Rubella and the Bubonic Plague A Comparison

1
Rubellaandthe Bubonic PlagueA Comparison
Ellen Perlow HS 5353 Epidemiology Dr.
Wiginton Fall 2002 Texas Womans University
Dept. of Health Studies December 9, 2002
http//www.a4access.org/epipaperrevised.ppt Narrat
ive at http//www.a4access.org/epipaper1202.doc Th
is presentation is available in alternative
formats upon request.
2
I.History and Current Status of Rubella
andThe Bubonic Plague
3
Agent Togavirus, genus Rubivirus, RNA virus
(isolated 1962 by Parkman and Weller)
Transmission Human to human respiratory
transmission. Replication in nasopharynx and
regional lymph nodes. Viremia (virus in
bloodstream) 5-7 days after exposure with spread
to tissues. Intrauterine placenta, fetus
affected during viremia. Centers for Disease
Control and Prevention (2002). Rubella.
Retrieved November 16, 2002, from
http//www.cdc.gov/nip/publications/pink/rubella.p
df
Rubella / German Measles / Greggs Syndrome Virus
4
History of Rubella - 1

• 1881 Officially recognized as a distinct
  clinical entity Before that time, confusion as to
  whether it was a mild form of measles (rubeola)
  or scarlet fever, or both Rubella name
  accepted.
• In the next 60 years, little attention paid to
  rubella since disease not considered serious.
• 1935 Epidemic of rubella, largely went
  unnoticed.
• 1940 Large rubella epidemic in Australia.
• (Horstmann, Dorothy M. (1986, Oct. 11). The
  rubella story, 1881-1985. South African Medical
  Journal, Supplement, 60-63.)

5
History of Rubella - 2

• 1941 Australian ophthalmologist Dr. Norman Gregg
  discovered relationship between maternal rubella
  during pregnancy and congenital defects in
  infants. Observed gt number of infants born with
  cataracts. Found mothers of most infants
  contracted rubella in 1st few months of pregnancy
  during 1940 epidemic. Published findings 78
  cases. Infants born with cataracts,
  microphthalmia, small in size, failure to thrive,
  cardiac abnormalities. Discovery profound impact
  on entire field of congenital disease. Rubella
  very first well defined teratogen agent causing
  developmental differences. Greggs findings
  confirmed in other studies in Europe, U.S., New
  Zealand, Australia. Many children born with
  differences-correlation mothers had rubella.
  (Horstmann, D.M. (1986, Oct. 11). The rubella
  story, 1881-1985. South African Medical Journal,
  Supplement, 60-63 Cooper, L.Z. (1966). German
  measles. Scientific American 215(7) 30-37.
  Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R.
  (1997, 2000). Vaccine developed for German
  measles, 1960-1969. DISCovering U.S. History.
  Gale Research. Retrieved Sept. 16, 2002, from
  Gale Research database.

6
History of Rubella - 3

• 1941-1961 Scientists tried to isolate virus no
  success.
• 1962 Drs. Parkman, Meyer, Hilleman at Walter
  Reed, Harvard, NIH labs isolated virus. New
  standard of cooperation in medical research.
• Early 1960s 40,000 and 45,000 cases of rubella
  per year.
• Spring 1964 Large U.S. epidemic. 7,000 fetal
  deaths, 20,000 babies born with congenital
  differences. Very different virologies of
  intra-uterine, post-natal infections
• July 1966 Pediatrician Louis Z. Cooper publishes
  German Measles, Scientific American.
• By 1969-3 vaccines HPV77 DE5, Cendehill, RA27/3
  strains ready for licensing
• (Horstmann, Dorothy M. (1986, Oct. 11). The
  rubella story, 1881-1985. South African Medical
  Journal, Supplement, 60-63. Parkman, P.D., Meyer,
  H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine
  developed for German measles, 1960-1969.
  DISCovering U.S. History. Gale Research.
  Retrieved September 16, 2002, from
  http//galenet.galegroup.com/servlet/SRCCE/.
  Cooper, L.Z. (1966). German measles. Scientific
  American 215(7) 30-37.)

7
History of Rubella - 4

• 1969 U.S. begins rubella vaccine program
• 1970 U.K., Australia,New Zealand vaccine
  programs begin
• 1989 Eradication of rubella goal of Healthy
  People 2000
• 1988-1991 Reduction in rubella cases 98 since
  pre-vaccine era. 2-3 fold increase in incidence
  of rubella since 1982
• 1990 1093 cases from 38 statesDC. California
  4x.
• 2002 CDC U.S. on verge of eradication of
  indigenous rubella. Rubella occurs mainly among
  foreign-born Hispanic adults who are either
  unvaccinated or whose vaccination status is
  unknown
• 1998-2002 Controversy MMR vaccine causes
  autism?
• November 7, 2002 Danish study no link MMR
  vaccine / autism.
• December 9, 2002 Threats due to lack of
  vaccination in other countries, threats due to
  terrorism?
• (Horstmann, Dorothy M. (1986, Oct. 11). The
  rubella story, 1881-1985. South African Medical
  Journal, Supplement, 60-63. Parkman, P.D., Meyer,
  H.M., Jr., Hilleman, M.R. (1997, 2000). Vaccine
  developed for German measles, 1960-1969.
  DISCovering U.S. History. Gale Research.
  Retrieved September 16, 2002, from
  http//galenet.galegroup.com/servlet/SRCCE/.
  Cooper, L.Z. (1966). German measles. Scientific
  American 215(7) 30-37.)

