Volume 96, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



The importance of spatial clusters, or “hotspots,” in infectious disease epidemiology has been increasingly recognized, and targeting hotspots is often seen as an important component of disease-control strategies. However, the precise meaning of “hotspot” varies widely in current research and policy documents. Hotspots have been variously described as areas of elevated incidence or prevalence, higher transmission efficiency or risk, or higher probability of disease emergence. This ambiguity has led to confusion and may result in mistaken inferences regarding the best way to target interventions. We surveyed the literature on epidemiologic hotspots, examining the multitude of ways in which the term is used; and highlight the difference in the geographic scale of hotspots and the properties they are supposed to have. In response to the diversity in the term's usage, we advocate the use of more precise terms, such as “burden hotspot,” “transmission hotspot,” and “emergence hotspot,” as well as explicit specification of the spatiotemporal scale of interest. Increased precision in terminology is needed to ensure clear and effective policies for disease control.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Hotez PJ, , 2014. Ten global “hotspots” for the neglected tropical diseases. PLoS Negl Trop Dis 8: e2496.[Crossref] [Google Scholar]
  2. Bousema T, Griffin JT, Sauerwein RW, Smith DL, Churcher TS, Takken W, Ghani A, Drakeley C, Gosling R, , 2012. Hitting hotspots: spatial targeting of malaria for control and elimination. PLoS Med 9: e1001165.[Crossref] [Google Scholar]
  3. Dowdy DW, Golub JE, Chaisson RE, Saraceni V, , 2012. Heterogeneity in tuberculosis transmission and the role of geographic hotspots in propagating epidemics. Proc Natl Acad Sci USA 109: 95579562.[Crossref] [Google Scholar]
  4. UNAIDS Reference Group on Estimates Modelling and Projections, 2013. Identifying Populations at Greatest Risk of Infection: Geographic Hotspots and Key Populations, 2526. [Google Scholar]
  5. U.S. President's Emergency Plan for AIDS Relief, PEPFAR 3.0, 2014. Controlling the Epidemic: Delivering on the Promise of an AIDS-Free Generation. Available at: http://www.pepfar.gov/documents/organization/234744.pdf. Accessed March 1, 2015. [Google Scholar]
  6. World Health Organization, Government of Guinea, Government of Liberia, Government of Sierra Leone, 2014. WHO Strategic Action Plan for Ebola Outbreak Response. Available at: http://www.who.int/csr/disease/ebola/evd-outbreak-response-plan-west-africa-2014-annex1.pdf. Accessed March 1, 2015. [Google Scholar]
  7. President's Malaria Initiative, 2013. Tanzania Malaria Operational Plan FY 2014. Available at: http://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy14/tanzania_mop_fy14.pdf?sfvrsn=10. Accessed March 1, 2015. [Google Scholar]
  8. United States Agency for International Development, 2014. Emerging Pandemic Threats Program Summary. Available at: https://scms.usaid.gov/sites/default/files/documents/1864/EPT2-Narrative-508.pdf. [Google Scholar]
  9. Hempel C, Quinn J, , 1848. Jahr's New Manual or Symptomen Codex. New York: Willam Radde. [Google Scholar]
  10. Prabhakar HB, Sahani DV, Fischman AJ, Mueller PR, Blake MA, , 2017. Bowel hot spots at PET-CT. Radiographics 27: 145159.[Crossref] [Google Scholar]
  11. Bulte JWM, , 2005. Hot spot MRI emerges from the background. Nat Biotechnol 23: 945946.[Crossref] [Google Scholar]
  12. Park B-J, Lord D, Lee C, , 2014. Finite mixture modeling for vehicle crash data with application to hotspot identification. Accid Anal Prev Elsevier Ltd 71: 319326.[Crossref] [Google Scholar]
  13. Yang T-C, McManus B, , 2010. Infant Mortality and Social Environment in Georgia: An application of hotspot detection and prioritization. Environ Ecol Stat 17: 455471.[Crossref] [Google Scholar]
