The Bubonic Plague and Rubella A Comparison

1
The Bubonic PlagueandRubellaA Comparison
Ellen Perlow HS 5353 Epidemiology Dr.
Wiginton Fall 2002 Texas Womans University
Dept. of Health Studies November 19, 2002
http//www.a4access.org/epipaper.ppt Narrative at
http//www.a4access.org/epipaper1102.doc This
presentation is available in alternative formats
upon request.
2
I.History and Current Status of The
Bubonic PlagueandRubella
3
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
4
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.

5
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.)

6
History of Bubonic Plague - 2

• Summer 430 B.C.E. Athens
• Athens at war with Sparta
• Sailors brought mysterious illness from Egypt.
  1/3 population of Athens died. Pericles killed.
• Changed history Athens lost to Sparta.
• Could have been typhus, smallpox, scarlet fever.
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins, 1-3.)

7
History of Bubonic Plague - 3

• 1346-1347 Black Sea/S. Ukraine
• Epidemic Victims suffered from headaches, felt
  weak and tired, and staggered when they try to
  walk. By the third day, the lymph nodes in the
  sufferers groins, or occasionally their armpits,
  began to swell. Swellingsbuboes. In Greek.
  groinboubondisease name Bubonic plague.
• Also named Black Death The Great Pestilence.
• Italian traders blamed. Infected, return to
  Sicily. Plague spread to Sicily, then mainland
  Italy.
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins,
  11-12. Working Group on Civiliian Biodefense
  (2000). Plague as a biological weapon. JAMA,
  283(17), 2281.)

8
History of Bubonic Plague - 4

• October 1347 Sicily -- Italy
• Italian sailors ordered to stay on board. Did not
  know that carriers were black rats and fleas that
  lived in their hair. Plague spread to port of
  Messina, ports of mainland Italy, Milan,
  Florence, Venice ...
• Splendid breeding ground garbage, garbage
• Venice decree of quaranta giorni quarantine of
  sailors on ships for 40 days
• Literary references Bocaccios Decameron.
• By winter 1348-1349, 1/3-1/2 population of Italy
  killed.
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins,
  13-20.)

9
History of Bubonic Plague - 5

• Sp. 1348 Marseilles-Avignon, France
• Avignon Popes home. Pilgrims unknowingly
  brought plague.
• Feb.-May 400 people/day, 1349 50,000-Paris
• Pope Clement fire/humors (Hippocrates, Galen)
• Church no dissection, autopsies. Humors/miasmas
  theories of Hippocrates, Galen.
• Attributed plague to imbalance of humors
  miasmas.
• Treatments bloodletting at site of buboes,
  prayer.
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins,
  21-25.)

10
History of Bubonic Plague - 6

• Summer 1349-1351 British Isles and Germany
  early 1400s.
• Plague killed up to 80 of some villages
• Devastation led to vehement persecution and
  discrimination against people who were different
• German Flagellant movement, 1st Holocaust,
  intense Anti-Semitism. Power of Church reduced
  (precursor to rise of Protestantism).
• Epidemics in Europe about every 10 years to early
  1400s. Europe lost ½ of population.
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins,
  26-40.)

11
History of Bubonic Plague - 7

• 15th-16th-17th Centuries
• Reform of Catholic Church ---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,
  41-49.)

12
History of Bubonic Plague - 8

• 18th-19th Centuries
• By 1750, bubonic plague faded out in western
  Europe, though still active in Mediterranean.
• 1855 pandemic in interior of China, to Canton
  and Hong Kong. Killed gt12 million people in India
  and China.
• Medicine Work of Pasteur, Koch with bacteria.
• 1894 Kitasato and Dr. Alexandre E.J. Yersin
  isolated and described the cause of plague. Dr.
  Yersin received the credit bacteria later named
  Yersinia pestis
• (Giblin, J.C. (1995). When plague strikes the
  Black Death, smallpox, AIDS. HarperCollins,
  49-50. Yancey, D. (1994). The hunt for hidden
  killers ten cases of medical mystery.
  Brookfield, CT Millbrook Press, 61-71.)