8
Agent BacteriumYersinia pestisVector
Blood-sucking rat flea Xenopsylla cheopis
Hosts Rodents-rats/shrews, prairie dogs, etc.
Environment Rodent-friendly food, garbage,
unsanitary conditionsTransmission a) Most
common mode bite of flea infected with Yersinia
pestis bacterium b) less frequently direct
contact with infectious body fluids or tissues
while handling infected animal or c) inhaling
infectious respiratory droplets or other
infectious materials.
Bubonic Plague Enzootic
9
Types of Plague

• Bubonic plague most common form of U.S. cases
  80-90. Case Fatality Rate if not treated
  50-60
• Septicemic plague when Yersinia pestis invades
  and continues to multiply in the bloodstream
  primary or secondary to bubonic plague. U.S.
  1947-1977 10 septicemic. Case fatality
  rate-50. Complications septic shock,
  consumptive coagulopathy, meningitis, coma.
• Pneumonic plague least common but most dangerous
  and fatal form - inhalation of infectious
  respiratory droplets. Incubation period 1-3
  days. Without treatment, death within 18 hours
  after onset of respiratory symptoms. (Centers for
  Disease Control and Prevention (1996). Prevention
  of plague recommendations of the Advisory
  Committee on Immunization Practices (ACIP).
  Morbidity and Mortality Weekly Report, 45(RR-14)
  1-15. )

10
History of Bubonic Plague - 1

• Biblical times circa 1000 B.C.E.
• 1 Samuel 5 capture of Ark of Covenant from
  Israelites by Philistines at battle of Aphek
  followed by outbreak of what appears to have been
  the plague in five cities of the Philistines
  starting in Ashdod. (Septuagint/Vulgate
  Philistines smitten with tumors and rats
  appeared in their land and death and destruction
  were throughout the cities.
• (Griffin, J.P. (2000) Bubonic plague in Biblical
  times. Letter. Journal of the Royal Society of
  Medicine, 93, 449.)

11
History of Bubonic Plague - 2

• Summer 430 B.C.E. Athens Illness from Egypt.
  1/3 Athens population, Pericles died. Athens lost
  to Sparta.
• Possibly typhus, smallpox, scarlet fever.
• 1346-1347 Black Sea/S. Ukraine
• Names Swellingsbuboes. Greek groinboubon.
  Also named Black Death and The Great
  Pestilence.
• Italian traders blamed. Infection to Sicily,
  mainland Italy
• October 1347 SicilyItaly. By Winter 1348-1349,
  1/3-1/2 population of Italy killed.
• Plague spread to Messina, other Italian ports,
  Milan, Florence, Venice quaranta giorni
  decree40-day quarantine on ships Garbage great
  breeding ground
• Literary references Bocaccios Decameron.
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins, 1-3,
  11-20). Working Group on Civiliian Biodefense
  (2000). Plague as a biological weapon. JAMA,
  283(17), 2281.)

12
History of Bubonic Plague - 3

• Spring 1348 Pilgrims bring plague to France
  (Marseilles-Avignon Home of Pope Feb.-May 400
  deaths/day, 1349 50,000 deaths in Paris.
• Pope Clement/Church belief in fire/humors/miasmas
  theories of Hippocrates, Galen. No dissection,
  autopsies.
• Treatments bloodletting at site of buboes,
  prayer.
• Summer 1349-1351-Early 1400s British Isles,
  Germany
• 80 of some villages died. Devastation?persecution
  German Flagellants, 1st HolocaustChurch power
  reduced
• Europe epidemics-every decade-to 1400s-½ pop.
  killed
• 15th-16th-17th Centuries Church
  reform--Protestantism
• Medicine Practical courses in anatomy, surgery.
  Medical textbooks in European languages, Consumer
  health, Scientific method, Gutenberg (1456),
  Discovery of America (1492)
• 1664-Fall 1665 Great Plague of London. 70,000
  died. Thought to be person to person
  transmission. Quarantines in homes (Giblin, J.C.
  (1995). When plague strikes the Black Death,
  smallpox, AIDS. HarperCollins, 21-49.)

