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2. Spectrum of Microbial Threats
Pages 23-52

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From page 23...
... Most developing nations have not shared fully in the public health and technological advances that have aided in the fight against infectious disease in the United States a fight that some had hoped would come close to eliminating these threats in this country (see Box 2-1~. In developing countries, clean water is scarce; sewage systems are overwhelmed or nonexistent; the urban metropolis is growing exponentially as the global market economy expands and rural agricultural workers migrate to cities; and economic need, political conflict, and wars are displacing millions of people and creating growing refugee populations (see Chapter 3~.
From page 24...
... This chapter begins by reviewing the global burden imposed by three of today's most devastating infectious diseases: AIDS, TB, and malaria. Other emerging infectious diseases and antimicrobial-resistant infections are discussed in the subsequent two sections.
From page 25...
... SPE CTR UM OF MICR OBIAL THREATS ' A.' 25 THE GLOBAL BURDEN OF AIDS, TUBERCULOSIS, AND MALARIA Efforts to reduce the global burden of infectious diseases must concentrate on AIDS, TB, and malaria. Combined, these three diseases could account for 500 million or more illnesses a year and at least 6 million deaths (WHO, 2002a)
From page 26...
... Specific projections of the number of anticipated HIV/AIDS cases are difficult because the incidence of HIV infection is declining in some populations and increasing in others, HIV-testing continues to be voluntary, and reporting may be incomplete. Generally, the number of cases is expected to rise in areas where poverty, poor health systems, poor access to health care services, and gender inequality are prevalent; where resources for health care and prevention are limited; and where a high degree of stigma and denial is associated with HIV infection (Monitoring the AIDS Pandemic Network, 2000~.
From page 27...
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From page 28...
... Together, these countries will account for 50 million to 75 million cases of HIV infection by 2010 (National Intelligence Council, 2002~. In northeast India, the widespread use of illicit injection drugs accounts for most HIV transmission; in other parts of the country, most cases of infection appear to have been acquired through contact with infected sex workers.
From page 29...
... Improved socioeconomic conditions, improved public health services, and the effectiveness of the antituberculosis therapies developed in the mid-twentieth century maintained a steady decline in TB through the early 1980s. The decreased public health focus on TB in the United States that occurred toward the end of the twentieth century, combined with increasing rates of homelessness and drug abuse, the growing HIV/AIDS epidemic, and increasing immigration rates from countries with high TB prevalence, led to a resurgence of the disease in the United States that peaked in 1992.
From page 30...
... . If present trends continue, more than 10 million new cases of TB are expected to occur in 2005, mainly in Africa and Southeast Asia; by 2020, nearly 1 billion people will be newly infected, 200 million will develop the disease, and 35 million of them will die (WHO, 2002a)
From page 31...
... Between 1990 and 1996, malaria increased as much as 100fold in certain southern regions of the former Soviet Union; more recently, it has begun to emerge even as far north as Moscow (Fayer, 2000~. Only a few isolated cases or small outbreaks have occurred in the United States, in areas where individuals with imported disease have provided a reservoir of infection for local-vector mosquitoes that have subsequently transmitted the infection to persons from that locality (Olliaro et al., 1996~.
From page 32...
... Figure 2-2 and Table 2-2 provide examples of several emerging infectious diseases identified by scientists in the final decades of the twentieth century. These examples include some diseases that have been known for decades, but have reemerged in new geographic locations and/or in newer, more deadly, drug-resistant forms.
From page 33...
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From page 38...
... Antimicrobial resistance may represent a more profound hindrance to TB prevention and control efforts than is the case with HIV, in that antituberculin drugs can cure the infected individual and also Prevent sub~ 1 , , _ , ,, ~ sequent infection of others. In 1997 more than 50 million cases of TB worldwide were resistant to one or more drugs (WHO, 1998a)
From page 39...
... Although MRSA infections are much more likely to develop in hospitals and long-term care facilities than in the general healthy population, several recent deaths due to MRSA infection in previously healthy children show that the condition is now circulating outside of hospitals (Groom et al., 2001~. Moreover, the incidence of MRSA in prison populations is unexpectedly high for non-health care settings (CDC, 2001b)
From page 40...
... and frequency of pneumococci with reduced susceptibility to fluoroquinolones in Canada according to the patient's age (bars)
From page 41...
