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The Nature of Plagues

Figure 1.1 Woman with Dead Child. Kathe Kollwitz etching. 1903. National Gallery of Art, Washington, D.C.

Disease can be a personal affair. Peter Turner, a World War II veteran, was a commander of the Pennsylvania Division of the American Legion. In the summer of 1976, Turner, a tall, well-built 65-year-old, decked out in full military regalia, attended the American Legion convention in Philadelphia. As a commander, Turner stayed at the Bellevue-Stratford Hotel, headquarters for the meeting. Two days after the convention Turner fell ill with a high fever, chills, headache, and muscle aches and pains. He dismissed the symptoms as nothing more serious than a “summer cold.” His diagnosis proved to be wrong. A few days later he had a dry cough, chest pains, shortness of breath, vomiting, and diarrhea. Within a week his lungs filled with fluid and pus, and he experienced confusion, disorientation, hallucinations, and loss of memory. Of 221 fellow Legionnaires who became ill, Commander Turner and 33 others died from pneumonia. The size and severity of the outbreak, called Legionnaires’ disease, quickly gained public attention, and federal, state, and local health authorities launched an extensive investigation to determine the cause of this “new” disease. There was widespread fear that Legionnaires’ disease was an early warning of an epidemic. Though no person-to-person spread could be documented, few people attended the funerals or visited with the families of the deceased veterans.

Statistical studies of Legionnaires’ disease revealed that all who had become ill spent a significantly longer period of time in the lobby of the Bellevue-Stratford Hotel than those who remained healthy. Air was implicated as the probable pathway of spread of the disease, and the most popular theory was that infection resulted from aspiration of bacteria (called Legionella) in aerosolized water either from cooling towers or evaporative condensers. Unlike infections caused by inhalation, in aspiration secretions in the mouth get past the choking reflex and, instead of going into the esophagus and stomach, mistakenly enter the lungs. Protective mechanisms that normally prevent aspiration are defective in individuals who are older, in smokers, and in those who have lung disease. The Legionnaires were near-perfect candidates for contracting the disease.

After the outbreak, the hotel, which had been the choice of conventions such as that held by the Legionnaires as well as those of Hollywood stars such as John Wayne, Grace Kelly, and Elvis Presley, was shunned by guests. The hotel closed down and was empty for almost 3 years, during which time there was talk of tearing the building down. After tens of millions of dollars in renovation, however, there was a new owner, and after reopening in 1989, today it is the Hyatt at The Bellevue.

Since the Philadelphia outbreak, there have been numerous reports of Legionnaires’ disease. For example, in 1985 in Stafford District Hospital in Stafford, England, there were 175 cases and 28 deaths; in 1999 in Bovekarspel, Holland, a hot tub was responsible for 318 cases and 32 deaths; in 2001, a hospital in Murcia, Spain, reported 800 cases; in 2005 at the Seven Oaks Home for the Aged in Toronto, Canada, 127 were sickened and 21 died; and in 2015 in a housing development in the South Bronx, NY, 128 were infected with Legionella and 13 died. It is estimated that in the United States there are 8,000 to 18,000 cases of legionellosis a year that require hospitalization, and worldwide the numbers are even greater.

A few years after the outbreak of Legionnaires’ disease in Philadelphia, another “new” disease appeared. Mary Benton, a graduate student and English composition teaching assistant at UCLA, knew something was amiss as she prepared for Monday’s class. She had spent the previous day happily celebrating her 24th birthday, but by evening she was doubling over in pain every time she went to the bathroom. Mary figured she probably had an infection or was suffering from overeating. Mary, who was previously healthy and active, became concerned as her symptoms worsened. By the time she saw her physician, she had nausea, chills, diarrhea, headache, and a sore throat. Her temperature was 104.7ºF, her heart rate 178 beats/min, and she had a red rash, initially on her thighs, but it had become diffuse over her face, abdomen, and arms. Her blood pressure had fallen to 84/50 mm Hg, she had conjunctivitis in both eyes, and her chest X-ray was normal, but a pelvic examination revealed a brownish discharge. Though her doctors administered antibiotics, oxygen, and intravenous fluids, her condition deteriorated over the next 48 h. She died of multiorgan failure: low blood pressure, hepatitis, renal insufficiency, and internal blood clots. Laboratory tests provided clues to the cause of death. Cultures made from her blood, urine, and stools were negative, but the vaginal sample contained the bacterium Staphylococcus aureus. The “new” disease that felled Mary Benton was named toxic shock syndrome, or TSS. The source of Mary’s infection, and whether it might be spread through the population as a sexually transmitted disease (STD), raised many concerns. TSS continued to appear for the next 10 years among previously healthy young women residing in several states. As with Mary Benton, each case began with vomiting and high fever, followed by light-headedness and fainting; the throat felt sore, and the muscles ached. A day later there appeared a sunburn-like rash, and the eyes became bloodshot. Within 3 to 4 days the victims suffered confusion, fatigue, weakness, thirst, and a rapid pulse; the skin became cool and moist; and breathing became rapid. These symptoms were followed by a sudden drop in blood pressure; if it remained low enough for a long enough period, circulatory collapse produced shock.

