Pandemics -Lessons from History--updated.pptx

The presentation is a journey throughout history to reveal the deadliest epidemics that attacked the human race from prehistoric era till COVID-19

1. Pandemics : Lessons from History Ekbal Mohamed Abohashem - MD Professor of Clinical Pathology Mansoura University-Egypt

2. In the realm of infectious diseases, a pandemic is the worst case scenario. When an epidemic spreads beyond a country’s borders, the disease officially becomes a pandemic. Throughout history, there have been a number of pandemics, such as smallpox , plague , cholera , influenza and tuberculosis. One of the most devastating pandemics was the Black Death, killing over 75 million people in 1350. The most recent pandemics include the HIV pandemic as well as the 1918 and 2009 H1N1 pandemics , and m ore recently : the COVID-19 pandemic. INTRODUCTION :

3. About 5,000 years ago, two epidemics wiped out a prehistoric village in China. The bodies of the dead were stuffed inside houses that were later burned down. No age group was spared . The archaeological site is now called " Hamin Mangha " Prehistoric epidemics in China: Pharaohs' Plague : The Nile provided an ideal spot for rats to carry the plague into urban communities. Around 3500 B.C., people began to build cities next to the Nile. During floods, the habitat of the Nile rat was disturbed, sending the rodent—and its flea and bacterial hitchhikers—into the human domain. Egyptian writings from a similar time period point to an epidemic disease with symptoms similar to the plague, the Ebers Papyrus identifies a disease that "has produced a bubo, and the pus has putrified , the disease has hit." Plague of Athens: 430 B.C

4. Timeline of most deadly pandemics in history

5. Timeline of most deadly pandemics in history (cont. )

6. Timeline of most deadly pandemics in history (cont. )

7. Time table of influenza pandemics

8. Outbreaks have sparked riots and propelled public health innovations, prefigured revolutions and redrawn maps.

9. * The practice of q uarantine, border control, sanitary measures and social distancing * Figuring out the concept of hand washing * Tracing the source of disease -Public health hygiene * Vaccination * Use of convalescent plasma Pandemics : Lessons From History

10. The English word “quarantine” is a direct descendent of quarantino the Italian word for a 40-day period and this period was chosen not for medical reasons but for scriptural ones, as both the Old and New Testaments make multiple references to the number forty in the context of safety , and the number had great symbolic and religious significance to medieval Christian: the forty days and forty nights of the flood in Genesis, the forty years of the Israelites wandering in the wilderness . . and Jesus fasted in the wilderness for 40 days  . Significance of a 40-Day 'Q uarantino '

11. The Adriatic port city of Ragusa (modern-day Dubrovnik) was the first to pass legislation requiring the mandatory quarantine of all incoming ships and trade caravans in order to screen for infection. The First Quarantine : The plague ravaged large cities and provincial towns in northern and central Italy from 1629 to 1631, killing more than 45,000 people in Venice alone and wiping out more than half the population of cities like Parma and Verona.

12. The city’s Major Council passed a law “which stipulates that those who come from plague-infested areas shall not enter [Ragusa] or its district unless they spend a month on the islet of Mrkan (an uninhabited rocky island south of the city ) , for the purpose of disinfection.”

13. Ragusa’s quarantine is considered one of the highest achievements of medieval medicine. By ordering the isolation of healthy sailors and traders for 30 days, Ragusan officials showed a remarkable understanding of incubation periods. New arrivals might not have exhibited symptoms of the plague, but they would be held long enough to determine if they were in fact disease-free.

14. Ragusa was also the first city to set up a temporary plague hospital on another island called Mljet . This new type of state-funded treatment facility would soon become known throughout Europe as a Lazaretto . The name is a corruption of the word Nazaretto the nickname for the lagoon island upon which Venice built its first permanent plague hospital, Santa Maria di Nazareth. The lazaretto served two functions, as a medical treatment center and a quarantine facility. The First Plague Hospital in Ragusa :

15. At a lazaretto , plague-infected patients would receive fresh food, clean bedding and other health-promoting treatments, all paid for by the state. They’re quite a remarkable early public health structure into which the government has to invest huge sums of money . These hospitals were permanently manned, ready and waiting for incoming ships that may be suspected of carrying an infectious disease .

