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The History of Pandemics: How Infectious Disease Outbreaks Shape the World

With the COVID-19 pandemic continuing worldwide, it is always interesting to look through our past and learn from those who have come before us. The term pandemic was first used in 1666 to describe “a continuously spreading disease in a country.” The terms epidemic and pandemic were often interchangeably used in many contexts across the 17th and 18th centuries. The terminology has now evolved to express how “frequent and geographically extent a disease is compared to previously.”


Ancient History


There have been many pandemics and epidemics across the globe from the earliest records of human lives. In some cases, ancient pandemics were discovered through archeological finds, and in others, through various records.


A case in China about 5,000 years ago wiped out a village. Archaeologists found skeletons across all age groups in two different sites, suggesting to researchers that an epidemic had taken over the region, but no official records were kept.


The earliest recorded pandemic happened during the Peloponnesian War around 430 B.C. Having passed through Libya, Egypt, and Ethiopia, it eventually crossed over the Athenian walls while the Spartans were also laying siege against the city and its people. It is estimated that as much as two-thirds of the population died. It is believed that this pandemic was exacerbated by the ‘modernization’ of cities, which often saw overcrowding. It is thought that this pandemic was a significant factor in the Athenian defeat by the Spartans.


Across Europe, there were plagues recorded throughout the early years of the A.D. era, such as the Antonine Plague in A.D. 165, which is thought to have killed as many as 5 million people, and the Cyprian plague in 250 A.D., which was estimated to have killed 5,000 people a day in Rome alone. Again, archaeologists found what seemed to be a mass burial site where the bodies were covered with a layer of lime which was used as a disinfectant. In 541 A.D., the Justinian Plague hit the Mediterranean region, estimated to have killed as much as 60% of that region. It was discovered later through DNA extracted from the dental pulp of the remains found in burial pits that this pandemic was caused by Yersinia pestis, which is still found in rodents and their fleas and occurs in many parts of the world, including the United States. This bacterium can lead to pneumonic, bubonic, and septicemic plagues. It is worth noting that this bacterium is easily destroyed by sunlight and drying, but it can survive for up to an hour (though, of course, it can vary depending on conditions.)




The 11th century saw leprosy grow into a pandemic in the Middle Ages, even though it had been around for a long time. A bacterial disease that causes numerous sores and deformities led to the ostracization of its victims due to the belief that the disease was a punishment from God. It still exists today but is known as Hansen’s disease and afflicts tens of thousands of people annually. It is fatal if not treated with antibiotics.


As the world continued to globalize, one of the more ‘famous’ plagues, the Black Plague from 1346-1353, traveled from Asia to Europe, causing massive devastation across Europe. Some guessed that it killed over half of it Europe’s population. This plague changed the course of Europe’s history. With so many dead, a massive labour shortage brought about better working conditions and compensation for workers, led to the end of serfdom in Europe, and may have even contributed to technological advances due to worker shortages.


The 16th through 18th centuries brought plagues to many European countries. The UK also suffered another (and their last major outbreak) of the black plague (sometimes called the black death) in 1665 and 1666, killing over 100,000 people, including 15% of London. Spread mainly by plague-infected fleas, it spread rapidly during the heat of summer, leading King Charles II to start a mass exodus from London to the countryside to help reduce the transmission. A similar plague infected Marseille, France, possibly from an infected cargo ship from the Mediterranean and likely from infected rodents. This plague killed as much as 30% of the population of Marseille, approximately 100,000 people. Russia also suffered a similar fate. China, India, and Hong Kong suffered from a similar plague in 1855 spread by fleas during a mining boom and is considered a factor in the Parthay rebellion and the Taiping rebellion. It also led to the British's increased use of repressive policies in India that helped spark a revolt against the colonizers. The pandemic was considered active for over 100 years until 1960, when cases finally dropped below a couple hundred.


Moving to North and Central America, the Cocoliztli Epidemic, a form of a viral hemorrhagic fever that lasted from 1545 to 1548, killed 15 million in Mexico and Central America. It was found when the victims' bodies were infected with a subspecies of salmonella, S. paratyphi C, from the same family as typhoid. It is still a threat today and can cause high fever, dehydration, and gastrointestinal problems.


