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Rubella and the Bubonic Plague A Comparison

Rubella and the Bubonic Plague A Comparison. Ellen Perlow HS 5353 Epidemiology Dr. Wiginton Fall 2002 – Texas Woman’s University Dept. of Health Studies December 9, 2002 – http://www.a4access.org/epipaperrevised.ppt Narrative at http://www.a4access.org/epipaper1202.doc

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Rubella and the Bubonic Plague A Comparison

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  1. Rubellaandthe Bubonic PlagueA Comparison Ellen Perlow HS 5353 Epidemiology Dr. Wiginton Fall 2002 – Texas Woman’s University Dept. of Health Studies December 9, 2002 – http://www.a4access.org/epipaperrevised.ppt Narrative at http://www.a4access.org/epipaper1202.doc This presentation is available in alternative formats upon request.

  2. I.History and Current Status of Rubella andThe Bubonic Plague

  3. Rubella / German Measles / Gregg’s Syndrome: Virus Agent: Togavirus, genus Rubivirus, RNA virus(isolated 1962 by Parkman and Weller) Transmission:Human to human respiratory transmission. Replication in nasopharynx and regional lymph nodes. Viremia (virus in bloodstream) 5-7 days after exposure with spread to tissues. Intrauterine: placenta, fetus affected during viremia.Centers for Disease Control and Prevention (2002). Rubella. Retrieved November 16, 2002, from http://www.cdc.gov/nip/publications/pink/rubella.pdf

  4. History of Rubella - 1 • 1881: Officially recognized as a distinct clinical entity Before that time, confusion as to whether it was a mild form of measles (rubeola) or scarlet fever, or both “Rubella” name accepted. • In the next 60 years, little attention paid to rubella since disease not considered serious. • 1935: Epidemic of rubella, largely went unnoticed. • 1940: Large rubella epidemic in Australia. (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, 1881-1985. South African Medical Journal, Supplement, 60-63.)

  5. History of Rubella - 2 • 1941: Australian ophthalmologist Dr. Norman Gregg discovered relationship between maternal rubella during pregnancy and congenital “defects” in infants. Observed > number of infants born with cataracts. Found: mothers of most infants contracted rubella in 1st few months of pregnancy during 1940 epidemic. Published findings: 78 cases. Infants born with cataracts, microphthalmia, small in size, failure to thrive, cardiac abnormalities. Discovery: profound impact on entire field of congenital disease. Rubella very first well defined teratogen: agent causing developmental differences. Gregg’s findings confirmed in other studies in Europe, U.S., New Zealand, Australia. Many children born with differences-correlation: mothers had rubella. (Horstmann, D.M. (1986, Oct. 11). The rubella story, 1881-1985. South African Medical Journal, Supplement, 60-63; Cooper, L.Z. (1966). German measles. Scientific American 215(7): 30-37. Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, 1960-1969. DISCovering U.S. History. Gale Research. Retrieved Sept. 16, 2002, from Gale Research database.

  6. History of Rubella - 3 1941-1961: Scientists tried to isolate virus: no success. 1962: Drs. Parkman, Meyer, Hilleman at Walter Reed, Harvard, NIH labs isolated virus. New standard of cooperation in medical research. Early 1960s: 40,000 and 45,000 cases of rubella per year. Spring 1964: Large U.S. epidemic. 7,000 fetal deaths, 20,000 babies born with congenital differences. Very different virologies of intra-uterine, post-natal infections July 1966: Pediatrician Louis Z. Cooper publishes “German Measles,” Scientific American. By 1969-3 vaccines: HPV77 DE5, Cendehill, RA27/3 strains ready for licensing (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, 1881-1985. South African Medical Journal, Supplement, 60-63. Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, 1960-1969. DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from http://galenet.galegroup.com/servlet/SRCCE/. Cooper, L.Z. (1966). German measles. Scientific American 215(7): 30-37.)

