World Brain Day 2025 in Piauí, Brazil

A community celebration of brain health focused on adults and older individuals.

By Natalia Rebeca Alves de Karpejany, Pedro Borges Bonfim Jr., Ademir Aragão Moura, Martha Maria da Silva Lira Batista, Denise Falcão Costa Coelho, Támara Larissa Silva Barbosa, Isis Maria Lima da Cruz, Artur Guilherme Feitosa Ferreira, Rafael Armando Coutinho Aguiar, and Yasmin Vitória Luz Alves

Natalia Rebeca Alves de Karpejany

World Brain Day, observed globally on July 22, is dedicated to raising awareness of the importance of brain health and mental well-being at every stage of life. This year, at the University Hospital of the Federal University of Piauí in Brazil, we celebrated the day with a vibrant and inclusive event focused on adults and older individuals. Our goal was to empower our community with simple, practical strategies to maintain a healthy brain.

The day began with a heartfelt video message from Prof. Tissa Wijeratne, co-chair of the World Brain Day campaign, setting a reflective and inspiring tone for the activities to follow. In both morning and afternoon sessions at the hospital’s outpatient clinics, the event provided a warm and engaging environment for patients, staff, students, and residents to come together and learn about the foundations of lifelong brain health.

Our approach emphasized three core principles: quality sleep, balanced nutrition, and regular physical activity. These pillars were tailored to individual needs, making the information both relatable and actionable. Throughout the day, our team — comprised of neurology residents, medical students, and other health care professionals — engaged directly with attendees through one-on-one conversations, interactive Q&A sessions, and informative handouts designed to be taken home and applied in everyday life.

We also conducted brief screening questionnaires and distributed educational materials that highlighted simple lifestyle changes known to enhance brain function and overall well-being.

The response from the community was overwhelmingly positive, with several hundred individuals joining us to learn, connect, and share their experiences.

The event was more than a health campaign; it was a celebration of community, learning, and hope. It reinforced the idea that brain health is not just a medical issue but a vital part of daily life, deserving attention from all of us, regardless of age.

This World Brain Day reminded us that with the right knowledge and support, everyone has the power to protect their brains and enjoy healthier, more fulfilling lives. We look forward to continuing this work in the months and years to come, building a more informed and resilient community together. •

Dr. Natalia Rebeca Alves de Karpejany and Pedro Borges Bonfim Jr. are neurology residents. Dr. Ademir Aragão Moura is a speech therapist. Martha Maria da Silva Lira Batista is a psychologist. Denise Falcão Costa Coelho, Támara Larissa Silva Barbosa, Isis Maria Lima da cruz, Artur Guilherme Feitosa Ferreira, Rafael Armando Coutinho Aguiar, and Yasmin Vitória Luz Alves are medical students. All of the contributors to this article work at University Hospital of the Federal University of Piauí in Brazil.

Three neuroinfections and vaccinations

A story of international collaboration on diphtheria, tetanus, and poliomyelitis.

By Peter J. Koehler

Pierre-Fidèle Bretonneau by René Théodore Berthon (c. 1810). © Académie nationale de médecine, Paris.

A few months after the birth of my grandfather in March 1884, two of his sisters died within 10 days of each other at ages 2 and 3. If we look at the child mortality statistics of that year in the Netherlands, we see that diphtheria, scarlet fever, measles, “other diseases of the respiratory organs,” and “diseases of the digestive organs” were among the major killers of children, especially in the age group of 1 to 4 years.1

It was a time in which knowledge about bacteria was increasing through the work of Robert Koch (1843-1910) and his colleagues. Louis Pasteur (1822-1895) was experimenting with vaccinations with weakened microorganisms. Antibiotics were not yet available. In current times of declining vaccination rates in developed countries, it is useful to revisit the history of some infections that also affect the nervous system.

Diphtheria

Caused by the Corynebacterium diphtheriae, epidemics of diphtheria have probably been recognized since antiquity. Sometimes, the name morbo strangulatorio was given. It was often confused with scarlet fever, caused by toxins of a Streptococcus.

