Did an epidemic of tularemia in Ancient Egypt affect the course of world history?

Tularemia - a re-emerging disease with growing concern

Tularemia caused by Gram-negative, coccobacillus bacterium, Francisella tularensis, is a highly infectious zoonotic disease. Human cases have been reported mainly from the United States, Nordic countries like Sweden and Finland, and some European and Asian countries. Naturally, the disease occurs in several vertebrates, particularly lagomorphs. Type A (subspecies tularensis) is more virulent and causes disease mainly in North America; type B (subspecies holarctica) is widespread, while subspecies mediasiatica is present in central Asia. F. tularensis is a possible bioweapon due to its lethality, low infectious dosage, and aerosol transmission. Small mammals like rabbits, hares, and muskrats are primary sources of human infections, but true reservoir of F. tularensis is unknown. Vector-borne tularemia primarily involves ticks and mosquitoes. The bacterial subspecies involved and mode of transmission determine the clinical picture. Early signs are flu-like illnesses that may evolve into different clinical forms of tularemia that may or may not include lymphadenopathy. Ulcero-glandular and glandular forms are acquired by arthropod bite or handling of infected animals, oculo-glandular form as a result of conjunctival infection, and oro-pharyngeal form by intake of contaminated food or water. Pulmonary form appears after inhalation of bacteria. Typhoidal form may occur after infection via different routes. Human-to-human transmission has not been known. Diagnosis can be achieved by serology, bacterial culture, and molecular methods. Treatment for tularemia typically entails use of quinolones, tetracyclines, or aminoglycosides. Preventive measures are necessary to avoid infection although difficult to implement. Research is underway for the development of effective live attenuated and subunit vaccines.

Tularemia seroprevalence in humans in the region of the Hittite-Arzawa War (Inner Aegean Region), where the first biological weapon was used 3300 years ago

BACKGROUND

: According to Egyptian records, tularemia emerged in the Canaan region, where it was first identified and spread to Anatolia over the Euphrates. It was used as an active biological weapon for the first time in the Hittite-Arzawa War in 1320-1318 BC. This study aimed to investigate the seroprevalence of tularemia in the Inner Aegean Region, which is thought to be the region where this war was fought 3300 years ago.

METHODS

Tularemia seropositivity in humans was investigated in 27 villages/neighborhoods in 3 districts in each of Manisa, Kütahya, and Uşak provinces. Before the study, the participants were informed about the disease via posters, and their blood samples were taken following filling out the questionnaire. Microagglutination tests were performed using in-house tularemia antigen and V plate for serological experiments. Rose-Bengal test was also performed on seropositive sera.

RESULTS

Of the total of 410 people, 226 (55.12%) were male. The mean age of the volunteers was 43.72 years. The highest participation was from Kütahya Province. According to the results of the tularemia microagglutination test, seropositivity was detected in 6 cases. It was determined that all of the seropositive volunteers were in Kütahya. When the tularemia antibody titers were examined, seropositivity was determined at 1/20-1/160 titers. No positivity was detected in the Rose-Bengal test for cross-reaction.

DISCUSSION

Kütahya has been identified as a risky region in terms of tularemia in the Inner Aegean Region. In order to use the resources in the country economically, first of all, the risk areas in terms of tularemia should be determined by serological studies in all regions. In order to increase awareness about the disease, physicians and filiation teams should be trained in risky areas. Surveillance studies should be conducted to identify and monitor possible sources in areas identified as risky.

Tick-borne diseases in Egypt: A one health perspective

Background

Ticks are important arthropod vectors that transmit pathogens to humans and animals. Owing to favourable climatic and environmental conditions, along with animal importation from neighbouring countries, ticks and tick-borne diseases (TBDs) are widespread in Egyptian localities. Here, we review the current knowledge on the epidemiology of TBDs in Egypt in light of the One Health paradigm.

Methods and results

Five scientific databases, including "Web of Science", "Scopus", "PubMed", "Science Direct", and "Google Scholar", were searched for articles describing TBDs in Egypt. A total of 18 TBDs have been reported in humans and animals, including three protozoal diseases (babesiosis, theileriosis, and hepatozoonosis), 12 bacterial diseases (anaplasmosis, ehrlichiosis, Lyme borreliosis, bovine borreliosis, tick-borne relapsing fever, Mediterranean spotted fever, African tick-borne fever, lymphangitis-associated rickettsiosis, bartonellosis, tularaemia, Q fever, and aegyptianellosis), and three viral diseases (Crimean-Congo haemorrhagic fever, Alkhurma haemorrhagic fever, and Lumpy skin disease).

