Foodborne disease: Widespread foodborne epidemics are now a common consequence of the massive food distribution system that permits contaminated beef or lettuce from Mexico to reach stomachs in distant multistate areas, with medical consequences involving hundreds or thousands of people. This includes the more recent emergence of the GII. These outbreaks seem likely to continue, with unpredictable pathogens in unpredictable places [ 33—35 ].
Heartland virus: A recently encountered tick-borne disease in Tennessee and Missouri with 10 cases and 2 deaths [ 36 ]. Polio-like virus infection with extremity paralysis has been recently reported in 5 and possibly 25 children in California [ 37 ]. Ebola virus: WHO has reported an outbreak in Guinea involving a new clade of this usually fatal infection [ 38 ].
This listing could continue almost indefinitely. The point is that epidemics are the domain of infectious diseases and public health, with the expectation for management or prevention of outbreaks with requirements for detection, reporting, isolation, and case management.
The listing here includes diverse pathogens, some life-threatening diseases, infections with important public health implications, an upsurge of pediatric infections in adults, many travel-related infections, multiple public health threats, and the continuous concerns for influenza and foodborne disease. The major weaponry of the infectious disease catalog includes antibiotics, vaccines, and public health. These categories are remedial reading, but some facets are worthy of emphasis.
The value of antibiotics seems obvious. She received penicillin intravenously starting 14 March , promptly recovered, and survived to age 90 years [ 39 ]. The more recent experience with bacterial resistance and sparse pipeline threatens this miracle, but antiviral development is quite different, primarily for HIV and hepatitis C virus HCV. It now appears that patients with HIV can achieve near-normal longevity [ 41 ]. HCV infection is even more impressive in terms of speed of progress and ability to cure.
The HCV treatment story reflects the efficiency of basic science to define targets, pharmaceutical skills of industry, well-organized trial networks, and a regulatory agency US Food and Drug Administration [FDA] that facilitated product development [ 42 ].
The impact of vaccines is also impressive. A recent report concluded that the global total for lives saved by vaccines exceeds million [ 43 ]. The impact could be substantially greater with more global access, fewer refusals, and a better pertussis vaccine. This illustrates the challenge and the priorities [ 44 ]. The epidemic was finally halted, but the toll was 18 cases and 6 fatalities over 6 months [ 45 , 46 ]. Another KPC epidemiologic investigation showed widespread distribution of this microbe from a long-term acute-care facility in the Chicago area [ 47 ], and others have demonstrated distribution of KPC by air travel from India to Europe [ 48 ].
There is no specialty field in medicine that demonstrates shifting priorities like infectious diseases. Note that the year interval resulted in a completely new agenda for what was considered timely and important in the field based on rapid changes in topical microbes, new epidemics, and new diagnostics, but not new antimicrobials. It is impossible to predict the menu for It is now known that genes for resistance to antimicrobial agents were well established in bacteria at least 3 million years before evidence of human life [ 49 ].
The use of antibiotics has selected for these genes by Mendelian laws, making it increasingly difficult to control previously treatable infections.
The microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out which can be passed to another individual and perhaps from there to others until they reach someone who gets a septicemia or a pneumonia which penicillin cannot save. In such a case, the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to an infection with penicillin-resistant organisms.
It now appears that Fleming's prediction is a harsh reality and evolutionary microbial resistance genes are gaining the upper hand, reflecting the combination of massive antibiotic use and lack of new pharmacologic agents.
A disturbing observation in the United States is the conspicuous absence of a national plan to deal with resistance, including the lack of a living record of antibiotic consumption and resistance correlated by location and trajectory. This is in sharp contrast to the European Union, which includes 28 countries with 24 official languages and diverse cultures, but has systematically collected data on antibiotic consumption and microbial resistance patterns for 15 years [ 52 , 53 ].
This has resulted in multiple publications with data reviews, studies of interventions, messages to consumers such as an eBug Internet program for students, a European Antibiotic Awareness Day, standardized methods to collect data [ 54 ] and a recent point plan with budget to address the issue [ 55 ].
Their data are striking in showing the dramatic association between per capita antibiotic use and national resistance patterns. For example, antibiotic consumption in Greece is nearly 4 times that of the Netherlands, so we expect more resistance problems in Greece, but the magnitude of this difference is alarming: Bacteremic carbapenemase strains among all bacteremic K.
