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Is COVID-19 the new plague?

written by Dr. Stephen A. Berger

A frightening pandemic arises from animals in Asia and spreads westward, killing thousands in Italy, France, Spain, and many other countries. The more severe infections are characterized by cough and fever, leading to progressive pneumonia. There is no specific treatment available, and entire cultures live in fear and uncertainty.  

And so, during 541-542 C.E. Yersinia pestis the bacterium that causes bubonic plague, spread out from China into the Byzantine Empire. Few were spared, and an estimated 25 to 100 million Europeans went on to die during repeated waves of infection that struck the region over the next 200 years. As many as 5,000 plague deaths per day were recorded in the city of Constantinople. This “Justinian Plague” is named for the Emperor Justinian, who managed to survive an attack of the illness (less-fortunate victims included Pope Pelagius II and Wighard, Archbishop of Canterbury) 

In recent years, much is written regarding the risk of the spread of infectious diseases related to global warming. In fact, there is some evidence that the Justinian plague was the product of global cooling. Five years before the onset of the pandemic, emissions from a volcano may have significantly lowered atmospheric temperature, resulting in the migration of rodents deprived of food. Fleas, which spread plague from rodents to humans, are unable to efficiently digest their blood meals at low temperatures, causing them to vomit as they attempt to feed again – injecting contaminated material into their hosts. 

The Justinian plague largely spared the Arabian Peninsula, thus nourishing the rise of Islam and Arab armies which easily went on to conquer large areas of a devastated Europe. 

From 1347 to 1351, a second plague pandemic – The Black Death – killed 75 to 200 million humans – an estimated ten-to-sixty percent of the European population. Once again, the disease originated in Asia, entering through Sicily on Genoese galleys, and reaching Venice in 1348. The irony of a pestilence from China spreading through northern Italy is obvious in light of current events. Just as the Justinian Plague claimed the life of Bishop Wighard, the Black Death killed two Archbishops of Canterbury in a single year – Thomas Bradwardine and John de Ufford.   

Just as the Justinian Plague altered the future of Europe, the Black Death may well have paved a path into the Renaissance.  

As of March 2020, there is little similarity between COVID-19 and Bubonic plague; but the current massive disruption of society will surely have consequences for human civilization in years to come.

Read more on the global status of Major Coronaviruses

Read more on the global status of Plague

Ebola, forgotten but not gone

written by Dr. Stephen A. Berger, Dr. Yaakov Dickstein, and Edward Borton

The recent WHO decision to declare the novel coronavirus outbreak a Public Health Emergency of International Concern (PHEIC), while both appropriate and hardly surprising, offers the opportunity to reflect on the previous PHEIC which was declared, namely the Ebola epidemic in Kivu region, Democratic Republic of the Congo (DRC). And you should really say the ongoing Ebola epidemic, as during the time since the declaration in July 2019 through to the present day (March 2020), a total of 3,453 cases have been reported [1].

The nCoV-2019 outbreak is still ballooning; as of today, over 400,000 confirmed cases worldwide with no signs of slowing down [2]. To date, there have been 19,786 fatalities, a mortality rate which is notably higher than the rate observed in the 2018-9 influenza pandemic (>2.5%) and significantly higher than AH1N1 (~0.05%) [3,4]. As you might have hoped, the response has been incredibly rapid, faster than ever seen before with a new human pathogen. Within weeks of identifying an outbreak of respiratory illness, the virus has been identified, sequenced and cultured; rapid tests are available for diagnosis (albeit with continuing broadening and narrowing); at least two randomized controlled trials (RCTs) are being performed to analyze the effect of antiviral medications, one with a new drug; and the largest infection control effort in history is underway, including the quarantine of more than 50 million inhabitants in Hubei province, China [5]. Internationally, airlines have ceased operating to China; large-scale surveillance of suspected patients and their contacts is being performed around the clock, and naturally, the media response has been extensive. It would prove more difficult to find someone who didn’t know of the new coronavirus than someone unaware.

