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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. The Convergence of Infectious Diseases and Noncommunicable Diseases: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25535.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

THE CONVERGENCE OF INFECTIOUS DISEASES AND NONCOMMUNICABLE DISEASES V. Ayano Ogawa, Cecilia Mundaca Shah, Yamrot Negussie, and Anna Nicholson, Rapporteurs Forum on Microbial Threats Board on Global Health Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and EcoHealth Alliance; Infectious Diseases Society of America; Johnson & Johnson (10003710); Merck & Co., Inc.; National Institute of Allergy and Infectious Diseases/National Institutes of Health (10003226); Sanofi Pasteur; The University of Hong Kong; Uniformed Services University of the Health Sciences (10003626); U.S. Agency for International Development; U.S. Army Medical Research and Materiel Command (10001249); U.S. Centers for Disease Control and Prevention (10002642); U.S. Department of Homeland Security (10003591); U.S. Department of Veterans Affairs (10003353); and U.S. Food and Drug Administration (10002125). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25535 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. The convergence of infectious diseases and noncommunicable diseases: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25535. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE ON BREAKING DOWN SILOS: THE CONVERGENCE OF INFECTIOUS DISEASES AND NONCOMMUNICABLE DISEASES1 PETER DASZAK (Chair), President, EcoHealth Alliance DAVID BRETT-MAJOR, Sanford Chair in Tropical Medicine, Uniformed Services University of the Health Sciences KEIJI FUKUDA, School Director and Clinical Professor, School of Public Health, The University of Hong Kong JESSE L. GOODMAN, Professor of Medicine and Infectious Diseases, Director, Center on Medical Access, Safety, and Stewardship, Georgetown University KENT E. KESTER, Vice President and Head, Translational Science and Biomarkers, Sanofi Pasteur RIMA F. KHABBAZ, Director, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention PETER R. LAMPTEY, Distinguished Scientist and President Emeritus, FHI360 MOSA MOSHABELA, Dean and Head, School of Nursing and Public Health, University of KwaZulu-Natal RACHEL NUGENT, Vice President, Global Noncommunicable Diseases, RTI International JULIE PARSONNET, George DeForest Barnett Professor in Medicine, Professor of Medicine and of Health Research and Policy, Stanford University PADMA SHETTY, Senior Infectious Disease Advisor, Emerging Threats Division, U.S. Agency for International Development Health and Medicine Division and Board on Global Health Staff CECILIA MUNDACA SHAH, Project Director, Forum on Microbial Threats V. AYANO OGAWA, Senior Program Officer, Forum on Microbial Threats YAMROT NEGUSSIE, Program Officer, Forum on Microbial Threats (from August 2019) EDITH AMPONSAH, Research Associate, Forum on Microbial Threats (from August 2019) 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the rapporteurs and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

STEPHEN CHUKWURAH, Senior Program Assistant, Forum on Micro- bial Threats (from August 2019) NATALIE LUBIN, Research Assistant, Forum on Microbial Threats (until May 2019) JULIE PAVLIN, Director, Board on Global Health National Academy of Medicine Staff JARRETT NGUYEN, Program Specialist, National Academy of Medicine (from May 2019) BHUMI SHAH, Intern, National Academy of Medicine (from June to August 2019) vi PREPUBLICATION COPY—Uncorrected Proofs

FORUM ON MICROBIAL THREATS1 PETER DASZAK (Chair), President, EcoHealth Alliance KENT E. KESTER (Vice Chair), Vice President and Head, Translational Science and Biomarkers, Sanofi Pasteur MARY E. WILSON (Vice Chair), Clinical Professor of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco KEVIN ANDERSON, Senior Program Manager, Science and Technology Directorate, U.S. Department of Homeland Security TIMOTHY BURGESS, Director, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences DENNIS CARROLL, Director, Global Health Security and Development Unit, U.S. Agency for International Development EMILY ERBELDING, Director, Division of Microbiology and Infectious ­ Diseases, National Institute of Allergy and Infectious Diseases, ­ ational Institutes of Health N MARCOS A. ESPINAL, Director, Communicable Diseases and Health Analysis, Pan American Health Organization KEIJI FUKUDA, School Director and Clinical Professor, The University of Hong Kong School of Public Health JENNIFER GARDY, Senior Scientist, BC Centre for Disease Control; Associate Professor, School of Population and Public Health, University of British Columbia, Canada JESSE L. GOODMAN, Professor of Medicine and Infectious Diseases; Director, Center on Medical Product Access, Safety, and Stewardship, Georgetown University EVA HARRIS, Professor, Division of Infectious Diseases and Vaccinology, University of California, Berkeley ELIZABETH D. HERMSEN, Head, Global Antimicrobial Stewardship, Merck & Co., Inc. RIMA F. KHABBAZ, National Center for Emerging and Zoonotic ­ nfectious Diseases, U.S. Centers for Disease Control and Prevention I MICHAEL MAIR, Acting Director, Office of Counterterrorism and Emerging Threats, U.S. Food and Drug Administration JONNA A. K. MAZET, Professor of Epidemiology and Disease Ecology; Executive Director, One Health Institute, School of Veterinary Medicine, University of California, Davis 1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

