Infectious Diseases Continue to Be the Foremost Cause of Death Worldwide

Our national interests are inevitably linked to the health of people throughout the world. Health, like education, is an investment in human capital that can help break cycles of poverty and political instability— contributing to national and global economic development—and is of fundamental importance in shaping the stability and well-being of a nation or region. The tragedy of HIV/AIDS in Africa has deeply scarred large regions of the continent, and it threatens to undermine economic progress, institutional strength, and the survival of family units. Although less visible than the AIDS epid-emic, the human toll of economic hardship and social instability in Russia has resulted in a 10-year decrease in life expectancy for men, and an over 40 percent decrease in birth rate from the mid-80s to the mid-90s, far lower than the replacement rate needed to sustain population levels, the economy, and current standards of living. These are only two examples of global health events that could threaten peace, prosperity, and international relationships in the decades to come. The global reach of emerging infectious diseases can be more immediate. Within days of the issuance of Microbial Threats to Health Emergence, Detection, and Response (2003), the SARS epidemic burst into worldview, reminding us that a pandemic can emerge with astonishing speed and spread globally in a matter of weeks. Shortly thereafter, bovine spongiform encephalopathy (Mad Cow Disease) and monkeypox emerged for the first time in the Americas.

Health, like education, is an investment in human capital…

The IOM contributes to improved global health through studies that advise on how to reduce the burden of disease and disability in developing countries, that illuminate emerging threats to international and global health, and that emphasize infectious diseases—the most truly global threats to health.

INFECTIOUS DISEASE

Infectious diseases today ignore geographic and political boundaries, and thus constitute a global threat that places every nation and every person at risk. Food products, livestock, exotic pets, and material goods and the microbes they carry are exchanged as cultures from every region of the world are explored. —Microbial Threats to Health, 2003

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. Through both committee studies and convening activities, the IOM assesses emerging threats, the capacity of national and international systems to respond to those threats, and the research and other investments necessary to mount an adequate response.

Microbial Threats to Health: Emergence, Detection, and Response (2003) concludes that the public health and medical communities in the United States are inadequately prepared to deal effectively with infectious diseases. The report extends and expands upon a 1992 IOM report, Emerging Infections: Microbial Threats to Health in the United States, which brought this issue to national attention and stimulated research efforts and policy actions. The new report describes scientific, social, and political trends that have influenced infection and disease emergence and control over the past decade. New or previously unrecognized diseases (such as SARS) have emerged, and known diseases that were thought to be virtually eradicated in the U.S. (such as measles and pertussis) have reappeared, occasionally in epidemic proportions. The report reviews the current state of knowledge on how infectious diseases emerge and identifies opportunities for public health actions, both domestic and worldwide, to strengthen capabilities for detecting and responding to microbial threats and preventing the spread of infectious diseases. It calls on the United States to make significant efforts to enhance the global capacity for responding to microbial threats, focusing in particular on threats in the developing world. This will require providing technical and financial assistance, expanding research and surveillance, and sharing knowledge and best public health practices across national boundaries. Among other recommendations, the report stresses the need for federal, state, and local governments to rebuild and sustain the infrastructure of the U.S. public health system, which has suffered from years of neglect.

Leading Infectious Causes of Death Worldwide, 2001

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Cause	Rank	Estimated Number of Deaths
Respiratory infections	1	3,871,000
HIV/AIDS	2	2,866,000
Diarrheal diseases	3	2,001,000
Tuberculosis	4	1,644,000
Malaria	5	1,124,000
Measles	6	745,000
Pertussis	7	285,000
Tetanus	8	282,000
Meningitis	9	173,000
Syphilis	10	167,000

An effective surveillance system is critical to detect and monitor infectious disease, both within the U.S. and globally. In 1996, the Executive Office of the President, acting on advice from its National Science and Technology Committee, issued a directive declaring that U.S. citizens were not being adequately protected from emerging infectious diseases. The directive (NSTC-7) stated that national and international capabilities for monitoring, responding to, and preventing infectious diseases were insufficient, and it called for a more robust national policy to improve these capabilities. Among actions taken in response, the Department of Defense in 1997 established the Global Emerging Infections Surveillance and Response System (GEIS). After several years of operation, managers of the GEIS asked IOM to conduct an independent evaluation of the system's structure and progress. Perspectives on the Department of Defense Global Emerging Infections Surveillance and Response System (2001) concludes that the GEIS is well organized, satisfies the requirements prescribed by the Presidential Directive, and comprises an appropriate response to the threat posed to national security by emerging infectious diseases. Although still in its early stages, the GEIS has made substantial progress toward achieving its goals in protecting the health of U.S. military and civilian populations, as well as global health interests. The report recommended some refinements—such as increasing the number of personnel who have applied epidemiological expertise, expanding training programs, and broadening communications efforts to include public health partners— and called for the government to increase financial support for the system to help ensure its long-term success.

