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India was plague-free from 1966 until 1994. In August 1994, a large rat die-off occurred in Mamala, a village near Beed. In September/October there were cases of plague in the city of Beed in the state of Maharashtra. Shortly afterwards there were numerous cases in the coastal city of Surat, 300 km further west in the state of Gujarat on the Gulf of Khambhat (250 km north of Bombay).
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Hundreds of thousands of people fled the city and headed for Bombay, New Delhi and Calcutta. The panic reactions and the enormous media response which then followed show how this disease still plays on the imagination and fears of mankind and what impact the media can have. However, the outbreak remained limited as a result of rapid intervention. About 800,000 tetracycline tablets were immediately distributed via the Haffkine Institute in Bombay and subsequently a further 10,000,000 were flown in. Hundreds of tons of DDT and malathion were dispersed around Beed and the neighbouring cities. Measures then followed to sanitise the mountains of rubbish and waste (breeding sites for rats). A vaccine against plague is available, but it was not used for various reasons. Question marks still remain. For example, why were there so many cases of pneumonic plague and so few of bubonic plague? Ribotyping indicated that this was a new strain of Y. pestis (new ribotype). The cheopsis index of the rats was < 5. The surrounding temperature was often 35°C, which should have made an epidemic from fleas particularly difficult. Are there still missing data in the chain of transmission?
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Response of other countries during the epidemic in India (1994)
In view of the epidemic potential of plague and the horror of the Black Death in the Middle Ages, international reaction was very intense when the epidemic in India was discovered. Detailed and reliable information was lacking at the outset. Several countries closed their borders to travellers from India, some airline companies cancelled all flights to India, trade embargoes were declared, and countries such as the United Arab Emirates even stopped postal traffic from India. Endless questions sprang up on the most varied of occasions. In retrospect, a more sober approach should have been adopted. It was not possible to deny the outbreak, but exaggerated reactions are best avoided. The potential for spread has to be monitored very rapidly. An efficient surveillance system has to be effective without being too cumbersome, either for the public or for the people responsible for implementing it. An outline is given below of how the CDC (Centers for Disease Control, USA) responded to this particular epidemic outbreak.
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1. Dissemination of information
The target groups were: the media, the public, doctors, authorities and public health personnel. Information was disseminated:
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2. Surveillance
Because resources were limited, primary, active, first-line surveillance was focused on individual critical control points, such as large international airports. Secondary, passive surveillance through private doctors and hospitals was less intensive, but more extensive. Follow-up of contacts was entrusted to existing epidemiological services, which were temporarily reinforced with additional staff.
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Active surveillance through permanent medical staff at the major airports. Aircraft personnel were specifically asked to be on the alert for people with fever, chills or cough. Sick people were examined at the airport by the quarantine staff, with telephone back-up from the duty doctor at CDC. If these doctors suspected an individual had plague, the patient was isolated and afterwards hospitalised in a predetermined hospital, where further investigations were carried out to establish whether this was in fact plague or whether it involved a different condition. If the airport doctors considered that the risk of plague was low, people were nevertheless recommended to monitor their temperature for 7 days. If the person was hospitalised, all fellow passengers were advised to monitor their temperature and report any illness. Passengers who were seated within a radius of 2 metres of the suspect person were considered to have a substantial risk of secondary transmission. The argument behind this was that as a result of the downward air stream in aircraft cabins an aerosol cannot spread much further than 2 meters. They received advice to begin prophylaxis with antibiotics and to take them for 7 days. If a case of plague was subsequently confirmed, all passengers were to be contacted and monitored.
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Passive surveillance. For people who became ill after disembarking, reliance was placed on private doctors and those doctors in hospitals. They could always telephone the CDC’s permanent duty unit. If suspected, the patient was hospitalised in isolation, diagnostic specimens were taken and treatment with antibiotics instituted. Contacts were traced and prophylactic antibiotics recommended. Investigations were undertaken to discover whether the patient was already symptomatic during the aeroplane journey. If so, the passenger list was requested, together with the seat numbering. All fellow passengers were contacted.
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3. End
At the end of October 1994 an on-site investigation by a WHO team established that the epidemic was more limited than had first been assumed and was declining. The increased surveillance that had lasted for a month was lifted. However, several cases were again reported in February 2002.
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Note: Doctors and the press
Sooner or later a number of us, whether we like it or not, will have to talk to the press. It is best to consider this in advance. The time frame is usually very short so that the complex situations with all the scientific uncertainties associated with the various aspects cannot be described in detail. There should be uniformity about: (1) what the message is, (2) who the main audience is, (3) who is to present the message. For this, joint consideration should be given in advance to:
