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The historical account of epidemic typhus

Louse-borne typhus is one of the oldest pernicious diseases, that has been haunting mankind since ages. Known by the many names such as “camp fever”, “war fever”, “jail fever” and “tabarillo” and confused with many other fevers and diseases, it was only in the late 15th century, it was identified as a cause of major epidemics. With Plague, Typhoid, and Dysentery, it is known to have wiped out armies and civilian populations from the 15th to the 20th century, playing a decisive role in the fate of wars in Europe. This paper will attempt to further analyze the historical impact of Louse-borne Typhus and how its epidemic propagation has led many to regard Pediculus humanus corporis to have a more remarkable influence on human history than any other parasite.

Epidemic typhus fever (tabarillo, classic or European typhus, jail fever, war fever)

The denomination “typhus” was derived from the Greek word typos, meaning “smoke” resembling the delirious state, that one suffers from, during infection. Originally, “typhus” represented any of the self-limiting fevers accompanied by stupor. In 1829, the French clinician Louis demarcated ‘Typhus Fever’ from ‘Typhoid Fever’.

Causative

Agent and transmission: Epidemic Typhus, as isolated and identified by DaRocha-Lima in 1916, is caused by small Gram-negative coccobacilli-shaped bacteria, Rickettsia prowazekii, that was originally believed to be a virus because of its minute size and difficulty of cultivation. Being an obligate intracellular parasite, it utilizes the components within the cell to survive and multiply. It was named in honor of H. T. Ricketts and L. von Prowazek, who in the course of their investigations died of infection. The cell wall being excessively permeable to many large metabolites accounts for the microorganism’s requirement for a living host. The host is believed to supply ATP, NAD, and CoA. (Brezina et al., 1973).

Transmission of Epidemic Typhus is through the body louse (Pediculus humanus corporis) feces contaminated with R. prowazekii. Louse bite causes itching and scratching, which allows the bacteria to enter the scratch or bite area through the skin. Indirect transmission may occur if the lice infect one person, who then develops the disease and the then infected lice move to the next individual, infecting by bites and defaecation or directly, via shared clothing between individuals.

SIGNS AND SYMPTOMS: After an incubation period of 7-14 days, fever, headache, and prostration occur suddenly. Temperature shoots up to 40° C in several days, with slight morning remission, for nearly 2 weeks. A headache is intense. Small, pink macules, appear on the 4th to the 6th day and rapidly cover the body, usually in the axillae and on the upper trunk excluding the palms, soles, and face. Later, the rash becomes dark and maculopapular. The rash may become petechial and hemorrhagic, in extreme cases. Splenomegaly occurs at times.

Epidemic Propagation: Propagation is regulated in human populations by the circulation of lice between individuals. The louse is a comparatively an inefficient vector, due to the short range of movement; it crawls and cannot fly. Moreover, the active stages survive only for 7-10 days without a suitable host to feed on, accompanied by the fact that they are exclusively human parasites. The epidemic spread is hence favored by the existence of a large louse population on humans who are crowded together in their living quarters. Scratching and itching on the part of heavily infested individuals cause lice to move to the outer surface of clothing and be readily transferred to others. Thus, in crowded tenements, jails, refugee camps, or times of war or disaster, when prisoners, refugees, or soldiers are unable to change clothes or bathe regularly, lice spread quickly within the entire population, especially during the winter, when bathing is made more difficult due to the chilled weather. Thus, in centuries and areas where overcrowding, malnourishment, and lack of sanitation were prevalent, typhus spread rapidly.

THE HISTORICAL IMPACT OF EPIDEMIC TYPHUS:

The Fifteen Century: The first record of epidemic typhus in history, was in 1489 during the Spanish Inquisition and Reconquista. A louse-borne typhus epidemic broke out within the Spanish army killing over 17,000 soldiers within a month out of which only 3,000 men had died in actual combat. Typhus, completely destructed the Spanish army.

