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Acrimonious 19th century disputes between the contagionists and the sanitarians 1 had given way to an alliance which was steadily improving health. Many of the victims were children or young adults. Eradication of bovine tuberculosis produced a welcome fall in infant cases, but about cases continued to be notified annually between and The success of this program prompted a postwar attempt to eradicate the disease from the civilian population, and the advent of streptomycin and sickness benefit payments made compulsory treatment acceptable to the community.
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Tuberculosis has again become resurgent in many countries. The high expense and long duration of triple therapy test the resources of the poorest countries. Undertreatment allows emergence of multidrug-resistant strains for which treatment reverts to pre-antibiotic options. In Australia, such strains are, mercifully, still uncommon. Syphilis also imposed a high burden of chronic disease on society.
Notification of acute cases and compulsory treatment were not successfully implemented, even in the army. In civilian settings, policies of testing only female prostitutes doomed any hope of eradication. Many acute infections also remained endemic. There were dedicated wards for patients with typhoid in general hospitals, and the prevalence and mortality of typhoid remained high until the advent of antibiotics.
Bedside vigils to await the crisis of pneumonia were all too familiar, and childhood infections claimed many young lives. In , gastroenteritis, diphtheria, scarlet fever, whooping cough and measles between them killed one of every 30 live-born children.
In the interwar decades, diphtheria and pertussis vaccines were produced in the newly established Commonwealth Serum Laboratories and school-based vaccination began. But in , public confidence was shaken by the Bundaberg tragedy, in which a multidose vial of diphtheria toxin—antitoxin became contaminated with staphylococci from the skin of a vaccinee.
Twelve other children died. However, almost a century on, the antivaccination movement still opposes mass vaccination of children in early life. During its first few years of publication, the MJA reported on mortality due to infection among WWI troops, which exceeded combat deaths. The MJA also reported episodes which, with hindsight, showed that evolutionary forces were altering the balance between microbes and their human hosts.
In , influenza killed more Europeans than had perished in the war. The source of the pandemic strain remains obscure, but there is no doubt about the role of returning troops in its global spread. Australia's isolation and its quarantine system protected it for some time, but eventually the country experienced a catastrophic outbreak. Pivotal influenza studies led by Frank Macfarlane Burnet at the Walter and Eliza Hall Institute were conducted during this period, and the Institute's interests soon broadened into basic scientific research on many important infections.
In the postwar period, the establishment of the Australian National University strengthened the national capability in infectious diseases research. This was the penalty for the delay in the average age when infection occurred, which was a consequence of improved hygiene. This in turn increased the numbers of clinical cases because the chance of neurological involvement increased spectacularly with age. Norman Gregg's pivotal discovery of the role of rubella in causing congenital defects 17 altered scientific attitudes to infections during pregnancy.
It was almost two decades before cell culture techniques paved the way for vaccines against polio, and then other childhood infections. The growing list of vaccines demanded new combinations to reduce the number of injections needed, and the cost became an issue even in wealthy countries where the plummeting prevalence of vaccine-preventable diseases justified the investment. Money is not the only problem. The projected global eradication of polio has stalled because conflicts in Africa and Pakistan have disrupted infrastructure and fanned ideological doubts about the political motivations of governments and charities.
In the optimistic political climate of the post-WWII years, the World Health Organization undertook an unprecedented program to achieve global eradication of smallpox. Frank Fenner was chairman of the project's management commission. Using Edward Jenner's 18th century vaccination technique and an international army of field workers, smallpox eradication was achieved in Not all microbial evolution resulted in populations of organisms with increased virulence for humans. Scarlet fever, after causing devastating epidemics in the late 19th century, declined in terms of incidence and mortality by the s.
This was attributed to the loss of toxin-encoding genes from Streptococcus pyogenes. Sulfonamides made their spectacular entry into medicine just before WWII and cut the mortality from pneumonia and puerperal fever dramatically. Prontosil, a forerunner of all sulfonamide drugs, was not patentable, and manufacturers flooded the market with sulfonamide-like drugs.
Penicillin soon followed — with Australian scientist Howard Florey being a key figure in its development — and was quickly adopted in military medicine. The antibiotic era had begun; as discovery followed discovery, it seemed that no bacterial infection would remain untreatable. Osteomyelitis, empyema, rheumatic fever and subacute bacterial endocarditis disappeared from the wards, and gonorrhoea and syphilis notifications plummeted.
Patients expected to recover from septicaemia, pneumonia and even meningitis; but it did not take long for the first drug-resistant organisms to appear.
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Sophisticated medical technology has offered unprecedented opportunities to microorganisms. Drug resistance has rapidly developed owing to selective pressure resulting from profligate use of antibiotics in medicine and agriculture. Australian hospitals experienced some of the earliest outbreaks of antibiotic-resistant staphylococci, 22 which led to radical improvements in infection control.