The history of Ebola is different, both in impact and response. Ebola is vicious; out of 3,453 cases confirmed since the beginning of the current outbreak, 2264 or 66% have died, similar to ratios from previous outbreaks and among the highest case fatality rates of any human pathogen [1]. First isolated in 1976 following separate outbreaks in Sudan and what was then Zaire, there have been numerous outbreaks of Ebola since, both small and large, however scientific and media attention was limited for the first 20 years. An average of just 9 yearly publications related to the virus was published between 1977-1994 and it was only in 1995, when a major outbreak occurred in DRC, that interest began to be generated [6]. Coincidentally, the movie ‘Outbreak’, released just two months before the first cases in the DRC, also served to increase public awareness of the disease. It was the 2014-6 epidemic, however, which displayed the epidemic potential of the disease, with nearly 30000 suspected cases and more than 11000 fatalities [7]. The declaration of a PHEIC and a global response followed, including the use of experimental antiviral treatment and vaccination. Nevertheless, it took two years before the epidemic terminated.

It may well be an inconvenient truth that the responsiveness to any outbreak will be based on the impact on Western society, chiefly the economy, rather than the severity of the illness and endangerment to human life and well-being. Notwithstanding the vast amount of funds the global economy generates for medical research and treatment production, a more consistent global approach to tackling both the outbreaks themselves and managing awareness and attention would give less developed countries a better platform to address the events in a timely manner, minimizing the risk of extreme outcomes.

Thankfully the current outbreak has been less explosive than that of 2014-6, which could explain, if not forgive, the correspondingly tepid response; while organizations such as Médecins Sans Frontières (MSF, Doctors Without Borders) have been on the front lines from the beginning, it took the WHO four reviews of its original negative decision before they announced a PHEIC. Unfortunately, the situation has been complicated considerably by an ongoing conflict, which has escalated to actively target healthcare workers, including 386 attacks with 77 injured and 7 dead in 2019 [8]. Nevertheless, work has continued and has borne fruit and new cases of Ebola have declined significantly during the current outbreak since the end of September 2019, with only one newly-confirmed case this past week and hopefully, an end is close [1].

Outside of any political or economic reason, it is perhaps human nature to be attracted and fascinated in that which is new and shrouded in mystery and misinformation, and it is seemingly appropriate that the word “novel” (from Latin Novus, “new” or “fresh”) has been incorporated into the name of the virus which now makes the headlines. All the same, the fact that a public health emergency is currently of less international import or concern does not make it any less important or pressing, especially to the locals and health care workers fighting the illness. Given the WHO saw fit to label it as such an emergency, it should also see fit to continue rendering assistance proportionate to that description until the emergency is completely over and the region free from further risk; otherwise why have such labels at all?

Read more on the global status of Ebola

  1. https://www.who.int/emergencies/diseases/ebola/drc-2019. Accessed 3rd March 2020
  2. https://coronavirus.jhu.edu/map.html. Accessed 11th March.2020
  3. Taubenberger JK, Morens DM. 1918 Influenza: the mother of all pandemics. Emerg Infect Dis 2006 Jan;12(1):15-22
  4. Nishiura H. The virulence of pandemic influenza A (H1N1) 2019: an epidemiological perspective on the case-fatality ratio. Expert Rev Respir Med. 2010 Jun;(4)3:329-38
  5. See ProMED string for Novel coronavirus at https://promedmail.org/
  6. Pubmed search for “Ebola”, performed 6.2.2020. https://www.ncbi.nlm.nih.gov/pubmed
  7. WHO Ebola virus disease fact sheet. https://www.who.int/en/news-room/fact-sheets/detail/ebola-virus-disease. Accessed 6.2.2020.
  8. https://www.scientificamerican.com/article/ebola-response-workers-killed-in-attacks-force-withdrawal-from-critical-drc-region/. Accessed 6.2.2020.

GIDEON API is in beta!

How do you get ‘customer’ data if you are a hospital or a research institute?

