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The Bubonic Plague and Rubella A Comparison Ellen Perlow HS 5353 Epidemiology Dr. Wiginton Fall 2002 – Texas Woman’s University Dept. of Health Studies.

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Presentation on theme: "The Bubonic Plague and Rubella A Comparison Ellen Perlow HS 5353 Epidemiology Dr. Wiginton Fall 2002 – Texas Woman’s University Dept. of Health Studies."— Presentation transcript:

1 The Bubonic Plague and Rubella A Comparison Ellen Perlow HS 5353 Epidemiology Dr. Wiginton Fall 2002 – Texas Woman’s University Dept. of Health Studies November 19, 2002 – Narrative at This presentation is available in alternative formats upon request.

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

3 Agent: Bacterium:Yersinia pestis Vector: Blood-sucking rat flea: Xenopsylla cheopis Hosts: Rodents-rats/shrews, prairie dogs, etc. Environment: Rodent-friendly: food, garbage, unsanitary conditions Transmission: 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. Bubonic Plague: Enzootic

4 Types of Plague Bubonic plague: most common form of U.S. cases: 80%-90%. Case Fatality Rate if not treated: 50%-60% 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 : 10% septicemic. Case fatality rate-50%. Complications: septic shock, consumptive coagulopathy, meningitis, coma. Septicemic plague: when Yersinia pestis invades and continues to multiply in the bloodstream; primary or secondary to bubonic plague. U.S : 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. ( 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):

5 History of Bubonic Plague - 1 Biblical times: circa 1000 B.C.E. 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.” 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.)

6 History of Bubonic Plague - 2 Summer 430 B.C.E.: Athens Summer 430 B.C.E.: Athens Athens at war with Sparta Athens at war with Sparta Sailors brought mysterious illness from Egypt. 1/3 population of Athens died. Pericles killed. Sailors brought mysterious illness from Egypt. 1/3 population of Athens died. Pericles killed. Changed history: Athens lost to Sparta. Changed history: Athens lost to Sparta. Could have been typhus, smallpox, scarlet fever. Could have been typhus, smallpox, scarlet fever. (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, 1-3.)

7 History of Bubonic Plague : Black Sea/S. Ukraine : Black Sea/S. Ukraine Epidemic: “Victims suffered from headaches, felt weak and tired, and staggered when they try to walk. By the third day, the lymph nodes in the sufferers’ groins, or occasionally their armpits, began to swell.” Swellings=buboes. In Greek. groin=boubon=disease name: Bubonic plague. Epidemic: “Victims suffered from headaches, felt weak and tired, and staggered when they try to walk. By the third day, the lymph nodes in the sufferers’ groins, or occasionally their armpits, began to swell.” Swellings=buboes. In Greek. groin=boubon=disease name: Bubonic plague. Also named “Black Death” “The Great Pestilence.” Also named “Black Death” “The Great Pestilence.” Italian traders blamed. Infected, return to Sicily. Plague spread to Sicily, then mainland Italy. Italian traders blamed. Infected, return to Sicily. Plague spread to Sicily, then mainland Italy. (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, Working Group on Civiliian Biodefense (2000). Plague as a biological weapon. JAMA, 283(17), 2281.)

8 History of Bubonic Plague - 4 October 1347: Sicily -- Italy October 1347: Sicily -- Italy Italian sailors ordered to stay on board. Did not know that carriers were black rats and fleas that lived in their hair. Plague spread to port of Messina, ports of mainland Italy, Milan, Florence, Venice... Italian sailors ordered to stay on board. Did not know that carriers were black rats and fleas that lived in their hair. Plague spread to port of Messina, ports of mainland Italy, Milan, Florence, Venice... Splendid breeding ground: garbage, garbage … Splendid breeding ground: garbage, garbage … Venice decree of quaranta giorni =quarantine of sailors on ships for 40 days Venice decree of quaranta giorni =quarantine of sailors on ships for 40 days Literary references: Bocaccio’s Decameron. Literary references: Bocaccio’s Decameron. By winter , 1/3-1/2 population of Italy killed. By winter , 1/3-1/2 population of Italy killed. (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, )

9 History of Bubonic Plague - 5 Sp. 1348: Marseilles-Avignon, France Sp. 1348: Marseilles-Avignon, France Avignon: Pope’s home. Pilgrims unknowingly brought plague. Avignon: Pope’s home. Pilgrims unknowingly brought plague. Feb.-May: 400 people/day, 1349: 50,000-Paris Feb.-May: 400 people/day, 1349: 50,000-Paris Pope Clement: fire/humors (Hippocrates, Galen) Pope Clement: fire/humors (Hippocrates, Galen) Church: no dissection, autopsies. Humors/miasmas theories of Hippocrates, Galen. Church: no dissection, autopsies. Humors/miasmas theories of Hippocrates, Galen. Attributed plague to imbalance of humors; miasmas. Attributed plague to imbalance of humors; miasmas. Treatments: bloodletting at site of buboes, prayer. Treatments: bloodletting at site of buboes, prayer. (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, )

10 History of Bubonic Plague - 6 Summer : British Isles and Germany … early 1400s. Summer : British Isles and Germany … early 1400s. Plague killed up to 80% of some villages Plague killed up to 80% of some villages Devastation led to vehement persecution and discrimination against people who were different Devastation led to vehement persecution and discrimination against people who were different German Flagellant movement, 1 st Holocaust, intense Anti-Semitism. Power of Church reduced (precursor to rise of Protestantism). German Flagellant movement, 1 st Holocaust, intense Anti-Semitism. Power of Church reduced (precursor to rise of Protestantism). Epidemics in Europe about every 10 years to early 1400s. Europe lost ½ of population. Epidemics in Europe about every 10 years to early 1400s. Europe lost ½ of population. (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, )

11 History of Bubonic Plague th -16th-17th Centuries 15 th -16th-17th Centuries Reform of Catholic Church ---Protestantism Reform of Catholic Church ---Protestantism Medicine: Practical courses in anatomy, surgery Medicine: Practical courses in anatomy, surgery Medical textbooks in European languages Medical textbooks in European languages Consumer health … Scientific method … Gutenberg (1456), Discovery of “America” (1492) 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 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, )

12 History of Bubonic Plague th-19th Centuries 18th-19th Centuries By 1750, bubonic plague faded out in western Europe, though still active in Mediterranean. By 1750, bubonic plague faded out in western Europe, though still active in Mediterranean. 1855: pandemic in interior of China, to Canton and Hong Kong. Killed >12 million people in India and China. 1855: pandemic in interior of China, to Canton and Hong Kong. Killed >12 million people in India and China. Medicine: Work of Pasteur, Koch with bacteria. Medicine: Work of Pasteur, Koch with bacteria. 1894: Kitasato and Dr. Alexandre E.J. Yersin isolated and described the cause of plague. Dr. Yersin received the credit: bacteria later named Yersinia pestis 1894: Kitasato and Dr. Alexandre E.J. Yersin isolated and described the cause of plague. Dr. Yersin received the credit: bacteria later named Yersinia pestis (Giblin, J.C. (1995). When plague strikes: the Black Death, smallpox, AIDS. HarperCollins, Yancey, D. (1994). The hunt for hidden killers: ten cases of medical mystery. Brookfield, CT: Millbrook Press, )