  14. Wilhelm M, Eberwein G, Hölzer J, Gladtke D, Angerer J, Marczynski B, Behrendt H, Ring J, Sugiri D, Ranft U, , 2007. Influence of industrial sources on children's health–hot spot studies in North Rhine Westphalia, Germany. Int J Hyg Environ Health 210: 591599.[Crossref] [Google Scholar]
  15. Cox GR, Owens C, Robinson J, Nicholas A, Lockley A, Williamson M, Cheung YT, Pirkis J, , 2013. Interventions to reduce suicides at suicide hotspots: a systematic review. BMC Public Health 13: 214.[Crossref] [Google Scholar]
  16. Fang Z, Kulldorff M, Gregorio DI, , 2004. Brain cancer mortality in the United States, 1986 to 1995: a geographic analysis. Neuro Oncol 6: 179187.[Crossref] [Google Scholar]
  17. Short MB, Brantingham PJ, Bertozzi AL, Tita GE, , 2010. Dissipation and displacement of hotspots in reaction-diffusion models of crime. Proc Natl Acad Sci USA 107: 39613965.[Crossref] [Google Scholar]
  18. Orgel A, Orgel LE, , 1965. Induction of mutations in bacteriophage T4 with divalent manganese. J Mol Biol 14: 453457. Available at: http://www.ncbi.nlm.nih.gov/pubmed/5880862. Accessed February 10, 2015.[Crossref] [Google Scholar]
  19. Dixit A, Yi L, Gowthaman R, Torkamani A, Schork NJ, Verkhivker GM, , 2009. Sequence and structure signatures of cancer mutation hotspots in protein kinases. PLoS One 4: e7485.[Crossref] [Google Scholar]
  20. Ma K, Qiu L, Mrasek K, Zhang J, Liehr T, Quintana LG, Li Z, , 2012. Common fragile sites: genomic hotspots of DNA damage and carcinogenesis. Int J Mol Sci 13: 1197411999.[Crossref] [Google Scholar]
  21. Liu Z, Luo K, He H, Hou J, , 2005. Hot-spot mutations in hepatitis B virus core gene: eliciting or evading immune clearance? J Viral Hepat 12: 146153.[Crossref] [Google Scholar]
  22. Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, Daszak F, , 2008. Global trends in emerging infectious diseases. Nature 451: 990993.[Crossref] [Google Scholar]
  23. Bejon P, Williams TN, Liljander A, Noor AM, Wambua J, Ogada E, Olotu A, Osier FH, Hay SI, Färnert A, Marsh K, , 2010. Stable and unstable malaria hotspots in longitudinal cohort studies in Kenya. PLoS Med 7: e1000304.[Crossref] [Google Scholar]
  24. Ernst KC, Adoka SO, Kowuor DO, Wilson ML, John CC, , 2006. Malaria hotspot areas in a highland Kenya site are consistent in epidemic and non-epidemic years and are associated with ecological factors. Malar J 5: 78.[Crossref] [Google Scholar]
  25. Bousema T, Drakeley C, Gesase S, Hashim R, Magesa S, Mosha F, Otieno S, Carneiro I, Cox J, Msuya E, Kleinschmidt I, Maxwell C, Greenwood B, Riley E, Sauerwein R, Chandramohan D, Gosling R, , 2010. Identification of hot spots of malaria transmission for targeted malaria control. J Infect Dis 201: 17641774.[Crossref] [Google Scholar]
  26. Srivastava A, Nagpal BN, Joshi PL, Paliwal JC, Dash AP, , 2009. Identification of malaria hot spots for focused intervention in tribal state of India: a GIS based approach. Int J Health Geogr 8: 30.[Crossref] [Google Scholar]
  27. Azman AS, Luquero FJ, Rodrigues A, Palma PP, Grais RF, Banga CN, Grenfell BT, Lessler J, , 2012. Urban cholera transmission hotspots and their implications for reactive vaccination : evidence from Bissau City, Guinea Bissau. PLoS Negl Trop Dis 6: e1901.[Crossref] [Google Scholar]
  28. Becerra MC, Bayona J, Freeman J, Farmer PE, Kim JY, , 2000. Redefining MDR-TB transmission “hot spots.” Int J Tuberc Lung Dis 4: 387394. [Google Scholar]
  29. Kulldorff M, , 1997. A spatial scan statistic. Commun Stat Methods 26: 14811496.[Crossref] [Google Scholar]
  30. Reyburn H, Mbatia R, Drakeley C, Bruce J, Carneiro I, Olomi R, Cox J, Nkya WM, Lemnge M, Greenwood BM, Riley EM, , 2005. Association of transmission intensity and age with clinical manifestations and case fatality of severe Plasmodium falciparum malaria. JAMA 293: 14611470.[Crossref] [Google Scholar]
