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Epidemic myalgic encephalomyelitis
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[[File:Nurses at the Los Angeles County Hospital, 1934.png|thumb|400x400px|Nurses who became ill during an [[1934 Los Angeles atypical polio outbreak|outbreak of "atypical polio"]] at the Los Angeles County Hospital in 1934.]] There have been [[List of myalgic encephalomyelitis and chronic fatigue syndrome outbreaks|at least 75 documented outbreaks]] of [[myalgic encephalomyelitis]] and [[chronic fatigue syndrome]] since the 1930s. The true number of clusters and outbreaks is likely much higher. Many of these outbreaks occurred in institutions like hospitals and schools, and frequently coincided with outbreaks of [[poliomyelitis]]. The first recorded outbreak of epidemic was in [[1934 Los Angeles atypical polio outbreak|1934 in Los Angeles]] and the most recent putative outbreak was in Arizona in 1996. Prior to the 1980s, while no infectious was ever isolated, the outbreaks were widely thought to be caused by a virus related to [[poliovirus]], i.e., by another, yet-to-be-unidentified [[enterovirus]]. After the [[1984 Incline Village chronic fatigue syndrome outbreak|Incline Village outbreak]] in 1984, [[herpesviruses]] and in particular, [[Epstein-Barr virus]] was posited as the cause. ==History== {{Main article| page_name =List of myalgic encephalomyelitis and chronic fatigue syndrome outbreaks}} The first recorded outbreak of epidemic myalgic encephalomyelitis was in [[1934 Los Angeles atypical polio outbreak|1934 in Los Angeles]] and was thought to be an outbreak of atypical polio. After the outbreak in [[Akureyri]], Iceland in 1946, the disease came to be called [[1948-49 Akureyri outbreak|''Akureyri Disease'']] or ''Icelandic disease'' through much of the 1940s and 1950s. It was named [[Myalgic encephalomyelitis|myalgic encephalomyelitis]] after London's [[Royal Free Hospital outbreak]] in 1955. Other names included benign myalgic encephalomyelitis and epidemic neuromyasthenia. After the [[1984 Incline Village chronic fatigue syndrome outbreak|Incline Village]] outbreak in Nevada in 1984, the disease came to be called and redefined as [[chronic fatigue syndrome|Chronic Fatigue Syndrome]]. The most recent was putative outbreak was in Arizona in 1996. == Onset == The incubation period was generally estimated at 4 to 8 days.<ref name="Sigurdsson1950" /><ref name="Parish1978" /><ref name="Sigurdsson1956">{{Cite journal| url = https://www.ncbi.nlm.nih.gov/pubmed/13320872 | title = The Lancet | last = Sigurdsson | first = B | author-link = Björn Sigurdsson | date = May 1956|journal=Clinical findings six years after outbreak of Akureyri disease|volume=270 | pages = 766-7|via=}}</ref> The illness generally began with a prodromal period of [[Flu-like illness|flu-like symptoms]], symptoms of an upper respiratory tract infection, [[low-grade fever]], [[sore throat]] or [[Gastrointestinal system|gastrointestinal]] distress,<ref name="Pellew1951" /><ref name="Ramsay1978" /><ref name="Levine1997">{{Cite journal | last = Levine | first = P. H. | author-link = Paul Levine | last2 = Snow | first2 = P. G. | authorlink2 = | last3 = Ranum | first3 = B. A. | authorlink3 = | last4 = Paul | first4 = C. | authorlink4 = | last5 = Holmes | first5 = M. J. | authorlink5 = | date = 1997-04-14 | title = Epidemic neuromyasthenia and chronic fatigue syndrome in west Otago, New Zealand. A 10-year follow-up | url =https://www.ncbi.nlm.nih.gov/pubmed/9125006|journal=Archives of Internal Medicine|volume=157|issue=7 | pages = 750–754|issn=0003-9926|pmid=9125006|quote=|via=}}</ref> followed by a symptom complex involving [[muscle weakness]], [[muscle fatigability]] and [[central nervous system]] involvement in a significant proportion of cases.