13 History of Bubonic Plague th Century 20 th Century : San Francisco outbreak: 121 cases,118 died : San Francisco outbreak: 121 cases,118 died Person/person transmission: Asian immigrants isolated. Person/person transmission: Asian immigrants isolated. Quarantine did not work; scientists’ explanation accepted Quarantine did not work; scientists’ explanation accepted Ships disinfected. Massive clean-up. Rats destroyed. Ships disinfected. Massive clean-up. Rats destroyed : Los Angeles outbreak: 40 cases, 38 died : Los Angeles outbreak: 40 cases, 38 died. 1940s: Development of antibiotics. Plague treatable. 1940s: Development of antibiotics. Plague treatable. By 1949: New Mexico U.S. leader in # of plague cases By 1949: New Mexico U.S. leader in # of plague cases Threat if no antibiotics; 9/94-India: pneumonic plague Threat if no antibiotics; 9/94-India: pneumonic plague , 1991, : Madagascar epidemics , 1991, : Madagascar epidemics Dec CDC MMWR Prevention of Plague Report Dec CDC MMWR Prevention of Plague Report (Giblin, J.C. (1995), 50-51; Boisier (2002)… Emerging Infectious Diseases; McClain, C. Of Medicine, Race and American Law-1900) (Giblin, J.C. (1995), 50-51; Boisier (2002)… Emerging Infectious Diseases; McClain, C. Of Medicine, Race and American Law-1900)

14 History of Bubonic Plague st Century … Today as we speak 21 st Century … Today as we speak November 7, 2002: CNN.com: “Bubonic plague suspected in New York City [NYC] Visitors” 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. Nov. 9, 2002: New Mexico visitors to NYC diagnosed with bubonic plague still in hospital. NYC’s first case of bubonic plague in a century. (CDC, 2002) NYC’s first case of bubonic plague in a century. (CDC, 2002) Couple suspected of contracting plague from rodents on their property (Robin, 2002) Couple suspected of contracting plague from rodents on their property (Robin, 2002) Plague as biological weapon (U.S. Working Group on Civilian Biodefense, JAMA (5/3/2000): Recommendations Plague as biological weapon (U.S. Working Group on Civilian Biodefense, JAMA (5/3/2000): Recommendations

15 History of Bubonic Plague st Century … Today as we speak, continued: 21 st Century … Today as we speak, continued: “According to the World Health Organization (WHO), as of May 27, 2002, the Malawian Ministry of Health has reported a total of 71 cases of bubonic plague in the district of Nsanje since the onset of the outbreak on April 16, The outbreak has affected 26 villages - 23 in the Ndamera area, 2 in Chimombo, and 1 village in neighboring Mozambique.” “According to the World Health Organization (WHO), as of May 27, 2002, the Malawian Ministry of Health has reported a total of 71 cases of bubonic plague in the district of Nsanje since the onset of the outbreak on April 16, The outbreak has affected 26 villages - 23 in the Ndamera area, 2 in Chimombo, and 1 village in neighboring Mozambique.” Centers for Disease Control and Prevention. National Center for Infectious Diseases. Travelers’ health: outbreak of bubonic plague in Malawi, as of May 27, Retrieved November 9, 2002, from

16 History of Bubonic Plague st Century, Controversy, Outbreaks, heightened interest, terrorism st Century, Controversy, Outbreaks, heightened interest, terrorism... How to prepare for terrorism via plague (especially pneumonic). (Don't miss smallpox/plague outbreaks: adapt strategies to track bioterrorism. ED management : the monthly update on emergency department management Jan; 14(1): 1-3.) How to prepare for terrorism via plague (especially pneumonic). (Don't miss smallpox/plague outbreaks: adapt strategies to track bioterrorism. ED management : the monthly update on emergency department management Jan; 14(1): 1-3.) History of Bubonic Plague: Was it really the plague, or scarlet fever, or ebola virus?... Delta 32 gene mutation History of Bubonic Plague: Was it really the plague, or scarlet fever, or ebola virus?... Delta 32 gene mutation Current Outbreaks: NYC …CDC Travelers’ Health Information on Plague (retrieved 11/9/2002): enzootic in wild rodent populations over large rural areas of the Americas, Africa, and Asia. Prophylactic measures: antibiotics, insect repellants … PBS... Current Outbreaks: NYC …CDC Travelers’ Health Information on Plague (retrieved 11/9/2002): enzootic in wild rodent populations over large rural areas of the Americas, Africa, and Asia. Prophylactic measures: antibiotics, insect repellants … PBS...

17 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 Rubella / German Measles / Gregg’s Syndrome: Virus

18 History of Rubella : Officially recognized as a distinct clinical entity at international medical congress in London. Before that time, confusion as to whether it was a mild form of measles (rubeola) or scarlet fever, or both, and what it should be called. 1881: Officially recognized as a distinct clinical entity at international medical congress in London. Before that time, confusion as to whether it was a mild form of measles (rubeola) or scarlet fever, or both, and what it should be called. The name “rubella”, first proposed in 1866, accepted. The name “rubella”, first proposed in 1866, accepted. In the next 60 years, little attention was paid to rubella since the disease was not considered serious and did not have serious complications. In the next 60 years, little attention was paid to rubella since the disease was not considered serious and did not have serious complications. (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, South African Medical Journal, Supplement, )

19 History of Rubella : Epidemic of rubella, largely went unnoticed. 1935: Epidemic of rubella, largely went unnoticed. 1940: Large rubella epidemic in Australia. 1940: Large rubella epidemic in Australia. 1941: Australian ophthalmologist Dr. Norman Gregg discovered relationship between maternal rubella during pregnancy and congenital “defects” in infants. 1941: Australian ophthalmologist Dr. Norman Gregg discovered relationship between maternal rubella during pregnancy and congenital “defects” in infants. 1941: Dr. Gregg had observed in his practice in Sydney a rise in the number of infants born with cataracts. Found that the mothers of most of the infants had contracted rubella when they were in their first few months of pregnancy during the 1940 epidemic. 1941: Dr. Gregg had observed in his practice in Sydney a rise in the number of infants born with cataracts. Found that the mothers of most of the infants had contracted rubella when they were in their first few months of pregnancy during the 1940 epidemic. Dr. Gregg’s colleagues also noticed numerous infants being born with cataracts, as well as infants born who were small in size, had failure to thrive, cardiac abnormalities, and microphthalmia – an unnatural smallness of the eyes. Dr. Gregg’s colleagues also noticed numerous infants being born with cataracts, as well as infants born who were small in size, had failure to thrive, cardiac abnormalities, and microphthalmia – an unnatural smallness of the eyes. 1941: Dr. Gregg documented 78 cases of congenital rubella syndrome [CRS] and published a paper in the Transactions of the Ophthalmological Society of Australia 1941: Dr. Gregg documented 78 cases of congenital rubella syndrome [CRS] and published a paper in the Transactions of the Ophthalmological Society of Australia (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, South African Medical Journal, Supplement, 60-63; Cooper, L.Z. (1966). German measles. Scientific American 215(7): )

20 History of Rubella : Discovery of association between maternal rubella and newborn’s differences - profound impact on the entire field of congenital disease. Rubella was the very first well defined teratogen: an agent that causes developmental differences. Dr. Gregg’s findings were confirmed in other studies in Europe, the U.S., New Zealand, and Australia. The studies showed that many children born with differences were correlated with their mothers having a history of rubella. (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, South African Medical Journal, Supplement, Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from Cooper, L.Z. (1966). German measles. Scientific American 215(7): )

