On her second day of life, Kimberly Cowley had congestive heart failure. Considering the vast array of health issues she had been born with hearing in vision loss, a rare condition known as tetrology of fullow caused by a combination of four heart defects, any one of which is a killer. Expectations of survival were low. Against all odds, Kimberly survived, but the road has been long and often painful. Born in Hamilton, Canada, in nineteen sixty four, Kimberly spent the
first two months of her life in the hospital. Her parents were young and shortly after marriage. Her mother became sick. She thought it might be a bout of flu, and then once she learned she was pregnant, she thought maybe that was why she felt unwell. It was neither. Her mother later learned that it had been rubella, having come into contact with an infected relative in her first trimester
in nineteen sixty four. The rubella vaccine was still five years away from being available when Kimberly was diagnosed with congestive heart failure. That second day in the hospital, her parents realized the problems were much bigger than they had thought. Those first two months were a whirlwind of tests. All Kimberly's parents were told was that they would have to wait until later in life to see how this translated
in reality. Like most children, Kimberly started school at age five, but in all other ways, she was profoundly different from the other kids in her class. Physically, she was the size of a small three year old, and school was an immense challenge. Given no special tools, Kimberly was expected to learn at the same rate as her classmates while
missing most of two of her senses. After eight hours of concentrating to hear, see, and keep up, she craved silence and to be left alone, meaning after school friends were few and far between, often lonely. She grew up being bullied and picked on for her differences. Kimberly's parents were at a loss, not knowing what to do or how to cope. I needed advocates, and they just weren't. She said. My mother had been a bully at school herself and continued that behavior with me. She was unable
to relate to my disability. It was hard to get close to my father or brothers too, because they didn't try to get close to me. Things became much worse emotionally for eleven year old Kimberly. When she was scheduled to have heart surgery. Her classmates taunted her, telling her she was going to die. One parent was allowed to go into the operating room with Kimberly while anesthesia was being administered, but neither of her parents chose to provide
this comfort. She went in alone. When she woke up, she smiled despite the incredible pain, knowing she was alive, proving her schoolmates and the unfeeling world around her wrong. Her surgeon called her a wilful, stubborn survivor. These days, Kimberly lives quietly. She has worked in the past, but seldom full time. She exercises daily or risks losing her mobility, and is a passionate archer. When she ventures out of her home, it's an exercise and extreme concentration. Kimberly uses
a long cane to help her get around. Her life is also about tools. Her laptop has magnification, her Kindle reader is on the second largest font, and she paints her nails with a magnifying glass clipped to her glasses. You get used to being stared at Kimberly said, the only difference between now and when I was a child is that now I don't care. I just smile. I like who I am and how far I have come. I'm looking forward to the next adventures in my life.
She said, I'm a vaccination crusader. If I can save just one life by telling, teaching, and pushing for vaccination, that I know it's all been worth it.
Oh, Aaron, that got me, I know, I know.
It's a Yeah. That firsthand was from Kimberly Cowley and I found it on a website called Measlesubella Initiative dot org and I will post a link to the full account. So that was excerpts. And also, according to this website, Kimberly is working on a book, so that would be awesome to check out. Yeah, yeah, Hi, I'm Aaron Welsh.
And I'm Erin Alman Update and.
This is this podcast will kill you Today.
I'm already crying. It's gonna be a great episode.
Setting the stage, setting the tone for this episode today. Yeah, yes, today we are covering rubella also known as German measles, although I don't know how many people still call it that nowadays.
In like textbooks. I feel like you still hear it.
Yeah, yeah, well, we'll be mostly calling it rubella Rubella, that's what it's called. Yeah ah well, I guess to start us off, it's quarantiny time.
It's definitely definitely quarantiny time.
What are we drinking this week?
We're drinking choo rubella.
Very well done, air, thank you? And what is in the chow Rebella? I don't know, Okay, I can tell you gin cherry juice, grenadine, a splash of soda water, and also a fancy liqueur that's like a raspberry liqueur called chambourd Chambard. Yeah, I liked the bottle was really pretty.
A very ruby rubella drink. I feel like that's appropriate Ruby Rebella.
Yeah exactly. We will post the full recipe to the chow Rebella on our website. This podcast will kill you dot Com as well as all of our social media channels, and that is also where you will be able to find the non alcoholic Placybrita.
Oh yeah, we got you covered.
We got you all right? Is there some there's some business? I guess we should run down the list of usual suspects before we dive in.
For example, we have incredible merch for sale on our website This podcast will kill You dot com. Just click on merch you can find it. We have incredible offerings by the artists Abigail Irvin Penner as well as Hollysullivan. Really truly, I just got some of the Holly Sullivan's Framed Prince and I am obsessed with them. They're so cute, my gosh.
And there are stickers of both which like, if you're running out of wall space for pictures, which I definitely am, you.
Have water bottle space.
We also have a good Reads list if you want to read more on any of the subjects that we talk about, in addition to a bookshop affiliate account, and when we post the references to all of these episodes, we will also post links, when available, to the books that we mentioned on the podcast.
Yep is that all of our business?
I think that's it. Okay, let's dive in.
Let's this is going to be a big fun not fun, a big episode.
It's going to be a big one. It's going to be very interesting. There's a lot I feel like to uncover that I had no idea about before diving in.
Oh, I can't wait to hear the history. But we'll start where we always do, with the biology right after this break. Obviously, we have two major points to talk about today in the biology, and that is rubella infection like in children and adults, and of course congenital rubella syndrome, which I think most people listening probably know already. The major complication of rubella infection is the effects that it can have on a fetus if someone is infected during pregnancy,
especially and specifically early in pregnancy. When we did our Triple E episode Eastern equine encephalitis like back in season three, I said during that episode that rubella was another and one of the only non arthropod born alpha viruses in the family Togaviridae. But apparently in twenty eighteen that was changed and Rubella was reclassified. So it's not really anymore a toga virus. It's in its whole own family called Motonaviridae,
in the genus Rubavirus. Huh okay, I know. So this is a self correction, because nobody has corrected me on that yet. I'm shocked. In any case, we are talking today about a virus. It is a single stranded positive RNA virus. Unlike a lot of other RNA viruses that we've talked about, it's pretty stable antigenically, so that's a
large part of why we have a pretty effective vaccine spoilers. So, in general, Rubella virus is transmitted via aerosols, much like measles, which I feel like rubella and measles often go hand in hand in terms of our conversations, even though they're really not that similar. But in this case Rubella, it's really large particle aerosols, so it doesn't linger in the air the way that measles does.
