The cause of the plague of Athens: plague, typhoid, typhus, smallpox, or measles?

Tick-Borne Rickettsiosis and Tsutsugamushi Disease Recorded in 313

Tsutsugamushi disease was first described in China by Hong Ge in 313. In his book Zhouhou Beiji Fang, three eschar-associated febrile diseases were described: Shashidu, Zhongxidu, and Shegongdu. Shashidu was identified as being identical to tsutsugamushi disease in Japan: it occurred in riverside areas, exhibited an eschar, and was transmitted by tiny red "sand lice". The nature of Zhongxidu remains unknown, but we propose that it is another type of Orientia tsutsugamushi infection: it occurred in mountainous areas, an eschar was observed, and the causative vector was not identified. Moreover, Zhongxidu would have predated Shashidu by five centuries; thus, the first documentation of tsutsugamushi disease would date back 2.2 millennia. O. tsutsugamushi infection without eschar has not been identified in ancient Chinese literature and may be included in Shanghan. Several ancient Chinese books describe that Shegongdu occurs following a Shegong bite. Shegong is described as a bug resembling a cockroach or cicada with a crossbow-like structure, possibly the hypostome and unfolded palps of tick, in its mouth. Thus, Shegong refers to an engorged tick and Shegongdu is a tick-borne rickettsiosis. However, due to a lack of entomological knowledge, these findings have not been recognized for the past 1.7 millennia.

The Importance of the One Health Concept in Combating Zoonoses

One Health fundamentally acknowledges that human health is linked to animal health and the environment. One of the pillars One Health is built on is zoonoses. Through the years, zoonotic infections have caused numerous outbreaks and pandemics, as well as millions of fatalities, with the COVID-19 pandemic being the latest one. Apart from the consequences to public health, zoonoses also affect society and the economy. Since its establishment, One Health has contributed significantly to the protection of humans, animals, and the environment, through preparedness, surveillance, and mitigation of such public dangers.

Historical microbiology: researching past bioevents by integrating scholarship (re)sources with paleomicrobiology assets

The analysis of past epidemics and pandemics, either spontaneous or of human origin, may revise the physical history of microbiota and create a temporal context in our understanding regarding pathogen attributes like virulence, evolution, transmission and disease dynamics. The data of high-tech scientific methods seem reliable, but their interpretation may still be biased when tackling events of the distant past. Such endeavors should be adjusted to other cognitive resources including historical accounts reporting the events of interest and references in alien medical cultures and terminologies; the latter may contextualize them differently from current practices. Thus 'historical microbiology' emerges. Validating such resources requires utmost care, as these may be susceptible to different biases regarding the interpretation of facts and phenomena; biases partly due to methodological limitations.

Aerosol transmission of human pathogens: From miasmata to modern viral pandemics and their preservation potential in the Anthropocene record

Ongoing uncertainty over the relative importance of aerosol transmission of COVID-19 is in part rooted in the history of medical science and our understanding of how epidemic diseases can spread through human populations. Ancient Greek medical theory held that such illnesses are transmitted by airborne pathogenic emanations containing particulate matter ("miasmata"). Notable Roman and medieval scholars such as Varro, Ibn al-Khatib and Fracastoro developed these ideas, combining them with early germ theory and the concept of contagion. A widely held but vaguely defined belief in toxic miasmatic mists as a dominant causative agent in disease propagation was overtaken by the science of 19th century microbiology and epidemiology, especially in the study of cholera, which was proven to be mainly transmitted by contaminated water. Airborne disease transmission came to be viewed as burdened by a dubious historical reputation and difficult to demonstrate convincingly. A breakthrough came with the classic mid-20th century work of Wells, Riley and Mills who proved how expiratory aerosols (their "droplet nuclei") could transport still-infectious tuberculosis bacteria through ventilation systems. The topic of aerosol transmission of pathogenic respiratory diseases assumed a new dimension with the mid-late 20th century "Great Acceleration" of an increasingly hypermobile human population repeatedly infected by different strains of zoonotic viruses, and has taken centre stage this century in response to outbreaks of new respiratory infections that include coronaviruses. From a geoscience perspective, the consequences of pandemic-status diseases such as COVID-19, produced by viral pathogens utilising aerosols to infect a human population currently approaching 8 billion, are far-reaching and unprecedented. The obvious and sudden impacts on for example waste plastic production, water and air quality and atmospheric chemistry are accelerating human awareness of current environmental challenges. As such, the "anthropause" lockdown enforced by COVID-19 may come to be seen as a harbinger of change great enough to be preserved in the Anthropocene stratal record.

