Lessons from the history of brucellosis.

The disease we now know as brucellosis was first discovered in the 1850s in Malta. It came to the attention of British medical officers serving on the island after the Crimean War. It was easy to eliminate the disease in British servicemen, but very difficult to reach Maltese citizens. Over the decades, more and more Maltese were infected asthe control measures introduced were half-hearted and were often not even enforced. The work of Dr Themistocles Zammit showed that infected goats transmitted brucellosis and that banning use of their milk would be effective. Pasteurisation was not introduced onto the island until the 1930s, when the production of cheap, small sterile containers became possible. Transmission was also possible through sexual contact and by inhalation when people were crowded in hot airless conditions. Success in controlling the disease requires sensible, strict control of animals and the elimination of infected ones, but will fail without an educated public willing to help. In Malta, failure to control rogue flocks and small flocks kept for family use led to an epidemic caused by the sale of cheeselets (small cheeses). In 2005, nearly a century after Zammit's discovery, Malta was finally free of brucellosis.

The curious affair of the identity of Fioravanti Sammut (b. 1863) and Temistocle Zammit (d. 1935).

Dr Zammit's experiments showed that brucellosis was transmitted by the milk of goats that did not show signs of infection or ill health. The British forces in Malta banned the use of goats' milk and brucellosis was eliminated in those forces. This research was published in the Proceedings of the Royal Society and earned him an Honorary DLitt from Oxford University and the Kingsley Medal of the Liverpool School of Tropical Medicine. The King knighted him. He was the great Maltese polymath but there is a mystery concerning his name.

Surgeon Captain Sheldon F. Dudley and the person to person spread of brucellosis by inhalation.

Analysis of brucellosis epidemics in ships of the Mediterranean fleet in the nineteenth century are most easily explained by aerosol transmission in grossly overcrowded, hot and humid confined spaces.

Diagnosis of acute flaccid paralysis: injection injury or polio?

In many countries, the treatment of choice for all fevers is one or more injections. These injections are associated with a risk of nerve damage. If cases of poliomyelitis are not to be missed, the diagnosis of injection trauma or traumatic neuritis (TN) must be exact. The guides for distinguishing between TN and polio are not clear. It is probable that some cases of polio are misdiagnosed as TN. As three-quarters of children with paralytic polio receive injections just before the onset of paralysis, their paralysis may be mistaken for TN. Clearer guidelines are proposed, together with suggestions for better documentation of muscles injected and paralysed. All cases of reported TN should be monitored and new diagnostic guidelines published. To protect their children, mothers must be educated to understand that injections for fever can cause harm. This must be an important part of the eradication programme for poliomyelitis.

Ending polio immunisation: stars and gutters.

Although we are moving towards eradication, risks remain. The number of people at risk of polio paralysis has been seriously underestimated, as has the danger of escape of polioviruses from laboratories. Virulent strains, still used in the US, should be destroyed. Surveillance of acute flaccid paralysis (AFP) and tracing suspected cases is difficult and still uncertain in many countries. The crucial definition by WHO of polio paralysis as asymmetric is ambiguous and misleading: in the Indian sub-continent and elsewhere, 75% have received unnecessary injections for fever 48 h before paralysis. These injections alter the severity and pattern of paralysis: 50% of Indian cases have symmetrical paralysis by limb and 25% by muscle. Eradication of polio promises a New Deal for Health, it must succeed.

Poliomyelitis in India: past, present and future.

In that they were made in temperate countries, most of the studies on poliomyelitis may not apply in sub-continent of endemic infantile paralysis. This review brings together data on polio in India, to present any changes which may have occurred since 1940. Only about 2% of children with polio die in the acute illness; about 95% of all cases have paralysis of one or both legs. In lameness surveys the adjustments for deaths and for arm paralysis are unnecessary and inflate the prevalence. Surveys suggest that prevalence has risen, but there may be other explanations for the figures. Around sentinel centres with effective cold chains, prevalence has decreased rapidly. The figures of the National Baseline Prevalence survey are examined. There are few cases of provocation, but a new phenomenon of aggravation by unnecessary intramuscular injections given to children with fever has been described. Such unnecessary injections are thought to be the cause of more severe paralysis in about 45% of cases and of converting a non-paralytic attack into paralysis in another 30% of the perhaps 200,000 cases in India each year. Aggravation is thought to be caused by a mechanism similar to the effects of physical activity. It is possible that massage might have a similar effect. Abscesses or their treatment may precipitate paralysis. The median age of paralysis fell by almost a half from about 2 yr to 1 yr, but may now have risen as many younger children receive vaccine. Rehabilitation has been neglected, with long lasting consequences. Assessment of disability should be based on need and not on current ability. Ethically, prevalence surveys should offer opportunity for immunization and rehabilitation. Prevalence of paralysis, numbers attending for rehabilitation and immunization have been analysed by gender and differences examined. The gender-gap widens with age after paralysis: there may be a high mortality among girls with paralysis. Past prevalence calculated from surveys might be seriously underestimated if many girls have died. The monthly pattern of polio was no different in epidemic years. Pulse immunization could be tried just before the seasonal rise each year. Difficulties of comparing vaccination schedules and the criteria for assessing the potency of vaccine are analysed. Paralysis among Indian soldiers in World War II suggests that adult cases may occur, but are not reported. Present investigations should concentrate on babies and adult cases. Research using virulent strains should be prohibited. The very low case-fatality rate suggests that many of the circulating viruses are of low virulence. The increasing proportion of cases with unnecessary injections just prior to paralysis might have caused the lower median age of paralysis, the severity of paralysis and at least part of the increasing prevalence of polio. The seasonal increases of polio might, in part, be a reflection of the injections given for fever caused by other infections. A national campaign against unnecessary injections for young children is urgently required. For children with fever, there is a strong case for postponing even DPT injections.