H1N1 Swine Flu in Bahrain - A Case Study

Colourised electron microscope photograph of the H1N1 virus (CDC)

As the world turns its eyes towards China and the seemingly escalating spread of the novel coronavirus, the media's coverage gave uncomfortable flashbacks to the news coverage of the swine flu epidemic in 2009. The H1N1 virus, a strain of the influenza virus endemic in pigs, was first noticed in March 2009 and before long, a global pandemic was declared. It was estimated that up to 21% of the world's population may have contracted the disease and at least 18,000 died (though estimates point up to 500,000 may have died worldwide as a result). Over the course of a year, the pandemic died down and the WHO declared in August 2010 that the pandemic was over.

Below is a brief chronological history of what transpired in the island nation of Bahrain as it coped with the H1N1 pandemic. It begins chronologically and ends in the winter of 2009 when swine flu statistics were no longer published. I previously posted the below to Wikipedia back in 2012.

As It Happened:

On 27 April 2009, Bahrain's health ministry declared the country to be free from the flu, citing that pig farms do not exist in the country and that live pork is not imported into the country.[1] On 28 April, Bahraini MPs from the Al Asalah Salafi party called for the prohibition of pork products in the country.[2] On 30 April, Bahrain banned pork imports from the United States and Mexico where the bulk of its imports originate from, with the Ministry of Health stating that the country is taking extra precautions despite the World Health Organization stating that the flu cannot be contracted via the consumption of pork.[3] The Ministry announced the creation of isolation wards in the country's main hospitals and also recommended that people should avoid hugging and kissing, so as to avoid contact with infected individuals.[4][5] Also on the same day, it was announced that passengers arriving through the Bahrain International Airport would be screened and would also send suspicious flu patients to isolation wards.[4] It was also announced that pharmacies in the country were stockpiled with enough Tamiflu (an antiviral medication for influenza) to cover 20% of the population.[6] A special hotline was also set up.[7]

Public health poster, 2009 (Ministry of Health, BH)

Concerns began to emerge in the country about whether or not the health care sector could handle the influx of flu patients.vThe Ministry of Health set up screening facilities on the King Fahd Causeway to screen travelers entering the country.[8] On 1 May, it was announced that a 41-year-old male American traveler and a female passenger from Paris were quarantined at Salmaniya Medical Complex after displaying flu-like symptoms. However, both passengers tested negative to H1N1 tests.[9] On 26 May, a Bahraini student who had recently arrived from New York was confirmed as having contracted the flu; he was the first confirmed case of swine flu to hit the island country. It is also the first case involving a Gulf national contracting the disease. Health officials have stated the boy had suffered a mild form of the disease and was discharged from the hospital after spending five days in quarantine.[10] On 15 June, seven Bahraini students, all age 17, tested positive for the H1N1 virus.[11] The students were among a group of students who had recently returned from a student exchange program in the United States.[11] On 17 June, three more Bahrainis tested positive for the flu, all of whom were in contact with the previous seven students.[12]

In July, the Ministry of Health launched an awareness campaign ahead of the start of the academic year, with many fearing the reopening of schools would lead to a much greater outbreak of the flu.[13] By early August, 18 confirmed cases of the flu were reported.[14] Haj travel agencies have reported that thousands of Bahraini pilgrims have cancelled their trips to Mecca over fears of contracting swine flu.Over 180 confirmed cases of the flu were reported in late August, all of whom had returned from traveling abroad.[15]

On 31 August, a 30-year-old Filipino housemaid died after contracting the H1N1 virus, becoming Bahrain's first confirmed death as a result of the virus.[16] On 3 September, it was reported that a 24-year-old Bahraini man died after succumbing to the H1N1 virus, being the first Bahraini to die of the disease.[17] He was pronounced dead at BDF Hospital and there were allegations that he had been earlier misdiagnosed by a private hospital.[17] On 8 September, it was announced that patients with flu-like symptoms would be treated with Tamiflu nationwide, regardless of having a fever or not. It was also announced that a million doses of the swine flu vaccine were ordered.[18] The Bahraini Ministry of Education had decided to postpone the opening of schools until October as a precaution, a decision that drew criticism from the World Health Organization.[19] In November 2009, the government stated that up to 1,346 cases of the H1N1 virus were confirmed in the country, along with 15,000 suspected cases of the virus.[20]

References:

1. Bahrain Flu Free says health ministry". TradeArabia(via HighBeam Research). 27 April 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
2. "Bahraini MPs call for ban on pork". Arab News (via HighBeam Research). 29 April 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
3. "Bahrain curb on pork imports". TradeArabia (via HighBeam Research). 30 April 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
4. "Fever patients quizzed in Bahrain flu alert". TradeArabia(via HighBeam Research). 30 April 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
5. "'Avoid hugs and kisses' says health officer". TradeArabia(via HighBeam Research). 30 April 2012. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
6. ^ "Municipalities bracing for possible swine flu outbreak". Arab News (via HighBeam Research). 4 May 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
7. "Bahrain launches swine flu hotline". Trade Arabia (via HighBeam Research. 5 May 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012
8.  "Flu vigil 'vital' for Bahrain". TradeArabia. 14 May 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
9. ^ "US National is First Suspected Swine Flu Case in Bahrain". News Blaze. 1 May 2009. Retrieved 1 September 2012.
10. "Bahrain confirms 1st case of swine flu". TradeArabia(via HighBeam Research). 26 May 2012. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
11. "7 Bahraini students hit by swine flu". TradeArabia. 15 June 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
12. ^ "Bahraini swine flu cases rise". TradeArabia. 17 June 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
13. "'Swine flu' alert as schools close for summer". Gulf Weekly (via HighBeam Research). 12 July 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
14. "Swine flu fight is on". Gulf Weekly (via HighBeam Research). 9 August 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012.
15.  "Flu scare hits Umrah trips from Bahrain". TradeArabia (via HighBeam Research). 23 August 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
16. "Bahrain reports first swine flu death". TradeArabia (via HighBeam Research. 31 August 2009. Archived from the original on 17 May 2013. Retrieved 1 September2012.
17.  "Second flu death in Bahrain". Trade Arabia (via HighBeam Research). 3 September 2009. Archived from the original on 17 May 2013. Retrieved 1 September2012. 
18. "Bahrain to treat all flu patients with Tamiflu". TradeArabia. 8 September 2009. Archived from the original on 17 May 2013. Retrieved 1 September 2012. 
19. "WHO raps Bahrain schools delay". TradeArabia (via HighBeam Research). 9 September 2009. Archived from the original on 17 May 2013. Retrieved 1 September2012. 
20. "Flu cases top 1,346 in Bahrain". TradeArabia. Archived from the original on 17 May 2013. Retrieved 1 September 2012

History of Medicine - Jean-Martin Charcot

Charcot

Medical students and doctors worldwide undoubtedly recognise the name Charcot in one form or another. Undoubtedly the father of modern neurology alongside his mentor Duchenne, Jean-Martin Charcot was a French neurologist and anatomist who has 15 medical eponyms towards his name. His work on hysteria and hypnosis, although later refuted, contributed to the development of modern psychiatry. He was so influential that he was even referenced in Bram Stoker's Dracula.

Born and raised in Paris, Charcot studied medicine at the University of Paris in 1853 and became a professor in 1860. He practiced at the largest hospital in France, the Salpetriere hospital, ever since and opened Europe's first neurology clinic in 1882. As a doctor with remarkable teaching skills, his clinic attracted students across the continent; Freud, Babinksi, Bouchard, Tourette amongst others became influential figures in medical history in their own rights

The Clinician:

Though Charcot trained as a pathologist, he became a prominent clinician and recognised the importance of correlating clinical and post-mortem anatomical findings. In conjunction with Duchenne's emphasis on clinical examinations, Charcot promoted a systematic neurological history & physical examination to his students. His unique teaching technique forms the basis of the modern-day bedside teaching; it included interviewing patients diagnosed with the same condition during case presentation, imitating neurological symptoms of the patients, and drawing pictures illustrating the main clinical findings of a disease.

Painting by Andre Brouillet of a clinical lesson on hysteria by Charcot (standing) with the vanishing woman Marie Blanche. The assistant holding Blanche is Joseph Babinski the central figure, sitting in front of the professor is Georges Gilles de la Tourette

Neurology:

Charcot described and named Multiple Sclerosis (MS) for the first time, correlating clinical features with postmortem findings of his patients' brains. Although prior descriptions of MS date back to the 14th century and the pathognomonic periventricular plaques were described by others before him, the clinical correlation was not established. He was the first to diagnose MS in a living patient; he proposed a triad of symptoms (as medical students would know) of nystagmus, intention tremor, and scanning speech.

Charcot demonstrated cortical motor centres in humans, delineated the brain's vascular supply and , with his intern Charles Bourchard, described miliary aneurysms (Charcot-Bouchard aneurysms). Amyotrophic lateral sclerosis (or Motor Neuron Disease), which he also described, is still referred to as Charcot's disease in many parts of the world. He noted that in infantile paralysis the spinal lesions were limited to the anterior horns of the grey matter. With Marie he described the peroneal form of muscular atrophy, later called Charcot-Marie-Tooth disease.

By studying a complication of syphilis called tabes dorsalis that led to a loss of sensation in both legs,  Charcot hypothesised that absent sensation led to abnormal weight-bearing while walking, eventually cause joint deformations and bony destructions. Although today it is predominantly associated with diabetes, a deformed joint due to impaired sensation is still called a Charcot joint (neuropathic joint).