Preventive Measures against Pandemics from the Beginning of Civilization to Nowadays—How Everything Has Remained the Same over the Millennia

As of 27 March 2022, the β-coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected more than 487 million individuals worldwide, causing more than 6.14 million deaths. SARS-CoV-2 spreads through close contact, causing the coronavirus disease 2019 (COVID-19); thus, emergency lockdowns have been implemented worldwide to avoid its spread. COVID-19 is not the first infectious disease that humankind has had to face during its history. Indeed, humans have recurrently been threatened by several emerging pathogens that killed a substantial fraction of the population. Historical sources document that as early as between the 10th and the 6th centuries BCE, the authorities prescribed physical–social isolation, physical distancing, and quarantine of the infected subjects until the end of the disease, measures that strongly resemble containment measures taken nowadays. In this review, we show a historical and literary overview of different epidemic diseases and how the recommendations in the pre-vaccine era were, and still are, effective in containing the contagion.

The COVID-19 pandemic and the "Plague of Athens": comparable features 25 centuries apart

Motivated by the up to now disastrous outcomes of the COVID-19 pandemic, we attempted a flashback to the so-called "Plague of Athens," which indicated a serious contagious disease, having taken place between 430 and 426 BC. The ancient pandemic was meticulously described by the Athenian historian and general Thucydides. We compared, as much as possible, the following parameters: background conditions, spreading of the pandemics, preceded and concurrent adverse events, duration and waves of the pandemics, symptoms, implicated infectious agents/diseases and mental/psychosocial consequences. The current pandemic was preceded by a global economic crisis, which particularly affected deprived population groups, while the ancient one started on the second year of a catastrophic civil war. Rivalry and different political systems between now (US/China) and then (Athens/Sparta) superpowers were the basis for conspiracy scenarios, concerning origins of the pandemics, which resulted to huge numbers of deaths, particularly in overcrowded and poor areas/cities. Both pandemics not sparing any age, sex, nationality, social group, may have had a zoonotic component, besides being air-born. However, their spreading is/was remarkably rapid, presenting 3-4 waves and lasting for several years. Some somatic signs and symptoms of the diseases coincide. Although for COVID-19, SARS-CoV-2 has been identified as causing agent, the antique pandemic has most probably been attributed to typhoid fever, although this is still a matter of debate. Additionally, both pandemics affected mental health and psychosocial behavior in close similarity. It is noteworthy, that in both eras physicians and healthcare workers, despite physical and psychological exhaustion, in the majority, presented admirable resilience and willingness to help suffering fellow people, often at the expense of their own lives. The considerable number of comparable features between COVID-19 and the "Plague of Athens" confirms that pandemics may present over time important similarities in their origin, evolution and outcomes.

In Sickness and in Health: Narratives on Epidemics as Tools for Science Teaching in Secondary Schools

In the context of the current COVID-19 pandemic, we deem of importance the identification of what content is privileged in secondary schools around health and disease. From our point of view, a relevant task is to accompany science teachers in their transit from teaching information to be evoked to teaching knowledge on that content that enables students' action. Accordingly, our aims in this article are (a) to move away from the extended biomedical approach to teaching topics around public health which some authors consider reductive and (b) to explore instead a multi-causal and multi-referential approach, conveyed through narratives. We examine the potential of the narrative format to provide context, information and relations that we think are useful for students to explain, through adequate scientific models, some aspects of pandemics.

