The Official Patients Sourcebook on Typhoid Fever

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For most of that time, Ebola infected rodents and other mammals, possibly bats, millions of years before Ebola was first recognized in humans in Could Ebola have spilled over into human populations during its long existence before ? Proof of such an outbreak would have been impossible as the virologic techniques required to detect Ebola were neither available prior to nor applied in a field setting until [ 8 ]. Nevertheless, we can use historic records to search for an epidemic whose features are compatible with Ebola.

This article selects one epidemic that occurred in Athens in bce whose cause remains a longtime subject of conjecture among physicians and historians [ 9 ]. Although scholars have postulated typhus [ 10 ], smallpox [ 11 ], and even Ebola [ 12 ] as possible etiologies, they have been unable to agree on what the retrospective diagnosis might have been, in part because limited information about a disease like Ebola has been an obstacle for making comparisons [ 13 ].

New clinical and epidemiologic information now available from today's large West African epidemic, however, has filled this gap of knowledge about Ebola [ 14 , 15 ] and permits a more accurate comparison of the Athenian outbreak with Ebola. In light of this new knowledge, I reexamine the Athenian outbreak to assess its compatibility with Ebola and to address what it can teach us about today's epidemic.

In bce , the historian Thucydides described an unexpected, terrifying summer outbreak that ravaged Athens. When chronicling the Peloponnesian War between the rival city-states Athens and Sparta, the eyewitness Thucydides presented a systematic account of a disease whose symptoms began with an abrupt onset of fever, headache, fatigue, and pain in the stomach and extremities. Seizures, confusion, cough, and a red livid rash, pustules, or ulcers that could lead to loss of digits presumably due to gangrene sometimes occurred [ 16 ].

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As symptoms progressed, dehydration became so profound that men plunged themselves into wells in a futile attempt to quench their unceasing thirst. The fulminant disease frequently ended in death, typically occurring by day 7—9 of the illness. Thucydides depicted a rapidly fatal clinical picture characterized by fever, vomiting, diarrhea, and hemorrhage. Thucydides also portrayed a distinct epidemiology that highlighted the susceptibility of healthcare workers.

As was true in Athens, caregivers of symptomatic Ebola patients today are especially susceptible as they come into contact with highly infectious bodily fluids; more than healthcare workers have died from the disease [ 19 ].

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In addition, the 5-year lifespan of the Athenian outbreak is within the realm of possibility for today's Ebola outbreak given its ongoing spread [ 20 ]. Furthermore, the congested locale of ancient Athens, with an estimated population of people, mirrors the overcrowded urban settings in which Ebola now thrives [ 21 ]. Thus, epidemiologic features of the ancient outbreak—the population at risk, projected time course, and setting—are consistent with Ebola. The geographic origin of the ancient disease also fits Ebola. The ancient epidemic then raged in the Mediterranean before reaching Athens.

In the ancient world, Africans from sub-Saharan regions migrated to Greece, where they found employment as farmers or servants [ 22 ]. Thus, the disease could have been spread by humans traveling along routes of transportation to an overcrowded urban center [ 23 ]. The sub-Saharan African origin of the ancient disease and its spread to a city is compatible with today's Ebola outbreak. The composite clinical, epidemiologic, and geographic features of the ancient Athenian outbreak are consistent with our knowledge of Ebola today.

In aggregate, the abrupt onset of generalized symptoms fever, myalgias, headache, fatigue , development of specific symptoms diarrhea, conjunctivitis, vomiting, confusion, hiccupping , fulminant nature resulting in death on day 7—10 following onset, high rate of spread to caregivers, and origin in sub-Saharan Africa are consistent with what we now know about Ebola [ 14 , 15 ].

In addition, a variety of rashes are described for Ebola today, including petechia, hemorrhagic bullae, hematoma, and potentially gangrenous digits if disseminated intravascular coagulation is present [ 24 ].

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Furthermore, Thucydides and Ovid noted that animals also developed the Athenian malady [ 16 , 18 ]. Because neither author specified the spectrum of animal species involved, their observation is consistent with Ebola as well as other zoonotic infections as the possible cause of the Athenian epidemic. Table 1 lists the aggregate features of the epidemic according to infections hypothesized by scholars.