A severe diphtheria epidemic occurred in New England during the 1735-1740 period. It killed more than 5,000 individuals, mostly children.2 In 1825, the French physician Pierre-Fidèle Bretonneau (1778-1862) performed the first successful tracheostomy for diphtheria, on 5-year-old Elizabeth de Puységur and described the contagious nature of the disease in 1826.

At the time, the laryngeal form of diphtheria was often fatal, even if tracheostomy was applied. It was another 60 years before the German physician/bacteriologist Friedrich Loeffler (1852-1915), who had worked with Koch, proved that a specific bacterium was the etiologic agent of diphtheria in 1884. This led to the discovery of antitoxin or serum therapy by Emil von Behring (1854-1917). Von Behring received the Nobel Prize for this work in 1901. The role of Paul Ehrlich (1854-1915) in the discovery was insufficiently recognized. However, he received the Nobel Prize for his work on immunity six years later.

Photomicrograph of a number of Gram-positive Corynebacterium diphtheriae bacteria, stained by the methylene blue technique. © CDC Public Health Image Library (Details: Public Health Image Library [PHIL]).

It was during this period that American physician Joseph O’Dwyer (1841-1898) applied intubation in New York (1890s), leading to successful treatment of asphyxia associated with laryngeal diphtheria. An analysis of data submitted by members of the American Pediatric Society on 1,700 children suffering from laryngeal diphtheria and treated with antitoxin was positive. It showed that antitoxin lowered the necessity for intubation from 90% to 39%. It also lowered the mortality rate from 73% to 27% in this severest form of diphtheria.3

In 1888, Émile Roux (1853-1833, collaborator of Pasteur) and Alexandre Yersin (1863-1843, co-discoverer of Yersinia pestis) were the first to demonstrate that the bacterium causing diphtheria was releasing a deadly toxin. In 1923, Gaston Ramon (1886–1963) treated the toxin with formalin and heat, resulting in the concept of anatoxin as a means of vaccination. The vaccination of infants against diphtheria with the Ramon anatoxin became compulsory in France in 1938.4 The use of anatoxin was a new type of vaccination following those with weakened microorganisms.

What are the symptoms and signs of diphtheria? The disease can have many different symptoms. These depend on the site of infection and whether the bacteria produce toxins. If the infection is confined to the nose, the course is usually mild. With diphtheria on the skin, sores develop there. However, if the respiratory tract is infected, the patient will likely have a fever and may become seriously ill with shortness of breath. It can lead to suffocation.

In 10% to 20% of patients, the toxin affects cardiac muscle and may affect the nervous system. Diphtheritic neuropathy is an acute demyelinating polyneuropathy, which has long been recognized as the most common severe complication. Guillaume-Benjamin-Amand Duchenne (1806-1875) contributed to the description of the disease.5 The patients may experience severe choking, squinting, or poor vision.

Today, diphtheria can be prevented by vaccination. However, multiple doses and booster doses are needed to produce and sustain immunity. Those who are not immunized or under-immunized are at risk of the disease. For unvaccinated individuals without proper treatment, diphtheria can be fatal in about 30% of cases, with young children at higher risk of dying.

Recent diphtheria outbreaks stress the importance of sustaining high levels of vaccination coverage in communities across the life course. In 2023, an estimated 84% of children worldwide received the recommended three doses of diphtheria-containing vaccine during infancy.6

Tetanus

The responsible bacillus Clostridium tetani, an obligate anaerobic bacterium, can form spores that survive in adverse environmental conditions.

Risus sardonicus and trismus (lockjaw) were described in ancient Egypt (c. 1500 BCE). Trismus was mentioned by Hippocrates (c. 460-c. 370 BCE) and opisthotonus by Aulus Cornelis Celsus (c. 25 BCE-50 CE). Aretaeus of Cappadocia (second-century CE) called tetanus an incurable disease.

Post-traumatic tetanus in soldiers has been well documented, and their death often resulted from a wound sustained in battle. The Roman historian Livy (59 BCE-17 CE) wrote about the war between the Romans and the Etruscans, in particular the siege of Sutrium, north of Rome, in 309 BCE. He mentioned that more soldiers died of their injuries after the battle than had fallen on the field. Ibn Sina (Avicenna, 980-1037) also wrote about tetanus.

