Petri Ruutu

Sharing medical knowledge and health information – health risks without frontiersSources of knowledge for public health action to combat infectious disease epidemics through history : Sharing medical knowledge and health information – health risks without frontiers Sources of knowledge for public health action to combat infectious disease epidemics through history Petri Ruutu, Research professor Department of Infectious Disease Epidemiology National Public Health Institute Helsinki, Finland


Historical ’snapshots’ : Historical ’snapshots’ Plague from medieval to the present Plague of Justinianus, 6th century Black death, 14th century The third plague pandemic, 19th century The plague epidemic that wasn’t, India, 1994 SARS, 2003 The influenza pandemic threat, intensifying international interaction


Hippocrates, c 450 – 370 BC : Hippocrates, c 450 – 370 BC Hippocrates http://www.praxisbenner.de/1/natverfahren.html Oath of Hippocrates, 12. Century, Byzantine manuscript http://homepage.univie.ac.at/michael.peintinger/main.html


Hippocrates’s concepts of disease : Hippocrates’s concepts of disease Epidemics (three books) On the Nature of Man On Airs, Waters, Places Influence of external and environmental factors climate, prevailing winds, marshes, water supply and soil, geographic location, sick persons, habits and life-styles humoral theory: ’bad air’ (miasma) has a role in disease causation ’exhalations that come from the ground through ruptures or clefts’ ’considering these, physician would know what epidemics to expect, and what particular disadvantages threatened an individual who changed his mode of life’ epidemics ’not punishment for sins’, naturalistic causes Theoretician looking for causes


Galen, 129 – c200/210 : Galen, 129 – c200/210 Galen: http://home.tiscalinet.ch/biografien/biografien/galen.htm Omnia Qvae Extant Opera: http://www.sk-szeged.hu/tortenet/galen.htm


Galen’s concepts of disease : Galen’s concepts of disease An ’epidemic constitution of the surrounding air’ the most important initiating factor for epidemics The presence of ’miasmas’ (’polluting agent’) due to filth putrefaction swampy conditions seasons Astronomical phenomena; solstices, equinoxes, positions of stars ’Seeds of disease’ carried by the air Practical clinician, practical advice Concepts not seriously challenged scientifically prior to the 15th-17th centuries


Sources of knowledge : Sources of knowledge Hippocrates and Galen The Old Testament The Book of Leviticus three chapters on preventing the spread of ’leprosy’ (covered more than one ailment, STDs) isolate ’unclean’ sufferers, cleanse their clothes and belongings impose a period of quarantine followed by inspection to determine their ’clean’ or ’unclean’ state ’Scientific’ and religious healing existed side by side Cure had to be ultimately credited to God


Jesus heals ’leprosy’ & other diseases : Jesus heals ’leprosy’ & other diseases http://www.united.edu/portrait/healer.shtml


Coran, Arabic healing : Coran, Arabic healing Corán del siglo XII del Al-Ándalus http://es.wikipedia.org/wiki/Andaluc%C3%ADa


Justinian Plague : Justinian Plague Plague caused by bacterium Yersinia pestis (identified in 1894) Bubonic form (multiple abscesses), mortality 50% Pulmonary form (pneumonia), mortality close to 100% Transmission by droplets person to person (pulmonary) and by fleas from rats Started in 541 AD Constantinople in 542 at the peak of the epidemic killed 10 000 per day ’not enough of the living to bury the death’ Reached Western Europe by 547 AD recurring epidemics in Mediterranean over 200 years No reference to any systematic control measures


Spread of Black Death : Spread of Black Death


Black death (Plague) : Black death (Plague) Illustration of the Black Death from the Toggenburg Bible (1411) http://en.wikipedia.org/wiki/Black_Death


Impact on the population : Impact on the population Deaths Estimated at 20-25 million in Europe (40% of the population) Throughout the world possibly >40 million ’Ended the Middle Ages and destroyed medieval social, economic and political arrangements’