Okay, So that explains the lower are not.
Exactly right. So it is a respiratory virus, and like every virus on the planet, it has to infect a cell in order to replicate. In the case of rubella, it generally first infects the cells of our respiratory tract and then the lymph tissue, which it's very easy to access from like our nose and nasal passages, but very
very quickly. Within five to seven days after exposure, Rubella is able to disseminate throughout our blood stream, so it causes a viremia, meaning you can detect virus in our blood if you took a sample, and it leads to a pretty widespread systemic infection. What that means is that, unlike some other viruses and pathogens that we've discussed, rubella has a very wide tropism, meaning it can infect a huge range of our cell types, not just a few types of cells.
That's very interesting.
It really is. We don't still know exactly what receptor it uses on our cells to gain entry into our cells, but we know that it must be something that's present on like almost every cell type, if that makes sense.
So that makes me wonder about other species. So, like, I know that rubella is human specific, it is, but if it infects all like, what is it then about all of these human cells?
Right?
Makes it not able to infect other animals?
Right? It's a really good question. So what is it using in our bodies to be able to infect almost all of our cells? But really just humans? I mean, experimentally, you can infect other animals. So it's not that it's impossible for other animals to become infected. It's just that in general, other animals, they're not good reservoirs. They're not like walking around in the world infected with Rubella virus.
Ooh, so I wonder whether it's like just the transmission dynamics and like human behavior, and or maybe like it just doesn't cause disease the way that it doesn't. That's so interesting, so interesting.
Right, yeah, I know it gets even more interesting, quite honestly, But keep that in mind, right, Like, this is a virus that can infect pretty much any cell type. Additionally, we know that, like many many viruses, at least part of the pathogenic effect of rubella is by directly killing cells. Essentially, so whind cells get infected with virus and the virus replicates inside those cells, that cell will undergo apoptosis, meaning that cell will die. So at least in part that
is responsible for the damage. That means it's not just our immune reaction or our immune response that's causing the symptoms that we see. But we'll put a pin in that because that's not the whole story, and we'll move on to the symptoms at least in grown humans. I want to skip ahead. Okay, okay, in general, in children or adults who get infected, we are talking with Rebella about a very very mild self limited illness. If you have symptoms at all. In general, it starts with a rash, not a fever.
Oh that's the other podcast.
It's starting with a fever asterisk. Unless it starts with the rash, we there go perfect. So in the case of rebella, it generally starts with a rash. This rash is very similar actually to the one that we see with measles, which I think is a large part of why there's this overlap. It starts on the face. It generally spreads downwards towards the feet, encompassing almost your whole body. They're just the rash looks like small red spots, maybe
with some bumps. But differences between the rubella rash and measles are that it spreads much more quickly, like within twenty four hours. It generally lasts only a couple of days, like two to three days, and the rash doesn't coalesque or darken the way that measles rashes tend to do.
Okay, I also read somewhere it was tingly.
Oh interesting. I took the cares that, oh, you can feel it tingling.
That's ad tingly rash, I mean. Granted, this description was from the mid mid eighteen hundred so, like, you know, I.
Wonder is that a description of how the rash feels or is it something about like is that how you describe rashes like a tingly rash versus a lacy rash? I don't know.
I assumed it was it tingles, but well, because does does measles tingle? I can't remember, or does it like itch or burn?
I don't think so.
I didn't think so. So I thought that was one of the designating like interesting or differentiating characteristics.
Really, yeah, really, I didn't read it. Doesn't mean it's not possible, but very differently from measles that rash is often it okay in terms of the symptoms of rubella if you have that at all, maybe you might also have a slight fever, maybe you might have some swollen lymph nodes, but really that's about it. It's a very mild illness. And again that's if you even have symptoms. The older that you are when you get infected, the
more likely that you'll have symptoms beyond the rash. But kids are more likely to like have the rash for sure, like have any symptoms whatsoever. And if you have symptoms, number one is going to be the rash okay. In some cases you can have things like arthralgias or joint pain, which can last for several weeks, but it's really rare, and even more rare are severe manifestations like encephalitis the
way that we do see with measles. We're talking though, like one to three per six thousand cases, so this is a very rare complication. But also other complications that you can get from a wide variety of viral and other infections, things like yon beret myocarditis, which is when the virus infects your heart, optic neuritis if it affects
your eyes. These things are all possible, but they're not specific to rubella, and they're very very unlikely with a rubella infection specifically gotcha, but that's not the big story when it comes to rubella. The big story is congenital
Rubella syndrome or CRS. This is what happens when a person gets infected with rubella, and usually this has to be a primary infection, so someone is being exposed and infected for the first time in their life while they are pregnant, specifically during the first trimester, which is the
first twelve weeks of pregnancy. Now, if we remember back to our philidamide episode, when I talked about the embryologic period of development, the first like ten weeks or so, I talked a lot about how anything that has effects on a developing fetus during this period when it's an embrya, not even a fetus, has huge downstream developmental effects. Rubella is one of those infections that can infect a fetus, especially at this early early stage. Essentially, what happens is
when a pregnant person gets infected with rubella. As we already talked about, that virus spreads really rapidly throughout our bodies, and one of the places that it spreads and can infect is the placenta in the place central tissue, and then it can travel through that placenta and go on to infect pretty much any cell in that developing embryo or fetus. Now, what exactly happens inside an infected fetus is still not entirely clear, which I think is fascinating.
So yeah, I'm so surprised by.
That, me too. But we do know some things, and they're really interesting. There's kind of three main ways that rubella has effects. We know that in grown humans. One of the main effects of rebella that causes symptoms is direct cell death, right, But in the case of the developing fetus, that doesn't seem to be a main mechanism by which damage is induced. Isn't that weird?
I wonder does this have something to do with the fact that we still don't know the receptor and that like maybe I don't know, I mean it does is it cell death? Okay? So if rubella virus can infect all those different cells that we have, does it cause cell death in all of those cells or is it just a subset?
Very good question. I don't know. And here's an on top of that. We think that at least part of the reason that a fetus is susceptible when it is, and part of why. So this is an interesting I was gonna say this later, but I'm going to say it now. If a baby is born with congenital rubella syndrome, they still harbor rubella virus for months, if not years, And so in a fetus and a newborn rubella is
not an acute infection. It's a chronic infection. So it's acting very differently in a fetus than it is in a person. Yes, so how much does that have to do with the fact that the immune system is still under development? Gosh, who knows, right, Like, what are those mechanisms and what's the interaction with a you know, well developed immune system versus a fetal immune system. It gets complicated, but erin, it's about to get more complicated. So I have to keep going.