French surgeon Ambroise Paré (c. 1510-1590) studied trismus and introduced a device to keep a patient’s mouth open despite the abnormal contracture. In 1838, Italian physician Luigi Carlo Farini (1812-1866) lectured on the use of electricity in the treatment of tetanus.7

Emil von Behring (© E. Behring, Digital Collections, National Library of Medicine) and Shibasaburo Kitasato (© [Shibasaburo Kitasato] Digital Collections, National Library of Medicine).

Arthur Nicolaier (1862-1942) described the bacillus in Berlin in 1884. Von Behring and his Japanese colleague Shibasaburo Kitasato (1853-1931) conducted experiments in which they immunized rabbits against an inactivated culture containing Clostridium tetani. They collected the blood from the animals and injected it into the abdominal cavity of mice. After that, they inoculated a virulent culture of the bacillus in the same group of mice.

The diphtheria experiments mentioned above were conducted again shortly thereafter by von Behring using guinea pigs. In 1890, they were able to produce the first serum capable of counteracting tetanus toxins.8 Serum therapy against tetanus was used widely during World War I, when it was administered to wounded soldiers admitted to military hospitals.9

The tetanus toxin was discovered by three groups of researchers in Denmark, France, and Italy. It was able to induce the disease and kill mice, guinea pigs, and rabbits. A vaccine was developed in a similar way as described above on diphtheria in the 1920s.

Poliomyelitis

Poliomyelitis, or polio, has been documented for many centuries. A funeral stele of the priest Ruma from the 19th Egyptian dynasty shows atrophy and shortening of the leg, which was probably caused by the disease.5 Although not yet described in Michael Underwood’s (1737-1820) first edition of his Treatise on the Diseases of Children, he described infantile poliomyelitis in the second edition of 1789.10,11 In a chapter titled “Debility of the Lower Extremities,” we find the following text:

“It seems to arise from debility, and usually attacks children previously reduced by fever … a debility of the lower extremities, which gradually become more infirm, and after a few weeks are unable to support the body. … When only one of the lower extremities has been affected, the above means, in two out of five or six, entirely removed the complaint: but when both have been paralytic, nothing has seemed to do any good but irons to the legs, for the support of the limbs, and enabling the patient to walk. At the end of four or five years, some have by this means got better, in proportion as they have acquired general strength …” 11

Figure 1. Heine’s third case K.M. on admission and after two years of treatment.

The German orthopedist Jacob Heine (1800-1879) described anterior poliomyelitis in 1838, when a child was demonstrated in Freiburg, and more extensively in his monograph Beobachtungen über Lähmungszustände der unteren Extremitäten und deren Behandlung [Observations on Paralysis Conditions of the Lower Extremities and Their Treatment] of 1840. (See Figure 1.)12

Although the disease was described in the first two editions (1855 and 1861), Duchenne gave an extensive description in the second chapter, “Paralysie Atrophique de l’Enfance,” of his De l’électrisation Localisée et de son Application à la Physiologie, à la Pathologie, et à la Thérapeutique [Localized Electrification and its Application to Physiology, Pathology, and Therapeutics], In that chapter, Duchenne wrote that he saw anterior horn cell atrophy.13

The atrophy of the anterior horn was confirmed by Victor André Cornil (1837-1908) in 1863.5 At a meeting of the Société de Biologie on Nov. 13, 1869, Jean-Martin Charcot (1825-1893) and Alix Joffroy (1844-1908) demonstrated pathology data of a patient who suffered from “paralysie infantile” at age 7 and died of pulmonary consumption at age 32:

“M. Charcot concluded that his case involved infantile paralysis, basing himself on the essential facts of the sudden development of the successive events of paralysis, of the muscle atrophy with limb deformity. He adds that the muscular atrophy seems to him to be linked to the lesion of the spinal cord, which he considers to reside in the anterior horns, and considers it to be subordinate to the lesion of the white matter when it exists.”14

Representation of a probable polio victim, Egypt, around Amenophis III’s reign, 1403-1365 BCE; © Ny Carlsberg Glyptotek, Copenhagen.