You could build a dedicated team for conducting surveys and crawling research papers, even develop your own IT system for storing and accessing this data. How often would you need to revise this data? Monthly? Quarterly? How comprehensive do you think it would be? 

If you are one of the many medical professionals pressed for time and/or money, the above may not be an easy solution to maintain, and when people’s lives are at stake there is no room for failure.

Imagine your organization had access to infectious diseases data collected from all over the globe, from thousands of patients, across hundreds of countries, updated every single day. That would be pretty amazing, right? With GIDEON it is a click away. We offer your organization access to data on hundreds of diseases, drugs, and bacteria, from across the world, dating back from as far as the 1920s – we do the legwork so you can conduct your expert analysis. 

To fully realize the benefits of our comprehensive database, we have developed the GIDEON API so you can leverage a direct feed of continuously updated information between our service and your established processes and tools. The service is now being offered to all our institutional subscribers free of charge.

With a service as broad as GIDEON, we understand that taking on an API integration can be a daunting task, even for a seasoned IT professional. To help make this invaluable feature more accessible to our customers we have written extensive guidance detailing every API call, including examples on the output you should expect. You can access the guidance through this link: API

We are confident building a deeper connection between our service and your systems will empower your analytics and reporting capabilities, bringing new insight to your existing and emerging data trends. Please take a peek at our documentation and let us know when you are ready to give it a go!

2020 is going to be an important and exciting year for GIDEON. We look forward to sharing many more announcements of enhancements and new services throughout the year.

Death By Corona: What Are the Numbers?

   This morning, we learned that actor Tom Hanks and his wife have contracted COVID-19 infection. Indeed, 43 famous persons have already been affected by the disease, including six Iranian leaders and four European soccer players. We might speculate that this reflects a single exposure event in Iran…or the fact that European athletes travel frequently in a high-incidence environment. Perhaps similar reasoning can be used to explain the striking variation in coronavirus death rates between countries.

As of March 12, 126,258 cases of COVID-19 had been reported worldwide; and 4,368 died of the disease – a case-fatality ratio (CFR) of 3.6%. This figure varies widely from country-to-country. Indeed, The CFR in Mainland China is 3.9% – vs. 3.2% of all other countries combined. Only 1.0% of infected passengers aboard the Diamond Princess cruise ship died of the disease. Among countries reporting more than 500 cases to date, the CFR (in descending order) is Italy 6.6%, Iran 4.3%, Spain 2.8%, United States 2.8%, Japan 2.5%, France 2.1%, United Kingdom 1.7%, South Korea 0.8%, Netherlands 0.8% and Switzerland 0.7%. Fatal infection is notably rare among the Scandinavian countries: Sweden 0.2%, Norway 0%, Denmark 0%. Finland, which has experienced 109 cases, has reported zero mortality.

The CFR in each country is largely determined by how the disease is identified, defined and reported. The quality, training professionalism and available resources available Health-Care workers will also influence case-finding and treatment; as will Demographic and cultural differences related to age, nutrition, access to local health facilities, lifestyle and exposure to animals. I suspect that much of this variation in CFR for COVID-19 is related to the very definition of “cases”. The death of an infected patient will be obvious and easily documented; while asymptomatic or relatively minor infections could remain undocumented. Indeed, the total number of “cases” used to calculate CFR might only represent those cases who are sufficiently ill to seek medical care. The patient with a mild febrile illness will not be “counted”

These questions can be easily solved using a standard serological survey in relevant communities. Such a survey should include a questionnaire regarding recent symptoms, exposure, occupation, etc. If a large proportion of the general population is found to be seropositive toward SARS-2 virus, we might conclude that the disease is less dangerous than current statistics seem to indicate.