Sources of information …… : Sources of information …… University of Paris (established in the 12th century), Faculty of Medicine, during Black Death ’It is known that in India in the region of the big ocean the stars which fought the sunbeams and warmth of the celestial fire had exerted their power above all against that ocean, and had vehemently sruggled with its waters. Thus often vapors develop which hide the sun, transforming its light to darkness. These vapors continuously repeated their descending and ascending for 28 days…….’ ’… these vapors spread by air to many parts of the world and veiled them with mist…’ ’.. If it comes to Sardinia, nobody will remain alive and the same will happen on all islands and in the neigbouring countries whereto this corrupted sea water from India shall reach ….’ Strong beliefs in cosmic or astral forces


Coffin bearers : Coffin bearers Ian Jessiman: A General Study of the Plague in England 1539-1640 With a Specific Reference to Loughborough http://www.loughborough.co.uk/plague/


Cart full of dead to bury : Cart full of dead to bury Ian Jessiman: A General Study of the Plague in England 1539-1640 With a Specific Reference to Loughborough http://www.loughborough.co.uk/plague/


Public health measures : Public health measures Starting from Italy, secular public health authorities were granted authority for implementing control measures Observations: plague was a contagious disease of the poor Massacre of dogs and cats (no effect) The rich fled the city (could afford) Keeping ships arriving from suspect areas separated for 30 days (Ragusa 1377; trentina) or 40 days (Marseille 1383; quarantina) Closing public bath houses and schools Measures much directed to protect the rich elite ’Moving about slowly while inhaling through aromatic sponge’ Elaborate protective costumes: bird-beaked masks contained aromatic substances Over 250 ’Plague treateses’ were written 1350-1500


Ships docking, Venice Lazzaretto : Ships docking, Venice Lazzaretto Ships docking at the Lazzaretto Vecchio, Venice, 14th century http://www.cdc.gov/ncidod/EID/vol11no05/04-0616.htm


Venice Lazzaretto : Venice Lazzaretto Francesco Guardi: View of the Island of San Secondo in the Venetian Lagoon; View of the Island of Lazzareto Vecchio in the Venetian Lagoon (Oil on canvas laid down on panel) http://www.richard-green.com/DesktopDefault.aspx?tabid=6&tabindex=5&objectid=1599


Plague mask : Plague mask http://www.brlsi.org/proceed03/science200203.htm


Plague epidemic late 19th century : Plague epidemic late 19th century Origin and impact China (1855), Hongkong (1894)  globally Changing concept of disease Advent of bacteriology (Anthrax, Tuberculosis etc) to define the etiology of infectious diseases in the late 19th century Competition to identify Yersinia pestis between Kitasato and Yersin in June – September, 1894 Followed by The chain of plague transmission discovered in a few years (man, rat, fleas, bacteria) Antiserum used for treatment Vaccine later developed


Kitasato and Yersin : Kitasato and Yersin Yersin: http://www.pasteur-international.org/images/personnalites/yersin.jpg Kitasato: http://www.discoveriesinmedicine.com/images/mdis_0000_0002_0_img0094.jpg


Slide26 : Lancet 1894;2:428-430 (25th August)


Figure in Yersin’s article : Figure in Yersin’s article


Yersin ’proclaimed the winner’ : Yersin ’proclaimed the winner’ Yersin described unequivocally the causative bacterium accurately Yersin’s article delivered at the French Academy of Sciences on July 30, 1894 Some of Kitasato’s findings not internally consistent (preparates contaminated with other bacteria?) Controversy on who has the priority on finding the bacterium, resolved gradually in Yersin’s favour


Plague in India - 1994 : Plague in India - 1994 Questionable whether there was any epidemic Some increase in deaths in slums (Maharashtra, Gujarat), numbers nationally very small Symptoms and the epidemiology were atypical for Plague Public health and health care service structures poor, no reliably laboratory confirmed cases A major unjustified disturbance in international air traffic; a great diversity of public health ’reactions’ in different countries India suffered billions of euros economically from the unjustified travel restrictions and media scare Diagnostics had existed for a century


Sources of information on epidemics : Sources of information on epidemics ’Globally, 65% of primary news on unexpected infectious disease events is in informal sources, such as press and internet’ (quality highly variable, need validation) Heymann DL. Lancet Infectious Diseases, 2001;1:345-53


