Bubonic plague historical perspective

Many nursery rhymes in modern culture are recited without much thought about what the words actually mean. One nursery rhyme, in particular, has adopted a much more morbid meaning than many would expect.

Ring around the rosey Pockets full of posies Ashes-ashes We all fall down

Ring around the rosey Many believe that the first line in the nursery rhyme refers to the hemorrhagic rings that form on a patient infected with the plague.

Pockets full of posies This is believed to represent the strong smelling flowers that physicians and others carried to help eliminate the smell of the disease.

Ashes-ashes This is believed to represent the cremation of all of the dead bodies.

We all fall down This represents that everyone died.

History
The earliest (though unvalidated) account describing a possible plague epidemic is found in I Samuel 5:6 of the Hebrew Bible (Tanakh). In this account, the Philistines of Ashdod were stricken with a plague for the crime of stealing the Ark of the Covenant from the Children of Israel. These events have been dated to approximately the second half of the eleventh century B.C. The word "tumors" is used in most English translations to describe the sores that came upon the Philistines. The Hebrew, however, can be interpreted as "swelling in the secret parts". The account indicates that the Philistine city and its political territory were stricken with a "ravaging of mice" and a plague, bringing death to a large segment of the population. In the second year of the Peloponnesian War (430 B.C.), Thucydides described an epidemic disease which was said to have begun in Ethiopia, passed through Egypt and Libya, then come to the Greek world. In the Plague of Athens, the city lost possibly one third of its population, including Pericles. Modern historians disagree on whether the plague was a critical factor in the loss of the war. Although this epidemic has long been considered an outbreak of plague, many modern scholars believe that typhus, smallpox, or measles may better fit the surviving descriptions. A recent study of the DNA found in the dental pulp of plague victims, led by Manolis J. Papagrigorakis, suggests that typhoid was actually responsible. Other scientists dispute this conclusions, citing serious methodologic flaws in the DNA study. In the first century A.D., Rufus of Ephesus, a Greek anatomist, refers to an outbreak of plague in Libya, Egypt, and Syria. He records that Alexandrian doctors named Dioscorides and Posidonius described symptoms including acute fever, pain, agitation, and delirium. Buboes&mdash;large, hard, and non-suppurating&mdash;developed behind the knees, around the elbows, and "in the usual places." The death toll of those infected was very high. Rufus also wrote that similar buboes were reported by a Dionysius Curtus, who may have practiced medicine in Alexandria in the third century B.C. If this is correct, the eastern Mediterranean world may have been familiar with bubonic plague at that early date. (ref. Simpson, W.J., Patrick, A.)

First Pandemic: Plague of Justinian
The Plague of Justinian in A.D. 541–542 is the first known pandemic on record, and marks the first firmly recorded pattern of bubonic plague. This outbreak is thought to have originated in Ethiopia or Egypt. The huge city of Constantinople imported massive amounts of grain, mostly from Egypt, to feed its citizens. The grain ships may have been the source of contagion for the city, with massive public granaries nurturing the rat and flea population. At its peak the plague was killing 10,000 people in Constantinople every day and ultimately destroyed perhaps 40 percent of the city's inhabitants. It went on to destroy up to a quarter of the human population of the eastern Mediterranean. In A.D. 588 a second major wave of plague spread through the Mediterranean into what is now France. A maximum of 25 million dead is considered a reasonable estimate. An outbreak of it in the A.D. 560s was described in A.D. 790 as causing "swellings in the glands...in the manner of a nut or date" in the groin "and in other rather delicate places followed by an unbearable fever". While the swellings in this description have been identified by some as buboes, there is some contention as to whether the pandemic should be attributed to the bubonic plague, Yersinia pestis, known in modern times.

Second Pandemic: Black Death
From 1347 to 1351, the Black Death, a massive and deadly pandemic, swept through Eurasia, killing approximately one third to one half of the population (according to some estimates) and changing the course of Asian and European history. It is estimated that anywhere from a quarter to two-thirds of Europe's population became victims to the plague, making the Black Death the largest death toll from any known non-viral epidemic. Although accurate statistical data does not exist, it is thought that 4.2 million died in England (1/4 of the population), while an even higher percentage of Italy's population was likely wiped out. On the other hand, Northeastern Germany, Bohemia, Poland and Hungary are believed to have suffered less, and there are no estimates for Russia or the Balkans at all. The Black Death continued to strike parts of Europe throughout the 14th, 15th, and 16th centuries, each time with reduced intensity and fatality, suggesting an increased resistance due to genetic selection. Some have also argued that changes in hygiene habits and efforts to improve public health and sanitation had a significant impact on the falling rates of infection.