Birds, Pigs and Silent VIP’s

It has become a tragic fact that every year the flu season brings an immense burden on health care services and now has dozens of subtypes cataloged, from ‘swine flu’ to ‘bird flu’ to ‘Asian flu’ and beyond. Typically, between late Fall and early Spring, over the last ten years, the United States alone has suffered hundreds of thousands of hospitalizations and tens of thousands of deaths across all ages [1]. But shortly after the turn of the century the ‘Spanish Flu’ pandemic of 1918 to 1920 was different in the extreme, and like every disease or virus did not discriminate on age, gender, race, even species, or, indeed, fame.

This year makes the centennial anniversary of the pandemics end so along with the estimated 50 million deaths let us remember how we are all equal in the face of such viruses.

Rose Cleveland – sister of President Grover Cleveland, who acted as ‘first lady’ to her bachelor brother – was one of approximately 150 famous people that perished in the ‘Spanish flu’ pandemic. Perhaps the best-known victims at the time were Francisco Rodrigues Alves (Brazilian President-Elect) and Louis Botha (President of South Africa), but no less than ten shining stars of the silent movie era are known to have also died during the deadly outbreak.

True Boardman, who appeared in 137 films in just an 8-year career and his son (also named True Boardman) went on to co-star in films with Charlie Chaplin and Mary Pickford.

William Courtleigh, Jr. who passed at only 26 years of age, after co-starring with Lillian Lorraine and Ann Pennington.

Dark Cloud (Elijah Tahamont), a Canadian Indian and chief of the Abenaki. During his 8 year career, he got to work with Francis Ford and Mary Pickford, appearing in 34 movies.

Myrtle Gonzalez, who is regarded as Hollywood’s first Latin and Hispanic star. She starred in some 78 movies, alongside the likes of William Desmond Taylor and Jean Hersholt.

Shelly Hull, brother of actor Henry Hull who was only just breaking into motion pictures following his success on Broadway, where he starred in plays such as The Amazons, The Cinderella Man and The Land of Promise.

Joseph Kaufman, both an actor and director with over 30 credits in each discipline. He married fellow silent film star Ethel Clayton who went on to star in as many as 180 movies.

Vera Kholodnaya, was the first Russian star of Silent Movies. Unfortunately, most of her films have been lost. Her first film was Anna Karenina and she went on to star in A Life for a Life, The Last Tango and some reported 50 other films. She also has a life-size bronze statue of herself in Odesa, Ukraine.

Julian L’Estrange, husband of Constance Collier, who starred in stage and movie productions on both sides of the Atlantic.

Harold A. Lockwood, was an actor, director, and producer who starred alongside May Allison no less than 23 films and also shared the screen with Mary Pickford (a repeating theme!).

Wayland Trask, Jr., a member of Mack Sennett’s company of actors, and a star of no less than 45 comedies.

Even prior to the recent outbreak, influenza has long contributed to thousands upon thousands of deaths across the globe, naturally including a number of famous names: Juan Peron (Argentina), Francesco Nitti and Paolo Boselli (Italy); performers Angela Baddeley, Lillie Langtree, Tallulah Bankhead, Jean Harlow, and Trevor Howard; baseball legends Dick Bertell and Hack Wilson; movie directors Jules Dassin and Luchino Visconti; and philosopher Bertrand Russell. In fact, three additional Silent Movie stars managed to join the famous-flu-deaths list – 2 shortly after the Spanish flu with Edward J. Connelly (1928) and Henry B. Walthall (1936); and the other as recent as 2018, with the passing of Lassie Lou Ahern, who had a career spanning over 50 years, starring in no less than 30 films including many from the ‘Our Gang’ films.

These lists are abstracted from the hobby of our founder and medical advisor, Dr. Steve Berger, who maintains an extensive database at www.VIPatients.com. The site is completely free to use, allowing you to explore and search the medical file of over 20,000 VIPs. Who will you look up?