21 History of Rubella : For twenty years, scientists tried to isolate the rubella virus, using experimental animals, but without success. 1962: Drs. Parkman, Meyer, Hilleman at 3 laboratories – Walter Reed, Harvard, and NIH - isolated rubella virus. New standard of cooperation in medical research. Early 1960s: 40,000 and 45,000 cases of rubella per year. (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, South African Medical Journal, Supplement, Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from Cooper, L.Z. (1966). German measles. Scientific American 215(7): )

22 History of Rubella - 5 Spring 1964: Large epidemic of rubella in the United States. 7,000 fetal deaths, 20,000 babies born with congenital differences. Investigators discovered very different virologies of rubella intra-uterine infection and the post-natal infection. July 1966:Pediatrician Louis Z. Cooper publishes “German Measles,” Scientific American. By 1969, three rubella vaccines ready for licensing.: HPV77 DE5 (via monkey kidney cells and duck embryo tissue cultures), the Cendehill strain (via rabbit kidney cells), and the RA27/3 strain (isolated in human diploid cells). Rubella vaccines induce seroconversions in approximately 95% of susceptible individuals. The vaccine-induced infection is non- communicable. Viremia – the existence of viral particles in the bloodstream – occurs at such a low level that it is not easily detected. (Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, South African Medical Journal, Supplement, Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from Cooper, L.Z. (1966). German measles. Scientific American 215(7): )

23 History of Rubella Beginning of rubella vaccination programs in US, UK, Australia,New Zealand. US/other nations different approaches: target populations for immunization. U.S.: focus on children who had not yet reached puberty, both boys and girls, 1 year and older. Goal to protect the age group in which most infections occurred. This way, it was reasoned, women who are pregnant would avoid being exposed to the infection. For the U.S. approach, a very high herd immunity in the population most greatly affected – young children, was necessary. Identification and immunization of women of child-bearing age also was recommended. U.S.: focus on children who had not yet reached puberty, both boys and girls, 1 year and older. Goal to protect the age group in which most infections occurred. This way, it was reasoned, women who are pregnant would avoid being exposed to the infection. For the U.S. approach, a very high herd immunity in the population most greatly affected – young children, was necessary. Identification and immunization of women of child-bearing age also was recommended. In the United Kingdom, Europe, and Australia, the immunization program begun in 1970 was limited to girls, usually between years of age and to susceptible women. Thought that incidence of the congenital disease would not be reduced until the mid- 1980s. ( Horstmann, Dorothy M. (1986, Oct. 11). The rubella story, South African Medical Journal, Supplement, Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from Cooper, L.Z. (1966). German measles. Scientific American 215(7): )

24 History of Rubella – Eradication of rubella: goal of Healthy People : Reduction in rubella cases 98% since pre- vaccination era. However, 2-3 fold increase in incidence of rubella since 1982 (JAMA, 1991) 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…” : Controversy: MMR vaccine causes autism? November 7, 2002: Publication of Danish study showing no link between administration of MMR vaccine and autism. November 19, 2002: Threats due to lack of vaccination in other countries, threats due to terrorism? … Centers for Disease Control and Prevention. National Center for Health Statistics (1999). Healthy people 2000 progress review objective charts. Increase in rubella and congenital rubella. (1991, March 6). JAMA, The Journal of the American Medical Association, 265(9), (Rubella almost eradicated in the United States. (2002, 5 February). Virus Weekly. Retrieved September 16, 2002 from, General Reference Center Gold. Madsen K. M., Hviid A., Vestergaard M., Schendel D., Wohlfahrt J., Thorsen P., Olsen J., Melbye M. (2000, November 7). A population-based study of measles, mumps, and rubella vaccination and autism. New England Journal of Medicine, 347,

25 II. Symptoms of The Bubonic Plague and Rubella II. Symptoms of The Bubonic Plague and Rubella

26 Symptoms of the Disease: Bubonic Plague – Symptoms Bubonic plague: enlarged, tender lymph nodes (buboes), fever, chills, prostration, gastrointestinal symptoms Bubonic plague: enlarged, tender lymph nodes (buboes), fever, chills, prostration, gastrointestinal symptoms Septicemic plague: fever, chills, prostration, abdominal pain, shock and bleeding into skin and other organs Septicemic plague: fever, chills, prostration, abdominal pain, shock and bleeding into skin and other organs Pneumonic plague: fever, chills, cough and difficulty breathing; rapid shock and death if not treated early 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

27 Symptoms of the Disease: Rubella Symptoms - 1 “Rubella is a mild, highly contagious illness that is caused by a virus. It is characterized by a rash, swollen glands and, especially in adults, joint pain. The rash usually lasts about three days and may be accompanied by a low fever. Other symptoms such as headache, loss of appetite and sore throat are more common in infected adults and teenagers than in children. Sometimes there are no symptoms at all. “Rubella is a mild, highly contagious illness that is caused by a virus. It is characterized by a rash, swollen glands and, especially in adults, joint pain. The rash usually lasts about three days and may be accompanied by a low fever. Other symptoms such as headache, loss of appetite and sore throat are more common in infected adults and teenagers than in children. Sometimes there are no symptoms at all. Rubella is caused by a different virus from the one that causes regular measles (rubeola). Immunity to rubella does not protect a person from measles, or vice versa.” Rubella is caused by a different virus from the one that causes regular measles (rubeola). Immunity to rubella does not protect a person from measles, or vice versa.” 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

28 Symptoms of the Disease: Rubella – Symptoms - 2 “Rubella is a mild illness which may present few or no symptoms. Symptoms may include a rash, slight fever, joint aches, headache, discomfort, runny nose and reddened eyes. The lymph nodes just behind the ears and at the back of the neck may swell, causing some soreness and/or pain. The rash, which may be itchy, first appears on the face and progresses from head to foot, lasting about three days. As many as half of all rubella cases occur without a rash. The incubation period for rubella is days; in most cases, symptoms appear within days.” “Rubella is a mild illness which may present few or no symptoms. Symptoms may include a rash, slight fever, joint aches, headache, discomfort, runny nose and reddened eyes. The lymph nodes just behind the ears and at the back of the neck may swell, causing some soreness and/or pain. The rash, which may be itchy, first appears on the face and progresses from head to foot, lasting about three days. As many as half of all rubella cases occur without a rash. The incubation period for rubella is days; in most cases, symptoms appear within days.” (New York State Department of Health. Communicable disease fact sheet: rubella. Retrieved October 23, 2002, from

29 Symptoms of the Disease: Rubella – Symptoms - 3 Rubella, lasts less than two weeks in children. Rubella, lasts less than two weeks in children. Symptoms: swollen glands, a low fever, transient three-day rash. Symptoms: swollen glands, a low fever, transient three-day rash. In women who are pregnant, the infection can pass to the developing fetus, especially during the first trimester of pregnancy, causing severe injuries to the fetus/newborn. In women who are pregnant, 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 women who are pregnant who acquire German measles during the 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, enlarged spleen, and hand abnormalities. Approximately 15-20% of women who are pregnant who acquire German measles during the 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, enlarged spleen, and hand abnormalities. About 10% of infants born with congenital rubella syndrome [CRS] die, while severe infections result in spontaneous abortion. About 10% of infants born with congenital rubella syndrome [CRS] die, while severe infections result in spontaneous abortion. Greatest period of virulence: first two months of pregnancy. Studies show that 50% of women infected during the first month of pregnancy gave births to babies with a host of differences. If women infected in 3rd month, 10% of infants have these differences. Infection after 4th month cause less severe differences in the fetus. (Parkman, Meyer, & Hilleman, 1997, 2000). Greatest period of virulence: first two months of pregnancy. Studies show that 50% of women infected during the first month of pregnancy gave births to babies with a host of differences. If women infected in 3rd month, 10% of infants have these differences. Infection after 4th month cause less severe differences in the fetus. (Parkman, Meyer, & Hilleman, 1997, 2000).