Conclusions

Despite the circulation of zoonotic tick-borne pathogens among livestock and tick vectors, human infections have been overlooked and are potentially limited to infer the actual communicable disease burden. Therefore, facility-based surveillance of TBDs, combined with capacity building for laboratory diagnostics in healthcare facilities, is urgently required to improve diagnosis and inform policy-making in disease prevention. Additionally, collaboration between expert researchers from various disciplines (physicians, biologists, acarologists, and veterinarians) is required to develop advanced research projects to control ticks and TBDs. Considering that domestic livestock is integral to many Egyptian households, comprehensive epidemiological studies on TBDs should assess all disease contributors, including vertebrate hosts (animals, humans, and rodents) and ticks in the same ecological region, for better assessment of disease burden. Additionally, upscaling of border inspections of imported animals is required to stop crossover movements of ticks and TBDs.

Tularemia research activity: a bibliometric analysis between 1980 and 2020

INTRODUCTION

Tularemia disease attracts attention as an important contagious zoonosis that has increased its impact in recent years. The aim of the study is to analyze the publications on tularemia between 1980 and 2020.

METHODS

We performed literature retrieval in the Web of Science (WoS) on 22 September 2021. Search terms were "Francisella tularensis" and "Tularemia" in the article title for the period between January 1980 and December 2020. We determined the number of articles, keywords, countries, authors, and institutions for each publication. We visualized the data with the VOS viewer tool.

RESULTS

After all inclusion and exclusion criteria were applied finally, 1688 articles were analyzed. The number of articles has increased in recent years. The three most productive countries in tularemia were the USA (777 articles 46.03%), Sweden (113 articles 6.69%), and Turkey (95 articles, 5.63%). Most of the articles were from the journal of Infection and Immunity (II), Plos one, Journal of Clinical Microbiology (JCM), Emerging Infectious Diseases (EID), and Vaccine. Sjostedt A. and Umea University-Sweden were the most influential author and institution.

CONCLUSIONS

Productivity trend has been shown to increase in tularemia. High-income countries had a great influence on the literature in the field. Publications from the USA were in a high percentage among all articles. Related work may lead to the future direction of this dossier in the next years.

Ticks and Tick-Borne Diseases of Livestock in the Middle East and North Africa: A Review

Ticks are important vectors of an array of viral, bacterial and protozoan pathogens resulting in a wide range of animal and human diseases. There is limited information in the literature about tick species in the Middle East and North Africa (MENA) countries, even though they have suitable climate and vegetation for ticks and their hosts. We reviewed the occurrence of tick species and the pathogens they transmit from the MENA on published papers from 1901-2020. We found taxonomic records of 55 tick species infesting livestock representing the following eight genera: Ornithodoros, Otobius, Amblyomma, Dermacentor, Haemaphysalis, Hyalomma, Ixodes, and Rhipicephalus. In addition, 15 pathogens were recorded causing diseases of significance, with Crimean-Congo hemorrhagic fever, theileriosis, babesiosis and anaplasmosis being widely distributed diseases in the region. In recent decades, there has been increasing trends in disease occurrence and movement associated with global movement of humans and global trade of animals. We suggest that disease control and prevention could be achieved effectively through good integration between public health, veterinary medicine and animal management, and ecological approaches. We recommend further research in the areas of tick ecology and tick born-disease transmission. Furthermore, we suggest evaluation and improvement of disease control policies in the region.

The History of Biological Weapons Use: What We Know and What We Don't

This article critically reviews the literature on the history of biological warfare, bioterrorism, and biocrimes. The first serious effort to review this entire history, made in 1969, had numerous limitations. In recent decades, several authors have filled many of the gaps in our understanding of the past use of biological agents (including both pathogens and toxins), making it possible to reconstruct that history with greater fidelity than previously possible. Nevertheless, there are numerous remaining gaps, and closer inspection indicates that some supposed uses of biological weapons never took place or are poorly substantiated. Topics requiring additional research are identified.