[1] Figures taken from the CDC: https://www.cdc.gov/flu/about/burden/2010-2011.html

COVID-19: What is the Denominator

Since the 1st cases of infection by SARS-CoV-2 were reported in China, we have all been confronted by death and case-fatality statistics, which are both misleading and inaccurate. As of this morning, 2837 from a total of 83 774 reported cases of COVID-19 were fatal. Public Health professionals, the lay public, and politicians will conclude that this disease carries a “mortality rate” of 3.4%. Relatively few realize that “only” 1.4% of patients treated outside of Mainland China have died of COVID-19: 0.7% of passengers on the Diamond Princess cruise ship, 0.5% of patients in South Korea, etc.

One explanation for these discrepant case-fatality statistics is related to demography. Patients reported by official sources have a higher mean age and prevalence of underlying chronic disease than the general Chinese population (or international travelers). Case-definition, variation in quality of care, genetic and nutritional factors might also explain higher fatality rates among Chinese patients. Indeed, several of the patients who died of COVID-19 outside of Mainland China have also been Chinese Nationals.

A fundamental error in all of this could be related to the term, “reported cases.” How many infections in China are asymptomatic or sub-clinical? If, for example, only one-in-10 individuals who acquire infection by SARS-CoV-2 are sufficiently ill to visit a clinic or hospital, the true case-fatality rate decreases from 3.4% to 0.34% A seroprevalence survey in the general population could easily determine the true impact of this disease.

This week, details of an antibody assay for SARS-CoV-2 infection were reported in Journal of Medical Virology. [1] The authors state that the procedure detects both IgM and IgG antibodies within 15 minutes, with a test sensitivity and specificity of 88.86% and 90.63%, respectively.

Beyond the search for vaccines and effective anti-viral agents, an immediate remedy for much of the uncertainty regarding COVID-19 will be a comprehensive serological survey of populations in affected areas. Tested individuals should be questioned regarding recent travel, occupational contact, and relevant symptoms which may have occurred during the preceding 2 months.

If a high background sero-prevalence rate exists among people in Wuhan (or China as a whole) COVID-19 becomes little more threatening than other “new strains of flu” that we deal with each year.

References:
1. Li S, Yi Y, Lou X, et al. 2020. Development and Clinical Application of a Rapid IgM‐IgG Combined Antibody Test for SARS‐CoV‐2 Infection Diagnosis. J Med Virol (ahead of print) PMID: 32104917 DOI: 10.1002/jmv.25727.

 

Note featured on ProMED

Cryptosporidiosis in Sweden

The incidence of cryptosporidiosis in Scandinavia has increased dramatically in recent years.  As shown in the following chart, rates in Sweden per 100,000 population are approximately twice those reported in the United States – and almost four-fold those reported in the European Region as a whole.  [1-3]

References:

  1. Gideon e-Gideon multi-graph tool,   https://www.gideononline.com/cases/multi-graphs/
  2. Berger S. Infectious Diseases of Sweden, 2019. 416 pages , 143 graphs , 1,146 references. Gideon e-books,  https://www.gideononline.com/ebooks/country/infectious-diseases-of-sweden/
  3. Berger S. Cryptosporidiosis: Global Status, 2019.  147 pages , 53 graphs , 2,041 references.  https://www.gideononline.com/ebooks/disease/cryptosporidiosis-global-status/

Note featured on ProMED

 

 

Viral Agents of Childhood Respiratory Tract Infection in the United States

As of October, 2019 Gideon www.GideonOnline.com and the Gideon e-book series contain details of 69,204 epidemiological surveys – of which 1,107 (1.6%) are related to the prevalence of specific viral species in patients with respiratory tract infection.  [1-3]

The following chronology of published studies summarizes the relative proportion of viral agents associated with non-influenza childhood respiratory infection in the United States.  Additional details and primary references are available on request.

1976 – 2001 Tennessee
hMPV accounted for 20% of acute respiratory illness among children ages 0 to 5 years having no other identifiable etiology. 78% of infections in this group occurred during the months December to April.