Wait, but can I ask two questions before try.
So?
Okay? My first question is if it can infect all these different types of cells?
Uh huh?
Can it also be transmitted through means other than respiratory? Is respiratory just the primary way?
Great question? And yes, yeah, so you can culture virus from a whole bunch of different bodily fluids poop pe i conjunctive fluid, even by scraping off the skin. Like the virus is in your skin, especially when you have a rash, it's actually in the rash and in non rashy skin. So the virus is definitely everywhere. It's in your blood, but it's at highest level in the respiratory tract.
Okay, that makes sense. Yeah, And my other question is in later trimesters or later on in the pregnancy, if someone becomes infected, does the fetus have an immunity, like, are there any effects?
Pause that question, Okay, I'll answer that.
I'll address that.
Thank you, We will get there erin, let's not jump our guns.
Sorry, I got really excited.
I know you did. So all I told you was what is not the main cause of the effects that we see in a developing fetus. I want to tell you what we think are okay, because we know something okay, and because it gets even weirder. Infection in the fetus results in decreased cell growth and division. So even if it's not killing cells directly, it's stopping cells from dividing.
That's what a fetus does, divide cells. But I mean that what that means is that in a developing fetus you have a reduction in cell mass, and that can result in not enough cells recruited to shape embryologic parts the way that they should be developed.
Okay, So that it's just a non it's almost a side effect of Like, there are so many downstream effects from a rebella infection that's not just oh, the rebella virus targets those.
Cells, and there's more talk about downstream effects another cell type. Even though we know that rebella can infect a lot of different cells. One of the big problems is when rubella in a developing fetus infects the endothelial cells of the blood vessels. Those are the cells that line blood vessels. We end up talking about those a lot on this podcast.
Interesting infection of those cells causes damage to fetal blood vessels, which can downstream cause damage enough that they cause ischemia or tissue death in organs that are supplied by those blood vessels. So you can have downstream effects of damage to organs because of damage to these blood vessels in the fetus.
Okay, I have a question. Okay, does the timing of infection during the first trimester matter or is it just sort of any time.
Absolutely, the timing matters. So the timing matt The timing is everything in terms of the effects that you see, in terms of the severity everything. So there's a lot of details in a lot of the papers that I will post in terms of like the exact number of weeks for when you have this effect versus that effect. But in general, it goes like this infection within the first twelve weeks almost always is going to result in
infection of the fetus. So infection of a pregnant person during the first twelve weeks of pregnancy for the first time with Rebella is going to end up infecting the fetus. In those first twelve weeks. Almost all of those infections, or a large proportion of those infections, are going to result in some kind of fetal malformation or problem down the line after like sixteen eighteen weeks especially. It's not that infection doesn't occur, it just doesn't have those long,
long term effects or downstream effects. And this is really weird. There's like a period of time in the second trimester where infection itself tends to be like lowest, and then in the third trimester the fetus could become infected, but the most that you might see would be like some growth restriction. Okay, but at almost any point in pregnancy a fetus could become infected. It's just that only in that early period of time are you going to see
the effects. So let's talk a little bit more specifically about what you see, because then we can talk about even more specifically about the timing. Okay, So, because this is a virus that can affect almost every cell, really almost any part can be affected almost any organ really everything, but classically there are kind of three large scale ways in which congenital Rubella syndrome can affect an infant born
with it. One is with transient, kind of short lived manifestations that tend to happen if the viral load in that baby is very high at the time of birth, and we'll talk about what those look like. The second is with permanent manifestations, so that means something that happened during development that doesn't change, that affected the development of
that fetus. And then finally there are and this actually blew my mind because I never learned this previously, there are late onset problems that can happen that are not detectable at the time of birth but become apparent later on. So we'll go through each of those. The transient ones, because this virus is infecting everywhere, they can be really
wide ranging. An infant can be borne with jaundice, so that means kind of yellowed skin, which usually has to do with anemia or homolysis, so like red blood cells lycing within their body because of infection, hepatitis, so infection of the liver, enlargement of the liver, or spleen. A kind of classic description of a baby born with CRS includes a blueberry muffin rash, which means purple spots on the skin.
Interesting.
Yes, and this is actually caused by This is very interesting. It's caused by eruthropuesis, which is the process of making red blood cells in the skin because you have anemia elsewhere and infection of the bone marrow potentially, so basically the baby is not making enough red blood cells, so other organs are like recruited to help make blood cells and then you end up with this type of rash.
WHOA.
You could also have pneumonia, myocarditis, diarrhea, like a lot of different things can happen. These manifestations do tend to clear on their own. However, it comes with the caveat of these infants are very sick, and on top of that, you don't generally have only these transient manifestations. These babies are oftentimes born with things like growth restriction or other
more permanent manifestations. So mortality in babies born with this type of congeneral rubella can be as high as thirty five percent in some cases.
Oh my gosh, it's very sad.
And I didn't even mention, but infection with rubella, especially super early on, can also cause pregnancy loss. But I have no idea what the proportion of that is because I was not able to find numbers on like the incidents of that compared to infection that results in these things that we can see in a baby that's born. Okay, so now we have these permanent manifestations, and that means that something went wrong during development. The most common consequence
is deafness. This happens in like two thirds of babies born with congeneral rubella, and it can be of varying levels so complete to just mild hearing loss. You also can have neurologic complications, including developmental delays, a huge range of heart defects. The heart, aside from the ear, is like the most second most common organ involved. I think one half of babies born with congeneral rubella have some type of heart defect. And then the third most common
is vision defects, which can be cataracts. Those are the most common. About a quarter of babies born with congeneral rubella have some degree of cataracts. But you can also have anopathy glaucoma, a whole number of vision problems. All of these happen either from problems during organogenesis, so the making of organs like your heart, or from tissue destruction and scarring like in the case of hearing loss and
some brain damage that can occur. Okay, then we have the long term or delayed manifestations, and this is truly wild. These are things like type one diabetes, which occurs at anywhere from fifty to two hundred times, depending on the paper you read, the rate of the general population. What right, So babies born with congeneral rebella can go on to develop type one diabetes. Also thyroid dysfunction, a number of
different like autoimmune related thyroid dysfunction, vascular problems. The most severe and most rare complication would be a pan encephalitis, so infection of the entirety of your brain, and that is often fatal. But these can occur years down the line.
Why why why?