30 III. Causative Agents and how they were determined: The Bubonic Plague and Rubella III. Causative Agents and how they were determined: The Bubonic Plague and Rubella

31 Causative Agent – Bubonic Plague (Bacterium Yersinia pestis) - 1 Source: CDC Public Health Image Library, Image # 2117 URL: 7 (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. “

32 Causative Agent – Bubonic Plague (Bacterium Yersinia pestis) - 2 Plague is an infectious disease of animals and humans caused by the bacteriumYersinia pestis. The fundamental but separate works by Yersin and Kitasato in 1894 on the discovery of the etiologic agent of plague in Hong Kong opened the way for investigating the disease and how it is spread. Kitasato and Yersin described, within days of each other’s findings, the presence of bipolar staining organisms in the swollen lymph node (bubo), blood, lungs, liver and spleen of dead patients. (Bibel et al., 1976). Plague is an infectious disease of animals and humans caused by the bacteriumYersinia pestis. The fundamental but separate works by Yersin and Kitasato in 1894 on the discovery of the etiologic agent of plague in Hong Kong opened the way for investigating the disease and how it is spread. Kitasato and Yersin described, within days of each other’s findings, the presence of bipolar staining organisms in the swollen lymph node (bubo), blood, lungs, liver and spleen of dead patients. (Bibel et al., 1976).

33 Causative Agent – Bubonic Plague (Bacterium Yersinia Pestis) - 2 Cultures isolated from patient specimens were inoculated into a variety of laboratory animals, including mice. These animals died within days after injection, and the same bacilli as those found in patient specimens were present in the animal organs. Though both investigators reported their findings, Yersin was accepted as the primary discoverer of the organism now named after him, Yersinia pestis Cultures isolated from patient specimens were inoculated into a variety of laboratory animals, including mice. These animals died within days after injection, and the same bacilli as those found in patient specimens were present in the animal organs. Though both investigators reported their findings, Yersin was accepted as the primary discoverer of the organism now named after him, Yersinia pestisYersinia pestisYersinia pestis

34 Causative Agent – Bubonic Plague (Bacterium Yersinia pestis) - 3 Yersin had recorded that rats were affected by plague not only during plague epidemics but also often preceding such epidemics in humans. In fact, plague was designated, in local languages, as a disease of the rats: villagers in China, India and Formosa (Taiwan) described that when hundreds and thousands of rats lie dead in and out of houses, plague outbreaks in people soon followed (Gross, 1995). Yersin had recorded that rats were affected by plague not only during plague epidemics but also often preceding such epidemics in humans. In fact, plague was designated, in local languages, as a disease of the rats: villagers in China, India and Formosa (Taiwan) described that when hundreds and thousands of rats lie dead in and out of houses, plague outbreaks in people soon followed (Gross, 1995).

35 Causative Agent – Bubonic Plague (Bacterium: Yersinia pestis) - 4 Simond described transmission of plague in Persons who became ill did not have to be in close contact with each other to acquire the disease. Simond observed residents of China and Formosa being frightened of dead rats and viewing these rats as a risk for developing plague. Simond suspected that the flea might be an intermediary factor in the transmission of plague. People were infected with plague only if they were in contact with recently dead rats. They were not infected if they touched rats that were dead for more than 24 hours. Simond demonstrated that the rat flea (Xenopsylla cheopis) transmitted the disease in an experiment in which a healthy rat, separated from direct contact with a recently plague-killed rat, died of plague after the infected fleas jumped from the first rat to the second. Centers for Disease Control and Prevention. Division of Vector-Borne Infectious Diseases. The plague: natural history. Retrieved October 22, 2002 from: Simond described transmission of plague in Persons who became ill did not have to be in close contact with each other to acquire the disease. Simond observed residents of China and Formosa being frightened of dead rats and viewing these rats as a risk for developing plague. Simond suspected that the flea might be an intermediary factor in the transmission of plague. People were infected with plague only if they were in contact with recently dead rats. They were not infected if they touched rats that were dead for more than 24 hours. Simond demonstrated that the rat flea (Xenopsylla cheopis) transmitted the disease in an experiment in which a healthy rat, separated from direct contact with a recently plague-killed rat, died of plague after the infected fleas jumped from the first rat to the second. Centers for Disease Control and Prevention. Division of Vector-Borne Infectious Diseases. The plague: natural history. Retrieved October 22, 2002 from:

36 Causative Agent – Rubella (Togavirus, genus Rubivirus) Source: CDC Public Health Image Library, Image # 269 URL: CDC Description: “Transmission electron micrograph of rubella virus” (1981) [image in public domain]

37 Causative Agent – Rubella (Togavirus, genus Rubivirus) - 1 Rubella as a separate entity not identified until Thought to be scarlet fever or measles. Rubella as a separate entity not identified until Thought to be scarlet fever or measles. Identity and severity discounted until 1941 since mild symptoms. Identity and severity discounted until 1941 since mild symptoms. 1941: Dr. Norman McAlister Gregg in Australia discovered maternal-fetus intrauterine transmission. 1941: Dr. Norman McAlister Gregg in Australia discovered maternal-fetus intrauterine transmission. General agreement that rubella caused by virus based on its incubation period (12-23 days), clinical course (symptoms appear days), and lack of response to antibiotics. (Cooper, 1966, 32. NYS Dept. of Health, 2002, Rubella, 2002) General agreement that rubella caused by virus based on its incubation period (12-23 days), clinical course (symptoms appear days), and lack of response to antibiotics. (Cooper, 1966, 32. NYS Dept. of Health, 2002, Rubella, 2002) : Unsuccessful attempts using experimental animals to isolate rubella virus : Unsuccessful attempts using experimental animals to isolate rubella virus. The rubella epidemic (1960s). (1998, 2000). American Decades CD-ROM. Gale Research. Retrieved November 15, 2002, from Student Resource Center College Edition database,

38 Causative Agent – Rubella (Togavirus, genus Rubivirus) : Isolation of virus at 3 labs: Drs. Paul Parkman and Edward L. Buescher, Walter Reed Army Institute for Research; Drs. Thomas Weller and Franklin Neva at Harvard University; Drs. John L. Sever and Gilbert M. Schiff at the National Institutes of Health [NIH]. Upon moving to NIH, Dr. Parkman worked with Dr. Harry M. Meyer on finding a way to curb the growth of the virus. They were responsible for developing the first test – the hemaglutination-inhibition test - that could determine a person’s immunity to the rubella virus. This test could provide results in three hours, rather than the three weeks required via an older testing method : Isolation of virus at 3 labs: Drs. Paul Parkman and Edward L. Buescher, Walter Reed Army Institute for Research; Drs. Thomas Weller and Franklin Neva at Harvard University; Drs. John L. Sever and Gilbert M. Schiff at the National Institutes of Health [NIH]. Upon moving to NIH, Dr. Parkman worked with Dr. Harry M. Meyer on finding a way to curb the growth of the virus. They were responsible for developing the first test – the hemaglutination-inhibition test - that could determine a person’s immunity to the rubella virus. This test could provide results in three hours, rather than the three weeks required via an older testing method. Investigators discovered very different virologies of the rubella intra-uterine infection and the post-natal infection just in time for major U.S. rubella epidemic. The rubella epidemic (1960s). (1998, 2000). American Decades CD-ROM. Gale Research. Retrieved November 15, 2002, from Student Resource Center College Edition database, Cooper, 1966). Investigators discovered very different virologies of the rubella intra-uterine infection and the post-natal infection just in time for major U.S. rubella epidemic. The rubella epidemic (1960s). (1998, 2000). American Decades CD-ROM. Gale Research. Retrieved November 15, 2002, from Student Resource Center College Edition database, Cooper, 1966).