1977 – 2001 Tennessee
Coronaviruses were found in 5.0% of nasal wash specimens from children below age 5 years with URI or LRI – 9% of these 229 E, 59% OC43 and 33% NL63

1982 – 2001 Tennessee – Nashville
hMPV accounted for 5% of upper respiratory tract infections among children, when other viruses are not identified

2000 – 2001 New York
hMPV was found in 3.9% of children ages 0 to 5 years, hospitalized for respiratory
illness

2001 – 2002 Ohio
HcoV-HKU1 was found in 1% of children below age 5 years with suspected viral infection in whom other viruses were not found

2001 – 2003 Multiple locations
Coronaviruses were found in 2.2% of children below age 2 years hospitalized for acute respiratory symptoms or fever

2001 – 2003 Multiple locations
hMPV was found in 3.8% of children below age <5 years old hospitalized with acute respiratory infection (rate 120 per 100,000 per year)

2001 – 2002 Connecticut
hMPV accounted for 6.4% of lower respiratory tract infections in children below the age of 5 years

2003 – 2004 Multiple locations
Rhinoviruses were found in 8.1% of children below age 5 years hospitalized with acute respiratory infection vs. 2.2% of a control group

2003 – 2009 Multiple locations
hMPV accounted for 6% of acute respiratory illness or fever among inpatient and outpatient children less than 5 years of age in three counties

2003 Washington – Seattle
hMPV was found in 11% of children with bronchiolitis, Coronavirus 8%, RSV 77%, Adenovirus 15%, Parainfluenza virus 6%

2003 – 2004 Missouri – St. Louis
WU polyomavirus (WUPyV) was found in 2.7% of children with respiratory infection

2004 Connecticut
Rhinoviruses were found in 26.3% of children below age 2 years with wheezing and 3% of asymptomatic children

2004 Connecticut
HBoV was present in 5.2% of respiratory specimens submitted from children below age 2 years, and negative for other detectable viruses

2004 – 2005 Colorado
Coronaviruses were found in 5% samples from children with respiratory infections which were negative for common viral etiologies

2004 New York
HBoV was found in 5.5% of tonsil samples from children undergoing elective tonsillectomy/adenoidectomy

2005 – 2006 Multiple locations
hMPV was found in 9% of children below age 2 years with acute bronchiolitis, and Rhinoviruses in 16%

2005 – 2007 Alaska
Rhinoviruses were found in 44% of Alaskan children below age 3 years hospitalized with respiratory infection, Adenovirus 30%, RSV 23%, Parainfluenza virus 18%, hMPV 15% and Coronavirus 6%

2005* Connecticut – New Haven
New Haven Coronavirus infection was identified in 8.8% of children below age 5 with respiratory disease

2006* California
Human Bocavirus (HBoV) was present in 5.6% of children with lower respiratory tract infection

2007 – 2011 na
Non-influenza respiratory viruses accounted for 41% of unexplained respiratory disease outbreaks investigated by CDC

2007 – 2010 Multiple locations
RSV was found in 51% of hospitalized children age <2 years with bronchiolitis, and Rhinovirus in 21%

2007 – 2008 Washington
HBoV was found in 2% of children ages 2 to 11 years with respiratory illness, and 3% of asymptomatic controls

2008* na
WU polyomavirus was found in 7.1% of symptomatic children and 6.3% of asymptomatic children

2008* na
KI polyomavirus (KIPyV) in 2.2% of symptomatic children and 0% of asymptomatic children

2008* California – San Diego
HBoV was found in 5.6% and hMPV in 5.2% of children presenting to an Emergency Department

2009 Missouri
Human parechovirus (HPeV) was found in respiratory specimens from 3% of children

2009 – 2013 Colorado
Viruses were identified in the nasopharynx of 41.9% of children hospitalized for Kawasaki disease

2010* Washington
HBoV was found in 59% of children attending daycare

2010 – 2011 Tennessee – Memphis
Rhinoviruses were found in 62% to 65% of children with cancer and respiratory tract infection

2011* na
Rhinovirus was the most commonly-detected virus (23.1% of viruses) in children ages 6 to 18 with cystic fibrosis

2012* na
Viruses were identified during 52% of febrile episodes among neutropenic children without bacterial infection

