Acknowledgments We gratefully acknowledge the valuable contributions of the following colleagues to the development of this plan: James R. Allen, Henry Anderson, Larry J. Anderson, Douglas L. Archer, Thomas Arrowsmith-Lowe, William H. Bancroft, C.L.R. Bartlett, Nancy H. Bean, David M. Bell, Abram S. Benenson, John E. Bennett, John V. Bennett, Bobbie A. Berkowitz, Guthrie S. Birkhead, Paul A. Blake, Coleen A. Boyle, Philip S. Brachman, Windell R. Bradford, A. D. Brandling-Bennett, Joel G. Breman, Don J. Brenner, Claire V. Broome, George T. Bryan, James W. Buehler, Michael J. Burkhart, Jay C. Butler, Ronald L. Cada, Carlos C. Campbell, Grant R. Campbell, Roger H. Carlson, Gail H. Cassell, Kenneth G. Castro, Willard Cates, Jr., Mary Ann Chiasson, Gary G. Clark, Barnett L. Cline, Mitchell L. Cohen, Daniel G. Colley, Mary-Paxton D. Colley, E. Mary Cooke, Jose F. Cordero, Jon M. Counts, Nancy J. Cox, Donald E. Craven, James W. Curran, Mary Ann Danello, Jeffrey P. Davis , Joe H. Davis, Barbara A. DeBuono, George K. Degnon, Scott D. Deitchman, David T. Dennis, Arthur F. DiSalvo, Lynda S. Doll, H. Denny Donnell, D. Peter Drotman, Jeffrey S. Duchin, Richard J. Duma, Herbert L. DuPont, William W. Dyal, Elaine Eaker, Mark L. Eberhard, Paul R. Epstein, Martin S. Favero, John C. Feeley, Bernard N. Fields, Reginald Finger, David W. Fleming, Thomas M. Folks, Christopher Foreman, Willis R. Forrester, Susan W. Forlenza, Joseph A. Foster, D. Bruce Francy, Linda U. Frank, Phyllis Freeman, Kenneth L. Gage, Eugene J. Gangarosa, Lynne S. Garcia, Julia S. Garner, G. William Gary, Jr., Howard E. Gary, Kristine Gebbie, Kathleen F. Gensheimer, Anne A. Gershon, Noel Gill, Roger I. Glass, John Glasser, Donald A. Goldmann, Robert C. Good, Richard A. Goodman, Michael Gottlieb, Steve Gradus, Alan E. Greenberg, Patricia M. Griffin, Donald S. Gromisch, Duane J. Gubler, James L. Hadler, Stephen C. Hadler, Robert W. Haley, Caroline B. Hall, Scott B. Halstead, Harlyn O. Halvorson, W. Lee Hand, George E. Hardy, Jr., William J. Hausler, Mary V. Hearn, D. A. Henderson, Kenneth L. Herrmann, Walter J. Hierholzer, Allen W. Hightower, George C. Hill, Elvin R. Hilyer, Richard E. Hoffman, Charles H. Hoke, King K. Holmes, Donald R. Hopkins, John M. Horan, Charles R. Horsburgh, C. James Hospedales, Robert Howard, Harold W. Jaffe, William R. Jarvis, Suzanne R. Jenkins, Lisa A. Jackson, Wanda K. Jones, J. Mehsen Joseph, Dennis D. Juranek, Robert L. Kaiser, Martha F. Katz, Arnold F. Kaufmann, Ali S. Khan, Edwin M. Kilbourne, Lonnie King, Douglas N. Klaucke, Heidi M. Klein, Jane E. Koehler, Edward J. Koenigsberg, Donald J. Krogstad, John R. LaMontagne, Alexander D. Langmuir, Edgar O. Ledbetter, Joshua Lederberg, James W. LeDuc, Harold R. Lentzner, Hans O. Lobel, Carlos E. Lopez, Rogelio Lopez, Joseph Z. Losos, Stephen P. Luby, John R. Lumpkin, Brian W. J. Mahy, Gerald L. Mandell, R. J. Martin, Stanley M. Martin, William J. Martin, William T. Martin, Adolfo Martinez-Palomo, William J. Martone, John J. Maupin, C. Glen Mayhall, Joseph E. McDade, J. Steve McDougal, Louise McFarland, Sara L. McGaughey, J. Michael McGinnis, Philip B. Mead, Amy Melnick, Rebecca Meriwether, Tom Messenger, Franklin R. Miller, Carl J. Mitchell, Violaine Mitchell, Phyllis L. Moir, Arnold S. Monto, Chester G. Moore, Melinda Moore, Patrick S. Moore, W. Meade Morgan, Stephen A. Morse, Stephen S. Morse, Ken E. Mott, Robert J. Mullan, Frederick A. Murphy, Bernard L. Nahlen, Verla J. Neslund, Ray M. Nicola, Stuart L. Nightingale, Gary R. Noble, Pat Nolan, Stanley C. Oaks, James G. Olson, Howard W. Ory, Michael T. Osterholm, Stephen M. Ostroff, Bradley A. Perkins, Dennis M. Perrotta, Georges Peter, Lyle R. Petersen, Larry K. Pickering, Morris E. Potter, Rosemary B. Ramsey, Nancy Rawding, William C. Reeves, Russell Regnery, Arthur L. Reingold, I. Paul Reiter, Roselyn