39 IV. How Diseases Spread: The Bubonic Plague and Rubella IV. How Diseases Spread: The Bubonic Plague and Rubella

40 How Disease Spread Bubonic Plague - 1 Zoonotic infectious disease spread principally by reservoir of infected rats, shrews, prairie dogs, and other mammals. Zoonotic infectious disease spread principally by reservoir of infected rats, shrews, prairie dogs, and other mammals. Vector: Rat flea Vector: Rat flea Source: CDC (in public domain) URL: 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.

41 How Disease Spread: Bubonic Plague - 2 People usually bitten by rodent flea carrying the plague bacterium, Yersinia pestis, or by handling an infected animal. People usually bitten by rodent flea carrying the plague bacterium, Yersinia pestis, or by handling an infected animal. Homes, places of work have flea-infested rats. Even with modern antibiotics, infected person is not treated promptly, the disease can cause illness or death. Homes, places of work have flea-infested rats. Even with modern antibiotics, infected person is not treated promptly, the disease can cause illness or death. Wild rodents in certain areas around world infected with plague. Outbreaks in people still occur in rural communities or in cities usually associated with infected rats, fleas that live in the home. Wild rodents in certain areas around world infected with plague. Outbreaks in people still occur in rural communities or in cities usually associated with infected rats, fleas that live in the home. (Centers for Disease Control and Prevention. CDC Plague Home Page, 2002) (Centers for Disease Control and Prevention. CDC Plague Home Page, 2002)

42 How Disease Spread: Bubonic Plague - 3 In U.S., last urban plague epidemic: : Los Angeles. Since then, in U.S., mostly scattered cases in rural areas (10-15 persons/year). In U.S., last urban plague epidemic: : Los Angeles. Since then, in U.S., mostly scattered cases in rural areas (10-15 persons/year). Globally, the World Health Organization: 1,000 to 3,000 cases of plague every year. Globally, the World Health Organization: 1,000 to 3,000 cases of plague every year. North America, plague in certain animals and their fleas: Pacific Coast to Great Plains, S.W. Canada to Mexico. North America, plague in certain animals and their fleas: Pacific Coast to Great Plains, S.W. Canada to Mexico. U.S. most human cases: 1) northern New Mexico, northern Arizona, and southern Colorado; and 2) California, southern Oregon, far western Nevada. U.S. most human cases: 1) northern New Mexico, northern Arizona, and southern Colorado; and 2) California, southern Oregon, far western Nevada. Also in Africa, Asia, and South America (see map). Also in Africa, Asia, and South America (see map). (Centers for Disease Control and Prevention. CDC Plague Home Page, 2002) (Centers for Disease Control and Prevention. CDC Plague Home Page, 2002)

43 How Disease Spread: Bubonic Plague - 4 Natural cycle in its enzootic environment, involving small mammals and fleas without human involvement. Natural cycle in its enzootic environment, involving small mammals and fleas without human involvement. Quiescent periods, during which few or no human cases are detected, may last for years, leading to mistaken declarations of plague eradication. Quiescent periods, during which few or no human cases are detected, may last for years, leading to mistaken declarations of plague eradication. However long the silent periods last, plague may suddenly reappear. The combination of false assurance of its eradication, and the failure of public health vigilance, sets the stage for the panic that may ensue when enzootic plague changes from its natural cycle into rodent and flea populations near where people live. However long the silent periods last, plague may suddenly reappear. The combination of false assurance of its eradication, and the failure of public health vigilance, sets the stage for the panic that may ensue when enzootic plague changes from its natural cycle into rodent and flea populations near where people live. Poor sanitation, overcrowding, high numbers of rodents are conditions that enhance urban plague transmission. Poor sanitation, overcrowding, high numbers of rodents are conditions that enhance urban plague transmission. Centers for Disease Control and Prevention. Division of Vector-Borne Infectious Diseases. The plague: natural history. Retrieved October 22, 2002 from: Centers for Disease Control and Prevention. Division of Vector-Borne Infectious Diseases. The plague: natural history. Retrieved October 22, 2002 from:

44 How Disease Spread: Bubonic Plague - 5 Controversy as to whether etiology was the same for all outbreaks of the plague: “Because of the limits inherent in historical sources on ancient plague epidemics, many questions concerning their etiology and epidemiology remain unanswered. Molecular biology tools and the use of dental pulp as a preserved source of bacterial DNA enabled us to demonstrate that Yersinia pestis was the etiologic agent of the 1347 European Black Death and of two additional epidemics in 1590 and 1722 in southern France.” (Drancourt, M. & Raoult, D. (2002, January). Molecular insights into the history of plague. Microbes and Infection / Institut Pasteur, 4(1): )

45 How Disease Spread: Bubonic Plague - 6 Controversy as to whether etiology was the same for all outbreaks of the plague: The primary hypotheses raised by the author, a medieval historian, are that: – –the Black Death of the 13 th and 14 th centuries was not the same disease as the rat-based bubonic plague of the 19 th century whose Yersinia pestis agent was first cultured in Hong Kong in 1894; – –Unlike populations of Western Europe who adapted to the pathogen of the Black Death at least for the first hundred years, humans do not have immunity for the modern bubonic plague. The hypotheses are based on the findings that the two diseases were different in their signs, symptoms, and epidemiologies.... (Cohn, S.K., Jr. (2002, June). The Black Death: end of a paradigm. American Historical Review, 107(3): Retrieved October 27, 2002, from Ebscohost database.)

46 How Disease Spread: Rubella - 1 Rubella caused by togavirus that is spread from person to person when an infected person coughs or sneezes. Rubella caused by togavirus that is spread from person to person when an infected person coughs or sneezes. Rubella also spread by direct contact with the nasal or throat secretions of an infected person. If a pregnant woman gets rubella during the first 3 months of pregnancy, her baby is at risk of having serious birth defects or dying. Rubella also spread by direct contact with the nasal or throat secretions of an infected person. If a pregnant woman gets rubella during the first 3 months of pregnancy, her baby is at risk of having serious birth defects or dying. Highly contagious. High herd immunity required, 85-90% Highly contagious. High herd immunity required, 85-90% National Coalition for Adult Immunization. (2002). Facts about rubella for adults. Retrieved October 23, 2002, from National Coalition for Adult Immunization. (2002). Facts about rubella for adults. Retrieved October 23, 2002, from

47 How Disease Spread: Rubella - 2 Congenital rubella being highly contagious also increases its virulence because affected newborns can infect others with the virus up to a year after birth. Congenital rubella being highly contagious also increases its virulence because affected newborns can infect others with the virus up to a year after birth. In a hospital setting, newborns with congenital rubella syndrome [CRS] can infect hospital personnel, other newborns, and other women who are pregnant and visitors to the hospital, very much compounding the spread of the virus. In a hospital setting, newborns with congenital rubella syndrome [CRS] can infect hospital personnel, other newborns, and other women who are pregnant and visitors to the hospital, very much compounding the spread of the virus. Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine developed for German measles, In DISCovering U.S. History. Gale Research. Retrieved September 16, 2002, from Student Resource Center College Edition database at