13
History of Bubonic Plague - 9

• 20th Century
• 1900-1904 San Francisco outbreak 121 cases,118
  died
• Person/person transmission Asian immigrants
  isolated.
• Quarantine did not work scientists explanation
  accepted
• Ships disinfected. Massive clean-up. Rats
  destroyed.
• 1924-1925 Los Angeles outbreak 40 cases, 38
  died.
• 1940s Development of antibiotics. Plague
  treatable.
• By 1949 New Mexico U.S. leader in of plague
  cases
• Threat if no antibiotics 9/94-India pneumonic
  plague
• 1898-1920, 1991, 1995-1998 Madagascar epidemics
• Dec. 1996 CDC MMWR Prevention of Plague Report
• (Giblin, J.C. (1995), 50-51 Boisier (2002)
  Emerging Infectious Diseases McClain, C. Of
  Medicine, Race and American Law-1900)

14
History of Bubonic Plague - 10

• 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 first case of bubonic plague in a century.
  (CDC, 2002)
• Couple suspected of contracting plague from
  rodents on their property (Robin, 2002)
• Plague as biological weapon (U.S. Working Group
  on Civilian Biodefense, JAMA (5/3/2000)
  Recommendations

15
History of Bubonic Plague - 11

• 21st Century Today as we speak, continued
• According to the World Health Organization
  (WHO), as of May 27, 2002, the Malawian Ministry
  of Health has reported a total of 71 cases of
  bubonic plague in the district of Nsanje since
  the onset of the outbreak on April 16, 2002. The
  outbreak has affected 26 villages - 23 in the
  Ndamera area, 2 in Chimombo, and 1 village in
  neighboring Mozambique.
• Centers for Disease Control and Prevention.
  National Center for Infectious Diseases.
  Travelers health outbreak of bubonic plague in
  Malawi, as of May 27, 2002. Retrieved November
  9, 2002, from http//www.cdc.gov/travel/other/plag
  ue-outbreak-malawi.htm.

16
History of Bubonic Plague - 12

• 21st Century, Controversy, Outbreaks, heightened
  interest, terrorism ...
• How to prepare for terrorism via plague
  (especially pneumonic). (Don't miss
  smallpox/plague outbreaks adapt strategies to
  track bioterrorism. ED management the monthly
  update on emergency department management. 2002
  Jan 14(1) 1-3.)
• History of Bubonic Plague Was it really the
  plague, or scarlet fever, or ebola virus? ...
  Delta 32 gene mutation
• Current Outbreaks NYC CDC Travelers Health
  Information on Plague (retrieved 11/9/2002)
  enzootic in wild rodent populations over large
  rural areas of the Americas, Africa, and Asia.
  Prophylactic measures antibiotics, insect
  repellants http//www.cdc.gov/travel/diseases/pl
  ague.htm PBS...

17
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
18
History of Rubella - 1

• 1881 Officially recognized as a distinct
  clinical entity at international medical congress
  in London. Before that time, confusion as to
  whether it was a mild form of measles (rubeola)
  or scarlet fever, or both, and what it should be
  called.
• The name rubella, first proposed in 1866,
  accepted.
• In the next 60 years, little attention was paid
  to rubella since the disease was not considered
  serious and did not have serious complications.
• (Horstmann, Dorothy M. (1986, Oct. 11). The
  rubella story, 1881-1985. South African Medical
  Journal, Supplement, 60-63.)

19
History of Rubella - 2

• 1935 Epidemic of rubella, largely went
  unnoticed.
• 1940 Large rubella epidemic in Australia.
• 1941 Australian ophthalmologist Dr. Norman Gregg
  discovered relationship between maternal rubella
  during pregnancy and congenital defects in
  infants.
• 1941 Dr. Gregg had observed in his practice in
  Sydney a rise in the number of infants born with
  cataracts. Found that the mothers of most of the
  infants had contracted rubella when they were in
  their first few months of pregnancy during the
  1940 epidemic.
• Dr. Greggs colleagues also noticed numerous
  infants being born with cataracts, as well as
  infants born who were small in size, had failure
  to thrive, cardiac abnormalities, and
  microphthalmia an unnatural smallness of the
  eyes.
• 1941 Dr. Gregg documented 78 cases of congenital
  rubella syndrome CRS and published a paper in
  the Transactions of the Ophthalmological Society
  of Australia
• (Horstmann, Dorothy 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.)

20
History of Rubella - 3

• 1941 Discovery of association between maternal
  rubella and newborns differences - profound
  impact on the entire field of congenital disease.
• Rubella was the very first well defined
  teratogen an agent that causes developmental
  differences. Dr. Greggs findings were confirmed
  in other studies in Europe, the U.S., New
  Zealand, and Australia. The studies showed that
  many children born with differences were
  correlated with their mothers having a history of
  rubella.
• (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.)