Putting the Jigsaw Together - A Brief Insight Into the Tularemia

Tularemia is a debilitating febrile and potentially fatal zoonotic disease of humans and other vertebrates caused by the Gram-negative bacterium Francisella tularensis. The natural reservoirs are small rodents, hares, and possibly amoebas in water. The etiological agent, Francisella tularensis, is a non-spore forming, encapsulated, facultative intracellular bacterium, a member of the γ-Proteobacteria class of Gram-negative bacteria. Francisella tularensis is capable of invading and replicating within phagocytic as well as non-phagocytic cells and modulate inflammatory response. Infection by the pulmonary, dermal, or oral routes, respectively, results in pneumonic, ulceroglandular, or oropharyngeal tularemia. The highest mortality rates are associated with the pneumonic form of this disease. All members of Francisella tularensis species cause more or less severe disease Due to their abilities to be transmitted to humans via multiple routes and to be disseminated via biological aerosol that can cause the disease after inhalation of even an extremely low infectious dose, Francisella tularensis has been classified as a Category A bioterrorism agent. The current standard of care for tularemia is treatment with antibiotics, as this therapy is highly effective if used soon after infection, although it is not, however, absolutely effective in all cases.

Epidemiology of tularemia

Tularemia is considered to have existed in Anatolia for several thousand years. There are suspicions regarding its use in biological warfare in the Neshite-Arzawan conflict. The causative agent of tularemia may have first been used as a biological weapon in 1320-1318 BC. The disease has recently become a significant re-emerging disease globally as well as in Turkey. In the period of 2001-2010, Kosovo had the highest annual incidence in Europe at a rate of 5.2 per 100,000. Sweden, Finland, Slovakia, Czech Republic, Norway, Serbia-Montenegro, Hungary, Bulgaria, and Croatia follow with rates of 2.80, 1.19, 1.0, 0.81, 0.42, 0.4, 0.36, 0.21, and 0.15 per 100,000 people, respectively. Tularemia in Turkey was first reported in the soldiers living in the region very close to the Kaynarca Stream of Thrace in 1936. It has started to gain more and more importance, especially in recent decades in Turkey, due to a very high number of cases and its spread throughout the country. A total of 431 tularemia cases were recorded in Turkey in 2005, but a significant reduction was observed in the number of the cases in the next three years; the number of patients decreased to 71 in 2008. The number of cases increased again in 2009 and continued in subsequent years. The number of cases reached 428, 1531, 2151, and 607 in 2009, 2010, 2011, and 2012, respectively. The number of cases peaked in 2011 in Turkey, and was in fact higher than the total number of cases in all European Union countries. The number of cases is higher in females than males in Turkey. In Turkey, 52% of cases of tularemia diagnoses occur from December to March and the most common clinical presentation is the oropharyngeal form caused by contaminated water. Rodents are the most likely sources of tularemia outbreaks in Turkey as well as in Kosovo. Organisms such as ticks, flies and mosquitoes are vectors of tularemia transmission to mammals. Because ticks can carry the bacteria by both transovarial and transstadial transmission, they play a role in the life cycle of tularemia as both reservoir and vector.

The 'Hittite plague', an epidemic of tularemia and the first record of biological warfare

A long-lasting epidemic that plagued the Eastern Mediterranean in the 14th century BC was traced back to a focus in Canaan along the Arwad-Euphrates trading route. The symptoms, mode of infection, and geographical area, identified the agent as Francisella tularensis, which is also credited for outbreaks in Canaan around 1715 BC and 1075 BC. At first, the 14th century epidemic contaminated an area stretching from Cyprus to Iraq, and from Israel to Syria, sparing Egypt and Anatolia due to quarantine and political boundaries, respectively. Subsequently, wars spread the disease to central Anatolia, from where it was deliberately brought to Western Anatolia, in what constitutes the first known record of biological warfare. Finally, Aegean soldiers fighting in western Anatolia returned home to their islands, further spreading the epidemic.