Challenges and Opportunities in the Use of High and Maximum Biocontainment Facilities in Developing and Licensing Risk Group 3 and Risk Group 4 Agent Veterinary Vaccines

New solutions are necessary for the singular global health security threat formed by endemic, epidemic, and emerging/re-emerging zoonoses, coupled with epizootic and enzootic transboundary animal diseases (TADs). This One Health issue is related to the daily interactions between wildlife, domesticated and indigenous livestock, and humans primarily associated with global trade, transboundary co-movement of humans and diverse livestock/livestock products, and agriculture production intensification and penetration into previously uninhabited areas. The World Health Organization defines Risk Group 3 (RG-3) and RG-4 pathogens as mainly viruses but also bacteria that serve as the foundation for approximately 60% of emerging infectious diseases that are zoonoses. The World Organisation for Animal Health defines trade-notifiable TADs, and subsets of these are zoonotic. Livestock vaccination policies mainly focus on TADs that are promulgated by the United Nations Food and Agriculture Organization and government agriculture agencies. The development, licensure, and product manufacturing of next-generation molecular-based RG-3 and RG-4 veterinary vaccines largely ignored by the global animal health biopharmaceutical sector can have an important positive impact on food security and One Health. There have been sharp increases in the global demand for livestock meat and milk products, especially in low- and middle-income countries in Africa and Asia. This relatively recent market driver-coupled with scientific advances in human EID and zoonotic disease vaccine platform technologies and increases in the number of high (US biosafety level 3 agriculture) and maximum (US animal biosafety level 4) biocontainment facilities with supporting workforce capabilities-offers new investment opportunities to the animal health biopharmaceutical sector. Moreover, a growing number of One Health public-private partnerships have moved the net present value calculus in favor of the financial feasibility of RG-3 and RG-4 veterinary vaccine product development and licensure. This article highlights the challenges and opportunities in the use of high and maximum biocontainment facilities in developing and licensing RG-3 and RG-4 veterinary vaccines that are safe and effective against epizootic and enzootic TADs and zoonotic diseases.

Are we Athens or Florence? COVID-19 in historical context

We have been here before. In 430 BCE, a plague struck Athens, killing as much as 25% of the population. In 1347 CE, the bubonic plague afflicted western Europe for 4 years, killing as much as 50% of the population. The plague of Athens led to a collapse of their religion, cultural norms and democracy. In contrast, the bubonic plague led eventually to the Renaissance, a growth of art, science and humanism. As we contend with the COVID-19 global pandemic, will we become Athens or Florence?

SARS-CoV-2: Outline, Prevention, and Decontamination

The new coronavirus began to spread around the world in late 2019. Initially, it was found only in China, but in the following days there were reported cases of infections in other countries. Subsequently, based on taxonomy, phylogeny, and accepted practice, the virus was officially designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As a result of the rapid spread of SARS-CoV-2 in different countries around the world, on March 11, 2020, the World Health Organization (WHO) announced a status change in the disease caused by this coronavirus-from an epidemic to a pandemic disease. Although the world is taking unprecedented efforts to control the spread of SARS-CoV-2, the number of confirmed cases is rising. Therefore, effective preventive measures are needed in order to limit the spread of illness. The prevention measures are mainly based on information on the virus transmission routes, its environmental stability, and persistence on commonly touched surfaces. Social distancing, mask usage, and good hygiene practice are the most important recommendations for general public. Healthcare professionals who are directly involved in SARS-CoV-2 patients care are more exposed to virus infection and additional protection measures are necessary, including protective suits, aprons, face shields, goggles, and gloves. Due to the stability of SARS-CoV-2 on different surfaces, such as glass, paper, or wood, proper disinfection is crucial. Several studies have shown that despite the virus's stability, it is sensitive to various disinfectants, such as ethanol, isopropanol, sodium hypochlorite, or hydrogen peroxide. These findings underline the importance of having comprehensive knowledge about SARS-CoV-2 and multidirectional strategies in order to limit the spread of the virus. This review is a summary of the most important information about SARS-CoV-2, such as its stability on different surfaces, protection strategies, and decontamination options.