J. Rice, Jose G. Rigau, John T. Roehrig, Trenton K. Ruebush, Kathy H. Rufo, Wilmon R. Rushing, Philip K. Russell, Merle Sande, Jay P. Sanford, F. T. Satalowick, Charles P. Schade, Gerald Schochetman, Lawrence B. Schonberger, Benjamin Schwartz, Denman H. Scott, Phillip E. Shambra, Janet Shoemaker, Robert E. Shope, Bruce Siegel, David R. Smith, Carol D. Snarey, Dixie E. Snider, P. Frederick Sparling, Harrison C. Spencer, Robert Steffen, Gerald V. Stokes, Susan L. Stokes, Al Strating, Donna F. Stroup, Balasubra Swaminathan, Ernest T. Takafugi, Robert V. Tauxe, Fred C. Tenover, Steven M. Teutsch, G. Torrigiani, Louis Trachtman, Dennis W. Trent, Kaye Wachsmuth, John W. Ward, MacWilson Warren, Reuben C. Warren, Robert Watkins, Jay D. Wenger, Scott F. Wetterhall, F. Stephen Wignall, Mary E. Wilson, Martin S. Wolfe, Herbert F. Young, Jane R. Zucker, Larry D. Zyla --- References 1. Institute of Medicine. Emerging Infections: Microbial Threats to Health in the United States. Washington, D.C.: National Academy Press, 1992. 2. Krause RM. The Restless Tide: The Persistent Challenge of the Microbial World. Washington, D.C.: The National Foundation for Infectious Diseases, 1981. 3. Morse SS, Schluederberg A. Emerging viruses: the evolution of viruses and viral diseases. J Infect Dis 1990;162:1-7. 4. Morse SS. Emerging viruses: defining the rules for viral traffic. Perspect Biol Med 1991;34:387-409. 5. Epstein PR. Commentary: pestilence and poverty historical transitions and the great pandemics. Am J Prev Med 1992;8:263-5. 6. Council of State and Territorial Epidemiologists Survey on Surveillance, 1993; M. Osterholm, personal communication, 1993. 7. Institute of Medicine. The U.S. Capacity to Address Tropical Infectious Disease Problems. Washington, D.C.: National Academy Press, 1987. 8. Institute of Medicine. The Future of Public Health. Washington, D.C.: National Academy Press, 1988. 9. WHO. Global Health Situations and Projections, Estimates 1992. WHO, Geneva, 1992. 10. NIAID. Report of the Task Force on Microbiology and Infectious Disease. US Department of Health and Human Services, Public Health Service, National Institutes of Health. NIH Publication 92-3320, 1992. 11. U.S. Department of Health and Human Services. Healthy People 2000. National Health Promotion and Disease Prevention Objectives. DHHS Publication No.(PHS) 91-50213, U.S. Government Printing Office, 1990. 12. Lederberg J. Medical science, infectious disease, and the unity of humankind. JAMA 1988;260:684-5. 13. CDC. Office visits for otitis media: United States, 1975-90. Advance Data 1992;214:1-9. 14. CDC. Drug utilization in office practice. National ambulatory medical care survey, 1990. Advance Data 1993;232:1-9. 15. Blaser MJ, Perez-Perez GI, Lindenbaum J, et al. Association of infection due to Helicobacter pylori with specific upper gastrointestinal pathology. Rev Infect Dis 1991;13(suppl 8):S704-8. 16. Reeves WC, Rawls WE, Brinton LA. Epidemiology of genital papillomaviruses and cervical cancer. Rev Infect Dis 1989;11:426-39. 17. Alter MJ, Margolis HS, Krawczynski K, et al. The natural history of community-acquired hepatitis C in the United States. N Engl J Med 1992; 321:1899-1905. 18. Kuo C, Shor A, Campbell LA, et al. Demonstration of Chlamydia pneumoniae in atherosclerotic lesions of coronary arteries. J Infect Dis 1993;167:841-9. 19. Glass GE, Watson AJ, LeDuc JW, et al. Infection with a ratborne hantavirus in US residents is consistently associated with hypertensive renal disease. J Infect Dis 1993;167:614-20. 20. CDC. The Center for Infectious Diseases: Toward the Year 2000. CDC, Public Health Service, Department of Health and Human Services, 1990. 21. CDC. Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR 1992;41:783-7. 22. Krause RM. The origin of plagues: old and new. Science 1992;257:1073-8. 