10/15/2013 INFECTIOUS DISEASE “infectious diseases can force enormous, sometimes cataclysmic changes on societies. They can determine not just who lives and who dies, but who wins and who loses, who gets wealthy and who stays poor, which ideas become popular and which ones wither away.” PLAGUES AND PESTILENCE Leanne Schimke MSN, FNP-C, CUNP Lancaster Urology Quote by Bryn Barnard, author of Outbreak Plagues that Changed History. Lancaster, PA DEFINITIONS DEFINITIONS • Epidemic: any excessive and related incidence of a • Anything that causes disease is called a pathogen. particular disease in a population. • Vector: an organism such as a flea that serves as an • Pandemic: when an epidemic extends beyond a continent intermediary in the transmission of host-to-host disease. • Endemic: a disease with a normal low to moderate • Fomite: any inanimate object that adheres to or incidence in the population, but intermittent episodes. i.e. transmits infectious material, i.e. bedding. common cold • Zoonotic: transmitted between species, for example • Two major types of infectious disease that can develop into animal to human, sometimes through a vector. epidemics: • Common source: arise from a contaminated source, such as water or food. • Host-to-host: transmitted from one infected individual to another via various, sometimes indirect routes. BLACK DEATH BLACK DEATH • Bubonic, Pneumonic, and Septicemic plague • 1st pandemic in 541-543 AD, 2nd 1346-1352, 3rd 1894 • Caused by Yersinia pestis, a rod shaped, Gram negative bacteria. Only 1 bacteria is needed to cause the plague. • Initial symptoms: fevers, painful buboes (from Greek bubo meaning groin) in groins and armpits as lymph • Reservoir is the female Indian rat flea. nodes swelled. • 3 days later: high fevers 104 or >, delirium, restlessness, staggering gait, skin hemorrhages resulting in black splotches, gangrene, necrotic tissue, • Feeds on rodents: prairie dogs, rats, squirrels, gerbils, field enlarging buboes up to hen’s egg size that caused mice, etc. severe pain when they burst. • Can jump several feet, so when their hosts die they jump to • 5 days later: convulsions, coma and death. If fever a new one broke usually survived, if buboes were lanced possible survival. Some victims died in 1 day. 1 10/15/2013 BUBONIC PLAGUE BLACK DEATH • In bubonic and septicemic plague, there is hemorrhagic illness, multiple system failure and death. • Mortality rate now for untreated bubonic plague is 50-70%, septicemic plague is 100% • Can change to pneumonic plague which enters the lungs, causes coughing, blood tinged mucous that changes to pulmonary edema. Death can occur in a matter of hours. Has 100% mortality rate if untreated. • During the pandemics so many people died that their bodies were unable to be buried fast enough, so they were dumped in rivers, streets and docks. Images from CDC PHIL SPREAD OF THE BLACK DEATH BLACK DEATH • People lived in crowded, filthy cities. Sewage was inadequate so rotting garbage and human waste were • No one then knew how the disease was spread. Fear and heaped in streets or dumped in rivers. terror ruled. People deserted cities and towns, work and service disrupted. • People hardly ever bathed. • Theories such as: • The black rats lived in the thatch of the roofs and in the • “bad air” or miasma ships that traveled between cities. Rats were highly • Result of conjunction of Saturn, Jupiter and Mars in the susceptible to the plague, they became infected and died, 40th degrees of Aquarius which forced the earth to exhale so the fleas jumped to humans nearby. a virulent sulfurous miasma. • Plague spread via ships, the rats infected the humans on • Divine punishment for sins of the world. Curse from God the ships and then left the ships to infect the land • Caused by spirits and devils population. • Caused by strangers, xenophobia was the norm. • In Venice, a quarantine was placed on ships. Quarantina is • Jews became targets, rumors of their poisoning the wells the Italian word for 40 days. Unfortunately, the rats were ran rampant. Numerous massacres occurred. able to leave via the ropes tied to the docks. BLACK DEATH PLAGUE DOCTORS As may be seen on picture here, • In Germany, a group formed to try to appease God through group mortification; known as the Brotherhood of the In Rome the doctors do appear, When to their patients they are Flagellants. called, • They would march from town to town and in the town square In places by the plague appalled, would form a large circle, strip themselves to the waist and Their hats and cloaks of fashion new, beat themselves with a whip in rhythm to their chanting Are made of oilcloth, dark of hue, hymn. Their caps with glasses are designed, • They would perform this rite three times daily for 33 days, a Their bills with antidotes all lined, day