Quelltext der Seite Benutzer:Bummibaer/Syndemic

{{Importartikel}}
{{more footnotes|date=March 2017}} 
{{Medical anthropology}}
A '''syndemic''' or [[synergistic]] epidemic is the aggregation of two or more [[epidemics]] in a population with positive biological interactions exacerbating the damaging effects of diseases. The term was developed by [[Merrill Singer]] in the mid-1990s with growing attention and use among [[Epidemiology|epidemiologists]] and [[Medical anthropology|medical anthropologists]] concerned with public health, [[community health]] and the effects of social conditions on health.  Syndemics develop under [[health disparity]], caused by [[poverty]], stress, or [[structural violence]], and contribute to [[Disease burden|burden of disease]] in affected populations. The term syndemic is further reserved to label the consequential interactions between concurrent or sequential diseases in a population and in relation to the social conditions that cluster the diseases within the population.

It departs from the traditional biomedical approach to diseases to diagnostically isolate, study, and treat diseases as distinct entities separate from other diseases and [[Independence (probability theory)|independent]] of social contexts. [[Synergistic]] disease interactions are important for [[prognosis]]. 

==Definition==
A syndemic is a [[synergistic]] epidemic. The term was developed by [[Merrill Singer]] in the mid-1990s, culminating in a 2009 textbook.<ref>Merrill, S. (2009) [http://www.josseybass.com/WileyCDA/WileyTitle/productCd-0470472030,descCd-tableOfContents.html Introducing Syndemics: A Critical Systems Approach to Public and Community Health] ''Wiley'' pp.304.</ref> 
Disease cooccurrence, with or without interactions, is known as [[comorbidity]], [[coinfection]], and associated terms. The differences between "comorbid" and "syndemic" are per Mustanski et al. (2008:40){{full}} "comorbidity research tends to focus on the [[Nosology|nosological]] issues of boundaries and overlap of diagnoses, while syndemic research focuses on communities experiencing co-occurring epidemics that additively increase negative health consequences." It is possible for two afflictions to be comorbid, but not syndemic i.e., the disorders are not [[epidemic]] in the studied population or their co-occurrence is not accompanied by worsened health.  Thus, two or more diseases can be comorbid without interactions, while in other cases interaction occurs but it is beneficial rather than deleterious. ''Syndemic theory'' seeks to draw attention to and provide a framework for the analysis of adverse disease interactions, including their causes and consequences for human life and well-being.

==Types of disease interaction==
There is growing evidence that diseases regularly interact and that this interaction influences disease course, expression, severity, transmission, and diffusion.  interaction among diseases may be both indirect (changes caused by one disease that facilitate another through an intermediary) and direct (diseases act in direct tandem). In syndemic interactions as the one between [[diabetes]] and [[SARS]], changes in biochemistry or damage to organ systems caused by one disease, in this case, weakening of the immune system by diabetes, promotes the progression of another disease, SARS.{{cn}}

HIV infection and opportunistic microbial infections and possibly viral-caused malignancies like [[Kaposi's Sarcoma]] or [[periodontitis]] may arise from a syndemic. Periodontitis is known to be caused by bacteria of several different species (e.g., ''[[Porphyromonas gingivalis]]'', ''Dialister pneumosintes'', ''[[Prevotella intermedia]]'') that adhere to and reproduce on tooth surfaces under the gum line. Multiplication of these pathogens occurs when bodily defenses are weakened by a [[herpesvirus]] infection of the [[periodontium]].{{cn}}

One disease can assist the physical transmission of another disease, for example, genital-tract ulceration caused by syphilis allows sexual transmission of HIV.{{cn}}
One disease may enhance the [[virulence]] of another, as for example, herpesvirus co-infection exacerbates HIV infection with progression to AIDS,  periodontal bacteria may enhance the virulence of herpesvirus, and HIV-infected individuals are more susceptible to tuberculosis; As of 2011 the cause was not fully understood.<ref>Diedrich, CR. (2011) [http://iai.asm.org/content/79/4/1407.full HIV-1/Mycobacterium tuberculosis Coinfection Immunology: How Does HIV-1 Exacerbate Tuberculosis?] Infection and Immunity. April 2011 vol. 79 no. 4 1407-1417</ref>


Direct interaction of diseases occurs in the case of [[genetic recombination]] among different pathogens, for instance between [[Avian sarcoma leukosis virus]] and [[Marek's disease]] virus (MDV) in domestic fowl.{{Citation needed|date=September 2010}} Both cancer-causing viruses are known to infect the same poultry flock, the same chicken, and, even the same anatomic cell. In coinfected cells, the retroviral DNA of the avian leukosis virus can integrate into the MDV genome, producing altered biological properties compared to those of the parental MDV. The frequency of gene reassortment among human pathogens is less clear than it is the among plant or animal species but of concern as animal diseases adapt to human hosts and as man new diseases comes into contact.{{Citation needed|date=September 2010}}

In some cases, [[coinfection]] may open up multiple syndemic pathways. Lethal synergism has been identified between influenza virus and pneumococcus, causing excess mortality from secondary bacterial pneumonia during influenza epidemics. Influenza virus alters the lungs in ways that increase the adherence, invasion and induction of disease by pneumococcus,  alters the immune response which weakening the ability to clear pneumococcus or, alternately amplifying the inflammatory cascade).

Syndemic interaction among diseases may be apparent, but the linkage is not yet clear, as for example in [[type 2 diabetes]] mellitus and hepatitis C virus infection.  Diet, obesity and aging are known factors for the onset of diabetes, but the role of infection is unclear.

==Counter-syndemics==

{{Original research|section|date=April 2013}}

The discovery of counter-syndemics is important because they may suggest novel strategies to prevent and treat disease. For example, human immunodeficiency virus is transiently suppressed during an acute [[measles]] infection. Several potential mechanisms could be responsible. Measles virus infection causes [[lymphopenia]], a reduction in the number of [[CD4+ T lymphocytes]] circulating in the blood. The low point occurs just prior to the onset of the characteristic skin rash. Within a month of this nadir, the number of lymphocytes return to normal levels. The drop in HIV virus levels may be due to a lack of target CD4+ T cells in which they replicate, or measles virus may stimulate the production of proteins suppressing HIV replication, including the β-chemokines, [[CD8+ cell noncytotoxic anti-HIV response]], and the cytokines [[IL-10]] and IL-16. median plasma levels of [[RANTES]], a chemokine that attracts immune system components like eosinophils , monocytes , and lymphocytes were higher in HIV-infected children with measles than in those without measles(Moss and co-workers).{{cn}}  
HIV suppression also has been identified in patients suffering [[tsutsugamuchi disease]], scrub typhus, a mite-borne infection found in Asia and Australia, but how this occurs is unclear.{{cn}}