21
History of Rubella - 4

• 1941-1961 For twenty years, scientists tried to
  isolate the rubella virus, using experimental
  animals, but without success.
• 1962 Drs. Parkman, Meyer, Hilleman at 3
  laboratories Walter Reed, Harvard, and NIH -
  isolated rubella virus. New standard of
  cooperation in medical research.
• Early 1960s 40,000 and 45,000 cases of rubella
  per year.
• (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.)

22
History of Rubella - 5

• Spring 1964 Large epidemic of rubella in the
  United States. 7,000 fetal deaths, 20,000 babies
  born with congenital differences. Investigators
  discovered very different virologies of rubella
  intra-uterine infection and the post-natal
  infection.
• July 1966Pediatrician Louis Z. Cooper publishes
  German Measles, Scientific American.
• By 1969, three rubella vaccines ready for
  licensing. HPV77 DE5 (via monkey kidney cells
  and duck embryo tissue cultures), the Cendehill
  strain (via rabbit kidney cells), and the RA27/3
  strain (isolated in human diploid cells).
  Rubella vaccines induce seroconversions in
  approximately 95 of susceptible individuals.
  The vaccine-induced infection is
  non-communicable. Viremia the existence of
  viral particles in the bloodstream occurs at
  such a low level that it is not easily detected.
• (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.)

23
History of Rubella - 6

• 1969 - Beginning of rubella vaccination programs
  in US, UK, Australia,New Zealand.
• US/other nations different approaches target
  populations for immunization.
• U.S. focus on children who had not yet reached
  puberty, both boys and girls, 1 year and older.
  Goal to protect the age group in which most
  infections occurred. This way, it was reasoned,
  women who are pregnant would avoid being exposed
  to the infection. For the U.S. approach, a very
  high herd immunity in the population most greatly
  affected young children, was necessary.
  Identification and immunization of women of
  child-bearing age also was recommended.
• In the United Kingdom, Europe, and Australia, the
  immunization program begun in 1970 was limited to
  girls, usually between 10-14 years of age and to
  susceptible women. Thought that incidence of the
  congenital disease would not be reduced until the
  mid-1980s.
• (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.)

24
History of Rubella - 7

• 1989 Eradication of rubella goal of Healthy
  People 2000.
• 1988-1991 Reduction in rubella cases 98 since
  pre-vaccination era. However, 2-3 fold increase
  in incidence of rubella since 1982 (JAMA, 1991)
• 1990 1093 cases from 38 states,DC. 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 Publication of Danish study
  showing no link between administration of MMR
  vaccine and autism.
• November 19, 2002 Threats due to lack of
  vaccination in other countries, threats due to
  terrorism?
• Centers for Disease Control and Prevention.
  National Center for Health Statistics (1999).
  Healthy people 2000 progress review objective
  charts. Increase in rubella and congenital
  rubella. (1991, March 6). JAMA, The Journal of
  the American Medical Association, 265(9),
  1076-1077.(Rubella almost eradicated in the
  United States. (2002, 5 February). Virus Weekly.
  Retrieved September 16, 2002 from, General
  Reference Center Gold. Madsen K. M., Hviid A.,
  Vestergaard M., Schendel D., Wohlfahrt J.,
  Thorsen P., Olsen J., Melbye M. (2000, November
  7). A population-based study of measles, mumps,
  and rubella vaccination and autism. New England
  Journal of Medicine, 347, 1477-1482.

25
II.Symptoms of The Bubonic Plague and
Rubella
26
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 and 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)

27
Symptoms of the DiseaseRubella Symptoms - 1

• Rubella is a mild, highly contagious illness
  that is caused by a virus. It is characterized by
  a rash, swollen glands and, especially in adults,
  joint pain. The rash usually lasts about three
  days and may be accompanied by a low fever. Other
  symptoms such as headache, loss of appetite and
  sore throat are more common in infected adults
  and teenagers than in children. Sometimes there
  are no symptoms at all.
• Rubella is caused by a different virus from the
  one that causes regular measles (rubeola).
  Immunity to rubella does not protect a person
  from measles, or vice versa.
• 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.