The biblical plague of the Philistines now has a name, tularemia

An epidemic thought to have been the first instance of bubonic plague in the Mediterranean reveals to have been an episode of tularemia. The deadly epidemic took place in the aftermath of the removal of a wooden box from an isolated Hebrew sanctuary. Death, tumors, and rodents thereafter plagued Philistine country. Unlike earlier explanations proposed, tularemia caused by Francisella tularensis exhaustively explains the outbreak. Tularemia fits all the requirements indicated in the biblical text: it is carried by animals, is transmitted to humans, results in the development of ulceroglandular formations, often misdiagnosed for bubonic plague, and is fatal. Moreover, there is the evidence from the box and rodents: mice, which are known carrier for F. tularensis and can communicate it to humans, were credited by the very Philistines to be linked to the outbreak, and are small enough to nest in the box. Mice also explain the otherwise odd statement in the biblical text of a small Philistine idol repeatedly falling on the floor at night in the building where the Philistines had stored the box as mice exiting the box would easily have tipped over the statuette. Tularemia scores yet another point: an episode of the disease is known to have originated in Canaan and spread to Egypt around 1715 BC, indicating recurrence for the disease, and suggesting Canaan was a reservoir for F. tularensis in the 2nd millennium BC.

LOUSE-BORNE BACTERIAL PATHOGENS IN LICE (PHTHIRAPTERA) OF RODENTS AND CATTLE FROM EGYPT

We collected 1,023 lice, representing 5 species, from rats and domestic cattle throughout 13 governorates in Egypt and tested these lice for Anaplasma marginale, Bartonella spp., Brucella spp., Borrelia recurrentis, Coxiella burnetii, Francisella tularensis, and Rickettsia spp. by PCR amplification and sequencing. Five different louse-borne bacterial agents were detected in lice from rodents or cattle, including "Bartonella rattimassiliensis", "B. phoceensis", and Bartonella sp. near Bartonella tribocorum, Coxiella burnetii, and Rickettsia typhi. More lice from governorates bordering the Mediterranean and Red Seas contained pathogens. Our data indicate that lice of urban and domestic animals harbor pathogenic or potentially pathogenic bacterial agents throughout Egypt.

Six medical papyri describe the effects of Santorini's volcanic ash, and provide Egyptian parallels to the so-called biblical plagues

Six medical papyri document how Santorini's volcanic ash from the Bronze Age biphasic eruption, otherwise attested by material retrieved at the bottom of lakes at the edge of the Nile Delta, severely affected the health of the inhabitants of Egypt as well as their society as a whole. Treatments for burns caused by particulate and dissolved acids are documented in the London Medical Papyrus as well as in the Ebers Papyrus, and are compatible with ash fallout and ash in rain, respectively. Furthermore, both instances of ash correlate to the first eight biblical plagues. Moreover, the latter text also presents a series of ailments coherent with serious inhalation of toxic substances in aerosol form. This scenario is confirmed by the Hearst Medical Papyrus, the Carlsberg Papyrus 8, and the Ramesseum Papyrus III, and fits a volcanic plume, which is also coherent with the ninth biblical plague of palpable obscurity as well as Santorini's second phase of its Bronze Age eruption. Finally, a sixth contemporary medical text, the Edwin Smith Surgical Papyrus, a manual to practice on wounded soldiers, supplies an insight into the collapse of the sociopolitical system of the time. The text appears to provide an insight into the sociopolitical climate in the aftermath of the Santorini eruption, possibly describing conditions that would have led to the tenth and final biblical plague of the massacre of firstborn as well as the escape of slaves from local labor camps.

Treatments for burns in the London Medical Papyrus show the first seven biblical plagues of Egypt are coherent with Santorini's volcanic fallout

Six treatments for burns in the London Medical Papyrus provide data regarding a volcanic fallout over Egypt. They confirm a previously established scenario linking the medical text to one specific eruption, the one at Santorini in the Bronze Age. One treatment describes the contamination of waters with the ash. Four treatments describe the effects of the ash on the skin. The sixth treatment describes the effect of acid rain following the dispersion of ash in the atmosphere, which triggered weather anomalies. The scenario derived from the medical document, is based on ash from Santorini that sedimented at the bottom of Egyptian lakes, and fits the description of Egypt in the papyrus The Admonitions of an Egyptian Sage. Finally, the scenario explains the nature of first seven biblical plagues of Egypt in light of the aftermath of volcanic ash littering Egypt.