Emerging Infections and Disease Emergence.

To the Editor: Emerging infections have been defined as diseases whose incidence in humans has increased within the last 2 decades or threatens to increase in the near future (1). This definition, with minor variations, has continued to be used, although occasional debate erupts over whether one disease or another is truly emerging. Use of the term "emerging" has facilitated communication about the changed pattern of infectious diseases in recent years. While the study of infectious organisms and clinical training about emerging infections are manifestly necessary, they are not a sufficient foundation for understanding the process of disease emergence. I would propose, specifically, that we distinguish between emerging diseases--the study of specific infections that are changing--and the study of disease emergence.

Studies of emerging infections typically rely on disease, organismic, or syndromic approaches. Meetings on emerging infections typically cover newly recognized or characterized organisms or diseases and update information about the recognition, diagnosis, treatment, prevention, and control of these infections. This ongoing education is essential for practicing clinicians, who finished their formal training before AIDS, Lyme disease, ehrlichiosis, Helicobacter pylori infection, cryptosporidiosis, cyclosporiasis, and many other infections were described. These meetings also help clinicians learn how to fit new information into their existing knowledge base: What is the probability that a person with rash and fever has ehrlichiosis and that a person with fever and pulmonary infiltrates has hantavirus pulmonary syndrome?

By contrast, understanding the process of disease emergence involves studying the origins and ecology of emerging infections. Many disciplines relevant to disease emergence lie outside traditional infectious disease training and research and include evolutionary biology, demography, population dynamics, ecology, vector biology, climatology, epidemiology, genetics, veterinary medicine, and behavioral sciences (2). Infectious diseases of animals and plants have both a direct and indirect impact on human health. The study of infectious diseases in other species may provide important insights into understanding the process of disease emergence in humans. The study is also relevant to understanding the species-to-species spread of organisms.

Tools used to study and understand disease emergence include mathematical modeling, geographic information systems, remote sensing, molecular methods to study the genetic relatedness of organisms, and molecular phylogeny. Paleobiology, paleoecology, and studies that allow the reconstruction of past events may help inform future research and policy.

A major challenge is to reach people with relevant skills, knowledge, and experience and develop a coherent framework to advance the understanding of the process of disease emergence. No one institution, organization, or country can itself prevent or manage emerging infectious diseases.

In the study of emerging infections we focus on the organism, the patient, and the human population. The study of disease emergence must be at the systems level and must look at ecosystems, evolutionary biology, and populations of parasites and hosts, whatever their species. A primary goal should be to identify conditions or combinations or sequences of events that herald a changed pattern of infections so that preventive strategies can be used.

References

(1.) Lederberg J, Shope RE, Oaks SC Jr., editors. Emerging infections: microbial threats to health in the United States. Institute of Medicine. Washington: National Academy Press, 1992.

(2.) Wilson ME, Levins R, Spielman A, editors. Disease in evolution: Global changes and emergence of infectious diseases. Vol 4. New York: Ann NY Acad Sciences; 1994.

Mary E. Wilson

Mount Auburn Hospital, Cambridge, Massachusetts, USA; Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts, USA