The European Union appears to have a mature and substantive model to learn from, with the important caveat that it functions well because there is no claimed ownership, as there are 28 equal partners. There are also some good national programs that have successfully addressed specific problems to learn from:. EU data for showed that France had embarrassingly high antibiotic use rates, accompanied by increasing resistance by S.
This prompted a national campaign targeting prescribers and consumers on antibiotic abuse and its consequences. A recent report from Israel showed a national campaign to reduce the incidence of KPC.
Analysis of their results with a prevention bundle showed a reduction from 55 per patient-days to 4. The 3 examples given are based on national data addressing major challenges with impressive results. In the United States, this remains a unanswered challenge, but is also an opportunity for the skills of the infectious disease discipline in terms of data collection, evaluation, interventional trials, and policy implementation into practice, primarily in the form of antibiotic stewardship.
Recent reports using gene sequencing suggest that conventional methods of infection control could substantially improve this effort. Examples: 1 Results from the United Kingdom have largely disproven conventional teaching regarding the epidemiology of C. It seems clear that as this technology gets faster and cheaper, it will be embraced as an infection control standard [ 61 ], although there needs to be caution and skill in interpreting results [ 62 ]. Some of this is direct patient care, but possibly very attractive targets for impact are the development and implementation of innovative programs that deal with the vast need combined with minimal resources [ 63 ].
The new healthcare system should value infectious disease expertise based on its important role in addressing resistance and costs associated with nosocomial infections. Nevertheless, it is feared that the current structure and payment system are not constructed as a good fit to prioritize infectious disease skills. Specifically, there is no code for preventing infections, conserving antibiotic use, or preventing resistant pathogens. This might be an erroneous conclusion, or the situation may change as the system matures and becomes serious about addressing the crisis.
An example is the 5-step central line bacteremia prevention bundle that proved effective in trials [ 64 ]. Stewardship: Solving or reducing the problem of antibiotic resistance largely depends on antibiotic development and reducing antibiotic abuse. The major on-site forces for improving smart antibiotic use at the point of care are antibiotic stewards—preferably infectious disease or pharmacy personnel trained in this skill to improve the speed of detecting resistant or epidemic pathogens.
The tools are obvious to infectious diseases—trained clinicians, but often require methods that are not well inculcated into hospital or clinic practice. Ingenuity, knowledge, and organization alter but cannot cancel humanity's vulnerability to invasion by parasitic forms of life. Infectious disease which antedated the emergence of humankind will last as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history.
The spectrum of infectious disease is changing rapidly in conjunction with dramatic societal and environmental changes. World- wide, explosive population growth with expanding poverty and urban migration is occurring; international travel and commerce are increasing; and technology is rapidly changing -- all of which affect the risk of exposure to infectious agents.
Recent examples of important emerging infectious diseases include prolonged diarrheal illness due to waterborne Cryptosporidium, hemorrhagic colitis and renal failure from foodborne Escherichia coli OH7, pneumonia and middle-ear infections caused by drug-resistant pneumococci, and rodentborne hantavirus pulmonary syndrome. These diseases as well as resurgent diseases e. Three recent reports by the Institute of Medicine document the need to address emerging infectious disease threats.
In partnership with representatives from health departments, other federal agencies, medical and public health professional associ- ations, and international organizations, CDC has developed a strategic plan to address emerging infectious disease threats. The plan contains four goals that emphasize surveillance, applied research, prevention and control, and public health infrastructure. To ensure sustain- ability, plan implementation will be approached in stages, as a long- term endeavor with emphasis on extramural programs.
As health-care reform proceeds, priority should be given to strengthening partner- ships between health-care providers, microbiologists, and public health professionals to detect and control emerging infectious diseases. Once expected to be eliminated as a public health problem, infectious diseases remain the leading cause of death and disability- adjusted life years DALYs worldwide 1 and are among the leading causes of death in the United States 2.
The term "emerging infectious diseases" refers to diseases of infectious origin whose incidence in humans has either increased within the past two decades or threatens to increase in the near future 3. To effectively address emerging infectious diseases, CDC has developed a strategic plan emphasizing surveillance, research, and prevention activities necessary to maintain a strong defense against infectious diseases that affect, or threaten to affect, the public's health.
The goals of this plan address priorities for surveillance, applied research, prevention and control, and public health infra- structure, respectively:.
