“A Brief History of Plagues and Pandemics: From the Black Death to COVID-19 - PLoS Blogs” plus 1 more

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A Brief History of Plagues and Pandemics: From the Black Death to COVID-19 - PLoS Blogs Posted: 09 Apr 2020 07:37 AM PDT Daily life in the age of coronavirus has affected us in different ways. For science writers, it means that many of the physicians and scientists we would in normal times talk to are too busy saving lives. At the same time, the science and medical journals are spewing articles faster than we can keep up, peer review necessarily delayed. For the first half of March, I wrote breaking news articles and quickly burnt out. No one was giving interviews as the publication cycle continually compressed, sometimes doubling back to correct errors as new information flooded in. And then the webinars began, some for media, some for physicians. I've been doing as many as I can, from government agencies, patient advocacy groups, and the journals. This is my sixteenth piece on the novel coronavirus, thanks largely to these constant updates from the experts. My favorite webinar series is the Live Stream Q&A sessions from The Journal of the American Medical Association's editor-in-chief Howard Bauchner, MD. (Yale) I especially liked the webcast on April 2 with Frank Snowden, PhD, professor emeritus of history of medicine at Yale and the author of Epidemics and Society: From the Black Death to the Present, published fortuitously this past fall. Listening to him reminded me of my favorite books about plagues and pandemics, which I'll list at the end. Dr. Anthony Fauci, who needs no introduction with his face plastered on tee shirts and donuts (I've joined his Facebook fan club), does the JAMA webinar regularly, most recently on April 8. So I'm going to pretend that both gentlemen are sitting here with me and my cats in my living room, briefing me on the past and future of COVID-19, and how it fits into the grand sweep of epidemiology. "An Extraordinary Convergence of Events" Dr. Snowden attributes the current pandemic to an "extraordinary convergence of events." "Number one, I am struck by the ease with which it has spread throughout the world, which is partly because of the kind of world we've built. Number two, I am struck by the lack of preparedness. The world was totally unprepared in ways that are difficult to comprehend, because since 1997, when we had avian influenza, a surge of epidemiologists and virologists were saying that another pandemic challenge is an inevitable part of our future." He expanded on the issue. In 2005 and 2006, in the wake of the SARS epidemic, the US Congress, the World Health Organization (WHO), and companies began working on preparedness plans. But they dropped the ball when the epidemic faded, "even after Anthony Fauci said to Congress that if you are living in the Caribbean, you'd expect a meteorologist to say a hurricane is inevitable, but couldn't say when it would hit or how powerful it would be. Virologists could tell you another epidemic was coming. We didn't know how powerful or when, but it was inevitable," Dr. Snowden recalled. By the time Ebola struck in West Africa in 2014, the world once again wasn't ready. "In 2018, WHO appointed a commission to look at global preparedness and they produced a report in 2019, "A World at Risk," Dr. Snowden said. He was amazed that the report predicted that millions could die in a pandemic, yet some countries (names unmentioned) cut their preparedness and public health budgets. Viruses are no longer named by presumed place of origin, but by taxonomic classification. This is SARS-CoV-2. "Thirdly, the lack of taking science seriously is what disturbs me the most about the onset of the pandemic," Dr. Snowden said, pointing out that skepticism about science persists in many nations. He brought up calling the new pathogen "the Chinese virus" long after the WHO had officially named it the more scientifically meaningful SARS-CoV-2. "In addition to being stigmatizing, that is saying to the scientists of the world. 'we're not taking your concerns seriously,'" he added. Comparison to 1918 Influenza Which past pandemic most resembled the current one? Dr. Snowden immediately answered "1918 influenza." "There is still debate about where and how it started: China or Kansas or at the British military base at Étaples in the north of France. It spread quickly from Étaples with forced movement of troops to the western front. From November 1918 into the new year, it caused 50 million to 100 million deaths, many times more than the number of deaths from the first world war." An important factor, ironically, was the peace that followed the war. Returning soldiers brought the disease to the U.S., where welcome-back parties fueled the fires of contagion. After a parade in Philadelphia, hundreds of thousands of people fell sick. "Other major cities took measures that look like what we're doing today: masks, social distancing, canceling major events like church services where people congregate," Dr. Snowden said. Did the mayor of New Orleans know about the Philadelphia parade when Mardi Gras 2020 happened? Another striking feature is that the 1918 pandemic was largely forgotten. "How could a disease that caused 100 million deaths not sear