SALLY A. MILLER, Professor of Plant Pathology and State Extension Specialist for Vegetable Pathology, Ohio Agricultural Research and Development Center, The Ohio State University SUERIE MOON, Director of Research, Global Health Centre, Graduate Institute of International and Development Studies, Geneva DAVID NABARRO, Advisor, Health and Sustainability, 4SD—Skills, Systems, and Synergies for Sustainable Development RAFAEL OBREGON, Chief of Communications for Development, United Nations Children’s Fund KUMANAN RASANATHAN, Board Member, Health Systems Global GARY A. ROSELLE, Chief of Medical Service, Veterans Affairs Medical Center; Director, National Infectious Disease Services, Veterans Health Administration PETER A. SANDS, Executive Director, The Global Fund to Fight AIDS, Tuberculosis and Malaria THOMAS W. SCOTT, Distinguished Professor, Department of Entomology and Nematology, University of California, Davis JAY P. SIEGEL, Retired Chief Biotechnology Officer, Head of Scientific Strategy and Policy, Johnson & Johnson PAIGE E. WATERMAN, Assistant Director for Biological Threat Defense, White House Office of Science and Technology Policy MATTHEW ZAHN, Medical Director, Division of Epidemiology and Assessment, Orange County Health Care Agency Health and Medicine Division and Board on Global Health Staff CECILIA MUNDACA SHAH, Project Director, Forum on Microbial Threats V. AYANO OGAWA, Senior Program Officer, Forum on Microbial Threats YAMROT NEGUSSIE, Program Officer, Forum on Microbial Threats (from August 2019) EDITH AMPONSAH, Research Associate, Forum on Microbial Threats (from August 2019) STEPHEN CHUKWURAH, Senior Program Assistant, Forum on Microbial Threats (from August 2019) NATALIE LUBIN, Research Assistant, Forum on Microbial Threats (until May 2019) JULIE PAVLIN, Director, Board on Global Health National Academy of Medicine Staff JARRETT NGUYEN, Program Specialist, National Academy of Medicine (from May 2019) viii PREPUBLICATION COPY—Uncorrected Proofs

