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 mosquito-borne transmission of Zika. There has been a steady march of the Zika virus across the Americas—an epidemic—and that is because the vector, the thoroughly “domesticated” Aedes mosquito, stays close to people and is present primarily in the Southwest and Southeast United States, as well as the Caribbean, Central and South America, and Europe. Indeed, by October 2016, according to the CDC, there were 3,936 cases in the continental U.S. and 25,955 cases in the U.S. territories of Puerto Rico, the U.S. Virgin Islands, and American Samoa. The number of cases of microcephaly may reach hundreds. The CDC director, Thomas Frieden, in an understatement, warned that without a vaccine “this is an emergency that we need to address.”
Despite the recognition that disease, such as SARS, Legionnaires’ disease, TSS, and Zika, may appear suddenly and with disastrous consequences, more often than not little notice has been given to the ways in which disease can and has shaped history. The influence of disease on history was often neglected because there appeared to be few hard-and-fast lessons to be learned from a reading of the past; sickness seemed to have no apparent impact except for catastrophic epidemics such as the bubonic plague, or it was outside our experience. We tend to live in an age in which diseases appear to have minimal effects—we are immunized as children, we treat illness with effective drugs and antibiotics, and we are well nourished. And so our impressions of how diseases can affect human affairs have been blunted. But this is an illusion: the sudden appearance of SARS, Legionnaires’ disease, TSS, AIDS, and Zika are simply the most recent examples of how disease can affect society. Our world is much more vulnerable than it was in the past.
New and old diseases can erupt and spread throughout the world more quickly because of the increased and rapid movements of people and goods. Efficiencies in transportation allow people to travel to many more places, and almost nowhere is inaccessible. Today, few habitats are truly isolated or untouched by humans or our domesticated animals. We can move far and wide across the globe, and the vectors of disease can also travel great distances, and, aided by fast-moving ships, trains, and planes, they introduce previously remote diseases into our midst (such as West Nile virus and SARS, influenza and Zika). New diseases may be related to advances in technology: TSS resulted from the introduction of “improved” menstrual tampons that favored the growth of a lethal microbe, and Legionnaires’ disease was the result of the growth and spread of another deadly “germ” through the hotel’s air conditioning system.
This book chronicles the recurrent eruptions of plagues that marked the past (Fig. 1.2), influence the present, and surely threaten our future. The particular occurrence of a severe and debilitating