13
History of Bubonic Plague - 4

• 18th-19th Centuries. By 1750, BP faded W. Europe,
  active Mediterranean. 1855 pandemic. gt12
  million killed in interior of China, Canton Hong
  Kong, India Medicine Pasteur, Koch work with
  bacteria.
• 1894 Kitasato and Dr. Alexandre E.J. Yersin
  isolated, described cause. Yersin credited
  bacteria Yersinia pestis
• 20th Century 1900-1904 San Francisco 121
  cases,118 died. Asian immigrants isolated.
  Quarantine did not work scientists views
  accepted. Ships disinfected. Clean-up. Rats
  destroyed.
• 1924-1925 Los Angeles 40 cases, 38 died. 1940s
  Development of antibiotics. Plague treatable.
• By 1949 New Mexico U.S. leader in of cases.
  Threat if no antibiotics 9/94-India pneumonic
• 1898-1920, 1991, 1995-1998 Madagascar. 12/1996
  CDC MMWR Prevention of Plague Report
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins,
  49-51. Yancey, D. (1994). The hunt for hidden
  killers ten cases of medical mystery.
  Brookfield, CT Millbrook Press, 61-71. Boisier
  (2002) Emerging Infectious Diseases McClain, C.
  Of Medicine, Race and American Law-1900)

14
History of Bubonic Plague - 5

• 21st Century Today as we speak
• November 7, 2002 CNN.com Bubonic plague
  suspected in New York City NYC Visitors
• Nov. 9, 2002 New Mexico visitors to NYC
  diagnosed with bubonic plague still in hospital.
• NYCs 1st case of bubonic plague in century (CDC,
  2002)
• Couple suspected of contracting plague from
  rodents on their property (Robin, 2002)
• April-May 2002 71 cases in Malawi
  http//www.cdc.gov/ travel /other/plague-outbreak-
  malawi.htm
• History of Bubonic Plague Was it really the
  plague, or scarlet fever, or ebola virus? ...
  Delta 32 gene mutation
• Plague as biological weapon (U.S. Working Group
  on Civilian Biodefense, JAMA (5/3/2000)
  Recommendations

15
II.Symptoms ofRubella and The Bubonic
Plague
16
Symptoms of the DiseaseRubella Symptoms

• Rubella mild, highly contagious virus.
  Symptoms rash, swollen glands/lymph nodes, and,
  especially in adults, joint pain. Rash lasts
  about 3 days, also may low fever. Infected
  adults, teens also headache, loss of appetite and
  sore throat. Sometimes no symptoms at all.
• 1/2 cases occur without rash. Lasts lt 2 wks in
  children.
• Incubation period12-23 days most cases,
  symptoms appear within 16-18 days.
• Rubella immunity does not protect against
  rubeola.
• National Institutes of Health. National
  Toxicology Program (NTP). Center for the
  Evaluation of Risks to Human Reproduction
  CERHR. Rubella (German measles) 5/24/02).
  Retrieved October 23, 2002, from
  http//cerhr.niehs.nih.gov/genpub/topics/rubella-c
  cae.html.
• (New York State Department of Health.
  Communicable disease fact sheet rubella.
  Retrieved October 23, 2002, from
  http//www.health.state.ny.us/nysdoh/consumer/rube
  lla.htm)

17
Symptoms of the DiseaseCongenital Rubella
Syndrome CRS

• In pregnant women, the infection can pass to the
  developing fetus, especially during the first
  trimester of pregnancy, causing severe injuries
  to the fetus/newborn.
• Approximately 15-20 of pregnant women infected
  during first trimester give birth to infants with
  heart defects (50), deafness (50), eye defects
  and blindness (40), mental retardation (40),
  blood defects such anemia and bleeding (30),
  bone lesions, enlarged liver, spleen, and hand
  abnormalities.
• About 10 of infants born with CRS die, while
  severe infections result in spontaneous abortion.
  
• Greatest virulence first 2 months of pregnancy.
  50 of women infected during 1st month of
  pregnancy babies born with host of differences.
  Infection in 3rd month 10 of infants. Infection
  after 4th month less severe differences.
  (Parkman, Meyer, Hilleman, 1997, 2000).

18
Symptoms of the DiseaseBubonic Plague
Symptoms

• Bubonic plague enlarged, tender lymph nodes
  (buboes), fever, chills, prostration,
  gastrointestinal symptoms
• Septicemic plague fever, chills, prostration,
  abdominal pain, shock, bleeding into skin and
  other organs
• Pneumonic plague fever, chills, cough and
  difficulty breathing rapid shock and death if
  not treated early
• (Centers for Disease Control and Prevention. CDC
  plague fact sheet. Retrieved October 22, 2002,
  from http//www.cdc.gov/ncidod/dvbid/plague/facts.
  htm)

19
III.Causative Agents and how they were
determinedRubella and the Bubonic Plague
20
Causative Agent Rubella(Togavirus, genus
Rubivirus)
Source CDC Public Health Image Library, Image
269 URL http//phil.cdc.gov/Phil/detail.asp?id26
9 CDC Description Transmission electron
micrograph of rubella virus (1981) image in
public domain
21
Causative Agent Rubella (Togavirus, genus
Rubivirus)

