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Bättre Livsvillkor Har Betytt Mer Än Vacciner Och Antibiotika

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Bättre Livsvillkor Har Betytt Mer Än Vacciner Och Antibiotika Stora förändringar i infektionspanoramat under 1900-talet Bättre livsvillkor har betytt mer än vacciner och antibiotika När seklet var ungt var infektioner den vanligaste dödsorsaken. Idag logisk diagnostik började dock sakta växa fram, och begränsning av smitt- svarar infektioner för en halv procent av dödsorsakerna. Människors spridning genom isolering av de sjuka bättre levnadsförhållanden – minskad trångboddhet, bättre kost blev en viktig princip. och bättre hygienisk standard – har förändrat sjukdomspanoramat, Tuberkulos – folksjukdomen sannolikt mycket mer än vacciner och antibiotika. Hoten idag är Tuberkulos var vid denna tid fortfarande spridningen av resistenta bakterier och risken för att nya sjukdomar den stora folksjukdomen, och tillsam- mans med övriga infektionssjukdomar av typen SARS dyker upp i globaliseringens spår. den främsta dödsorsaken. Det första svenska sanatoriet invigdes strax före sekelskiftet. Därefter dök sanatorierna ❙❙ Läkartidningen började redan 1904 mitten av 1960-talet tog Statens bakteri- upp som svampar ur jorden och förlades publicera »Öfversikt af sammandragen ologiska laboratorium över epidemirap- som regel till en naturskön trakt med för- af epidemirapporter« två gånger i måna- porterna, och på senare år står Smitt- modat hälsosamt klimat, gärna högt men den. I faksimil visas här den första rap- skyddsinstitutet för rapporteringen. ändå nära skog och sjö. Den rena luften, porten. Som synes är landet indelat i Det sjukvården kunde erbjuda vid in- den rofyllda vilan och den närande ma- »städer« och »landsbygd« med 3–4 fektionssjukdomar under tidigt 1900-tal ten ansågs vara värdefulla faktorer för gånger fler sjukdomsfall på landsbyg- var i princip symtomatisk behandling ett tillfrisknande. För de drabbade blev den. Man får förmoda att detta bl a av- och någon gång serumterapi. Bakterio- det inte sällan månader och år i sanato- speglar stadsbefolkningarnas mindre riemiljön med sina numerär i början av 1900-talet. inglasade balkonger. Redan på 1880-talet Epidemierna i seklets början hade Robert Koch vi- Under två veckor i januari 1904 anmäl- sat att tbc orsakas av des hela 750 fall av difteri och 45 fall en stavformad bakte- av nervfeber (tyfoidfeber) enligt över- rie. Tio år senare sikten. De sjukdomar som dominerade trodde Koch att han epidemirapporterna från seklets början fått fram ett boteme- till och med andra världskriget var del genom tuberku- scharlakansfeber och difteri. Antalet lin, som han fram- fall av dessa varierade något från år till ställt från avdödade år (Tabell I) och ökade kraftigt under tuberkelbakterier. krigstider (Tabell II). Även nervfeber, Tyvärr visade sig rödsot (dysenteri) och barnförlamning detta overksamt som (polio) hörde till de sjukdomar som re- behandling, men tu- dovisades i epidemirapporterna. Från berkulin fick i stället stor nytta som dia- gnostikum. De äldre av oss minns det ofta Författare återkommande tu- berkulinprovet, som efter några dagar för- väntades resultera i Sten Iwarson en ömmande rodnad som tecken på att Sten Iwarson, professor i infektions- sjukdomar vid Göteborgs universitet, man hade ett gott har under 35 år medverkat i Läkartid- skydd mot tbc. Om ningen som skribent, gästredaktör och Redan 1904 började Läkartidningen publicera översikter av den önskvärda reak- referent. epidemirapporter; här den första i faksimil. tionen uteblev gjor- ❙ ❙ ❙ 82 Läkartidningen Nr 1–2 2004 Volym 101 ANDELS SAMLING S ARL /K ILDBYRÅ : IBL B OTO F Det framväxande folkhemmet och det ökade välståndet medförde så små- ningom bättre levnadsförhållanden och rymligare bostäder. Dricksvatten- försörjningen och avloppen förbättrades. Kvarvarande kåk- och slumområden i städerna revs eller omvandlades till kulturreservat. Bilden visar exteriör vid Badstugatan på Södermalm i Stockholm, hösten 1938. lig som syfilissjukdomen kom under Tabell I. Antal rapporterade fall av olika sjukdomar från epidemirapporter i Läkartidningen (LT) för pe- rioden 1–15 januari 1904–1964 visar infektionspanoramats förändringar under 60-årsperioden. Efter medicinsk och epidemiologisk kontroll. 