48 V. Mechanisms of Containment : The Bubonic Plague and Rubella

49 Mechanisms of Containment: Bubonic Plague - 1 OPPORTUNITIES OPPORTUNITIES Increased self-sufficiency of state and county public health labs Increased self-sufficiency of state and county public health labs Expanded active surveillance through carnivore serosurveys and application of geographic information systems (GIS) to surveillance programs Expanded active surveillance through carnivore serosurveys and application of geographic information systems (GIS) to surveillance programs Increased education of public and health professionals Increased education of public and health professionals Collaborative applied research on plague prevention and control with other federal, state, and local health agencies, including application of GIS to surveillance Collaborative applied research on plague prevention and control with other federal, state, and local health agencies, including application of GIS to surveillance Centers for Disease Control and Prevention. CDC plague fact sheet. Retrieved October 22, 2002, from

50 Mechanisms of Containment: Bubonic Plague - 2 RESEARCH RESEARCH Ecology-based prevention and control strategies Ecology-based prevention and control strategies Improved diagnostic reagents and methods Improved diagnostic reagents and methods Development of potential vaccine candidates Development of potential vaccine candidates Risk factor identification using landscape ecology and epidemiology Risk factor identification using landscape ecology and epidemiology CDC (2002). CDC plague fact sheet. Retrieved October 22, 2002, from PRACTICE PRACTICE People refrain from contact with rodents, especially if population known to be infected People refrain from contact with rodents, especially if population known to be infected People use insect repellant when outside in areas with potential for having vectors and/or hosts. People use insect repellant when outside in areas with potential for having vectors and/or hosts. People wear proper attire to protect selves. People wear proper attire to protect selves.

51 Mechanisms of Containment: Rubella - 1 Vaccination Vaccination In 1969, three rubella vaccines ready for licensing: In 1969, three rubella vaccines ready for licensing: – HPV77 DE5 (via monkey kidney cells and duck embryo tissue cultures) –Cendehill strain (via rabbit kidney cells), and –RA27/3 strain (isolated in human diploid cells.) Rubella vaccines induce seroconversions in approximately 95% of susceptible individuals. The vaccine-induced infection is non-communicable. Viraemia – the existence of viral particles in the bloodstream – occurs at such a low level that it is not easily detected. Rubella vaccines induce seroconversions in approximately 95% of susceptible individuals. The vaccine-induced infection is non-communicable. Viraemia – the existence of viral particles in the bloodstream – occurs at such a low level that it is not easily detected. (New York State Department of Health. (2002). Communicable disease fact sheet: rubella. Retrieved October 23, 2002, from (New York State Department of Health. (2002). Communicable disease fact sheet: rubella. Retrieved October 23, 2002, from

52 Mechanisms of Containment: Rubella - 2 Vaccination Vaccination Rubella vaccine is given on or after a child's first birthday, and is usually given in combination with measles and mumps (MMR) vaccine. Children usually receive the first dose between 12 and 15 months or age and the second dose prior to school entry are 4-6 years of age. Rubella vaccine is given on or after a child's first birthday, and is usually given in combination with measles and mumps (MMR) vaccine. Children usually receive the first dose between 12 and 15 months or age and the second dose prior to school entry are 4-6 years of age. (New York State Department of Health. (2002). Communicable disease fact sheet: rubella. Retrieved October 23, 2002, from

53 Mechanisms of Containment: Rubella - 2 Vaccination Vaccination U.S. followed a different rubella immunization strategy than did nations in Europe, Australia, and the United Kingdom. In the U.S., the focus of immunizations was on children who had not yet reached puberty, both boys and girls, 1 year and older. The goal was to protect the age group in which most infections occurred. This way, it was reasoned, women who are pregnant would avoid being exposed to the infection. For the U.S. approach, a very high herd immunity in the population most greatly affected – young children, was necessary. Identification and immunization of women of child-bearing age also was recommended. U.S. followed a different rubella immunization strategy than did nations in Europe, Australia, and the United Kingdom. In the U.S., the focus of immunizations was on children who had not yet reached puberty, both boys and girls, 1 year and older. The goal was to protect the age group in which most infections occurred. This way, it was reasoned, women who are pregnant would avoid being exposed to the infection. For the U.S. approach, a very high herd immunity in the population most greatly affected – young children, was necessary. Identification and immunization of women of child-bearing age also was recommended. Horstmann, Dorothy M. (1986, October 11). The rubella story, South African Medical Journal, Supplement, Horstmann, Dorothy M. (1986, October 11). The rubella story, South African Medical Journal, Supplement,

54 Mechanisms of Containment: Rubella - 3 Vaccination Vaccination In the United Kingdom, Europe, and Australia, the immunization program begun in 1970 was limited to girls, usually between years of age and to susceptible women. It was thought that the incidence of the congenital disease would not be reduced until the mid-1980s. Horstmann, Dorothy M. (1986, October 11). The rubella story, South African Medical Journal, Supplement, In the United Kingdom, Europe, and Australia, the immunization program begun in 1970 was limited to girls, usually between years of age and to susceptible women. It was thought that the incidence of the congenital disease would not be reduced until the mid-1980s. Horstmann, Dorothy M. (1986, October 11). The rubella story, South African Medical Journal, Supplement, During 2000, 87% of all reported cases of rubella occurred among people years of age. As many as 8 million women of childbearing age are susceptible to rubella. Up to 10% of young adults are susceptible to the rubella virus. National Coalition for Adult Immunization. (2002). Facts about rubella for adults. Retrieved October 23, 2002, from During 2000, 87% of all reported cases of rubella occurred among people years of age. As many as 8 million women of childbearing age are susceptible to rubella. Up to 10% of young adults are susceptible to the rubella virus. National Coalition for Adult Immunization. (2002). Facts about rubella for adults. Retrieved October 23, 2002, from

55 Mechanisms of Containment: Rubella - 4 “Maintaining high levels of rubella immunization in the community is critical to controlling the spread of the disease. Control of the spread of rubella is needed primarily to prevent the birth defects caused by CRS. Therefore, women of childbearing age should have their immunity determined and receive rubella vaccine if needed. Infected children should not attend school during their infectious period.”“Maintaining high levels of rubella immunization in the community is critical to controlling the spread of the disease. Control of the spread of rubella is needed primarily to prevent the birth defects caused by CRS. Therefore, women of childbearing age should have their immunity determined and receive rubella vaccine if needed. Infected children should not attend school during their infectious period.” (New York State Department of Health. Communicable Disease Fact Sheet. Rubella. Retrieved October 23, 2002, from

56 Mechanisms of Containment: Rubella - 5 Caution re vaccination programs Caution re vaccination programs According to the World Health Organization, two cautions: variability of the epidemiology of the rubella infection and the need to achieve and sustain very high coverage to avoid the potential increase in CRS. Immunization increases the average age at infection, and if coverage is not high enough to reduce rubella transmission close to zero, there could be a paradoxical increase in CRS incidence in the presence of an immunization program. According to the World Health Organization, two cautions: variability of the epidemiology of the rubella infection and the need to achieve and sustain very high coverage to avoid the potential increase in CRS. Immunization increases the average age at infection, and if coverage is not high enough to reduce rubella transmission close to zero, there could be a paradoxical increase in CRS incidence in the presence of an immunization program. (World Health Organization. Vaccines, Immunization and Biologicals: Rubella vaccine. Retrieved October 23, 2002, from

57 Mechanisms of Containment: Rubella - 6 MMR – Autism Link Controversy: MMR – Autism Link Controversy: February 28, 1998: British study “Early report” published in Lancet by Andrew Wakefield, Royal Free and University College Medical School: February 28, 1998: British study “Early report” published in Lancet by Andrew Wakefield, Royal Free and University College Medical School: (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), ). Retrieved November 16, 2002, from EBSCOHost Academic Search Premier database.) May be a link between the measles, mumps, and rubella [MMR] vaccination and inflammatory bowel disease/autism.May be a link between the measles, mumps, and rubella [MMR] vaccination and inflammatory bowel disease/autism. Each side had its supporters. Websites:Each side had its supporters. Websites: Researcher lost position at University because of controversy,Researcher lost position at University because of controversy, (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.)