  7. History of Rubella - 4 1969 – U.S. begins rubella vaccine program 1970 – U.K., Australia,New Zealand vaccine programs begin 1989 – Eradication of rubella: goal of Healthy People 2000 1988-1991: Reduction in rubella cases 98% since pre-vaccine era. 2-3 fold increase in incidence of rubella since 1982 1990: 1093 cases from 38 states+DC. California: 4x. 2002: CDC: U.S. on verge of eradication of indigenous rubella. “Rubella occurs mainly among foreign-born Hispanic adults who are either unvaccinated or whose vaccination status is unknown…” 1998-2002: Controversy: MMR vaccine causes autism? November 7, 2002: Danish study: no link: MMR vaccine / autism. December 9, 2002: Threats due to lack of vaccination in other countries, threats due to terrorism? … (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, 1881-1985. South African Medical Journal, Supplement, 60-63. Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, 1960-1969. DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from http://galenet.galegroup.com/servlet/SRCCE/. Cooper, L.Z. (1966). German measles. Scientific American 215(7): 30-37.)

  8. Bubonic Plague: Enzootic Agent: Bacterium:Yersinia pestisVector: Blood-sucking rat flea: Xenopsylla cheopisHosts: Rodents-rats/shrews, prairie dogs, etc. Environment: Rodent-friendly: food, garbage, unsanitary conditionsTransmission: a) Most common mode: bite of flea infected with Yersinia pestis bacterium; b) less frequently: direct contact with infectious body fluids or tissues while handling infected animal or c) inhaling infectious respiratory droplets or other infectious materials.

  9. Types of Plague • Bubonic plague: most common form of U.S. cases: 80%-90%. Case Fatality Rate if not treated: 50%-60% • Septicemic plague: when Yersinia pestis invades and continues to multiply in the bloodstream; primary or secondary to bubonic plague. U.S. 1947-1977: 10% septicemic. Case fatality rate-50%. Complications: septic shock, consumptive coagulopathy, meningitis, coma. • Pneumonic plague: least common but most dangerous and fatal form - inhalation of infectious respiratory droplets. Incubation period: 1-3 days. Without treatment, death within 18 hours after onset of respiratory symptoms. (Centers for Disease Control and Prevention (1996). Prevention of plague: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 45(RR-14): 1-15. )

  10. History of Bubonic Plague - 1 • Biblical times: circa 1000 B.C.E. • 1 Samuel 5: capture of Ark of Covenant from Israelites by Philistines at battle of Aphek followed by outbreak of what appears to have been the plague in five cities of the Philistines starting in Ashdod. (Septuagint/Vulgate: Philistines smitten with tumors … “and rats appeared in their land and death and destruction were throughout the cities.” (Griffin, J.P. (2000) Bubonic plague in Biblical times. [Letter]. Journal of the Royal Society of Medicine, 93, 449.)

  11. History of Bubonic Plague - 2 • Summer 430 B.C.E.: Athens: Illness from Egypt. 1/3 Athens population, Pericles died. Athens lost to Sparta. • Possibly typhus, smallpox, scarlet fever. • 1346-1347: Black Sea/S. Ukraine • Names: Swellings=buboes. Greek: groin=boubon. Also named “Black Death” and “The Great Pestilence.” • Italian traders blamed. Infection to Sicily, mainland Italy • October 1347: Sicily–Italy. By Winter 1348-1349, 1/3-1/2 population of Italy killed. • Plague spread to Messina, other Italian ports, Milan, Florence, Venice: quaranta giorni decree=40-day quarantine on ships Garbage: great breeding ground • Literary references: Bocaccio’s Decameron. (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, 1-3, 11-20). Working Group on Civiliian Biodefense (2000). Plague as a biological weapon. JAMA, 283(17), 2281.)

  12. History of Bubonic Plague - 3 • Spring 1348: Pilgrims bring plague to France (Marseilles-Avignon: Home of Pope Feb.-May: 400 deaths/day, 1349: 50,000 deaths in Paris. • Pope Clement/Church belief in fire/humors/miasmas theories of Hippocrates, Galen. No dissection, autopsies. • Treatments: bloodletting at site of buboes, prayer. • Summer 1349-1351-Early 1400s: British Isles, Germany • 80% of some villages died. Devastationpersecution; German Flagellants, 1st Holocaust;Church power reduced • Europe epidemics-every decade-to 1400s-½ pop. killed • 15th-16th-17th Centuries: Church reform--Protestantism • Medicine: Practical courses in anatomy, surgery. Medical textbooks in European languages, Consumer health, Scientific method, Gutenberg (1456), Discovery of “America” (1492) • 1664-Fall 1665: Great Plague of London. 70,000 died. Thought to be person to person transmission. Quarantines in homes (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, 21-49.)

  13. History of Bubonic Plague - 4 • 18th-19th Centuries. By 1750, BP faded W. Europe, active: Mediterranean. 1855: pandemic. >12 million killed in interior of China, Canton Hong Kong, India Medicine: Pasteur, Koch work with bacteria. • 1894: Kitasato and Dr. Alexandre E.J. Yersin isolated, described cause. Yersin credited: bacteria: Yersinia pestis • 20th Century: 1900-1904: San Francisco: 121 cases,118 died. Asian immigrants isolated. Quarantine did not work; scientists’ views accepted. Ships disinfected. Clean-up. Rats destroyed. • 1924-1925: Los Angeles: 40 cases, 38 died. 1940s: Development of antibiotics. Plague treatable. • By 1949: New Mexico U.S. leader in # of cases. Threat if no antibiotics; 9/94-India: pneumonic • 1898-1920, 1991, 1995-1998: Madagascar. 12/1996 CDC MMWR Prevention of Plague Report (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, 49-51. Yancey, D. (1994). The hunt for hidden killers: ten cases of medical mystery. Brookfield, CT: Millbrook Press, 61-71. Boisier (2002)… Emerging Infectious Diseases; McClain, C. Of Medicine, Race and American Law-1900)

  14. History of Bubonic Plague - 5 • 21st Century … Today as we speak • November 7, 2002: CNN.com: “Bubonic plague suspected in New York City [NYC] Visitors” • Nov. 9, 2002: New Mexico visitors to NYC diagnosed with bubonic plague still in hospital. • NYC’s 1st case of bubonic plague in century (CDC, 2002) • Couple suspected of contracting plague from rodents on their property (Robin, 2002) • April-May 2002: 71 cases in Malawi http://www.cdc.gov/ travel /other/plague-outbreak-malawi.htm • History of Bubonic Plague: Was it really the plague, or scarlet fever, or ebola virus? ... Delta 32 gene mutation • Plague as biological weapon (U.S. Working Group on Civilian Biodefense, JAMA (5/3/2000): Recommendations

  15. II.Symptoms ofRubella and The Bubonic Plague

  16. Symptoms of the Disease:Rubella Symptoms • Rubella: mild, highly contagious virus. Symptoms: rash, swollen glands/lymph nodes, and, especially in adults, joint pain. Rash lasts about 3 days, also may low fever. Infected adults, teens also headache, loss of appetite and sore throat. Sometimes no symptoms at all. • 1/2 cases occur without rash. Lasts < 2 wks in children. • Incubation period:12-23 days; most cases, symptoms appear within 16-18 days. • Rubella immunity does not protect against rubeola. National Institutes of Health. National Toxicology Program (NTP). Center for the Evaluation of Risks to Human Reproduction [CERHR]. Rubella (German measles) 5/24/02). Retrieved October 23, 2002, from http://cerhr.niehs.nih.gov/genpub/topics/rubella-ccae.html. (New York State Department of Health. Communicable disease fact sheet: rubella. Retrieved October 23, 2002, from http://www.health.state.ny.us/nysdoh/consumer/rubella.htm)

  17. Symptoms of the Disease:Congenital Rubella Syndrome [CRS] • In pregnant women, the infection can pass to the developing fetus, especially during the first trimester of pregnancy, causing severe injuries to the fetus/newborn. • Approximately 15-20% of pregnant women infected during first trimester give birth to infants with heart defects (50%), deafness (50%), eye defects and blindness (40%), mental retardation (40%), blood defects such anemia and bleeding (30%), bone lesions, enlarged liver, spleen, and hand abnormalities. • About 10% of infants born with CRS die, while severe infections result in spontaneous abortion. • Greatest virulence: first 2 months of pregnancy. 50% of women infected during 1st month of pregnancy: babies born with host of differences. Infection in 3rd month: 10% of infants. Infection after 4th month: less severe differences.(Parkman, Meyer, & Hilleman, 1997, 2000).