a long-term memory into our institutions and economy? It was overshadowed by war, and then by peace, and it didn't besiege communities like bubonic plague, but swept and left devastation and was gone in a few weeks," Dr. Snowden said. He pointed out that Britain has many monuments to remember the first world war and the bravery of the soldiers, but just one monument to remember "the heroes of the 1918 influenza, the doctors and nurses who put their lives on the line to care for patients and their colleagues." Influenza virus. (credit: CDC) The influenza virus circled the globe in three undulations. "The early waves were in the spring of 1918 and were rather benign, not a major cause of mortality. Probably the virus mutated between the spring and the autumn, when it became catastrophic and coincided with the end of the war. The curve of mortality was pronounced," Dr. Snowden said. Curiously, the influenza pandemic of 1918 spared the very young and the elderly, creating "a W-shaped curve and not a U, with that spike in the middle the young people, like the soldiers," Dr. Snowden explained. The soldiers died of an overactive immune response that filled their lungs rapidly with fluid, the "cytokine storm" that today is ravaging lungs infected with SARS-CoV-2. In 1918 the young were vulnerable because they were crowded in the hellish environment of war, on transport ships and in military camps. Their elders may have been protected from having survived previous flu epidemics and building up a strong antibody response to similar viruses. Will COVID-19 follow a path similar to the 1918 flu? If so, it will do so over a landscape vastly different from the scattered towns and cities of the U.S. a century ago. "There was extraordinary morbidity and mortality in 1918, and yet it didn't affect the world in the way that this coronavirus seems to be doing. The new virus may be having a more lasting effect, we don't yet know. Clearly there will be major long term effects on the economy, on the relationships between industrial countries and emerging markets, international supply links, and all sorts of things," Dr. Snowden said. The famous Broad Street pump. The Legacy of Cholera "Each epidemic, each pandemic, is unique. Pandemics are not interchangeable. Each is experienced by society a different way. It's interesting to think about why some have left a huge footprint and others seem not to have," Dr. Snowden said. He recalled the classic epidemiology tale of London's Broad Street water pump handle, to which local physician Dr. John Snow and Reverend Henry Whitehead traced a fierce epidemic of cholera in September, 1854 that would have lasting effects on public health. Patient zero was a baby girl who lived at 40 Broad Street and developed severe diarrhea on September 28. Her mother washed her nappies out a few feet from the pump, sending bacteria-laden stool into the neighborhood's water supply. Ten percent of the street's residents died within two weeks. Cholera kills in days. The cholera outbreak "had a huge impact on the sanitary movement: making drinking water safer and instituting housing regulations paved the road towards the idea of the germ theory of disease. These accomplishments emerged out of this major cataclysm that was much smaller than the 1918 flu," Dr. Snowden said. The Black Death and Tuberculosis Breed Blame Parallel to the spread of a pathogen may be the spread of discrimination. Bubonic plague, caused by the bacterium Yersinia pestis, is perhaps the most long-lasting and pervasive example. Dr. Snowden spoke softly of the horrors. A depiction of the burning of Jews in Strasbourg in 1349, accused of having poisoning the wells with plague bacteria. "The Black Death was a time of extraordinary violence. In Strasbourg (on the border of France and Germany, in 1349) 12,000 Jews were rounded up and taken to a Jewish cemetery and given the option to convert or be killed on the spot. Half refused and were burned alive." The Jews had been accused of poisoning wells with plague bacteria. A novel published in 1827 and set in 1630 Milan, The Betrothed, by Alessandro Manzoni, illustrated another plague-driven travesty. "The Spaniards were innocent, but in the wrong place and time and were rounded up and tortured until they confessed. Their bodies were broken on the wheel and they were burned alive, accused of spreading a disease by poisoning the wells," Dr. Snowden said. Tuberculosis also seemed to bring out the worst in frightened people. "With TB it began, paradoxically, when people understood that it wasn't hereditary but caused by a germ, which they associated with filth. Working classes were held responsible. Social tension and stigma arose on a class and ethnic basis in places like New York because immigrants were more likely to be dangerous," Dr. Snowden said. HIV/AIDS vs COVID-19 Closer to our own time, Dr. Snowden pointed out, is the horrific stigmatization of the "4H" groups that emerged as high risk in the early days of the HIV/AIDS pandemic: in the language of the time, homosexuals, Haitians, hemophiliacs, and heroin addicts. Dr. Fauci was on the frontlines back then. He recalled: "I got involved with HIV a week after the first report in the MMWR (CDC's weekly newsletter) in June 1981. I completely turned my lab around to delve into a