==Iatrogenic==

{{Original research|section|date=April 2013}}

The term [[iatrogenesis]] means "brought forth by a healer" and refers to [[adverse effect]]s on health caused by medical treatment. This is possible if medical treatment or medical research creates conditions that increase the likelihood that two or more diseases come together in a population. For example, if [[gene splicing]]  unites two pathogenic agents and the resulting novel organism infects a population. One study suggests the possibility of iatriogenic syndemics. During a randomized, double-blind clinical trial testing the efficacy of the prototype HIV vaccine called V520 there appeared to be an increased risk for HIV infection among the vaccinated participants. Notably, participants immune to the common cold virus [[adenovirus]] type 5 had a higher risk of HIV infection. The vaccine was created using a replication-defective version of Ad5 as a carrier, or delivery vector, for three synthetically produced HIV genes. On November 6, 2007, Merck & Co. announced that research had been stopped suspecting the higher rate of HIV infection among individuals in the vaccinated was because the vaccine lowered defenses against HIV.{{cn}}

==Examples==
Various syndemics though not always labeled as such have been described in the literature, including the SAVA syndemic (substance abuse, violence and AIDS, <ref>{{Cite journal |title=Substance Abuse, Violence, and HIV in Women: A Literature Review of the Syndemic |url=https://www.researchgate.net/publication/51214609_Substance_Abuse_Violence_and_HIV_in_Women_A_Literature_Review_of_the_Syndemic |journal=Journal of Women's Health  |publication-date=June 2011 |volume=20·  |issue=7 |pages=991-1006  |doi=10.1089/jwh.2010.2328}}</ref> the [[hookworm]], [[malaria]] and HIV/AIDS syndemic,<ref>Merrill Singer,[https://idpjournal.biomedcentral.com/articles/10.1186/2049-9957-2-26 Development, coinfection, and the syndemics of pregnancy in Sub-Saharan Africa.] Infectious Diseases of Poverty. 20132:26, DOI: 10.1186/2049-9957-2-26</ref> the [[Chagas disease]], [[rheumatic heart disease]] and [[congestive heart failure]] syndemic,<ref>Bocchi EA1, Arias A, Verdejo H, Diez M, Gómez E, Castro P; Interamerican Society of Cardiology.The reality of heart failure in Latin America.J Am Coll Cardiol. 2013 Sep 10;62(11):949-58. doi: 10.1016/j.jacc.2013.06.013.PMID:23850910</ref> the possible [[asthma]] and [[infectious disease]] syndemic,<ref>Atkinson, T.P. Is Asthma an Infectious Disease? New Evidence. Curr Allergy Asthma Rep (2013) 13: 702. doi:10.1007/s11882-013-0390-8</ref> the [[malnutrition]] and [[depression (mood)|depression]] syndemic, the TB, HIV and [[violence]] syndemic, the [[whooping cough]], [[influenza]], [[tuberculosis]] syndemic, the HIV and [[Sexually transmitted disease|STD]] syndemic; the [[Stress (medicine)|stress]] and [[obesity]] syndemic, and the HIV Infection, [[mental health]] and substance abuse syndemic. 
In January 2006, in a speech at the Enhancing the Healing Environment conference hosted by The Prince's Foundation for the Built Environment and The King's Fund, St James's Palace, London, [[Prince Charles]], The Prince of Wales, noted the importance of paying attention to the built environment, physical inactivity and the [[obesity]]/[[diabetes]] syndemic.

==In history==
While the rate at which new syndemics develop has accelerated through human history, as populations became larger and ever wider tracts of land were inhabited, as the speed of transportation increased with new technologies, and as human impact on the Earth's climatic and other environmental systems increased, syndemics are not a new phenomenon. Contact between Native Americans and Europeans led to syndemics among the Native American population due to diseases introduced during the [[Columbian Exchange]]. This resulted in many deaths due to the Native Americans' lack of built-up immunity to these diseases, which they had not encountered before.

An example of a syndemic from the 19th century can be found on the reservations on which Native Americans were confined with the closing of the U.S. frontier. It is estimated that in 1860 there were well over 10 million [[bison]] living on the American [[Great Plains|Plains]]. By the early 1880s, the last of the great herds of bison upon which [[Plains Indian]] peoples like the [[Sioux]] were dependent as a food source were gone, victims of economic greed as well as a conscious plan to control Plains Indian populations.  White hunting parties scoured the region, sometimes shooting hundreds or even thousands of bison a day.  At the same time, after the U.S. military's defeat at the [[Battle of the Little Bighorn]] in 1876, there was a concerted effort to beat the Sioux into total submission.   Thus, in 1872, Secretary of the Interior [[Columbus Delano]] stated: "as they become convinced that they can no longer rely upon the supply of game for their support, they will return to the more reliable source of subsistence [i.e., farming]." As a result, they were forced to give up their struggle for an independent existence on their own lands and take up reservation life at the mercy of government authority.  Treaties that were signed with the Sioux in 1868 and 1876 stipulated that they would be provided with government annuities and provisions in payment for sections of their land and with the expectation among federal representatives that the Sioux would become farmers on individually held plots of land.  The Sioux found themselves confined on a series of small reservations where they were treated as a conquered people. Moreover, as was typical of treaties with Native peoples, the government reneged on its promises.  The food that was provided to the Sioux was insufficient and of low quality.  [[Black Elk]], a noted Sioux folk healer, told his biographer: "There was hunger among my people before I went across the big water [to Europe in 1886], because the Wasichus [whites] did not give us all the food they promised in the Black Hills treaty...  But it was worse when I came back [1889]. My people looked pitiful…  We could not eat lies and there was nothing we could do."  Under extremely stressful conditions, and with inadequate diets, as well as being the victims of overt racism on the part of the registration agents appointed to oversee Indian reserves, the Sioux confronted exposure to infectious disease transmitted from contact with whites.  While knowledge about the epidemiology of the Sioux from this period is limited, [[James Mooney]], an anthropologist and representative of the [[Bureau of Indian Affairs]] sent to investigate a possible Sioux rebellion, described the health situation on the reservation in 1896: "In 1888 their cattle had been diminished by disease.  In 1889, their crops were a failure ...  Thus followed epidemics of measles, grippe [influenza], and whooping cough [[Pertussis]], in rapid succession and with terrible fatal results…"  Similarly, the ''Handbook of American Indians'' notes, "The least hopeful conditions in this respect prevail among the Dakota [Sioux] and other tribes of the colder northern regions, where pulmonary tuberculosis and scrofula are very common…  Other more common diseases, are various forms of, bronchitis… pneumonia, [[pleurisy]], and [[measles]] in the young. Whooping cough is also met with."  Indian children who were removed to white boarding schools were diagnosed with a wide range of diseases, including tuberculosis, trachoma, measles, smallpox, whooping cough, influenza, and pneumonia.