• Rubella as separate entity not identified until
  1881. Thought to be scarlet fever or measles.
  Mild symptoms identity, severity discounted to
  1941.
• 1941 Gregg, Australia maternal-fetus
  transmission
• Caused by virus based on incubation period (12-23
  days), clinical course (symptoms 16-18 days),
  lack of response to antibiotics. (Cooper, 1966,
  32. NYS Dept. of Health, 2002, Rubella, 2002)
• 1941-1961 Unsuccessful attempts to isolate
  virus.
• 1960-1962-Virus isolated-Walter Reed,Harvard, NIH
  labs
• Discovery of very different virologies of
  intra-uterine and post-natal infections by
  1963-1965 major U.S. epidemic
• The rubella epidemic (1960s). (1998, 2000).
  American Decades CD-ROM. Gale Research. Retrieved
  November 15, 2002, from Student Resource Center
  College Edition database, http//galenet.galegroup
  .com/servlet/SRCCE. The rubella epidemic (1960s).
  (1998, 2000). American Decades CD-ROM. Gale
  Research. Retrieved November 15, 2002, from
  Student Resource Center College Edition database,
  http//galenet.galegroup.com/servlet/SRCCE.
  Cooper, 1966).

22
Causative Agent Bubonic Plague (Bacterium
Yersinia pestis) - 1
Source CDC Public Health Image Library, Image
2117 URL http//phil.cdc.gov/Phil/detail.asp?id2
117 (image in public domain) CDC Description
Yersinia (Pasteurella) pestis causes plague in
animals and humans. People usually get plague
from being bitten by a rodent flea that is
carrying the plague bacterium, or by handling an
infected animal.
23
Causative Agent Bubonic Plague(Bacterium
Yersinia pestis) - 2

• Agent bacterium Yersinia pestis. Kitasato/Yersin
  described bipolar staining organisms in dead
  patients swollen lymph node (bubo), blood,
  lungs, liver, spleen (Bibel et al., 1976).
• Patient specimen cultures into animals, mice.
  Animals died within days after injection. Same
  bacilli in animal organs as in patient specimens.
  Yersin, primary discoverer rats affected during,
  before humans.
• 1898 Simond Persons who became ill did not have
  to be in close contact with each other to be
  infected. Suspected flea as intermediary factor.
  Infection only if in contact with rats that had
  died within 24 hours. Simond experiment healthy
  rat, separated from direct contact with a
  recently plague-killed rat, died of plague after
  infected fleas jumped from first rat to second.
• Centers for Disease Control and Prevention.
  Division of Vector-Borne Infectious Diseases. The
  plague natural history. Retrieved October 22,
  2002 from http//www.cdc.gov/ncidod/dvbid/plague/
  history.htm

24
IV. How Diseases Spread Rubella
andThe Bubonic Plague
25
How Disease SpreadRubella

• Person to person infected person coughs or
  sneezes.
• Direct contact with nasal, throat secretions of
  infected person. If woman infected during first 3
  months of pregnancy, baby risk of serious birth
  defects or dying.
• Highly contagious. High herd immunity required,
  85-90
• CRS highly contagious gt virulence affected
  newborns can infect others with virus up to 1
  year after birth.
• In a hospital setting, newborns with CRS can
  infect hospital personnel, other newborns, and
  other women who are pregnant and visitors to the
  hospital, compounding spread of the virus.
•  National Coalition for Adult Immunization.
  (2002). Facts about rubella for adults.
  Retrieved October 23, 2002, from
  http//www.nfid.org/factsheets/rubellaadult.html
• Parkman, P.D., Meyer, H.M., Jr., Hilleman, M.R.
  (1997, 2000). Vaccine developed for German
  measles, 1960-1969. In DISCovering U.S. History.
  Gale Research. Retrieved September 16, 2002,
  from Student Resource Center College Edition
  database at http//galenet.galegroup.com/servlet/S
  RCCE/

26
How Disease Spread Bubonic Plague - 1

• Zoonotic infectious disease spread principally by
  reservoir of infected rats, shrews, prairie dogs,
  and other mammals.
• Vector Rat flea

Source CDC (in public domain) URL
http//www.cdc.gov/ncidod/ dvbid/plague/cheob6x4.h
tm CDC Description Male Xenopsylla cheopis
(oriental rat flea) engorged with blood. This
flea is the primary vector of plague in most
large plague epidemics in Asia, Africa, and South
America. Both male and female fleas can transmit
the infection.
27
How Disease SpreadBubonic Plague - 2