  18. Symptoms of the Disease:Bubonic Plague – Symptoms • Bubonic plague: enlarged, tender lymph nodes (buboes), fever, chills, prostration, gastrointestinal symptoms • Septicemic plague: fever, chills, prostration, abdominal pain, shock, bleeding into skin and other organs • Pneumonic plague: fever, chills, cough and difficulty breathing; rapid shock and death if not treated early (Centers for Disease Control and Prevention. CDC plague fact sheet. Retrieved October 22, 2002, from http://www.cdc.gov/ncidod/dvbid/plague/facts.htm)

  19. III.Causative Agents and how they were determined:Rubella and the Bubonic Plague

  20. Causative Agent – Rubella(Togavirus, genus Rubivirus) Source: CDC Public Health Image Library, Image # 269 URL: http://phil.cdc.gov/Phil/detail.asp?id=269 CDC Description: “Transmission electron micrograph of rubella virus” (1981) [image in public domain]

  21. Causative Agent – Rubella (Togavirus, genus Rubivirus) • Rubella as separate entity not identified until 1881. Thought to be scarlet fever or measles. Mild symptoms: identity, severity discounted to 1941. • 1941: Gregg, Australia: maternal-fetus transmission • Caused by virus based on incubation period (12-23 days), clinical course (symptoms 16-18 days), lack of response to antibiotics. (Cooper, 1966, 32. NYS Dept. of Health, 2002, Rubella, 2002) • 1941-1961: Unsuccessful attempts to isolate virus. • 1960-1962-Virus isolated-Walter Reed,Harvard, NIH labs • Discovery of very different virologies of intra-uterine and post-natal infections by 1963-1965 major U.S. epidemic The rubella epidemic (1960s). (1998, 2000). American Decades CD-ROM. Gale Research. Retrieved November 15, 2002, from Student Resource Center College Edition database, http://galenet.galegroup.com/servlet/SRCCE. The rubella epidemic (1960s). (1998, 2000). American Decades CD-ROM. Gale Research. Retrieved November 15, 2002, from Student Resource Center College Edition database, http://galenet.galegroup.com/servlet/SRCCE. Cooper, 1966).

  22. Causative Agent – Bubonic Plague (Bacterium Yersinia pestis) - 1 Source: CDC Public Health Image Library, Image # 2117 URL: http://phil.cdc.gov/Phil/detail.asp?id=2117 (image in public domain) CDC Description: “Yersinia (Pasteurella) pestis causes plague in animals and humans. People usually get plague from being bitten by a rodent flea that is carrying the plague bacterium, or by handling an infected animal. “

  23. Causative Agent – Bubonic Plague(Bacterium Yersinia pestis) - 2 • Agent: bacterium Yersinia pestis. Kitasato/Yersin described bipolar staining organisms in dead patients’ swollen lymph node (bubo), blood, lungs, liver, spleen (Bibel et al., 1976). • Patient specimen cultures into animals, mice. Animals died within days after injection. Same bacilli in animal organs as in patient specimens. Yersin, primary discoverer: rats affected during, before humans. • 1898: Simond: Persons who became ill did not have to be in close contact with each other to be infected. Suspected flea as intermediary factor. Infection only if in contact with rats that had died within 24 hours. Simond experiment: healthy rat, separated from direct contact with a recently plague-killed rat, died of plague after infected fleas jumped from first rat to second. • Centers for Disease Control and Prevention. Division of Vector-Borne Infectious Diseases. The plague: natural history. Retrieved October 22, 2002 from: http://www.cdc.gov/ncidod/dvbid/plague/history.htm

  24. IV. How Diseases Spread: Rubella andThe Bubonic Plague

  25. How Disease Spread:Rubella • Person to person; infected person coughs or sneezes. • Direct contact with nasal, throat secretions of infected person. If woman infected during first 3 months of pregnancy, baby: risk of serious birth defects or dying. • Highly contagious. High herd immunity required, 85-90% • CRS highly contagious: > virulence: affected newborns can infect others with virus up to 1 year after birth. • In a hospital setting, newborns with CRS can infect hospital personnel, other newborns, and other women who are pregnant and visitors to the hospital, compounding spread of the virus. National Coalition for Adult Immunization. (2002). Facts about rubella for adults. Retrieved October 23, 2002, from http://www.nfid.org/factsheets/rubellaadult.html Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, 1960-1969. In DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from Student Resource Center College Edition database at http://galenet.galegroup.com/servlet/SRCCE/