23. Davis JP, Chesney PJ, Wand PJ, et al. Toxic shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med 1980;303:1429-35. 24. CDC. Lyme disease United States, 1991-1992. MMWR 1993;42:345-8. 25. Thacker SB, Addiss DG, Goodman RA, Holloway BR, Spencer HC. Infectious diseases and injuries in child day care: opportunities for healthier children. JAMA 1992;268:1720-6. 26. Armstrong D. History of opportunistic infection in the immunocompromised host. Clin Infect Dis 1993;17(suppl 2):S318-21. 27. Gradon JD, Timpone JG, Schnittman SM. Emergence of unusual opportunistic pathogens in AIDS: a review. Clin Infect Dis 1992; 15:134-57. 28. Eisenstein BI. New opportunistic infections more opportunities. N Engl J Med 1990;323:1625-7. 29. Dolan MJ, Wong MT, Regnery RL, et al. Syndrome of Rochalimaea henselae adenitis suggesting cat scratch disease. Ann Intern Med 1993; 118:331-6. 30. Tompkins DC, Steigbigel RT. Rochalimaea's role in cat scratch disease and bacillary angiomatosis. Ann Intern Med 1993; 118:388-90. 31. Bryan RT. Microsporidiosis. In: Mandell GS, Bennett JE, Dolin R (Eds.). Principles and Practice of Infectious Diseases, 4th Ed. New York: Churchill Livingstone, 1994. 32. Wood CW, MacDonald KL, Osterholm MT. Campylobacter enteritis outbreaks associated with drinking raw milk during youth activities. A 10-year review of outbreaks in the United States. JAMA 1992;268:3228-30. 33. Hedberg CW, Korlath JA, D'Aoust JY, et al. A multistate outbreak of Salmonella javiana and Salmonella oranienburg infections due to consumption of contaminated cheese. JAMA 1992;268:3203-7. 34. Hedberg CW, David MJ, White KE, et al. Role of egg consumption in sporadic Salmonella enteritidis and Salmonella typhimurium infections in Minnesota. J Infect Dis 1993; 167:107-11. 35. Hedberg CW, Levine WS, White KE, et al. An international foodborne outbreak of shigellosis associated with a commercial airline. JAMA 1992;268:3208-12. 36. CDC. Cholera associated with an international airline flight. MMWR 1992;41:134-5. 37. DuPont HL. How safe is the food we eat? (Editorial). JAMA 1992;268:3240. 38. CDC. Salmonella serotype Tennessee in powdered milk products and infant formula Canada and the United States, 1993. MMWR 1993;42:516-17. 39. CDC. Multistate outbreak of viral gastroenteritis related to consumption of oysters Louisiana, Maryland, Mississippi, and North Carolina, 1993. MMWR 1993;42:945-8. 40. CDC. Fish botulism Hawaii, 1990. MMWR 1991;40:412-4. 41. CDC. Paralytic shellfish poisoning Massachusetts and Alaska, 1990. MMWR 1991;40:157-61. 42. Epstein PR, Ford TE, Colwell RR. Marine ecosystems. Lancet 1993;342:1216-9. 43. CDC. Preliminary report: Foodborne outbreak of Escherichia coli O157:H7 infections from hamburgers western United States, 1993. MMWR 1993;42:85-6. 44. CDC. Update: multistate outbreak of Escherichia coli O157:H7 infections from hamburgers western United States, 1992-1993. MMWR 1993;42:258-63. 45. Hayes DB, Matte TD, O'Brien TR, et al. Large community outbreak of cryptosporidiosis due to contamination of a filtered public water supply. N Engl J Med 1989;320:1372-6. 46. Personal communication, Jeffrey P. Davis, M.D., Communicable Disease Epidemiologist, December 1993. 47. CDC. Outbreak of acute illness southwestern United States, 1993. MMWR 1993;42(22):421-24. 48. CDC. Hantavirus infection southwestern United States: interim recommendations for risk reduction. Recommendations and Reports. MMWR 1993;42(RR-11):1-13. 49. CDC. Progress in the development of hantavirus diagnostic assays United States. MMWR 1993;42:770-72. 50. CDC. Hantavirus pulmonary syndrome United States, 1993. MMWR 1994;43:45-8. 51. CDC. Update: Cholera Western Hemisphere, 1992. MMWR 1993;42:89-91. 52. CDC. Isolation of Vibrio cholerae O1 from oysters Mobile Bay, 1991-1992. MMWR 1993;42:91-93. 