• People bitten by rodent flea carrying Yersinia
  pestis handle infected animal. Homes, places of
  work with flea-infested rats. Wild rodents in
  certain areas.
• Los Angeles 1924-25 last U.S. urban epidemic.
  Since then, most cases rural areas (10-15/year).
  Globally, WHO 1,000-3,000 cases every year.
• N. America Pacific Coast-Great Plains, SW
  Canada-Mexico. Africa, Asia, S. America. U.S.
  most human cases N. NM, AZ, S. CO CA, S.
  Oregon, far W. Nevada.
• Natural cycle small mammals/fleas, no humans
  involved
• Periods few/no human cases last years. Not
  eradicated. May suddenly reappear in rodents,
  fleas near homes. Panic. gt risk Poor sanitation,
  overcrowding, rodents
• Controversy if etiology was the same for all
  outbreaks .
• (Centers for Disease Control and Prevention. CDC
  Plague Home Page, 2002) Centers for Disease
  Control and Prevention. Division of Vector-Borne
  Infectious Diseases. The plague natural history.
  Retrieved October 22, 2002 from
  http//www.cdc.gov/ncidod/dvbid/plague/history.htm
  Drancourt, M. Raoult, D. (2002, January).
  Molecular insights into the history of plague.
  Microbes and Infection / Institut Pasteur, 4(1)
  105-9.) Cohn, S.K., Jr. (2002, June). The Black
  Death end of a paradigm. American Historical
  Review, 107(3) 703-738. Retrieved October 27,
  2002, from Ebscohost database.)

28
V. Mechanisms of Containment Rubella
andThe Bubonic Plague
29
Mechanisms of ContainmentRubella - 1

• Vaccination (3 strains) since 1969
• Induces seroconversions in approximately 95 of
  susceptible individuals. Vaccine-induced
  infection non-communicable. Viremia-low level
  not easily detected.
• Rubella vaccine given on or after a child's 1st
  birthday usually combined with measles / mumps
  (MMR) vaccine
• Children 1st dose 12-15 months or age 2nd dose
  before starting school at 4-6 years of age.
• During 2000, 87 reported cases among people
  15-39 years of age. About 8 million women of
  childbearing age susceptible. Up to 10 of young
  adults susceptible.
• (National Coalition for Adult Immunization.
  (2002). Facts about rubella for adults.
  Retrieved October 23, 2002, from
  http//www.nfid.org/factsheets/rubellaadult.html
  (New York State Department of Health. (2002).
  Communicable disease fact sheet rubella.
  Retrieved October 23, 2002, from
  http//www.health.state.ny.us/nysdoh/consumer/rube
  lla.htm)

30
Mechanisms of ContainmentRubella - 2

• N.Y. State Health Dept., WHO High coverage in
  immunization programs needed to avoid increase in
  CRS.
• (New York State Department of Health.
  Communicable Disease Fact Sheet. Rubella.
  Retrieved October 23, 2002, from
  http//www.health.state.ny.us/nysdoh/consumer/rube
  lla.htm) World Health Organization. Vaccines,
  Immunization and Biologicals Rubella vaccine.
  Retrieved October 23, 2002, from
  http//www.who.int/vaccines/en/rubella.shtml)
• MMR Autism Link Controversy 1998-2002 whether
  link between MMR vaccine - inflammatory bowel
  disease/autism 2/28/1998 British study Early
  report in Lancet. Researcher Andrew Wakefield
  lost university position because of controversy.
• (Wakefield AJ, Murch SH, Linnell AAJ, Casson DM,
  Malik M, Berelowitz M, et al. (1998, February
  28). Ileal-lymphoid-nodular hyperplasia,
  non-specific colitis and pervasive developmental
  disorder in children. Lancet, 351(9103), 637-41.
  ). Retrieved November 16, 2002, from EBSCOHost
  Academic Search Premier database. Ramsey, S.
  (2001, December 8). Controversial MMR-autism
  investigator resigns from research post. Lancet,
  358(9297). Retrieved November 16, 2002, from
  EBSCOHost Academic Search Premier database.)

31
Mechanisms of ContainmentRubella - 3

• MMR Autism Link Controversy
• Claims on anti-vaccination websites
• vaccines cause idiopathic illness (100 of sites)
• vaccines erode immunity (95)
• adverse vaccine reactions underreported (95)
• vaccination policy is motivated by profit (91)
• links to other anti-vaccination sites (100)
• information for legally avoiding immunizations
  (64)
• emotionally charged stories of children who had
  allegedly been killed or harmed by vaccines
  (55).
• (Wolfe, L.K., Sharp, M., Lipsky, M. (2002, June
  26). Content and design attributes of
  anti-vaccination web sites (brief report). JAMA
  The Journal of the American Medical Association,
  287(24), 3245-3249.)

32
Mechanisms of ContainmentRubella - 4

• In 1986, the U.S. Congress passed the National
  Childhood Vaccine Injury Act that established the
  National Vaccine Injury Compensation Program
  (VICP), a federal system to compensate
  individuals or families injured by childhood
  vaccines, claims for severe shock, paralytic
  polio, and brain damage.
• A physician from the YSDHHS reviews claims, then
  claims are decided in federal court.
• Act also established the Vaccine Adverse
  Reporting System (VAERS) to which anyone can
  report a suspected reaction to any vaccine. Act
  also provided for increased communication about
  risks from immunizations. The Institute of
  Medicine established a Vaccine Safety Ctte. to
  study risks of childhood vaccines. (Hyde, M.O.,
  Forsythe, E.H. (2000). Vaccinations from
  smallpox to cancer. New York Franklin Watts, 66.)