Reviewers T his Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: TOM FRIEDEN, Resolve to Save Lives, Initiative of Vital Strategies RACHEL NUGENT, RTI International JULIE PARSONNET, Stanford University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by DAVID R. CHALLONER, University of Florida. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. ix PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments T he Forum on Microbial Threats staff and planning committee deeply appreciate the many valuable contributions from individuals who assisted us with this project. Thank you to Charlanne Burke, Bridgette Charles, and Naveen Rao for graciously hosting the workshop at The Rockefeller Foundation, and Tara Hoda and Anthony Ramos from the EcoHealth Alliance for their invaluable assistance organizing the logistics of the workshop. The workshop and this Proceedings of a Workshop would not be possible without the presenters and discussants at the workshop, who gave so generously of their time and expertise. A full list of the speakers and moderators and their biographical information may be found in Appendix C. xi PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xix 1 INTRODUCTION 1 Workshop Objectives, 3 Organization of the Proceedings of the Workshop, 4 2 AN OVERVIEW OF COLLIDING EPIDEMICS AND SYNDEMICS 7 Convergent Action for Colliding Epidemics of Infectious and Noncommunicable Diseases, 7 Syndemics of Infectious and Noncommunicable Diseases, 16 Discussion, 20 3 EMERGING RESEARCH ON ASSOCIATIONS BETWEEN INFECTIOUS AND NONCOMMUNICABLE DISEASES 23 Alzheimer’s Disease and P. gingivalis, 24 Epstein-Barr Virus in Autoimmune and Inflammatory Diseases, 28 Role of the Microbiome in Food Allergies, 31 Discussion, 34 4 RISKS POSED BY CHRONIC DISEASES TO THE DEVELOPMENT AND SEVERITY OF INFECTIOUS DISEASES 39 Metabolic Syndrome and the Risk for Enteric Infection, 39 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv CONTENTS Converging Epidemics of Diabetes and Tuberculosis, 42 Discussion, 46 5 MICROBIAL DIMENSION TO HUMAN DEVELOPMENT AND WELL-BEING 51 Influence of the Microbiome, 51 Global Microbial Biodiversity Crisis, 52 Complexity of the Human Microbiome, 53 Research Directions to Explore Microbiome Complexity, 56 Discussion, 60 6 CONFRONTING “THE BLIND PEOPLE AND THE ELEPHANT” METAPHOR TO BRIDGE THE SILOS 65 Examining the Challenges and Opportunities of the Convergence, 66 Language and Conceptual Barriers, 71 Discussion, 73 Converging Toward the Middle, 75 7 INTEGRATING HEALTH CARE DELIVERY MODELS AND INTERVENTIONS 77 HIV and Noncommunicable Disease Integration Platforms, 78 The AMPATH Model in Kenya, 83 Addressing the Convergence with Integration Science, 85 Mass Administration of Antibiotics to Reduce Child Mortality, 89 Discussion, 92 8 POTENTIAL APPROACHES FOR RESEARCH, POLICY, AND PRACTICE IN THE IMMEDIATE TERM 97 Potential Priority Strategies and Actions from Table Group Discussions, 97 Discussion, 100 9 VISIONARY STATEMENTS ON POTENTIAL PRIORITIES TO ADDRESS THE CONVERGENCE 105 Adapting Public Health Practice in Africa to a New Understanding of Microbes and Health, 105 A Multifaceted Understanding of the Convergence, 109 Rethinking and Reframing Efforts to Address the Convergence, 113 Final Synthesis Discussion, 116 Closing Remarks, 121 REFERENCES 123 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xv APPENDIXES A STATEMENT OF TASK 145 B WORKSHOP AGENDA 147 C SPEAKER BIOGRAPHIES 151 PREPUBLICATION COPY—Uncorrected Proofs

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Boxes, Figures, and Tables BOXES 2-1 Esther’s Narrative, 19 5-1 Future Tools for Personalized Microbiome Tracking, 59 FIGURES 2-1 Crude death rate by country income status, 2015, 9 2-2 Risk factors shared between infectious and noncommunicable diseases, 12 3-1 Oral P. gingivalis infection induces Alzheimer’s disease pathology after 22 weeks, 27 3-2 Some species of microbes keep humans healthy, 34 5-1 Linkages among the microbiome, metabolites, and diseases, 52 5-2 Map of the human microbiome, 54 7-1 The long tail of global health equity in Rwanda, 86 9-1 Public health impact pyramid, 107 xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii BOXES, FIGURES, AND TABLES TABLES 2-1 Spectrum of Exposures, Health Services, and Potential Outcomes, 13 7-1 HIV Program Functions Are Applicable to Many Noncommunicable Diseases, 81 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations BMI body mass index CDR crude death rate CMA cow’s milk allergy CVDRF cardiovascular disease risk factor DALY disability-adjusted life year EBV Epstein-Barr virus GWAS genomewide association study HMP Human Microbiome Project HPV human papillomavirus NCD noncommunicable disease OTU operational taxonomic unit PEPFAR The President’s Emergency Plan for AIDS Relief TB tuberculosis xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACRONYMS AND ABBREVIATIONS USAID U.S. Agency for International Development WHO World Health Organization PREPUBLICATION COPY—Uncorrected Proofs

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On June 11 and June 12, 2019, the National Academies convened a workshop to explore the growing understanding of how the interplay between humans and microbes affects host physiology and causes noncommunicable diseases. Discussions included an overview of colliding epidemics, emerging research on associations between infectious and noncommunicable diseases, risks posed by chronic diseases to the development and severity of infectious diseases, and the influence of the microbiome. Workshop participants also examined the challenges and opportunities of convergence, the integration of health care delivery models and interventions, potential approaches for research, policy, and practice in the immediate-term, and potential directions for the long-term. This publication summarizes the presentations and discussions from the workshop.

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