2012* Multiple locations
RSV and / or Human Rhinovirus was found in 84.5% of children below age 2 years hospitalized with severe bronchiolitis

2012* Multiple locations
hMPV was found in 9.0% of high-risk children with severe lower respiratory tract infection, and RSV in 45%

2012 – 2013 Georgia
RSV infection was identified in 6.4% of children admitted to Intensive Care, and respiratory Picornaviruses in 22.6%

2013* Tennessee
Rhinovirus was identified in 62% of children with sickle cell disease and acute respiratory illness

2015* Washington, DC
hMPV was found in 11% of children ages <=5 years with viral respiratory infection

2015* Multiple locations
Viruses were identified in 66% of children hospitalized for community-acquired pneumonia

2017* na
Human bocavirus DNA was identified in 10.4% of children with community-acquired pneumonia

*     Year of publication

na   Location of study not available

 

References:

  1. Berger SA. Gideon Guide to Surveys. 2019. 4,441 pages, 10,603 tables, 59,327 references. Gideon e-books, https://www.gideononline.com/ebooks/surveys/
  2. Berger SA. Miscellaneous Respiratory Viruses: Global Status, 2019. 94 pages, 1,395 references. Gideon e-books, https://www.gideononline.com/ebooks/disease/miscellaneous-respiratory-viruses-global-status/
  3. Berger SA. Infectious Diseases of the United States, 2019. 1,422 pages, 513 graphs, 18,048 references. Gideon e-books, https://www.gideononline.com/ebooks/country/infectious-diseases-of-the-united-states/

Coccidioidomycosis in the United States

Although largely limited to the western and southwestern states, Coccidioidomycosis is more commonly reported than legionellosis. More Americans die from Coccidioidomycosis than from the other two regional mycoses, Blastomycosis and Histoplasmosis. [1,2]

 

While Coccidioidomycosis is best known as a disease of California (“Valley Fever”) , highest incidence is reported from Arizona.  These data are even more striking when adjusted for relative population size (cases per 100,000 population).

 

References:

  1. Berger S. Infectious Diseases of the United States, 2019. 1,422 pages , 513 graphs , 18,048 references.  Gideon e-books,  https://www.gideononline.com/ebooks/country/infectious-diseases-of-the-united-states/
  2. Gideon e-Gideon multi-graph tool,   https://www.gideononline.com/cases/multi-graphs/

India: Diphtheria, Pertussis and Tetanus

Although global incidences of Diphtheria, Pertussis and Tetanus declined dramatically during the second half of the twentieth century, relatively high rates for these diseases continue to be reported from India.  India accounted for 17.7% of the total World’s population in 2018, but reported 46% of global Tetanus, 53% of global Diphtheria (and only 10.2% of global Pertussis) that year.  Similarly, 68% of the population of Southeast Asia (SEA) live in India, while that country accounted for 85% of Diphtheria, 75% of Pertussis and 90% of tetanus for SEA in 2018. [1-4]   Trends for these data are charted in the following three graphs. [5]

References:

  1. Berger S. Infectious Diseases of India, 2019. 620 pages , 109 graphs , 6,807 references. Gideon e-books, https://www.gideononline.com/ebooks/country/infectious-diseases-of-india/
  2. Berger S. Diphtheria: Global Status, 2019. 389 pages , 451 graphs , 699 references. Gideon e-books, https://www.gideononline.com/ebooks/disease/diphtheria-global-status/
  3. Berger S. Tetanus: Global Status, 2019. 561 pages , 816 graphs , 390 references. Gideon e-books, https://www.gideononline.com/ebooks/disease/tetanus-global-status/
  4. Berger S. Pertussis: Global Status, 2019. 417 pages , 514 graphs , 1,028 references. Gideon e-books, https://www.gideononline.com/ebooks/disease/pertussis-global-status/
  5. Gideon e-Gideon multi-graph tool,   https://www.gideononline.com/cases/multi-graphs/

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