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Epidemic myalgic encephalomyelitis
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==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 = 569β595 | 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 β 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 = BjΓΆrn 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% |}
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