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Infectious Disease Control

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Title: Infectious Disease Control


1
Infectious Disease Control
Milestones in Public Health Chapter 4
Complete, Combined Lectures for Undergraduate,
Graduate Public Health, and Medical and Clinical
Education Levels
January 2011
2
Learning ObjectivesAll Learner Levels
  • Describe the 150-year history of world efforts to
    control infectious disease
  • Discuss Darwins concept of adaptation as applied
    to infectious diseases
  • Describe the roles of federal agencies and
    advocacy organizations
  • Review the CDCs OPLAN for Avian Influenza

3
Learning Objectives Undergraduate Education
  • List the sources of infection
  • Describe how organisms gain entry into the body
  • Describe how infectious agents spread within the
    body
  • Discuss when infection occurs

4
Learning Objectives Graduate Public Health
Education
  • Describe public health interventions to control
    communicable diseases
  • List the purposes of surveillance
  • Discuss examples of domestic surveillance
  • Discuss surveillance systems for MRSA

5
Learning Objectives Medical and Clinical
Education
  • Distinguish between emerging and re-emerging
    diseases
  • Summarize human and microbial factors in the
    emergence of new infectious diseases
  • Describe human behaviors which play a role in
    re-emerging infectious diseases

6
Lecture Outline
  1. Historical Perspective
  2. The Milestone and its Impact on Public Health
  3. Aspects of Biology, Behavior and Science of
    Infectious Diseases
  4. Systems, Policies and Programs
  5. Looking Ahead
  6. Wrap-Up
  7. References and Resources

7
Infectious Disease Control
  • Historical Perspective

8
Historical Perspective Infectious Disease
Control
  • The War is Over! In 1967, the U.S. Surgeon
    General William Stewart supposedly stated
  • It is time to close the book on infectious
    diseases, and declare the war against pestilence
    won.

FAQs (2004)
7
9
Historical Perspective (Cont.)
  • To tell the real war story, the current one,
    we need to go back to 1859 to Charles Darwins
    Theory of Natural Selection as the explanation of
    the functional designs of organisms.

Neese and Williams (1996)
10
The Concept of Adaptation by Natural Selection
  • Adaptations by which we combat pathogens
  • Adaptations of pathogens that counter our
    adaptations
  • Maladaptive but necessary costs of our adaptations

Neese and Williams (1996)
11
New Take on Darwinian Medicine
  • Bacteria and viruses seen as sophisticated
    opponents in an endlessly escalating arms race
  • These pests have evolved ways to overcome our
    defenses or even use them to their own benefit
  • Explains why we cannot eradicate all infections

Neese and Williams (1996)
12
New Take on Darwinian Medicine (Cont.)
  • From time of Darwin to those premature
    declarations of the end of the war against
    infectious disease, there is a rich history of
    our increasing understanding of infectious
    diseases and of our efforts to control them.

Neese and Williams (1996)
13
Stern and Markel (2004)
  • Identified three eras of international
    approaches to controlling infectious diseases
  • 1851-1881 Setting the stage The first
    International Sanitary Conference
  • 1881-1945 Advent of germ theory and rise of
    bacteriology
  • 1945-2004 The WHO A new definition of health
    to the present

14
Growth in Understanding the Spread of Disease
from Person-to-Person
  • Since microbes are invisible to humans, nothing
    was known about them until the 1600s
  • Microorganisms seen under microscopes of Robert
    Hooke (1664) and Anton Van Leeuwenhoek (1684) had
    to be definitively linked to disease, which was
    accomplished by Robert Koch in 1891

Stern and Markel (2004) and Black (2008)
14
15
Kochs Postulates of 1891 The Germ Theory of
Disease
  • Four fundamental concerns
  • 1. Microbe must be present in every case of
    the disease
  • 2. Microbe must be isolated from the
    diseased host and grown in culture
  • 3. Disease must be reproduced when a pure
    culture is introduced into a non- diseased
    susceptible host
  • 4. Microbe must be recoverable from an
    experimentally infected host