Unlike viruses and microorganisms—the agents of most known infectious diseases—prions are an abnormally shaped form of a normal mammalian protein. Identified in 1982, prions appear to be associated with a group of uniformly fatal neurodegenerative diseases called transmissible spongiform encephalopathies (TSEs), which include "Mad Cow Disease." Conventional methods useful to diagnose most infectious diseases fail to detect TSEs. There is no cure, prophylaxis, or fail-safe antemortem diagnostic test for TSEs. A decade's worth of attempts to develop effective prion-detection tests have largely failed. Consequently, the U.S. Department of Defense launched the National Prion Research Program in 2002 with $42.5 million and requested the assistance of the IOM to review scientific knowledge about TSEs and to recommend the highest-priority research for funding. Advancing Prion Science: Guidance for the National Prion Research Program (2003) concludes that progress in developing an antemortem diagnostic test to detect prions will be slow unless fundamental questions are answered about the molecular biology of prions and the normal prion protein from which it is derived. The committee stressed that the infrastructure capability for research on TSEs in the U.S. is limited due to constraints in funding, lab facilities, and number of investigators trained in this highly specialized area. International collaboration offers opportunities to expand that capacity.

…prions appear to be associated with a group of uniformly fatal neurodegenerative diseases called transmissible spongiform encephalopathies (TSEs), which include "Mad Cow Disease."

Antimalarials

Malaria remains the leading killer of children in Africa and a significant cause of morbidity among adults and children in Africa, Asia, and focally, in other parts of the world. Resistance to inexpensive antimalarial drugs is widespread, and few effective drugs—even expensive ones—exist to fill the current need, which is growing. An upcoming IOM report will examine evolving patterns of malaria (including drug resistance) and the options forcontrolling it, with the aim of developing policy strategies, particularly financing strategies, that could lead to the greatest good for those most affected, as well as for the larger population at risk. The potential for incremental improvement of existing, new antimalarials through pharmaceutical technology also will be explored.

FORUM ON MICROBIAL THREATS

The challenges posed by infectious diseases demand concerted and coordinated efforts along a number of fronts, from treating individual patients and preventing the spread of disease within communities to shaping public policies in the United States and worldwide. The IOM's Forum on Microbial Threats, created in 1996, fosters wide-ranging discussions among the various parties who share a stake in improving the prevention, detection, and management of these diseases. Forum workshops provide timely opportunities for representatives from academia, industry, professional and interest groups, and government to discuss, in a neutral setting, critical and sometimes contentious issues. Such cross-sector dialogue has helped in establishing priorities for research and public health policy, identifying areas in need of greater attention, and illuminating opportunities for more effective collaboration between the private and public sectors. Recent workshop reports include:

• Emerging Infectious Diseases from the Global to the Local Perspective (2001). Infectious diseases are the world's greatest killers, accounting for more than 13 million deaths annually among children and young adults alone. Most deaths from infectious diseases occur in developing countries, where they account for half of all deaths. But no region is free from concern, and every inhabited continent regularly experiences large outbreaks of some type of infectious disease. The IOM report concludes that fighting the global spread of infectious diseases will take political resolve and sufficient financial resources. The workshop brought together key representatives from the Americas, Africa, Asia and the Pacific, and Europe. They surveyed such issues as the factors that contribute to the emergence of infectious diseases, efforts to coordinate surveillance activities and responses within and across borders, and remaining needs for research and resources. In the report, participants stressed that the world community must work toward a set of common goals. Among these goals are strengthening disease surveillance of humans and domestic animals (which can pass diseases to humans), fostering good public health practices, expanding training programs, conducting collaborative research in a number of targeted areas, and accelerating vaccine development and distribution.