The Seventeenth Century: in the Thirty Years War (1618-1648), the first 15 years, was also impacted tremendously after its introduction to Typhus. Along with Plague, typhus was responsible for the death of 10,000,000 soldiers, compared to merely 350,000 men who died in combat. (1632).

The Nineteenth Century: The 1812 campaign of Napoleon Bonaparte, against the Russians, remains the classic example. Napoleon’s Grand Armee, originally had over 600,000 tactful soldiers, marching their way with little resistance to take over Russian province. France and Russia had been tense allies. In 1812, His army entered Russian controlled Poland.

Poland is where things took a turn for Napoleon. The territory was filthy beyond belief. The peasants were unwashed, with matted hair and infested with lice and fleas, and the wells were fouled. Being in an enemy state, the resources soon began to dwindle and it became difficult to provide food and water to the soldiers. The army was too huge to keep its military formation intact, and the greater part of the army dissolved into straggling and sprawling mobs. Many of the soldiers, therefore raided the homes, livestock, and fields of the local peasants that were full of the parasite. The typical war intestinal diseases such as dysentery began to appear, and although new hospitals were set up, they were unable to deal with the innumerable sick soldiers.

Few days after crossing the Nieman, many soldiers started to develop a high fever and red rashes on their bodies. Some developed a bluish tinge to their faces and died. Typhus had made its appearance. Typhus had been present in Poland and Russia for many years, but it had worsened since the Russian army had devastated Poland while retreating from Napoleon’s forces. A lack of cleanliness combined with the unexpectedly heated summer provided a perfect environment for the infestation and spread of lice. It was an entire century after the 1812 campaign before the scientists discovered that typhus is spread through lice excreta.

The French soldiers were sweaty, unclean and lived in the same clothes for days; providing the suitable environment for a louse to feed and find inhabit in his clothing. Once the skin and clothes of the soldier were contaminated with louse excreta, the smallest abrasion or scratch was enough for the germ to enter the soldier’s body. To magnify the problem, the soldiers were sleeping in large groups in confined spaces, for safety. This closeness enabled the lice to get transmitted easily. Within a month into the campaign, Napoleon lost 80,000 soldiers who were either had died from typhus or were incapacitated.

Soldiers suffering from typhus, lying in the streets.

On July 28, Napoleon’s officers expressed concerns with him that the battle with the Russians was becoming fatal. The loss of comrades to desertion and disease was inestimable. In addition, to which, there was a problem of finding provisions in hostile territory, he, however, argued that his men could withstand the bitterest of Russian winters- which turned out to be his biggest mistake.

Napoleon and his sick, weary soldiers marched on. The Russians retreated as the French advanced, drawing Napoleon deeper into Russian territory. By Aug. 25, Napoleon had lost 105,000 of his main army of 265,000, leaving only 160,000 soldiers. Within two weeks, typhus had decreased the army to 103,000.

On Sept. 7, French forces engaged the Russians resulting in heavy casualties. Napoleon then marched onto Moscow with only 90,000 soldiers. He had expected the Russians to surrender; however, the citizens simply left Moscow to Napoleon after burning three-fourth of it leaving no food or provisions. Fifteen thousand reinforcements joined Napoleon in Moscow, but of those, 10,000 died of typhus. With the Russian winter rapidly approaching, Napoleon had no choice but to retreat.

World war I: During World War I, minimum of 20,000 Austrians were taken prisoner by the Serbs. There was a lack of physicians and other medical professionals, that led to the rapid collapse of the health status of defenseless populations. Malnutrition, overcrowding and a lack of hygiene paved the way for typhus. In November 1914, typhus made its first occurrence among refugees and prisoners, spreading rapidly among the troops. A year after the outbreak of hostilities, typhus killed 150,000 people, of whom 50,000 were prisoners in Serbia. The mortality rate reached an epidemic peak of approximately 60 to 70% during this period. Drastic measures were taken, such as the quarantine of people with the first clinical signs of the disease, along with attempts to apply standards of hygiene among the troops to prevent body lice infestations.

