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Milestones in Public Health: Chapter 4. Infectious Disease Control. Complete, Combined Lectures for Undergraduate, Graduate Public Health, and Medical and Clinical Education Levels. January 2011. Learning Objectives: All Learner Levels.

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infectious disease control

Milestones in Public Health: Chapter 4

Infectious Disease Control

Complete, Combined Lectures for Undergraduate, Graduate Public Health, and Medical and Clinical Education Levels

January 2011

learning objectives all learner levels
Learning Objectives:All Learner Levels
  • Describe the 150-year history of world efforts to control infectious disease
  • Discuss Darwin’s concept of adaptation as applied to infectious diseases
  • Describe the roles of federal agencies and advocacy organizations
  • Review the CDC’s OPLAN for Avian Influenza
learning objectives undergraduate education
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
learning objectives graduate public health education
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
learning objectives medical and clinical education
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
lecture outline
Lecture Outline
  • Historical Perspective
  • The Milestone and its Impact on Public Health
  • Aspects of Biology, Behavior and Science of Infectious Diseases
  • Systems, Policies and Programs
  • Looking Ahead
  • Wrap-Up
  • References and Resources
infectious disease control1

Infectious Disease Control

Historical Perspective

historical perspective infectious disease control
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)


historical perspective cont
Historical Perspective (Cont.)

To tell the real war story, the current one, we need to go back to 1859 to Charles Darwin’s Theory of Natural Selection as the explanation of the functional designs of organisms.

Neese and Williams (1996)

the concept of adaptation by natural selection
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)

new take on darwinian medicine
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)

new take on darwinian medicine cont
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)

stern and markel 2004
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
growth in understanding the spread of disease from person to person
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)


koch s postulates of 1891 the germ theory of disease
Koch’s 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)


infectious disease control2

Infectious Disease Control

The Milestone and Its Impact on Public Health

populations at risk
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)


why are infectious diseases still among the leading causes of death worldwide
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))

infectious disease control3

Infectious Disease Control

Aspects of Biology, Behavior and Science of Infectious Diseases

aspects of biology behavior and science of infectious diseases
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)

sources of infection
Sources of Infection

Microorganisms enter the body through:

  • Air
  • Food
  • Water
  • Contact with skin
  • Contact with vectors

Black (2008)

sources of infection cont
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)

sources of infection cont1
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)

sources of infection cont2
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)

sources of infection cont3
Sources of Infection (Cont.)
  • Water-borne diseases:
    • Usually spread by fecal-oral route
    • Common in less-developed countries
    • Also from food sources

Black (2008)

sources of infection cont4
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)

how do organisms gain entry to the body
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
sites of entry
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)

sites of entry cont
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)

sites of entry cont1
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)

spread of infectious agents in body
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)

when does infection occur
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)

when does infection occur cont
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)

when does infection occur cont1
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)

when does infection occur cont2
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)

infectious disease interventions
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

improved resistance to environmental hazards
Improved Resistance to Environmental Hazards
  • Hygiene
  • Nutrition
  • Immunity
  • Antibiotics
  • Psychological factors
  • Exercise
  • Genetic alteration

Aschengrau & Seage (2008)

improved environmental safety
Improved Environmental Safety
  • Sanitation
  • Air
  • Water
  • Food
  • Infectious agents
  • Vectors
  • Animal reservoirs

Aschengrau & Seage (2008)

enhanced public health systems
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

four important systems related means of controlling communicable disease
Four Important Systems-related Means of Controlling Communicable Disease
  • Containment
  • Contact tracing for prophylaxis and therapy
  • Education
  • Measurement (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)

purposes of surveillance
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)

surveillance is crucial for prevention and control
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
domestic surveillance national notifiable disease surveillance system nndss
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)

domestic surveillance nndds
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)

s aureus related hospitalizations
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

  • Jhung’s Enhanced Detection of Staphylococcus aureus-related Hospitalizations Using Administrative Databases, United States, 1999-2005

Jhung (2008)

s aureus related hospitalizations cont
S. Aureus-Related Hospitalizations (Cont.)