1964 publicerades epidemirapporterna inte längre i LT. Seklets svåra influensaepidemier 1904 1914 1924 1944 1964 Influensa kom i blickpunkten genom det stora utbrottet av ryska snuvan åren Nervfeber (tyfoid) 45 34 25 7 0 1888–1892. Världen hade då varit prak- Skarlakansfeber 326 487 386 1 488 181 tiskt taget influensafri under mer än 40 Difteri 752 626 185 123 0 år, vilket förklarar den kraft med vilken Rödsot (dysenteri) 12 0 0 34 2 den nya pandemin slog till. Befolkning- Barnförlamning – 14 9 47 0 en saknade den grundimmunitet som tä- tare influensaepidemier ger upphov till. Ryska snuvan beräknas ha drabbat ungefär 40 procent av jordens befolk- des ett nytt försök. Ifall resultatet var ne- ning, men jämfört med den senare upp- gativt även denna gång blev det vacciner- Tabell II. Utdrag ur epidemirapporterna i LT visar trädande spanska sjukan var ryska snu- ing enligt Calmette. I slutet av 1920-talet antalet anmälda fall av difteri, scharlakansfeber van lindrig. Den viktigaste konsekven- och nervfeber under åren 1904 och 1914 respek- hade ett franskt forskarlag äntligen fått tive just efter första världskriget (1919). Som sy- sen av ryskan var den relativa immunitet fram ett vaccin mot tbc som uppkallats ef- nes mångdubblades antalet fall av difteri och ty- den gav mot spanska sjukan 30 år sena- ter bakteriologen Albert Calmette. foid (nervfeber) i samband med kriget. re. Människor äldre än 40 år klarade sig Först efter andra världskriget fick vi de tämligen hyggligt under utbrottet av första verksamma läkemedlen mot tbc i 1904 1914 1919 spanskan åren 1918–1919. Det var kom- form av streptomycin och paraaminosali- plikationerna och särskilt de svåra lung- cylsyra (PAS); det senare genom svens- Difteri 16 488 11 869 40 914 inflammationerna som orsakade hög ken Jörgen Lehman. Skarlakansfeber 8 082 10 253 9 252 dödlighet under spanskan. Det talas idag Nervfeber (tyfoidfeber) 1 857 1 922 3 798 om dödstal i storleksordningen 50 mil- Syfilis fortfarande farsot joner globalt. Senare års forskning tyder Syfilis var i början av 1900-talet fortfa- på att det inte bara var fråga om dålig im- rande en aktuell farsot. 1905 tog syfilis- munitet mot influensa A i åldrarna under forskningen dock ett steg framåt när spi- Tyvärr var salvarsanbehandlingen både 40 år utan också att det rörde sig om en roketen för första gången kunde påvisas långvarig och smärtsam och inte utan bi- ytterst virulent virusstam den gången. i mikroskop av den tyske biologen verkningar. Behandlingen var också in- Vid årsskiftet 1918–1919 hade omkring Schaudinn. Ungefär samtidigt utveckla- effektiv i sjukdomens senare stadier. 27 000 svenskar avlidit i spanska sjukan de immunologen Wassermann ett enkelt Under första världskriget vann den (Tabell III). Det skulle bli ytterligare test, med vilket man kunde ställa dia- sk malariaterapin inträde i behandling- 10 000 under de två följande årens efter- gnos och bedöma eventuell behand- en av syfilissjukdomens slutstadier. Den epidemier. lingseffekt. byggde på idén att ge den syfilisdrabba- När asiaten angrep oss 1957 hade Några år efter upptäckten av smitt- de hög feber genom insprutning av ma- våra kunskaper om sjukdomen ökat, in- ämnet presenterade Paul Ehrlich det lariaplasmodier i blodet. Fortfarande un- fluensavirus hade isolerats och vaccin första verksamma medlet mot syfilis. der mellankrigstiden var antalet syfilis- kunde framställas. Liksom under spans- Han kallade preparatet salvarsan, och fall betydande, och det var först när pe- ka sjukan blev dock sjukligheten omfat- den aktiva beståndsdelen var arsenik. nicillinbehandling blev allmänt tillgäng- tande, omkring en tredjedel av alla Läkartidningen ❙ Nr 1–2 ❙ 2004 ❙ Volym 101 83 ILD Tabell III. Dödsfall i influensa och lungtuberku- B los i Sverige 1916–1920. Ur Socialstyrelsens dödsorsaksregister. RESSENS : P OTO Lung- Total F År Influensa tuberkulos dödlighet 1916 314 9 562 77 771 1918 27 379 8 429 104 591 1920 2 853 7 712 78 128 svenskar drabbades, men dödligheten var låg. Ett decennium senare, 1968, ut- bröt nästa influensapandemi, kallad Hongkong. Den viktigaste lärdomen av Hongkongutbrottet var att sambandet djur–människa–influensa A stärktes. Ef- ter detta har vi lärt oss mycket om hur de världsomfattande epidemierna av influ- Kyrkogård för spanska sjukans offer i Longyearbyen på Spetsbergen. Människor över 40 år klarade sig tämligen hyggligt under utbrottet av spanska sjukan åren 1918–1919. ensa A uppstår i Kina och sprids globalt. Det var komplikationerna, särskilt lunginflammationerna, som orsakade den höga dödligheten. Det talas idag om dödstal i storleksordningen 50 miljoner globalt. Polio – efterkrigstidens gåtfulla hot Det svenska samhället hade fortfarande under 1940- och 1950-talen brister i så- väl bostadsstandard som hygienisk stan- ners framfart. Även dricksvattenförsörj- (Ouchterlony respektive Perlman/Eng- dard över huvud taget. Detta ledde till en ningen och avloppen förbättrades suc- vall), är exempel på analysmetoder som cirkulation av bl a poliovirus i samhäl- cessivt under efterkrigstiden. Kvarva- kom att bli mycket spridda. Mullis’ be- let. Så länge småbarn allmänt exponera- rande kåk- och slumområden i städerna skrivning av PCR-metoden 1987 var en des för poliovirus ställde sjukdomen inte sanerades alternativt jämnades med annan viktig milstolpe. Härigenom eta- till så stor skada, men när den hygienis- marken eller omvandlades till kulturre- blerades den i särklass känsligaste meto- ka standarden efter hand
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