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Plague in the modern day: Public health outbreaks at home and away

From mumps and measles, to the plague and Ebola, it is critical EMS is aware of the outbreaks, syndromes and conditions on the radar of public health

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Infectious and contagious diseases are ever-present, and it takes considerable monitoring, countermeasures and prevention to ensure we protect the entire U.S. population.


This article was originally posted Dec. 3, 2019. It has been updated with new information.

Whenever I present at EMS conferences, I ask my audience, “Who knows the name of their local public health director?” Usually, less than half of attendees raise their hand! While emergency service is the primary role of the EMS profession, we are also a major player in the world of public health.

Agencies must connect and collaborate with their public health directors to ensure they understand current and emerging risks that could affect the population. Infectious and contagious diseases are ever-present, and it takes considerable monitoring, countermeasures and prevention to ensure we protect the entire U.S. population. 

Currently, we are seeing a global resurgence of diseases common to the Middle Ages. Last month, a husband and wife in China were reported to have died of bubonic plague – that’s right, the precursor to the Black Death – and a third man tested positive after eating wild rabbit. It may be hard to believe, but the CDC reports that there have been a few dozen cases of the plague right here in the U.S. every year.

By developing a relationship with your public health director, you can become better informed of the infections, contagions, outbreaks, syndromes and conditions you could encounter. While there is in fact a whole alphabet of disease that could be covered, from Anthrax to Zoster, here are seven infectious disease threats on public health directors’ radars.

1. Plague 

The World Health Organization reports that from 2010 to 2015, there were 3,248 cases of plague worldwide, resulting in 584 deaths. Since the first cases were recorded in Europe in the 14th Century, the Plague has caused over 200 million deaths and the potential exists for it to be weaponized as a bioweapon of mass destruction by any number of global bad actors. It is now internationally recognized as a re-emerging disease.

Plague, especially the pneumonic variety, is potentially fatal if left untreated, so recognizing symptoms recognition is vitally important. The best-known symptom of bubonic plague is one or more infected, enlarged and painful lymph nodes, known as buboes (leading to the term “bubonic”), commonly found in armpits, upper femoral, groin and neck.

Plague symptoms include: 

  • Chills

  • Malaise

  • High fever >102.2 °F (39 °C)

  • Muscle cramps

  • Seizures

  • Smooth, painful lymph gland swelling (buboes)

  • Gangrene of the extremities, such as toes, fingers, lips and the tip of the nose

2. Ebola

In addition to global concern over the plague, Ebola, a major concern in the United States a few years ago, is still claiming lives in the Democratic Republic of the Congo.

On June 1, 2020, the Government of the Democratic Republic of the Congo announced a new outbreak of Ebola in the Wangata health zone, Mbandaka, in Équateur province. This is the eleventh outbreak of Ebola reported in the Democratic Republic of the Congo, and is occurring as a difficult outbreak in the eastern Democratic Republic of the Congo is in its final phase. At the time of the announcement, surveillance was increasing, and six suspected Ebola cases had been detected in Wangata: including four fatalities and two under care, with three of the six cases confirmed with laboratory testing.

Ebola symptoms include: 

  • Fever

  • Aches and pains, such as severe headache, muscle and joint pain, and abdominal (stomach) pain

  • Weakness and fatigue

  • Gastrointestinal symptoms, including diarrhea and vomiting

  • Unexplained hemorrhaging, bleeding or bruising

Other symptoms may include red eyes, skin rash and hiccups (late-stage).

3. Measles

Measles is more than just a rash; it is dangerous, especially for young children and babies. From Jan. 1 to Nov. 7, 2019, 1,261 individual cases of measles have been confirmed in 31 states, the greatest number of cases reported in the U.S. since 1992. Perhaps unsurprisingly, most cases occurred in those who had not been vaccinated against measles.

Meanwhile, back in the DRC, Measles killed nearly 5,000 people in 2019, in what the WHO describes as the world’s largest and fastest-moving epidemic that has now killed more than twice as many people as Ebola in the region. The WHO intends to inoculate more than 800,000 children to attempt to contain the spread. 

Measles symptoms include:

  • High fever (may spike to more than 104° F)

  • Cough

  • Runny nose (coryza)

  • Red, watery eyes (conjunctivitis)

4. Mumps

From Jan. 1 to Oct. 11, 2019, the CDC received reports from 48 states and the District of Columbia in the U.S. of mumps infections in 2,618 people. Before the U.S. mumps vaccination program started in 1967, about 186,000 cases were reported each year, but the actual number of cases was likely much higher due to underreporting. The risk factor for an increase in mumps is very real with the ongoing reluctance in some segments of society that are averse to vaccination.

