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Sharing medical knowledge and health information health risks without frontiers Sources of knowledge

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Title: Sharing medical knowledge and health information health risks without frontiers Sources of knowledge


1
Sharing medical knowledge and health information
health risks without frontiersSources 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

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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 wasnt, India, 1994
  • SARS, 2003
  • The influenza pandemic threat, intensifying
    international interaction

5
Hippocrates, c 450 370 BC
Oath of Hippocrates, 12. Century, Byzantine
manuscript http//homepage.univie.ac.at/michael.pe
intinger/main.html
Hippocrates http//www.praxisbenner.de/1/natverfa
hren.html
6
Hippocratess 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

7
Galen, 129 c200/210
Galen http//home.tiscalinet.ch/biografien/biogra
fien/galen.htm Omnia Qvae Extant Opera
http//www.sk-szeged.hu/tortenet/galen.htm
8
Galens 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

9
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

10
Jesus heals leprosy other diseases
http//www.united.edu/portrait/healer.shtml
11
Coran, Arabic healing
Corán del siglo XII del Al-Ándalus http//es.wikip
edia.org/wiki/AndalucC3ADa
12
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

13
Spread of Black Death
14
Black death (Plague)
Illustration of the Black Death from the
Toggenburg Bible (1411) http//en.wikipedia.org/wi
ki/Black_Death
15
Impact on the population
  • Deaths
  • Estimated at 20-25 million in Europe (40 of the
    population)
  • Throughout the world possibly gt40 million
  • Ended the Middle Ages and destroyed medieval
    social, economic and political arrangements

16
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

17
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
/
18
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/
19
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

20
Ships docking, Venice Lazzaretto
Ships docking at the Lazzaretto Vecchio, Venice,
14th century
http//www.cdc.gov/ncidod/EID/vol11no05/04-0616.ht
m
21
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/DesktopDefaul
t.aspx?tabid6tabindex5objectid1599
22
Plague mask
http//www.brlsi.org/proceed03/science200203.htm
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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

25
Kitasato and Yersin
Yersin http//www.pasteur-international.org/image
s/personnalites/yersin.jpg Kitasato
http//www.discoveriesinmedicine.com/images/mdis_0
000_0002_0_img0094.jpg
26
Lancet 18942428-430 (25th August)
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Figure in Yersins article
30
Yersin proclaimed the winner
  • Yersin described unequivocally the causative
    bacterium accurately
  • Yersins article delivered at the French Academy
    of Sciences on July 30, 1894
  • Some of Kitasatos findings not internally
    consistent (preparates contaminated with other
    bacteria?)
  • Controversy on who has the priority on finding
    the bacterium, resolved gradually in Yersins
    favour

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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

33
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,
20011345-53
34
SARS epidemic, 2003
  • Sudden acute respiratory syndrome
  • A definitely new human disease

35
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
36
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

37
Transmission of SARS by an individual from
Guangdong province to Hotel M in Hong Kong, and
globally by infected hotel guests
CID 2004381422
38
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

39
SARS coronavirus
Electron microscopic graph http//www.ktl.fi/ap-p
ics/suomi/osastot/infe/sars-hongkong3.jpg Surface
structures visualised http//www.infojet.cz/scien
ce/images/SARS_coronavirus.gif Three-dimensional
structure http//www.aps.anl.gov/News/APS_News/20
03/Images/20030805a.jpg
40
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 (lt 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

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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?

43
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?

44
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 12), Routledge,
    1997
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