There were also numerous plagues across North and South America brought by European colonization and led to the collapse of both the Inca and Aztec civilizations in the 16th century. A disease carried by mosquitos, yellow fever was a constant battle in America. In 1793, Philadelphia suffered from a yellow fever epidemic, leading to over 5,000 deaths.

Smallpox is thought to have existed for at least 3,000 years with the discovery of smallpox-like rashes on Egyptian mummies, but its origin is unknown. Also spread by global exploration, smallpox was a worldwide threat, with each continent suffering from it. Smallpox is a horrible disease where on average, three out of every ten people who got it died. Those who survived often did so with scars, which could be quite severe.


Modern Plagues




Polio, not thought of often anymore and not as feared by the younger generations today in the western world, was a devastating disease that terrified parents. Polio epidemics occurred sporadically in the United States and Canada (and across the globe) until the Salk vaccine became available, leading to global vaccination efforts responsible for drastically reducing the disease, though it is not eradicated yet.


There have been seven major cholera pandemics seen in the Middle East, North Africa, Europe, Russia, and the Americas. The first six pandemics lasted from 1817 to 1923, with the seventh still considered ongoing, starting in 1961 with an estimated 2.86 million cases and 95,000 deaths each year. It is estimated that 1.6 billion people are at risk of cholera.

Like COVID-19, which spreads easily across a completely globalized world, flu pandemics spread easily in the late 1800s and the early 1900s due to modernization brought on by the industrial age. This era saw the Asian flu from 1957 to 1958, which is estimated to have claimed one million lives globally. The Hong Kong flu containing a gene from the 1957 Asian flu started in 1968. Though milder than the previous flu, it was highly contagious and is estimated to have caused one to four million deaths globally.


The Spanish flu is perhaps one of the most well-known pandemics outside COVID-19. The avian-borne flu resulted in more than 50 million deaths worldwide and was first observed in Europe. At the time, there were no vaccines or effective treatments. Starting in 1918, it ended in 1919 after most of the infected had developed immunity or had died.


SARS, or Severe Acute Respiratory Syndrome, is a more recent outbreak that was first identified in 2003 and spread to 26 countries from China, where it is believed to have possibly started with bats that spread it to cats and then humans.


The West African Ebola outbreak from 2014 to 2016 ravaged the region with over 26,800 cases, killing over 11,000. The first case was thought to be in Guinea, and it spread quickly to Sierra Leone and Liberia. It also spread to Nigeria, Mali, Senegal, the United States, and Europe, but most cases and deaths occurred in the first three countries. There is no cure or vaccine for Ebola, but efforts continue toward finding one.


Ongoing Epidemics


In addition to COVID-19, there are still many epidemics that continue to impact the lives of millions worldwide.


Perhaps one of the most well-known ongoing epidemics was first officially identified in 1982 as Acquired Immune Deficiency Syndrome (AIDS) after numerous reports of rare diseases such as Pneumocystis carinii pneumonia (PCP) and Kaposi’s sarcoma in young gay men in 1981. In 1985, the CDC redefined AIDS to note that it is caused by a newly identified virus, which in 1986 would officially be defined as Human Immunodeficiency Virus (HIV.) Since the start of the epidemic, HIV has infected over 79 million, with over 36 million deaths due to AIDS-related illnesses, though these numbers could be higher.


Zika, first identified in 2015, is ongoing and is mainly found in South and Central America. The virus is often spread through mosquitoes but can also be spread sexually. While Zika is not usually harmful to adults or children, it attacks infants in the womb leading to congenital disabilities. The types of mosquitoes that carry the Zika virus are often found in warm and humid climates, making South America, Central America, and the southern US key areas for the virus.


Middle East Respiratory Syndrome (MERS) is another new viral respiratory illness. First reported in Saudi Arabia in 2012, it has spread to other countries, including the US. Most people who develop this illness develop severe respiratory illness, with symptoms like that of the initial COVID-19 infection such as fever, cough, and shortness of breath. Many of those with MERS have died.


