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Archived Comments for: Infectious disease emergence and global change: thinking systemically in a shrinking world

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  1. follow up (comment re US surgeon general)

    Colin Butler, University of Canberra

    15 August 2013

    Dear editor - this is not intended for posting - but I'm just writing to see if you received my earlier comment, sent early December I think. Very pleased that my paper is the most accessed (at least to date). Best wishes, Colin

    Competing interests

    None declared

  2. An apology to US Surgeon General William Stewart

    Colin Butler, University of Canberra

    15 August 2013

    My comment about U.S. Surgeon General William Stewart's dismissal of infectious diseases as a major problem in 1969 - though widely quoted - may have been unfair. According to Dr Brad Spellberg there is considerable doubt about this.(1) Spellberg reports persuasively how he has spent years trying to verify Stewart's statement, with no success. Most citations he could find are circular, i.e. they cite each other.

    He adds that the US Public Health Service Web site states that ¿Although this remark has often been cited in the literature, the Office of the PHS Historian has never been able to locate the source of the statement, or to confirm that Dr. Stewart actually made such a comment. We have asked Dr. Stewart about it, and he cannot recall whether or not he made this statement¿. He suggests that "perhaps it is time to replace Dr. Stewart¿s possibly apocryphal quotation with citations from verifiable sources, such as by Dr. Fauci or Dr. Petersdorf .

    1. Spellberg B. Dr. William H. Stewart: Mistaken or Maligned? Clinical Infectious Diseases. 2008; 47: 294

    Spellberg B. Dr. William H. Stewart: Mistaken or Maligned? Clinical Infectious Diseases. 2008; 47: 294.

    Competing interests

    I am author of the paper on which I am commenting.

  3. MERS - more to worry about than SARS or avian flu?

    Colin Butler, University of Canberra

    15 June 2015

    When I drafted this paper in mid-2012 Middle East Respiratory Sydndrome (MERS) was unknown to me. However, soon after, the first case of MERS was reported (Zaki et al., 2012). When I learned of SARS I began to speculate (with colleagues and probably at some conference talks and I think in an email to the editor of this journal) that MERS might post a greater risk to human health than SARS or avian influenza. I thought this plausible on theoretical grounds, grounded in the thinking that I did leading to the paper published here.

    A key issue was the proximity of the initial outbreaks of MERS with the great Muslim pilgrimage sites. It occurred to me not only that patients with asymptomatic or mild MERS (i.e. early or very early in the course of human infection) could mix with others in the mass gatherings of the Haj, but also that patients with more severe symptoms may not only participate but remain in prolonged contact and with more people than in most other modern settings.

    I thus speculated that evolutionary factors might favour viral dynamics that tend towards both easier viral transmission between humans but also lacked the normal evolutionary penalty of rapid symptomatic deterioration or even death, as Oxford et al did (2002).

    Although the steps to explain the hypothesis of how the Great War (World War I) contributed to the high transmissability and high lethality of avian influenza during the Spanish Flu epidemic are poorly understood (and speculative) there appear to be at least two similarities between Spanish flu and MERS. These include (a) crowding [Haj vs WWI hospitals and other settings] and (b) a possible tendency for symptomatic people to be crowded together with non or partially immune people.

    I do not have time (including research time) to explore this hypothesis further, including to even try to publish this idea as a letter (other than here). I know my evidence is thin, but I want to put on record that my comparatively relaxed position about H5N1 does not extend to MERS (and never has). If there is any validity in my hypothesis, then it is important for the Saudi and other authorities to stress that people with possible MERS symptoms remove themselves from these  mass gathering as fast as possible. The lure of the Haj, the crowding, and the difficulty of effectively communicating this health protective message to hundreds of thousands or even millions of people is an extremely daunting challenge.

    It is also possible that epidemic enhancement (Pulliam et al, 2007) is a co-factor. This hypothesis is stated as "a pathogen introduced into a population containing individuals with acquired immunity can result in an epidemic longer in duration and/or larger in size than if the pathogen were introduced into a naive population." In the case of MERS and the Haj, it is possible that repeated introduction of MERS into the Haj population might also affect evolutionary dynamics.

    I am, of course, motivated to find the time to record this because of the current MERS outbreak in South Korea.


    Oxford, J.S., Sefton, A., Jackson, R., Innes, W., Daniels, R. and Johnson, N., 2002. World War I may have allowed the emergence of "Spanish" influenza. The Lancet Infectious Diseases 2, 111-114.

    Pulliam, J.R.C., Dushoff, J.G., Levin, S.A. and Dobson, A.P., 2007. Epidemic enhancement in partially immune populations. PLoS ONE e165.

    Zaki, A.M., van Boheemen, S., Bestebroer, T.M., Osterhaus, A.D.M.E. and Fouchier, R.A.M., 2012. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. New England Journal of Medicine 367, 1814-1820.


    Competing interests