disease that had no name, no known etiology, and we didn't know what we were doing. In the early years of HIV/AIDS, 30,000 to 35,000 people died a year. It was insidious then, seeming to involve a very circumscribed demographic." He compared HIV/AIDS' stealth trajectory to the stunning speed of COVID-19: "HIV/AIDS didn't instill fear for awhile. It was only when we found out, through antibody testing, that ill patients were the tip of the iceberg did people realize it was turning into a global problem that would extend four decades and at the end of the day would kill infinitely more people than COVID-19. With COVID the timeline is truncated into weeks. It explodes and everyone is vulnerable all over the world, in real time, and all are afraid." Will We Be Ready Next Time? My grandfather met my grandmother in the midst of the 1918 influenza pandemic – she was his nurse. He rarely got so much as a sniffle in his remaining years, dying at age 103. Those antibodies must have been powerful. We don't remember the 1918 influenza. Plague is now exceedingly rare, and cholera and TB no longer seen in many parts of the world. But people my age remember the "childhood diseases" of measles, mumps, chickenpox, and rubella, the empty classrooms, the "parties" parents held to expose their little ones to get the diseases over with, for only rarely were they dangerous (see "Vaccine Memories"). We can all recall recent outbreaks of influenza, and the vaccines that might not seem to have worked, partly because other types of viruses, like rhinovirus, adenovirus, syncytial virus, and other coronaviruses, cause respiratory infections too. The shared symptoms reflect the responses of our immune systems, not weapons that the pathogens directly deploy. We've all heard of HIV/AIDS. And SARS. So anyone who didn't think a pandemic was possible just wasn't paying close enough attention – to the clues from history and to the informed predictions of today's scientists, medical researchers, clinicians, and others. Will we let a pandemic sneak up on us again? Is the warning from COVID-19, enough? Dr. Anthony Fauci, director of the NIAID Dr. Fauci thinks this crisis is a game changer. "I hope when we get out of this that we take a look at long term investment in public health. We have a habit of when we get over a challenge, we say 'let's move on.' We should never be in a position to be hit like this again and have to scramble to respond. This is historic." Ricki's Pandemic Reading List The Great Influenza: The Story of the Deadliest Pandemic in History, by John Barry The Ghost Map: The Story of London's Most Terrifying Epidemic and How it Changed Science, Cities, and the Modern World, by Steven Johnson The American Plague: The Untold Story of Yellow Fever, the Epidemic That Shaped Our History, by Molly Caldwell Crosby The Hot Zone: The Terrifying True Story of the Origins of the Ebola Virus by Richard Preston Fever: A Novel by Mary Beth Keane and of course Spillover: Animal Infections and the Next Human Pandemic, by David Quammen

How 5 of History's Worst Pandemics Finally Ended - History Posted: 17 Mar 2020 12:00 AM PDT As human civilizations flourished, so did infectious disease. Large numbers of people living in close proximity to each other and to animals, often with poor sanitation and nutrition, provided fertile breeding grounds for disease. And new overseas trading routes spread the novel infections far and wide, creating the first global pandemics. Here's how five of the world's worst pandemics finally ended. 1. Plague of Justinian—No One Left to Die Yersinia pestis, formerly pasteurella pestis, was the bacteria responsible for the plague. Here it's seen under optical microscopy X 1000. BSIP/Universal Images Group/Getty Images Three of the deadliest pandemics in recorded history were caused by a single bacterium, Yersinia pestis, a fatal infection otherwise known as the plague. The Plague of Justinian arrived in Constantinople, the capital of the Byzantine Empire, in 541 CE. It was carried over the Mediterranean Sea from Egypt, a recently conquered land paying tribute to Emperor Justinian in grain. Plague-ridden fleas hitched a ride on the black rats that snacked on the grain. The plague decimated Constantinople and spread like wildfire across Europe, Asia, North Africa and Arabia killing an estimated 30 to 50 million people, perhaps half of the world's population. "People had no real understanding of how to fight it other than trying to avoid sick people," says Thomas Mockaitis, a history professor at DePaul University. "As to how the plague ended, the best guess is that the majority of people in a pandemic somehow survive, and those who survive have immunity." 2. Black Death—The Invention of Quarantine A couple suffering from the blisters of the Black Death, the bubonic plague that swept through Europe in the Middle Ages. From the Swiss manuscript the Toggenburg Bible, 1411.  