As these accounts suggest, it is likely that the Sioux were victims of a syndemic that combined a number of interacting infectious diseases (including the [[1889–1890 flu pandemic]]), inadequate diet, and stressful and extremely disheartening life conditions, including, with events like the massacre at [[Wounded Knee Massacre|Wounded Knee]] in 1890 and the murder of their leader [[Sitting Bull]], outright brutalization.  As a result, while the official mortality rate on the reservation was between one and two percent, the death rate was probably closer to 10 percent, a devastatingly high figure.

==Influenza==
{{Main article|Influenza pandemic}}
There were three [[influenza]] [[pandemics]] during the 20th century that caused widespread illness, mortality, social disruption, and significant economic losses.  These occurred in 1918, 1957, and 1968.  In each case, mortality rates were determined primarily by five factors: the number of people who became infected, the virulence of the virus causing the pandemic, the speed of global spread, the underlying features and vulnerabilities of the most affected populations, and the effectiveness and timeliness of the prevention and treatment measures that were implemented.  These factors unite a range of bio-social causal forces, including production, communication, and transportation technologies; the medical and public health infrastructures; the specific pathogens involved and the nature of their interactions with human hosts; and the pre-existing health status of patients.  All of these, in turn, are shaped, to greater or somewhat lesser degree, by overarching political economic structures globally and locally.  Epidemics, in short, including their emergence, course, and impact (and whether they become widespread pandemics that exact a sorrowful toll on life and well-being) are sculpted by the configuration of human social relationships including prevailing patterns of social inequality.

The 1957 pandemic was caused by the Asian influenza virus (known as the H2N2 strain), a novel influenza variety to which humans had not yet developed immunities. The death toll of the 1957 pandemic is estimated to have been around two million globally, with approximately 70,000 deaths in the United States.  A little over a decade later, the comparatively mild Hong Kong influenza pandemic erupted due to the spread of a virus strain (H3N2) that genetically was related to the more deadly form seen in 1957.  The pandemic was responsible for about one million deaths around the world, almost 34,000 of which were in the United States.  In both of these pandemics, death may not have been due only to the primary viral infection, but also to secondary bacterial infections among influenza patients; in short, they were caused by a viral/bacterial syndemic (but see Chatterjee 2007).

The worst of the 20th century influenza pandemics was the 1918 outbreak, which epidemiologists estimate was responsible for the deaths of between 40-100 million people worldwide, making it one of the most deadly events in human history.  More people died of the so-called [[Spanish flu]] (caused by the [[H1N1]] viral strain) pandemic in the single year of 1918 than during all four-years of the [[Black Death]] ([[Bubonic plague]]) scourge that lasted from 1347 to 1351 (although a significantly higher percentage of the world’s population died of the plague than of Spanish flu).  It is estimated that between 20-40 percent of the world’s population became ill during the 1918 pandemic.

The pandemic had devastating effects as disease spread along trade and shipping routes and other corridors of human movement until it had circled the globe. In places like India, the mortality rate reached 50 per 1,000 population.  Arriving during the closing phase of the World War I, the pandemic had a significant impact on mobilized national armies.  Half of U.S. soldiers who died in the "Great War," for example, were victims of influenza not of enemy bombs and bullets. It is estimated that almost ¾ of a million Americans died during the pandemic.  As noted by one alarmed scientific observer at the time, "[if the pandemic continues] civilization could easily disappear from the face of the earth within a matter of a few more weeks". In part, the death toll during the pandemic was caused by viral pneumonia characterized by extensive bleeding in the lungs resulting in suffocation.  Many victims died within 48 hours of the appearance of the first symptom.  In fact, it was not uncommon for people who appeared to be quite healthy in the morning to have died by sunset.  Among those who survived the first several days, however, many died of secondary bacterial pneumonia. Moreover, it has been argued that countless numbers of those who expired quickly from the disease were co-infected with tuberculosis, which would explain the notable plummet in TB cases after 1918 (because so many carriers of the disease perished during the influenza pandemic). Again, as seen with the previous two 20th century global influenza outbreaks, disease interaction appears to have been critical, underlining the importance of syndemics more generally in the production of major public health crises.

==Environment==
As a result of the floral changes produced by global warming, a significant escalation is occurring in global rates of allergies and asthma.  Currently, allergic diseases constitute the sixth leading cause of chronic illness in the United States, impacting the lives of 17 percent of the population.  [[Asthma]], characterized by episodic inflammation and narrowing of small airway passages in the lungs, affects about 8 percent of the U.S. population, but the rate of affected individuals has been steadily climbing in recent years, especially in low income, ethnic minority neighborhoods in cities.  Thus, in 1980 asthma was found to affect only about three percent of the U.S. population according to the U.S. Centers for Disease Control and Prevention.  Asthma among children has been increasing at an even faster pace than among adults, with the percentage of children with asthma going up from 3.6 percent in 1980 to 9 percent in 2005.  Among ethnic minority populations, Puerto Ricans the rate of asthma is 125 percent higher than non-Hispanic white people and 80 percent higher than non-Hispanic black people. The asthma prevalence among American Indians, Alaska Natives and black people is 25 percent higher than white people.  As is so often the case with health, including health conditions directly affected by global warming, the poor and marginalized suffer the gravest consequences.

Increases in rates of asthma have occurred despite improvements in air quality produced by the passage and enforcement of clean air legislation, such as both the Clean Air Act of 1963 and the Clean Air Act of 1990 in the United States.  In other words, existing legislation and regulation have not kept pace with changing climatic conditions and their health consequences.  Compounding the problem of air quality is the fact that air-borne pollens have been found to attach themselves to diesel particles from truck or other vehicular exhaust floating in the air, resulting in heightened rates of asthma in areas where busy roads bisect densely populated areas, most notably in poorer inner city areas. Research by the American Cancer Society found that a six percent increase in cardiopulmonary deaths occurs for every elevation of 10 μg/m3 in particulate matter concentration in the air.  Exhaust from the burning of diesel fuel is a complex mixture of vapors, gases, and fine particles, including over 40 known pollutants like nitrogen oxide and known or suspected carcinogenic substances such as benzene, arsenic, and formaldehyde.  Exposure to diesel exhaust irritates the eyes, nose, throat and lungs, causing coughs, headaches, light headedness and nausea, while causing people with allergies to be more susceptible allergy triggers like dust or pollen. Many particles in disease fuel are so tiny they are able to penetrate deep into the lungs when inhaled.  Importantly, diesel fuel particles appear to have even greater immunologic effects in the presence of environmental allergens than they do alone.  According to Robert Pandya and co-workers who are studying the role of diesel fuel in asthma, "This immunologic evidence may help explain the epidemiologic studies indicating that children living along major trucking thoroughfares are at increased risk for asthmatic and allergic symptoms and are more likely to have objective evidence of respiratory dysfunction."