Goal II. Integrate laboratory science and epidemiology to optimize. Goal IV. Strengthen local, state, and federal public health infra-. Many factors or combinations of factors can contribute to disease emergence. Newly emergent infectious diseases may result from changes in or evolution of existing organisms; known diseases may spread to new geographic areas or human populations; or previously unrecognized infections may appear in persons living or working in areas undergoing ecologic changes e.
Infectious diseases may reemerge because of either the develop- ment of antimicrobial resistance in existing agents e. In the United States and elsewhere, infectious diseases increas- ingly threaten public health and contribute substantially to the esca- lating costs of health care.
In addition, infectious agents may be causing diseases previously considered noninfectious: Helicobacter pylori has a well- established association with peptic ulcer disease and gastritis 9 ; sexually transmitted human papillomavirus is associated with cervical cancer 10 ; and infection with hepatitis C virus -- now recognized as a leading cause of chronic liver disease and cirrhosis in the United States -- occurs in an estimated , persons annually Chlamydia infections have long been implicated in infertility and, more recently, have been tentatively associated with coronary artery disease 12 , and rodentborne hantaviruses may play a role in hyper- tensive renal disease Direct and indirect costs of infectious diseases e.
Such approxi- mations, however, most likely underestimate the burden of infectious diseases. For example, the International Classification of Diseases ICD-9 distributes infectious diseases across several categories, obscuring their public health impact e. As a consequence of changes in society, technology, and the environment, pathogens evolve or spread, and the spectrum of infectious diseases expands.
Since the early s, the U. Moreover, the incidence of many diseases widely presumed to be under control -- such as cholera 24 , dengue 25 , yellow fever 26 , and tuberculosis TB 27,28 -- has increased in many areas or spread to new regions or populations throughout the world.
Other groups that may be disproportionately affected by emerging infections include the elderly; persons being cared for in institutional settings, such as hospitals and nursing homes; and persons with inadequate access to health care, such as the homeless, migrant farm workers, and others of low socioeconomic status. The number of children attending day care facilities has increased in the past decade as more mothers of young children have entered the work force. These children, now numbering more than 11 million, are at a substantially increased risk for enteric infections, such as hepatitis A, giardiasis, and cryptosporidiosis; acute respir- atory illnesses; and middle-ear infections.
Also, children who become infected can infect other members of a household Emerging infections transmitted by contaminated public water supplies place entire communities at risk. In the spring of , contamination of a municipal water supply with the intestinal parasite Cryptosporidium caused the largest recognized outbreak of waterborne illness in the history of the United States; an estimated , persons in Milwaukee, Wisconsin, had prolonged diarrhea, and approxi- mately 4, persons required hospitalization personal communication, Jeffrey P.
Davis, communicable disease epidemiologist, Wisconsin. Large segments of populations may also be exposed to emerging infections through contaminated food products.
For example, in , hamburgers contaminated with the bacterial pathogen Escherichia coli OH7 and served at a fast-food restaurant chain caused a multistate outbreak of hemorrhagic colitis bloody diarrhea and serious kidney disease, resulting in the deaths of at least four children 37, Limitations in both surveillance and the availability of appro- priate diagnostic tests constrain public health efforts to prevent and control outbreaks.
Both E. Exposure to certain animals also poses a risk for emerging infectious diseases. Hantavirus pulmonary syndrome, first recognized in the southwestern United States in , has been linked to exposure to infected rodents in more than a dozen states. Once considered "exotic," tropical infectious diseases are having an increasing effect on the U. Recent examples include severe illness and at least one death due to cholera among interna- tional airline passengers arriving in California 39 ; malaria among residents of southern California and immigrants in North Carolina 40,41 ; fever and heart failure in New York and Canada among patients who received blood transfusions contaminated with the bloodborne parasite Trypanosoma cruzi that causes Chagas' disease in Latin America 42,43 ; and a newly described form of leishmaniasis among troops returning from the Persian Gulf conflict 44, From a historical perspective, cholera, smallpox, and plague are examples of infectious diseases that spread globally with devastating impact, often during periods of rapid economic change or population growth 7.
These examples underscore the fact that emerging infections can affect persons in geographically widespread areas, regardless of factors such as lifestyle, cultural or ethnic back- ground, or socioeconomic status. The public health infrastructure is insufficiently prepared to confront today's emerging disease problems.