53. CDC. Imported cholera associated with a newly described toxigenic Vibrio cholerae O139 strain California, 1993. MMWR 1993;42:501-3. 54. Maldonado YA, Nahlen BL, Roberto RR, et al. Transmission of Plasmodium vivax malaria in San Diego County, California, 1986. Am J Trop Med Hyg 1990;42:3-9. 55. CDC. Malaria in Montagnard refugees North Carolina, 1992. MMWR 1993; 42:180-3. 56. Schantz PM, Moore AC, Muoz JL, et al. Neurocysticercosis in an orthodox Jewish community in New York City. N Engl J Med 1992;327:692-5. 57. Gellert GA, Neumann AK, Gordon RS. The obsolescence of distinct domestic and international health sectors. J Public Health Policy 1989;10:421-4. 58. Berkley SF. AIDS in the global village. Why US physicians should care about HIV outside the United States (Editorial). JAMA 1992; 268:3368-9. 59. Levy SB. Confronting multidrug resistance: a role for each of us. JAMA 1993;269:1840-2. 60. Reichler MR, Allphin AA, Breiman RF, et al. The spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio. J Infect Dis 1992;166:1346-53. 61. CDC. Drug-resistant Streptococcus pneumoniae Kentucky and Tennessee. MMWR 1994;43:23-31 62. Schwartz B, Facklam RR, Breiman RF. Changing epidemiology of group A streptococcal infection in the USA. Lancet 1990; 336: 1167-71. 63. King GE, Markowitz LE, Patriarca PA, Dales LG.Clinical efficacy of measles vaccine during the 1990 measles epidemic. Pediatr Infect Dis J 1991;10:883-7. 64. Maggini M, Salmoso S, Alegiani S, Caffari B, Raschetti R. Epidemiological use of prescriptions as markers of disease frequency: an Italian experience. J Clin Epidemiol 1991;44:1299-307. 65. Henderson DA. Strategies for the twenty-first century, control or eradication? In: Walker D, ed. Global Infectious Diseases: Prevention, Control, and Eradication. Vienna: Springer-Verlag, 1992. 66. Dobson A, Carper R. Biodiversity. Lancet 1993;342:1096-99. 67. Henderson DA. Surveillance of smallpox. Inter J Epidemiol 1976;5, 19-28. 68. Berkelman RL, Buehler JW. Surveillance. In Holland NH, Detels R, Knox G, eds. Oxford Textbook of Public Health, 2nd ed., vol. 2: Methods of Public Health. New York: Oxford University Press, 1991:161-76. 69. Gaynes RP, Banerjee S, Emori G, et al. The National Nosocomial Infections Surveillance (NNIS) System: plans for the 1990's and beyond. Am J Med 1991;91(3B):116S-120S. 70. Rogers DJ, Williams BG. Monitoring trypanosomiasis in space and time. Parasitology 1993;106:S77-S92. 71. Epstein PR, Rogers DJ, Slooff R. Satellite imaging and vector-borne disease. Lancet 1993;341:1404-6. 72. Henderson DA. Surveillance systems and intergovernmental Cooperation. In Emerging Viruses, Morse SS, ed. New York: Oxford University Press, 1993;283-289. 73. Bartlett C, Gill N. International surveillance of disease. Communicable disease control after Maastricht: germs and subsidiarity. Lancet 1993;341:997-8. 74. Desenclos J-C, Bijkerk H, Huisman J. Variations in national infectious diseases surveillance in Europe. Lancet 1993;341:1003-6. 75. Roberts B (Ed.). Biological Weapons: Weapons of the Future? Washington, D.C.: Center for Strategic and International Studies, 1993. 76. Cohen ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science 1992;257:1050-5. 77. Frieden TR, Munsiff SS, Low DE, et al. Emergence of vancomycin- resistant enterococci in New York City. Lancet 1993;342:76-9. 78. Mourad AS, Metwally M, Nour El Deen A, et al. Multiple-drug-resistant Salmonella typhi. Clin Infect Dis 1993:17:135-6. 79. Tauxe RV, Puhr ND, Wells JG, Hargrett-Bean N, Blake PA. Antimicrobial resistance of Shigella isolates in the USA: the importance of international travelers. J Infect Dis 1990;162:1107-11. 80. Telenti A, Imboden P, Marchesi F, et al. Detection of rifampicin- resistance mutations in Mycobacterium tuberculosis. Lancet 1993;341:647-50. 81. Holmberg SD, Osterholm MT, Senger KA, Cohen ML. Drug-resistant Salmonella from animals fed antimicrobials. N Engl J Med 1984;311:617-22. 