LAZARETTOS & QUARANTINE The infected patient between hospitality & rejection Professor Alasdair Geddes School of Medicine University of Birmingham Birmingham, UK [email protected] LAZARETTOS & QUARANTINE Plague doctor LAZARETTOS & QUARANTINE • A Lazaretto (lazaret; lazarette) is a place used to quarantine the sick, especially those with plague. [Name probably derived from the biblical beggar Lazarus.] • The first lazaretto ‐ Lazaretto Vecchio ‐ was established in 1423 on an island in the Venetian lagoon (Santa Maria di Nazareth) for plague victims. Others followed in Malta, Genoa, Minorca. • Quarantine (quarantina ‐ 40 days) . ? Based on biblical 40 days in the desert. Lazarus “The Triumph of Death” Bruegel, 1562 Museo del Prado, Madrid San Lazaretto Nuovo, Venice Ships at the Lazaretto, Venice The Lazaretto at Genoa - John Howard 1789 LAZARETTOS & QUARANTINE “An Account of the Principal Lazarettos of Europe” John Howard (1789) The prison reformer, John Howard, deliberately sailed from Smyrna to Venice in a ship with a ‘foul bill of health’ (i.e. full of infectious diseases!) so that he could gain firsthand experience of lazarettos; his account presents a depressing picture. John Howard:‐ “In those of them (lazarettos) I visited I observed pale and dejected persons, and many fresh graves. To prevent as much as possible these disagreeable circumstances, a lazaretto should have the most cheerful aspect. A spacious and pleasant garden in particular, would be convenient as well as salutary”. John Howard visiting a lazaretto -1790 Lazaretto Island, Menorca LAZARETTOS & QUARANTINE Plague hospitals in Europe • Plague hospitals were commoner on mainland Europe (e.g. in Vienna in 1679) than in the UK. In London, infected patients were often ‘locked up’ at home under ‘plague orders’. Doors were nailed closed and a red cross placed upon them. The ‘upper classes’, including physicians and clergy, fled from the city! • The first ‘pest house’ in London was built in 1637 ‐ outside the city wall. [Great Plague of London ‐ 1665] • Did the plague hospitals do any good? For the individual patient, no. For the community, possibly yes. Plague hospital, Vienna, circa1679 Ship’s quarantine flag Plague hospital, Scilly Isles, South West England. Infected sailors were left here en route to the UK from Africa and the Caribbean LAZARETTOS & QUARANTINE Hospitals for Infectious Diseases [Lancet, May 20, 1875, 764‐65] “Isolation is the only means we possess of controlling the spread of infectious disease, except smallpox, and perhaps enteric fever; so long as vaccination is not good, and sanitary conditions of towns as to drainage and filth‐disposal is such as it commonly is, isolation must be an essential element in the effective limitation of both diseases. These diseases are mainly fostered amongst the crowded houses of the poorer classes. In these houses isolation is impossible. There is but one true method of breaking this bond ‐ by rooting each infection out as it occurs. This is the function of the (isolation) hospital, where all the conditions of transmission are altered. There, casual intercommunication of neighbours is done away with, and the patient is put under such circumstances that the infection of his disease is not stored up, or aggravated, by foul surroundings. In fact, infection is placed there under almost absolute control.” [A benevolent receptacle for the contagious poor!!] London isolation hospital, 1871 LAZARETTOS & QUARANTINE Infections requiring isolation “He is unclean: without the camp shall his habitation be” Leviticus 13: 46 • Middle ages Plague; leprosy; cholera • 18th/19th Century Smallpox; yellow fever (PhiladelphiaÆ Lazaretto in 1799); leprosy • 20th Century Smallpox; tuberculosis; cholera; childhood infections (diphtheria, scarlet fever, pertussis, measles etc.) LAZARETTOS & QUARANTINE Smallpox Hospitals in the UK (I) • Compulsory smallpox vaccination started in 1853 [Jenner, 1796] • 1870 ‐ large outbreak of smallpox in London • Pan‐European smallpox epidemic ‐ 1901 to 1903 • First smallpox hospital in London was built at Fulham (site now Chelsea Football Club!) in 1877. • Great controversy about airborne transmission of smallpox to the local population. Excessive incidence of infection close to Fulham Hospital (W.H. Power’s spot maps) • Hospital ships sited on the River Thames; however, still spread of infection to the local community! Smallpox ships - River Thames, London - 1884 to 1902 LAZARETTOS & QUARANTINE Smallpox/Isolation Hospitals in the UK (2) • Public Health Act of 1875: Each city authority given responsibility for sanitation and the control of infectious diseases. • Concerns about smallpox resulted in cities outside London building smallpox hospitals in the country outside the city. • By the time that these hospitals were completed e.g. in Birmingham in 1895, endemic smallpox began to disappear in the UK. • However, in the overcrowded cities of the Industrial Revolution such as Birmingham, diseases of poverty and inadequate sanitation (diphtheria, scarlet fever, measles and tuberculosis) were becoming major problems. The hospitals built originally for smallpox were therefore used to isolate these infections. LAZARETTOS & QUARANTINE Isolation Hospitals in the UK (3) • Before antibiotics and universal immunization (pre‐1940)’s: “At the present time we are reduced to allowing the patient to fight his own battle and to put him in as favourable a condition as possible for doing so” Frank Ker (1939), commenting on the treatment of typhoid fever]. Isolation was virtually the only available ‘treatment’ for such infections. • After antibiotics and universal immunization (post 1945): Initially, there was a European‐wide outbreak of poliomyelitis, then significant immigration from the Indian sub‐continent resulted in the importation of ‘tropical’ infections, and large outbreaks of common infections such as measles in un‐immunized children. Isolation hospitals were still required. LAZARETTOS & QUARANTINE Isolation Hospitals in the UK (4) • Decline in infectious Diseases (post1960’s/70’s) Improvements in housing, nutrition and the availability of antibiotics and vaccines, resulted in a decline in infectious diseases, and a fall in the requirement for isolation beds, leading to the closure of isolation hospitals (protective isolation became more important). • The last smallpox hospital The last smallpox hospital, sited outside Birmingham, UK, (probably the last such hospital in the world) closed in 1978. East Birmingham Hospital 1895 East Birmingham Hospital 1995 Smallpox Hospital - nr. Birmingham -1978 Smallpox - Bangladesh Smallpox hospital Bangladesh Cholera hospital, Dacca LAZARETTOS & QUARANTINE “The infected patient between hospitality & rejection” Hospitality • Lodging; bed (usually); food & drink (sometimes); nursing care (often very good) Rejection • Removed from home (often forcibly) • Isolated and cold (fresh air), often at a distance from home • Locked up (in a ‘pest house’) against their will • Few, or no, visitors, even for children (few toys) LAZARETTOS & QUARANTINE 21st Century and beyond • MRSA; Drug Resistant TB; SARS; Avian influenza • Multi‐drug resistant Acinetobacter baumanii • Biological warfare associated infections (e.g. plague, smallpox, viral haemorrhagic fevers). • Climate change‐associated infections ‐ zoonoses ? Will isolation hospitals be required again ??? William Shakespeare in The Tempest:‐ “What is past is prologue” → The future is history .