Fredricks and Relman (1996)

15
16
Infectious Disease Control
  • The Milestone and Its Impact on Public Health

17
Top 10 Causes of Death (Due to Infectious
Disease)by Broad Income Group
High-Income Middle-Income Low-Income
Lower Respiratory Infections 4th (Diarrheal Diseases, HIV/AIDS, TB, and Malaria not in top 10) Lower Respiratory Infections 4th - Tuberculosis 9th (Diarrheal Diseases, HIV/AIDS, and Malaria not in top 10) Lower Respiratory Infections 1st Diarrheal Diseases 3rd HIV/AIDS 4th Tuberculosis 7th Malaria 9th
WHO (2007)
18
Populations at Risk
  • In the developed world, old people are most at
    risk of infectious diseases, while in the
    developing world, infants and young children
    remain most at risk
  • Other vulnerable populations to hazards of
    infection include immunocompromised persons and
    those on steroid therapy for chronic diseases

Milestones (2006)

18
19
Why Are Infectious Diseases Still Among the
Leading Causes of Death Worldwide?
  • Emergence of new infectious diseases
  • Re-emergence of old infectious diseases
  • Persistence of intractable infectious diseases

Milestones (2006))
20
Infectious Disease Control
  • Aspects of Biology, Behavior and Science of
    Infectious Diseases

21
Aspects of Biology, Behavior and Science of
Infectious Diseases
  • Occurrence and Spread of Infection
  • Infection occurs when micro-organisms invade
    sterile body tissues
  • An infectious disease occurs when infection is
    associated with clinically manifested tissue
    damage

Black (2008)
22
Sources of Infection
  • Microorganisms enter the body through
  • Air
  • Food
  • Water
  • Contact with skin
  • Contact with vectors

Black (2008)
23
Sources of Infection (Cont.)
  • Commensal organisms (organisms that normally
    live in the body without causing harm)
  • Become pathologic because of change in host
    environment
  • Examples
  • Another disease results in immunosuppression
  • Natural barriers breached by injury or invasive
    pathological processes (ulceration or malignancy)

Black (2008)
24
Sources of Infection (Cont.)
  • Air-borne diseases
  • Many kinds of organisms enter respiratory system
    by inhalation of air-borne droplets
  • Cause infection of respiratory tract
  • Can also cause main impact elsewhere after spread

Black (2008)
25
Sources of Infection (Cont.)
  • Food-borne diseases
  • Contracted from any food not preserved or
    isolated from potential sources of contamination
  • Not only cooking properly, but handling properly
    is important
  • Food handlers hygiene (infected or carriers)

Black (2008)
26
Sources of Infection (Cont.)
  • Water-borne diseases
  • Usually spread by fecal-oral route
  • Common in less-developed countries
  • Also from food sources

Black (2008)
27
Sources of Infection (Cont.)
  • Body fluids
  • Organisms can be secreted in body fluids of
    infected person and spread by direct contact with
    those fluids
  • Mechanism of spread for sexually-transmitted
    diseases
  • Blood and blood products present risk

Black (2008)
28
How Do Organisms Gain Entry to the Body?
  • Examples of sites of entry
  • Avenues and methods used by infectious agents to
    get into tissues
  • Signs and symptoms may point to a particular site
    or organ system

29
Sites of Entry
  • Ingestion into gastrointestinal tract
  • Caused by microorganisms contaminating food or
    water
  • Salmonella, Vibrio,cholera
  • Experience abdominal pain, nausea, vomiting,
    diarrhea
  • Inhalation into respiratory tract
  • Caused by microorganisms in air
  • Experience cough, chest pain, shortness of
    breath, coughing blood