Importantly, the damaging effects of diesel fuel pollution appears to go significantly beyond playing a synergistic role in the development of asthma.  Recent research suggests that exposure to a combination of microscopic diesel fuel particles among people with high blood cholesterol (i.e., low-density lipoprotein, LDL or "bad cholesterol") increases the risk for both heart attack and stroke significantly above levels found among those exposed to only one of these health risks.  According to André Nel, Chief of Nanomedicine at the David Geffen School of Medicine at UCLA who led the study of duel exposure, "When you add one plus one, it normally totals two…  But we found that adding diesel particles to cholesterol fats equals three. Their combination creates a dangerous synergy that wreaks cardiovascular havoc far beyond what's caused by the diesel or cholesterol alone."  The synergy begins when free radical molecules that are attached to diesel exhaust particles enter the body through the lungs and pass into the circulatory system.  Another source of free radicals is the fatty acids that comprise LDL cholesterol, which produce free radicals during cell metabolism.  Free radical molecules are highly unstable because they have an odd number of electrons in their outer ring.  As a result, they react quickly with other compounds in order to "steal" an electron and gain stability.  When the "victimized" molecule loses its electron, it, in turn, becomes a free radical and a chain reaction called oxidation is produced that is known to be damaging to living cells and tissues.  Of interest to the Los Angeles research team was the consequences of both sources of free radical production coming into contact.  Experimentation revealed that the two mechanisms worked in tandem to stimulate genes that promote cell inflammation, a primary risk for hardening and blockage of blood vessels ([[atherosclerosis]]) and, as narrowed arteries collect cholesterol deposits and trigger blood clots, for [[heart attacks]] and [[strokes]] as well.  Atherosclerotic cardiovascular disease is the leading cause of death in developed countries.

==Mathematical modelling==
A [[mathematical model]] is a simplified representation using mathematical language to describe natural, mechanical or social system dynamics.  In the early 20th century, epidemiologists became increasingly interested in the use of mathematical modelling procedures to project possible patterns in the spread of [[infectious diseases]], including potential outcomes of an epidemic.  To achieve these goals, epidemiological modelers unite several types of information and analytic capacity, including: 1) mathematical equations and computational algorithms; 2) computer technology; 3) epidemiological knowledge about [[infectious disease dynamics]], including information about specific pathogens and disease [[Vector (epidemiology)|vectors]]; and 4) research data on social conditions and human behavior.  [[Mathematical modelling in epidemiology]] is now being applied to syndemics.  Abu-Raddad, Patnaik, and Kublin (2006), for example, used modelling to quantify the syndemic effects of malaria and HIV in sub-Saharan Africa based on research in Kisumu, Kenya.  These researchers point out that infection with HIV facilitates disease progression in individuals exposed to malaria.  At the same time, immune reaction to malaria doubles the infectious level of HIV infected individual.  In short, in typical syndemic fashion, each of these diseases amplifies the effects of the other.  Using mathematical modelling, Abu-Raddad and co-workers found that 5% of HIV infections (or 8,500 cases of HIV since 1980) in Kisumu are the result of the higher HIV infectiousness of malaria-infected HIV patients.  Additionally, their model attributed 10% of adult malaria episodes (or almost one million excess malaria infections since 1980) to the greater susceptibility of HIV infected individuals to malaria.  Their model also suggests that HIV has contributed to the wider geographic spread of malaria in Africa, a process previously thought to be the consequence primarily of global warming.  Other researchers (e.g., Herring and Sattenspiel 2007) also have begun to apply mathematical modelling to syndemics.  Modelling offers an enormously useful tool for anticipating future syndemics, including eco-syndemic, based on information about the spread of various diseases across the planet and the consequent co-infections and disease interactions that will result.

In this regard, Jeremy Lauer and colleges (2003) have developed PopMod, a longitudinal population tool that models distinct and possibly interacting diseases.  Unlike other life-table population models, PopMod is specifically designed to not assume the statistical independence of the diseases of interest.  The PopMod has several intended purposes, including describing the time evolution of population health for standard demographic purposes (such as estimating healthy life expectancy in a population), and providing a standard measure of effectiveness for health interventions and cost-effectiveness analysis.  PopMod is used as one of the standard tools of the World Health Organization’s ([[WHO]]) CHOICE (Choosing Interventions that are Cost-Effective) program, an initiative designed to provide national health policy makers in the WHO’s 14 epidemiological sub-regions around the world with findings on a range of health intervention costs and effects.

== Statistical modeling in research ==
Although [[Merrill Singer]]'s conceptual work on syndemics specifically identifies the study of disease interaction as a central concept in the theory of syndemics, most empirically based research studies have not actually used appropriate statistical models to do so. This problem with the syndemics literature was recently highlighted in a seminal systematic review published by Tsai and Burns in the journal ''[[Social Science & Medicine|Social Science and Medicine]]''.<ref>{{Cite journal|title = Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept|url = http://www.sciencedirect.com/science/article/pii/S0277953615300034|journal = Social Science & Medicine|date = 2015-08-01|pmc = 4519429|pmid = 26150065|pages = 26–35|volume = 139|doi = 10.1016/j.socscimed.2015.06.024|first = Alexander C.|last = Tsai|first2 = Bridget F. O.|last2 = Burns}}</ref> Of the papers identified in the systematic review, the vast majority (78%) used a statistical model that actually provides no information about disease interaction. The methodological and public health consequences of this type of statistical model were further highlighted in a methodological paper by Tsai and Venkataramani published in the journal ''[[AIDS and Behavior]]''.<ref>{{Cite journal|title = Syndemics and Health Disparities: A Methodological Note|url = http://link.springer.com/article/10.1007/s10461-015-1260-2|journal = AIDS and Behavior|date = 2015-12-12|issn = 1090-7165|pages = 1–8|doi = 10.1007/s10461-015-1260-2|first = Alexander C.|last = Tsai|first2 = Atheendar S.|last2 = Venkataramani}}</ref> While this criticism of the literature does not undermine the concept of disease concentration, which is another central concept in the theory of syndemics, it nonetheless highlights a serious flaw in the way that syndemics have been investigated.

