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Table of Contents:

Abstract
Introduction
Definition and Description of Plague
Brief History of Plague Epidemics
Facts of the Outbreak
Conditions for India's 1994 Plague Outbreak
WHO Plague Action Plan, Compared with Actions Actually Taken in India to Curb the Epidemic of Plague

Prevention from Exposure for Local Residents
Policy Options and Conclusions
Appendices
References

Abstract:

Untreated bubonic plague, a bacterial infection transmitted to humans by the bite of a flea when preferred blood meals are not available from rats or cats, becomes systemic with person-toperson airborne droplets spread by coughing. This is pneumonic plague which occurred in Surat, India in September 1994. The spread of pneumonic plague was probably due to workers with incubating plague leaving Maharashtra, arriving at Surat's crowded riverside shanty-town. Prodromal conditions in Maharashtra included a recent earthquake, corpses of animals ignored due to Indian aversion to touching dead beings, and Hindu customs preventing people from killing rats. Surat's pneumonic plague caused panic which drove thousands of people to cities all over India where cases of plague were reported. A brief history of the plague outbreak and techniques for prevention and containment are summarized. The paper discusses inappropriate government directives, the suppression of actual case numbers, panicbuying of Tetracycline (inexpensive antibiotic treatment) causing shortages, and delayed intervention at several levels. All these factors contributed to the spread of plague .

Key words: Plague epidemic, bubonic, pneumonic; plague: history; plague: prevention; plague: treatment; rats, fleas, India, Tetracycline

Introduction

"Plague" is a part of all human history, and delivers a twinge of fear to persons who may be exposed to the disease. In this day of rapid air travel, exposure to an epidemic outbreak of plague which is occurring half-way around the world can impinge on our security. If an individual developed symptoms of plague after arriving in a distant city, we expect public health authorities would take immediate action to control the possibility of disease spread, and isolate, diagnose, and properly treat the individual. Ineffective procedures allowing spread of plague undermine the public's confidence in health policy which should protect citizens from illness. Residents of any country want to trust in the training of employees who work at docks where boats bring huge sealed containers from India. Rats rarely escape from measures designed to eliminate them. Airline hostesses would also receive training to recognize a possibly serious contagious disease on long airplane flights if a person showed suggestive symptoms. Ground crews would be prepared to isolate such an individual on arrival. written information would be given to passengers debarking the plane to take certain steps should they note specific symptoms. These methods citizens expect will always be done to protect them from a serious imported health problem which could spread rapidly in a vulnerable population. Unfortunately, for reasons related to political, financial, educational, communication, and public health structural problems, India was not prepared to deal with an outbreak of plague in 1994.

Definition and Description of Plague:

Plague is a bacterial infection caused by the bacterium Yersinia pestis. The causative organism is carried by rodents (the reservoir of infection) and spread by the bite of a flea (Xenopsylla cheopsis). When certain breeds of susceptible rats (sylvatic plague: Rattus rattus, bubonic plague: Rattus norwegicus and ground squirrels) become infected and die off, the fleas look to other, less preferable sources of blood meals: cats, dogs and humans. People entering the area where rats and humans live intimately become infected by bites of infected fleas causing the more common bubonic plague, or "Black Death." When not treated, bubonic disease becomes systemic and effects the lungs and other vital organs; coughing spreads plague bacillus through the air. This virulent infection then spreads by droplet from person-toperson, and when inhaled, infects the lungs causing pneumonic plague. Plague may become systemic initially, causing death the first day of the infection (septicemic plague). Plague meningitis is more rare, developing over a week after the original infection was inadequately treated: mortality is high (Butler in Strickland, 1991, pp. 411-414). Humans are an "accidental host"-they play no role in the continuation of spread of plague in nature except in pneumonic spread, person-to-person (Butler, p. 409). Appendix A illustrates transmission patterns of the three types of plague.

Signs of bubonic plague will occur within 1-7 days of infection: fever, chills, headache, malaise, aching muscles, prostration, nausea, and abdominal discomfort. Bubonic plague will manifest in swollen and "exquisitely" tender Iymph nodes (buboes) especially in the groin, occasionally under the arms or in the neck (the patient will hold his head sideways to relieve the discomfort from the swelling). Other symptoms, which gave Black Death its name, include hemorrhage, but at the same time widespread clotting of the blood in blood vessels, causing 1centimeter areas of necrosis (dead tissue which turns black) and becomes gangrenous rapidly (Taylor, 1985, p. 1301). Untreated, this is fatal in 50% of cases (Benenson,1990, p.324). Pneumonic plague symptoms include cough, bloody sputum, sub sternal chest pain (from the enlarged Iymph nodes in the mediastinal area) and difficulty breathing. Septicemic plague may result in sudden and intense shock without signs of localized infection. A person may show combinations of symptoms of any of these three types (MMWR, 1994, 689-690). Untreated pneumonic and septicemic plague are invariably fatal. Early treatment with streptomycin or tetracycline improves survival considerably. Recovery from plague does not confer immunity: reinfection occurs (Benenson, 1990, p. 324, 326).

