Index case

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The index case or patient zero is the first documented patient in a disease epidemic within a population,[1] or the first documented patient included in an epidemiological study.[2] It can also refer to the first case of a condition or syndrome (not necessarily contagious) to be described in the medical literature, whether or not the patient is thought to be the first person affected.[citation needed] An index case can achieve the status of a "classic" case study in the literature, as did Phineas Gage, the first known person to exhibit a definitive personality change as a result of a brain injury.[3]


The index case may or may not indicate the source of the disease, the possible spread, or which reservoir holds the disease in between outbreaks, but may bring awareness of an emerging outbreak.[4][5] Earlier cases may or may not be found and are labeled primary or coprimary, secondary, tertiary, etc.[4] The term primary case can only apply to infectious diseases that spread from human to human, and refers to the person who first brings a disease into a group of people.[5] In epidemiology, the term is often used by both scientists and journalists alike to refer to the individual known or believed to have been the first infected or source of the resulting outbreak in a population as the index case, but such would technically refer to the primary case.[5][6]

Patient zero was used to refer to the supposed source of HIV outbreak in the United States, flight attendant Gaëtan Dugas, but later research found he was not the index case of this outbreak.[7] The expression was based on a misunderstanding: in the 1984 study of Centers for Disease Control and Prevention (CDC), one of the earliest recorded HIV-patients was code-named "patient O", which stands for "patient out of California". The letter O, however, was interpreted by some readers of the report as the numeral 0. The designation patient zero (for Gaëtan Dugas) was subsequently propagated by the San Francisco Chronicle journalist Randy Shilts in his book And the Band Played On in 1987.

The term has been expanded into general usage to refer to an individual identified as the first carrier of a communicable disease in a population (the primary case), or the first incident in the onset of a catastrophic trend.[8][9] In some cases, a known or suspected patient zero may be informally referred to as an index case for the purpose of a scientific study, such as the two-year-old boy in a remote village in Guinea who was thought to be the source of the largest Ebola virus outbreak in history.[2][10]

In genetics, the index case is the case of the original patient (i.e. propositus or proband) that stimulates investigation of other members of the family to discover a possible genetic factor.[11]

The term can also be used in non-medical fields to describe the first individual affected by something negative that since propagated to others, such as the first user on a network infected by malware.[12]


Gaëtan Dugas[edit]

A now disproven 1984 paper[13] linked 40 AIDS patients by sexual contact. Of those patients, Dugas was supposedly the first to experience an onset of symptoms of AIDS. In the above graph, Dugas is represented by the circle labeled 0, highlighted in red.

In the early years of the AIDS epidemic, a patient zero transmission scenario was compiled by Dr. William Darrow and colleagues at the United States Centers for Disease Control and Prevention (CDC).[14] This epidemiological study showed how patient zero had infected multiple partners with HIV, and they, in turn, transmitted it to others causing rapid spread of the virus to locations all over the world (Auerbach et al., 1984). The CDC identified Gaëtan Dugas as a carrier of the virus from Europe to the United States, who spread it to other men he had intimate relations with at gay bathhouses.[15]

Journalist Randy Shilts subsequently wrote about patient zero, based on Darrow's findings,[14] in his 1987 book And the Band Played On, which identified patient zero as being Gaëtan Dugas.[16] Dugas was a flight attendant who was sexually promiscuous in several North American cities, according to Shilts' book. He was vilified for several years as a "mass spreader" of HIV, and was seen as the original source of the HIV epidemic among homosexual men. Four years later, Darrow repudiated the study's methodology and how Shilts had represented its conclusions.[14]

A 2007 study by Michael Worobey and Dr. Arthur Pitchenik published in the Proceedings of the National Academy of Sciences of the United States of America claimed that, based on the results of genetic analysis, current North American strains of HIV probably moved from Africa to Haiti before entering the United States around 1969,[17] probably through a single immigrant. However, a teenager named Robert Rayford died in St. Louis, Missouri, possibly of complications from AIDS in 1969, having most likely become infected with the virus before 1966. This would imply that there were prior carriers of HIV-strains in North America.[18][19]

The phrase patient zero is now used in the media to refer to the primary case for infectious disease outbreaks, as well as for computer virus outbreaks, and more broadly, as the source of ideas or actions that have far-reaching consequences.[20][21][22][23][24]