28
Symptoms of the DiseaseRubella Symptoms - 2

• Rubella is a mild illness which may present few
  or no symptoms. Symptoms may include a rash,
  slight fever, joint aches, headache, discomfort,
  runny nose and reddened eyes. The lymph nodes
  just behind the ears and at the back of the neck
  may swell, causing some soreness and/or pain. The
  rash, which may be itchy, first appears on the
  face and progresses from head to foot, lasting
  about three days. As many as half of all rubella
  cases occur without a rash. The incubation period
  for rubella is 12-23 days in most cases,
  symptoms appear within 16-18 days.
• (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)

29
Symptoms of the DiseaseRubella Symptoms - 3

• Rubella, lasts less than two weeks in children.
• Symptoms swollen glands, a low fever, transient
  three-day rash.
• In women who are pregnant, 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 women who are pregnant
  who acquire German measles during the 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, enlarged spleen, and
  hand abnormalities.
• About 10 of infants born with congenital rubella
  syndrome CRS die, while severe infections
  result in spontaneous abortion.
• Greatest period of virulence first two months of
  pregnancy. Studies show that 50 of women
  infected during the first month of pregnancy gave
  births to babies with a host of differences. If
  women infected in 3rd month, 10 of infants have
  these differences. Infection after 4th month
  cause less severe differences in the fetus.
  (Parkman, Meyer, Hilleman, 1997, 2000).

30
III.Causative Agents and how they were
determinedThe Bubonic Plague and Rubella
31
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.
32
Causative Agent Bubonic Plague(Bacterium
Yersinia pestis) - 2

• Plague is an infectious disease of animals and
  humans caused by the bacteriumYersinia pestis.
  The fundamental but separate works by Yersin and
  Kitasato in 1894 on the discovery of the
  etiologic agent of plague in Hong Kong opened the
  way for investigating the disease and how it is
  spread. Kitasato and Yersin described, within
  days of each others findings, the presence of
  bipolar staining organisms in the swollen lymph
  node (bubo), blood, lungs, liver and spleen of
  dead patients. (Bibel et al., 1976).

33
Causative Agent Bubonic Plague(Bacterium
Yersinia Pestis) - 2

• Cultures isolated from patient specimens were
  inoculated into a variety of laboratory animals,
  including mice. These animals died within days
  after injection, and the same bacilli as those
  found in patient specimens were present in the
  animal organs. Though both investigators reported
  their findings, Yersin was accepted as the
  primary discoverer of the organism now named
  after him, Yersinia pestis

34
Causative Agent Bubonic Plague(Bacterium
Yersinia pestis) - 3

• Yersin had recorded that rats were affected by
  plague not only during plague epidemics but also
  often preceding such epidemics in humans. In
  fact, plague was designated, in local languages,
  as a disease of the rats villagers in China,
  India and Formosa (Taiwan) described that when
  hundreds and thousands of rats lie dead in and
  out of houses, plague outbreaks in people soon
  followed (Gross, 1995).

35
Causative Agent Bubonic Plague(Bacterium
Yersinia pestis) - 4

• Simond described transmission of plague in 1898.
  Persons who became ill did not have to be in
  close contact with each other to acquire the
  disease. Simond observed residents of China and
  Formosa being frightened of dead rats and viewing
  these rats as a risk for developing plague.
  Simond suspected that the flea might be an
  intermediary factor in the transmission of
  plague. People were infected with plague only if
  they were in contact with recently dead rats.
  They were not infected if they touched rats that
  were dead for more than 24 hours. Simond
  demonstrated that the rat flea (Xenopsylla
  cheopis) transmitted the disease in an experiment
  in which a healthy rat, separated from direct
  contact with a recently plague-killed rat, died
  of plague after the infected fleas jumped from
  the first rat to the 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

36
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
37
Causative Agent Rubella (Togavirus, genus
Rubivirus) - 1

• Rubella as a separate entity not identified until
  1881. Thought to be scarlet fever or measles.
• Identity and severity discounted until 1941 since
  mild symptoms.
• 1941 Dr. Norman McAlister Gregg in Australia
  discovered maternal-fetus intrauterine
  transmission.
• General agreement that rubella caused by virus
  based on its incubation period (12-23 days),
  clinical course (symptoms appear 16-18 days), and
  lack of response to antibiotics. (Cooper, 1966,
  32. NYS Dept. of Health, 2002, Rubella, 2002)
• 1941-1961 Unsuccessful attempts using
  experimental animals to isolate rubella virus.
• 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.

38
Causative Agent Rubella (Togavirus, genus
Rubivirus) - 2

• 1960-1962 Isolation of virus at 3 labs Drs.
  Paul Parkman and Edward L. Buescher, Walter Reed
  Army Institute for Research Drs. Thomas Weller
  and Franklin Neva at Harvard University Drs.
  John L. Sever and Gilbert M. Schiff at the
  National Institutes of Health NIH. Upon
  moving to NIH, Dr. Parkman worked with Dr. Harry
  M. Meyer on finding a way to curb the growth of
  the virus. They were responsible for developing
  the first test the hemaglutination-inhibition
  test - that could determine a persons immunity
  to the rubella virus. This test could provide
  results in three hours, rather than the three
  weeks required via an older testing method.
• Investigators discovered very different
  virologies of the rubella intra-uterine infection
  and the post-natal infection just in time for
  1963-1965 major U.S. rubella 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/ser
  vlet/SRCCE. Cooper, 1966).