Why? Yeah? But yeah, So your question earlier about the specific timing part of the reason. And I found this very interesting because I was trying to I was worried you were going to ask me a lot of real specifics about like how does cataracts occur? And how does okay? So I went down some rabbit holes to try and figure out, like what specific things are causing each of these, like the three most common effects that we see, which
are deafness, heart defects, and cataracts or vision problems. And part of the reason that hearing loss is one of the most common effects is because, in contrast to some of the other more serious deficits, the effects that can produce hearing loss can happen later. The organ of in your ear is vulnerable to the effects of the virus up to the first sixteen weeks, whereas most of like
the heart defects. The heart defects are uncommon after like eight weeks or so, and then cataracts are uncommon after like weeks nine to eleven, et cetera. So that's part of the reason why the ear tends to be affected the most out of all imporn with CRS. Interesting, the good news is there's a vaccine.
There's a vaccine and.
Erin I can't wait to hear about like the development and things like that. But it's a live attenuated vaccine. So it's a live strain of rubella virus that's been grown in a lab so that it doesn't cause infection. One dose produces immunity in ninety five percent of people that has been shown to last upwards of twenty one years, which is phenomenal.
It's a good one.
It's a very good one. So in general, that's the only good news that I have. So erin, what's up with this? Can you tell me about it? Like? Where did this virus come from? Why is it only in humans? How did we come up with a vaccine? And why isn't it gone yet? I don't know.
My gosh, these are lots of questions, and I don't know if I'm going to be able to answer all of them, but I'll do the best that I can. Right after this break, So Aarin, you asked, where does this come from?
Yeah, we don't really know. Why are you me or something? I know? I know?
Okay, here's what I'm gonna do in the in the history section, just to sort of like prepare you for the fact that there's gonna be thousands of years of like me not talking about the history. I'm going to start with the evolutionary history and what we do know about it, Okay, and then basically I have to jump
right to almost modern history. What because in terms of ancient history, Rubella was unlikely to be distinguished from the other relatively mild or often mild rash causing illnesses, right, I mean, as you describe, the symptoms aren't super specific. So unfortunately that means like no mentions of ancient Egyptian papyri or Hippocrates or whatever.
Well, I'm done listening to that, just kidding.
Okay, But as I mentioned, yeah, there seems to be this big question mark over the origins of the Rubella virus. I did read in one paper that looked at the molecular epidemial of Rubella viruses and the different Rubella virus genotypes across the Asian continent, and they said that, oh, it's thought to have originated there, like somewhere in Asia.
Okay, all right.
But then I found a paper that was published like super recently in Nature in October twenty twenty, so like, whoa, just a couple months ago, cool, just for us, And they reported the first known relatives of the Rubella virus, which they isolated from several different species of mammals. What
this is interesting? So yeah, Ruhugu virus, which is most closely related to Rebella was found in a species of bat called the Cyclops leaf nose bats, which I believe were in Uganda, and they appeared otherwise healthy, And it was wasn't just like this isolated infection and one bat. It was found in around fifty percent of the individuals
that they sampled. What yes, And they found the other virus, which they called rostrella virus in animals and a zoo in Germany that had gotten sick and eventually died from a severe acute neurological disease. What the animals were a donkey, a cappy bara, and a red necked wallaby.
What sarin?
I know, I know, I know. And so when they were searching for the cause of this these these deaths, they found Rostrella virus in the brain tissue of all three of these animals. And then they subsequently sampled other animals around the area to see if they could find the same thing, and they found this virus in about half of the yellow necked field mice that they tested.
So they found these two like brand new viruses, and then they were like, where what are these And they figured out that closely related to rubella.
Really closely related, so like if you look at their genomes, they're like very similar in terms of like coding regions and stuff and the arrangement of those what yeah, like.
Did they come from rubella or did they come from a shared common ancestor? How old are these?
Let me so, I don't know how old they are. Let me pull up the paper to see what sort of their the evolutionary implications or timeline or whatever if I'm reading this correctly, So all three of them came from a shared common ancestor, but Rustrella virus diverged before those two. Wow, so it went first Rustrella went off the tree, then Ruhugu, and then like Rubella split secondly. Yeah, I don't know about the timeline or anything. Ye maybe it was in the paper and I just missed it.
But yeah, But basically, so from this paper there were a couple of take homes. One was that given the ability for these viruses, especially Rustrella, to infect a diversity
of mammal species. And now I'm adding my own little thing about what we know about the Rubella virus to infect all different kinds of cell types, like that's yeah, the Rubella virus may have initially spilled over from wildlife into humans, and that this does raise some concerns for future zoonotics spillover events, although I do want to give a psa as we always do, to say that bats are not evil, and the more funds and effort we put into this type of research and bat conservation, the
less likely spillover events are going to occur anyway. Okay, but the other really cool implication from this paper is that these new viruses give us the ability to do more comparative studies or to explore different animal models so that we can better understand things about why this virus has such wide ranging impacts on the body or on the fetus.
And yeah, so, yeah, that's really fascinating.
Yeah so now we need to launch ourselves quite a bit forward in time to around the eighteenth century.
Wow. Yeah, yeah.
The debate over whether or not these rashy illnesses were different diseases or just different forms of the same disease was still kind of like ongoing, although there had been some clarity reached regarding at least measles and scarlet fever being separate, and a handful of researchers had started talking about a third separate illness, one that they called rutilm I am going to be terrible pronouncing this, which is
German for to reddin according to Google Translate. Throughout much of the eighteenth century and into the early nineteenth century, it was in fact to mostly German researchers who seemed interested in characterizing this new disease, hence the name by which it would be popularly known in many places outside of Germany. German measles again not a name that we still use. It is not, but it did. But it was very It was like much more heavily in use than ruten and bella.
Yeah.
Throughout the eighteen hundreds, there was growing acceptance that this disease was a separate like a truly separate entity from measles and scarlet fever. But even with all of this discussion and research and a description in the early eighteen hundreds that basically covers many of the key features of rubella, people in the medical science community remained a bit hesitant
to accept that this was actually a separate disease. But finally the tides seemed to be turning when in eighteen sixty six, following continued epidemics and other smaller reports of the disease, a British Royal Artillery surgeon published an article describing a current outbreak of the disease known as routine rutiln in India. He closed out this article with a paragraph proposing a name change. Quote. The name of a
disease is always a matter of some importance. It should be short for the sake of convenience and writing, and euphonious for ease and pronunciation. I agree with that part, but that's only because I'm terrible at pronouncing anything. To continue, it should, if possible, indicate a definite group of pathological conditions. Rutel is harsh and foreign to our ears. Rubiola notha and Rosalia idiopathica are too long and yet to be proved. I therefore propose rubella as a name for the disease.
