• Open Access

Forgotten but not gone

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Australians might be forgiven for believing that infectious and communicable diseases are all but a thing of the past. Unless something dramatic occurs on our shores, such as a human death from equine Morbillivirus or an outbreak of Legionnaires disease, infections and communicable diseases are generally out of sight and out of most people's minds. Parents say, when lending the car keys, ‘drive carefully’ and ‘don't drink too much’ and ‘don't forget to eat’, but never ‘don't get chicken pox’ or ‘condoms are good for avoiding chlamydia’.

Sometime between 1967 and 1970 (the precise date is unclear) then United States Surgeon General, William Stewart, allegedly said:

“It's time to close the book on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease.”

A recent review article provides an interesting counterbalance to this argument.1 In it, palaeontologist Stephen Jay Gould describes the contribution of the discipline of microbiology to the control of infectious diseases as a series of Golden Ages. The first Age was the time of discovery of microbes and the development of their classification systems. Vaccines were developed for a number of major diseases, and the potential power of antibiotics revealed. The second era involved the development of microbial genetics, and the restructuring of existing microbiological classifications based on insights gained from genotyping. The third era progressed our understanding to that of microbial physiology and ecology, and gave us mechanisms for applying this knowledge to nanotechnologies. Included in this paper is a fascinating quote from Gould:

“We live now in the ‘Age of Bacteria.’ Our planet has always been in the “Age of Bacteria,” ever since the first fossils—bacteria, of course—were entombed in rocks more than 3 billion years ago. On any possible, reasonable or fair criterion, bacteria are—and always have been—the dominant forms of life on Earth. Our failure to grasp this most evident of biological facts arises in part from the blindness of our arrogance but also, in large measure, as an effect of scale. We are so accustomed to viewing phenomena of our scale—sizes measured in feet and ages in decades—as typical of nature.”1

In considering the views of Stewart and Gould, I am inclined toward the latter. While infectious and communicable diseases might not be a major burden on disease in high-income countries, they are far from gone in low and middle income countries. The World Health Organization (WHO) Global Alert and Response (GAR) and its outbreak response network GOARN2 clearly articulate the reasons all countries need to remain vigilant, and point to emerging (such as HIV/AIDS, dengue fever, the Paramyxoviridae viruses such as Hendra, and various kinds of hepatitis) and re-emerging (such as tuberculosis) infections. In most of the world, other important diseases, for example malaria and cholera, have never gone away. Worldwide, the most recent WHO reports tell us that in 2008 these diseases still account well over one-third of all deaths in children, and for 17% of all deaths each year. At more than a quarter of a million a month, that is just about one every second.3

Although short-lived in most people's memories, Australia has had some interesting outbreaks of various diseases, and this Journal has consistently published papers and research letters about these – 10 in 2012 (not including four in this issue), 10 in 2011 and 11 in 2010. Our 2012 papers have been about papillomavirus,4 tuberculosis,5 chlamydia,6 hepatitis B,7 pandemic influenza,8 pertussis,9 Ross River virus,10‘flu immunisation11 and immunisation in general.12,13 They cover many areas of understanding, from analysis of outbreaks, thinking about legal requirements, techniques for enhancing surveillance, interesting case studies and outbreak reports, and demonstrate a huge range of investigative and analytical techniques.

We have a few tools in the tool-box to deal with some, but not all, of these diseases. Australia's excellent surveillance databases – about illness as well as those indicating salutogenic programs such as the Australian Childhood Immunisation Register – remain the bedrock of public health knowledge about communicable diseases, and WHO commends this as the key to communicable disease control. Antibiotics, the trigger for the US Surgeon General's remarks, are another of these tools (although with resistance to microbes a growing problem, particularly in the light of international travel, it is not heartening to read that about 40% of antibiotic prescriptions, at least in aged care home residents, are for problems which do not appear to be infections at all, and specimens are not taken to confirm an infection in approaching two-thirds of people for whom antibiotics are prescribed14– clearly not best-practice). We also have many versions of ‘so 20th century’ infection control guidelines that would be effective if we all washed our hands, covered our mouths when sneezing, staying home when sick, and so on. We have vaccines, wonderful gifts capable of protecting us and our children from microbes which as recently as 50 years ago killed and maimed us in large numbers, and in resource-poor countries, still do.

At Christmas time it is appropriate to remember these important gifts to the world, some of which were boxed and wrapped by us, that have made such of a difference to the health of people of every colour and creed. World peace might not be just around the corner, but we can save a lot of lives while we are waiting for it.

Ancillary