==Future research==
Medical anthropologist, epidemiologists, and clinical researchers are just beginning to understand the nature of syndemics.  There is a critical need for new research in this area. Important arenas of inquiry include the following: First, there is a need for studies that examine the processes by which syndemics emerge, including the specific sets of health and social conditions that foster the occurrence of multiple epidemics in a population and how syndemics function to produce specific kinds of health outcomes in populations.  Second, there is a need to better understand processes of interaction between specific diseases with each other and with health-related factors like malnutrition, structural violence, discrimination, stigmatization, and toxic environmental exposure that reflect oppressive social relationships.  Specifically, there is a need to identify all of the ways, directly and indirectly, that diseases can interact and have, as a result, enhanced impact on human health. Third there is a need for the development of an '''eco-syndemic''' understanding of the ways in which [[global warming]] is contributing to the spread of diseases to new areas and to the potential for new disease interactions. Already it is clear that as a result of global warming infectious diseases such as [[West Nile Virus]] are spreading to new places.  Similarly malaria is now found in new places because it is spread by particular mosquito species that are migrating to new locations as a result of changing climates.  As a consequence, diseases that did not often interact in the past---through co-infection of the same individuals within a population---may begin interacting more regularly. Finally, there is a need for a better understanding of how the public health systems and communities can best respond to and limit the health consequences of syndemics. Systems are needed to monitor the emergence of syndemics and to allow ''early-bird'' medical and public health responses designed to lessen their impact. Systematic ethno-epidemiological surveillance with populations subject to multiple social stressors must be one component of such a monitoring system. Current efforts by researchers at the CDC to expand the discussion of syndemics in public health discourse is an important step in the development of a funded research agenda that addresses these research needs. Given the nature of syndemics, this research requires a bio-cultural/social approach that attends to both clinical and social processes.

==See also==
* [[Coinfection]]
* [[Endemic (epidemiology)|Endemic]]
* [[Epidemic]]
* [[List of epidemics]]
* [[List of human diseases associated with infectious pathogens]]
* [[Merrill Singer]]
* [[Pandemic]]

==References==
{{reflist}}

== Further reading==
A continually updated bibliography of the rapidly growing syndemics literature is provided below:

===Books===
* Marshall, Mac 2013 ''Drinking Smoke: The Tobacco Syndemic in Oceania.''  Honolulu, HI: University of Hawai'i Press.
* Mendenhall, Emily 2012  ''Syndemic Suffering: Social Distress, Depression, and Diabetes among Mexican Immigrant Women.'' Left Coast Press, Inc.
* Singer, Merrill 2009  ''Introduction to Syndemics: A Systems Approach to Public and Community Health.''  San Francisco, CA: Jossey-Bass.