Paleomicrobiology: Diagnosis and Evolution of Ancient Pathogens

The last century has witnessed progress in the study of ancient infectious disease from purely medical descriptions of past ailments to dynamic interpretations of past population health that draw upon multiple perspectives. The recent adoption of high-throughput DNA sequencing has led to an expanded understanding of pathogen presence, evolution, and ecology across the globe. This genomic revolution has led to the identification of disease-causing microbes in both expected and unexpected contexts, while also providing for the genomic characterization of ancient pathogens previously believed to be unattainable by available methods. In this review we explore the development of DNA-based ancient pathogen research, the specialized methods and tools that have emerged to authenticate and explore infectious disease of the past, and the unique challenges that persist in molecular paleopathology. We offer guidelines to mitigate the impact of these challenges, which will allow for more reliable interpretations of data in this rapidly evolving field of investigation.

Paleopathology of Human Infections: Old Bones, Antique Books, Ancient and Modern Molecules

Paleopathology studies the traces of disease on human and animal remains from ancient times. Infectious diseases have been, for over a century, one of its main fields of interest. The applications of paleogenetics methods to microbial aDNA, that started in the 90s combined to the recent development of new sequencing techniques allowing 'paleogenomics' approaches, have completely renewed the issue of the infections in the past. These advances open up new challenges in the understanding of the evolution of human-pathogen relationships, integrated in "One Health" concept.In this perspective, an integrative multidisciplinary approach combining data from ancient texts and old bones to those of old molecules is of great interest for reconstructing the past of human infections. Despite some too optimistic prediction of their eradication in the late 20th century, some of these ancient human diseases, such as plague, leprosy or tuberculosis, are still present and continue their evolution at the beginning of this 21rst century. Better know the past to predict a part of the future of human diseases remains, more than ever, the motto of the paleopathological science.

Microbial Genomics of Ancient Plagues and Outbreaks

The recent use of next-generation sequencing methods to investigate historical disease outbreaks has provided us with an unprecedented ability to address important and long-standing questions in epidemiology, pathogen evolution, and human history. In this review, we present major findings that illustrate how microbial genomics has provided new insights into the nature and etiology of infectious diseases of historical importance, such as plague, tuberculosis, and leprosy. Sequenced isolates collected from archaeological remains also provide evidence for the timing of historical evolutionary events as well as geographic spread of these pathogens. Elucidating the genomic basis of virulence in historical diseases can provide relevant information on how we can effectively understand the emergence and re-emergence of infectious diseases today and in the future.

Comparative Microbial Genomics and Forensics

Forensic science concerns the application of scientific techniques to questions of a legal nature and may also be used to address questions of historical importance. Forensic techniques are often used in legal cases that involve crimes against persons or property, and they increasingly may involve cases of bioterrorism, crimes against nature, medical negligence, or tracing the origin of food- and crop-borne disease. Given the rapid advance of genome sequencing and comparative genomics techniques, we ask how these might be used to address cases of a forensic nature, focusing on the use of microbial genome sequence analysis. Such analyses rely on the increasingly large numbers of microbial genomes present in public databases, the ability of individual investigators to rapidly sequence whole microbial genomes, and an increasing depth of understanding of their evolution and function. Suggestions are made as to how comparative microbial genomics might be applied forensically and may represent possibilities for the future development of forensic techniques. A particular emphasis is on the nascent field of genomic epidemiology, which utilizes rapid whole-genome sequencing to identify the source and spread of infectious outbreaks. Also discussed is the application of comparative microbial genomics to the study of historical epidemics and deaths and how the approaches developed may also be applicable to more recent and actionable cases.