Domestic surveillance systems for most infectious diseases are inadequate and global surveillance is fragmentary at best. For example, foodborne and waterborne disease outbreaks may be either unrecognized or detected late, and the magnitude of the problem of antimicrobial drug resistance is unknown. Surveillance of infectious diseases in the United States depends on voluntary collaboration between CDC and state and local health departments, which depend on reporting by health-care professionals of a limited number of specific, recognized infectious diseases.
Reporting is generally incomplete. Results of a recent survey conducted by the Council of State and Territorial Epidemiologists underscore the inadequacy of existing infectious disease surveillance by documenting the limited number of professional positions dedicated to infectious disease surveillance in most states.
For example, in 12 of the 50 states surveyed, no professional position is dedicated to surveillance of foodborne and waterborne diseases.
Funding for infectious disease surveillance is restricted primarily to diseases for which public health crises have already developed. Osterholm, Council of State and Territorial Epidemiologists survey on surveil- lance.
However, no federal resources are provided to state and local health departments to support the national notifiable disease system. In addition, the ability of state public health laboratories to support the surveillance and control of infectious diseases has diminished Timely recognition of emerging infections requires early warning systems to detect such problems so they may be promptly investigated and controlled before they evolve into public health crises.
Prompt detection of these new threats depends on careful monitoring by effective surveillance systems; on a thorough understanding of trends in incidence and distribution of known infectious agents; and on effective communication among clinicians, clinical laboratory personnel, and public health professionals. The ability to detect what is new or reemerging depends on the capacity to identify and track both the routine and the unusual.
Like radar or "early warning" systems that detect threats to national security, surveillance with appropriate laboratory support is a critical element in the effective defense against these diseases. Surveillance systems are the most important tools for determining which infectious diseases are emerging or receding. Effective surveillance also provides a basis for evaluating the outcome of both public health and personal medical-care programs. Surveillance information is essential to ensure the use of the most efficacious and cost-effective approaches to preventive, as well as curative, health care.
Regardless of the direction of health-care reform, surveillance will be critical to the meaningful evaluation of new prevention programs. In addition to comprehensive and innovative surveillance systems, effective preparation for detecting, preventing, and controlling emerging infectious diseases requires sound foundations in profes- sional expertise, laboratory support, and research capability to strengthen the infrastructure needed to address the ongoing, but often changing, threats from emerging infections.
Despite the continued emergence of such threats, support for applied research and control efforts has declined over the past decade. The earliest of these reports, "The U. Capacity to Address Tropical Infectious Disease Problems" 48 , documented the inadequate state of readiness to recognize, treat, or control infectious disease threats emanating from the tropics -- regions that have yielded microbial threats such as Lassa fever and Ebola viruses, chloroquine-resistant malaria, and penicillin-resistant gonorrhea.
This report emphasized that the U. The third IOM report, "Emerging Infections, Microbial Threats to Health in the United States," emphasized the ongoing threat to domestic and global health from emerging infectious diseases 3. The report provided specific recommendations for CDC, the National Institutes of Health, the Food and Drug Administration, the Department of Defense, and other federal and state agencies for addressing microbial threats to health in the United States and elsewhere.
This report emphasized a critical leadership role for CDC in a national and global effort to detect and control emerging infectious disease threats. To effectively detect and prevent emerging infections, improve- ments are needed in public health systems, program design, and infra- structure. To accomplish these improvements and to achieve the objectives of Healthy People , CDC has developed a strategy to address these microbial threats.
Because meeting the broad challenge of emerging infections requires interaction, cooperation, and coordination among a wide range of public and private organizations, the development of this strategy has taken place in partnership with state and local health departments, other federal agencies, academic institutions, health-care providers, medical laboratory personnel, and international organizations.
Goal I Surveillance emphasizes the improvement and expansion of surveillance capabilities for infectious diseases in the United States and internationally. Other objectives emphasize improved detection and monitoring of trends in antimicrobial resistance in both institutional and community settings; expansion of field investigations and epidemic response capabilities; prevention of foodborne and waterborne infectious diseases and improved knowledge of the distribution of animal reservoirs and vectors associated with human infectious diseases.
Goal II Applied Research focuses on applied research and the integration of laboratory science and epidemiology with public health practice. Emphasis is placed on determining how behavioral factors influence exposure to new infections; better characterizing the health burden of both well-established and emerging infections; and evalu- ating the effectiveness and economic benefit of strategies to prevent emerging infectious diseases.