But also, that's just so English centric? Is that not that I can't pronounce German?
So let's call it this thing that I'm going to make up entirely. Yeah, yes, but the name did catch on. People were like, yeah, sure, let's do it. Although the term German measles would stick around for much longer in many places to kind of an annoying degree because it caused a whole lot of confusion. It's not from Germany, and it's also not a type of measles, and at times it also caused anti German sentiment. For instance, in World War One, although it lagged behind other diseases such
as influenza and typhus, rubella did do some damage. US Army hospitals admitted more than seventeen thousand soldiers for rubella, and rubella was the cause of over two hundred and eleven thousand days lost from duty. Wow, and the high prevalence of this disease led to lots of German measles jokes about Germany, and in World War Two the disease was nicknamed the liberty itch or victory measles like freedom fries and victim measles.
Yeah, oh my god.
Okay, for the next big development in rubella history, we have to jump ahead again, this time to the early twentieth century, around nineteen forty one. Far let's do a bit of context building here, my favorite thing to do in terms of infectious disease and medicine. So it's kind of hard to imagine just how much the field of medicine had changed in one hundred years from like eighteen forty one to nineteen forty one.
I want a compilation of every time that you've said that.
I know, I know, and I'm like, I feel self conscious saying it because I'm like, God, surely people are sick of hearing the same thing.
I love it though.
It helps me get into the mindset of like why, like why nineteen forty one was an important year? Why that year? Why things happen when they happen? And yeah, yeah, anyway, So, germ theory had a lot to do with advancing knowledge regarding some of the most common or prevalent diseases in that time, but medical technology, allowing for close observation and measurement of things previously only able to be described qualitatively, turned the art of medicine into a science. Definitely have
said that before. Oh yeah, And a great deal of this change can be described by a single word specialization. The growing body of knowledge regarding human anatomy and disease processes and treatments made it possible for different highly specialized fields to develop. Okay, now, onto the infectious disease context. Germ theory had been around for decades, but the pace of discoveries in terms of uncovering new pathogens or new
treatments or vaccines was still incredibly high. Around nineteen forty one, we had a smallpox vaccine, a call or a vaccine, a typhoid vaccine, and others, and we were more easily able to tell you, oh, this disease is likely caused
by a bacterium versus a virus versus a parasite. Antibiotics were on the cusp of widespread use just a couple of years away, and as a result of our increased understanding of how different diseases were transmitted and improved sanitation infrastructure, the world was facing lower rates of death due to infectious disease than ever before, But of course there was still an incredibly long way to go. Things like tuberculosis and polio still sickened or killed many people, and it
also made them terrified. So a potential vaccine or treatment for these feared diseases held a lot of promise and hope for people. But I think it's important to remember that not all diseases were as equally feared or like. The need for a vaccine for every disease was not as self evident as it may be is today.
Yeah, which is it's very interesting, especially in the context of rubella exactly.
So it was like you know when you are when you have tuberculosis or polio outside your door, like you don't have room or even reason to be scared of something as mild and routine like rubella, right, which is what it seemed at the time.
Yeah.
And so while epidemics of rubella were tracked and control attempts were made, and research on the causative agents still continued, it didn't really take front and center the way other things did. But that would change starting in nineteen forty one.
Oh Australian pediatric ophthalmologist Norman McAllister greg there's your specialization, yep, had been he'd been practicing for close to twenty years when in nineteen forty and nineteen forty one he started to notice an unusual number of parents bringing in their babies with the same concerns unusual cataracts or eye infections
or other rare eye disorders. And you know, he had been in the field for a while, and so he recognized that the rate of these conditions that he was seeing was uncommonly high, and he wondered whether there was some sort of link that was connecting them. And maybe it was unusual for the time, but he was the type of doctor that listened to their patients' concerns and to their hypotheses as to why their kid was sick and what had caused it. He exhibited patience and empathy,
at least from what I've read about him. And one day, Greg which was HiT's his last name, But it's really just funny for me to be like Greg Greg. I see there are two g's here, but like Greg Greg. So one day Greg overheard a couple mothers of his patients, so children with rare cataracts, talking in the waiting room about what they thought had caused their child's poor eyesight.
One of the mothers wondered out loud whether it could have been the rubella infection that she had early in her pregnancy, and the other mother also mentioned that she too had gotten sick with rubella while pregnant, and instead of immediately dismissing this as another superstition, which there were plenty of superstitions, as no doubt many other physicians would have done, he considered it a plausible idea, despite the fact that at that point the idea of an infectious
disease affecting a fetus had not really been considered, much less explored fascinating Aaron, and so he asked around to other colleagues whether they had seen similar cataracts in babies or young children, and if they said yes, he reached out to the parents of those children to ask whether
the mother had experienced a rubella infection during pregnancy. And what he was finding was that a substantial proportion of those women said yes, a proportion that was at least great enough for him to spanned his efforts and conduct an actual, official, planned study into this phenomenon. Wow. And through this additional research, he found that a rubella infection during pregnancy, especially early on in pregnancy, was associated with a suite of eye problems, but that it wasn't limited
to just the eyes. There was there also seemed to be cardiac involvement in some of the children. In nineteen forty one, he compiled his findings into a report that he presented at the October meeting of the Ophthalmological Society
of Australia. Some Australian newspapers also happened to pick up this story, and Greg found himself the recipient of tons of phone calls from people who had been infected with rubella during pregnancy and their child had either sight or hearing or heart or developmental issues, and so public and scientific interest in this possible link between rubella infection during pregnancy and congenital defects grew, and the bigger picture of
congenital rubella syndrome took shape, Although that term wouldn't be really used until the nineteen sixties. Rubella has been likely infecting humans for thousands of years, and so I think it's natural to ask the question, why did it take until nineteen forty one for people to make the connection between a rubella infection during pregnancy and congenital abnormalities? What was so special about that year or about doctor greg.
I set up some of the historical context earlier, especially the role that specialization in medicine likely played, but there's more to the story. First, Norman greg was notable in that he listened to the mothers in his office and pursued ly that others may have dismissed due to the fact that a nothing like it had been observed before, and b it was originally put forth by women. Most of whom weren't medically trained in any way or even
maybe had received formal education. In his writings and interview use Greg acknowledged the contribution of these mothers, whose strong interest in their child made them observant and willing to recount any information that might be relevant. In addition, Greg was not just a pediatric ophthalmologist, whose specialization meant he saw a ton of patients from a wide geographic area.