33
Mechanisms of ContainmentRubella - 5

• MMR Autism Link Controversy
• German measles-rubella vaccine is a live
  attenuated vaccine made from live but weakened
  microbes. The microbes are weakened by growing
  them under special conditions in tissue cultures
  in the laboratory. The vaccine stimulates the
  immune system more strongly than do inactivated
  vaccines (made from killed bacteria or viruses
  that have been inactivated by chemicals or heat).
  People usually need only one booster. Once the
  rubella vaccine is injected, weakened microbes
  from a live vaccine can change into a virulent
  form, so that live vaccines are not given to
  pregnant women or people with damaged immune
  systems such as people with HIV, cancer, or
  people who take medications that suppress their
  immune systems.
• (Offit, P.A., Bell, L.M. (1998). What every
  parent should know about vaccines. New York
  Macmillan, 70-72.)

34
Mechanisms of ContainmentRubella - 6

• CDC Autism Link Controversy (last word)
• While rubella is usually mild in children and
  adults, up to 90 percent of infants born to
  mothers infected with rubella during the first
  trimester of pregnancy will develop congenital
  rubella syndrome (CRS), resulting in heart
  defects, cataracts, mental retardation, and
  deafness. In 1964-1965, before rubella
  immunization was used routinely in the U.S.,
  there was an epidemic of rubella that resulted in
  an estimated 20,000 infants born with CRS, with
  2,100 neonatal deaths and 11,250 miscarriages. Of
  the 20,000 infants born with CRS,11,600 were
  deaf, 3,580 were blind, and 1,800 were mentally
  retarded.Due to the widespread use of rubella
  vaccine, only six CRS cases were provisionally
  reported in the U.S. in 2000. Because many
  developing countries do not include rubella in
  the childhood immunization schedule, many of
  these cases occurred in foreign-born adults.
  Since 1996, greater than 50 percent of the
  reported rubella cases have been among adults.
  Since 1999, there have been 40 pregnant women
  infected with rubella. If we stopped rubella
  immunization, immunity to rubella would decline
  and rubella would once again return, resulting in
  pregnant women becoming infected with rubella and
  then giving birth to infants with CRS.
• (Centers for Disease Control and Prevention.
  Rubella (German measles) What would happen if we
  stopped vaccinations? Retrieved October 26, 2002,
  from http//www.cdc.gov/nip/publications/fs/gen/Wh
  atIfStop.htmRubella)

35
Mechanisms of ContainmentBubonic Plague

• Increased self-sufficiency of public health labs
• Surveillance through animal serosurveys GIS
  systems
• Increased education public and health
  professionals
• Research on prevention, control with other
  agencies
• Ecology-based prevention, control
• Development of new potential vaccines
• Identify risk factors landscape ecology,
  epidemiology
• Refrain from contact with rodents
• Use insect repellent in areas with potential
  vectors, hosts
• Wear proper attire to protect selves
• Centers for Disease Control and Prevention. CDC
  plague fact sheet. Retrieved October 22, 2002,
  from http//www.cdc.gov/ncidod/dvbid/plague/facts.
  htm

36
VI. Percentage of FatalitiesRubella and The
Bubonic Plague
37
Percentage of Fatalities Rubella

• U.S. Rubella Epidemic of 1964-1965
• 12.5 million rubella cases 2,000 encephalitis
  cases
• 11,250 surgical, spontaneous abortions 2,100
  neonatal deaths 20,000 CRS cases possibly all
  organs affected fetal death. 85 of infants
  infected in 1st trimester affected. CRS causes
  deafness, heart defects, cataracts, blindness,
  microcephaly, mental retardation, bone
  alterations, liver/spleen damage
• 2002 Current CRS Incidence
• 0.5-2.2/1000 live births in developing countries
  during epidemics (every 4-7 years) High
  susceptibility 25
• 1996 CRS estimate developing nations-110,000
  cases
• (Centers for Disease Control and Prevention
  (2002). Rubella. Retrieved November 16, 2002,
  from http//www.cdc.gov/nip/publications/pink/rube
  lla.pdf)
• Hinman, A.R., Irons, B., Lewis, M., Kandola, K.
  (2002, April). Economic analyses of rubella and
  rubella vaccines a global review. Bulletin of
  the World Health Organization, 80(4), 264-271.
  Retrieved September 16, 2002, from Infotrac
  General Reference Center Gold database.