<ref name="Parish1978" /><ref name="Shelokov, 1957" /> == Symptoms == Reported symptoms could vary considerably from outbreak to outbreak. Common symptoms included: * [[muscle fatigability|muscle fatigability]] * [[muscle weakness]] / [[paresis]]<ref name="Jackson1957">{{Cite journal| url = http://journals.co.za/content/m_samj/31/21/AJA20785135_45533 | title = A disease resembling poliomyelitis; report of an outbreak in Johannesburg | last = Jackson | first = B | date = May 1957|journal=South African Medical Journal|volume=31 | pages = 514-517|via=}}</ref><ref name="Hill1959">{{Cite journal| url = https://www.ncbi.nlm.nih.gov/pubmed/13642847 | title = Epidemic myalgic encephalomyelopathy: the Durban outbreak | last = Hill | first = RC | date = April 4, 1959|journal=The Lancet|volume=1 | pages = 689-693|via=}}</ref> (10-80%<ref name="Acheson, 1959" /> of cases), commonly occurring in the legs<ref name="Sigurdsson1956" /><ref name="Pellew1951">{{Cite journal | first =R.A. | last = Pellew|url = http://www.cabdirect.org/abstracts/19522700678.html;jsessionid=AA4534CA199AC800732B3877608F5CE0 | title = A Clinical Description of a Disease resembling Poliomyelitis, seen in Adelaide, 1949-1951|journal =Medical Journal of Australia | date =June 30, 1951|volume =1 |issue =26 | pages =944-6}}</ref> * [[ataxia]] * [[myalgia]]<ref name="Sigurdsson1956" /><ref name="Jackson1957" /> and [[neuralgia]] * severe [[headache]]<ref name="Pellew1951" /><ref name="Jackson1957" /><ref name="Hill1959" /> * stiffness of the neck and spine<ref name="Sigurdsson1956" /><ref name="Pellew1951" /><ref name="Jackson1957" /><ref name="Hill1959" /> * [[Swollen lymph nodes|tender lymph nodes]], spleen and/or liver * [[Cognitive dysfunction|cognitive symptoms]] including [[Memory problems|impaired memory]]<ref name="Sigurdsson1956" /> and concentration<ref name="Hill1959" /> * [[Sleep dysfunction|sleep disturbances]]<ref name="Hill1959" /> * sensory symptoms including sensitivity to [[Photophobia|light]] and sound, [[paresthesia|paraesthesiae]],<ref name="Sigurdsson1956" /><ref name="Jackson1957" /><ref name="Hill1959" /> [[hyperaesthesiae|hyperaesthesia]] * [[Dysautonomia|autonomic symptoms]] such as tachychardia, coldness of the extremities, sweating * [[post-exertional malaise]], worsening of symptoms with exertion<ref name="Sigurdsson1956" /><ref name="Shelokov, 1957" /><ref name="Hill1959" /><ref name="Albrecht1964">{{Cite journal | last = Albrecht | first = Robert | date = March 21, 1964 | title = Epidemic Neuromyasthenia Outbreak in a Convent in New York State | url =https://www.ncbi.nlm.nih.gov/pubmed/14100144|journal=Journal of the American Medical Association|volume=187 | pages = 904-907|via=}}</ref><ref name="Poskanzer, 1957" /> ("fatigue on walking short distances and on the least exertion was prominent"<ref name="Parish1978" />) == Findings == Findings varied considerably based on the technology of the time and what tests physicians attending to these outbreaks chose or were able to run: * Low-grade [[fever]]<ref name="Sigurdsson1956" /><ref name="Jackson1957" /><ref name="Albrecht1964" /><ref name="Hill1959" /> * Abnormal electromyogram showing generalized, mild, lower motor neuron changes indicative of a radiculopathy.