• The Emergence of Zoonotic Diseases: Understanding the Impact on Animal and Human Health (2002). Diseases passed to humans from animals—zoonoses—are leading causes of illness and death in many nations, and they negatively affect commerce, travel, and economies worldwide. Many factors influence the emergence and spread of zoonoses, ranging from molecular interactions in microbes to forces that trigger the growth and movement of populations and changes in the environment. There also is concern about the potential use of zoonotic agents as "bioweapons" by terrorists. The IOM report explores the forces that drive zoonotic diseases and offers some broad-based strategies that will help the United States and the world in preventing and controlling them. Participants cited a need to expand research in a variety of areas, including the pathogenesis of zoonotic agents and the development of vaccines; to enhance national and international laboratory capabilities; to strengthen surveillance systems that can provide early warning for emerging zoonoses; and to mount education programs to increase public awareness of the problems and minimize undue fears. Perhaps the most fundamental need is for improved collaboration and cooperation among government agencies at all levels, as well as among members of the human health, veterinary, wildlife health communities.

• Considerations for Viral Disease Eradication: Lessons Learned and Future Strategies (2002). The success in using vaccines to eradicate smallpox suggests the possibility of eradicating many other viral diseases that once were considered beyond hope. Indeed, the eradication of several diseases, including polio and measles, is on the horizon. This prospect raises the importance of addressing early on a range of issues likely to surround the cessation of immunization and other prevention activities. The IOM report examines the biological challenges, medical interventions, and operational considerations to be faced and highlights efforts that may facilitate wise decision-making in the post-eradication era. Participants particularly emphasized that eradication must not beget complacency. Reemergence of a virus—or its intentional reintroduction—will remain a threat, especially as immunity wanes and the population at large grows more susceptible to infection. Enough vaccine should be stockpiled (or provision made for emergency replenishment) to cope with any outbreaks that might arise, and surveillance should continue to quickly identify local outbreaks before they can spread. Among other actions, it is vital to continue research on viral biology and vaccine technology, and to make sure that remaining viral stocks—if it is deemed necessary to maintain such stocks—be securely contained.

• In the wake of September 11 and recent anthrax events, our nation's bioterrorism response capability has become an imminent priority for policymakers, researchers, public health officials, academia and the private sector. In a three-day workshop that was captured in a workshop summary titled Biological Threats to Terrorism: Assessing the Science and Response Capabilities (2002), experts from each of these communities came together to identify, clarify, and prioritize the next steps that need to be taken in order to prepare and strengthen bioterrorism response capabilities. From the discussions, it became clear that of utmost urgency is the need to cast the issue of a response in an appropriate framework to attract the attention of Congress and the public in order to garner sufficient and sustainable support for such initiatives. No matter how the issue is framed, numerous workshop participants agreed that there are many gaps in the public health infrastructure and countermeasure capabilities that must be prioritized and addressed in order to assure a rapid and effective response to another bio-terrorist attack.

• The Resistance Phenomenon in Microbes and Infectious Disease Vectors: Implications for Human Health and Strategies for Containment (2003). Resistance in bacteria, viruses, and protozoa to therapeutic agents is an increasing challenge. More microbes are becoming resistant to moredrugs, thereby reducing the power of drugs for combating infectious diseases. The IOM report discusses the causes and consequences of drug resistance in microbes and examines current and potential strategies for mitigating its impact on human health. Participants stressed that the emergence of resistance must be recognized as an integral part—not an aberrant part—of microbial life. Developing a fuller understanding of how microbes evolve when faced with drugs may lead to innovative ways to bring them under control. Additionally, the report examines the influence of pesticide and insecticide resistant infectious disease vectors on control measures for diseases such as malaria. Other suggestions for action include fully implementing national and international programs being developed to contain microbial resistance, expanding surveillance efforts to ensure early detection of problems, supporting scientific and epidemiological studies in targeted areas, strengthening professional education and training, and conducting economic studies to both inform policy making and suggest incentives for encouraging individuals and institutions to adopt practices that will help limit the spread of antimicrobial resistance.

Figure

Emerging and Re-emerging Infectious Diseases, 1996–1997. SOURCE: Emerging Infectious Diseases from the Global to the Local Perspective: Workshop Summary, 2001, page 3.

There also is concern about the potential use of zoonotic agents as "bioweapons" by terrorists…

…our nation's bioterrorism response capability has become an imminent priority for policymakers, researchers, public health officials, academia and the private sector.

