Mapping disease: the development of a multidisciplinary field

Going on retreat to Middle-earth Catching up with Sarah Brett

Mapping disease: the development of a multidisciplinary field

By Andrew Cliff and Matthew Smallman-Raynor

For over two centuries, the landscape that lies on the marchland of two very ancient subjects — geography and medicine — has been explored from several directions. One of the main benefits of this intermingling has been the increased use of maps to chart the geographical distribution of diseases in the hope that the patterns revealed will give insights into the aetiologies and prevention of diseases.

Leonard Finke (1792-95) may have been the first to have written about this notion in his Attempt at a general medical-practical geography. In three volumes, this work maps out medical descriptions of the world. It contains anthropological descriptions of its peoples and their possible diseases. But the actual mapping of disease was costly even then and needed agreements on both disease definitions and adequate disease data collection. It was the 1820s before such conditions began to be put in place when the great outbreaks of cholera and yellow fever commenced in cities on both sides of the Atlantic. So some 29 cholera maps were published in the 12 years following the first great cholera pandemic of 1817 which spread from India. Most of these maps plotted routes of spread, dates, and regions of occurrence. In the following decades sophisticated maps showing the distribution of cholera within European cities began to appear. Rothenburg’s 1836 map of cholera in Hamburg and, at a local scale, John Snow’s famous map of individual cholera deaths in the Soho area of London in 1854 are examples. Although medical cartography by 1850 was beginning to be established at local and national scales, the world picture remained difficult to map except in the broadest terms.

Bornholm disease in southeast England, 1956.
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Bornholm disease is a distressing illness caused by
enteroviruses in the Coxsackie B virus group. Symptoms may
include fever and headache, but the distinguishing
characteristic of this disease is attacks of severe pain in the
lower chest, often on one side. Coxsackie B virus is spread
by contact and epidemics usually occur during warm
weather in temperate regions and at any time in the tropics.
As is typical with this virus family, it is shed in large amounts
in the faeces of infected persons. The illness lasts about a
week and is rarely fatal. The average family doctor may
recognise no cases for several years and then, perhaps, only
see one or two aff ected patients in a whole summer. This
was true of doctors in southeast England during 1956, but a
collective enquiry led by Williams (later Director of the
Swansea Unit) and Watson at the Epidemic Observation
Unit for the new College of General Practitioners showed
Bornholm disease (red circles) to have been prevalent in a
band of country stretching along the lines of road and rail
from Bournemouth and Portsmouth to the London area. Yet
while this was occurring, other doctors in Sussex and East
Kent, and to the north of the aff ected area, uniformly
reported having seen no cases (yellow circles). Source:
based on Watson (1960, Figure 1, p. 318).

Malaria: the distribution of anopheline mosquitoes in southeastern England, 1918.
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Extract from a work
originally prepared by William D. Lang of the Department of Entomology, British Museum, showing the localities in which
diff erent species of anopheline mosquito had been recorded in England and Wales. The preponderance of Anopheles
maculipennis (now A. atroparvus), the principal vector of P. vivax malaria in southeastern England during the outbreak of
1917–22, is clear. Source: Local Government Board (1918a, after p. 85, extract).

Plague contol Liverpool.
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Onshore cases of human plague were recorded in Liverpool on several occasions in
the early twentieth century, with the years 1901 (11 cases), 1908 (3 cases), 1914 (10 cases) and 1916 (6 cases) being especially
noteworthy. Many of the cases occurred in connection with the docks and port warehouses, and exposure to plague-infected
rats at these locations is suspected. This image dates to the early twentieth century and shows staff of the Liverpool Port
Sanitary Authority dipping rats in buckets of petrol to kill fl eas. Source: Wellcome Library, London.

Enteric fever: investigation of a local disease outbreak.
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In September 1905, the Local Government Board
instructed Dr Reginald Farrar to undertake an investigation of an explosive outbreak of enteric fever in the old market town of
Basingstoke, Hampshire. This plate shows the central area of Farrar’s map which depicts the widespread distribution of notifi ed
cases (red dots) in relation to the mains water supply (blue lines). The inset shows a sketch of the bottle-shaped chalk well in
the northeastern quarter of the town from which the town’s water supply was derived. Investigations revealed that, under
certain conditions, water in the well could become contaminated with sewage matter from low-lying parts of the town. Such
conditions may have been engendered at about the time of the outbreak by work then being undertaken on the town’s sewer
system. Dissemination of enteric fever through transient contamination of the mains water supply was hypothesised.
Source: Farrar (1907, Figure A, p. 43 and unnumbered map, between pp. 56–7).

Spread of Wave II of Spanish infl uenza in the Borough of Cambridge, 1918.
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Vectors trace the
time-ordered sequence of fi rst appearance of infl uenza
deaths in the districts of Cambridge, October–November
1918. The fi rst death was recorded in New Town on
1 October 1918, followed by Romsey Town (13 October),
Sturton Town (17 October), Centre (18 October), Newmarket
Road (21 October), Castle End, New Chesterton and
Newnham (all on 25 October), Cherry Hinton (28 October)
and, fi nally, Old Chesterton on 17 November. Based on
information in Copeman (1920, p. 396).

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Mortality from pulmonary tuberculosis in England and Wales, 1850–1960.
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The annual rate of tuberculosis
mortality, plotted as a line trace, has been detrended and is expressed in standard score form. For reference, the number of
European countries at war in each year is plotted as a bar chart. Wartime peaks in tuberculosis mortality refl ect confl icts in
which Britain held a direct military stake (Crimean War, Boer War and the World Wars), and the overspill from continental
European wars in which Britain maintained a non-belligerent status (Austro–Prussian War and Franco–Prussian War). Source:
redrawn from Smallman-Raynor and Cliff (2003, Figure 4.1, p. 74).