An additional focus is the development and application of improved laboratory techniques for the identifi- cation of new pathogens and the expanded use of molecular epidemio- logic techniques in investigating emerging diseases.
Supporting the national Childhood Immunization Initiative by conducting vaccine efficacy studies and improving rapid response capabilities for vaccine development and delivery is also a priority. A final focus is the reestablishment of CDC extramural programs to promote effective partnerships with public agencies, universities, and private industry and to support applied research in surveillance, epidemiology, and prevention of emerging infections. Goal III Prevention and Control addresses enhanced communi- cation of public health information and the implementation of prevention strategies for emerging infections.
Highlighted under this goal are proposals for expanded dissemination of the MMWR, as well as other important public health information sources. Another priority is the creation of an accessible and comprehensive infectious disease database for the United States that increases awareness of infectious diseases and promotes public health action.
The database will contain current information on topics such as antimicrobial resistance, foodborne and waterborne disease outbreaks, travelers' health, antimicrobial drug availability, vaccine-preventable diseases, and vaccine guidelines. This goal also addresses the development and implementation of guidelines for preventing emerging infectious diseases and the provision of critical prevention materials.
Goal IV Infrastructure deals with issues relating to local, state, and federal infrastructure, particularly personnel and physical resources. Points of emphasis include maintaining expertise in rare or unusual infectious diseases and establishing training programs that emphasize the diagnosis of infectious diseases. A public health laboratory fellowship in infectious diseases is proposed.
Also emphasized is the need for state-of-the-art physical resources such as laboratory space, training facilities, and equipment. Laboratory capabilities must be maintained in a manner that optimizes flexibility and "surge capacity" so that unanticipated public health threats can be adequately, efficiently, and safely addressed.
Plans for expanding facilities for maintaining specimen banks of etiologic agents and clinical specimens are also a priority. This plan reflects CDC's commitment to meet the urgent public health challenge of important emerging infectious diseases. The need to proceed rapidly is made more urgent for many reasons. Many diseases pose an immediate danger. For example, methicillin-resistant Staphylococcus aureus, a common cause of hospital infections, may potentially develop resistance to vancomycin 29,50 ; penicillin resistance is spreading in Streptococcus pneumoniae 29,31,51 ; the potential exists for extension of the current cholera epidemic in Latin America to the Caribbean Islands 24 ; and Vibrio cholerae O, a new strain for which existing cholera vaccines are ineffective and prior infection with V.
Changing food-industry practices, dietary choices, and globalization of food supplies will bring new challenges to provide a diet safe from pathogens such as Salmonella sp.
Ongoing investigations of hantavirus pulmonary syndrome document that the geographic distribution of this infection goes beyond the desert Southwest These infectious disease problems emphasize the necessity of expeditiously implementing this plan through a balanced intramural and extramural effort.
The implementation of the goals and objectives in this plan is relevant to health-care reform. Examples of relevant issues include prolonged hospitalizations caused by hospital-acquired infections; increased morbidity and treatment costs resulting from antimicrobial drug resistance; and excessive burdens placed on public and private health-care delivery facilities because of community-wide outbreaks of foodborne and waterborne infections. Some of the activities listed in this document are already in the planning stages and will be implemented soon.
Many of the proposed activities need further development in full cooperation with other federal agencies, state and local health authorities, academic insti- tutions, professional societies, private industry, and others. With this document serving as both a guide and a first step, implementation will be based on public health priorities and resource availability. The strategy of this plan is based on repeated experience demon- strating that it is less costly to anticipate and prevent infectious disease threats than to react with expensive treatment or containment measures to public health crises.
Public health policy and practice that combine investments in surveillance, laboratory research and training, and epidemiologic investigations with prevention and control efforts will reduce the impact of emerging infectious disease threats, in terms of both human suffering and economic losses. Further guidance was provided at a meeting of infectious disease and public health experts in Atlanta in March and at a meeting of state and territorial public health epidemio- logists, laboratory directors, and veterinarians in Minneapolis in June De Oliveira, D.
Drolet, M. Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect. Falkow, S.
I never met a microbe I didn't like. Fiers, W. Gut mycobiota under scrutiny: fungal symbionts or environmental transients? Fleming, A. The story of penicillin. PubMed Abstract Google Scholar. Gambotto, A. Human infection with highly pathogenic H5N1 influenza virus. Lancet , — Hotez, P. Combating vaccine hesitancy and other 21st century social determinants in the global fight against measles. Hussain, A. The anti-vaccination movement: a regression in modern medicine.