  26. How Disease Spread Bubonic Plague - 1 • Zoonotic infectious disease spread principally by reservoir of infected rats, shrews, prairie dogs, and other mammals. • Vector: Rat flea Source: CDC (in public domain) URL: http://www.cdc.gov/ncidod/ dvbid/plague/cheob6x4.htm CDC Description: Male Xenopsylla cheopis (oriental rat flea) engorged with blood. This flea is the primary vector of plague in most large plague epidemics in Asia, Africa, and South America. Both male and female fleas can transmit the infection.

  27. How Disease Spread:Bubonic Plague - 2 • People bitten by rodent flea carrying Yersinia pestis; handle infected animal. Homes, places of work with flea-infested rats. Wild rodents in certain areas. • Los Angeles 1924-25 last U.S. urban epidemic. Since then, most cases rural areas (10-15/year). Globally, WHO: 1,000-3,000 cases every year. • N. America: Pacific Coast-Great Plains, SW Canada-Mexico. Africa, Asia, S. America. U.S. most human cases: N. NM, AZ, S. CO; CA, S. Oregon, far W. Nevada. • Natural cycle: small mammals/fleas, no humans involved • Periods: few/no human cases: last years. Not eradicated. May suddenly reappear in rodents, fleas near homes. Panic. > risk: Poor sanitation, overcrowding, rodents • Controversy if etiology was the same for all outbreaks . (Centers for Disease Control and Prevention. CDC Plague Home Page, 2002) Centers for Disease Control and Prevention. Division of Vector-Borne Infectious Diseases. The plague: natural history. Retrieved October 22, 2002 from: http://www.cdc.gov/ncidod/dvbid/plague/history.htm Drancourt, M. & Raoult, D. (2002, January). Molecular insights into the history of plague. Microbes and Infection / Institut Pasteur, 4(1): 105-9.) Cohn, S.K., Jr. (2002, June). The Black Death: end of a paradigm. American Historical Review, 107(3): 703-738. Retrieved October 27, 2002, from Ebscohost database.)

  28. V. Mechanisms of Containment : Rubella andThe Bubonic Plague

  29. Mechanisms of Containment:Rubella - 1 • Vaccination (3 strains) since 1969 • Induces seroconversions in approximately 95% of susceptible individuals. Vaccine-induced infection non-communicable. Viremia-low level: not easily detected. • Rubella vaccine given on or after a child's 1st birthday; usually combined with measles / mumps (MMR) vaccine • Children: 1st dose: 12-15 months or age; 2nd dose before starting school: at 4-6 years of age. • During 2000, 87% reported cases among people 15-39 years of age. About 8 million women of childbearing age susceptible. Up to 10% of young adults susceptible. (National Coalition for Adult Immunization. (2002). Facts about rubella for adults. Retrieved October 23, 2002, from http://www.nfid.org/factsheets/rubellaadult.html (New York State Department of Health. (2002). Communicable disease fact sheet: rubella. Retrieved October 23, 2002, from http://www.health.state.ny.us/nysdoh/consumer/rubella.htm)

  30. Mechanisms of Containment:Rubella - 2 • N.Y. State Health Dept., WHO: High coverage in immunization programs needed to avoid increase in CRS. (New York State Department of Health. Communicable Disease Fact Sheet. Rubella. Retrieved October 23, 2002, from http://www.health.state.ny.us/nysdoh/consumer/rubella.htm) World Health Organization. Vaccines, Immunization and Biologicals: Rubella vaccine. Retrieved October 23, 2002, from http://www.who.int/vaccines/en/rubella.shtml) • MMR – Autism Link Controversy: 1998-2002: whether link between MMR vaccine - inflammatory bowel disease/autism: 2/28/1998: British study “Early report” in Lancet. Researcher Andrew Wakefield lost university position because of controversy. (Wakefield AJ, Murch SH, Linnell AAJ, Casson DM, Malik M, Berelowitz M, et al. (1998, February 28). Ileal-lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children. Lancet, 351(9103), 637-41. ). Retrieved November 16, 2002, from EBSCOHost Academic Search Premier database. Ramsey, S. (2001, December 8). Controversial MMR-autism investigator resigns from research post. Lancet, 358(9297). Retrieved November 16, 2002, from EBSCOHost Academic Search Premier database.)