38
Fatalities Bubonic Plague

• Bubonic plague most common form of U.S. cases
  80-90. Case Fatality Rate if not treated
  50-60
• Septicemic plague when Yersinia pestis invades
  and continues to multiply in the bloodstream
  primary or secondary to bubonic plague. U.S.
  1947-1977 10 septicemic. Case fatality
  rate-50. Complications septic shock,
  consumptive coagulopathy, meningitis, coma.
• Pneumonic plague least common but most dangerous
  and fatal form - inhalation of infectious
  respiratory droplets. Incubation period 1-3
  days. Without treatment, death within 18 hours
  after onset of respiratory symptoms. (Centers for
  Disease Control and Prevention (1996). Prevention
  of plague recommendations of the Advisory
  Committee on Immunization Practices (ACIP).
  Morbidity and Mortality Weekly Report, 45(RR-14)
  1-15.

39
VII. TreatmentsRubella and The Bubonic
Plague
40
Treatments Rubella

• There is no specific treatment for congenital
  rubella syndrome. Certain problems that are
  common in the newborn period-such as blood and
  liver abnormalities-usually go away without
  treatment. Other individual birth defects-such as
  eye or heart defects-can sometimes be corrected
  or at least improved with early surgery. Babies
  with hearing or vision loss benefit from special
  education programs that provide early stimulation
  and build communication and learning skills.
  Children with mental retardation also benefit
  from early special education. Children with
  multiple differences may require early
  intervention from a team of experts.
• National Institutes of Health. National
  Toxicology Program (NTP). Center for the
  Evaluation of Risks to Human Reproduction
  CERHR. Rubella (German measles) 5/24/02).
  Retrieved October 23, 2002, from
  http//cerhr.niehs.nih.gov/genpub/topics/rubella-c
  cae.html

41
Treatments Bubonic Plague

• In medieval times bloodletting at site of
  buboes, prayer
• Fire-to keep away rats-used by Pope Clement
• Strict isolation.
• Antibiotics (resistant to bacterium).
• Maintenance of sanitary conditions.
• Pneumonic plague gas masks?
• CDC Travelers warning
• Travelers considered to be at high risk for
  plague because of unavoidable exposures in active
  epizootic or epidemic areas should be advised to
  consider antibiotic chemoprophylaxis with
  tetracycline or doxycycline during periods of
  exposure.
• (Centers for Disease Control and Prevention.
  National Center for Infectious Diseases.
  Travelers health plague. Retrieved November 16,
  2002, from http//www.cdc.gov/travel/diseases/plag
  ue.htm)

42
VIII. Advice about Avoiding Further
Outbreaks Rubella and The Bubonic Plague
43
Advice about avoiding further outbreaks of Rubella

• WHO effort to establish national vaccination
  programs for rubella in all nations. (WHO, 2002)
• In U.S., special outreach to women of Hispanic
  ethnicity in Spanish, to other women in native
  languages (re CRS)
• Immediate quarantine of people diagnosed as
  having rubella (although may be too late).
• Comprehensive surveillance of immunization
  programs
• Continued public awareness campaigns to promote
  MMR immunizations, safety of MMR vaccines.
• CDC Travelers Warning
• Rubella occurs worldwide, and the risk of
  exposure to rubella outside the United States can
  be high. Few countries routinely use rubella
  vaccine, so rubella remains a common disease in
  many countries in the world.
• (Centers for Disease Control and Prevention.
  Travelers' health information on rubella.
  Retrieved November 9, 2002, from
  http//www.cdc.gov/travel/diseases/rubella.htm)
• Public awareness about differabilities and
  accessibility issues. Equity of access for
  people with differabilities.

44
Advice about avoiding further outbreaks of
Bubonic Plague

• Good sanitation and hygiene
• Avoid rodents, reservoirs of flea vectors
• Be alert to deaths of populations of rats
  population, other animals.
• Apply insect repellent, wear protective clothing
  in affected areas.
• Public awareness about types of plague
• To investigate and stop spread, must seek out
  anyone who was in contact even casually with
  victim.
• Treatment antibiotics. Possible source if
  victim hunter, has pets (if let fleas-infested
  dog sleep on bed)-if show symptoms within ½ wks.
  
• Animal carriers of fleas some can remain
  healthy. If set traps, animals probably died.
  Then need to find fleas (i.e. in burrows) and do
  flea eradication program.
• In 1992 alone, at least 10 cases of plague
  reported. Plague-infested rodents, such as
  chipmunks and mice, probably more numerous in
  North America today than were in Europe at time
  of Black Death.
• (Yancey, D. (1994). The hunt for hidden killers
  ten cases of medical mystery. Brookfield, CT
  Millbrook Press, 61-71.)