===Articles, chapters, and dissertations===
* {{cite journal |author1=Abu-Raddad Laith |author2=Patnaik P. |author3=Kublin J | year = 2006 | title = Dual Infection with HIV and Malaria Fuels the Spread of Both Diseases in sub-Saharan Africa | url = | journal = Science | volume = 314 | issue = | pages = 1603–1606 | doi=10.1126/science.1132338 | pmid=17158329}}
* Acevedo, Gabriel 2008  Causal Determinism, Elective Affinities, and Syndemic Networks: An Application of Epidemiological Theory to the Study of non-Medical Phenomenon.  ''All Academic Research''. Available online at: http://www.allacademic.com//meta/p_mla_apa_research_citation/1/8/4/6/3/pages184630/p184630-1.php.
* Akksilp, Somsak, Karnkawinpong, Opart, Wattanaamornkiat, Wanpen, Viriyakitja, Daranee, Monkongdee, Patama, Sitti, Walya, Rienthong, Dhanida, Siraprapasiri,Taweesap, Wells, Charles D., Tappero, Jordan W. and Varmaet, Jay K. 2007 Antiretroviral Therapy during Tuberculosis Treatment and Marked Reduction in Death Rate of HIV-infected Patients, Thailand. ''Emerging Infectious Diseases'' 13(7). Available online at: http://www.cdc.gov/EID/content/13/7/1001.htm.
* {{cite journal |author1=Alisjahbana B. |author2=van Crevel R. |author3=Sahiratmadja E. |author4=den Heijer M. |author5=Maya A. | year = 2006 | title = Diabetes mellitus is strongly associated with tuberculosis in Indonesia | url = | journal = International Journal Tuberculosis and Lung Disease | volume = 10 | issue = | pages = 696–700 }}
* {{cite journal |author1=Andreani Guadalupe |author2=Lodge Robert |author3=Richard Dave |author4=Tremblay Michel | year = 2012 | title = Mechanisms of Interaction between Protozoanarasites and HIV | url = | journal = Current Opinion in HIV and AIDS | volume = 7 | issue = | pages = 276–282 | doi=10.1097/coh.0b013e32835211e9}}
* Baer, Hans and Singer, Merrill 2008 ''Global Warming and the Political Ecology of Health: Emerging Crises and Systemic Solutions.''  Left Coast Press.
* Baer, Hans, Singer, Merrill, and Susser, Ida 2004  ''Medical Anthropology and the World System''.  Begin & Garvey: Westport, CT.
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* Singer, Merrill 2008  Drug-related Syndemics and the Risk Environment: Assessing Street risk among Hispanics in Hartford. Presented at the 8th Annual National Hispanic Science Network on Drug Abuse. Bethesda, Maryland.
* Singer, Merrill 2009  Desperate Measures: A Syndemic Approach to the Anthropology of Health in a Violent City. In ''Global Health in the Time of Violence'', Barbara Rylko-Bauer, Linda Whiteford, and Paul Farmer, Editors.  Sante Fe, NM: SAR Press.
* {{cite journal | author = Singer Merrill | year = 2009 | title = Doorways in Nature: Syndemics, Zoonotics, and Public Health: A Commentary on Rock, Buntain, Hatfield & Hallgrímsson | url = | journal = Social Science & Medicine | volume = 68 | issue = 6| pages = 996–999 | doi=10.1016/j.socscimed.2008.12.041}}
* {{cite journal | author = Singer Merrill | year = 2009 | title = Pathogens Gone Wild?: Medical Anthropology and the "Swine Flu" Pandemic | url = | journal = Medical Anthropology | volume = 28 | issue = 3| pages = 199–206 | doi=10.1080/01459740903070451}}
* {{cite journal | author = Singer Merrill | year = 2010 | title = Pathogen-Pathogen Interaction: A Syndemic Model of Complex Biosocial Processes in Disease | url = | journal = Virulence | volume = 1 | issue = 1| pages = 10–18 | doi=10.4161/viru.1.1.9933}}
* Singer, Merrill 2010  Ecosyndemics: Global Warming and the Coming Plagues of the 21st Century. In ''Plagues: Models and Metaphors in the Human ‘Struggle’ with Disease'', D. Ann Herring and Alan C. Swedlund, Editors, pp.&nbsp;21–38.  London: Berg.
* Singer, Merrill 2011  Double Jeopardy: Vulnerable Children and the Possible Global Lead Poisoning/Infectious Disease Syndemic. In ''Routledge Handbook in Global Health'', Richard Parker and Marni Sommer, Editors, pp.&nbsp;154–161. New York: Routledge.
* Singer, Merrill 2011 The Infectious Disease Syndemics of Crack Cocaine. ''Journal of Equity in Health'' (in press).
* {{cite journal | author = Singer Merrill | year = 2011 | title = Toward a Critical Biosocial Model of Ecohealth in Southern Africa: The HIV/AIDS and Nutrition Insecurity Syndemic | url = | journal = Annals of Anthropological Practice | volume = 35 | issue = 1| pages = 8–27 | doi=10.1111/j.2153-9588.2011.01064.x}}
* Singer, Merrill and Baer, Hans 2007 ''Introducing Medical Anthropology: A Discipline in Action.''  AltaMira/ Rowman Littlefield Publishers, Inc.
* {{cite journal |author1=Singer Merrill |author2=Clair Scott | year = 2003 | title = Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context | url = | journal = Medical Anthropology Quarterly | volume = 17 | issue = 4| pages = 423–441 | doi=10.1525/maq.2003.17.4.423}}
* {{cite journal |author1=Singer Merrill |author2=Erickson Pamela |author3=Badiane Louise |author4=Diaz Rosemary |author5=Ortiz Dueidy |author6=Abraham Traci |author7=Nicolaysen Anna Marie | year = 2006 | title = Syndemics, Sex and the City: Understanding Sexually Transmitted Disease in Social and Cultural Context | url = | journal = Social Science and Medicine | volume = 63 | issue = 8| pages = 2010–2021 | doi=10.1016/j.socscimed.2006.05.012 | pmid=16782250}}
* Singer, Merrill, Herring, D. Ann, Littleton, Judith, and Rock, Melanie 2011 Syndemics in Global Health. In ''A Companion to Medical Anthropology,'' Merrill Singer and Pamela I. Erickson, Editors, pp.&nbsp;219–249.  Malden, MA: Wiley-Blackwell.
* {{cite journal |author1=Singer Merrill |author2=Snipes Charlene | year = 1992 | title = Generations of Suffering: Experiences of a Pregnancy and Substance Abuse Treatment Program | url = | journal = Journal of Health Care for the Poor and Underserved | volume = 3 | issue = 1| pages = 325–239 }}
* {{cite journal |author1=Singer Merrill |author2=Bulled Nicola |author3=Ostrach Bayla | year = 2013 | title = Syndemics and Human Health: Implications for Prevention and Intervention | url = | journal = Annals of Anthropological Practice | volume = 36 | issue = 2| pages = 205–211 | doi=10.1111/napa.12000}}
* Singer, Merrill and Weeks, Margaret 2005  The Hartford Model of AIDS Practice/Research.  In ''Community Interventions and AIDS'' edited by Edison Trickett and Willo Pequegnat, pp.&nbsp;153–175. Oxford, UK: Oxford University Press.
* {{cite journal |author1=Singer Merrill |author2=Bulled Nicola | year = 2013 | title = Interlocked Infections: The Health Burdens of Syndemics of Neglected Tropical Diseases | url = | journal = Annals of Anthropological Practice | volume = 36 | issue = 2| pages = 326–344 | doi=10.1111/napa.12007}}
* Solomon, T., Halkitis, P., Moeller, R., Siconolfi, D., Kiang, M., and Barton, S. 2011 Sex Parties among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: Attendance and Behavior.  ''Journal of Urban Health''[in press]
* {{cite journal | author = Southgate Erica, Weatherall Day, Marr Anne, Carolyn Dolan, Kate  | year = 2005 | title = What's in a Virus? Folk Understandings of Hepatitis C Infection and Infectiousness among Injecting Drug users in Kings Cross, Sydney | url = | journal = International Journal for Equity in Health | volume = 4 | issue = | page = 5 }}
* Specter, Michael 2005 Higher Risk: Crystal Meth, the Internet, and dangerous Choices about AIDS.  ''The New Yorker'', May 23, pp.&nbsp;39–45.
* Stall, Ron 2007 An Update on Syndemic Theory Among Urban Gay Men. Presented at the American Public Health Association meetings, Washington, D.C. Abstract #155854. Abstract available online at: http://apha.confex.com/apha/135am/techprogram/paper_155854.htm.
* Stall, Ron, Friedman, M.S., and Catania, J. 2007 Interacting Epidemics and Gay Men’s Health: A theory of Syndemic Production among Urban Gay Men. In ''Unequal Opportunity: Health Disparities Affecting Gay and Bisexual Men in the United States'', Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri (Eds). Oxford: Oxford University Press.
* Stall, Ron, Friedman, M.S., Kurz, M. and Buttram, M.— 2012 Syndemic associations of HIV risk among sex-working MSM in Miami and Ft. Lauderdale, USA. Presented at the XIX International AIDS Conference, Washington, D.C. (MOPE328, Poster exhibit).
* {{cite journal |author1=Stall Ron |author2=Mills Thomas |author3=Williamson J. |author4=Hart T. | year = 2003 | title = Association of Co-occurring Psychosocial Health Problems and Increased Vulnerability to HIV/AIDS Among Urban men who have Sex with Men | url = | journal = American Journal of Public Health | volume = 93 | issue = 6| pages = 939–942 | doi=10.2105/ajph.93.6.939}}