The History of Biological Weapons Use: What We Know and What We Don't

This article critically reviews the literature on the history of biological warfare, bioterrorism, and biocrimes. The first serious effort to review this entire history, made in 1969, had numerous limitations. In recent decades, several authors have filled many of the gaps in our understanding of the past use of biological agents (including both pathogens and toxins), making it possible to reconstruct that history with greater fidelity than previously possible. Nevertheless, there are numerous remaining gaps, and closer inspection indicates that some supposed uses of biological weapons never took place or are poorly substantiated. Topics requiring additional research are identified.

Ebola in Antiquity?

This article addresses whether Ebola may have been present in an urban setting in Athens in 430 bce and explores the historical importance of the ancient outbreak. New knowledge from today's West African epidemic allows a more accurate assessment of whether Ebola may have caused the Athenian outbreak than was once possible. The Athenian disease, whose etiology remains unknown, developed abruptly with fevers, abdominal pain, vomiting, diarrhea, dehydration, and hemorrhage. It originated in sub-Saharan Africa and was especially contagious to doctors and caregivers. No remedies were effective. But the few survivors who were reexposed to diseased patients were not attacked a second time, suggesting protective immunity. What lessons can we learn from the ancient outbreak that bears a clinical and epidemiologic resemblance to Ebola? The historian Thucydides, an eyewitness and disease sufferer, described how the unsuspecting city panicked as it struggled to handle the rapidly spreading, devastating disease. Moreover, he stressed a theme that has relevance today—namely, that fear and panic intensified the disruption of society and damage to the individual that was directly caused by the disease. Moreover, fear amplified the spread of disease. The destructive nature of fear has remained a signature feature of pestilences that have subsequently caught ill-prepared societies off-guard—Bubonic plague in medieval times, AIDS in the 1980s, and Ebola today. The ancient Athenian epidemic is relevant for today's West African Ebola outbreak because it shows how fear and panic can endanger the individual, our society, and our efforts to handle the disease.

Extracting key information from historical data to quantify the transmission dynamics of smallpox

Background

Quantification of the transmission dynamics of smallpox is crucial for optimizing intervention strategies in the event of a bioterrorist attack. This article reviews basic methods and findings in mathematical and statistical studies of smallpox which estimate key transmission parameters from historical data.

Main findings

First, critically important aspects in extracting key information from historical data are briefly summarized. We mention different sources of heterogeneity and potential pitfalls in utilizing historical records. Second, we discuss how smallpox spreads in the absence of interventions and how the optimal timing of quarantine and isolation measures can be determined. Case studies demonstrate the following. (1) The upper confidence limit of the 99th percentile of the incubation period is 22.2 days, suggesting that quarantine should last 23 days. (2) The highest frequency (61.8%) of secondary transmissions occurs 3–5 days after onset of fever so that infected individuals should be isolated before the appearance of rash. (3) The U-shaped age-specific case fatality implies a vulnerability of infants and elderly among non-immune individuals. Estimates of the transmission potential are subsequently reviewed, followed by an assessment of vaccination effects and of the expected effectiveness of interventions.

Conclusion

Current debates on bio-terrorism preparedness indicate that public health decision making must account for the complex interplay and balance between vaccination strategies and other public health measures (e.g. case isolation and contact tracing) taking into account the frequency of adverse events to vaccination. In this review, we summarize what has already been clarified and point out needs to analyze previous smallpox outbreaks systematically.

Insights into infectious disease in the era of Hippocrates

Hippocrates is traditionally considered the father of modern medicine, still influencing, 25 centuries after his time, various aspects of medical practice and ethics. His collected works include various references to infectious diseases that range from general observations on the nature of infection, hygiene, epidemiology, and the immune response, to detailed descriptions of syndromes such as tuberculous spondylitis, malaria, and tetanus. We sought to evaluate the extent to which this historical information has influenced the modern relevant literature. Associating disease to the disequilibrium of body fluids may seem an ancient and outdated notion nowadays, but many of the clinical descriptions presented in the Corpus Hippocraticum (Hippocratic Collection) are still the archetypes of the natural history of certain infectious diseases and their collective interplay with the environment, climate, and society. For this reason, modern clinicians and researchers continue to be attracted to these 'lessons' from the past - lessons that remain extremely valuable.