for each year of Jesus Christ’s life. That foulsome air may do no harm, • As time went on instead of just hurting themselves, they Nor cause the doctor man alarm, began to lead in persecution and murder of the Jews The staff in hand must serve to show Their noble trade where 'er they go. Seventeen century poem about Plague Doctors 2 10/15/2013 BLACK DEATH BLACK PLAGUE HISTORICAL SIGNIFICANCE Most famous plague doctor was Michel de • Plague of 541 AD raged in Constantinople, Europe, North Africa and Middle East by 600 AD population was reduced Nostraedame, known more commonly as by 100 million, approximately 50% of the population. Nostradamus. • Marked the end of the Classical World, of Greek and Roman His advice: drink only boiled water, sleep in Civilization, ushered in the Dark Ages. clean beds, and leave infected towns as • Followed trade routes, how the disease spread from country to country and continent. soon as possible. BLACK DEATH HISTORICAL SIGNIFICANCE BLACK DEATH EFFECT ON MEDICINE nd • In 1346, the 2 pandemic hit Europe, was called the Great • Medieval society had 4 kinds of medical practitioners: Mortality, the Pestilence and the Pest. 1. Academic physicians-knew theory but didn’t care for the • In 4 years, it killed a third of Europe’s population. sick. • Before 1346, Europe was ruled by aristocrats and the 2. Surgeons- main caregivers of the sick, Church. They owned all the land, controlled the wealth, 3. Barbers who did bloodletting and minor surgery. determined the laws and were gatekeepers of all 4. Folk medicine practitioners which were mostly women. knowledge. • Academic physicians believed Hippocrates's and Galen theories • The Black Death did not discriminate, wealthy and poor alike were afflicted and died. Religious leaders died along that bad humors in the body caused disease. The four humors with sinners. were blood, phlegm, black and yellow bile. Since this couldn’t be applied to the plague, confidence in these practitioners • So with fewer workers, wages went up. With fewer diminished. consumers, prices went down. • Surgeons who wore the Plague doctor costume died at higher • In the countryside and cities, a rising middle class was able rates than barbers or folk practitioners, so they were not valued. to buy property, businesses and wealth the dead had left behind. BLACK DEATH BLACK DEATH • New prestige fell to the barber, which lead to an emphasis • In 1894, Alexander Yersin, a student of Louis Pasteur, was on study of the human anatomy in health and disease. sent to Hong Kong to discover the cause of the plague. He • The Galenic system which had no clear theory of contagion identified Yersinia pestis bacterium, a gram negative declined in importance. bacteria. Originally named Pasteurella pestis, the name was changed in 1970 to reflect the person who identified it. • In the 1500’s Girolamo wrote that infectious disease could be transmitted by semanaria (germs) in 3 ways-by direct • Yersin did not identify how it was spread. contact, through carriers, and through airborne • In 1898, Paul Simond, another student of Pasteur, was sent transmission. Other physicians did not believe him and his to Vietnam and India to follow up on Yersin’ s observations. theory was not followed up until the 19th century by Louis He noted there were large numbers of dead and dying rats Pasteur and Robert Koch and their associates. and from there went to discover the intermediary the rat flea. 3 10/15/2013 BLACK DEATH TRIVIA THINGS LEARNED FROM THE BUBONIC PLAGUE • God Bless You: Pope Gregory I in 590 AD ordered unending prayer to fight the plague in Rome. Sneezing was thought to be an early • Quarantine symptom, so God Bless you became a common saying to halt the disease. • Need to understand the pathogen and the • Eau de cologne: invented in Germany, named after the city of Cologne, was used to “purify” the air from the stench of death from the plague. vector of disease to be able to control it. • Pied Piper of Hamlin: Pied piper offered large sum of money to rid the • Protective clothing for caregivers city of rats, played his flute and lead rats to river where they drowned. Officials reneged on payment, so the pied piper played his flute again, • Burning of clothing and bedding this time all the children followed him to the mountain and were never seen again • Burying the dead in shallow graves sprinkled • Ring Around the Rosie: debate whether it was written due to the plague or not. Sung from the 1790s, but didn’t appear in print literature with lye until 1822. • “Ring around the rosies. • A pocket full of posies, • Ashes, ashes! BUBONIC PLAQUE PLAGUE AS A BIOTERRORISM WEAPON Last case of Bubonic plague Aug 2013 in Kyrgyzstan 15 • An aerosolized plague weapon could cause fever, year old boy died before diagnosed. Endemic in region.