David Heymann, professor of Infectious Disease Epidemiology at the London School of Hygiene & Tropical Medicine, and formerly with the World Health Organization (WHO),[25] has questioned the importance of finding patient zero, stating, "Finding patient zero may be important in some instances, but only if they are still alive and spreading the disease; and more often than not, especially in large disease outbreaks, they're not."[26]


  • Mary Mallon ("Typhoid Mary") was an index case of a typhoid outbreak in the early 1900s. An apparently healthy carrier, she infected 47 people while working as a cook. She eventually was isolated to prevent her from spreading the disease to others.[27]
  • The first recorded victim of Ebola was a 44-year-old schoolteacher named Mabalo Lokela, who died on 8 September 1976, 14 days after symptom onset.[28]
  • 64-year-old Liu Jianlun, a Guangdong doctor, transmitted SARS internationally by infecting other super-spreaders during a stay in the Hong Kong Metropole Hotel in 2003.[29][30]
  • A baby in the Lewis House at 40 Broad Street is considered the index patient in the 1854 cholera outbreak in the Soho neighborhood of London. (The Ghost Map, Steven Johnson, 2005.)[31]
  • Édgar Enrique Hernández may be patient zero of the 2009 flu pandemic.[32] He recovered, and a bronze statue has been erected in his honor.[33] Maria Adela Gutierrez, who contracted the virus about the same time as Hernández, became the first officially confirmed fatality.
  • One-year-old Emile Ouamouno is believed to be patient zero in the 2014 Ebola epidemic in Guinea and West Africa.[34]
  • 51-year-old Jesus Lujan was the index case of the 1924 Los Angeles pneumonic plague outbreak which killed 33.
  • Sgt. Albert M. Gitchell is commonly believed to be the index patient of the Spanish flu, which killed 50,000,000 from 1918 to 1920. Gitchell survived and died in 1968.
  • The first confirmed case of the COVID-19 disease, caused by the SARS-CoV-2 virus, was traced back to a 55-year-old patient in Hubei province, and was reported in a Chinese newspaper on 17 November 2019.[35] Nonetheless, more recently, on 27 March 2020, news outlets, citing a government document, reported that a 57-year-old woman, who tested positive for the coronavirus disease on 10 December 2019, and described in The Wall Street Journal on 6 March 2020, may have been patient zero in what became a pandemic.[36][37]

Non-medical usage[edit]

The term is used to identify the first computer or user to be infected with malware on a network, which then infected other systems.[12][38]

Monica Lewinsky has described herself as the "patient zero" of online harassment, meaning that she was the first person to receive widespread public harassment via the internet.[39]

In the media[edit]

In journalism and documentaries[edit]

The thirteenth season of the WNYC radio series Radiolab included an hour-long segment on patient zero.[40]

In fiction[edit]