Black (2008)
30
Sites of Entry (Cont.)
  • Ascension into urinary tract
  • Caused by microorganisms that enter bladder
    through urethra or catheter
  • Experience painful urination, blood in urine,
    pelvic pain, flank pain
  • Ascension into biliary tree
  • Caused by microorganisms entering common bile
    duct from GI tract
  • Experience abdominal pain, jaundice

Uehilng, Johnson, Hopkins (1999) and Clincea,
Chalasani, Gaddipati (2002)
31
Sites of Entry (Cont.)
  • Crossing of mucosal surfaces
  • Caused by microorganisms that penetrate oral,
    anal, genital, or conjunctival linings
  • Human papillomavirus, HIV, herpes simplex virus,
    Neisseria gonorrhea
  • Experience local irritation, ulceration, pain,
    redness
  • Entrance through wound sites
  • Direct inoculation of microorganisms leads to
    direct spread

Black (2008)
32
Spread of Infectious Agents In Body
  • Travel via the bloodstream
  • Septicemia
  • Travel via the lymphatic system
  • Enlarged tender lymph nodes suggest possible
    infection at site
  • Travel via the body cavity
  • Can spread in cerebrospinal fluid, peritoneal
    fluid, joint space
  • Crossing the placenta to the fetus
  • Basis for congenital infection

Black (2008)
33
When Does Infection Occur?
  • Colonization the presence of organisms on a body
    surface or in a lumen, but not producing disease
  • All persons have bacteria (and some fungi) on
    skin surfaces or in the oral cavity
  • Invasion organisms have moved into tissues to
    cause disease

Black (2008)
34
When Does Infection Occur? (Cont.)
  • Virulence the ability of an organism to cause
    infectious disease
  • Some organisms are unlikely to cause disease
  • Some organisms, like Vibrio cholera, Salmonella
    typhi, Mycobacterium tuberculosis, or Yersinia
    pestis (plague) are highly virulent and
    potentially fatal

Black (2008)
35
When Does Infection Occur? (Cont.)
  • Resistance the ability of the host to prevent
    infection from occurring and infectious disease
    from developing
  • Resistance is normally aided by
  • Barriers to infection intact, functional
    epithelial surfaces (respiratory tract, gastric
    acid, antibacterial action of bladder secretions
    and saliva of oral cavity)
  • Immune system

Black (2008)
36
When Does Infection Occur? (Cont.)
  • Resistance is diminished by
  • Debilitation from malnutrition (poor diet,
    alcoholism)
  • Cancer
  • Poorly functioning immune system (congenital or
    acquired)
  • Drug therapy corticosteroids, antibiotics
  • Previously damaged or abnormal anatomical
    structure

Black (2008)
37
Infectious Disease Interventions
  • Three major public health interventions to
    control communicable diseases follow
  • Improved resistance to environmental hazards
  • Improved environmental safety
  • Enhanced public health systems

Department of Health and Human Services
38
Improved Resistance to Environmental Hazards
  • Hygiene
  • Nutrition
  • Immunity
  • Antibiotics
  • Psychological factors
  • Exercise
  • Genetic alteration

Aschengrau Seage (2008)
39
Improved Environmental Safety
  • Sanitation
  • Air
  • Water
  • Food
  • Infectious agents
  • Vectors
  • Animal reservoirs

Aschengrau Seage (2008)
40
Enhanced Public Health Systems
  • Access
  • Efficiency
  • Resources
  • Priorities
  • Containment
  • Contact tracing for prophylaxis and therapy
  • Education
  • Social forces
  • Laws
  • Measurement of problems and of the efficiency and
    effectiveness of control

Department of Health and Human Services
41
Four Important Systems-related Means of
Controlling Communicable Disease
  • Containment
  • Contact tracing for prophylaxis and therapy
  • Education
  • Measurement (surveillance)

42
Surveillance
  • The ongoing systematic collection, collation,
    analyses, and interpretation of data and the
    dissemination of information to those who need to
    know so that action may be taken