<ref name="Parish1978" /><ref name="Marinacci1965">{{Cite journal | last = Marinacci | first = AA | date = October 1965 | title = The value of the electromyogram in the diagnosis of Iceland disease | url =https://www.ncbi.nlm.nih.gov/pubmed/5889546|journal=Electromyography|volume=5 | pages = 241-51|via=}}</ref> * [[Paresis|Muscle weakness]] measured via quantitative muscular-testing<ref name="Shelokov, 1957">{{Cite journal | last1 = Shelokov | first1 = Alexis | author-link1 = | last2 = Habel | first2 = Karl | authorlink2 = | last3 = Verder | first3 = Elizabeth | authorlink3 = | last4 = Welsh | first4 = William | author-link4 = | title = Epidemic Neuromyasthenia — An Outbreak of Poliomyelitis-like Illness in Student Nurses | journal = New England Journal of Medicine | volume = | issue = 257 | page = 345-355 | date = August 1957 | url = https://www.cabdirect.org/cabdirect/mobile/abstract/19582700721 | doi = 10.1056/NEJM195708222570801 }}</ref> * Normal or minimal [[cerebrospinal fluid]] findings<ref name="Sigurdsson1956" /><ref name="Shelokov, 1957" /><ref name="Hill1959" /><ref>{{Cite journal| url = https://www.sciencedirect.com/science/article/pii/S0033350657800225 | title = Encephalomyelitis simulating poliomyelitis | last = Ramsay | first = Melvin | date = May 26, 1956|journal=The Lancet|volume=270 | pages = 761-764|via= | last2 = O'Sullivan | first2 = E}}</ref> * Normal or mildly increased [[erythrocyte sedimentation rate]]<ref name="Jackson1957" /><ref name="Hill1959" /><ref name="Ramsay1978" /> * Mild increase in white blood cell count<ref name="Hill1959" /> * [[Dysautonomia|Autonomic nervous system dysfunction]], [[Hypothalamus|hypothalamic]] dysfunction * [[Postural orthostatic tachycardia syndrome|Orthostatic tachycardia]]<ref name="Hill1959" /> * Ulnar neuritis, neuropathy or lesion<ref name="Sigurdsson1950" /><ref name="Levine1994">{{Cite journal | last = Levine | first = PH | date = January 1994 | title = Epidemic neuromyasthenia and chronic fatigue syndrome: epidemiological importance of a cluster definition | url = https://www.ncbi.nlm.nih.gov/pubmed/8148446|pmid=8148446|journal=Clinical Infectious Diseases|volume=18| pages=S16-20|via=}}</ref><ref name="White1954">{{Cite journal | last = White | first = D | last2 = Burtch | first2 = Robert | date = July 1, 1954 | title = Iceland Disease: A New Infection Simulating Acute Anterior Poliomyelitis |url = http://n.neurology.org/content/4/7/506.short|journal=Neurology|volume=4| pages=|via=}}</ref> * Microscopic infiltration of nerve roots with [[lymphocyte]]s and [[Mononuclear cell|mononuclear cell]]s; patchy damage to the myelin sheaths and axon swellings (in monkeys infected with unidentified virus from the [[1949-53 Adelaide outbreak|Adelaide]] outbreak) * Raised urinary [[creatine]] excretion<ref name="Albrecht1964" /><ref name="White1954" /> * abnormally high [[lactic dehydrogenase]] and [[glutamic oxaloacetic transaminase]]<ref name="Ramsay1978" /> In the majority of early epidemics, no viral or bacterial infectious agent was successfully cultured.<ref name="Sigurdsson1956" /><ref name="Jackson1957" /><ref name="Hill1959" /> In a small number of epidemics [[Coxsackie B]]<ref name="Fegan1983">{{Cite journal | last1 = Fegan | first1 = KG | author-link1 = KG Fegan | last2 = Behan | first2 = PO | authorlink2 = Peter Behan | last3 = Bell | first3 = EJ | authorlink3 = Eleanor Bell | title = Myalgic encephalomyelitis — report of an epidemic | journal = J R Coll Gen Pract | volume = 33 | issue = 251| pages = 335–337 | date = Jun 1, 1983 | pmid = 6310104 | url = http://bjgp.org/content/33/251/335 }}</ref><ref name="Calder1984">{{Cite journal | last1 = Calder | first1 = BD | author-link1 = BD Calder | last2 = Warnock | first2 = PJ | authorlink2 = PJ Warnock | title = Coxsackie B infection in a Scottish general practice | journal = Jrnl Royal Coll Gen Pract | volume = 34 | issue = 258| pages = 15–19 | date = Jan 1984 | pmid = 6319691 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959663/ }}</ref> or [[Bethesda-Ballerup paracolon organism]]<ref name="Shelokov, 1957" /> were found. In others, infection of animal models with samples from patients results in identifiable nervous system damage on autopsy and in one case, [[myocarditis]], in spite of being unable to identify the agent.