16.           The town of Ferrara, population approximately 30,000, offers a fascinating success story. Ferrara managed to prevent even a single death from the plague after the year 1576—even as neighboring communities were devastated. How did they do it? Critical in the city's success, were border controls, sanitary laws and personal hygiene . The Italian City of Ferrara Fended Off the Plague

17. Starting in the 15th century, large Italian cities like Venice and Florence stayed in constant communication with smaller towns like Ferrara to track the spread of new plague outbreaks. The information was used to set threat levels and coordinate public health responses. In Ferrara, the highest threat level meant closing all but two of the city gates and posting permanent surveillance teams composed of wealthy noblemen, city officials, physicians and apothecaries. Anyone arriving at the city gates needed to carry identification papers as Fedi (“proofs”) to ensure they had arrived from a plague-free zone. Then they would be screened for any signs of disease. Border control

18. The public sanitation campaigns ensured that s treets were swept of garbage and cleared of “ filthy ” animals like dogs, cats and chickens (no mention of rats). Lime powder was spread liberally on any surface that may have come in contact with an infected person. Inside homes, residents tried a host of measures to disinfect objects and surfaces. Any damaged or cracked furniture was taken out and burned. Valuable objects and money were heated close to a fire and perfumes were sprayed throughout the house for 15 days. Clothing and other textiles were hung out in the sun, beaten and doused with perfumes. Sanitary lows

19.   Starting in 1348, soon after the plague arrived in cities like Venice and Milan, city officials , who had no notion of bacteria or viruses , put emergency public health measures in place that foreshadowed today’s best practices of social distancing and disinfecting surfaces. “They were very careful with goods that are being traded, because the disease could be spread on objects and surfaces, and ensured that one should try his best to limit person-to-person contact ,” Social Distancing

20. T he citizens of Ferrara turned to several popular natural remedies prescribed for protection against the plague using the natural antimicrobial properties of some plants, herbs and oils . A medicinal oil called ( Composito ) was to be stored in a locked box set into the wall of the municipal palace and only distributed in times of plague. The secret recipe for Composito was concocted by the Spanish physician Pedro Castagno, who wrote Ferrara’s influential “ Reggimento contra la peste ” (“Regimen against the plague”), in which he described how the oily balm should be applied to the body. Personal hygiene:

21. “Before getting up in the morning, after lighting a fire of scented woods (juniper, laurel and vine shoots), warm the clothes and above all the shirt, rub first the heart region, near the fire to ease balm absorption, then the throat,” wash hands and face with acqua chiara (clean water) mixed with wine or vinegar of roses, with which sometimes all the body should be cleaned, using a sponge.”

22. the balm contained myrrh and Crocus sativus , both known for their antibacterial properties, as well as venom from both scorpions and vipers. In fact, the recipe for Composito was not dissimilar to anti-plague regimens used in other parts of Italy, particularly “Oil of Scorpions” and an ancient ointment called Theriac , also made from viper venom. “ The choice to use venom is that only a true poison could combat the poison of plague,” Venom Added to Medicine

23. An early proponent of hand washing was Ignaz Semmelweis , a Hungarian doctor who worked at the Vienna General Hospital between 1844 and 1848. The hospital was one of the largest in the world for teaching, and its maternity wing was so big that it was divided into two wards: one for doctors and their students and one for midwives and their students. Figuring Out the Benefits of Hand Washing

24. T here was a stark disparity between these wards. Between 1840 and 1846, the maternal mortality rate for the midwives’ ward was 36.2 per 1000 births, while the mortality rate for the doctors’ ward was 98.4 per 1000 births . Specifically, the doctors’ ward had a higher rate of “childbed fever,” now known as streptococcal infection. Semmelweis started to look for any differences between the wards.

25. Then in 1847, the death of Semmelweis ’ colleague Jakob Kolletschka led him to a breakthrough. Kolletschka had cut his finger on a scalpel during an autopsy, and developed an infection that killed him. Semmelweis wondered whether a similar type of infection could be happening in the doctors’ maternity ward. Semmelweis realized that, unlike the hospital’s midwives, doctors sometimes examined women in the maternity ward after performing autopsies. In the absence of germ theory , Semmelweis theorized Kolletschka had died because “ cadaveric matter ” entered his body through his wound, and that women in the doctors’ ward might also be dying because cadaveric matter from doctors’ hands was entering their body through their genitalia.