He was also a university researcher, meaning he could he could undertake an epidemiological study and do some stats to see whether his research questions were answered and if so, what those answers were. And the other notable thing, not necessarily about Greg, but about the time period, was that World War II was underway and the assembly and movement of troops led to widespread Rubella epidemics, not just in
Australia but across the globe as well. And those rubella epidemics in the military, of course, spilled over into the broader public, and so the increase in the frequency of those unusual cataracts he was seeing was likely the result of those Rubella epidemics.
Yeah, that makes sense, whoa eric.
I know, it's interesting. I just like to put myself in the shoes of like, you know, why why then why this person? Yeah, you know, it's cool to think about.
Yeah. I think the whole epidemics thing about rubella is very interesting too, because it's definitely like majority of disease of childhood, but in all populations there before vaccines, there was going to be some proportion of people of child
bearing age who are still susceptible. So then what causes an outbreak in kids versus in adults versus in people who are pregnant, Like, it's just so interesting to think about all of the different factors that would have had to combine to lead to these not just rubella, but congenital rubella outbreaks. Like, ugh, it's very.
Interesting, right, especially at a time when you know, I think the other really key thing is that rebella at least then, like people knew it was a virus, but they didn't know which virus, and diagnosis based on like clinical presentation was iffy. A lot of the times. It was usually a process of elimination. Have you gotten measles before? Have you gotten scarlet fever? Before? Yes? Okay, this is probably Rebella's reubella.
Well, and on top of that, there's such a high rate, especially in adults of no symptoms whatsoever, like a completely asymptomatic infection. It's like, right, yeah, it's it's about fifty percent in kids that are okay asymptomatic, and in adults it can be as high as like six or seven
to one, So a really high rate. So the fact that he was able to like find statistical significance in his samples of like asking people, hey, did you get rubella when you were pregnant or whatever, like that's oh man.
Yeah, it's it's amazing to think about if it is. But what did the rest of the world think of Greg's hypothesis.
Craig, I don't know. Well.
While researchers and clinicians in Australia were pretty quick to accept doctor Greg's findings as fact and start informing people about the dangers of rebella infection during pregnancy, the rest of the world wasn't so keen or so quick to believe him or his research, which does have some merit.
Greg's datus had only included children with congenital defects. The methodology behind how he collected the data was unclear, and there was still some doubt that rebella could be reliably distinguished from measles and scarlet fever, and his critics argued that Greg's findings were suggestive of a link, but not conclusive. Okay, but I think it's also interesting that scientifically, the idea that compounds or pathogens could cross the placenta was not new.
It was something that embryologists and pathologists had known for probably at least a few decades, but most clinicians at the time probably didn't receive training or specific education in embryology the way they do now. And still nothing like this had ever really been observed before in humans in terms of a virus, and so this got some people thinking that viruses represented this whole new realm to be
feared in terms of negative effects during pregnancy. Huh so anyway, but despite this initial doubt, the link became more accepted as clinicians did their own tracking of patients or patient case histories in places like North America and Europe, and data supporting the link just seemed to grow and grow and grow, and the boundaries of congenital Rubella syndrome also seemed to be like you know, grow as well or expand as well, and from there it trickled out into
the public. For some people who had had a child with congenital rubella syndrome, it was a relief to know why that had happened, to have some sort of an answer, because it relieve some of the anxiety or worry they may have carried in terms of deciding whether to have another child, or may have relieved some of the guilt that they may have carried with them. With the dangers of rubella uncovered and yet no vaccine for its prevention, doctors considered what to do to minimize the risk of
infection in pregnant people. Stop epidemics in their tracks, inform the public of the risks of this virus, which had previously been thought to be minimal. Prophylaxis really seemed like the only way to actually ensure the safety to pregnant people.
Others recommended that people should try to become infected while young to gain lifelong immunity, like you know, rubella parties like those were actually a thing, although others strongly recommended against that, considering like there could be severe consequences of infection, like why invite a pathogen when there could be something that you don't know happens until there was a vaccine.
There was also the recognition that rubella and thus congenital rubella syndrome was not entirely unavoidable, and some of the advice, like keep away from small kids was completely impractical for some mothers who maybe already had a couple of school age and kids. Yeah, that was like, yeah, what are the supposed to do, like live in a hotel for nine months?
Oh? That's like, well, I just this is a little bit off topic. But like after a c section, you're not supposed to like lift over twenty pounds, So if you have a toddler, it's like, well, what if you can't touch them? Yeah, but it's yeah, oh dear, Yeah.
And so recognizing this in the popular media, the headlines shifted towards a concern that the continued epidemics of rubella would lead to what was framed as an enormous social problem where an institutions or long term care facilities would be overwhelmed and families would be hugely stressed. This time, the prevailing view in the US was that children with CRS were seen as tragedies and the parents and families
of those children as the victims of those tragedies. Now, of course, our society has evolved a bit in empathy, but this framing wasn't just because of a lack of empathy back then. It was also because during that time period we lacked the knowledge and resources to adequately care
for people who were differently abled. Often the solution was institutionalization, which was a huge financial strain, and public schools weren't equipped also to provide additional resources that that's going to make education possible for children with congenital rebella syndrome.
Yeah, and especially when you think about deafness and hearing loss, that often wasn't able to be diagnosed until much later in life, which is still the case in some parts of the world, which is hugely detrimental to learning about. Whereas now, if you're able to identify it early on, you can already get you know, things in place to be able to help that child with what they need. So that's that's huge for sure, yep.
And all of these things also were compounded by the social stigma and shame that was associated with having a child with congenital defects. Why didn't you take better care of yourself during pregnancy, like all of these accusational you know, questions of like pointing fingers and assigning blame to people who like it's blame the mothers to mothers primarily Yes, yeah, and you know, the emotional turmoil would have affected everyone
in the family. And of course, what parent doesn't want the best for their child, for their child to be healthy and to have no limits on what they can do and achieve. The media attention on congenital rubella syndrome reached new heights in the early nineteen sixties when an enormous rubella epidemic was underway in the US. But although it was like quite a sizable epidemic, this was not
the first rubella epidemic in decades. In nineteen fifty eight, for example, there was another rebella epidemic across the US, but it didn't make nearly as many headlines. So let's consider why this early nineteen sixties rebella epidemic might have caused such alarm.
I can take some guesses.
Yes, if you've listened to the podcast before, there are two possible reasons you could guess right away. Number one was polio Jonas Salk's polio vaccine had been developed and deployed a little over ten years before, and so the specter of polio and the paralysis that it could cause was still pretty fresh in the minds of many people.