Aschengrau Seage (2008)
43
Purposes of Surveillance
  • Monitor disease trends
  • Monitor progress
  • Estimate magnitude of a problem
  • Detect outbreaks of an infectious disease
  • Evaluate interactions and programs
  • Identify research needs

Aschengrau Seage (2008)
44
Surveillance is Crucial for Prevention and
Control
  • Examples of national and international
    surveillance programs follow
  • Summary of notifiable disease (National
    Notifiable Disease Surveillance System)
  • S. aureus-related hospitalizations

45
Domestic Surveillance National Notifiable
Disease Surveillance System (NNDSS)
  • Statistical summary of notifiable diseases in
    U.S. is published to accompany each volume of
    Morbidity and Mortality Weekly Report by CDC
  • Contains texts, graphs, and maps of official
    occurrences of nationally-notifiable diseases in
    U.S. for the year
  • Operated by CDC in collaboration with Council of
    State and Territorial Epidemiologists (CSTE)
  • Published in week reported

CDC (2010)
46
Domestic Surveillance NNDDS
  • When published, data can be used by
  • State and local health departments
  • Schools of public health
  • Communications media
  • Local, state, and federal agencies
  • Other interested agencies

CDC (2010)
47
S. Aureus-Related Hospitalizations
  • Example of analysis of U.S.-based S.
    aureus-related hospitalizations using
    administrative databases and other surveillance
    sources raised possibility that majority of the
    overall increases in S. aureus-related discharges
    are due to community-associated diseases
  • Jhungs Enhanced Detection of Staphylococcus
    aureus-related Hospitalizations Using
    Administrative Databases, United States,
    1999-2005

Jhung (2008)
48
S. Aureus-Related Hospitalizations (Cont.)
  • Findings
  • S. aureus-related discharges increased
    significantly over the period 1995-2005
  • Majority of staph-related discharges due to skin
    infections in patients less than 45 years of age

Jhung (2008)
49
Surveillance Systems for MRSA (Methicillin-Resista
nt Staph Aureus)
  • NHSN National Health Care Safety Network -
    Monitors health care-associated infections
    including those caused by MRSA
  • ABCs Active Bacterial Care - Surveillance of
    the Emerging Infections Programs
  • From 2004-present, invasive MRSA infections are
    monitored in nine sites across the U.S. which
    currently participate in the ABCs MRSA
    surveillance, represent- ing a population of 16.3
    million persons
  • NNIS-National Nosocomial Infection Surveillance
    System (1970s-2005) Publications and Reports

Milestones (2006)
50
Public Health System Capacity
  • For surveillance system and response networks
    to be successful in prevention and control, the
    following are necessary
  • Good communication among all government levels
    local, state, federal
  • Working across disciplines
  • Policy development
  • Planning
  • Training
  • Improved laboratory capability
  • Human resource capacity

IOM (2003)
51
The Problem with Surveillance
  • Experience has shown that despite the U.S.s
    extensive disease surveillance system and
    response network, there exist gaps in the ability
    to detect outbreaks early.

IOM (2003)
52
Challenge for Public Health
  • The challenge is to use surveillance
    information systematically in outcome-driven
    business practices to
  • Improve emergency response
  • Build routine organization effectiveness
  • Give necessary attention to specific emergent
    issues and simultaneously to develop fundamental
    infrastructures

IOM (2003)
53
Application to Surveillance
  • We must
  • Improve information
  • Process information better
  • Connect information into response plans/systems
    in order to link surveillance to more efficient
    action to identify and control ID

IOM (2003)
54
Infectious Disease Realities
  • Emergence of new infectious diseases
  • Re-emergence of old infectious diseases
  • Persistence of intractable infectious diseases

55
Emerging Infectious Diseases
  • Include outbreaks of previously unknown diseases
    or known diseases whose incidence in humans has
    significantly increased in past two decades
  • Innovative research and improved diagnostic
    methods have revealed a number of previously
    unknown human pathogens