So, What Can We Learn from Our Global Ancestors and Previous Plagues in Response to COVID-19?


In some cases, such as the documented cases in China, those sites were not inhabited again. And while this is not a possibility for most of the world, it is interesting to see how civilizations have addressed serious pandemics and epidemics over time.


The Spanish Flu brought about new quarantine, isolation, and masking interventions.

The Russian flu, which is estimated to have killed one million people from 1889 to 1890, is thought to have provided some protection against the Spanish flu for those who had got the Russian flu and survived. Which we know now is related to our antibodies and immune systems.


The fight against smallpox led to the start of vaccinations after variolation was used to help protect people from smallpox. It was a process where people who had not had smallpox were exposed to material from smallpox sores (pustules) by scratching the material into their arm or inhaling it through their noses. After variolation, people often developed symptoms associated with the illness, such as fever and a rash. However, fewer people died from variolation than if they caught smallpox naturally.


The basis for vaccination began after an English doctor, Edward Jenner, noticed that milkmaids who had gotten cowpox were protected from smallpox. With his knowledge of variolation, he hypothesized that exposure to cowpox could protect against smallpox and began work towards testing this. While his testing methods would be considered unethical and illegal now (he took samples from an infected milkmaid and infected another child), they did lead to the discovery of a vaccine. After this, vaccination became widely accepted and gradually replaced variolation.


The smallpox vaccine and the global efforts to vaccinate their populations led to WHO declaring the world free of this illness on May 8, 1980, nearly two centuries after Jenner began work on vaccinations.


The SARS pandemic was declared over due to the remarkable global efforts to identify and isolate cases of the virus and its use of contact tracing.


The HIV epidemic, while still ongoing, has made remarkable strides toward reducing the transmission and spread and its terms of treatment, where now those living with HIV can live relatively long and healthy lives with the use of antiretroviral treatments (ART). There is also work using the gene-editing technology CRISPR to discover a cure that is currently in its first human trials. There has also been significant headway toward creating a vaccine for HIV. The mRNA technology used in the COVID vaccines is now being used for many other diseases and illnesses, such as finding an HIV vaccine.


Summary


So far, there have been over 516 million cases of COVID-19 and over 6 million deaths, but the total continues to climb for both. We have seen various ways of managing pandemics and epidemics throughout history, with varying success depending on different factors.

Another impactful tool used to help manage illnesses and diseases, especially infectious diseases, is the use of testing. The only way to know with certainty that someone is infected is to test. Testing has been a vital pillar of HIV prevention and treatment, helping reduce transmission, increase awareness, and help get more people on treatment.


The use of rapid tests, now ubiquitous due to the COVID-19 pandemic, have been around for years. With the ability to test at home, when convenient for people, these tests have helped keep communities safe and aware. Along with isolation and masking, testing has been critical in helping society open once again. Tests such as the iStatis COVID-19 Antigen Home Test offer people a tool to help manage the spread of the virus in the comfort of their own homes.


HIV has benefited widely from rapid testing, as it makes tests available across multiple settings, so they can easily test no matter where it is required. The INSTI® HIV-1/2 Antibody Test is a one-minute test that helps screen for HIV and is used across the globe.


Using the tools that have been developed and improved over the years, such as testing, vaccinations, treatments, and isolation, help the world manage the pandemics and epidemics. While no one method is perfect on its own, together, they create a powerful toolkit we can use to help reduce COVID-19 infections and eventually end the pandemic.


References


Catie: https://www.catie.ca/a-history-of-hivaids

CDC: https://www.cdc.gov/coronavirus/mers/index.html

CDC: https://www.cdc.gov/smallpox/history/history.html

History: https://www.history.com/topics/middle-ages/pandemics-timeline

HIV.gov: https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline

Live Science: https://www.livescience.com/worst-epidemics-and-pandemics-in-history.html

MPHonline: https://www.mphonline.org/worst-pandemics-in-history/

Sampath et al.: https://www.cureus.com/articles/69273-pandemics-throughout-the-history

UNAIDS: https://www.unaids.org/en/resources/fact-sheet

WHO: https://covid19.who.int/

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