<ref name="Parish1978" /><ref name="Pellew1955">{{Cite journal| url = https://www.ncbi.nlm.nih.gov/pubmed/13272481 | title = Further Investigations on a Disease Resembling Poliomyelitis Seen in Adelaide | last = Pellew | first = R.A.A. | date = September 24, 1955|journal=The Medical Journal of Australia|volume=2 | pages = 480-2|via=}}</ref> ==Epidemiology== Many of these outbreaks occurred at institutions for example, hospitals,<ref name="Shelokov, 1957" /><ref name="Gilliam, 1936-38" /><ref name="Hill1959" /> schools, army bases or convents. The pattern of spread suggested a highly infectious agent that spread person to person, rather than through contaminated food or drink or exposure to a single toxic agent.<ref name="Parish1978">{{Cite journal | last = Parish | first = JG | date = 1978 | title = Early outbreaks of 'epidemic neuromyasthenia'| url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2425322/|journal=Postgraduate Medical Journal|volume=54 | pages = 711-7|issue=|via=|quote= | author-link = Gordon Parish|pmid=370810|pmc=2425322}}</ref><ref name="Gilliam, 1936-38">{{Cite journal | last1 = Gilliam | first1 = A.G. | author-link1 = | title = Epidemiological Study Of An Epidemic, Diagnosed As Poliomyelitis, Occurring Among The Personnel Of The Los Angeles County General Hospital During The Summer Of 1934 | journal = Public health bulletin, 1936-1938 | volume = | issue = 231-240 | page = | date = 1938 | pmid = | url = http://babel.hathitrust.org/cgi/pt?id=mdp.39015022082260;view=1up;seq=617 }}</ref><ref name="Poskanzer, 1957" /><ref name="Hill1959" /> Outbreaks tended to begin in the summer months, with most initial cases reported from April to September in the Northern hemisphere, October to March in the Southern hemisphere.<ref name="Hill1959" /><ref name="Acheson, 1959" /> In outbreaks involving both medical personnel and the general community, medical personnel had a higher attack rate and/or greater central nervous system involvement.<ref name="Poskanzer, 1957" /> A similar pattern was seen in hospital outbreaks, where those in roles that involved more frequent or intimate contact with patients or those working in an infectious disease ward were more affected than other hospital staff.<ref name="Parish1978" /><ref name="Gilliam, 1936-38" /> A large proportion of recorded outbreaks have taken place in hospital settings.<ref name="Acheson, 1959" /> In many outbreaks including [[1934 Los Angeles atypical polio outbreak|Los Angeles]], [[Akureyri]], [[1953 Maryland outbreak|Rockville, MD]], [[1955 Royal Free Hospital outbreak|Royal Free Hospital]], and [[1956 Punta Gorda outbreak|Punta Gorda, Florida]], women were affected at higher rates.<ref name="Sigurdsson1950" /><ref name="Parish1978" /><ref name="Shelokov, 1957" /><ref name="Gilliam, 1936-38" /><ref name="Acheson, 1959">{{Citation | last1 = Acheson | first1 = E.D. | author-link1 = | title = The Clinical Syndrome Variously Called Benign Myalgic Encephalomyelitis, Iceland Disease and Epidemic Neuromyasthenia | journal = American Journal of Medicine | volume = 26 | issue = 4 | page = 569–595 | date = 1959 | pmid = | url = http://www.name-us.org/defintionspages/DefinitionsArticles/Acheson1959.pdf }}</ref><ref name="Poskanzer, 1957">{{Cite journal | last1 = Poskanzer | first1 = David C. | author-link1 = | last2 = Henderson | first2 = Donald A. | authorlink2 = | last3 = Kunkle | first3 = E. Charles | author-link3 = | last4 = Kalter | first4 = Seymour S. | authorlink4 = | last5 = Clement | first5 = Walter B. | authorlink5 = | last6 = Bond | first6 = James O. | author-link6 = | title = Epidemic Neuromyasthenia — An Outbreak in Punta Gorda, Florida | journal = New England Journal of Medicine | volume = | issue = 257 | page = 356-364 | date = 1957 | pmid = 13464939 | doi = 10.1056/NEJM195708222570802 | url = http://www.nejm.org/doi/full/10.1056/NEJM195708222570802 }}</ref><ref name="PMC1962472" /><ref name="Levine1997" /><ref name="Jackson1957" /> In other outbreaks, including the 1949-1953 [[1949-53 Adelaide outbreak|Adelaide]] outbreak and an outbreak in [[1955 North of England outbreak|northern England in 1955]], a 1:1 gender ratio was reported.