摘要：We examined how different drivers of infectious disease could interact to threaten control efforts in Europe. We considered projected trends through 2020 for 3 broad groups of drivers: globalization and environmental change, social and demographic change, and health system capacity. Eight plausible infectious disease threats with the potential to be significantly more problematic than they are today were identified through an expert consultation: extensively drug-resistant bacteria, vector-borne diseases, sexually transmitted infections, food-borne infections, a resurgence of vaccine-preventable diseases, health care–associated infections, multidrug-resistant tuberculosis, and pandemic influenza. Preemptive measures to be taken by the public health community to counteract these threats were identified. The 2009 pandemic influenza A (H1N1) virus is perhaps exemplary of what is to be expected from a 21st-century pathogen. It is zoonotic, with a genome of human, swine, and avian elements whose reassortments may have been facilitated by intensive agricultural practices 1 ; its initial worldwide spread strongly correlated with global air traffic patterns 2 ; its emergence led to moral panic as the World Health Organization declared a pandemic 3 ; public consensus about whether it was safe or necessary to vaccinate was lacking 4 , 5 ; and its principal medical products, vaccines and antivirals, appear to have been unevenly distributed across the world. The 2009 influenza A (H1N1) pandemic may not have had the catastrophic impact initially feared, but its consequences were nonetheless significant. There were more than 18 000 laboratory-confirmed deaths worldwide, 6 and the number of attributable deaths may be several orders of magnitude higher: estimates for the United States alone, provided by the US Centers for Disease Control and Prevention, range from 8700 to 18 000 deaths. The number of estimated hospitalizations was in the hundreds of thousands and estimated cases in the millions. 7 Furthermore, because young people were particularly vulnerable to the virus, 8 the disease burden in terms of years of life lost has been substantial. 9 The pandemic serves as the latest addition to a long list of recent examples of the emergence and spread of infectious diseases, which currently account for roughly 20% of the global burden of disease. 10 Malaria, HIV, and tuberculosis; novel diseases such as severe acute respiratory syndrome 11 ; resurgent vector-borne diseases such as dengue 12 and chikungunya 13 ; and drug-resistant microbes quickly come to mind when considering emerging and reemerging infectious diseases (EIDs), but they are not alone. A 2005 study suggested that 177 human pathogens have been labeled as emerging or reemerging, of which more than half (58%) are zoonotic agents. 14 A separate study reported that 335 new diseases emerged between 1940 and 2004 and that the frequency of emergence has risen significantly over time, with a peak coinciding with HIV in the 1980s. 15 The northeastern United States, Western Europe, Japan, and southeastern Australia have been identified as emerging disease “hot spots”; socioeconomic factors (human population density, agriculture, antibiotic drug usage), alongside environmental factors, are hypothesized as key drivers of EIDs in these regions, and this notion has been widely corroborated by the literature. 16 – 19 In a period of rapid global change, it is reasonable to expect that the conditions amenable to the transmission of EIDs will, in some instances, be created or exacerbated. To thoroughly assess how this might affect disease transmission dynamics, it has been advocated that a wider range of methodological approaches be incorporated into epidemiological research and that EIDs and human health be viewed from a broader, social–ecological systems perspective. 20 – 22 This could also help guide public health prioritization activities. Under the premise that Western Europe is indeed an EID hot spot and that the European Union (EU) is highly connected to other global EID hot spots, the European Centre for Disease Prevention and Control (ECDC) conducted a foresight project to ascertain how the European Union's social–ecological context might change over the coming decade and what this might mean for infectious disease control in the European Union by 2020. Eight plausible threat scenarios were formulated on the basis of an analysis of how exacerbating (and not mitigating) EID drivers could interact.