... The era of molecular biology and intensive research efforts in the field of AIDS have led to powerful advances in technology for the sensitive detection of infectious agents. These diagnostic tools, plus the realization that organisms of otherwise unimpressive virulence can produce slowly progressive chronic disease with a wide spectrum of clinical manifestations and disease outcomes, have resulted in the discovery of new infectious agents and new concepts in the understanding of infectious diseases.
From page 42...
... Human immunodeficiency viruses (HIV-1, HIV-2) Guillain-Barre syndrome Lyme arthritis Peptic ulcer disease Gastric adenocarcinoma Gastric lymphoma Immunoproliferative small intestinal disease Mucosa-associated lymphoid tissue lymphoma Infertility Atherosclerosis Arthritis Reiter's syndrome Hemolytic uremic syndrome Post-herpetic neuralgia Congenital mental retardation Congenital mental retardation Kaposi's sarcoma Primary effusion lymphoma Castleman's disease Hepatocellular carcinoma Hepatocellular carcinoma Genital carcinomas (cervical, penile, vulvar, anal)
From page 43...
... and chronic asthma in adults (Sabato et al., 1984; Seggev et al., 1986; Yano et al., 1994; Henderson et al., 1979~. It has been estimated that more than 15 percent of cancersincluding more than 50 percent of stomach and cervical cancers and 80 percent of liver cancers could be avoided by preventing the associated infectious diseases (WHO, 1996~.
From page 44...
... In addition, infectious agents lead to an increase in other factors, such as C-reactive protein, that may play a causal role in atherosclerosis. Human Papillomaviruses and Cervical Cancer Cervical cancer is one of the most common malignant diseases of women.
From page 45...
... Many people, however, have a genital HPV infection without genital warts. Today, it is well established that infection with certain HPV types is the central causal factor in cervical cancer (Franco et al., 2001; Holly, 1996; International Agency for Research on Cancer Working Group, 1995; Koutsky et al., 1992; Nobbenhuis et al., 1999; Shah, 1997~.
From page 46...
... The United States has been rather complacent about the threat of bioterrorism until recently. A number of factors could account for this complacency, including insufficient intelligence concerning which nations and states have weaponized infectious agents, a naivete regarding the ease with which biological agents can be obtained and weaponized using today's molecular and biological technology, a general lack of familiarity and skepticism with regard to the dangers of biological weapons, the unpredictable nature of a bioterrorist attack, and little supporting evidence that biological weapons have been widely used thus far.
From page 48...
... Since the l950s, one of these strains has been used as a live attenuated vaccine in humans in countries of the former Soviet Union. An inactivated cell-free product is currently used in the United States to vaccinate military personnel and laboratory workers.
From page 49...
... Several features make it an attractive bioterrorist agent: it is moderately stable; it is infectious by droplets and aerosol; it is moderately contagious; and, because vaccination against smallpox ceased after eradication in 1980, most of the worId's population is highly susceptible to infection. While a smallpox vaccine exists, several bioterrorism-related issues regarding prophylactic smallpox vaccination are unresolved (IOM, 2003~.
From page 50...
... The vaccine has been recommended for use in people who work routinely with the organism in the laboratory, but how useful it would be among first responders at high risk for exposure is unknown. Botulinum Toxin Botulinum toxin has several features that make it an attractive bioweapon, including its extreme potency and lethality; the ease of its production, transport, and misuse; and its profound impact on its victims as well as the health care infrastructure.
From page 51...
... C, D, and E, and not F and G; it is very painful to receive; it requires a booster at 1 year; and its use deprives the recipient of access to medicinal botulinum toxin for life. The army has developed an equine antitoxin that provides coverage against all seven serotypes, but the supply is limited, and the drug carries the risk of serious allergic reaction.
From page 52...
... A number of factors could account for this complacency, including insufficient intelligence concerning which nations and states have weaponized infectious agents, a naivete regarding the ease with which biological agents can be obtained and weaponized using todays molecular and biological technology, a general lack of familiarity and skepticism with regard to the dangers of biological weapons, the unpredictable nature of a bioterror~st attack, and little supporting evidence that biological weapons have been widely used thus far. Recent reports have reviewed the threat of biote~Torism (e.g., National Commission on Terrorism, 2000)


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