SARS epidemic, 2003 : SARS epidemic, 2003 Sudden acute respiratory syndrome A definitely new human disease


Slide35 : Figure 1. The geographic distribution of SARS outbreaks in Guangdong Province, Nov 16,2002, to Feb 9, 2003. Number of cases in brackets. Approximate dates of the onset of the outbreaks for each city were Foshan, Nov 16, 2002; Heyuan, Dec 17, 2002; Zhongshan, Dec 26, 2003; Guangzhou, Jan 31, 2003; Jiangmen, Jan 10, 2003; Shenzhen, Jan 15, 2003. Zhong et al, Lancet, Oct 25, 2003


Identification of the problem : Identification of the problem Information on an epidemic in Guangdong 11.2.2003 In Hong Kong and Hanoi several clusters of disease in health care personnel treating pneumonia cases 26.2.-12.3. An international outbreak alarm from World Health Organisation (WHO) on 12.3. A recommendation by WHO on 15.3. to restrict travel to the affected South-East Asian countries Cause uknown


Slide37 : Transmission of SARS by an individual from Guangdong province to Hotel M in Hong Kong, and globally by infected hotel guests CID 2004;38:1422


Identification of the cause of SARS : Identification of the cause of SARS (International outbreak alarm: 12.3.2003) Electron microscopy: belongs to paramyxoviruses (reported in Promed 17.3.-18.3. by two groups) Virus culture: coronavirus (Promed 25.3.) Hongkong, Canada: Clinical presentation reported (e-published in New Engl J Med 31.3.) Hong Kong: 50 SARS cases compared with two comparison materials: the cause is definitely a coronavirus (e-published in Lancet 8.4.) Further characterisation of the virus in two reports (e-published in NEJM 10.4) The virus sequenced for all of its genome (’in web’ 13.4.); it has no close relatives in the coronavirus family Intense collaboration of over 10 centres coordinated by WHO


SARS coronavirus : SARS coronavirus Electron microscopic graph: http://www.ktl.fi/ap-pics/suomi/osastot/infe/sars-hongkong3.jpg Surface structures visualised: http://www.infojet.cz/science/images/SARS_coronavirus.gif Three-dimensional structure: http://www.aps.anl.gov/News/APS_News/2003/Images/20030805a.jpg


SARS public health measures : SARS public health measures Transmission mechanism quickly resolved by epidemiological studies without microbiology, later consolidated by laboratory confirmation no transmission from a person before first symptoms droplets (< 2 m distance) of or contact with contaminated respiratory secretions Measures there were no rapid and sensitive enough laboratory methods during the whole epidemic to guide decisions on immediate infection control measures on cases or their contacts decisions based on simple decision trees based on the possibility of exposure, symptoms and signs restriction of travel, isolation (patients), quarantine (7 days, contacts of patients), ’social distancing’ (closing schools etc), hygiene = ’means from medieval’


Sources of e-information on epidemics : Sources of e-information on epidemics WHO Global Outbreak and Alert Response Network Proved its ’muscle’ during SARS, further developed Weekly and ad hoc dissemination of outbreak ’intelligence’ information PROMED Public domain, well-moderated very rapid news on all biological sciences related to microbial disease Daily dissemination, variable degrees of confirmation European Centre for Disease Control (ECDC) 2005  Weekly routine ’risk assessments’ of ongoing threats Within 24h ’risk assessments’ of important unexpected events Others Flooding of information: which should we react to?


Towards a pandemic ? : Towards a pandemic ? WHO International Health Regulations 2005 (2007) WHO and Member state obligations and rights well described Strengthens the WHO position as a coordinator Transparency in information flow Strengthened role in giving guidelines for control measures International scientific collaboration in epidemic situations Mechanisms of Epidemic Intelligence and dissemination of knowledge WHO European CDC US CDC etc Electronic scientific publishing and media How to ’command’ information inflow in crisis situation?


Acknowledgements and references : Acknowledgements and references Great support was given by Annikki Roos Jukka Lindeman Eija-Liisa Mäkelä Book references LM Magner: A history of Medicine, Dekker, 1992 WF Bunyum & R Porter: Companion encyclopedia of the History of Medicine (vols 1&2), Routledge, 1997