Although most of the resistant organisms were no more and often less virulent than the original susceptible strains, their competitive advantage meant that acute urinary infections could no longer be reliably treated with ampicillin, nor gonorrhoea with penicillin, by the mid s. Discovery of new antibiotics could not keep pace, and regulatory attempts to restrict their use have proved difficult.
The need for mass screening prompted development of commercial testing kits, which have revolutionised laboratory diagnostic services. The most concerning feature of hepatitis B infection was the recognition during the s that adult carriers often developed liver cancer, which was then the leading cause of cancer deaths in Asia. The hepatitis B vaccine was the first human recombinant DNA vaccine and the first human cancer vaccine.
Other agents soon emerged from obscurity, often in response to changes in human activity. The inexorable rise in prevalence and apparently inevitable mortality of HIV infection spurred public health initiatives and scientific investigation. In Australia, safe-sex campaigns had an almost immediate effect in reducing numbers of new cases, as did controversial needle-exchange and harm-minimisation strategies for injecting drug users. However, in the populous countries of Africa, South America and Asia, heterosexual transmission dominated and led to epidemics of neonatal infection via transplacental transmission.
The shadowy entity of non-A, non-B hepatitis unexpectedly proved to cause both liver cirrhosis and cancer. Acute hepatitis C infection causes only minor symptoms, but the hepatitis C virus often establishes chronic infection with sinister consequences. Tests were developed to screen donated blood and it soon became apparent that injecting drug use had silently amplified prevalence of hepatitis C infection in young people in Western countries.
Treatment was protracted and beset by the adverse effects of interferon, a key component of drug regimens that were initially used. Newer drugs achieve high cure rates, but cost puts them out of reach for patients in poor countries, where the reservoir of infection remains high.
Genital warts were well known to the ancient Romans, and for centuries they were regarded as an embarrassing but harmless sexually transmissible disease. This attitude changed dramatically when their association with cervical cancer was established in the s. In Australia, preventive human papillomavirus vaccination was pioneered by Ian Frazer and viral DNA detection has been added to screening by Pap smear, but neither of these approaches are affordable in poor countries, where death rates from cervical cancer are highest.
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In , old infections still lurk, while human and environmental changes create new opportunities. Malaria — which depends on humans as a reservoir for the parasite and mosquitoes for transmission — was vulnerable to a combination of treating patients with drugs and spraying the environment with dichlorodiphenyltrichloroethane DDT to kill mosquitoes. Large areas of the temperate zone and even the tropics became malaria free but, because mosquito eradication measures were inconsistently applied, drug-resistant parasites and DDT-resistant mosquitoes soon emerged.
In the absence of an effective vaccine, prevention now relies on avoidance of mosquito bites by use of repellents, protective clothing and screens, plus an ever-diminishing number of effective prophylactic drugs. Malaria has been holding its own in many countries, aided by global warming. Military deployment of troops in exotic areas and large-scale movement of refugees are associated with outbreaks of communicable diseases. Cholera has been a recurrent problem when people seek shelter from war or natural disaster, most recently in Haiti.
Hantaan virus 36 caused over cases of Korean haemorrhagic fever and almost deaths among American troops during the Korean war. The soldiers were exposed through inhalation of aerosolised rodent faeces when camped in wilderness areas. Other haemorrhagic fevers — such as Ebola virus disease and Lassa fever, for which native wildlife act as reservoirs — have caused human outbreaks with high mortality, particularly in sub-Saharan Africa.
Australia has several indigenous arboviruses, including Murray Valley encephalitis, and Ross River and Barmah Forest viruses.
As global population pressure drives clearance of forested areas for agriculture, humans have become targets for many infections carried by wild animals. In Australia, outbreaks of Hendra virus infection and the emergence of the Australian Lyssavirus have been linked to contact with flying foxes. Severe acute respiratory syndrome SARS , which caused a deadly outbreak of respiratory disease centred in southern China in —, is a bat virus 38 but was transmitted to humans via infected palm civets, which were often for sale in Chinese markets.
Control of SARS was achieved through international cooperation in identifying the new coronavirus and applying strict isolation procedures. Memories of the influenza pandemic lent renewed vigour to the WHO surveillance system for respiratory infections that emerge from reservoirs of influenza viruses in pigs, horses, poultry and wild birds the latter two in particular.
Alas, the ability to identify novel strains has not been matched by the ability to predict infectivity and severity of disease. Intensive agricultural production also provides new routes of infection. Mad cow disease resulted from the use of inadequately rendered animal-based food supplements for cattle which allowed the variant Creutzfeldt—Jakob disease agent to survive.
The ramifications of this outbreak were economic and social. More new infections will undoubtedly emerge as humans change their environment. These pressures also affect old infections such as tuberculosis, malaria, cholera and even plague. The lessons of the past should not be forgotten. Aboriginal Australians who endure poverty and limited access to medical resources have not shared this luck.
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Abolishing this gap is the immediate priority for the forthcoming century. Provenance: Commissioned; externally peer reviewed.
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