45
IX. Differences and SimilaritiesRubellaandTh
e Bubonic Plague
46
Differences Rubella (R) and Bubonic Plague (BP)

• R Agent togavirus / BP agent bacteria
• R person to person / BP zoonotic carriers
• R vaccination / BP antibiotic treatment
• R mild symptoms / BP severe symptoms
• R also intrauterine in which severe
  consequences / BP infection touch/inhalation
• R virus isolated 1962 BP bacterium 1864
• R incubation12-23 days / BP 2-6 days
• R symptoms sometimes inapparent or mistaken for
  other diseases / BP symptoms apparent

47
Similarities Rubella (R) and Bubonic Plague (BP)

• R BP
• Symptoms swelling of lymph nodes
• Exanthem diseases causing skin eruptions
• Transmittable via inhalation. Highly contagious.
• Epidemics have caused mass panic
• R infection inhalation, also intrauterine /
  Plague (pneumonic) infection via inhalation
• Originally confusion as to agents of disease
  attributions to scarlet fever, measles

48
X. Effects on SocietyRubella and The Bubonic
Plague
49
Effects on Society Rubella

• First identified teratogen
• Focused world on intrauterine disease
  transmission from mother to fetus
• Focused world on importance of good health for
  women, particularly women who are, intend to
  become pregnant
• Disease with mild symptoms, can have devastating
  effects (highly contagious CRS)
• Public awareness concerning need for
  vaccinations, national immunization programs
• MMR vaccine controversy health scares / Internet
  age
• Public awareness and programs, re
  differabilities, equity of access/civil rights,
  special ed. needs, Deaf culture.
• 1988 Deaf President Now movement at Gallaudet
  University 20-25 years after epidemic great
  impetus for passage of The ADA civil rights law
  in 1990

50
Effects on SocietyBubonic Plague

• Bubonic plague changed the course of history.
• Wars won and lost influenced power of Church
• Resulted mass death, destruction, persecution
• Mass fear, panic. Pandemic. Terrorism. Special
  threat from pneumonic plague. Plague as a
  Biological Weapon From Working Group on Civilian
  Biodefense. (2000). Consensus statement plague
  as a biological weapon medical and public health
  management. JAMA, Journal of the American
  Medical Association, 283(17), 2281-2290.
  Retrieved October 29, 2002, from Academic Search
  Premier/Ebscohost database.
• Conclusions An aerosolized plague weapon could
  cause fever, cough, chest pain, and hemoptysis
  with signs consistent with severe pneumonia 1 to
  6 days after exposure. Rapid evolution of disease
  would occur in the 2 to 4 days after symptom
  onset and would lead to septic shock with high
  mortality without early treatment. Early
  treatment and prophylaxis with streptomycin or
  gentamicin or the tetracyclin or fluoroquinolone
  classes of antimicrobials would be advised.
  Peace.

51
XI. Recent OutbreaksRubella and The Bubonic
Plague
52
Recent outbreaks - Rubella - 1

• 1999 Nebraska 82 cases from workers of
  Hispanic origin in meat-packing plant (JAMA, Dec.
  6, 2000)
• July-Sept. 14, 2002 3 cases in United Kingdom
  9/02 case Sri Lankan woman pregnant for first
  time and her infant, born at 34 weeks with
  intrauterine growth restriction, thrombocytopenia
  (high level of platelets), both tested positive
  for rubella virus.
• At least 5 cases of congenital rubella infection
  in areas of London with large numbers of
  immigrant women from countries where rubella is
  endemic and childhood vaccination is not routine.
  
• Belief that rubella may be underdiagnosed.
• (Thomas, R.M. (2002, September 14). Cases of
  congenital rubella may be the tip of the iceberg
  Letter. British Medical Journal, 325(7364),
  596-597.)

53
Recent outbreaks - Rubella - 2

• According to Dr. Susan Reef, M.D., Chief, CDC
  National Immunization Program (2002, January)
• 1997-1999 20 of 24 babies born with the birth
  defects associated with rubella were born to
  Hispanic mothers.
• Of the 47 countries in the Americas, only 44 have
  rubella immunization programs, and most of those
  programs have only been operating for a few
  years. Countries like India, China and Russia do
  not routinely vaccinate against rubella. Neither
  do most African countries.(Edwards, Bob. (2002,
  January 23, 10-11 AM EST). Profile efforts to
  eradicate rubella in the United States
  transcript of interview with Dr. Susan Reef,
  M.D.,Chief, CDC National Immunization Program,
  National Public Radio Morning Edition.)

54
Recent outbreaks - Rubella - 3

• Zimmerman, L. Reef, S.E. (2001, March).
  Incidence of congenital rubella syndrome at a
  hospital serving a predominantly Hispanic
  population, El Paso, Texas. Pediatrics, 107(3)
  E40.
• The rate of infants meeting the definition of
  confirmed and probable CRS congenital rubella
  syndrome was 3.1 per 10,000 hospital births.
• Reported CRS rate in U.S. 0.01-0.08 per 10,000
  live births.
• Conclusion Need for greater awareness and
  reporting of cases among populations at risk by
  physicians.

55
Recent outbreaks Bubonic Plague

• April 16, 2002-May 2002 71 cases in Malawi,
  Mozambique
• November 2002 two cases, New York City, Couple
  infected in New Mexico, probably near home. First
  cases in NYC in over 100 years.

56
Thank You. Thank you, Dr. Wiginton.End of
Presentationhttp//www.a4access.org/epipaperrevis
ed.pptThis presentation is available in
alternative formats upon request.Peace.