39
IV. How Diseases Spread The Bubonic
PlagueandRubella
40
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.
41
How Disease SpreadBubonic Plague - 2

• People usually bitten by rodent flea carrying the
  plague bacterium, Yersinia pestis, or by handling
  an infected animal.
• Homes, places of work have flea-infested rats.
  Even with modern antibiotics, infected person is
  not treated promptly, the disease can cause
  illness or death.
• Wild rodents in certain areas around world
  infected with plague. Outbreaks in people still
  occur in rural communities or in cities usually
  associated with infected rats, fleas that live in
  the home.  
• (Centers for Disease Control and Prevention. CDC
  Plague Home Page, 2002)

42
How Disease SpreadBubonic Plague - 3

• In U.S., last urban plague epidemic 1924-25 Los
  Angeles. Since then, in U.S., mostly scattered
  cases in rural areas (10-15 persons/year).
• Globally, the World Health Organization 1,000 to
  3,000 cases of plague every year.
• North America, plague in certain animals and
  their fleas Pacific Coast to Great Plains, S.W.
  Canada to Mexico.
• U.S. most human cases 1) northern New Mexico,
  northern Arizona, and southern Colorado and 2)
  California, southern Oregon, far western Nevada.
• Also in Africa, Asia, and South America (see
  map).
• (Centers for Disease Control and Prevention. CDC
  Plague Home Page, 2002)

43
How Disease SpreadBubonic Plague - 4

• Natural cycle in its enzootic environment,
  involving small mammals and fleas without human
  involvement.
• Quiescent periods, during which few or no human
  cases are detected, may last for years, leading
  to mistaken declarations of plague eradication.
• However long the silent periods last, plague may
  suddenly reappear. The combination of false
  assurance of its eradication, and the failure of
  public health vigilance, sets the stage for the
  panic that may ensue when enzootic plague changes
  from its natural cycle into rodent and flea
  populations near where people live.
• Poor sanitation, overcrowding, high numbers of
  rodents are conditions that enhance urban plague
  transmission.  
• 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

44
How Disease SpreadBubonic Plague - 5

• Controversy as to whether etiology was the same
  for all outbreaks of the plague
• Because of the limits inherent in historical
  sources on ancient plague epidemics, many
  questions concerning their etiology and
  epidemiology remain unanswered. Molecular biology
  tools and the use of dental pulp as a preserved
  source of bacterial DNA enabled us to demonstrate
  that Yersinia pestis was the etiologic agent of
  the 1347 European Black Death and of two
  additional epidemics in 1590 and 1722 in southern
  France.
• (Drancourt, M. Raoult, D. (2002, January).
  Molecular insights into the history of plague.
  Microbes and Infection / Institut Pasteur, 4(1)
  105-9.)

45
How Disease SpreadBubonic Plague - 6

• Controversy as to whether etiology was the same
  for all outbreaks of the plague The primary
  hypotheses raised by the author, a medieval
  historian, are that
• the Black Death of the 13th and 14th centuries
  was not the same disease as the rat-based bubonic
  plague of the 19th century whose Yersinia pestis
  agent was first cultured in Hong Kong in 1894
• Unlike populations of Western Europe who adapted
  to the pathogen of the Black Death at least for
  the first hundred years, humans do not have
  immunity for the modern bubonic plague.
• The hypotheses are based on the findings that the
  two diseases were different in their signs,
  symptoms, and epidemiologies. ...
• (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.)

46
How Disease SpreadRubella - 1

• Rubella caused by togavirus that is spread from
  person to person when an infected person coughs
  or sneezes.
• Rubella also spread by direct contact with the
  nasal or throat secretions of an infected person.
  If a pregnant woman gets rubella during the first
  3 months of pregnancy, her baby is at risk of
  having serious birth defects or dying.
• Highly contagious. High herd immunity required,
  85-90
•  National Coalition for Adult Immunization.
  (2002). Facts about rubella for adults.
  Retrieved October 23, 2002, from
  http//www.nfid.org/factsheets/rubellaadult.html

47
How Disease SpreadRubella - 2

• Congenital rubella being highly contagious also
  increases its virulence because affected newborns
  can infect others with the virus up to a year
  after birth.
• In a hospital setting, newborns with congenital
  rubella syndrome CRS can infect hospital
  personnel, other newborns, and other women who
  are pregnant and visitors to the hospital, very
  much compounding the spread of the virus.
• 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/
•  