26. In 1843, the American doctor Oliver Wendell Holmes published a paper arguing doctors with dirty hands could cause childbed fever in their patients. The British nurse Florence Nightingale, considered the founder of modern nursing, wrote “ Every nurse ought to be careful to wash her hands very frequently during the day .” Semmelweis ’ response to his theory was pretty good. He started mandating that doctors wash their hands with chlorinated lime after autopsies. And it was a big improvement—between 1848 and 1859, the maternal mortality rate in the doctors’ ward dropped to around the same level as the midwives’ ward.

27. Still, the importance of hand washing for medical professionals didn’t really become understood until scientists hit upon germ theory—the idea that certain diseases and infections are caused by microorganisms we can’t even see. In particular, the British surgeon Joseph Lister drastically improved patient mortality by advocating that surgeons wash their hands and sterilize their instruments in between patients.

28. Today, medical and health professionals consider hand washing a critical hygienic practice, both for themselves and their patients. The Centers for Disease Control and Prevention, or CDC, even provides guidelines for how to properly wash your hands. To properly kill germs, the CDC advocates scrubbing them with soap for at least 20 seconds before rinsing the soap off with water. Drying them completely is also important, since wet hands spread germs more easily.

29. VACCINATION : A victory to humankind

30. In the late 18th-century, Edward Jenner , a British doctor , discovered that milkmaids infected with a milder virus called cowpox seemed immune to smallpox. Jenner inoculated his gardener’s 9-year-old son with cowpox and then exposed him to the smallpox virus with no ill effect . “The eradication of the smallpox, the most dreadful threat of the human species, must be the final result of this practice,” wrote Jenner in 1801 . And he was right. It took nearly two more centuries, before the World Health Organization announced in 1980 that smallpox had been completely eradicated from the face of the Earth .

31. In the early- to mid-19th century, cholera tore through England, killing tens of thousands. It was thought that the disease was spread by foul air known as a “miasma.” But a British doctor named John Snow suspected that the mysterious disease, which killed its victims within days of the first symptoms, lurked in London’s drinking water. Snow started to investigate hospital records and morgue reports to track the precise locations of deadly outbreaks. He created a geographic chart of cholera deaths over a 10-day period and found a cluster of 500 fatal infections surrounding the Broad Street pump, a popular city well for drinking water. He suspected some contamination of the water of the much-frequented street-pump in Broad Street . Tracing the source of infection — A Victory for Public Health Research

32. Snow convinced local officials to remove the pump handle on the Broad Street drinking well, rendering it unusable, and like magic the infections dried up. Snow’s work didn’t cure cholera overnight, but it eventually led to a global effort to improve urban sanitation and protect drinking water from contamination . While cholera has largely been eradicated in developed countries, it’s still a persistent killer in third-world countries lacking adequate sewage treatment and access to clean drinking water .

33. The use of convalescent plasma to Save Lives T he very first Nobel Prize in Physiology and Medicine was awarded in 1901 to Emil von Behring for his life-saving work developing a cure for diphtheria, a bacterial infection that was particularly fatal in children. His groundbreaking treatment, known as diphtheria antitoxin, worked by injecting sick patients with antibodies taken from animals who had recovered from the disease. Von Behring’s antitoxin wasn’t a vaccine, but the earliest example of a treatment method called “convalescent plasma” that’s being resurrected as a potential treatment for COVID-19 . Convalescent plasma is blood plasma extracted from an animal or human patient who has “convalesced” or recovered from infection with a particular disease.

34. The method has been used against diphtheria, the 1918 flu pandemic, measles and Ebola.  . During the pandemic influenza outbreak of 1918 known as the “ Spanish flu ,” fatality rates were cut in half for patients who were treated with blood plasma compared to those who weren’t. The method seemed particularly effective when patients received the antibodies in the early days of their infection, before their own immune systems had a chance to overreact and damage vital organs.