  • The film Outbreak focuses around the search for a patient zero of an epidemic.
  • The novel Rant stars the character Rant Casey, patient zero of the book's rabies epidemic.
  • The phone game Plague Inc. can have the CDC look for patient zero for more info on the player's virus.
  • In the video game Dead Rising 3 the protagonist, Nick Ramos, is patient zero of the zombification phenomenon.
  • The film Contagion character Elizabeth Emhoff is patient zero of the fatal MEV-1 virus.
  • Tarman from The Return of the Living Dead can be considered the story's patient zero as the toxic smokes that leak out his broken barrel kickstart a zombie outbreak by bringing the dead back to life and slowly turning into zombies the living who inhaled the contents of his drum.
  • In Peter Jackson's Braindead Vera Cosgrove, the abusive mother of the protagonist, is infected by the bite of the Sumatran Rat-Monkey at the zoo, thus becoming undead and eventually the cause of the movie's zombie outbreak.
  • In the horror comedy Slither Grant Grant is patient zero and host of the "Long One", an alien parasite that takes over his body after crashing on Earth inside a meteorite and through him it infects other people to generate alien zombies and fuse together to grow larger and spread all over the planet.
  • The main character of Zombieland only mentions the cause of the plague being a patient zero who bit into a burger that contained a mutated strain of mad cow disease.
  • In the Planet of the Apes film series, Robert Franklin (portrayed by Tyler Labine) is patient zero of the Simian flu pandemic.
  • In the game Prototype, Alex Mercer steals something in GenTek labs and becomes the unwilling patient zero for the virus the lab created.
  • In the TV series Fear The Walking Dead, Gloria is speculated to be patient zero in the show's pilot.
  • In the animated TV series South Park, in S1E7 episode "Pinkeye" Kenny became patient zero of a zombie epidemic. In a later episode, "The Pandemic Special", Randy Marsh and Mickey Mouse are both revealed to be patient zero of COVID-19 after having group sex with a pangolin in China.
  • In the book series The Passage, Timothy Fanning is patient zero of the virus that caused the near extinction of humanity and responsible for the outbreak of the new "viral" race of vampires.
  • In the 2013 film World War Z the protagonist Gerry Lane (Brad Pitt) searches for patient zero of a Zombie Apocalypse.
  • In the tokusatsu series Kamen Rider Ex-Aid, the protagonist Emu Hojo is patient zero of a digital virus that kills those infected by it and replace them with videogame characters. Although he manages to survive and develop immunity, the infection spreads, threatening humanity.
  • In the video game Hitman and its sequel, Hitman 2, a DLC called Patient Zero is available, where the protagonist (Agent 47) must eliminate targets who helped create the fictional Nabazov virus. This DLC culminates in a mission also named "Patient Zero". One of the targets to be killed in the mission is Owen Cage, the patient zero, leading to the virus being eradicated.
  • In the TV series Sliders, in S1E2 episode "Fever" an alternate version of Quinn Mallory became Patient Zero.

See also[edit]