* Stall, Ron and Mills, Thomas 2006 Health Disparities, Syndemics and Gay Men’s Health. Presented at the Center for Health Intervention and Prevention. University of Connecticut. Available online at: http://www.chip.uconn.edu/lec/Stall%20-%20Connecticut%20Talk.pdf.
* Stall, Ron and van Griensven, Frits 2005  New Directions in Research Regarding Prevention for Positive Individuals: Questions Raised by the Seropositive Urban Men's Intervention Trial. ''AIDS'' 19 Supplement 1: S123-S127.
* Stephens, Christianne V. 2008  "She was Weakly for a Long time and the Consumption Set" In Using Parish Records to Explore Disease Patterns and Causes of Death In a First Nations Community. Research in Anthropology and Linguistics (RAL-e) Monograph Series. Ann Herring, Judith Littleton, Julie Park and Tracy Farmer (eds.) No. 3 134-148.  
* Stephens, Christianne V. 2009 Syndemics, Structural Violence and the Politics of Health: A Critical Biocultural Approach to the Study of Disease and Tuberculosis Mortality in a Parish Population at Walpole Island (1850-1885). In ''Proceedings of the 39th Annual Algonquian Conference.'' Vol. 39 581-613. Karl Hele, (ed). London: University of Western Ontario.  
* {{cite journal | author = Storholm E., Halkitis P., Siconolfi D., Moeller R. | year = 2011 | title = Cigarette Smoking as Part of a Syndemic among Young Men Who Have Sex with Men Ages 13–29 in New York City | url = | journal = Journal of Urban Health | volume =  88| issue = | pages =  663–676| doi = 10.1007/s11524-011-9563-8 }}
* {{cite journal |author1=Talman Anna |author2=Bolton Susan |author3=Walson Judd | year = 2012 | title = Interactions Between HIV/AIDS and the Environment: Toward a Syndemic Framework | url = | journal = American Journal of Public Health | volume = 103 | issue = 2| pages = 253–261 | doi=10.2105/ajph.2012.300924}}
* {{cite journal | author = Tezal Mine | year = 2012 | title = Interaction between Chronic Inflammation and Oral HPV Infection in the Etiology of Head and Neck Cancers | url = | journal = International Journal of Otolaryngology | volume = 2012| issue = | page = 575242 | doi = 10.1155/2012/575242 }}
* {{cite journal |author1=Tian Li-Guang |author2=Wang Tian-ping |author3=Lv Shan |author4=Wang Feng-Feng |author5=Guo Jian |author6=Yin Xiao-Mei |author7=Cai Yu-Chun |author8=Dickey Mary |author9=Steinmann Peter |author10=Chen Jia-Xu | year = 2013 | title = HIV and intestinal parasite co-infections among a Chinese population: an immunological profile | url = | journal = Infectious Diseases of Poverty | volume = 2 | issue = | page = 18 | doi = 10.1186/2049-9957-2-18 }}
* {{cite journal |author1=Tieu Van |author2=Koblin B | year = 2009 | title = HIV, Alcohol, and Noninjection Drug Use | url = | journal = Current Opinion in HIV AIDS | volume = 4 | issue = 4| pages = 314–318 | doi=10.1097/coh.0b013e32832aa902}}
* {{cite journal |author1=Tobian Aaron |author2=Quinn Thomas | year = 2009 | title = Herpes simplex virus type 2 and syphilis infections with HIV: An evolving synergy in transmission and prevention | url = | journal = Current Opinion in HIV and AIDS | volume = 4 | issue = 4| pages = 294–299 | doi=10.1097/coh.0b013e32832c1881}}
* {{cite journal |author1=Thuy T. |author2=Shah N |author3=Hoang Anh M.H |author4=Nghia D.T. |author5=Thom D. |author6=Linh T. |author7=Sy D.N. |author8=Duong B.D. |author9=Chau L.T.M. |author10=Mai P.T.P. |author11=Wells C. |author12=Laserson K. |author13=Varma J.K. | year = 2007 | title = HIV-Associated TB in An Giang Province, Vietnam, 2001–2004: Epidemiology and TB Treatment Outcomes | url = | journal = PLoS ONE | volume = 2 | issue = 6| page = e507 | doi = 10.1371/journal.pone.0000507 }}
* {{cite journal |author1=Van Lettow M. |author2=Fawzi W. |author3=Semba R. | year = 2003 | title = Triple Trouble: The Role of Malnutrition in Tuberculosisand Human Immunodeficiency Virus Co-infection | url = | journal = Nutrition Reviews | volume = 61 | issue = 3| pages = 81–90 | doi=10.1301/nr.2003.marr.81-90}}
* {{cite journal |author1=van Zyl-Smitt Richard |author2=Brunet Laurence |author3=Madhukar Pai |author4=Yew Wing-Wai | year = 2010 | title = The Convergence of the Global Smoking, COPD, Tuberculosis, HIV, and Respiratory Infections Epidemics | url = | journal = Infectious Disease Clinics of North America | volume = 24 | issue = | pages = 693–703 | doi=10.1016/j.idc.2010.04.012}}
* {{cite journal |author1=van Zyl-Smitt Richard |author2=Madhukar Pai |author3=Yew Wing-Wai |author4=Leunig C. |author5=Zumla E. |author6=Bateman E. |author7=Dheda L. | year = 2010 | title = Global Lung Health. The Colliding Epidemics of Tuberculosis, Tobacco Smoking, HIV and COPD | url = | journal = European Respiratory Journal | volume = 35 | issue = 1| pages = 27–33 | doi=10.1183/09031936.00072909 | pmid=20044459}}
* {{cite journal |author1=Ventura H. |author2=Mehra M. | year = 2004 | title = The Growing Burden of Health Failure: The "Syndemic" is Reaching Latin America | url = | journal = American Heart Journal | volume = 147 | issue = 3| pages = 412–417 | doi=10.1016/j.ahj.2003.10.009}}
* {{cite journal |author1=Vogenthaler Nicholas |author2=Hadley Craig |author3=Rodriguez Allan |author4=Valverde Eduardo |author5=Rio Carolos |author6=Metsch Lisa | year = 2010 | title = Depressive Symptoms and Food Insufficiency Among HIV-Infected Crack Users in Atlanta and Miami | url = | journal = AIDS and Behavior | volume = 15 | issue = 7| pages = 1520–1526 | doi=10.1007/s10461-010-9668-1}}
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* {{cite journal |author1=Walkup James |author2=Blank Michael |author3=Gonzalez Jeffrey |author4=Safren Steven |author5=Schwartz Rebecca |author6=Brown Larry |author7=Wilson Ira |author8=Knowlton Amy |author9=Lombard Frank |author10=Grossman Cynthia |author11=Lyda Karen |author12=Schumacher Joseph | year = 2008 | title = The Impact of Mental Health and Substance Abuse Factors on HIV Prevention and Treatment | url = | journal = Journal of Acquired Immune Deficiency Syndrome | volume = 47 | issue = 1 Supplement | pages = S15–S19 | doi=10.1097/qai.0b013e3181605b26}}
* {{cite journal | author = Wallace R. A | year = 1988 | title = Synergism of Plagues | url = | journal = Environment Research | volume = 47 | issue = | pages = 1–33 | doi=10.1016/s0013-9351(88)80018-5 | pmid=3168963}}
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* {{cite journal | author = Wasserheit J | year = 1992 | title = Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases | url = | journal = Sexually Transmitted Disease | volume = 19 | issue = | pages = 61–77 | doi=10.1097/00007435-199219020-00001}}
* {{cite journal |author1=Weaver Lesley Jo |author2=Mendenhall Emily | year = 2013 | title = Applying Syndemics and Chronicity: Interpretations from Studies of Poverty, Depression, and Diabetes | url = | journal = Medical Anthropology | volume =  33| issue = | pages =  92–108| doi = 10.1080/01459740.2013.808637 }}
* {{cite journal |author1=Wim Vanden Berghe |author2=Laga Marie Nöstlinger Christiana | year = 2014 | title = Syndemic and Other Risk Factors for Unprotected Anal Intercourse Among an Online Sample of Belgian HIV Negative Men Who have Sex with Men | url = | journal = AIDS and Behavior | volume = 18 | issue = | pages = 50–58 | doi=10.1007/s10461-013-0516-y}}
* Workman, Cassandra 2013 A Critical Ethnography of Globalization in Lesotho, Africa: Syndemic Water Insecurity and the Micro-politics of Participation. Doctoral Dissertation, Department of Anthropology, University of South Florida.
* Young, C., Ann 2004  A Syndemic Perspective on Whooping Cough Epidemics at York Factory. Presented at the Canadian Association for Physical Anthropology, London, Ontario, Canada.
* {{cite journal |author1=Young Fiona |author2=Critchley Julia |author3=Johnstone Lucy |author4=Unwin Nigel | year = 2009 | title = A review of co-morbidity between infectious and chronic disease in Sub Saharan Africa: TB and Diabetes Mellitus, HIV and Metabolic Syndrome, and the impact of globalization | url = | journal = Globalization and Health | volume = 5 | issue = | page = 9 | doi = 10.1186/1744-8603-5-9 }}
* Yu, F. 2012 Smoking Syndemics among a Sample of Men Who Have Sex with Men in Shanghai, China. ''Master's Thesis'' Emory University.
* {{cite journal | author = Yuwen Weicho | year = 2012 | title = In Response to the Published Article "A Syndemic Model of Substance Abuse, Intimate Partner Violence, HIV Infection, and Mental Health among Hispanics" | url = | journal = Public Health Nursing | volume = 29 | issue = 5| pages = 388–389 | doi=10.1111/j.1525-1446.2012.01028.x}}