Nature of the disease
In the early 20th century, following the identification by Yersin and Kitasato of the plague bacterium that caused the late 19th and early 20th century Asian bubonic plague (the Third Pandemic), most scientists and historians came to believe that the Black Death was an incidence of this plague, with a strong presence of the more contagious pneumonic and septicemic varieties increasing the pace of infection, spreading the disease deep into inland areas of the continents. It was claimed that the disease was spread mainly by black rats in Asia and that therefore there must have been black rats in north-west Europe at the time of the Black Death to spread it, although black rats are currently rare except near the Mediterranean. This led to the development of a theory that brown rats had invaded Europe, largely wiping out black rats, bringing the plagues to an end, although there is no evidence for the theory in historical records. Some historians suggest that marmots, rather than rats, were the primary carriers of the disease. The view that the Black Death was caused by Yersinia pestis has been incorporated into medical textbooks throughout the 20th century and has become part of popular culture, as illustrated by recent books, such as John Kelly's The Great Mortality.

Many modern researchers have argued that the disease was more likely to have been viral (that is, not bubonic plague), pointing to the absence of rats from some parts of Europe that were badly affected and to the conviction of people at the time that the disease was spread by direct human contact. According to the accounts of the time the black death was extremely virulent, unlike the 19th and early 20th century bubonic plague. Samuel K. Cohn has made a comprehensive attempt to rebut the bubonic plague theory. In the Encyclopedia of Population, he points to five major weaknesses in this theory: Cohn also points out that while the identification of the disease as having buboes relies on accounts of Boccaccio and others, they described buboes, abscesses, rashes and carbuncles occurring all over the body, the neck or behind the ears. In contrast, the modern disease rarely has more than one bubo, most commonly in the groin, and is not characterised by abscesses, rashes and carbuncles.
 * very different transmission speeds — the Black Death was reported to have spread 385 km in 91 days in 664, compared to 12-15 km a year for the modern Bubonic Plague, with the assistance of trains and cars
 * difficulties with the attempt to explain the rapid spread of the Black Death by arguing that it was spread by the rare pneumonic form of the disease — in fact this form killed less than 0.3% of the infected population in its worst outbreak (Manchuria in 1911)
 * different seasonality — the modern plague can only be sustained at temperatures between 50 and 78 °F (10 and 26 °C) and requires high humidity, while the Black Death occurred even in Norway in the middle of the winter and in the Mediterranean in the middle of hot dry summers
 * very different death rates — in several places (including Florence in 1348) over 75% of the population appears to have died; in contrast the highest mortality for the modern Bubonic Plague was 3% in Mumbai in 1903
 * the cycles and trends of infection were very different between the diseases — humans did not develop resistance to the modern disease, but resistance to the Black Death rose sharply, so that eventually it became mainly a childhood disease

Researchers has offered a mathematical model based on the changing demography of Europe from 1000 to 1800 AD demonstrating how plague epidemics, 1347 to 1670, could have provided the selection pressure that raised the frequency of a mutation to the level seen today that prevent HIV from entering macrophages that carry the mutation (the average frequency of this allele is 10% in European populations). It is suggested that the original single mutation appeared over 2500 years ago and that persistent epidemics of a haemorrhagic fever that struck at the early classical civilizations.

Third Pandemic
The Third Pandemic began in China in 1855, spreading plague to all inhabited continents and ultimately killing more than 12 million people in India and China alone. Casualty patterns indicate that waves of this pandemic may have come from two different sources. The first was primarily bubonic and was carried around the world through ocean-going trade, transporting infected persons, rats, and cargos harboring fleas. The second, more virulent strain was primarily pneumonic in character, with a strong person-to-person contagion. This strain was largely confined to Manchuria and Mongolia. Researchers during the "Third Pandemic" identified plague vectors and the plague bacterium (see above), leading in time to modern treatment methods.

Plague occurred in Russia in 1877–1889 in rural areas near the Ural Mountains and the Caspian Sea. Efforts in hygiene and patient isolation reduced the spread of the disease, with approximately 420 deaths in the region. Significantly, the region of Vetlianka in this area is near a population of the bobak marmot, a small rodent considered a very dangerous plague reservoir. The last significant Russian outbreak of Plague was in Siberia in 1910 after sudden demand for Marmot skins (a substitute for Sable) increased the price by 400 percent. The traditional hunters would not hunt a sick Marmot and it was taboo to eat the fat from under the arm (the axillary lymphatic gland that often harboured the plague) so outbreaks tended to be confined to single individuals. The price increase however attracted thousands of Chinese hunters from Manchuria who not only caught the sick animals but ate the fat which was considered a delicacy. The plague spread from the hunting grounds to the terminus of the Chinese Eastern Railway and then followed the track for 2,700 km. The plague lasted 7 months and killed 60,000 people.

