Epidemics and pandemics have been around since ancient times, evidence suggests that smallpox virus emerged 3,000-4,000 years ago. The Greek word pandemic (πανδημία) describes the continued spread of disease in a country and nearby countries (epidemic) and into other continents (pandemic).
Documents show that over 1000 years ago in China, people were given a powder to inhale, derived from dried up lesions of people recovering from smallpox, in an attempt to generate immunity (‘vaccinate’) against smallpox. Deaths were uncommon in those who were ‘vaccinated’, compared to those who were not.
In the 1700’s, some 700 years later, smallpox was still killing over 60 per cent of the European population. Edward Jenner at the time had noted that milkmaids who were in contact with cows which were infected with cowpox (cow version of smallpox), rarely contracted smallpox. The idea of cross species protection emerged, so he injected an eight-year-old boy with cowpox vesicles and challenged him with smallpox, the boy was subsequently protected against smallpox.
Vaccination using this method was common and many people were protected against smallpox, however there was much criticism from the public. Two hundred years later however, smallpox vaccination became popular and between 1967 and 1977, there was a world-wide mass vaccination campaign which resulted in complete eradication of smallpox. In 1980 the WHO declared smallpox to be eradicated, the only infectious disease to have been completely eradicated from the world, this is a remarkable effort – a 3,000-year-old pandemic, was eradicated in 10 years of a world-wide mass-vaccination effort.
Epidemics and pandemics from Ancient to Modern times
Athenian plague (430 BC), an epidemic that devastated Athens and lasted for three years. Symptoms included rash, headache, abdominal cramps, hemoptysis, death within 1 week, with a total death toll reaching 25 per cent of the Athenian population (75,000-100,000 people). The disease that caused this outbreak is unknown although it is believed that it may have been smallpox.
Antonine plague (165-180 AD), or the plague of Galen the Greek physician who described it; spread to the entire Roman empire via troops from Iraq which killed about 5-10 million people (10 per cent of the population). Symptoms included rashes, blood pustules, diarrhea with blood, hemoptysis and fever. The cause is not known although it is believed to have been either smallpox or measles. The disease spread rapidly and even nine years after the first outbreak it still killed around 2,000 people a day in Rome.
Justinian plague (541-549 AD) was prominent in the Mediterranean basin, Europe and the Near East; known as the first plague and it recurred for 200 years, making it one of the deadliest pandemics in history. It was transmitted from rats to humans via flea bites and then via human-to-human transmission. Symptoms included cough, dyspnea, fever, fatigue, hallucinations and killed 60 per cent of the Mediterranean world at the time of the first plague. The cause of the pandemic by the bacterium Yersinia pestis.
Black death (1346-1353), also known as the Plague, or bubonic plague pandemic, was prominent in Europe, North Africa and Asia. It killing over 200 million people, and is considered the most fatal of all pandemics (killing 60 per cent of Europe’s population). The plague was caused by the bacterium Yersinia pestis, transmitted via rat fleas then from human-to-human contact, and symptoms were sudden, causing septicemia and gangrene of extremities lasting one week before death. Black death plague is known as the second plague. It killed 30-60 per cent of the European population, 30 per cent of the Middle East and reduced the world population from 475 million to approximately 375 million.
Seven cholera pandemics (1817-present). The first cholera pandemic started in India and extended to nearby countries including China, Indonesia, Japan, Middle East, Russia and was followed by five further pandemics spanning almost 100 years, 1827-1923 and included USA and Europe. It is transmitted by the bacterium Vibrio Cholerae present in contaminated water. The seventh cholera pandemic began in 1961 and is ongoing and endemic in several countries. The first 6 pandemics resulted in 1 million deaths whilst the current one has caused 2.86 million deaths with 95,000 deaths per year, and 1.3 billion at risk of infection.
Spanish flu (1918-1920) is a H1N1 influenza A virus which emerged at the end of WWI, in USA. Approximately one third of the world population (or 500 million people) became infected with the virus and resulted in over 50 million deaths (and possibly as high as 100 million); making it the deadliest of the 20th century. A further 2 pandemics have resulted from H1N1 influenza A virus, the 1977 Russian flu and the 2009 Swine flu pandemics.
Swine flu (2009-2010) is also caused by a new H1N1 influenza A virus strain as a result of reassortment of bird, swine and human flu viruses which further combined with Eurasian pig flu virus leading to ‘swine flu’. Swine flu affected 10-20 per cent (0.7-1.4 billion) of the world population but was not as deadly as the Spanish flu, killing around 200-500,000 people. Within 6 weeks the virus rapidly spread to 122 countries due to travel and global trade. Anti-virals and vaccines were rapidly produced and within 16 months the swine flu pandemic was declared over.
COVID-19 (2019-present) is caused by the SARS-CoV-2 virus with the first case being reported in December 2019 and declared a pandemic on 11 March 2020. The origin is believed to be from zoonotic source and is rapidly spread through talking, sneezing, coughing, Thus far, there have been over 690 million cases and almost 6.9 million deaths. Emergency use vaccines and anti-virals have significantly reduced the mortality rate worldwide, in addition to quarantine measures, physical distancing, hand washing, masks, and hygiene. Studies are now emerging which suggest that at least 20% of those with COVID-19 have or will experience long-COVID.
Other epidemics / pandemics include the Plague of Cyprus (250-271), Cocoliztli epidemic (1545-1548), Great Plague of London (1665-1666), Great Plague of Marseille (1720-1723), Russian Plague (1770-1772), Philadelphia yellow fever (1793), flu pandemic (1889-1890), Russian typhus (1918-1922), Asian flu (1957), Hong Kong flu (1968), HIV/AIDS (1981-), SARS-CoV (2002), MERS (2012), Ebola (2013-2016), Zika virus (2015-).
Where now?
Polio was prevalent between 1948-1955 but the development of a polio vaccine in 1955, saw a rapid decline of polio in industrialised countries by 1991. The decline of Polio in the industrial world was followed by the Americas in 1994, Western Pacific, Southeast Asia by 2000, and all of Europe was polio-free by 2002. In 1996 the African leader, Nelson Mandela announced the ‘kick polio out of Africa’ campaign a partnership with Rotary International, and polio vaccines were administered in every town and country in Africa; so in August 2020 Africa was free of wild polio. Today only Pakistan and Afghanistan are the two remaining countries with polio.
With the aim to eradicate some other common infectious diseases, worldwide vaccinations in children include, diphtheria, tetanus, whooping cough, measles, mumps, rubella, haemophilus influenza type-b, polio, pneumococcus, hep-A, hep-B and the HPV vaccine against cervical cancer given by the age of 13.
Over the history of the world epidemics and pandemics occur again and again, killing millions of people. Most people were taken by surprise with the current COVID-19 pandemic, but it was not a matter of, ‘if’, but ‘when’ will be the next, and this will continue. With more awareness and much progress in research, we are better placed now and more prepared, for the ‘next’ pandemic.