VCG Wilson/Corbis/Getty Images The plague never really went away, and when it returned 800 years later, it killed with reckless abandon. The Black Death, which hit Europe in 1347, claimed an astonishing 200 million lives in just four years. As for how to stop the disease, people still had no scientific understanding of contagion, says Mockaitis, but they knew that it had something to do with proximity. That's why forward-thinking officials in Venetian-controlled port city of Ragusa decided to keep newly arrived sailors in isolation until they could prove they weren't sick. At first, sailors were held on their ships for 30 days, which became known in Venetian law as a trentino. As time went on, the Venetians increased the forced isolation to 40 days or a quarantino, the origin of the word quarantine and the start of its practice in the Western world. "That definitely had an effect," says Mockaitis. READ MORE: How Rats and Fleas Spread the Black Death 3. The Great Plague of London—Sealing Up the Sick Scenes in the streets of London during the Great Plague of 1665. The Print Collector/Getty Images London never really caught a break after the Black Death. The plague resurfaced roughly every 20 years from 1348 to 1665—40 outbreaks in 300 years. And with each new plague epidemic, 20 percent of the men, women and children living in the British capital were killed. By the early 1500s, England imposed the first laws to separate and isolate the sick. Homes stricken by plague were marked with a bale of hay strung to a pole outside. If you had infected family members, you had to carry a white pole when you went out in public. Cats and dogs were believed to carry the disease, so there was a wholesale massacre of hundreds of thousands of animals. The Great Plague of 1665 was the last and one of the worst of the centuries-long outbreaks, killing 100,000 Londoners in just seven months. All public entertainment was banned and victims were forcibly shut into their homes to prevent the spread of the disease. Red crosses were painted on their doors along with a plea for forgiveness: "Lord have mercy upon us." As cruel as it was to shut up the sick in their homes and bury the dead in mass graves, it may have been the only way to bring the last great plague outbreak to an end. 4. Smallpox—A European Disease Ravages the New World Dr. Edward Jenner performing his first vaccination against smallpox on James Phipps, circa 1796. DEA Picture Library/Getty Images Smallpox was endemic to Europe, Asia and Arabia for centuries, a persistent menace that killed three out of ten people it infected and left the rest with pockmarked scars. But the death rate in the Old World paled in comparison to the devastation wrought on native populations in the New World when the smallpox virus arrived in the 15th century with the first European explorers. The indigenous peoples of modern-day Mexico and the United States had zero natural immunity to smallpox and the virus cut them down by the tens of millions. "There hasn't been a kill off in human history to match what happened in the Americas—90 to 95 percent of the indigenous population wiped out over a century," says Mockaitis. "Mexico goes from 11 million people pre-conquest to one million." Centuries later, smallpox became the first virus epidemic to be ended by a vaccine. In the late 18th-century, a British doctor named Edward Jenner discovered that milkmaids infected with a milder virus called cowpox seemed immune to smallpox. Jenner famously inoculated his gardener's 9-year-old son with cowpox and then exposed him to the smallpox virus with no ill effect. "[T]he annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice," wrote Jenner in 1801. And he was right. It took nearly two more centuries, but in 1980 the World Health Organization announced that smallpox had been completely eradicated from the face of the Earth. READ MORE: How an African Slave in Boston Helped Save Generations from Smallpox 5. Cholera—A Victory for Public Health Research A satirical cartoon showing the River Thames and its offspring cholera, scrofula and diptheria, circa 1858. Hulton Archive/Getty Images In the early- to mid-19th century, cholera tore through England, killing tens of thousands. The prevailing scientific theory of the day said that the disease was spread by foul air known as a "miasma." But a British doctor named John Snow suspected that the mysterious disease, which killed its victims within days of the first symptoms, lurked in London's drinking water. Snow acted like a scientific Sherlock Holmes, investigating hospital records and morgue reports to track the precise locations of deadly outbreaks. He created a geographic chart of cholera deaths over a 10-day period and found a cluster of 500 fatal infections surrounding the Broad Street pump, a popular city well for drinking water. "As soon as I became acquainted with the situation and extent of this irruption (sic) of cholera, I suspected some contamination of the water of the much-frequented street-pump in Broad Street," wrote Snow. With dogged effort, Snow convinced local officials to remove the pump handle on the Broad Street drinking well, rendering it unusable, and like magic the infections dried up. Snow's work didn't cure cholera overnight, but it eventually led to a global effort to improve urban sanitation and protect drinking water from contamination. While cholera has largely been eradicated in developed countries, it's still a persistent killer in third-world countries lacking adequate sewage treatment and access to clean drinking water.  READ MORE: Pandemics that Changed History See all pandemic coverage here.

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