Fauci (2004) and NIAID
56
National Institute of Allergy and Infectious
Diseases (NIAID) Categories Group 1
  • Some of the pathogens newly recognized in past
    two decades
  • Two new hepatitis viruses
  • Three new herpes viruses
  • Helicobactor pylori
  • Borrelia burgdorferi

NIAID
57
Status of New Infectious Diseases
  • New infectious diseases evolve and emerge due
    to
  • Changes in human demographics, behaviors, and
    land use
  • People are in closer and more frequent contact
    with animal or arthropod carriers of disease
  • Increasing trade in exotic animals for pets or
    food service
  • Contributes to rise in opportunity for pathogens
    to jump from animal reservoirs to humans

NIAID
58
Re-emerging Diseases
  • Diseases in which natural genetic variations,
    recombinations, and adaptations allow new strains
    of known pathogens to appear to which immune
    system has not been previously exposed and is
    therefore not primed to recognize

NIAID
59
Re-Emerging Diseases (Cont.)
  • Role of Human Behaviors
  • Increased and occasional, imprudent use of
    antimicrobial drugs and pesticides has led to
    development of resistant pathogens allowing many
    diseases that were formerly treatable to return
  • Malaria, TB, nosocomial, food-borne infections
  • Decreased compliance of vaccination policy has
    led to re-emerging diseases that were under
    control
  • Measles and pertussis
  • Increased use of deadly pathogens as agents of
    bioterrorism
  • Anthrax or smallpox

NIAID
60
Re-Emerging Diseases (Cont.)
  • Current infectious diseases that have posed
    ongoing health problems in developing countries
    are re-emerging in the U.S.
  • For example
  • Food and water-borne infections
  • Dengue
  • West Nile virus

NIAID
61
NIAID Research Plans and Priorities
  • HIV/AIDS
  • Pandemic influenza
  • Emerging and re-emerging infectious diseases such
    as TB, malaria, and tropical disease
  • Immune-mediated diseases

Fauci (2007)
62
Infectious Disease Control
  • Systems, Policies and Programs

63
Human and Microbial Factors in Emergence of New
Infectious Diseases
  • Human demographics
  • International travel
  • Technology
  • Industry
  • Climate change
  • Poverty
  • War
  • Intent to harm
  • Breakdown in public health measures
  • Microbial adaptation, changes and counter defenses

Milestones (2006)
64
Antibiotic Resistance
  • Our use/misuse/overuse of antibiotics in
    human and veterinary medicine and in animal feed
    has resulted in large amounts of antibiotics in
    our pantries and environments.

Milestones (2006)
65
Federal Agencies and Advocacy Organizations
  • Various organizations have provided
    regulations and guidance, creating much
    controversy about correct ways to handle growing
    problem of antibiotic resistance
  • Federal agencies
  • Centers for Disease Control and Prevention (CDC),
    US Department of Agriculture (USDA),
    Environmental Protection Agency (EPA), Food and
    Drug Administration (FDA) and National Institutes
    of Health (NIH)
  • Advocacy organizations
  • American Public Health Association (APHA) and
    American College of Physicians (ACP)


Milestones (2006)
66
Federal Agencies
  • CDCViews antibiotic resistance as one of its
    top concerns
  • USDA- Concerned with labeling and
  • claims on meat packages - 70 of antibiotic
    use is an
  • additive to animal feed, not to
  • treat disease

Milestones (2006)
67
Federal Agencies (Cont.)
  • EPAHas jurisdiction and authority
  • over water pollutants that enter environment
  • NIHConducts research, develops
  • solutions and educates public
  • about emerging problem

Milestones (2006)
68
Federal Agencies (Cont.)
  • FDA
  • Has authority to restrict use of
  • antibiotics in animals based on
  • the potential risk to human health
  • Controversy has surrounded use in animals due to
    strong evidence that practice of giving livestock
    antibiotics results in inability to treat some
    human illness