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Although typhus, bubonic plague, and anthrax involve animals, none of those diseases account for the vomiting, diarrhea, conjunctivitis, or preferential spread to healthcare workers. Furthermore, the absence of buboes and the generalized rash do not fit bubonic plague; the hemorrhaging would be unlikely with typhus; and the absence of a necrotic ulcer would be atypical for anthrax [ 26 ]. It is noteworthy that hiccupping is associated with Ebola but with no other disease [ 14 , 26 ]. The summertime occurrence would be unusual for epidemic typhus, which ordinarily occurs during winter times of crowding.

The involvement of animals excludes infections that involve humans exclusively ie, smallpox, measles, toxic shock syndrome. Although no disease outlined in Table 1 fits the clinical or epidemiologic pattern and geographic location as closely as Ebola, definitive proof of the ancient disease would require genetic analysis of skeletal remains.

Until those studies are performed, Ebola is a plausible, if not likely, cause of the disease Thucydides described. One question remains: If the ancient plague was due to Ebola, why did it not reappear until ? One possible explanation is that diagnostic tests for Ebola were not introduced until the s.

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Thus, an earlier epidemic due to Ebola in Africa or elsewhere would have gone unrecognized. Another possible explanation is that the clinical features of a particular disease vary over time, as those of Ebola have done over the past 30 years. Thus, Ebola may have reappeared before this time in Africa or elsewhere in a pattern that was not as devastating as the Athenian plague. Furthermore, because the features of a particular disease can evolve over time, the clinical pattern as we know it today may not match perfectly with the manifestations described in the past.

Syphilis, for example, is one disease where the predominant cutaneous manifestation during its description in —vesicles—are no longer associated with this disease today [ 27 ]. In light of these considerations, one cannot exclude the possibility that Ebola reappeared prior to As a corollary, even though no disease listed in Table 1 precisely matches each clinical feature of the Athenian plague, Ebola accounts for the overall features—fever, vomiting, diarrhea, dehydration, and high mortality occurring at week 1 of illness—as well or better than other conditions listed in Table 1.

After describing the disease, Thucydides explored society's response to the epidemic. He focused on the destructive nature of fear and asserted that fear and panic compounded damage to society and to the individual caused by the disease itself. As a consequence of the social disorder, the highly disciplined Athenian democratic society unraveled as citizens abdicated their accountability to family and government. As they abandoned their work, a famine ensued. There may have been other causes of the Athenian famine, including failure of crops to be cultivated and harvested as a result of a military decision by the Athenian general Pericles to seclude citizens within the city's walls during the battle.

Nonetheless, as healthy but anxious citizens abdicated their responsibilities to care for their ill family members, the ill found isolation at a time when they most needed support.

Thucydides and, later, Ovid described the isolation of disease sufferers, whom citizens believed may have contracted the disease by drinking well water poisoned by the invading Peloponnesians or by displeasing the vengeful goddess Juno [ 16 , 18 ]. Fear, Thucydides showed, not only accentuated the damage caused by the disease to society and the individual, it also exacerbated disease spread.

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Fearful citizens who fled their homes, he noted, obtained shelter by residing in congested urban huts. Based on today's knowledge of Ebola, unattended corpses lying uncovered in the street may have intensified disease spread as bodily fluids after death remain contagious to those living in proximity, particularly in overpopulated regions of the city [ 1 ]. Thucydides did not mention whether these overcrowded regions were also impoverished, as in the case of spread of Ebola today, or whether it occurred most often among Athenian soldiers who resided in close proximity to one another.

Nevertheless, unlike Ebola today, where adherence to traditional funeral customs eg, touching and washing of the deceased body facilitates disease spread, it was the violation of traditional individual burial customs that may have exacerbated the spread of the ancient epidemic. Nonetheless, Thucydides' insights into the detrimental consequences that fear had for society, the individual, and spread of disease would be echoed in lethal pestilences that were to emerge. In , the Italian writer Giovanni Boccaccio wrote about the effects of fear on European society during an untreatable bubonic plague epidemic.

Society became disorderly as frightened citizens grew to disregard their affairs and disrespect authority. In , fear that accompanied another unexpected, incurable epidemic, AIDS, again had negative repercussions for society, the individual, and efforts to control the epidemic.