  31. Mukandavire Z, Liao S, Wang J, Gaff H, Smith DL, Morris JG, , 2011. Estimating the reproductive numbers for the 2008–2009 cholera outbreaks in Zimbabwe. Proc Natl Acad Sci USA 108: 87678772.[Crossref] [Google Scholar]
  32. Munch Z, Van Lill SW, Booysen CN, Zietsman HL, Enarson DA, Beyers N, , 2003. Tuberculosis transmission patterns in a high-incidence area: a spatial analysis. Int J Tuberc Lung Dis 7: 271277. [Google Scholar]
  33. Spence DP, Hotchkiss J, Williams CS, Davies PD, , 1993. Tuberculosis and poverty. BMJ 307: 759761.[Crossref] [Google Scholar]
  34. Yang K, LeJeune J, Alsdorf D, Lu B, Shum CK, Liang S, , 2012. Global distribution of outbreaks of water-associated infectious diseases. PLoS Neglected Trop Dis 6: e1483.[Crossref] [Google Scholar]
  35. Thomas JC, Tucker MJ, , 1996. The development and use of the concept of a sexually transmitted disease core. J Infect Dis 174 (Suppl 2): 134143.[Crossref] [Google Scholar]
  36. Azman AS, Lessler J, , 2015. Reactive vaccination in the presence of disease hotspots. Proc Biol Sci 282: 20141341. Available at: http://dxdx.doi.org/10.1098/rspb.2014.1341. Accessed February 15, 2015.[Crossref] [Google Scholar]
  37. Wu JT, Peak CM, Leung GM, Lipsitch M, , 2016. Fractional dosing of yellow fever vaccine to extend supply: a modelling study. Lancet 388: 29042911.[Crossref] [Google Scholar]
  38. Preston R, , 1995. The Hot Zone. United States. [Google Scholar]
  39. Myers N, Mittermeier R, , 2000. Biodiversity hotspots for conservation priorities. Nature 403: 853858. Available at: http://www.nature.com/articles/35002501. Accessed March 5, 2015.[Crossref] [Google Scholar]
  40. Horby PW, Pfeiffer D, Oshitani H, , 2013. Prospects for emerging infections in east and southeast Asia 10 years after severe acute respiratory syndrome. Emerg Infect Dis 19: 853860.[Crossref] [Google Scholar]
  41. Pedersen AB, Davies TJ, , 2009. Cross-species pathogen transmission and disease emergence in primates. EcoHealth 6: 496508.[Crossref] [Google Scholar]
  42. Chan EH, Brewer TF, Madoff LC, Pollack MP, Sonricker AL, Keller M, Freifeld CC, Blench M, Mawudeku A, Brownstein JS, , 2010. Global capacity for emerging infectious disease detection. Proc Natl Acad Sci USA 107: 2170121706.[Crossref] [Google Scholar]
  43. Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, Daszak P, , 2008. Global trends in emerging infectious diseases. Nature 451: 990993.[Crossref] [Google Scholar]
  44. Heymann DL, Rodier GR, , 2001. Hot spots in a wired world: WHO surveillance of emerging and re-emerging infectious diseases. Lancet Infect Dis 1: 345353.[Crossref] [Google Scholar]
  45. National AIDS Control Organization, 2007. Targeted Interventions Under NACP III: Operational Guidelines; Volume I Core High Risk Groups. Available at: http://naco.gov.in/sites/default/files/NACP-III.pdf. Accessed March 22, 2015. [Google Scholar]
  46. World Health Organization Regional Office for the Eastern Mediterranean, 2007. EMRO Technical Publications Series 33: Guidelines on the Elimination of Residual Foci of Malaria Transmission. Cairo, Egypt: World Health Organization. Available at: http://applications.emro.who.int/dsaf/dsa742.pdf. Accessed March 22, 2015. [Google Scholar]
  47. United States Agency for International Development, 2008. Report on the Global AIDS Epidemic. Available at: http://data.unaids.org/pub/GlobalReport/2008/jc1510_2008globalreport_en.pdf. Accessed March 22, 2015. [Google Scholar]

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  • Received : 26 May 2016
  • Accepted : 26 Feb 2017
  • Published online : 24 Apr 2017

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