  1. ^ "Diseases – Activity 1 – Glossary, page 3 of 5". Retrieved 2017-11-10.
  2. ^ a b "WordNet Search – 3.0". Princeton University, Retrieved 3 November 2010.
  3. ^ "Why Brain Scientists Are Still Obsessed With The Curious Case Of Phineas Gage". Retrieved 2017-11-18.
  4. ^ a b "Sporadic STEC O157 Infection: Secondary Household Transmission in Wales". Centers for Disease Control and Prevention, USA. 1 January 1994. Retrieved 3 November 2010.
  5. ^ a b c Giesecke, Johan (2014). "Primary and index cases". The Lancet. 384 (9959): 2024. doi:10.1016/s0140-6736(14)62331-x. PMID 25483164.
  6. ^ "index case". HarperCollins. Retrieved 2017-11-18.
  7. ^ Davis, Nicola (27 October 2016). "Gaétan Dugas: 'patient zero' not source of HIV/Aids outbreak, study confirms". The Guardian.
  8. ^ "Patient Zero – definition of Patient Zero in the Medical dictionary – by the Free Online Medical Dictionary, Thesaurus and Encyclopedia". Retrieved 3 November 2010.
  9. ^ "patient zero | Definition of patient zero in English by Oxford Dictionaries". Oxford Dictionaries | English. Retrieved 2017-11-18.
  10. ^ "Ebola outbreak: 'Patient zero' at start of deadly virus spread". The Independent. 2014-08-11. Retrieved 2017-11-18.
  11. ^ "Definition of index case". The free medical dictionary by farlex.
  12. ^ a b "Search for patient zero: uncovering malware infection at the source". Infosecurity Magazine. 10 July 2012. Retrieved 31 March 2017. Medical researchers look for patient zero to find out where a virus outbreak started and what places and people patient zero came into contact with in order to contain the outbreak and prevent further infections. Similarly, infosec researchers need to look for the user who first introduced the malware into the network, which application was carrying the malware, and the files that are causing it to spread in order to contain it, eliminate it, and prevent reinfection, explained Huger, vice president of development at Sourcefire's cloud technology group.
  13. ^ Auerbach, David M.; Darrow, William W.; Jaffe, Harold W.; Curran, James W. (1984). "Cluster of cases of the acquired immune deficiency syndrome. Patients linked by sexual contact". The American Journal of Medicine. 76 (3): 487–92. doi:10.1016/0002-9343(84)90668-5. PMID 6608269.
  14. ^ a b c "The Origin of HIV and the First Cases of AIDS". AVERT. Retrieved 2010-11-03.
  15. ^ Pence, G. E. (2008). Preventing the Global Spread of AIDS. In Medical Ethics Accounts of the Cases That Shaped and Define Medical Ethics (p. 331). New York, USA, McGraw-Hill.
  16. ^ Matt & Andrej Koymasky - Famous GLTB - Gaëtan Dugas Archived December 14, 2005, at the Wayback Machine
  17. ^ Bowdler, Neil (2007-10-30). "Key HIV strain 'came from Haiti'". BBC News. Retrieved 2010-05-05.
  18. ^ "HIV Spread from Haiti to NYC in 1970". The Scientist.
  19. ^ Worobey, Michael et al "1970s and 'Patient 0' HIV-1 genomes illuminate early HIV/AIDS history in North America" Nature (2016) doi:10.1038/nature19827
  20. ^ "Have Doctors Found Swine "Patient Zero?"". CBS News. 2009-04-29.
  21. ^ "Researchers trawl for Conficker's 'Patient Zero' –". Archived from the original on 2011-07-18. Retrieved 2010-11-03.
  22. ^ "Patient Zero". 2006-03-20. Retrieved 2010-11-03.
  23. ^ Lemos, Robert. "Witty worm traced to 'Patient Zero'". The Register.
  24. ^ "That Man in the White House". The Weekly Standard. 28 November 2003. Retrieved 3 November 2010.
  25. ^ "WHO | Members of, and Advisers to, the International Health Regulations (2005) Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations". WHO. Retrieved 2019-12-25.
  26. ^ Mohammadi, Dara (2015-01-15). "Finding patient zero". The Pharmaceutical Journal. 294 (7845). Retrieved 2015-01-16.
  27. ^ "NOVA | The Most Dangerous Woman in America | In Her Own Words". PBS. 1938-11-11. Retrieved 2010-11-03.
  28. ^ "Ebola haemorrhagic fever in Zaire, 1976" (PDF). Bull. World Health Organ. 56 (2): 271–93. 1978. PMC 2395567. PMID 307456. Archived from the original (PDF) on 8 August 2014. Retrieved 22 May 2018.
  29. ^ "How SARS changed the world in less than six months" (PDF). Bulletin of the World Health Organization. 81 (8). 2003.
  30. ^ Laurance, Jeremy (2003-04-24). "One family went on holiday – and made Toronto a global pariah". The Independent. London. Retrieved 2010-05-05.
  31. ^ "Molecular Interventions – CLOCKSS" (PDF). Retrieved 14 October 2014.
  32. ^ "Have Doctors Found Swine "Patient Zero?"". CBS News. 2009-04-29. Retrieved 2010-11-03.
  33. ^ "Statue erected of first boy in world who caught swine flu". Mirror. Retrieved 2009-04-25.
  34. ^ Beukes, Suzanne (2014-10-28). "Finding Ebola's 'patient zero'". The Guardian. Retrieved 28 November 2014.
  35. ^ Walker, James (14 March 2020). "China Traces Cornovirus To First Confirmed Case, Nearly Identfying 'Patient Zero'". Newsweek. Retrieved 14 March 2020.
  36. ^ Oliveira, Nelson (27 March 2020). "Shrimp vendor identified as possible coronavirus 'patient zero,' leaked document says". New York Daily News. Retrieved 27 March 2020.
  37. ^ Page, Jeremy; Fan, Wenxin; Khan, Natasha (6 March 2020). "How It All Started: China's Early Coronavirus Missteps". The Wall Street Journal. Retrieved 27 March 2020.
  38. ^ Savitz, Eric (5 June 2012). "Finding Patient Zero: The Key To Responding To Malware Attacks". Forbes. Retrieved 31 March 2017. In the physical world, the first thing researchers look for during an outbreak is patient zero. Where did the virus start and where are all of the places and who are all of the people it could have touched? In the cyber world this almost never happens. But it is just as fundamental.
  39. ^ Merica, Dan (October 21, 2014). "Lewinsky makes emotional plea to end cyberbullying". CNN. Retrieved October 22, 2014.
  40. ^ "Patient Zero - Updated". Radiolab. Season 13, Episode 3. Retrieved November 15, 2015.

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