In Russia, over past two years of the turmoil and the Bolshevik revolution, approximately 2.5 million deaths were recorded. Typhus was latent in Russia long before the World War I. The mortality rate rose from 0.13 per 1,000 in peacetime to 2.33 per 1,000 in 1915. Typhus was imported and propagated throughout the country through the soldiers and refugees. During the brutal winter of 1917–18, the biggest outbreak of typhus of modern history began in a Russia that was already devastated by famine and war resulting in five million deaths in Russia and Eastern Europe.

WORLD WAR II: Henrique da Rocha Lima, a Brazilian doctor, discovered the cause of epidemic typhus in 1916 while doing research in Germany. The discovery by Cox (1938) that R. prowazekii could be grown in the yolk sac of developing chick embryos made it possible to prepare an Epidemic Typhus vaccine, consisting of a killed suspension of R. prowazekii grown in the chick embryo. Even though delousing station was set up and a typhus vaccine was developed, typhus epidemics continued to seek its victims, especially in German concentration camps during the Holocaust, where typhus was a major scourge (Anne Frank died in a camp at age 15 from typhus) and it will never be known how many inmates succumbed to the disease. Upon the liberation of Buchenwald, it was discovered that over 8,000 inmates were suffering from typhus. Major typhus outbreaks occurred throughout Germany during the course of the war. With statistical data available in 1945 16,000 cases of typhus were revealed in that year. Japan, also was afflicted by the scourge of typhus during World War II, with approximately 45,000 cases.

The U.S. Army, which had been vaccinated for typhus and had a good amount of supplies of DDT available, set up many delousing to keep the disease from spreading, that proved to be largely successful. The historical role played by Epidemic Typhus in World War II, therefore, due to the mass of research on its prevention and control by Cox, Durand, and others, became largely a matter of introducing and refining methods for its control in military and civilian populations so as to minimize its impact.

Typhus is now considered to be endemic only in specific few areas of the world, including Eastern Africa and South and Central America. No vaccines are currently available to prevent typhus (Cox vaccine was ineffective), but improved hygienic practices, improved insecticides, and antibiotics have made it easier to combat the disease and the vector that spread it. Only a few epidemics (Africa, Middle East, Eastern Europe, and Asia) have occurred since then. Because of toxicity, DDT has been banned in the U.S. since 1972.

DIAGNOSIS: The diagnosis involves identification of the bacterial genus and species by PCR testing of a skin biopsy from skin rash or lesions or blood samples. Immunohistological staining identifies the bacteria within the infected tissue (skin tissue, usually). Typhus can also be diagnosed, usually late or after the disease has been treated with antibiotics when significant titers of anti-rickettsial antibodies are detected by immunological techniques.

TREATMENT: Antibiotics are commonly used to treat the disease including doxycycline, the most preferred treatment. Chloramphenicol, for those not pregnant or breastfeeding. ciprofloxacin is used for adults as a substitute for doxycycline.

After centuries of war when typhus played a leading role in the mortality, the disease has finally been suppressed. It is therefore evident from this paper, that an inestimable amount of History has been impacted by Man’s contact with the body louse and the pathogens it harbors that can never be estimated in its true sense, for historical facts and statistical data are rather pale shadows of the impact of typhus. Indeed, the spectacular advances of science have successfully relegated typhus to a pestilence of yesteryear. However, the World Health Organization still describes it as a “disease under surveillance”. The eradication of poverty, famine, and warfare are a priority. Yet one cannot help but wonder if the truly salient feature of Man’s encounter with louse-borne typhus is not its effects on Man’s continual struggle to overcome his enemies, but rather the opportunity afforded to those in retrospect to feel the humility necessary for the survival of our species in a world of which we are, of necessity, but a small part.

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