48
V. Mechanisms of Containment The Bubonic
PlagueandRubella
49
Mechanisms of ContainmentBubonic Plague - 1

• OPPORTUNITIES
• Increased self-sufficiency of state and county
  public health labs
• Expanded active surveillance through carnivore
  serosurveys and application of geographic
  information systems (GIS) to surveillance
  programs
• Increased education of public and health
  professionals
• Collaborative applied research on plague
  prevention and control with other federal, state,
  and local health agencies, including application
  of GIS to surveillance
• Centers for Disease Control and Prevention. CDC
  plague fact sheet. Retrieved October 22, 2002,
  from http//www.cdc.gov/ncidod/dvbid/plague/facts.
  htm

50
Mechanisms of ContainmentBubonic Plague - 2

• RESEARCH
• Ecology-based prevention and control strategies
• Improved diagnostic reagents and methods
• Development of potential vaccine candidates
• Risk factor identification using landscape
  ecology and epidemiology
• CDC (2002). CDC plague fact sheet. Retrieved
  October 22, 2002, from http//www.cdc.gov/ncidod/d
  vbid/plague/facts.htm
• PRACTICE
• People refrain from contact with rodents,
  especially if population known to be infected
• People use insect repellant when outside in areas
  with potential for having vectors and/or hosts.
• People wear proper attire to protect selves.

51
Mechanisms of ContainmentRubella - 1

• Vaccination
• In 1969, three rubella vaccines ready for
  licensing
• HPV77 DE5 (via monkey kidney cells and duck
  embryo tissue cultures)
• Cendehill strain (via rabbit kidney cells), and
• RA27/3 strain (isolated in human diploid cells.)
  
• Rubella vaccines induce seroconversions in
  approximately 95 of susceptible individuals.
  The vaccine-induced infection is
  non-communicable. Viraemia the existence of
  viral particles in the bloodstream occurs at
  such a low level that it is not easily detected.
• (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)

52
Mechanisms of ContainmentRubella - 2

• Vaccination
• Rubella vaccine is given on or after a child's
  first birthday, and is usually given in
  combination with measles and mumps (MMR) vaccine.
  Children usually receive the first dose between
  12 and 15 months or age and the second dose prior
  to school entry are 4-6 years of age.
• (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)

53
Mechanisms of ContainmentRubella - 2

• Vaccination
• U.S. followed a different rubella immunization
  strategy than did nations in Europe, Australia,
  and the United Kingdom. In the U.S., the focus
  of immunizations was on children who had not yet
  reached puberty, both boys and girls, 1 year and
  older. The goal was to protect the age group in
  which most infections occurred. This way, it was
  reasoned, women who are pregnant would avoid
  being exposed to the infection. For the U.S.
  approach, a very high herd immunity in the
  population most greatly affected young
  children, was necessary. Identification and
  immunization of women of child-bearing age also
  was recommended.
• Horstmann, Dorothy M. (1986, October 11). The
  rubella story, 1881-1985. South African Medical
  Journal, Supplement, 60-63.

54
Mechanisms of ContainmentRubella - 3

• Vaccination
• In the United Kingdom, Europe, and Australia, the
  immunization program begun in 1970 was limited to
  girls, usually between 10-14 years of age and to
  susceptible women. It was thought that the
  incidence of the congenital disease would not be
  reduced until the mid-1980s. Horstmann, Dorothy
  M. (1986, October 11). The rubella story,
  1881-1985. South African Medical Journal,
  Supplement, 60-63.
• During 2000, 87 of all reported cases of rubella
  occurred among people 15-39 years of age. As many
  as 8 million women of childbearing age are
  susceptible to rubella. Up to 10 of young adults
  are susceptible to the rubella virus. National
  Coalition for Adult Immunization. (2002). Facts
  about rubella for adults. Retrieved October 23,
  2002, from http//www.nfid.org/factsheets/rubellaa
  dult.html

55
Mechanisms of ContainmentRubella - 4

• Maintaining high levels of rubella immunization
  in the community is critical to controlling the
  spread of the disease. Control of the spread of
  rubella is needed primarily to prevent the birth
  defects caused by CRS. Therefore, women of
  childbearing age should have their immunity
  determined and receive rubella vaccine if needed.
  Infected children should not attend school during
  their infectious period.
• (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)