The bubonic plague continued to circulate through different ports globally for the next fifty years; however, it was primarily found in Southeast Asia. An epidemic in Hong Kong in 1894 had particularly high death rates, greater than 75%. As late as 1897, medical authorities in the European powers organized a conference in Venice, seeking ways to keep the plague out of Europe. The disease reached the Republic of Hawaii in December of 1899, and the Board of Health of Hawaii decision to initiate controlled burns of select buildings in Honolulu’s Chinatown turned into an uncontrolled fire which lead to the inadvertent burning of most of Chinatown on January 20 1900 according to the Star Bulletin's Feature on the Great Chinatown Fire. Plague finally reached the United States later that year in San Francisco.

Although the outbreak that began in China in 1855 is conventionally known as the Third Pandemic, (the First being the Plague of Justinian and the second being the Black Death), it is unclear whether there have been fewer, or more, than three major outbreaks of bubonic plague. Most modern outbreaks of bubonic plague amongst humans have been preceded by a striking, high mortality amongst rats, yet this phenomenon is absent from descriptions of some earlier plagues, especially the Black Death. The buboes, or swellings in the groin, that are especially characteristic of bubonic plague, are a feature of other diseases as well.

Plague as a biological weapon
Plague has a long history as a biological weapon. Historical accounts from ancient China and medieval Europe detail the use of infected animal carcasses, such as cows or horses, and human carcasses, by the Xiongnu/Huns, Mongols, Turks, and other groups, to contaminate enemy water supplies. Han Dynasty General Huo Qubing is recorded to have died of such a contamination while engaging in warfare against the Xiongnu. Plague victims were also reported to have been tossed by catapult into cities under siege.

During World War II, the Imperial Japanese Army developed weaponised plague, based on the breeding and release of large numbers of fleas. During the Japanese occupation of Manchuria, Unit 731 deliberately infected Chinese, Korean, and Manchurian civilians and prisoners of war with the plague bacterium. These subjects, called "logs", were then studied by dissection, others by vivisection while still conscious. Members of the unit such as Shiro Ishii were exonerated from the Tokyo tribunal by Douglas MacArthur but twelve of them were prosecuted during the Khabarovsk War Crime Trials in 1949.

After World War II, both the United States and the Soviet Union developed means of weaponising pneumonic plague. Experiments included various delivery methods, vacuum drying, sizing the bacterium, developing strains resistant to antibiotics, combining the bacterium with other diseases (such as diphtheria), and genetic engineering. Scientists who worked in Soviet Union]] bio-weapons programs have stated that the Soviet effort was formidable and that large stocks of weaponised plague bacteria were produced. Information on many of the Soviet projects is largely unavailable. Aerosolized pneumonic plague remains the most significant threat. The plague can be easily treated with antibiotics, and a widespread epidemic is highly unlikely in developed countries.



Contemporary cases
Two non-plague Yersinia, Yersinia pseudotuberculosis and Yersinia enterocolitica, still exist in fruit and vegetables from the Caucasus Mountains east across southern Russia and Siberia, to Kazakhstan, Mongolia, and parts of China; in Southwest and Southeast Asia, Southern and East Africa (including the island of Madagascar); in North America, from the Pacific Coast eastward to the western Great Plains, and from British Columbia south to Mexico; and in South America in two areas: the Andes mountains and Brazil. There is no plague-infected animal population in Europe or Australia.


 * On 31 August, 1984, the Centers for Disease Control and Prevention reported a case of plague pneumonia in Claremont, California. The CDC believes that the patient, a Veterinarian, contracted plague from a stray cat.  This could not be confirmed since the cat was destroyed prior to the onset of symptoms.


 * In the U.S., about half of all food cases of plague since 1970 have occurred in New Mexico. There were 2 plague deaths in the state in 2006, the first fatalities in 12 years.


 * On 19 April 2006, CNN News and others reported a case of plague in Los Angeles, California, lab technician Nirvana Kowlessar, the first reported case in that city since 1984.


 * In May 2006, KSL Newsradio reported a case of plague found in dead field mice and chipmunks at Natural Bridges about 40 mi west of Blanding in San Juan County, Utah.


 * In May 2006, The Arizona Republic reported a case of plague found in a cat.


 * One hundred deaths resulting from pneumonic plague were reported in Ituri district of the eastern Democratic Republic of the Congo in June 2006. Control of the plague was proving difficult due to the ongoing conflict.


 * It was reported in September 2006 that three mice infected with Yersinia pestis apparently disappeared from a laboratory belonging to the Public Health Research Institute, located on the campus of the University of Medicine and Dentistry of New Jersey, which conducts anti-bioterrorism research for the United States government.


 * On 16 May 2007, an 8-year-old hooded capuchin monkey in Denver Zoo died of the bubonic plague. Five squirrels and a rabbit were also found dead on zoo grounds and tested positive for the disease.


 * On 5 June 2007 in Torrance County, New Mexico a 58 year old woman developed bubonic plague, which progressed to plague pneumonia