58 Mechanisms of Containment: Rubella - 7 MMR – Autism Link Controversy MMR – Autism Link Controversy Claims on anti-vaccination websites: 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), )

59 Mechanisms of Containment: Rubella - 8 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.)

60 Mechanisms of Containment: Rubella - 9 MMR – Autism Link Controversy 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, )

61 Mechanisms of Containment: Rubella - 10 CDC – Autism Link Controversy (last word) 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 , 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 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

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

63 Fatalities: Bubonic Plague - 1 Bubonic plague: most common form of U.S. cases: 80%-90%. Case Fatality Rate if not treated: 50%-60% 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 : 10% septicemic. Case fatality rate-50%. Complications: septic shock, consumptive coagulopathy, meningitis, coma. Septicemic plague: when Yersinia pestis invades and continues to multiply in the bloodstream; primary or secondary to bubonic plague. U.S : 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 respuratory symptoms. ( 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 respuratory 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):

64 Fatalities: Bubonic Plague - 2 “ “ The Bubonic Plague was called “Black Death” because black sores appeared on the skins of victims. The first record of plague was in Athens in 430 B.C. The most famous outbreak of plague was in in 14 th century Asia and Europe, killing up to 25% of the population. Te plague continued to devastate Europe until the late 17 th century. “Plague doctors” wore protective clothing (their long beak was filled with antiseptic substances). But the plague killed all who caught it. Some people were buried alive, with their gums having turned red and their skin pale. Stories of vampires were common. The bubonic plague bacillus Yersinia pestis carried by fleas of black rats. It is thought to have originated in the Himalayas. As early humans migrated to Asia, the rats moved to these areas and then Europe to find food. The plague exists today but now victims have 50% survival rate.” (Roden, K. (1996). Plague. Brookfield, CT: Copper Beech Books, 11.)

65 Percentage of Fatalities: Rubella - 1 Rubella Epidemic of in U.S. Rubella Epidemic of in U.S. –12.5 million rubella cases –2,000 encephalitis cases –11,250 surgical or spontaneous abortions – 2,100 nronatal deaths – 20,000 cases of Congenital Rubella Syndrome-CRS –CRS: Possibly all organs affected; fetal death. Infants infected in 1 st trimester: 85% affected –CRS causes: deafness, cataracts, blidness, heart defects, microcepaly, mental retardation, bome alterations, liver and spleen damage (Centers for Disease Control and Prevention (2002). Rubella. Retrieved November 16, 2002, from

66 Percentage of Fatalities: Rubella : Current Congenital Rubella Syndrome [CRS] Incidence 2002: Current Congenital Rubella Syndrome [CRS] Incidence – per 1000 live births in developing countries during epidemics (every 4-7 years) –High susceptibility in these countries: 25% –1996 estimate for CRS in developing countries: 110,000 cases 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), Retrieved September 16, 2002, from Infotrac General Reference Center Gold database.

67 VII. Treatments: The Bubonic Plague and Rubella

68 Treatments: Bubonic Plague - 1 In medieval times: bloodletting at site of buboes, prayer Fire-to keep away rats-used by Pope Clement Strict isolation. Strict isolation. Antibiotics (resistant to bacterium). Antibiotics (resistant to bacterium). Maintenance of sanitary conditions. Maintenance of sanitary conditions. Pneumonic plague: gas masks? Pneumonic plague: gas masks?

69 Treatments: Bubonic Plague - 2 CDC Travelers’ warning 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. Trimethoprim-sulfamethoxazole is an acceptable substitute for use in infants and in children younger than 8 years of age. Personal protective measures should also be recommended, including the use of insect repellents containing N,N-diethylmetatoluamide (DEET) on skin and clothing. Clothing also can be treated with insecticidal sprays containing permethrin. Travelers should be advised to avoid sick or dead animals or rodent nests and burrows. Whenever possible, travelers should also avoid visiting areas that have experienced recent plague epidemics or epizootics. Travelers are unlikely to be at high risk for plague while staying in modern accommodations. “ “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. Trimethoprim-sulfamethoxazole is an acceptable substitute for use in infants and in children younger than 8 years of age. Personal protective measures should also be recommended, including the use of insect repellents containing N,N-diethylmetatoluamide (DEET) on skin and clothing. Clothing also can be treated with insecticidal sprays containing permethrin. Travelers should be advised to avoid sick or dead animals or rodent nests and burrows. Whenever possible, travelers should also avoid visiting areas that have experienced recent plague epidemics or epizootics. Travelers are unlikely to be at high risk for plague while staying in modern accommodations. “ ( ( Centers for Disease Control and Prevention. National Center for Infectious Diseases. Travelers’ health: plague. Retrieved November 16, 2002, from

70 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.” 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

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

72 Advice about avoiding further outbreaks of Bubonic Plague - 1 Peace ( Dr. Wiginton stays home). Peace ( Dr. Wiginton stays home). Good sanitation and hygiene. Good sanitation and hygiene. Avoid rodents, reservoirs of flea vectors. Avoid rodents, reservoirs of flea vectors. Be alert to deaths of populations of rats population and other animals. Be alert to deaths of populations of rats population and other animals. Apply insect repellent and wear protective clothing in potentially affected areas. Apply insect repellent and wear protective clothing in potentially affected areas. Public awareness about types of plague. Public awareness about types of plague.

73 Advice about avoiding further outbreaks of Bubonic Plague - 2 CDC Traveler’s Warning: CDC Traveler’s Warning: “Plague is a zoonosis involving rodents and their fleas… Plague continues to be enzootic in wild rodent populations over large areas of the Americas, Africa, and Asia, with occasional outbreaks among commensal rodents (those rodents living a symbiotic life with humans) in villages and small towns. Wild rodent plague poses a real, though limited risk to people.” (Centers for Disease Control and Prevention. Travelers' health information: plague. Retrieved November 9, 2002, from

74 Advice about avoiding further outbreaks of Bubonic Plague - 3 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 week or two. 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 ten 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, )

75 Advice about avoiding further outbreaks of Rubella - 1 Effort [WHO] to establish national vaccination/immunization programs for rubella in all countries according to their needs. Need for cost benefit analyses re rubella (WHO. Economic analyses …, 2002) Effort [WHO] to establish national vaccination/immunization programs for rubella in all countries according to their needs. Need for cost benefit analyses re rubella (WHO. Economic analyses …, 2002) In U.S., special outreach to women of Hispanic ethnicity – in Spanish, and to other women in their native languages (CRS prevention) In U.S., special outreach to women of Hispanic ethnicity – in Spanish, and to other women in their native languages (CRS prevention) Immediate quarantine of people diagnosed as having rubella (although may be too late). Immediate quarantine of people diagnosed as having rubella (although may be too late). Comprehensive surveillance of immunization programs Comprehensive surveillance of immunization programs Continued public awareness campaigns to encourage MMR immunizations and promotion of information on safety of MMR vaccines. Continued public awareness campaigns to encourage MMR immunizations and promotion of information on safety of MMR vaccines.