<ref name="Parish1978" /> In hospital epidemics, young female nurses were disproportionately affected, but this may have been due to risk factors like higher repeated exposure to the same infection during an epidemic<ref name="Parish1978" /> and in some outbreaks, gender-segregated living quarters.<ref name="PMC1962472">[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1962472/ An Outbreak of Encephalomyelitis in the Royal Free Hospital Group, London, in 1955 - The Medical Staff Of The Royal Free Hospital]</ref> However, the higher ratio of women were also reported in outbreaks in the general population.<ref name="Acheson, 1959" /> In Akureyri, while the incidence among adults was higher for females, there was no significant difference in incidence between sexes among those under twenty.<ref name="Sigurdsson1950">{{Cite journal| url = https://www.ncbi.nlm.nih.gov/pubmed/14771044 | title = A disease epidemic in Iceland simulating poliomyelitis | last = Sigurdsson | first = B | author-link = Björn Sigurdsson | date = September 1950|journal=American Journal of Hygiene|volume=52 | pages = 222-38|via=}}</ref> This comports with patterns of age and sex distribution in sporadic cases.{{Citation needed}} In most outbreaks, those most affected tended to be adults in their twenties,<ref name="Parish1978" /><ref name="Gilliam, 1936-38" /><ref name="Albrecht1964" /><ref name="Hill1959" /> although cases of young children and adults as old as 80 have been recorded in outbreaks.<ref name="Acheson, 1959" /> In Akureyri, the highest attack rate was among ages 15-19.<ref name="Sigurdsson1956" /> [[Melvin Ramsay]] observed an absence of cases among sedentary people, and postulated that this might explain why hospital staff frequently became affected, while patients in hospital rarely did.<ref name="Ramsay1978">{{Cite journal | last = Ramsay | first = A. Melvin | date = November 1978 | title = Epidemic neuromyasthenia' 1955-1978| url = https://www.ncbi.nlm.nih.gov/pubmed/746017|journal=Postgraduate Medical Journal|volume=54 | pages = 718-721|issue=|via=|quote= | author-link = Melvin Ramsay|pmc=2425324|pmid=746017}}</ref> {| class="wikitable" !Outbreak !Type !Peak months !Percent female !Most affected age group !Attack rate |- |[[1934 Los Angeles atypical polio outbreak|1934 Los Angeles]] |Institution |May to December |75% |< 30 years |4.5% |- |[[1937 Erstfeld outbreak|1937 Erstfeld]] |Institution |July |NA (all male soldier) | |14% |- |[[1948-49 Akureyri outbreak|1948-49 Akureyri]] |Community |Winter |50% (< age 20), 70% ( > age 20) <ref name="Sigurdsson1956" /> |15-19 years<ref name="Sigurdsson1956" /> |6.7% (town), 0.8% (rural)<ref name="Sigurdsson1956" /> |- |[[1949-53 Adelaide outbreak|1949-53 Adelaide]] |Community |Winter (August) |50% | | |- |[[1950 Louisville outbreak|1950 Louisville]] |Institution |October |NA (mainly female nurses) | |23% |- |[[1953 Maryland outbreak|1953 Maryland]] |Institution |July |NA (mainly female nurses) | |13.7% |- |[[1954 Johannesburg outbreak|1954 Johannesburg]] |Community |August to March |72%<ref name="Jackson1957" /> | | |- |[[1955 Dalston outbreak|1955 Dalston]] |Community |January |50%<ref name=":10">{{Cite book | title = An investigation into an unusual disease seen in epidemic and sporadic form in a general practice in Cumberland in 1955 and subsequent years, M.D. Thesis | last = Wallis | first = A.L. | publisher = University