IMPROVING CARE IN THE DEVELOPING WORLD

Brain disorders now affect at least 250 million people in the developing world, and this number is expected to increase as more people live to old age. Brain disorders encompass a wide range of disabling conditions, including epilepsy, stroke, schizophrenia, unipolar depression, bipolar disorder, mental retardation, cerebral palsy, and autism. Yet public and private health systems in developing countries have paid relatively little attention to brain disorders, concentrating instead on the major communicable diseases. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World (2001) concludes that there are effective and affordable ways to treat or even prevent many brain disorders in developing countries, and it presents a comprehensive plan designed to help these countries help their citizens who have or are at risk of developing epilepsy, schizophrenia, depression, or other such disorders. The report outlines strategies that can be implemented immediately in developing countries, such as increasing public and professional awareness and understanding of brain disorders, extending and strengthening systems of primary care to deliver health services for brain disorders, and making cost-effective interventions available to patients who will benefit. It also proposes strategies for creating better options for the future. Actions include assessing the cost-effectiveness of specific treatments and health services in local settings and monitoring the incidence, prevalence, and burden of brain disorders in developing countries; creating national centers in developing countries to carry out training and research on brain disorders, and linking these centers with institutions in high-income countries; and crafting and funding global programs devoted to improving understanding of brain disorders in the developing world.

The death of a mother, fetus, or newborn is tragic wherever it occurs. While relatively rare in the industrialized world, these deaths are considerably more common in developing countries, accounting for the vast majority of the 515,000 maternal deaths; 4 million late fetal deaths; and 4 million neonatal deaths conservatively estimated to occur each year. Most of these deaths occur between late pregnancy and the end of the first week of a child's life. Each year, more than 4 million children are born with birth defects, one of the major causes of death in newborns. A set of companion reports, Improving Birth Outcomes: Meeting the Challenges in the Developing World (2003) and Reducing the Impact of Birth Defects: Meeting the Challenges in the Developing World (2003), review the evidence on interventions that can improve birth outcomes and reduce birth defects. The Outcomes report recognizes the important role of women's education, social, and economic status on birth outcomes. It also reviews the available statistics on major causes of maternal and neonatal mortality and morbidity and of fetal loss, summarizes current knowledge and practice with regard to a healthy pregnancy, and identifies cost-effective opportunities for improving birth outcomes. Three adverse birth outcomes are addressed in more detail: low birthweight; birth defects; and perinatal transmission of HIV/AIDS. The report concludes that a skilled birth assistant should attend every birth.

Accessible essential obstetric and neonatal care facilities are also necessary. The Defects report highlights the unprecedented opportunity to improve the lives of children and families in developing countries by preventing some birth defects and reducing the consequences of some others. The report concludes that incidence and burden of certain birth defects can be reduced at very low costs and recommends increased collection of epidemiological data and increased genetic screening.

Selected Recommendations for Health Sciences Research

The Role of Large-Scale Science: NIH and other federal funding agencies that support large-scale biomedical science should develop a more open and systematic method for assessing important new research opportunities emerging from the scientific community in which a large-scale approach is likely to achieve the scientific goals more effectively or efficiently than traditional research efforts. (Large-Scale Biomedical Science: Exploring Strategies for Future Research, 2003)

Protecting Research Participants: Federal regulations should be extended to include every research project that involves human participants, regardless of the source of funding or the setting.

The Institutional Review Board (IRB), as the principal representative of the interests of potential research participants, should focus on the ethical aspects of protecting participants with other organizational units taking responsibility for risk management and regulatory compliance.

The informed consent process should be an ongoing, interactive dialogue between research staff and research participants that includes an assessment of participants' understanding of the discussion. (Responsible Research: A Systems Approach to Protecting Research Participants, 2002)

Focus on Integrity in Research: Funding agencies should establish research grant programs to identify, measure, and assess those factors that influence integrity in research. Also, each research institution should develop and implement a comprehensive program designed to promote integrity in research, using multiple approaches adapted to the specific environments within each institution.

Institutions should implement effective educational programs that enhance the responsible conduct of research. (Integrity in Scientific Research, 2002)

Expanding Research on the Role of Sex in Human Health: Promote research on sex at the cellular level; study sex differences over a lifetime; and examine genetic variability, disorders of sex differentiation, reproductive status, and environmental influences to better understand human health. Also, expand research on sex differences in brain organization and function. Monitor sex differences and similarities for all human diseases that affect both sexes. (Exploring the Biological Contributions to Human Health: Does Sex Matter?, 2001)

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Source: https://www.ncbi.nlm.nih.gov/books/NBK216159/

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