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Anxious citizens rejected scientific evidence that the virus was transmitted only through body fluids and remained unconvinced that it could not be transmitted casually [ 30 , 31 ]. AIDS patients were denied the medical care they needed or were shunned by those who feared becoming infected by casual contact even though medical evidence told them otherwise [ 32 ]. There was anxiety about the potential for the epidemic to breach its stigmatized risk groups and cause widespread deaths among the entire population [ 33 ].

Accompanying this panic were calls of permanent quarantines that disregarded scientific recommendations [ 34 ]. The distress of being shunned and fears of discrimination in the workplace deterred some from seeking healthcare, taking their antiretroviral drugs, or practicing safe sex—behaviors that encouraged the spread of AIDS [ 35 ].

Fear of disease has shut down transportation systems and kept people away from their jobs [ 23 ]. With citizens fleeing affected communities and with travel restrictions, businesses and schools have closed, road construction has declined, and the food supply has become endangered [ 36 ]. Due to fear of catching disease, there has been an inadequate supply of healthcare workers willing to provide care for sick patients or workers willing to transport or bury bodies [ 23 ].

In West Africa today, fear of Ebola has contributed to its continued spread as there are not enough workers to carry out the tasks required to control the disease, and patients die in solitude without receiving basic medical care [ 37 , 38 ]. Moreover, talk of mandatory quarantines of asymptomatic healthcare workers returning to the United States that reject scientific evidence are based on fear of disease rather than scientific knowledge of how the disease actually spreads [ 39 ]. These restrictive measures have the potential to discourage volunteering and reduce humanitarian assignments that are needed to handle disease spread in West Africa [ 40 ].

These responses show that a scientific understanding of diseases such as Ebola and AIDS today, as well as the knowledge of factors that place a person at risk of acquiring these infections, did not lessen society's response of fear and fright that had been evident during the Athenian plague and subsequent epidemics.

Furthermore, as was the case in prior epidemics, fear today is intensifying the damage to society and individuals caused by Ebola itself and interfering with efforts to control its spread.


For Ebola today, it is important to explore linkages with rather than ruptures from the past. During today's epidemic, attention by the medical and lay press have aptly focused on the pandemic's distinct features—the need to quickly develop a coordinated international response to perform surveillance, isolate cases, deliver appropriate gear to protect healthcare providers, and provide therapies to help manage victims. While acknowledging the necessity of addressing these unique features of today's Ebola outbreak, it is also important to address how past epidemics can provide wisdom and insights for us today.

A look back to an ancient outbreak that resembled Ebola on the basis of clinical, epidemiologic, and geographic similarities shows us how society's panic-stricken responses to pestilences have intensified the damage and devastation directly caused by the disease itself. From antiquity to medieval times to Ebola today, society's response of anxiety has worsened the suffering of the individual, disrupted society, marginalized civic or scientific authority, decimated economies, and intensified the spread of epidemics.

For current and past epidemics, suffering and deprivation have been caused by the image of pestilence with its associated fear, flight, and isolation as well as by the microbe itself. Potential conflict of interest. Author certifies no potential conflicts of interest. Be sure to receive another series of 4 capsules every 5 years during continued exposure to typhoid. Do not drink alcohol within 2 hours after you take a typhoid vaccine capsule.

Alcohol can damage the capsule and could make the vaccine ineffective. In addition to using this vaccine, take precautions while traveling to further prevent coming into contact with bacteria that cause typhoid fever:. Get emergency medical help if you have signs of an allergic reaction : hives; difficult breathing; swelling of your face, lips, tongue, or throat.

Becoming infected with typhoid fever is much more dangerous to your health than receiving this vaccine. However, like any medicine, this vaccine can cause side effects but the risk of serious side effects is extremely low. This is not a complete list of side effects and others may occur.

Call your doctor for medical advice about side effects. You should not take an anti-malaria medicine that contains proguanil such as Malarone for at least 10 days after you have received your last dose of typhoid vaccine. Proguanil may make typhoid vaccine less effective. Other drugs may affect typhoid vaccine, including prescription and over-the-counter medicines, vitamins, and herbal products. Tell your doctor about all your current medicines and any medicine you start or stop using.