Mumps symptoms include: 

Mumps is best known for the puffy cheeks and tender, swollen jaw that it causes. Other symptoms that might begin a few days before the swelling include:

  • Fever

  • Headache

  • Muscle aches

  • Tiredness

  • Loss of appetite

Symptoms typically appear 16-18 days after infection, but this period can range from 12-25 days after infection. Some people who get mumps have very mild symptoms (like a cold), or no symptoms at all and may not know they have the disease.

5. Pertussis 

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. Pertussis is known for uncontrollable, violent coughing that often makes it hard to breathe. After coughing fits, someone with pertussis often needs to take deep breaths, which result in a “whooping” sound, hence the name whooping cough. 

In 2012, 48,277 cases were reported. Pertussis is a very contagious disease only found in humans. People with pertussis usually spread the disease to another person by coughing or sneezing, or spending a lot of time near one another where in a shared breathing space. During outbreaks, it is imperative that babies, in particular, are protected from getting sick and dying as they could be infected by older siblings, parents, or caregivers who might not even know they have the disease. 

Infected people are most contagious up to about 2 weeks after the cough begins. Antibiotics may shorten the amount of time someone is contagious. The coughing fits can go on for up to 10 weeks or more. In China, pertussis is known as the “100-day cough.”

After infection with Pertussis, it takes about seven to 10 days for signs and symptoms to appear. Pertussis symptoms are usually mild at first and resemble those of a common cold:

  • Runny nose

  • Nasal congestion

  • Red, watery eyes

  • Fever

  • Cough

After a week or two, signs and symptoms worsen. Thick mucus accumulates inside the airways, causing uncontrollable coughing. Severe and prolonged coughing attacks may:

  • Provoke vomiting

  • Result in a red or blue face

  • Cause extreme fatigue

  • End with a high-pitched “whoop” sound during the next breath of air

6. Influenza 

Influenza may not grab the mainstream media headlines like an outbreak of Ebola or the plague, but as we all know, the flu as an infectious disease is highly contagious, with hundreds of strains that mutate frequently. Influenza is also incurable and orbits the planet on an almost annual infection cycle.

The statistics in the U.S. alone for the last flu season are sobering. The CDC reports that in the 2017-2018 season 45 million people (an eighth of the entire U.S. population) caught the flu. Of these, there were 20 million related medical visits, over 800,000 hospitalizations and 61,000 flu-related deaths. From an EMS perspective, this places considerable strain on the service delivery system from both pure demand and attrition on the workforce as they also succumb.

Influenza symptoms can last anywhere from 2-7 days, but 4-5 days is the usual time frame. Flu symptoms can include a combination of the following:

  • Cough

  • Runny or stuffy nose

  • Itchy/watery eyes

  • Sore throat

  • Fever

  • Body aches

  • Extreme fatigue

  • Headache

7. COVID-19

The World Health Organization declared COVID-19 a pandemic on Mar. 11, 2020.

The CDC began closely monitoring an outbreak caused by a new coronavirus strain first identified in Wuhan, China in December 2019, which quickly spread to southeast Asia, Europe, Canada and the U.S. The first case in the United States was announced on Jan. 21, 2020, in the state of Washington, where the patient recently returned from Wuhan.

The World Health Organization declared the novel coronavirus outbreak a global health emergency on Jan. 30, 2020. The announcement came shortly after the first human-to-human transmission of the virus in the U.S. was confirmed by the CDC.

Officially named COVID-19 by the World Health Organization on Feb. 11, 2020, the novel coronavirus is thought to be spread by respiratory droplet transmission and/or contact with infected patients.

COVID-19 symptoms may include:

  • Runny nose
  • Headache
  • Cough
  • Sore throat
  • Fever
  • A general feeling of being unwell

Vaccination, universal precautions

We shouldn’t be complacent, thinking that some of these conditions are taking place on other continents. While they may be occurring thousands of miles from our shores, air travel renders them mere hours away. The coughing and spluttering passenger on a transatlantic flight can infect the whole aircraft before it lands, and they’re unlikely to declare their contagion at customs.

Closer to home, the reluctance to vaccinate, while an emotive subject, is simply increasing the chances of getting and passing something on that could have been prevented.

For the medic on the street, understanding what is out there and what to look for is the first universal precaution for the provider. Agencies must ensure they provide training for providers on knowing when to mask up and don PPE, as well as when to notify public health.

With another flu season heading our way, we must also think about protecting our own workforce, and our patients, with early immunization and a thorough understanding of the precautions being a key activity.

We can also think about joining in with the public health messaging and being a part of a local PSA to promote precautions and even offer stations and HQs as vaccination sites if necessary. We have to take infectious diseases and contagions as seriously as the East coast hurricane that we see forming in the Atlantic, and know they have a good probability of striking us and causing havoc. Flu is flying on all of our radars and, from a devastation perspective, is completely off the Saffir-Simpson scale.

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.