==External links==
* http://syndemic.chip.uconn.edu {{dead link|date=August 2013}}
* {{cite web | url=http://www.amazon.com/Introduction-Syndemics-Critical-Approach-Community/dp/0470472030/ref=sr_1_1?ie=UTF8&s=books&qid=1246594334&sr=1-1 | title=Introduction to Syndemics: A Critical Systems Approach to Public and Community Health: Merill Singer: 9780470472033 | publisher=[[Amazon.com]]}}
* http://web.archive.org/web/20060823101806/http://www.cdc.gov/syndemics/
* {{cite web|url=http://www.aaanet.org/publications/upload/49-7-Merrill-Singer-In-Focus.pdf |title=The Perfect Epidemiological Storm: food insecurity, HiV/aids and Poverty in southern africa |author=Merrill Singer |publisher=In Focus |date=October 2008 |deadurl=yes |archiveurl=https://web.archive.org/web/20110607085043/http://www.aaanet.org/publications/upload/49-7-Merrill-Singer-In-Focus.pdf |archivedate=2011-06-07 |df= }}
* {{cite web | url=http://syndemics.blogspot.com | title=Syndemics Research | date=May 5, 2007}}
* {{cite web | url=http://forio.com/resources/syndemic-2003/ | title=Syndemic Simulation | publisher=Forio's Forum | date=August 9, 2013}}
* {{cite web | url=http://www.medterms.com/script/main/art.asp?articlekey=22591 | title=Definition of Syndemic | publisher=[[MedicineNet]] | date=June 14, 2012}}
* {{cite web | url=http://www.answers.com/topic/cultural-anthropology?cat=health | title=cultural anthropology | year=2013}}
* http://web.archive.org/web/20080308030643/http://www.cdc.gov/syndemics/pdfs/Encyclopedia.pdf 
* http://web.archive.org/web/20071010051235/http://www.princeofwales.gov.uk/speechesandarticles/a_speech_by_hrh_the_prince_of_wales_at_the_enhancing_the_hea_66.html 
* {{cite web | url=http://aids-clinical-care.jwatch.org/cgi/content/full/2007/402/7 | title=New Data on HIV and Viral Hepatitis Coinfection | author=Helmut Albrecht | publisher=[[Massachusetts Medical Society]] | date=April 2, 2007}}
* http://web.archive.org/web/20070928204637/http://www.healthdecisions.org/Dental/News/default.aspx?doc_id=109688 
* {{cite web|url=http://www.nastad.org/Docs/Public/Publication/200772_July07Bulletin_webfinal.pdf |title=NASTAD HIV Prevention |deadurl=yes |archiveurl=https://web.archive.org/web/20080603030506/http://www.nastad.org/Docs/Public/Publication/200772_July07Bulletin_webfinal.pdf |archivedate=2008-06-03 |df= }}
* {{cite web | url=http://forio.com/simulation/syndemic2003/Syndemic2003pres.pdf | title=A Dynamic Simulation Model of Syndemics: Casual Structure, Assumptions, and Results | author1=Jack Homer 
| author2=Bobby Milstein | publisher=[[Centers for Disease Control and Prevention]] | date=April 2003}}
* {{cite web | url=http://www.amazon.com/gp/reader/0761941169/ref=sib_dp_srch_pop?v=search-inside&keywords=syndemic | title=The SAGE Dictionary of Health and Society | publisher=[[Amazon.com]]}}
* {{cite web|url=http://blog.pucp.edu.pe/blog/ecosalud |title=ECOSALUD Y ECOSINDEMIAS |deadurl=yes |archiveurl=https://web.archive.org/web/20110618154448/http://blog.pucp.edu.pe:80/blog/ecosalud |archivedate=2011-06-18 |df= }}
* {{cite web | url=http://medanth.wikispaces.com/Syndemic | title=Syndemic | publisher=Medanth}}

<nowiki>[[Category:Epidemiology]]
[[Category:Influenza pandemics]]</nowiki>