of Edinburgh| year = 1957|isbn=|location=| pages=}}</ref> | |13.9%<ref name=":10" /> |- |[[1955 Durban outbreak|1955 Durban]] |Institution |late summer (February) |NA (mainly female nurses) |< 25 years | |- |[[1955 Royal Free Hospital outbreak|1955 London]] |Institution |July to November | | | |- |[[1956 Punta Gorda outbreak|1956 Punta Gorda]] |Mixed |mid-March to June |74%<ref name="Poskanzer, 1957" /> |20-49 years<ref name="Poskanzer, 1957" /> |6.1%<ref name="Poskanzer, 1957" /> (community), 42% (hospital) |- |[[1961 New York State outbreak|1961 New York State]] |Institution |July to January |NA (all female nuns) |< 30 years |37.7% |} == Pathophysiology == Due to limited of objective findings, very little was known about the pathophysiology of the disease. Several investigators postulated damage to the [[hypothalamus]]<ref name="Ramsay1978" /> owing to the symptoms of orthostatic tachycardia, abnormal glucose regulation, circulatory impairment, and problems with temperature regulation. == Prognosis == Although many patients improved over time, in follow-up studies, a large percentage were still ill months to years later. Many case studies note long periods of convalescence with relapses following exertion<ref name="Sigurdsson1956" /><ref name="Shelokov, 1957" /><ref name="Hill1959" /><ref name="Albrecht1964" /><ref name="Poskanzer, 1957" /> or before or during [[Menstrual cycle|menstrual periods]].<ref name="Shelokov, 1957" /><ref name="Albrecht1964" /><ref name="Poskanzer, 1957" /> {| class="wikitable" !Outbreak !Time after outbreak !Subjective recovery rate !Objective recovery rate |- |[[1948-49 Akureyri outbreak]] |7 years |13%<ref name="Sigurdsson1956" /> |31%<ref name="Sigurdsson1956" /> |- |[[1953 Maryland outbreak]] |5 months |0%<ref name="Shelokov, 1957" /> | |- |[[1955 Durban outbreak]] |3 years | |89%*<ref name="Hill1959" /> |- |[[1961 New York State outbreak]] |1 year | |35%<ref name="Albrecht1964" /> |} *Follow-up was with those patients considered disabled. Others may have been more mildly affected. ==Relationship to polio== Prior to the poliovirus vaccine, several [[outbreaks]] of what later came to be called [[myalgic encephalomyelitis]] coincided with confirmed outbreaks of [[poliomyelitis]] including the [[1934 Los Angeles atypical polio outbreak|1934 Los Angeles outbreak]], the [[1948-49 Akureyri outbreak|1948 Akureyri, Iceland outbreak]], and 1949 outbreak in [[1949-53 Adelaide outbreak|Adelaide, Australia]].<ref name="Pellew1951" /> Many outbreaks were initially misinterpreted as clusters of [[poliomyelitis]] or [[abortive poliomyelitis]], hence one of [[myalgic encephalomyelitis|ME]]'s earliest names, [[atypical polio]]. It is not known whether there is a direct relationship between polio outbreaks and ME or if outbreaks of ME were more likely to be reported when public health authorities were already mobilized for an earlier crisis. No serological evidence of polio was ever found in these outbreaks and the ultimate pattern of the outbreaks differed in significant ways, chief among them the higher attack rate, the tendency to affect adults rather than children, and the higher [[morbidity]] than poliomyelitis but no [[mortality]].<ref name="Parish1978" /><ref name="Acheson, 1959" /> Findings in several outbreaks seemed to suggest that symptoms were caused by an [[enterovirus]] distinct from but related to polio: findings of mild, diffuse peripheral nervous system damage in monkeys infected with the virus; a stronger response to polio vaccination in children who had been in epidemic areas; and seasonal patterns of infection resembling polio, i.e., the rise in cases during summer months.