TSS was a gender-specific disease. From 1979 to 1996, it affected 5,296 women, median age 22, with a peak death rate of 4%. TSS, however, was not an STD. Ultimately it was linked to the use of certain types of tampons, especially those containing cross-linked carboxymethyl cellulose with polyester foam, which provided a favorable environment for the toxin-producing S. aureus. Elevated vaginal temperature and neutral pH, both of which occur during menses, were enhanced by the use of these super-absorbent tampons. In addition, tampons obstruct the flow of menstrual blood and may cause reflux of blood and bacteria into the vagina. By the late 1980s, when these tampon brands were removed from the market, the number of deaths from TSS declined dramatically.

The effects of disease at the personal level can be tragic (Fig. 1.1), but when illness occurs in many people, it may produce another emotion—fear—for now that disease might spread rapidly, causing death, as well as inflaming the popular imagination. The 2003 outbreak of SARS (severe acute respiratory syndrome) had all the scary elements of a plague—panic, curtailed travel and commerce, and economic collapse. It began in February 2003 when a 64-year-old Chinese physician who was working in a hospital in Guandong Province in southern China traveled to Hong Kong to attend a wedding and became ill. He had a fever, a dry cough, a sore throat, and a headache. Unconcerned, he felt well enough to go sightseeing and to shop with his brother-in-law in Hong Kong; during that day, however, his condition worsened and he found that he had difficulty breathing. Seeking medical attention at a nearby hospital, he was taken immediately to the ICU (intensive care unit) and given antibiotics, anti-inflammatory drugs, and oxygen. These were to no avail, and several hours later he suffered respiratory failure and died. The brother-in-law, who was in contact with him for only 10 h, suffered from the same symptoms 3 days later and was hospitalized. Again, all measures failed, and he died 3 weeks after being hospitalized.

Laboratory tests for the physician (patient 1) and his brother-in-law (patient 2) were negative for Legionnaires’ disease, tuberculosis, and influenza. A third case of this severe respiratory syndrome occurred in a female nurse who had seen the physician in the ICU, and the fourth case was a 72-year-old Chinese-Canadian businessman who had returned to Hong Kong for a family reunion. He stayed overnight in the same hotel and on the same floor as the physician. (He would ultimately carry SARS to Canada when he returned home.) Patient 5 was the nurse who attended the brother-in-law, and patients 6, 7, 8, and 9 were either visitors to the hospital or nurses who had attended patient 4. Patient 10 shared the same hospital room with patient 4 for 5 days. In less than a month 10 patients had SARS, with 6 (patients 3, 4, 6, 8, 9, and 10) surviving and 4 (patients 1, 2, 5, and 7) dying. Over the next 4 months the SARS survivors sowed the seeds of infection that led to more than 8,000 cases and 800 deaths in 27 countries, representing every continent except Antarctica.

On February 1, 2016, the World Health Organization (WHO), after recording a surge in the number of babies born with microcephaly—an abnormally small head—sounded the alarm that Zika virus was a threat to pregnant women and could cause serious harm to their fetuses. Six months later, on August 1, 2016, the Los Angeles Times reported that there were 1,638 confirmed cases of microcephaly and other neurological defects in Brazil as a consequence of the Zika virus. Worldwide, 64 countries and territories have reported to the WHO evidence of...