  31. Mechanisms of Containment:Rubella - 3 • MMR – Autism Link Controversy • Claims on anti-vaccination websites: • vaccines cause idiopathic illness (100% of sites) • vaccines erode immunity (95%) • adverse vaccine reactions underreported (95%) • vaccination policy is motivated by profit (91%) • links to other anti-vaccination sites (100%) • information for legally avoiding immunizations (64%) • emotionally charged stories of children who had allegedly been killed or harmed by vaccines (55%). (Wolfe, L.K., Sharp, M., & Lipsky, M. (2002, June 26). Content and design attributes of anti-vaccination web sites (brief report). JAMA: The Journal of the American Medical Association, 287(24), 3245-3249.)

  32. Mechanisms of Containment:Rubella - 4 • In 1986, the U.S. Congress passed the National Childhood Vaccine Injury Act that established the National Vaccine Injury Compensation Program (VICP), a federal system to compensate individuals or families injured by childhood vaccines, claims for severe shock, paralytic polio, and brain damage. • A physician from the YSDHHS reviews claims, then claims are decided in federal court. • Act also established the Vaccine Adverse Reporting System (VAERS) to which anyone can report a suspected reaction to any vaccine. Act also provided for increased communication about risks from immunizations. The Institute of Medicine established a Vaccine Safety Ctte. to study risks of childhood vaccines. (Hyde, M.O., & Forsythe, E.H. (2000). Vaccinations: from smallpox to cancer. New York: Franklin Watts, 66.)

  33. Mechanisms of Containment:Rubella - 5 • MMR – Autism Link Controversy • “German measles-rubella vaccine is a live attenuated vaccine made from live but weakened microbes. The microbes are weakened by growing them under special conditions in tissue cultures in the laboratory. The vaccine stimulates the immune system more strongly than do inactivated vaccines (made from killed bacteria or viruses that have been inactivated by chemicals or heat). People usually need only one booster. Once the rubella vaccine is injected, weakened microbes from a live vaccine can change into a virulent form, so that live vaccines are not given to pregnant women or people with damaged immune systems such as people with HIV, cancer, or people who take medications that suppress their immune systems.” • (Offit, P.A., & Bell, L.M. (1998). What every parent should know about vaccines. New York: Macmillan, 70-72.)

  34. Mechanisms of Containment:Rubella - 6 • CDC – Autism Link Controversy (last word) • “While rubella is usually mild in children and adults, up to 90 percent of infants born to mothers infected with rubella during the first trimester of pregnancy will develop congenital rubella syndrome (CRS), resulting in heart defects, cataracts, mental retardation, and deafness. In 1964-1965, before rubella immunization was used routinely in the U.S., there was an epidemic of rubella that resulted in an estimated 20,000 infants born with CRS, with 2,100 neonatal deaths and 11,250 miscarriages. Of the 20,000 infants born with CRS,11,600 were deaf, 3,580 were blind, and 1,800 were mentally retarded.Due to the widespread use of rubella vaccine, only six CRS cases were provisionally reported in the U.S. in 2000. Because many developing countries do not include rubella in the childhood immunization schedule, many of these cases occurred in foreign-born adults. Since 1996, greater than 50 percent of the reported rubella cases have been among adults. Since 1999, there have been 40 pregnant women infected with rubella. If we stopped rubella immunization, immunity to rubella would decline and rubella would once again return, resulting in pregnant women becoming infected with rubella and then giving birth to infants with CRS.” • (Centers for Disease Control and Prevention. Rubella (German measles): What would happen if we stopped vaccinations? Retrieved October 26, 2002, from http://www.cdc.gov/nip/publications/fs/gen/WhatIfStop.htm#Rubella)