And secondly, even more recently, Aaron the litamide. That's right, the lidimide, and if you haven't listened to our Leo or thelytamide episodes, go check those out for more historical context on that situation. But the litamide had this enormous impact on the US, even though the US largely escaped, not entirely, as we talked about in the episode, but people read the news articles and testimonials of parents and saw the pictures of children born with limb alformations.
Yeah, that makes sense, and.
Essentially it put this image to their fears of what could happen with rubella epidemic, especially since unlike polio, there was no vaccine, and unlike the lidamide, it was not safely off the shelves.
Right. Yeah. Yeah.
The thltamide scandal of a few years before turned this rubella epidemic from what would have been a largely private matter to a public one. The rubella epidemic that began in nineteen sixty three and continued through nineteen sixty five was enormous. Approximately twelve point five million people became infected with th rebella whoa, and an estimated twenty thousand babies were born with congenital rebella syndrome.
Oh my gosh.
With around there are death, tons of different numbers quoted, but one I saw was eleven thousand miscarriages and therapeutic abortions.
Wow.
Which brings me to the next big step in the history of rebella. It was the combination of both the thilatamide scandal and this rubella epidemic of the early nineteen sixties that led to more open discussion of abortion and ultimately widespread abortion law reform in the US.
Really, yes, no way, I had no idea.
I know, I know me either. I stumbled across it when I was looking for like books on reubella. Wow. Huh. So, as we talked about in our birth control episode, birth control isn't new. Abortions aren't new. They're not a twentieth century invention at all. Although I think we tend to think of roversuade as being the moment where abortion came into the open, and it had only been practiced in back alleys and in people's basements up to that point.
That's not quite accurate. During the depression, for instance, safe abortion clinics practiced openly, but with the conservative moral backlash really only beginning in the nineteen forties and nineteen fifties, which was also a very politically conservative time. Abortions didn't stop, of course, but they just became more unsafe and more secretive and more like, you know, there were more moral
implications to it. In the early nineteen sixties, you could still seek an abortion in some states through applying for one and having a hospital abortion review committee look over your case. It was basically like a panel of generally male doctors.
Yeah, a bunch of dudes deciding whether or not you get to Oh, my goodness.
And then often, at least like in some instances, you would have to undergo several physical or gynecological exams with members of that abortion review committee.
Absolutely not, isn't that?
Yeah, Yeah, that's appalling. And throughout the nineteen forties and nineteen fifties, abortion was painted as an incredibly dangerous thing to do, is often resulting in death, and those seeking or performing abortions were criminals or immoral, or deficient or evil in some way. The lidamide and I highly recommend people read about Sherry Finkbine sometime and this because that also plays a huge role in the history of abortion
and abortion law reform. But the litamide and the rubella epidemic of the early nineteen sixties turned this discussion of abortion into one of a right to be informed and make an informed choice, to choose what a woman felt was right for herself and for her family. It began to be considered as necessary or right, and its illegality was considered more immoral than its legality. Interesting, and it is true that the image of people seeking abortions changed
during this time. It became more of a middle class problem, and so that did definitely put a spin on like it had to be a white, middle class.
Educated Yeah, they're the only ones who can seek abortions.
Huh ye. Early legal battles in abortion often sued physicians and hospitals that provided false information or refused to provide any at all, which prevented the patient or the person seeking the abortion from making their own decisions about their body, or their family, or their own life. For instance, a woman would go to a doctor and say I don't feel well, something's wrong with me, and he would be in his brain thinking, oh, that looks like rubella, but
it's probably not. It might not be. I don't want to worry her unnecessarily, and so then he might note it on her chart but not ever tell her what HM. So that would happen, or would be a doctor saying, actually, I'm not sure if it was rubella. These early legal battles were all about information and access to information and a patient's right to access that information.
Right. Yeah.
Some of these lawsuits came to be known as wrongful birth or wrongful life suits, and they ended up revolutionizing abortion law in the US. But there is one quick note that I want to make about rubella, abortion and people of color during this period. Often whether or not an abortion committee granted someone the approval to seek a therapeutic abortion depended on a recorded positive diagnosis of rebella.
But as we discussed in our Rocky Mountain spotted fever episode, skin rash diagnoses in people of color is notoriously difficult and lacking in guidance in the medical literature. But there is a medical student named Malone Muquende, who is working on a book that is going to address this and the problem of not having like accurate pictures or like information in medical literature. It's like twenty twenty. I can't believe that it's but it's incredible.
I'm so yeah, yeah, I can't wait for that book.
So anyway, but this added one more layer of discrimination and bias against people of color in the medical realm, you know, just as per usu as per usue. Anyway. In addition to propelling abortion law reform forward, the Rebella epidemic in the US in the nineteen sixties also propelled
scientific research forward. The virus that caused rubella was identified nineteen sixty two, and the first test for rubella, like whether someone was newly infected or had been previously infected, was developed in nineteen sixty five by a stand plot Plotkin.
I read some of his papers.
Yeah, But the biggest goal was a vaccine, which was seen as the best solution scientifically and culturally in light of abortion. Since rebella epidemics tended to occur every four to six years, nineteen seventy was sort of this looming deadline when the next big epidemic was expected to happen. Fortunately, a live attenuate vaccine was developed in nineteen sixty six by scientists at the NIH who agreed to share it
widely on the condition that it not be patented. Awesome, and I know, Aarin you were like, I can't wait to hear about the story of the vaccine, but like, that's basically all I have for the development.
That I mean, that's what I wanted to know, Like what was the impetus because exactly, yeah, because in the context of like such a mild generally illness, I was really interested in, like what were the factors driving the vaccine development? So you answered those question.
And so once this vaccine was available, there was a massive vaccination campaign in the US and the late nineteen sixties, and despite Nixon's ridiculous budget cuts and basically like having to depend on an army of volunteers, it would prove to be one of the most successful vaccination campaigns in history, hopefully to be upset by the COVID vaccine.
Fingers cross, fingers.
Crossed by the spring. So here's a quote. By the spring of nineteen seventy two, seventy five percent of all school children, and more than half of all children between one and four years old had been immunized against rebella.
From nineteen sixty six you said it was developed.
Sixty nine is when this campaign started.
And then sixty Wow, so in three years. Yeah's pretty phenomenal, it's huge.
A few years later, the rubella vaccine would be combined with the measles and mumps vaccine, and by I don't know, the nineteen eighties, for many people, rubella simply came to mean just the R in MMR.
Yep. That's absolutely, which is fascinating.
How fast we forget these things?
Oh yeah.