Cureus e Kalra, R. Pathogens Le Magnen, C. Optimizing mouse models for precision cancer prevention. Lockhart, S. Simultaneous emergence of multidrug-resistant Candida auris on 3 continents confirmed by whole-genome sequencing and epidemiological analyses. Medzhitov, R. Disease tolerance as a defense strategy. Science , — Meis, J. Candida auris: a global fungal public health threat.
Morens, D. The challenge of emerging and re-emerging infectious diseases. Nature , — Netea, M. Defining trained immunity and its role in health and disease. Perlin, D. The global problem of antifungal resistance: prevalence, mechanisms, and management. Plichta, D. Therapeutic opportunities in inflammatory bowel disease: mechanistic dissection of host-microbiome relationships.
Poland, G. The old and the new: successful vaccines of the 20th century and approaches to making vaccines for the important diseases of the 21st century.
Randolph, H. Immunity 52, — Rocklov, J. Climate change: an enduring challenge for vector-borne disease prevention and control. Schiller, J. Next generation prophylactic human papillomavirus vaccines. Lancet Oncol. Schrager, L. The guidelines of the German Reich's Ministry of the Interior of reacted to the increasingly intense political debate by specifically emphasizing the necessity of explicit informed consent und the moral inadequacy of exploiting a person's difficult social situation for performing studies that pose a risk to the participant's health Steinmann, When building research capacity in developing countries and intensifying efforts to meet the global challenge of infectious diseases today, we need to make sure that ambition, greed, or even the genuine wish to alleviate and prevent suffering do not compromise these ethical principles that have been agreed on worldwide.
It is true that not all questions regarding research ethics have already been settled. Particularly clinical trials that include some form of collaboration between rich countries and developing countries are raising issues, like permissible standards of care for control groups and after-trial obligations, that need to be addressed in a fair and transparent manner.
In conclusion, overall increase in publication activities on infectious diseases during the last 10 years is a very promising sign. However, concerning research priorities, the scientific community should focus on the most prominent diseases affecting large parts of the world's population like diarrhoeal diseases and malaria, but also on neglected diseases like schistosomiasis and trypanosomiasis.
Taking into account that national research activities are of course driven by national funding this is a difficult task.
Based on the publication activities, the countries with the highest infectious disease burdens are still not given the opportunity to contribute adequately to the scientific field. More political engagement of the scientific community might help to overcome this problem in the long term. According to our survey, the pioneer discoveries in infectious diseases still have the greatest impact; most of these pioneer studies were directly related to chemo therapy, prophylaxis or aetiology indicating that applied research is still considered most important.
As delineated above, there is no doubt that good basic research is needed in order to reduce the global mortality and global burden of infectious diseases. But beyond basic research intense efforts are needed to translate these findings into the realm of public policy and public health. And sometimes, mere translation will not be enough.
In order to really make a difference we will continuously have to check if our research agenda responds to the most pressing needs rather than to the biggest markets. In order to actually tackle the global challenge of infectious diseases we need to find the best and most efficient ways to transfer knowledge from the labs to the field.
As developing countries are the ones for whom the burden of disease is greatest, their participation in the definition of research goals and the implementation of results is essential. Clinical trial partnerships between rich and developing countries are an important step in that direction cf.
We will have to make sure, however, that blind enthusiasm or conflicts of interest do not compromise the ethical dimension of an urgently needed global effort to reduce mortality and burden of infectious diseases.
National Center for Biotechnology Information , U. Int J Med Microbiol. Published online Jan Author information Article notes Copyright and License information Disclaimer. Katja Becker: ed. All rights reserved. Elsevier hereby grants permission to make all its COVIDrelated research that is available on the COVID resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source.
This article has been cited by other articles in PMC. Abstract Infectious diseases represent a continuous and increasing threat to human health and welfare. Keywords: Infectious diseases, Research activities, Publications. Infectious diseases — current situation Due to multiple drug resistances, migration of populations, and emerging pathogens infectious diseases represent a continuous and increasing threat to human health and welfare. Table 1 Ranking of different countries based on their contribution to publications in the field of infectious diseases between and Open in a separate window.
0コメント