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Title: 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.
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