Polio became the first disease of the nervous system to be described clinically and from the laboratory standpoint. The epidemic nature was noted by the Swedish pediatrician Karl Oskar Medin (1847-1927) in 1890.15 It was the Swedish physician Ivar Wickman (1872-1914) who, during the Swedish epidemic of 1905, described the infectious nature of the virus in a monograph in 1907.16 As written by Flexner and Lewis, “The most convincing evidence of the contagiousness of epidemic poliomyelitis is supplied by Wickman’s studies of several Swedish epidemics.”17

Two groups were able to transmit the virus and the disease to monkeys.5  Karl Landsteiner (1868-1943), who left Vienna for The Hague (1919-1922) and then New York (1922), and Erwin Popper (1875-1955) transmitted polio to monkeys by intraperitoneal injection of spinal cord material from a child who had died of polio in 1909. Simon Flexner (1863-1946) and Paul A. Lewis (1879-1929) reported similar experiments in 1910: “In September 1909, we secured the spinal cord from two cases of infantile paralysis in human beings.”17

Figure 2. Eugène-Joseph Woillez’s design: “The adult spirophore is far too large for use in newborns; a small apparatus, of which we provide a drawing, is sufficient to treat their asphyxia.”18

Poliomyelitis played an important role in the development of mechanical ventilation and intensive care. The first iron lung, or “spirophore,” was built by Eugène-Joseph Woillez (1811-1882) for drowning victims in in 1876 in Paris.

“Dès l’année 1854, il y a plus de vingt ans, je déposais sous pli cacheté, à l’Académie des sciences (Institut de France), la description d’un appareil qui était l’application primitive du principe de respiration artificielle, d’après lequel a été construit plus tard le spirophore.18 [As early as 1854, more than 20 years ago, I deposited in a sealed envelope to the Académie des Sciences (Institut de France), the description of an apparatus the primitive application of the principle of artificial respiration, after which the spirophore was later constructed].”

A smaller apparatus for asphyxia was suggested by him. (See Figure 2.) An apparatus that was more widely used, however, was made in Boston in 1929 by the industrial hygienist Philip Drinker (1894-1972) and instructor of physiology Louis Agassiz Shaw (1886-1940). The iron lung is a cylinder in which, with the aid of a piston, alternating negative and positive pressures can be created. It was used to treat patients with polio.19

Children in an iron lung ventilator before the advent of the polio vaccination, 1937. The children’s heads poked through a hole at the back of the room so they could communicate with each other. (Permission was not obtained for the more familiar photo taken from the other side, with the faces of the children and nurse recognizable.) © Boston Children’s Hospital.
A short film (1939) on the iron lung ventilator can be found on Wikipedia. © Netherlands Institute of Sound and Vision.

In 1952, Denmark was hit by a major epidemic of poliomyelitis. Within a few months, 2,300 patients were admitted, 1,000 of whom developed paralytic symptoms. The physicians realized that it was not the virus that was the direct cause of death, but rather carbonic acid intoxication due to severe hypoventilation. With the help of 250 medical students, 600 nurses and many volunteers, manual ventilation reduced mortality from 90% to 25%.20 The epidemic soon led to the construction of positive pressure ventilators.21

In 1954, John F. Enders (1897-1985), Thomas H. Weller (1915-2008), and Frederick C. Robbins (1916-2003) received the Nobel Prize “for their discovery of the ability of poliomyelitis viruses to grow in cultures of various types of tissue.” It provided opportunities to produce polio vaccines, both inactivated as well as live.

Global immunization against polio became possible through two types of vaccines. The first, “salkvaccin,” was an inactivated preparation developed by Jonas E. Salk (1914-1995) and his co-workers. The live, attenuated virus preparations were developed by several people, including Albert B. Sabin (1906-1993), whose vaccine preparation can be taken orally. These vaccines have dramatically changed the lives of millions of children and proved extraordinarily effective.22

In 1988, the World Health Assembly, the decision-making body of the World Health Organization (WHO), adopted a resolution for the worldwide eradication of polio, marking the launch of the Global Polio Eradication Initiative. Wild poliovirus cases have decreased by more than 99% since 1988, from an estimated 350,000 cases in more than 125 endemic countries to six reported cases in 2021.23 •