  35. Mechanisms of Containment:Bubonic Plague • Increased self-sufficiency of public health labs • Surveillance through animal serosurveys; GIS systems • Increased education: public and health professionals • Research on prevention, control with other agencies • Ecology-based prevention, control • Development of new potential vaccines • Identify risk factors: landscape ecology, epidemiology • Refrain from contact with rodents • Use insect repellent in areas with potential vectors, hosts • Wear proper attire to protect selves Centers for Disease Control and Prevention. CDC plague fact sheet. Retrieved October 22, 2002, from http://www.cdc.gov/ncidod/dvbid/plague/facts.htm

  36. VI. Percentage of Fatalities:Rubella and The Bubonic Plague

  37. Percentage of Fatalities: Rubella • U.S. Rubella Epidemic of 1964-1965 • 12.5 million rubella cases; 2,000 encephalitis cases • 11,250 surgical, spontaneous abortions; 2,100 neonatal deaths; 20,000 CRS cases; possibly all organs affected; fetal death. 85% of infants infected in 1st trimester affected. CRS causes: deafness, heart defects, cataracts, blindness, microcephaly, mental retardation, bone alterations, liver/spleen damage • 2002: Current CRS Incidence • 0.5-2.2/1000 live births in developing countries during epidemics (every 4-7 years) High susceptibility: 25% • 1996 CRS estimate: developing nations-110,000 cases (Centers for Disease Control and Prevention (2002). Rubella. Retrieved November 16, 2002, from http://www.cdc.gov/nip/publications/pink/rubella.pdf) Hinman, A.R., Irons, B., Lewis, M., & Kandola, K. (2002, April). Economic analyses of rubella and rubella vaccines: a global review. Bulletin of the World Health Organization, 80(4), 264-271. Retrieved September 16, 2002, from Infotrac General Reference Center Gold database.

  38. Fatalities: Bubonic Plague • Bubonic plague: most common form of U.S. cases: 80%-90%. Case Fatality Rate if not treated: 50%-60% • Septicemic plague: when Yersinia pestis invades and continues to multiply in the bloodstream; primary or secondary to bubonic plague. U.S. 1947-1977: 10% septicemic. Case fatality rate-50%. Complications: septic shock, consumptive coagulopathy, meningitis, coma. • Pneumonic plague: least common but most dangerous and fatal form - inhalation of infectious respiratory droplets. Incubation period: 1-3 days. Without treatment, death within 18 hours after onset of respiratory symptoms. (Centers for Disease Control and Prevention (1996). Prevention of plague: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 45(RR-14): 1-15.

  39. VII. Treatments:Rubella and The Bubonic Plague

  40. Treatments: Rubella • “There is no specific treatment for congenital rubella syndrome. Certain problems that are common in the newborn period-such as blood and liver abnormalities-usually go away without treatment. Other individual birth defects-such as eye or heart defects-can sometimes be corrected or at least improved with early surgery. Babies with hearing or vision loss benefit from special education programs that provide early stimulation and build communication and learning skills. Children with mental retardation also benefit from early special education. Children with multiple [differences] may require early intervention from a team of experts.” National Institutes of Health. National Toxicology Program (NTP). Center for the Evaluation of Risks to Human Reproduction [CERHR]. Rubella (German measles) 5/24/02). Retrieved October 23, 2002, from http://cerhr.niehs.nih.gov/genpub/topics/rubella-ccae.html

  41. Treatments: Bubonic Plague • In medieval times: bloodletting at site of buboes, prayer • Fire-to keep away rats-used by Pope Clement • Strict isolation. • Antibiotics (resistant to bacterium). • Maintenance of sanitary conditions. • Pneumonic plague: gas masks? • CDC Travelers’ warning: • “Travelers considered to be at high risk for plague because of unavoidable exposures in active epizootic or epidemic areas should be advised to consider antibiotic chemoprophylaxis with tetracycline or doxycycline during periods of exposure…. (Centers for Disease Control and Prevention. National Center for Infectious Diseases. Travelers’ health: plague. Retrieved November 16, 2002, from http://www.cdc.gov/travel/diseases/plague.htm)

