7 2009;24(4) South Afr J Epidemiol Infect Review: A century of South African battles against the pneumococcus A century of South African battles against the pneumococcus –‘the Captain of Death’ HJ Koornhof, SA Madhi, C Feldman, A von Gottberg, KP Klugman Introduction and background A hundred years ago, Sir William Osler described the pneumococcus as the ‘Captain of the men of death’, referring to John Bunyuan’s phrase in his book ‘The life and death of Mr Badman’, written more than 200 years earlier: “Yet the captain of all these men of death that came against him to take him away was the consumption, for it was that that brought him down to the grave”. For Osler the captain of the men of death was not ‘consumption’ (tuberculosis) but pneumonia or the pneumococcus. During his time, acute pneumonia was responsible for more deaths than tuberculosis and the pneumococcus killed adolescents and young adults in the prime of their lives. Death followed a severe illness with high fever from 105°F to 107°F, fighting for air with rapid and shallow, often painful breathing. The condition escalated to a crisis, characterised by a sharp fall in temperature, and in many, death. Concerning those that recover Osler states, “Usually there is an abundant sweat and the patient sinks into a comfortable sleep” and “With the fall in the fever the respirations become reduced almost to normal, the pulse slows, and the patient passes from perhaps a state of extreme hazard and distress to one of safety and comfort”. Osler also called the pneumococcus the ‘friend of the aged’ as it kills them gently without severe symptoms (“Taken off by it in an acute, short, not often painful illness, the old escape those ‘cold gradations of decay’ that make the last stage of all so distressing”) and “one may say that to die of pneumonia is almost the natural end of old people”. The advent of antibiotics in the 1940s dealt a severe blow to the captain’s reign of terror and thanks to them the harshness of the escalating severity and crisis by death is now muted or rarely seen among young adults, at least in industrialised countries. It remains, however, a captain of the men of death among HIV-infected adults with limited access to antiretroviral treatment and also among small children in the poorest countries without access to antibiotics. Small wonder the consternation then, when multiresistant strains emerged in South Africa in the 1970s. South Africa has a rich history depicting the ravages of pneumonia and its prevention, notably in the gold mines during the early mining years and thereafter, dramatically, its role during the 1918 pandemic influenza. Similarly, medical scientists have been active in the fight against this and other microbial diseases in this country. The early history of pneumococcal vaccines was eruditely described by Dr Robert Austrian in a Jeremiah Metzger lecture entitled ‘Of gold and pneumococci’ in 1977. 1 Because of the public health and financial consequences of pneumonia and other infectious diseases in South Africa and particularly in the mining industry, the South African government with a major input from the mining industry initiated steps which led to the establishment of the South African Institute for Medical Research (SAIMR) in 1912. The principal aim of this decision was to combat the scourge of infectious diseases in the country. Famous names which are linked to the early history of this fight in South Africa include General WCG Gorcas from the United States of America (USA) and Sir Almroth Wright from Britain. Gorcas, who became Surgeon-General of the United States Army, was renowned for his role in ridding the Panama Canal Zone of yellow fever. He was invited to come to South Africa and he and his wife sailed to Cape Town in 1913 accompanied by Major RE Noble and Samuel T Darling. Earlier in 1905, Darling described the pathological features of three fatal cases of histoplasmosis from Martinique and Panama and named the causative organism Histoplasma capsulatum which he thought was a protozoon. During this visit, Gorcas recommended to the Transvaal Chamber of Mines the appointment of Dr AJ Orenstein to assist with the combating of infectious diseases in the mines. Orenstein gained international recognition for his indefatigable energy and drive in the institution of hygienic measures and proper housing with improved bed spacing in dormitories (sleeping compounds) in the mines. His incisive reports also resulted in the reconstruction of hospital wards and operating rooms, the appointment of full time mine medical officers, improved nursing services, better diets for miners, and the introduction of waterborne sewerage on all mines. 1 Wright, who had been called the founder of modern vaccine therapy 2 and was almost as well known for his eccentricity as his scientific expertise, 1 conducted the first pneumococcal vaccine trial in the mines in 1911 with a vaccine which contained multiple local strains of pneumococci, the diversity of which had not been determined. Dr Spencer Lister assisted with this trial and his involvement was the beginning of the illustrious career of Sir Spencer Lister who later HJ Koornhof, 1 SA Madhi, 2,3 C Feldman, 4 A von Gottberg, 2 KP Klugman 2,5 1 National Tuberculosis Reference Laboratory, National Institute for Communicable Diseases, National Health Laboratory Service, and Division of Virology and Communicable Disease Surveillance, University of the Witwatersrand 2 Respiratory and Meningeal Pathogens Research Unit, National Institute for Communicable Diseases, Medical Research Council and University of the Witwatersrand, Johannesburg. 3 Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand. 4 Department of Medicine, Division of Pulmonology, University of the Witwatersrand, South Africa. 5 Hubert Department of Global Health, Rollins School of Public Health and Division of Infectious Diseases, School of Medicine, Emory University, Atlan ta, GA, USA Correspondence to: HJ Koornhof, NTBRL, NICD, Private Bag X4, Sandringham 2131 E-mail: hendrik.koornhof@nhls.ac.za South Afr J Epidemiol Infect 2009;24(4):7-19