<ref name="Parish1978" /><ref name="Acheson, 1959" /> There is indirect evidence of cross-immunity between [[poliovirus]] and the unidentified virus or viruses in epidemic myalgic encephalomyelitis outbreaks. After the Akureyri outbreak, children in areas that had been affected responded to poliomyelitis vaccination with higher antibody titres, as if these children had already been exposed to an agent immunologically similar to the poliovirus.<ref name="Parish1978" /><ref>{{Cite journal| url = https://www.ncbi.nlm.nih.gov/pubmed/13515219 | title = Response to poliomyelitis vaccination | last = Sigurdsson | first = B | author-link = Björn Sigurdsson | date = February 15, 1958|journal=The Lancet|volume=1 | pages = 370-1|via=}}</ref> During the [[1949-53 Adelaide outbreak|outbreak in Adelaide]], cases of classic poliomyelitis dropped by 43%.<ref name="PMC2542300">{{Cite journal | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542300/| title = Poliomyelitis in 1953"|journal =Bulletin of the World Health Organization | date = 1955|volume =12|issue =4| pages =595-649|pmc=PMC2542300}}</ref> == Controversy == In 1970, a paper by [[Colin McEvedy|Colin P. McEvedy]] and [[William Beard|AW Beard]] claimed that the [[1955 Royal Free Hospital outbreak]] was actually [[mass hysteria]]<ref name="PMC1700894">{{Cite journal | title = Royal Free Epidemic of 1955: A Reconsideration | date = 1970-01-03| url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1700894/|journal=British Medical Journal|volume=1|issue=5687 | pages = 7–11 | last = McEvedy | first = Colin P. | author-link = Colin McEvedy | last2 = Beard | first2 = A.W. | authorlink2 = William Beard | last3 = | first3 = | authorlink3 = | last4 = | first4 = | authorlink4 = | last5 = | first5 = | authorlink5 = |doi=|pmc=1700894|pmid=5411611|access-date=|issn=0007-1447|quote=|via=}}</ref><ref name="Apology2015">{{Cite news |url = https://www.telegraph.co.uk/news/health/12033810/Its-time-for-doctors-to-apologise-to-their-ME-patients.html | title = It's time for doctors to apologise to their ME patients|publisher =The Telegraph | first = Charles | last = Shepherd | authorlink = Charles Shepherd | date =December 7, 2015}}</ref> despite never examining patients.<ref name="Speight2013">{{Cite journal | last = Speight | first = Nigel | authorlink = Nigel Speight | date = 2013 | title = Myalgic encephalomyelitis/chronic fatigue syndrome: Review of history, clinical features, and controversies |url = http://dx.doi.org/10.4103/1658-631x.112905|journal=Saudi Journal of Medicine and Medical Sciences|volume=1|issue=1 | pages = 11|doi=10.4103/1658-631x.112905|issn=1658-631X|quote=|via=}}</ref> == Outbreaks of the 1980s and 1990s == The case reports of the 1980s and 1990s differed substantially from those of earlier decades. Whereas reports from the 1930s-1960s focused heavily on neurological and muscle symptoms and findings, and compared and contrasted the disease to [[poliomyelitis]], reports of the 1980s focused far more heavily on fatigue and the possible relationship to [[herpesviruses]]. == See also == * [[Ramsay definition]] * [[Enterovirus]] * [[List of enterovirus infection studies]] * [[List of myalgic encephalomyelitis and chronic fatigue syndrome outbreaks]] * [[Non-cytolytic enterovirus]] * [[Eightfold increase in ME/CFS incidence in the 1980s]] == Learn more== *[https://www.newyorker.com/magazine/1965/11/27/in-the-bughouse In the Bughouse] - The New Yorker by Berton Roueché<ref name="NewYorker1965">{{Cite news | publisher = The New Yorker |volume =41 |issue =Part 6 | page =208 | title = In The Bughouse | date = Nov 19, 1965 | last = Roueché | first = Berton | url = http://www.newyorker.com/magazine/1965/11/27/in-the-bughouse }} </ref> *[[Osler's Web]] by [[Hillary Johnson]] == References == {{Reflist}} [[Category:Outbreaks]] [[Category:Epidemiology]]
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