82. Jansson C, Franklin A, Skold O. Trimethoprim resistance arising in animal bacteria and transferring into human pathogens. J Infect Dis 1993;167:785-7. 83. CDC. Coccidioidomycosis United States, 1991-1992. MMWR 1993;42:21-28. 84. Meslin FX. Surveillance and control of emerging zoonoses. World Health Stat Q 1992;45:200-07. 85. Edelstein PH. Legionnaires' disease. Clin Infect Dis 1993;16:741-9. 86. McCormick JB, Webb PA, Krebs JW, Johnson KM, Smith ES. A prospective study of the epidemiology and ecology of Lassa fever. J Infect Dis 1987;155:437-44. 87. Relman DA. The identification of uncultured microbial pathogens. J Infect Dis 1993;168:1-8. 88. Maslow JN, Mulligan ME, Arbeit RD. Molecular epidemiology: application of contemporary techniques to the typing of microorganisms. Clin Infect Dis 1993;17:153-64. 89. Ou CY, Ciesielski CA, Myers G, et al. Molecular epidemiology of HIV transmission in a dental practice. Science 1992;256:1165-71. 90. Pinner RW, Schuchat A, Swaminathan B, et al. Role of foods in sporadic listeriosis: II. Microbiologic and epidemiologic investigation. JAMA 1992; 267:2046-50. 91. Pinner RW, Onyango F, Perkins BA, et al. Epidemic meningococcal disease in Nairobi, Kenya, 1989. J Infect Dis 1992; 166:359-64. 92. Moore PS, Reeves MW, Schwartz B, et al. Intercontinental spread of an epidemic group A Neisseria meningitidis strain. Lancet 1989;1:260-3. 93. Wenger JD, Hightower AW, Facklam RR, et al. Bacterial meningitis in the United States, 1986: report of a multistate surveillance study. J Infect Dis 1990; 162:1316-1323. 94. Levy MH, Jalaludin B, Roberts C. Infectious disease notification progress at last. New South Wales Public Health Bulletin 1992;3:53-5. 95. ASTPHLD Task Force. Task Force Report on the Public Health Laboratory A Critical National Resource, 29 January 1993. 96. Schuchat A, Deaver KA, Wenger JD, et al. Role of foods in sporadic listeriosis: I. Case-control study of dietary risk factors. JAMA 1992; 267:2041-45. 97. CDC. Emergency mosquito control associated with Hurricane Andrew Florida and Louisiana. MMWR 1993;42:240-2. --- Summary of Figures, Tables, and Boxes Figures 1. Examples of Emerging and Resurgent Infectious Diseases in the 1990s 2. Institute of Medicine report, "Emerging Infections: Microbial Threats to Health in the United States," National Academy Press, 1992 3. Emergence of Foodborne and Waterborne Pathogens A. E. coli O157:H7 B. Cryptosporidium 4. Spread of Epidemic Cholera Latin America, 19911993 5. Increasing Incidence of Vancomycin-Resistant Enterococci in U.S. Hospitals by Year National Nosocomial Infections Surveillance System, 1989-1993 6. The Expanding Epizootic of Racoon Rabies Eastern United States, 1979-1993 7. Potential Projects for Emerging Infections Epidemiology and Prevention Centers, United States Tables 1. Factors in Emergence 2. Chronic Manifestations of Infectious Diseases, United States 3. Proposed Sentinel Surveillance Networks 4. Examples of Potential Members of a Global Consortium of Epidemiology/Biomedical Research Programs/Centers 5. Behaviors Shown to Reduce the Risk of Emerging Infections 6. Implementation: High Priorities for 1994-1996 Boxes Waterborne Cryptosporidiosis The National Nosocomial Infection Surveillance (NNIS) System Sentinel Surveillance for Influenza Hepatitis Sentinel Counties Population-based Active Surveillance Project Coccidioidomycosis in California Monitoring Yellow Fever in Kenya, East Africa Human Ehrlichiosis, 1985-1992 Diagnostic Assays and Reagents for Detecting Measles Virus Pulsed-field Gel Electrophoresis of E. coli O157:H7 Multilocus Enzyme Electrophoresis of Group C N. meningitidis Vaccination Strategies for Meningococcal Disease Racoon Rabies Investigation of Hantavirus Pulmonary Syndrome in the United States, 1993