References:

  1. Sterfte-oorzaken in het jaar 1884 NTVG 1885;29:123-4.
  2. Shulman ST. The History of Pediatric Infectious Diseases. Pediatr Res. 2004 Jan;55(1):163-76.
  3. Northrup WP, O’Dwyer J, Holt LE, Adams SS. The American pediatric society’s report of the collective investigation of the antitoxin treatment of laryngeal diphtheria in private practice. Trans Am Pediatr Soc. 1897;9:32-38.
  4. Cavaillon JM. From Bacterial Poisons to Toxins: The Early Works of Pasteurians. Toxins (Basel). 2022 Nov 3;14(11):759.
  5. McHenry LC. Garrison’s History of Neurology. Thomas, Springfield, Illinois, 1969.
  6. World Health Organization, July 2024 Diphtheria. Accessed March 16, 2025.
  7. Galassi FM, Bianucci R, Donell ST, Vittori V, Nerlich A, Martini M, Varotto E. Tetanus: historical and palaeopathological aspects considering its current health impact. J Prev Med Hyg. 2025 Jan 31;65(4):E580-E585.
  8. Pucca MB, Cerni FA, Janke R, Bermúdez-Méndez E, Ledsgaard L, Barbosa JE, Laustsen AH. History of Envenoming Therapy and Current Perspectives. Front Immunol. 2019 Jul 10;10:1598.
  9. Kaufmann SH. Remembering Emil von Behring: From Tetanus Treatment to Antibody Cooperation With Phagocytes. mBio. 2017 Feb 28;8(1):e00117-17.
  10. Underwood M. A treatise on the diseases of children, with directions for the management of infants from the birth. London, Mathews, 1784.
  11. Underwood M. A treatise on the diseases of children, in two parts, etc. London, Mathews, 1789; vol. 2, p. 53.
  12. Heine J (1840) Beobachtungen über Lähmungszustände der unteren Extremitäten und deren Behandlung. Köhler, Stuttgart.
  13. Duchenne GA. De l’électrisation localisée et de son application à la physiologie, à la pathologie et à la thérapeutique saw anterior horn cell atrophy. Paris, Baillière, 1872, pp. 381-425.
  14. Charcot JM, Joffroy A. Une observation de paralysie infantile s’accompagnant d’une altération des cornes antérieures de la substance grise de la möelle. CR Soc Biol 1870;1 :312-5.
  15. Medin O. En epidemi af infantil paralysi [An epidemic of infantile paralysis]. Hygiea, Stockholm, 1890, 52:657-668.
  16. Wickman I. Beiträge zur Kenntnis der Heine-Medinschen Krankheit (Poliomyelitis acuta und verwandter Erkrankungen). Berlin, Karger, 1907.
  17. Flexner S, Lewis PA. Experimental epidemic poliomyelitis in monkeys. J Exp Med. 1910;12(2):227-55
  18. Woillez EJ. Appareil de sauvetage pour le traitement de l’asphyxie et principalement de l’asphyxie des noyés et des nouveau-nés : du spirophore. Paris, Delahaye, 1876.
  19. Drinker P, Shaw LA. An apparatus for the prolonged administration of artificial respiration: I. A design for adults and children. J Clin Invest 1929;7:229–247.
  20. Meinesz AF, Wijkstra PJ, Zijlstra JG, Albers MJ, Köter GH. Van de poliomyelitisepidemie naar de oprichting van beademingscentra, intensivecareafdelingen en centra voor thuisbeademing [From the poliomyelitis epidemic to the founding of artificial respiration centres, intensive care units and centres for home mechanical ventilation]. Ned Tijdschr Geneeskd. 2006 Feb 25;150(8):444-9.
  21. Slutsky AS. History of Mechanical Ventilation. From Vesalius to Ventilator-induced Lung Injury. Am J Respir Crit Care Med. 2015 May 15;191(10):1106-15.
  22. Norrby E, Prusiner SB. Polio and Nobel prizes: looking back 50 years. Ann Neurol. 2007 May;61(5):385-95.
  23. World Health Organization Poliomyelitis (polio). Accessed March 23, 2025.
« Previous Page