The first part of this series of articles looks at the current impact old, almost forgotten diseases are currently having and could continue to have.
Hearing the words Leprosy, Plague, Scarlet Fever and Tuberculosis (TB) sound like they should be confined to the history books and not the current medical or even general press, but it seems that we haven’t quite seen the back of these ‘old’ diseases just yet.
Just the word ‘Plague’ can conjure up images of 6th century contorted faces as depicted in our school history books, but the severity of this infectious disease still resonates when you consider it killed up to half the population of European cities such as Florence, Venice and Paris in as little as four years. However its impact on human history may be greater still; to 1900, and despite intense competition from violence and starvation, it is believed by some that the Plague may have caused half of all human deaths up to that point. Still academics talk about the Plague as if it is a historic disease but it’s still around today, and it’s not alone.
In February 2019, UK national newspapers sported headlines of ‘Hospitals seeing rise in Victorian diseases such as Scarlet Fever and whooping cough’ and ‘Huge increase in ‘Victorian diseases’ including Rickets, Scurvy and Scarlet Fever, NHS data reveals.’ And such headlines are no longer unusual. The media are periodically reporting on ‘old diseases’ re-emerging as well as the threat of more recently identified infections that are equally concerning. So how do we fight the old and deal with the new, preventing re-emergence of those we thought we’d seen the last of while controlling the emergence of new superbugs.
With the ease with which so many of us now travel internationally, and given the number of people travelling here - and potentially walking into your practice or clinic on a given day - it’s no wonder that the number of viruses and bacteria encountered can spread as quickly and as far as they do. So how can you protect your practice and community from the risk of these diseases; is HTM01-05 enough?3 These three articles will explore what are the re-emergence issues, the new threats and finally where we are fighting back and protecting our communities.
Some of these diseases have been restricted to certain parts of the world for years but are now spreading for the first time. Most of these new infections are spread from animals to humans and, as a result of globalisation, intercontinental jet travel, increased urbanisation, climate change and ever-expanding trade routes, these ‘bugs’ now have a greater chance than ever of spreading more aggressively.
Emerging and re-emerging infectious diseases, whether caused by viruses or bacteria, are worrying for scientists as they can evolve and spread fast, and when an epidemic strikes, scientists, governments and pharmaceutical companies must act fast to produce vaccines to stop the spread. But this can take years and often a quarantine is necessary to control the disease spreading further. Or, as can be the case even where a vaccine is available, it may eventually prove ineffective as the bug becomes immune from it. There is also the added risk that many symptoms experienced are hard to diagnose, as they are non-specific to a particular disease or they can be missed entirely until it’s too late. Many start with ‘flu-like’ symptoms which are all too common and unlikely to cause enough concern from an initial medical examination to prompt the action necessary to contain it.
‘Notable diseases’ in the UK are defined as those that medical professionals such as dental professionals have a statutory requirement to inform local authority’s protection teams within three days of any suspected or confirmed cases. This includes diseases such as Anthrax, Cholera, Plague, SARS, Legionnaires disease, Yellow Fever, Scarlet Fever and TB.
Tuberculosis (TB) is the world’s leading infectious bacterial killer. Despite advances in identifying and treating the disease, every year over 10 million people around the world are diagnosed with TB and 1.6 million die as a result. The World Health Organization (WHO) estimates that a third of the world’s population are affected, but fewer than 60% of those diagnosed find a cure. Further problems are posed as the disease can stay dormant and remain inactive for some time so could be contracted and not show up until later.
Despite its prevalence in countries with effective treatment it is both curable and preventable. However, since the late 80s there has been a huge rise in the UK that we are only now getting under control. Although there are still around 5,000 cases a year. However, it is still concerning as this is higher than any other Western European county and proving to be a significant health problem and security threat considering the multidrug-resistant version MDR-TBT.
Specialist TB nurse Emma Gluba, based at hospitals in Chichester and Portsmouth, said “The great news is that in the last two years the incident rate has nearly halved in England, with under 10 cases per 100,000 of the population. Over the 10 years I have specialised in this area, it is good to see such a dramatic decrease in the incident rate. The main reason for this is the government’s focus on identifying and treating people with the latent form. Anyone applying for a visa from a high-risk country is now screened and if they show signs, are treated before they can be issued with a visa. Also support at home to treat the disease is a current focus, targeting vulnerable members of our society.