Over the next few decades, massive vaccination campaigns decreased the global prevalence of reubella and congenital reubella syndrome dramatically, and it was eliminated in the US in two thousand and four. However, lapsed vaccination rates I can hear you, I could hear that intake of breath, Aaron, anticipating the bad news to come.
However, yep, yep.
Lapsed vaccination rates and lack of access to vaccinations in other places has led to rubella and congenital reubella syndrome continuing to be a huge problem in many places, which is where I end my story and passed the mic to you, Aaron.
Oh great, love to pick it up on happy notes that you're welcome. We'll take a quick break first and then dive in, so this will be relatively quick and like kind of mostly good news. Erin that's good, nice, not good, great news, but decent.
Good, not great, excellent, not great.
So let me just hit you with numbers straight off the bat, all right, and we're just gonna talk really about the last twenty years from like two thousand to twenty twenty.
Okay, cool.
So, as of early twenty nineteen, one hundred and sixty eight out of one hundred and ninety four countries that the World Health Organization like monitors had introduced rubella vaccination as part of their childhood vaccination series. One sixty eight out of one ninety four, so that's a lot. Yeah, global coverage was estimated. So that means the total number of kids who get vaccinated was estimated at sixty nine percent, which was up from in two thousand twenty one percent.
Wow.
Yeah, so that's pretty great.
Yeah.
Because of that, the and this is going to get interesting, the total reported cases of rubella, not congenital rubella syndrome, but rubella declined by ninety seven percent, oh, in the last twenty years, in the last twenty years, from over six hundred and seventy thousand cases reported in two thousand to just over twenty six thousand cases reported in twenty eighteen. And here's what's really important about that. Reporting has gotten worlds better for rubella in that time period.
It's even it's likely that it's even more than a ninety seven percent decrease.
Right, So we've had a huge increase in the number of countries that report. In two thousand, only fifty three percent of countries reported their rubella numbers, and in twenty eighteen,
ninety one percent of countries we're reporting something. Granted, this is all going to be an underestimate, blah blah, we always say that that's always true, but still that's major, yeah, right, like fifty percent more or like forty percent more countries are reporting, and we have a ninety seven percent decline in rubella cases. WHOA, Right, that's amazing, it's incredible. And that's because of vaccines.
Okay, because of vaccines.
For congenital rubella syndrome. The story is not quite as beautifully perfect, but it's still very reassuring. In two thousand, there were one hundred and fifty six cases reported. Do you think there were only one hundred and fifty six cases erin No, definitely not. In twenty eighteen there were only four hundred and forty nine cases reported, So that's an increase. But again here the percent of countries reporting
increased from thirty nine percent to seventy one percent. Wow, so that means that seventy one percent of countries are doing some kind of surveillance to look for congenital rubella and identify it and then reporting those numbers to the World Health Organization. That's excellent, It's very excellent. So in our Measos episode, when was that season two?
Yeah, I think it would.
Go anyways, way back when we talked a lot, I'm pretty sure if I remember correctly, about the Global Vaccine Action Plan and the Measles and Rubella Initiative, which are these groups of plans that the World Health Organization kind of helps coordinate administer across all the regions where most regions, not every region, but most regions had a goal to eliminate measles and rubella by the year twenty twenty.
All this year.
So yeah, here we are. We're recording at the end of twenty twenty. This episode will be out in early twenty twenty one. We have not achieved those targets. We don't have the data from twenty twenty yet, but as of the twenty nineteen Global Vaccine Action Plan Reports, I will post a link to the full reports which has
every region. That the five different regions, which is the African Region, the American Region, the Eastern Mediterranean Region, the European Region, and the Southeast Asian Region and the Western Pacific Region. So those are all the regions. Each of them have their own reports. Each of them had slightly different goals. Each of them are at slightly different places on meeting those goals. No one has met their goals completely, but every region has made major progress for the most
part on getting towards those goals. And the Americas were declared free of endemic rubella in twenty fifteen, and as far as I can tell, they have maintained this status. But like you said, Aaron, because of lack of low vaccine rates in certain places. The report actually combines measles and rubella, and so some countries in the Americas have had endemic transmission. I think so far is just of measles and not rubella. But I mean that just kind
of means that Rebella could be not far behind. Right.
Sure, all it takes is just one exactly right.
Yeah, but still that's pretty major progress. And I feel like this year, especially, any progress is something that we should celebrate. Yes, we need some victories, agreed. So yeah, I mean that's pretty much the status of rubella. It's just sort of these vaccination campaigns and trying to make sure that every kid has access to a rubella vaccine.
I mean this is a more uplifting ending than many of our episodes.
I think so too.
Yeah. Yeah, good, I'm glad. Okay, I guess is a time for sources.
Yeah, I think so.
I read a book called Dangerous Pregnancies, Mother's Disabilities, and Abortion in Modern America, and this is by someone named Leslie Reagan who is at the University of Illinois.
Really yeah, interesting.
Yeah, it was a very interesting read. I yeah, I really enjoyed it. It was it did totally open my mind to like, oh my gosh, I had no idea about the link between us fascinating. And then I want to shout out the Nature paper I mentioned by Bennett at All from twenty twenty called Relatives of Rubella Virus in Diverse Mammals. And then finally just a couple other
like older papers. I pulled the history from one by Cooper from nineteen eighty five called the History and Medical Consequences of Rebella and by Forbes from nineteen sixty nine Rubella Historical Aspects. And there were a few more that I'll post as well.
I found a very phenomenal book chapter in Remington and Kline's Infectious Diseases of the Fetus and Newborn Infant written by none other than Reef and Plotkin, Oh Plotkin, that was very thorough. And then a number of other papers as well, which we'll link to on our website, this Podcast will Kill You dot Com. Just click on our episodes tab and you can find the sources from every single episode we've ever done.
Sixty single one, sixty four four yesh wow. Well, thank you to Bloodmobile for providing the music for this episode and all of our episodes.
And this Podcast Would Kill You is a member of Exactly Right network. So if you love us, check out all the other exactly right podcasts.
There's so many. Heck, yes, they make this stuff happen. They make it possible. And you know who else makes it possible is you. Listeners, do thank you, thank you, thank you from the bottoms of our hearts. Seriously, from the bottom of our hearts. For the bottoms of our hearts.
Well, so the bottom is the ventricles, which are the the ventricles of our hearts, the ventricles of our hearts, specifically the left ventricle.
You heard it here first, listeners, thank you from the left ventricle of our hearts.
That the powerful one.
Oh oh my gosh. Well, okay, let's end this thing. Until next time, wash your hands.
You fill the animals a