He had clear views on the differentiation of hysteria from epilepsy, neurosis from psychoses, and multiple sclerosis from paralyses agitans (the old name for Parkinson's disease, literally meaning Shaking Palsy). Charcot advocated the renaming of the disease to Parkinson's disease (la maladie de Parkinson) in honour of James Parkinson, the first man to describe the disease decades prior.

Charcot's Trainees:

Medical students and doctors would likely recognise a few familiar names:

• Sigmund Freud
• Joseph Babinski
• Charles-Joseph Bouchard - his intern and perhaps the most dramatic protégé. After Bouchard attained professorship at the University of Paris, his relationship with his mentor Charcot gradually deteriorated. Their strong personalities, their ambition to have schools of their own, and their competition to become the most influential man in the medical school resulted in antagonism between them. The most tragic consequence of this antagonism took place in 1892 when Bouchard presided over the competitive examinations for agrégation, in which Joseph Babinski, one of Charcot's youngest pupils, was a candidate. Charcot wanted his pupil to be nominated but Bouchard eliminated him in order to nominate his own pupils. The nominations were appealed but finally Bouchard's decision was upheld. Babinski did not retake the examination and never became a professor at the medical school.
• Pierre Janet
• William James
• Pierre Marie
• Albert Londe
• Georges Gilles de la Tourette - Charcot bestowed the eponym for Tourette syndrome in his honour. 
• Alfred Binet
• Albert Pitres amongst others.

Proudly borrowed from Wikipedia

Further Reading:

For the definitive biography, I recommend Christopher Goetz's in-depth 1995 biography of Charcot (ISBN 978-0-19-507643-1). It is a scholarly masterpiece and details his life in exquisite detail.

Charcot's original works and documents can also be freely accessed on the Internet Archive.

References for the article are as follows:

Tan SY, Shigaki D. Jean-Martin Charcot (1825–1893): pathologist who shaped modern neurology. Singapore Med J. 2007;48:383–384
Kumar DR, Aslinia F, Yale SH, Mazza JJ. Jean-Martin Charcot: the father of neurology. Clin Med Res. 2011;9(1):46–49. doi:10.3121/cmr.2009.883
The Science Museum: Jean-Martin Charcot (1825-93). 
HAAS L. Jean Martin Charcot (1825-93) and Jean Baptiste Charcot (1867-1936). Journal of Neurology, Neurosurgery & Psychiatry. 2001;71:524

History of Medicine - Duchenne de Boulogne

The history of science fascinates me for many reasons. The most signficant being that it is a brazen example of the cumulative efforts of men and women separated by time & space but united through their ideas. Perhaps it is best described by the saying Isaac Newton popularised; "to be standing on the shoulders of giants". Today, I would like to briefly look at the history of neurology and see how (and why) many eponymous diseases and signs have obtained their names.

Duchenne de Boulogne

We start with Duchenne de Boulogne, a French neurologist in the 1800s, whose understanding of electrophysiology, neural pathways, diagnostic techniques have arguably made him a father of the speciality and one of the 19th century's original clinicians.

Born in Calais in 1805, he studied medicine in Paris and became a physician in 1831. At Paris, he was taught by the likes of Cruveilhier, Dupuytren, Velpeau, and Laennec (inventor of the stethoscope). He remained in Calais as a practitioner of general medicine until his wife died of puerperal fever in 1844. He returned to Paris to initiate his pioneering studies on electrical stimulation of muscles.

He pioneered the use of deep tissue biopsy using a trochar he constructed, and described an array of myopathies that bear his name today. This includes Duchenne's muscular dystrophy, Erb-Duchenne palsy amongst others.

Interestingly, he published a monographic album of the muscles involved in human expressions (see adjacent photo). This album would later serve as a resource for a young Charles Darwin in his own study on the genetics of behaviour.

Duchenne (right) and his patient, an "old toothless man, with a thin face, whose features, without being absolutely ugly, approached ordinary triviality".

Over the course of his career, he worked with Armand Trousseau, Pierre Rayer, and Jean-Martin Charcot - all of whom he described as his closest friends. Duchenne was a shy yet hard-working physician. Despite his contributions, he was never given any hospital appointments or academic chair, likely due to his modesty and speech difficulties when presenting at conferences. Most of his work would not have been published without the help of his friends, Trousseau and Charcot.

Duchenne died in Paris in 1875.

Duchenne had many students throughout his career passing down his methodology and theoretical knowledge, as was common for physicians in training the next generation. Perhaps his most famous student was Jean-Martin Charcot, the "founder of modern neurology" who has at least 15 eponymous medical diseases and signs named after him, and perhaps the bane of medical students worldwide. He will be covered in detail next time.

References:
1. Parent A. Duchenne De Boulogne: a pioneer in neurology and medical photography. Canadian journal of neurological sciences. 2005 Aug;32(3):369-77.
2. Broussolle E, Poirier J, Clarac F, Barbara JG. Figures and institutions of the neurological sciences in Paris from 1800 to 1950. Part III: neurology. Revue neurologique. 2012 Apr 1;168(4):301-20.