56
Mechanisms of ContainmentRubella - 5

• Caution re vaccination programs
• According to the World Health Organization, two
  cautions variability of the epidemiology of the
  rubella infection and the need to achieve and
  sustain very high coverage to avoid the potential
  increase in CRS. Immunization increases the
  average age at infection, and if coverage is not
  high enough to reduce rubella transmission close
  to zero, there could be a paradoxical increase in
  CRS incidence in the presence of an immunization
  program.
• (World Health Organization. Vaccines,
  Immunization and Biologicals Rubella vaccine.
  Retrieved October 23, 2002, from
  http//www.who.int/vaccines/en/rubella.shtml)

57
Mechanisms of ContainmentRubella - 6

• MMR Autism Link Controversy 1998-2002
• February 28, 1998 British study Early report
  published in Lancet by Andrew Wakefield, Royal
  Free and University College Medical School
• (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.)
• May be a link between the measles, mumps, and
  rubella MMR vaccination and inflammatory bowel
  disease/autism.
• Each side had its supporters. Websites
• Researcher lost position at University because of
  controversy,
• (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.)

58
Mechanisms of ContainmentRubella - 7

• 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.)

59
Mechanisms of ContainmentRubella - 8

• 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.)

60
Mechanisms of ContainmentRubella - 9

• 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.)

61
Mechanisms of ContainmentRubella - 10

• 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)

62
VI. Percentage of FatalitiesThe Bubonic
PlagueandRubella
63
Fatalities Bubonic Plague - 1

• 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 respuratory 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.

64
Fatalities Bubonic Plague - 2

• The Bubonic Plague was called Black Death
  because black sores appeared on the skins of
  victims. The first record of plague was in
  Athens in 430 B.C. The most famous outbreak of
  plague was in in 14th century Asia and Europe,
  killing up to 25 of the population. Te plague
  continued to devastate Europe until the late 17th
  century. Plague doctors wore protective
  clothing (their long beak was filled with
  antiseptic substances). But the plague killed all
  who caught it. Some people were buried alive,
  with their gums having turned red and their skin
  pale. Stories of vampires were common.
• The bubonic plague bacillus Yersinia pestis
  carried by fleas of black rats. It is thought to
  have originated in the Himalayas. As early
  humans migrated to Asia, the rats moved to these
  areas and then Europe to find food. The plague
  exists today but now victims have 50 survival
  rate.
• (Roden, K. (1996). Plague. Brookfield, CT Copper
  Beech Books, 11.)

65
Percentage of Fatalities Rubella - 1

• Rubella Epidemic of 1964-1965 in U.S.
• 12.5 million rubella cases
• 2,000 encephalitis cases
• 11,250 surgical or spontaneous abortions
• 2,100 nronatal deaths
• 20,000 cases of Congenital Rubella Syndrome-CRS
• CRS Possibly all organs affected fetal death.
  Infants infected in 1st trimester 85 affected
• CRS causes deafness, cataracts, blidness, heart
  defects, microcepaly, mental retardation, bome
  alterations, liver and spleen damage
• (Centers for Disease Control and Prevention
  (2002). Rubella. Retrieved November 16, 2002,
  from http//www.cdc.gov/nip/publications/pink/rube
  lla.pdf)

66
Percentage of Fatalities Rubella - 2

• 2002 Current Congenital Rubella Syndrome CRS
  Incidence
• 0.5-2.2 per 1000 live births in developing
  countries during epidemics (every 4-7 years)
• High susceptibility in these countries 25
• 1996 estimate for CRS in developing countries
  110,000 cases
• 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.

67
VII. TreatmentsThe Bubonic
PlagueandRubella
68
Treatments Bubonic Plague - 1

• 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?

69
Treatments Bubonic Plague - 2

• 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. Trimethoprim-sulfamethoxazole is an
  acceptable substitute for use in infants and in
  children younger than 8 years of age. Personal
  protective measures should also be recommended,
  including the use of insect repellents containing
  N,N-diethylmetatoluamide (DEET) on skin and
  clothing. Clothing also can be treated with
  insecticidal sprays containing permethrin.
  Travelers should be advised to avoid sick or dead
  animals or rodent nests and burrows. Whenever
  possible, travelers should also avoid visiting
  areas that have experienced recent plague
  epidemics or epizootics. Travelers are unlikely
  to be at high risk for plague while staying in
  modern accommodations.
• (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)

70
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

71
VIII. Advice about Avoiding Further
OutbreaksThe Bubonic PlagueandRubella
72
Advice about avoiding further outbreaks of
Bubonic Plague - 1

• Peace ( Dr. Wiginton stays home).
• Good sanitation and hygiene.
• Avoid rodents, reservoirs of flea vectors.
• Be alert to deaths of populations of rats
  population and other animals.
• Apply insect repellent and wear protective
  clothing in potentially affected areas.
• Public awareness about types of plague.