Crawford (2003), Milestones (2006), Pyrek
(2003), and Taraporewala (2008)
69
Federal Agencies (Cont.)
  • In 1998, the FDA began to
  • restructure drug-approval system
  • for use of antibiotics in food producing animals
  • In 2003, the FDA took action in the campaign
    against resistance in issuing new labeling
    regulations for human use The intention was to
    reduce the inappropriate prescription of
    antibiotics for common ailments such as ear
    infections and common coughs

Crawford (2003), Milestones (2006), Pyrek
(2003), and Taraporewala (2008)
70
Federal Agencies (Cont.)
  • In 2005, the agency withdrew a
  • livestock antibiotic based on its
  • growing concerns about resistance being
    transmitted from food animals to humans
  • FDA has variety of regulatory tools to help
    developers of antimicrobial drugs , including an
    accelerated approval process for drugs that
  • treat illnesses
  • show meaningful benefit over existing drugs to
    control disease

Crawford (2003), Milestones (2006), Pyrek
(2003), and Taraporewala (2008)
71
Federal Agencies (Cont.)
  • Guidance document issued
  • targeting pharmaceutical
  • industry which develops veterinary drugs for
    widespread agricultural use
  • FDAs National Center for Toxicological Research
    has studied mechanisms of resistance to
    antibiological agents in human GI tract

Crawford (2003), Milestones (2006), Pyrek
(2003), and Taraporewala (2008)
72
Advocacy Organizations
  • The American Public Health Association (APHA)
    has prepared a fact sheet on antibiotic
    resistance, supporting
  • Education programs for providers and patients in
    the appropriate use of antibiotics
  • Improved surveillance programs at local and
    national level, with feedback to policy makers,
    health officials and providers

APHA (2003)
73
Advocacy Organizations(Cont.)
  • Withdrawal of all antibiotics given to healthy
    animals for economic reasons when those
    antibiotics are also used for people

APHA (2003)
73
74
Advocacy Organizations(Cont.)
  • The American College of Physicians (ACP) has
    issued guidelines for patients, multiple levels
    of health care providers, and others in support
    of
  • Adequate funding for state surveillance efforts
    to study antibiotic resistance and other diseases
  • In-state surveillance programs for diseases that
    are nationally-notifiable, and subsequent
    reporting of such information to the CDC

Milestones (2006)
75
Infectious Disease Control
  • Looking Ahead

76
Looking Ahead
  • Major infectious disease threats currently
    facing the U.S. and world
  • Every important bacterium has become resistant in
    some way to antibiotics
  • The spread of avian influenza (H5N1) viruses
    among birds continues to cause human disease with
    high mortality and to pose threat of a pandemic
  • One-stop access to U.S. government avian and
    pandemic flu information at http//www.pandemicflu
    .gov/

Milestones (2006)
77
Mission of CDC
  • To immediately detect onset of outbreaks with
    influenza pandemic potential
  • To assist with containment of such outbreaks
  • To delay introduction and transmission of
    pandemic viruses in the U.S.
  • To assist state, local, territorial and tribal
    health authorities in management of influenza
    pandemic event

Milestones (2006) and CDC (2008)
78
THE CDC OPLAN (January 11, 2008)
  • Operation plan delineates how CDC (under HHS)
    will prepare for and fight a potentially
    devastating outbreak and disease from a new
    influenza strain, Influenza A (H5N1)
  • Designed to allow planners, at every level within
    CDC, to gain insights into what actions need to
    be taken in preparing for an influenza epidemic

CDC (2008) and Update on H5N1 (2008)
79
Infectious Disease Control
  • Wrap-up

80
Wrap-Up
  • Germ theory
  • Great strides have been made to control and
    decrease infectious disease, yet still among the
    leading cause of death worldwide
  • Various surveillance systems exist, yet
    infectious disease is difficult to monitor due to
    multiple sources of causation and different sites
    of entry
  • Emergence of new infectious diseases and
    re-emergence of existing infectious diseases
  • Various agencies, policies and programs exist to
    help control infectious disease