The public health process with an active TB case is to screen anyone who has been in contact with the affected person. If they are found to be positive they are screened further to rule out active disease. If they are found to have a latent TB they are offered treatment for this. Once active TB treatment has been commenced, it is generally thought they are not infectious after 2weeks of treatment, although they will be closely monitored by their local TB team. TB is completely curable if compliant with the treatment regime.”
One such example at the end of last year that was in the media is of a woman in Wales who died of the disease five days after being told she had contracted it, leading to hundreds of people being screened. By doing so, they identified nearly 30 people with the infection and nearly 8 with an inactive form.
The BCG vaccine offers good protection where received as a child and for about 30 years afterwards, although it isn’t given routinely in schools anymore and there is no evidence that it works once you’re older.
Even though the dental team are likely to encounter patients with TB, there is still limited guidance as to how to deal with the patients once you do, or how to protect yourself, your team and your other patients against the potential risks. It is important therefore to thoroughly follow disinfection control practises for the surgery and use masks at all times due to the disease being airborne of course, as well as having specific procedures identified in your infection control policy manual.
Every March, the WHO have a World TB Day that could help to provide a focus for your team on the risks. The WHO have also launched a global framework this year to try to end the epidemic.
From 2010 to 2015 there were over 3,000 cases globally of the Plague with a mortality rate of up to 60% for the Bubonic Plague. Travelling to Madagascar has been the biggest areas of concern since 2017 when there was an outbreak of the Pneumonic Plague, where all untreated cases had proven fatal, but where the number of new infections is finally in decline. In March last year the WHO implemented drastic steps in Madagascar with their plaque detention systems.
There haven’t been any reported cases in the UK but be careful where you travel abroad, as it is found in Africa, Asia, South America and the USA, where there are still cases annually and 12 recorded deaths since 2000. In 2016 there was a case in Siberia after a boy caught it while out hunting marmots. And in May 2019 a quarantine was issued for hundreds of tourists and locals in Mongolia because of a couple who died of the Bubonic Plaque after eating a raw marmot.
In 2016 in Siberia there was a deadly outbreak of Anthrax claiming its first local victim for decades; a 12-year-old boy. Nearly 100 people were sent to hospital with a suspected infection, in this first reported outbreak since 1941. Investigators from the Russian army’s elite biological warfare unit suspected its cause was a 70-year-old reindeer carcass thawing due to temperatures increasing. In May 2019 there were three Anthrax outbreaks near game reserves in South Africa, which is worrying with the many tourists travelling there every year.
Scarlet Fever is another bacterial infection that we need to be on the lookout for as there are around 10,000 cases every year. The number of deaths from it declined with the discovery of penicillin and further advances in antibiotics. However, PHE at the start of the year were advising parents to be aware of Scarlet Fever symptoms in their children. And in March 2019 the Centre for Disease Control and Prevention indicted that lately there had been the highest incident rate in England and Wales for 50 years, so they recommended that frontline clinicians were aware of the symptoms, they are currently looking to future transmission patterns to improve the strategy for prevention.
Since it was first written about in the 1500s, Scurvy has proven to be an elusive disease with a definitive diagnosis that was only made in the 1930s when it was isolated, as it only becomes evident in about two to three months from a diet lacking sufficient vitamin C. It was famously associated with long sea voyages and naval expeditions. In 2011 in Wales, a 13-year-old boy died from scurvy without seeing any healthcare professionals as his parents didn’t recognise the symptoms. And last year there were nine admissions to UK hospitals for scurvy of under nine-year olds, up from four the year before. With the admissions for scurvy, vitamin D deficiency and gout up by 24% through 2017 and 18. Also, in the past ten years, several refugee populations that are wholly dependent on food aid have developed scurvy such as an outbreak in Southern Sudanese refugees at a camp in Kenya reported in January 2019.
The more awareness you have, both for yourself and your family when you travel, and your team and your patients when in practice, the more you can prepare and protect them from contracting an infectious disease. The second part of this article will look at Legionnaires disease and how we can fight back both locally and globally.
References available on request.
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