73
Advice about avoiding further outbreaks of
Bubonic Plague - 2

• CDC Travelers Warning
• Plague is a zoonosis involving rodents and
  their fleas Plague continues to be enzootic in
  wild rodent populations over large areas of the
  Americas, Africa, and Asia, with occasional
  outbreaks among commensal rodents (those rodents
  living a symbiotic life with humans) in villages
  and small towns. Wild rodent plague poses a real,
  though limited risk to people.
• (Centers for Disease Control and Prevention.
  Travelers' health information plague. Retrieved
  November 9, 2002, from http//www.cdc.gov/travel/d
  iseases/plague.htm)

74
Advice about avoiding further outbreaks of
Bubonic Plague - 3

• 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 week
  or two.
• 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 ten 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.)

75
Advice about avoiding further outbreaks of
Rubella - 1

• Effort WHO to establish national
  vaccination/immunization programs for rubella in
  all countries according to their needs. Need for
  cost benefit analyses re rubella (WHO. Economic
  analyses , 2002)
• In U.S., special outreach to women of Hispanic
  ethnicity in Spanish, and to other women in
  their native languages (CRS prevention)
• Immediate quarantine of people diagnosed as
  having rubella (although may be too late).
• Comprehensive surveillance of immunization
  programs
• Continued public awareness campaigns to encourage
  MMR immunizations and promotion of information on
  safety of MMR vaccines.

76
Advice about avoiding further outbreaks of
Rubella - 2

• 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.

77
IX. Differences and SimiliaritiesThe Bubonic
PlagueandRubella
78
Differences Bubonic Plague (BP) and Rubella (R)

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

79
Similarities Bubonic Plague (BP) and Rubella (R)

• BP R
• Symptoms swelling of lymph nodes
• Exanthem diseases causing skin eruptions
• Transmittable via inhalation. Highly contagious.
• Epidemics have caused mass panic
• BP infection touch/inhalation / R also
  intrauterine
• BP bacterium isolated 1864 \ R virus 1962
• BP incubation \ R incubation 12-23 days
• Originally confusion as to agents of disease
  attributions to scarlet fever, measles

80
X. Effects on SocietyThe Bubonic
PlagueandRubella
81
Effects on SocietyBubonic Plague - 1

• Bubonic plague has been said to have changed the
  course of history.
• Wars won and lost.
• Influenced power of Church
• Resulted in great persecution of people
• Mass death and destruction
• Mass fear, panic. Pandemic.
• Attribution to other forces, other diseases
• Terrorism. Special threat from pneumonic plague

82
Effects on SocietyBubonic Plague - 2

• Plague is an infectious disease of humans and
  animals caused by the bacterium Yersinia pestis.
  During the Middle Ages millions of people in
  Europe died from plague, whose current
  mortality-if untreated-ranges from 50 to 90.The
  plague has been a great protagonist in history
  because it has often been grimly present in the
  collective events of humans. Its plurisecular
  history, tied to the whole chain of ecological
  balance, has had a strong influence on the
  collective imagination on account of its sudden
  occurrence and unavoidable mortality. In the
  past, the passage from contagion to illness ended
  in death, as human remedies had no effect. The
  only way to conquer it was invoke the
  incorruptible spirit of a saint. Therefore, in
  the past, the major plague icons were saints to
  whom ordinary people attributed a fame for
  healing. More recently, many epidemic diseases
  have ceded place to biological weapons, and
  terrorists have become the modern icons of such a
  threatening reality. As a matter of fact,
  bioterrorism has become a great public health and
  infection control threat, and, among the number
  of potential biological agents, plague has
  assumed a key role.(Lippi, D. Conti, A.A.
  (2002, May). Plague, policy, saints and
  terrorists a historical survey. Journal of
  infection, 44(4) 226-228. Retrieved October 22,
  2002, from FirstSearch WilsonSelect Plus Fulltext
  database.)

83
Effects on SocietyBubonic Plague - 3

• 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.
• Group Objective come to consensus as to measures
  to be taken by medical and public health
  professionals if plague used as a biological
  weapon against civilians.
• Evidence MEDLINE searches 1/1966-1/2000 for
  MESH subject headings Yersinia pestis,
  biological weapon, biological terrorism.
  Biological warfare, biowarfare

84
Effects on SocietyBubonic Plague - 4

• 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.

85
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 a