81
Resources and References
  1. American Public Health Association. (2003).
    Antibiotic Resistance Fact Sheet. Retrieved from
    http//www.apha.org/advocacy/reports/facts/advocac
    yfactantibiotic.htm
  2. Aschengrau, A., G. R. Seage III. (2009).
    Essentials of Epidemiology in Public Health.
    Boston Jones and Bartlett Publishers.
  3. Black, J.G. (2008). Microbiology Principles and
    Explorations (7th ed.). Hoboken, NJ J. Wiley
    Sons.
  4. Centers for Disease Control and Prevention.
    (January 11, 2008). Influenza Pandemic OPLAN.
    Retrieved from http//www.cdc.gov/flu/pandemic/cdc
    plan.htm
  5. Centers for Disease Control and Prevention.
    (January 25, 2010). National Notifiable Diseases
    Surveillance System. Retrieved from
    http//www.cdc.gov/ncphi/disss/nndss/nndsshis.htm
  6. Clincea, R., Chalasani, H.G., Gaddipati, K.V.
    (2002). Infections of the Biliary Tree.
    Hospital Physician Infectious Diseases Board
    Review Manual. 8(4), 1-2.
  7. Crawford, L.M. (2003). Testimony Regulatory
    Program of the Food and Drug Administration
    before the sub-committee on Conservation, Credit,
    Rural Development and Research Committee on
    Agriculture, United states of Representatives.
    HHS. June 17, 2003. Washington, D.C. U.S.
    Department of Health Human Services. Retrieved
    from http//www.hhs.gov/asl/testify/t030617a.html

82
Resources and References
  1. Fauci, A.S. (2004, October). Emerging Infectious
    Diseases. A Clear and Present Danger to Humanity.
    JAMA. 292(15), 1887-1888.
  2. Fauci, A. (2007). NIAID Investment, Research Make
    Strides For Improving Health Globally. U.S.
    Medicine.NIAID. Retrieved from http//www.usmedici
    ne.com/column.cfm?columnID243issueID95
  3. FAQs. (2004). The Office of Public Health Service
    History. NIH. Retrieved August 29, 2008 from
    http//lhncbc.nlm.nih.gov/apdb/phsHistory/faqs.htm
    l
  4. Fredericks, D., Relman, D. (1996).
    Sequence-based identification of microbial
    pathogens A reconsideration of Koch's
    postulates. Clinical Microbiology Reviews, 9(1),
    18-33.
  5. Institute of Medicine (IOM). 2003. Microbial
    Threats to Health Emergency, Detection, and
    Response. Washington, DC National Academies
    Press.
  6. Jhung, M.A, Banerjee, S.N., Fridkin, S., Tenover,
    F.C., McDonald, L.C., (2008) Enhanced Detection
    of Staphylococcus aureus-related
    Hospitalizations Using Administrative Databases,
    United States-1999-2005 Slide Presentation.
    Atlanta, GA Centers for Disease Control and
    Prevention. Retrieved from http//www.cdc.gov/ncid
    od/dhqp/SHEA_EnhanDetecS_aureus_textonly.html
  7. Pfizer Inc. (2006). Milestones in public health
    Accomplishments in public health over the last
    100 years. New York, NY Pfizer Inc.

83
Resources and References
  1. Neese, R. Williams, G. (1996). Why we get sick
    The new science of Darwinian medicine. New York
    Vintage Books.
  2. National Institute of Allergy and Infectious
    Diseases (n.d.). Emerging and Re-Emerging
    Infectious Diseases Research at NIAID. Retrieved
    from http//www.niaid.nih.gov/topics/emerging/Page
    s/Default.aspx
  3. Pyrek, K.M. (2003). Reducing Resistance FDA
    Adopts New Antibiotic Regulations. Infection
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