Great Plagues of the Past and Remaining Questions

Due to the difficulty of obtaining tissue samples from victims of the ancient plagues, it is not always possible to utilise palaeomicrobiology techniques to determine the etiology of ancient infection. Therefore, it is often necessary to utilise other means to arrive at a likely diagnosis. The most helpful of these is the literary description of the disease. While this is often the best evidence available, working with such documents can prove difficult. Three great plagues of the ancient world, the Plague of Athens, the Antonine Plague, and the Justiniac Plague are described in either Latin or ancient Greek. The difficulties encountered when translating any ancient foreign language are compounded by the fact that so many words in these languages have a variety of meanings. This chapter reviews the three great plagues of antiquity from a clinical perspective.

Ancient typhoid epidemic reveals possible ancestral strain of Salmonella enterica serovar Typhi

In contrast to other serotypes of Salmonella enterica, S. Typhi is exclusively adapted to human hosts. Recently, S. Typhi was identified in ancient skeletal material, thereby incriminating typhoid fever for the Plague of Athens. Since, according to Thucydides' report, animals were also affected by the disease, a working hypothesis is constituted that the causative agent of the Plague might be the anticipated original strain of S. Typhi, purportedly capable of infecting animals as well as humans. Possible future sequencing of the discovered ancient strain of S. Typhi may help towards identifying its genomic differences responsible for its modern specification to humans.

DNA examination of ancient dental pulp incriminates typhoid fever as a probable cause of the Plague of Athens

BACKGROUND

Until now, in the absence of direct microbiological evidence, the cause of the Plague of Athens has remained a matter of debate among scientists who have relied exclusively on Thucydides' narrations to introduce several possible diagnoses. A mass burial pit, unearthed in the Kerameikos ancient cemetery of Athens and dated back to the time of the plague outbreak (around 430 BC), has provided the required skeletal material for the investigation of ancient microbial DNA.

OBJECTIVE

To determine the probable cause of the Plague of Athens.

METHOD

Dental pulp was our material of choice, since it has been proved to be an ideal DNA source of ancient septicemic microorganisms through its good vascularization, durability and natural sterility.

RESULTS

Six DNA amplifications targeted at genomic parts of the agents of plague (Yersinia pestis), typhus (Rickettsia prowazekii), anthrax (Bacillus anthracis), tuberculosis (Mycobacterium tuberculosis), cowpox (cowpox virus) and cat-scratch disease (Bartonella henselae) failed to yield any product in 'suicide' reactions of DNA samples isolated from three ancient teeth. On the seventh such attempt, DNA sequences of Salmonella enterica serovar Typhi were identified providing clear evidence for the presence of that microorganism in the dental pulp of teeth recovered from the Kerameikos mass grave.

CONCLUSION

The results of this study clearly implicate typhoid fever as a probable cause of the Plague of Athens.

The origins of new pandemic viruses: the acquisition of new host ranges by canine parvovirus and influenza A viruses

Transfer of viruses between hosts to create a new self-sustaining epidemic is rare; however, those new viruses can cause severe outbreaks. Examples of such viruses include three pandemic human influenza A viruses and canine parvovirus in dogs. In each case one virus made the original transfer and spread worldwide, and then further adaptation resulted in the emergence of variants worldwide. For the influenza viruses several changes were required for growth and spread between humans, and the emergence of human H2N2 and H3N2 strains in 1957 and 1968 involved the acquisition of three or two new genomic segments, respectively. Adaptation to humans involved several viral genes including the hemagglutinin, the neuraminidase, and the replication proteins. The canine adaptation of the parvoviruses involved capsid protein changes altering the recognition of the host transferrin receptors, allowing canine transferrin receptor binding and its use as a receptor for cell infection.