  • 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)

surveillance systems for mrsa methicillin resistant staph aureus
Surveillance Systems for MRSA (Methicillin-Resistant 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 ABC’s MRSA surveillance, represent- ing a population of 16.3 million persons
  • NNIS-National Nosocomial Infection Surveillance System (1970’s-2005) Publications and Reports

Milestones (2006)

public health system capacity
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)

the problem with surveillance
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)

challenge for public health
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)

application to surveillance
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)


Infectious Disease Realities

  • Emergence of new infectious diseases
  • Re-emergence of old infectious diseases
  • Persistence of intractable infectious diseases
emerging infectious diseases
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

national institute of allergy and infectious diseases niaid categories group 1
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


status of new infectious diseases
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
re emerging diseases
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


re emerging diseases cont
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


re emerging diseases cont1
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 research plans and priorities
NIAID Research Plans and Priorities
  • Pandemic influenza
  • Emerging and re-emerging infectious diseases such as TB, malaria, and tropical disease
  • Immune-mediated diseases

Fauci (2007)

infectious disease control4

Infectious Disease Control

Systems, Policies and Programs

human and microbial factors in emergence of new infectious diseases
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)

antibiotic resistance
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)

federal agencies and advocacy organizations
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)

federal agencies
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)

federal agencies cont
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)

federal agencies cont1
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)

federal agencies cont2
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)

federal agencies cont3
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)

federal agencies cont4
Federal Agencies (Cont.)
  • Guidance document issued

targeting pharmaceutical

industry which develops veterinary drugs for widespread agricultural use

  • FDA’s 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)

advocacy organizations
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)

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

APHA (2003)


advocacy organizations cont1
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)

looking ahead
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

Milestones (2006)

mission of cdc
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)

the cdc oplan january 11 2008
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)

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
resources and references
Resources and References
  • American Public Health Association. (2003). Antibiotic Resistance Fact Sheet. Retrieved from
  • Aschengrau, A., & G. R. Seage III. (2009). Essentials of Epidemiology in Public Health. Boston: Jones and Bartlett Publishers.
  • Black, J.G. (2008). Microbiology: Principles and Explorations (7th ed.). Hoboken, NJ: J. Wiley & Sons.
  • Centers for Disease Control and Prevention. (January 11, 2008). Influenza Pandemic OPLAN. Retrieved from
  • Centers for Disease Control and Prevention. (January 25, 2010). National Notifiable Diseases Surveillance System. Retrieved from
  • 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.
  • 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
resources and references1
Resources and References
  • Fauci, A.S. (2004, October). Emerging Infectious Diseases. A Clear and Present Danger to Humanity. JAMA. 292(15), 1887-1888.
  • Fauci, A. (2007). NIAID Investment, Research Make Strides For Improving Health Globally. U.S. Medicine.NIAID. Retrieved from
  • FAQs. (2004). The Office of Public Health Service History. NIH. Retrieved August 29, 2008 from
  • Fredericks, D., & Relman, D. (1996). Sequence-based identification of microbial pathogens: A reconsideration of Koch's postulates. Clinical Microbiology Reviews, 9(1), 18-33.
  • Institute of Medicine (IOM). 2003. Microbial Threats to Health: Emergency, Detection, and Response. Washington, DC: National Academies Press.
  • 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
  • Pfizer Inc. (2006). Milestones in public health: Accomplishments in public health over the last 100 years. New York, NY: Pfizer Inc.
resources and references2
Resources and References
  • Neese, R. & Williams, G. (1996). Why we get sick: The new science of Darwinian medicine. New York: Vintage Books.
  • National Institute of Allergy and Infectious Diseases (n.d.). Emerging and Re-Emerging Infectious Diseases: Research at NIAID. Retrieved from
  • Pyrek, K.M. (2003). Reducing Resistance: FDA Adopts New Antibiotic Regulations. Infection Control Today. Retrieved from
  • Stern, A.M., & Markel, H. (2004). International Efforts to Control Infectious Diseases, 1851 to Present. JAMA. 292(12), 1474-1479.
  • Taraporewala, I.B. (2008). The Growing Problem of Antibiotic Resistance: Medical, Legislative, and Legal Implications. Update (2), 6-11.
  • Uehling, D.T., Johnson, D.B., & Hopkins, W.J. (1999). The Urinary Tract Response to Entry of Pathogens. World Journal of Urology. 17(6), 351-8.
  • Update on avian influenza A (H5N1) virus infection in humans. (2008). New England Journal of Medicine, 358(3), 261-273. Retrieved from
  • World Health Organization. (2007). The top 10 causes of death. Retrieved from