Pandemics Throughout Human History

I
n one form or another, disease has plagued man throughout history as new microbes or variations have
emerged, or vulnerable populations have been exposed to previously unencountered foes, both bacterial
and viral.

But when does an epidemic become a pandemic? Everyone is accustomed to epidemics, such as seasonal
flu which can rip through a community, or the SARS epidemic of 2003 that rampaged across Asia. However,
if an epidemic spreads to become a global problem, then you have a pandemic on your hands.

Cholera, bubonic plague, smallpox, and influenza have been some of the most brutal killers through history.
Here we discuss some of the most notable pandemics known to afflict humanity.

The Black Death of the mid 1300s

The Black Death, also known as “The Great Plague”, was caused by Yersinia pestis and originated in China.
Fleas are the primary source of infection and main route of transmission from infected rodents, some of
which are plague-resistant reservoirs, to the dead-end human host.

Infection with Yersinia pestis takes on three clinical forms – bubonic, septicemic and pneumonic plague, with
bubonic the most common. The “Black Death” earned its name from the black skin spots that developed on
the skin of those infected.

Trade between China, Constantinople and Europe formed the main transmission route – where people and
animals travelled, so did the fleas and their deadly cargo. The Black Death virtually wiped out whole towns
and claimed the lives of around one third of the European population.Worldwide, at least 75 million are
believed to have perished during the pandemic, with some estimates as high as 200 million.

Whilst plague still circulates (3248 cases were reported worldwide between 2010 and 2015, including 584
deaths), rapid treatment with antibiotics can be effective in clearing infection and death rates are now
around one in six.

The sixth cholera pandemic (1899-1923)

Like the five major cholera pandemics that preceded it, the sixth cholera pandemic originated in India where
the Ganges delta provided a reservoir of infection. During the third cholera pandemic in 1854, John Snow
had traced the source of cholera infection in London to public water pumps, demonstrating how infection
was spread. It wasn’t until 1883 however, that Robert Koch demonstrated a link between cholera and the
bacterium Vibrio cholerae – the causative agent earlier named in 1854 by Filippo Pacini.
Whilst the sixth pandemic ravaged India, Russia, the Middle East and northern Africa, western Europe and
North America remained largely unaffected. The infection is thought to have entered the USA via New York
in 1910 where infected passengers arrived by boat from Naples, Italy. However, thanks to lessons learned
in previous outbreaks, the USA authorities took swift action to isolate those infected and only 11 people
died in the USA. Containment was not so effective elsewhere and it is estimated that over 800,000 people
perished during the pandemic.

As well as contaminated water, cholera is transmitted through consumption of contaminated food, such as
fish, shellfish and rice, that live in contaminated water. If untreated, cholera can kill within hours as a result
of severe dehydration. Whilst there are hundreds of strains of the bacteria, thus far only two types (O1 and
O139) have been associated with human outbreaks, O1 being responsible for the sixth pandemic.

The next cholera pandemic, which started in 1961 and is still considered to be ongoing, originated in
Indonesia and was caused by a different strain. Even today, the World Health Organization (WHO) considers
cholera a major public health issue, particularly in the developing world where access to clean water and
adequate sanitation is often lacking and infection has become endemic. Researchers have estimated that
there are approximately 1.3 to 4.0 million cases of cholera every year, leading to 21,000 to 143,000 deaths
worldwide.

1918 Spanish Flu

The global flu pandemic of 1918, dubbed “Spanish flu”, killed 50 million people worldwide including the
young, fit and healthy. It got its name, not because Spain was the epicenter, but due to wartime censorship
which suppressed case reports in many other countries.

Between 1918 and1920 when the pandemic drew to a close, it is estimated that one third of the world’s
population (500 million people) became infected. The origins of the outbreak have been hotly debated
for decades, but lower mortality rates in China suggest some degree of prior immunity, and support
suggestions that the infection stemmed from there.

The spread of the disease was likely exacerbated by living conditions during the first world war and mass
movements of civilians and troops around the globe.Infection came in several waves; the first in early 1918
was highly contagious but not particularly lethal. In contrast, the second and third waves in autumn 1918
and spring 1919 had high fatality rates. In some places, it was a struggle to keep up with the mounting
numbers of bodies for storage and burial.
The 1918 pandemic stood apart from many other influenza outbreaks because of the demographic
succumbing to infection. Typically, the very young, elderly and sick are worst affected which was not the
case in this outbreak. Ironically, it is thought that overzealous immune reactions to infection in the fit and
healthy were responsible for many deaths.

It wasn’t until the 1930’s that scientists proved influenza was caused by a virus, and the strain that caused
the pandemic since identified as the H1N1 strain.

There have been influenza pandemics since, but none are as notable as the Spanish flu.

With the constant mutation of influenza strains by antigenic drift and antigenic shift, it is only a matter of
time before the next influenza pandemic.

HIV/AIDS - a modern scourge peaking 2005-2012

Pinpointing the origin of HIV is difficult but much of the evidence points to the Democratic Republic of
Congo as the source, where it is believed to have passed from chimpanzees (as Simian Immunodeficiency
Virus) to humans in around the 1920s. Poorly understood until the 1980’s, the HIV virus spread through
populations unhindered for many years, transmitted by contact at mucous membranes or by blood (e.g. via
used needles and transfusions).

Divided into two sub-types (HIV-1 and HIV-2), HIV-1 is the pandemic strain, being more virulent and more
easily transmissible than HIV-2. HIV can progress to cause acquired immune deficiency syndrome (AIDS),
which was first reported in 1981. Since then, an estimated 78 million people have become infected with HIV
and 35 million have died from AIDS-related illnesses.

In 2017, 36.9 million people worldwide are thought to be living with HIV/AIDS, with approximately 5000 new
infections acquired every day.

Whilst awareness of HIV prevention and treatments are improving, and mortality from AIDS is falling
(940,000 deaths in 2017 compared with 1.9 million in 2004), this is a pandemic that we are still fighting.

What will the next pandemic be?