35. In 1934,. Dr. J. Roswell Gallagher extracted blood serum from a student who had recently recovered from a serious measles infection and began injecting the plasma into 62 other boys who were at high risk of catching the disease. Only three students ended up contracting measles and all were mild cases. “Convalescent plasma has been used throughout history when confronting an infectious disease where some people recover and there’s no other therapy available,” “There must be something in their plasma—i.e. an antibody—that helped them recover.”

36. Convalescent plasma interacts differently with the immune system than a vaccine. When a person is treated with a vaccine, his immune system actively produces its own antibodies that will kill off any future encounters with the target pathogen. That’s called active immunity. Convalescent plasma offers what’s called “passive immunity.” The body doesn’t create its own antibodies, but instead “borrows” them from another person or animal who has successfully fought off the disease. Unlike a vaccine, the protection doesn’t last a lifetime, but the borrowed antibodies can greatly reduce recovery times and even be the difference-maker between life and death. “Convalescent plasma is the crudest of the immunotherapies, but it can be effective ,”

37. By the 1940s and 1950s, antibiotics and vaccines began to replace the use of convalescent plasma for treating many infectious disease outbreaks, but the old-fashioned method came in handy yet again during the Korean War when thousands of United Nations troops were stricken with Korean hemorrhagic fever, also known as Hantavirus. With no other treatment available, field doctors transfused convalescent plasma to sickened patients and saved untold numbers of lives . C onvalescent plasma was even deployed against 21st century outbreaks of MERS, SARS and Ebola , all novel viruses that spread through communities with no natural immunity, no vaccine and no effective antiviral treatment. Today, the best treatment for Ebola is still a pair of “monoclonal antibodies,” individual antibodies isolated from convalescent plasma and then cloned artificially in a lab. Korean War Troops Were Saved by Plasma Treatments

38. In March 2020, doctors at Johns Hopkins University began testing convalescent plasma as a promising stop-gap treatment for COVID-19 while the search continued for a permanent vaccine. The advantage of convalescent plasma is that it can be drawn from recovered patients using the same plasma separation technology used at blood banks

39. Improving Hospital Care and Health Care Delivery Prepare for Unexpected Increases in Demand for Services A ll hospitals should have detailed disaster plan that includes the following: what areas of the hospital to expand to and in what order , how to increase ability to care for incoming patients and how to gain immediate access to additional staff. Maintain Line of Sight . During the pandemic, the number of times nurses entered patients’ rooms should be minimized, yet still evaluating patients. Strategies included placing windows in walls, replacing wood doors with glass doors, and using communication and video devices in rooms. Lessons From the COVID-19 Pandemic

40. Mind the Air Hospitals are required to have minimum air changes in patient rooms, with more frequent air changes required for isolation rooms .. additional methods of decreasing potential transmission of COVID-19, such as placement of high-efficiency particulate air filters and UV lights are recommended. Other promising strategies for decreasing aerosolized transmission of disease are electronic (bipolar ionization) filtration and high fresh air exchange. Wearing masks in the hospital should continue even if SARS-CoV-2 disappears (an unlikely possibility ). It is likely that SAR S-CoV-2 is spread primarily through droplets but can also be airborne, requiring rethinking of respiratory infection control procedures and raising the question of whether it is appropriate to still have multioccupancy rooms in the hospital. Masks Forever (at Least for Some)

41. Electronic health record systems should continue after the pandemic to allow physicians and nurses to spend more time with patients and to reduce burnout Use Technology to Connect Families Near and Far COVID-19 exacerbated existing health disparities with racial and ethnic minority and low-income communities experiencing disproportionate infections, hospitalizations, and death . Address Persistent Racial and Ethnic Disparities in Health Reduce the Burden of Unnecessary Documentation Support Health Care workers

42. In the past it's taken four to 20 years to create conventional vaccines . For the new messenger RNA ( mRNA ) vaccines from Pfizer- BioNTech and Moderna , it was a record-setting 11 months. The process may hav e changed forever the way drugs are developed . Vaccines may one day treat heart disease and more. In the near future, mRNA technology could lead to better flu vaccines that could be updated quickly as flu viruses mutate with the season, or the development of a “ universal ” flu shot that might be effective for several years. Drug developers are looking at vaccines for rabies, Zika virus and HIV . “We expect to see the approval of more mRNA-based vaccines in the next several years. COVID-19 Vaccines : A Revolution in Medicine

