lethally, microbial pathogens constitute a grave threat to the health of humans. Indeed, a majority of countries recently identified the spread of infectious disease as the greatest global problem they confront. Throughout history, humans have struggled to control both the causes and consequences of infectious diseases and we will continue to do so into the foreseeable future.

Following up on a high-profile 1992 report from the Institute of Medicine, Microbial Threats to Health examines the current state of knowledge and policy pertaining to emerging and re-emerging infectious diseases from around the globe. It examines the spectrum of microbial threats, factors in disease emergence, and the ultimate capacity of the United States to meet the challenges posed by microbial threats to human health. From the impact of war or technology on disease emergence to the development of enhanced disease surveillance and vaccine strategies, Microbial Threats to Health contains valuable information for researchers, students, health care providers, policymakers, public health officials. and the interested public.

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