  42. VIII. Advice about Avoiding Further Outbreaks: Rubella and The Bubonic Plague

  43. Advice about avoiding further outbreaks of Rubella • WHO effort to establish national vaccination programs for rubella in all nations. (WHO, 2002) • In U.S., special outreach to women of Hispanic ethnicity in Spanish, to other women in native languages (re CRS) • Immediate quarantine of people diagnosed as having rubella (although may be too late). • Comprehensive surveillance of immunization programs • Continued public awareness campaigns to promote MMR immunizations, safety of MMR vaccines. • CDC Traveler’s Warning: “Rubella occurs worldwide, and the risk of exposure to rubella outside the United States can be high. Few countries routinely use rubella vaccine, so rubella remains a common disease in many countries in the world.” (Centers for Disease Control and Prevention. Travelers' health information on rubella. Retrieved November 9, 2002, from http://www.cdc.gov/travel/diseases/rubella.htm) • Public awareness about “differabilities” and accessibility issues. Equity of access for people with differabilities.

  44. Advice about avoiding further outbreaks of Bubonic Plague • Good sanitation and hygiene • Avoid rodents, reservoirs of flea vectors • Be alert to deaths of populations of rats population, other animals. • Apply insect repellent, wear protective clothing in affected areas. • Public awareness about types of plague • To investigate and stop spread, must seek out anyone who was in contact even casually with victim. • Treatment: antibiotics. Possible source: if victim hunter, has pets (if let fleas-infested dog sleep on bed)-if show symptoms within ½ wks. • Animal carriers of fleas – some can remain healthy. If set traps, animals probably died. Then need to find fleas (i.e. in burrows) and do flea eradication program. • In 1992 alone, at least 10 cases of plague reported. Plague-infested rodents, such as chipmunks and mice, probably more numerous in North America today than were in Europe at time of Black Death. (Yancey, D. (1994). The hunt for hidden killers: ten cases of medical mystery. Brookfield, CT: Millbrook Press, 61-71.)

  45. IX. Differences and SimilaritiesRubellaandThe Bubonic Plague

  46. Differences: Rubella (R) and Bubonic Plague (BP) • R Agent: togavirus / BP agent = bacteria • R person to person / BP zoonotic carriers • R vaccination / BP antibiotic treatment • R mild symptoms / BP severe symptoms • R: also intrauterine – in which severe consequences / BP infection: touch/inhalation • R virus isolated: 1962 BP bacterium 1864 • R incubation:12-23 days / BP: 2-6 days • R symptoms sometimes inapparent or mistaken for other diseases / BP symptoms apparent

  47. Similarities: Rubella (R) and Bubonic Plague (BP) • R + BP • Symptoms: swelling of lymph nodes • Exanthem: diseases causing skin eruptions • Transmittable via inhalation. Highly contagious. • Epidemics have caused mass panic • R infection inhalation, also intrauterine / Plague (pneumonic) infection via inhalation • Originally confusion as to agents of disease: attributions to scarlet fever, measles …

  48. X. Effects on SocietyRubella and The Bubonic Plague

  49. Effects on Society: Rubella • First identified teratogen • Focused world on intrauterine disease transmission from mother to fetus • Focused world on importance of good health for women, particularly women who are, intend to become pregnant • Disease with mild symptoms, can have devastating effects (highly contagious; CRS) • Public awareness concerning need for vaccinations, national immunization programs • MMR vaccine controversy: health scares / Internet age • Public awareness and programs, re differabilities, equity of access/civil rights, special ed. needs, Deaf culture. • 1988 – Deaf President Now movement at Gallaudet University 20-25 years after epidemic; great impetus for passage of The ADA civil rights law in 1990

  50. Effects on Society:Bubonic Plague • Bubonic plague: changed the course of history. • Wars won and lost; influenced power of Church • Resulted mass death, destruction, persecution • Mass fear, panic. Pandemic. Terrorism. Special threat from pneumonic plague. Plague as a Biological WeaponFrom: Working Group on Civilian Biodefense. (2000). Consensus statement: plague as a biological weapon: medical and public health management. JAMA, Journal of the American Medical Association, 283(17), 2281-2290. Retrieved October 29, 2002, from Academic Search Premier/Ebscohost database. “Conclusions: “An aerosolized plague weapon could cause fever, cough, chest pain, and hemoptysis with signs consistent with severe pneumonia 1 to 6 days after exposure. Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment. Early treatment and prophylaxis with streptomycin or gentamicin or the tetracyclin or fluoroquinolone classes of antimicrobials would be advised.” … Peace.

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