43. T he COVID-19 vaccine spotlight will motivate people to keep up with all of their vaccines , including childhood and adult vaccines for such diseases as measles , chicken pox, shingles , and other viruses .   It may also target our biggest killers. Future mRNA therapies could help regenerate muscle in failing hearts and target the unique genetics of individual cancers with personalized cancer vaccines . “Every case of cancer is unique, with its own genetics. “ Doctors will be able to sequence one’s tumor and use it to make a vaccine that awakens his immune system to fight it.” Such mRNA vaccines will also prepare us for future pandemics .

44. We Befriended Technology, and There's No Going Back : TELEMEDICINE " Arguably the biggest long-term societal effect of the pandemic will be a grand flipping of the switch that makes the digital solution the first choice “.COVID has shown us how resilient and adaptable humans are as a society when forced to change . Telemedicine was ready for prime time and has proved to be a godsend, particularly for those with chronic health conditions. Lessons to the society

45. We need to push for more access. The pandemic underlines the need for more home-based medical help with chronic conditions. But that takes both willingness and a lot of gear, such as Bluetooth-enabled blood pressure monitors and, on the doctor side, systems to store and analyze the data. “ People need access to the equipment, and health care systems have to be ready to handle all that data,” What we’ve learned: W hile there are still problems for which we need to see a doctor in person, the pandemic introduced a new urgency to what had been a gradual switch over to platforms like Zoom for remote patient visits .  More doctors also encouraged patients to track their blood pressure at home , and to use at-home equipment for such purposes as diagnosing sleep apnea and ev en testing for colon cancer . Doctors also can fine-tune cochlear implants remotely .

46. Masks are a case in point. They are a key COVID-19 prevention strategy because they provide a barrier that can keep respiratory droplets from spreading. Mask-wearing became more common across East Asia after the 2003 SARS outbreak in that part of the world. The Crowds Will Return, but We'll Gather Carefully Masks and sanitizers will be the norm for years to come ,as well as sanitary measures in airports and public areas .

47. Community is essential—and technology is , too : People who were part of a community during the pandemic realized the importance of human connection, Many of us have become aware of how much we need other people . —Many have managed to maintain their social connections, even if they had to use technology to keep in touch . There was a rise in reported mental health problems that have been described as “a second pandemic,” highlighting mental health as an issue that needs to be addressed . Having COVID-19 may contribute, with its lingering or long COVID symptoms, which can include “foggy mind,” anxiety , depression, and post-traumatic stress disorder .

48. Scientists and nonscientists alike learned that a vi rus can be more powerful than they are. This was evident in the way knowledge about the virus changed over time in the past two years as scientific investigation of it evolved . We know that COVID-19 is not the flu. All these strokes and clots, and the loss of smell and taste that have gone on for months are things that we could have never known or predicted. So, you have to have respect for the unknown and respect science , “most of us have had to have the humility to sometimes say, ‘I don't know. We ‘are learning as we go.’" Sometimes we need a dose of humility :

49. We have the capacity for resilience The pandemic was among the toughest slap-in-the-face moments in recent history to remind us that everything — everything -- in our lives can change in a moment.. That is why the word of the year, and perhaps the coming century, is “ resilience.” Not just at the individual level but at every social tier, from family to community to the world as a whole. . The concept of resilience is very important, because we have this effective reservoir inherent in all of us, —be it the product of evolution, or our ancestors going through catastrophes, including wars, famines, and plagues. inherently, we have the means to deal with crisis. Resilience is part of our psyche. It's part of our DNA, essentially.”

50. Banish fear. “ We don't have to live in fear” of some looming disaster, “ By strengthening our defenses and investing in preparedness, we can live easier knowing that communities have what they need to better respond in moments of crisis. We Can Hope for Stability — but Best Be Prepared for the Opposite Even small changes are highly effective tools for creating resilience. These may sound like the same old advice: exercise more, eat healthy food, start a meditation practice , keep up with friends and family .