Legionnaires’ disease outbreak in relation to BBC Broadcasting House, Portland Place, London, 1988.
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On
27 April 1988, two cases of Legionnaires’ disease were admitted to Rush Green Hospital, Essex. (Left) Both cases worked at the
British Broadcasting Company’s (BBC’s) Broadcasting House in Central London. (Right) Map of the outbreak area, showing the
position of Broadcasting House; the dominant wind direction during the most likely time of outbreak exposure to L.
pneumophila (19–21 April 1988; red arrow) and during an experimental tracer gas release from the implicated cooling tower
(26 May 1988; yellow arrow); and the main area where the experimental tracer gas released from the cooling tower on 26 May
was detected at street level (pink circle). Source: map (B) adapted from Westminster Action Committee (1988, Appendix N,
Figures 3 and 6, after p. 8) and Newson (2009, Figure 6, p. 100).

(Upper) Measles is back.
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The interruption of sustained indigenous measles virus transmission was achieved in
the United Kingdom in the late 1990s (Section 8.3). After almost a decade of sub-optimal measles vaccination coverage in
the wake of the MMR vaccine controversy, the Health Protection Agency noted in June 2008 that “the number of children
susceptible to measles is now suffi cient to support the continuous spread of measles” and urged health services to “exploit all
possible opportunities to off er MMR vaccine(s) to children of any age who have not received two doses” (Health Protection
Agency, 2008, unpaginated). The image shows an MMR public information poster used by Lewisham NHS Primary Care
Trust, London, in 2009.

Measles outbreak in London, December 2001–May 2002.
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After an extended period in which only sporadic
cases of measles were reported in London, a cluster of cases was identifi ed among pre-school children in the south of the city
in December 2001. This marked the onset of the largest outbreak of measles in London since the mid-1990s. The epidemic was
eventually associated with 129 confi rmed and 451 suspected cases of measles; 75 percent of the cases were aged under 5 years
and, of those for which relevant information was obtained, 98 percent had no record of measles immunisation. The map plots
the distribution of confi rmed measles cases (blue circles) against a backdrop of ward-level deprivation scores (choropleth
shading; relatively dark shading categories mark relatively more deprived areas). The majority of the confi rmed measles cases
occurred in south inner London and, when compared to the distribution of contemporaneous cases of meningococcal disease
(green circles), were found to be resident in relatively more affl uent wards of the city. The evidence is consistent with a measles
outbreak in which virus transmission was driven by lower levels of MMR vaccine uptake in more affl uent localities. Source:
redrawn from Atkinson, et al. (2005, Figure 1, p. 425).

Filling in the world map awaited the work of the great German physician, August Hirsch, who avoided cartography himself but pioneered the global study of diseases. His two volume Handbuch der historische-geographische pathologie, the first edition of which was published between 1859 and 1864, was a monumental attempt to describe the world distribution of disease, drawing upon more than ten thousand sources. Hirsch had close links with England and dedicated his book to the London Epidemiological Society. Twenty years later, a much revised version was translated by Charles Creighton as Handbook of geographical and historical pathology. This time the adjectives in the title were reversed (a reversal approved by Hirsch) and the contents had swollen to three volumes, covering acute infectious diseases (1883), chronic and constitutional diseases (1885), and diseases of organs (1886).

Then Creighton himself went on to produce his magisterial two-volume A History of Epidemics in Britain, covering the history and geography of epidemic diseases in the British Isles from AD 664 to the end of the nineteenth century. Described at the time in The Lancet as “a great work – great in conception, in learning, in industry, in philosophic insight,” Creighton’s History began with the spread of a mysterious pestilence (pestis ictericia) in southern England in ad 664, and ended with an appended note on the emergence of a seemingly new disease in the 1800s (‘cerebrospinal fever’ or meningococcal meningitis). Creighton’s narrative is imbued with a sense of the historical ebb and flow of infection. It covered all the familiar infectious diseases such as measles, whooping cough, scarlet fever, smallpox, as well as a host of now unfamiliar infections in the British Isles like plague, cholera and typhus.

We attempt to continue the disease mapping tradition by extending Creighton’s account into the 21st century in The Atlas of Epidemic Britain. Creighton would have been recognised a number of epidemic outbreaks of infectious diseases in the first decade of the new millennium; there are also parallels with Creighton’s ‘new’ infection, cerebrospinal fever. In 2003, SARS (severe acute respiratory syndrome) reached some 30 countries around the world within a few months. In 2004, ‘Bird flu’, highly pathogenic avian influenza (A/H5N1), took the world to Phase 3 (of 6) on the World Health Organization’s (WHO) scale of alert for an influenza pandemic before it receded into the background. In 2009, swine flu, caused by a novel virus subtype of swine lineage (A/H1N1), spread globally from initial cases in Mexico to reach WHO’s Phase 6 (sustained human-to-human transmission) by 11 June. The ebb and flow of infection reveals a century of change from the historically important infections to new and re-emerging infections and a geography of epidemics of communicable diseases in the British Isles.

Professor Matthew Smallman-Raynor has been Professor of Geography at the University of Nottingham since 2004. Professor Andrew Cliff has been Professor of Theoretical Geography at the University of Cambridge since 1997 and Pro-Vice-Chancellor since 2004. They are the authors of the Atlas of Epidemic Britain, which was awarded the Public Health and Medical Book of the Year Awards at the BMA’s Medical Book Awards 2013 at the ceremony in September.

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