76 Advice about avoiding further outbreaks of Rubella - 2 CDC Traveler’s Warning: 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 Public awareness about “differabilities” and accessibility issues. Equity of access for people with differabilities. Public awareness about “differabilities” and accessibility issues. Equity of access for people with differabilities.

77 IX. Differences and Similiarities The Bubonic Plague and Rubella

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

79 Similarities: Bubonic Plague (BP) and Rubella (R) BP + R: BP + R: Symptoms: swelling of lymph nodes Symptoms: swelling of lymph nodes Exanthem: diseases causing skin eruptions Exanthem: diseases causing skin eruptions Transmittable via inhalation. Highly contagious. Transmittable via inhalation. Highly contagious. Epidemics have caused mass panic Epidemics have caused mass panic BP infection: touch/inhalation / R: also intrauterine BP infection: touch/inhalation / R: also intrauterine BP bacterium isolated 1864 \ R virus: 1962 BP bacterium isolated 1864 \ R virus: 1962 BP incubation: \ R incubation: days BP incubation: \ R incubation: days Originally confusion as to agents of disease: attributions to scarlet fever, measles … Originally confusion as to agents of disease: attributions to scarlet fever, measles …

80 X. Effects on Society The Bubonic Plague and Rubella

81 Effects on Society: Bubonic Plague - 1 Bubonic plague has been said to have changed the course of history. Bubonic plague has been said to have changed the course of history. Wars won and lost. Wars won and lost. Influenced power of Church Influenced power of Church Resulted in great persecution of people Resulted in great persecution of people Mass death and destruction Mass death and destruction Mass fear, panic. Pandemic. Mass fear, panic. Pandemic. Attribution to other “forces,” other diseases Attribution to other “forces,” other diseases Terrorism. Special threat from pneumonic plague Terrorism. Special threat from pneumonic plague

82 Effects on Society: Bubonic Plague - 2 “Plague is an infectious disease of humans and animals caused by the bacterium Yersinia pestis. During the Middle Ages millions of people in Europe died from plague, whose current mortality-if untreated-ranges from 50% to 90%.The plague has been a great protagonist in history because it has often been grimly present in the collective events of humans. Its plurisecular history, tied to the whole chain of ecological balance, has had a strong influence on the collective imagination on account of its sudden occurrence and unavoidable mortality. In the past, the passage from contagion to illness ended in death, as human remedies had no effect. The only way to conquer it was invoke the incorruptible spirit of a saint. Therefore, in the past, the major plague icons were saints to whom ordinary people attributed a fame for healing. More recently, many epidemic diseases have ceded place to biological weapons, and terrorists have become the modern icons of such a threatening reality. As a matter of fact, bioterrorism has become a great public health and infection control threat, and, among the number of potential biological agents, plague has assumed a key role.” (Lippi, D. & Conti, A.A. (2002, May). Plague, policy, saints and terrorists: a historical survey. Journal of infection, 44(4): Retrieved October 22, 2002, from FirstSearch WilsonSelect Plus Fulltext database.)

83 Effects on Society: Bubonic Plague - 3 Plague as a Biological Weapon Plague as a Biological Weapon From: 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), Retrieved October 29, 2002, from Academic Search Premier/Ebscohost database. Group Objective: come to consensus as to measures to be taken by medical and public health professionals if plague used as a biological weapon against civilians. Evidence: MEDLINE searches: 1/1966-1/2000 for MESH subject headings: Yersinia pestis, biological weapon, biological terrorism. Biological warfare, biowarfare

84 Effects on Society: Bubonic Plague - 4 Plague as a Biological Weapon Plague as a Biological Weapon From: 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), 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.

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

86 XI. Recent Outbreaks The Bubonic Plague and Rubella

87 Recent outbreaks – Bubonic Plague April 16, 2002-May 2002: 71 cases in Malawi, Mozambique April 16, 2002-May 2002: 71 cases in Malawi, Mozambique November 2002: two cases, New York City, Couple infected in New Mexico, probably near home. First cases in NYC in over 100 years. November 2002: two cases, New York City, Couple infected in New Mexico, probably near home. First cases in NYC in over 100 years.

88 Recent outbreaks - Rubella : Nebraska: 82 cases: from workers of Hispanic origin in meat-packing plant (JAMA, Dec. 6, 2000) 1999: Nebraska: 82 cases: from workers of Hispanic origin in meat-packing plant (JAMA, Dec. 6, 2000) July-Sept. 14, 2002: 3 cases in United Kingdom: 9/02 case: Sri Lankan woman pregnant for first time and her infant, born at 34 weeks with intrauterine growth restriction, thrombocytopenia (high level of platelets), both tested positive for rubella virus. July-Sept. 14, 2002: 3 cases in United Kingdom: 9/02 case: Sri Lankan woman pregnant for first time and her infant, born at 34 weeks with intrauterine growth restriction, thrombocytopenia (high level of platelets), both tested positive for rubella virus. At least 5 cases of congenital rubella infection in areas of London with large numbers of immigrant women from countries where rubella is endemic and childhood vaccination is not routine. At least 5 cases of congenital rubella infection in areas of London with large numbers of immigrant women from countries where rubella is endemic and childhood vaccination is not routine. Belief that rubella may be underdiagnosed. Belief that rubella may be underdiagnosed. (Thomas, R.M. (2002, September 14). Cases of congenital rubella may be the tip of the iceberg [Letter]. British Medical Journal, 325(7364), )

89 Recent outbreaks - Rubella - 2   According to Dr. Susan Reef, M.D., Chief, CDC National Immunization Program (2002, January):   : 20 of 24 babies born with the birth defects associated with rubella were born to Hispanic mothers.  ( )  Of the 47 countries in the Americas, only 44 have rubella immunization programs, and most of those programs have only been operating for a few years. Countries like India, China and Russia do not routinely vaccinate against rubella. Neither do most African countries.(Edwards, Bob. (2002, January 23, AM EST). Profile: efforts to eradicate rubella in the United States [transcript of interview with Dr. Susan Reef, M.D.,Chief, CDC National Immunization Program], National Public Radio Morning Edition.)

90 Recent outbreaks - Rubella - 3   Zimmerman, L. & Reef, S.E. (2001, March). Incidence of congenital rubella syndrome at a hospital serving a predominantly Hispanic population, El Paso, Texas. Pediatrics, 107(3): E40.   “The rate of infants meeting the definition of confirmed and probable CRS [congenital rubella syndrome] was 3.1 per 10,000 hospital births.   Reported CRS rate in U.S per 10,000 live births.   Conclusion: Need for greater awareness and reporting of cases among populations at risk by physicians.

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92 Thank You. Thank you, Dr. Wiginton. End of Presentation This presentation is available in alternative formats upon request. Peace. Thank You. Thank you, Dr. Wiginton. End of Presentation This presentation is available in alternative formats upon request. Peace.


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