Brief History of Plague Epidemics

Plague is one of the oldest diseases recorded. l Samuel 5:9 says, . . . "the Lord's hand was against that city, throwing it into a great panic. He afflicted the people of the city, both young and old, with an outbreak of tumors in the groin."

How did plague spread from the Middle East in 1000 BC as widely as it now exists? "An understanding of the geographic diffusion process of a disease can result in new insights into its environmental associations, means of survival between epidemics, and transmission" (Meade,1988, p. 250). Historically, plague has been spread from one country to another by rats in the holds of ships, fleas in bundles of blankets on the backs of camels, or in backpacks, and through people traveling from place to place, infected with the bacillus but not yet showing any symptoms. Countries with basic public health needs may be more likely to have large outbreaks of infectious diseases. Rats and fleas are frequently associated with poor sanitation, especially when living intimately with humans in crowded slum conditions. Epidemics of plague occurred in 542 AD in Egypt, Turkey and Europe, in the fourteenth century in Asia Minor, Africa and Europe (killing about 25% of the population), in Europe during the fifteenth to eighteenth centuries, and the present pandemic which began in 1860 in China (spreading by ship to Hong Kong, India, Brazil and California). Thousands have died of plague, and large-scale panic has always ensued in those areas of incidence. "For death had filled the city with panic . . . those who did not die were afflicted with tumors, and the outcry of the city went up to heaven" (I Samuel 5:11-12).

Thomas Butler (1991) summarizes a brief world history of plague in Strickland's Hunter's Tropical Medicine. In the first half of the twentieth century, India had more deaths from plague than any other country. In 1966 India officially declared that plague had been conquered there. In the 1960's, Vietnam, reporting 10,000 deaths/year from plague through the 1970's, became the country of highest incidence. By comparison, this year's outbreak in India (reportedly over 4500 suspected, and 1000 diagnosed cases, but fewer than 100 officially reported deaths) is not remarkable. Much larger numbers of Indian citizens die of either measles or diarrheal illness in any given year. Antibiotics, readily and cheaply available over-the-counter without a prescription, have radically reduced plague deaths in India. However, even with such a historical and ongoing problem with plague, conditions which encourage the persistence of plague continue in India.

The Facts of the Outbreak

In mid-August the warning sign of ratfall (domestic rats falling from rafters onto the floors of dwellings and dying there) was noted in Mamla village (John, 1994, p. 972). Reuter's and AP news agencies reported that "doctors in Mamla village in the southern state of Maharashtra found thirtyfive people with tumors in their armpits and groins, symptoms of bubonic plague." John (1994, p. 972) notes that by mid-September 10% of the population of that village had bubonic plague (see map of India, Appendix B).

Intemet's "soc.culture.indian" news group (transcribed from Reuter's and AP news services) described on September 19-20, 1994, that several people in Surat exhibited symptoms of fever, headache and breathlessness, and coughing up blood. Doctors initially treated it as an influenza epidemic. Panic began when the patients died within hours of reporting sick: symptoms of pneumonic plague. Finally, on September 25, the first sputum cultures grew Yersinia pestis (the bacteria causing plague) six days after the original wave of deaths was reported (John, 1994, p. 972).

For various reasons, widely varying numbers of deaths due to plague were reported. The poor cannot afford medical care, so usually nurse their own and die in their homes. A funeral pyre is then built over the body which is thus cremated in the best of circumstances. In other cases, the body is thrown into the river. Deaths among the poor are seldom reported, merely estimated.

A financial reason for minimizing the incidence and severity of plague was the location of factories (Surat is India's diamond-cutting and silk-production center) in the area of the slums. The "cordon sanitaire" sealing the epidemic off from the rest of the city would have prevented workers getting to the factory, cutting off their income, as well as slowing production.

One major political reason for making efforts to deny the outbreak was the holiday season to begin only one month hence, with much visiting of family members from other countries, as well as large conferences with international guests invited to present papers and draw thousands of international tourists. Tourism is one of India's major financial businesses. India had much to lose by allowing news of a plague epidemic to reach the international press.

From the first cases noted in outlying villages in Maharashtra state in mid-August (bubonic plague, with enlarged and draining Iymph nodes in groin and axilla) to the last reported pneumonic plague cases in Surat during the first week of October, seven weeks elapsed. The total official number of deaths reported was 234 nationwide: 52 (or 61 or 300) from Surat, 3 from Delhi. Unofficial estimates indicate several hundred deaths. Cases occurred in seven of India's states: Gujarat, Maharashtra, Rajasthan, Punjab, Uttar Pradesh, Bihar and Madhya Pradesh (See map, Appendix B).

Conditions for India's 1994 Plague Outbreak

How and why did "Black Plague" happen to flare up in India in 1994? Of course, many factors led to this and these are considered below. Plague is a nidal disease, one which exists in a "nest," a reservoir of animals which perpetuate the bacillus (see Appendix D). For this disease to emerge from the "silent zone" into infecting a human population, four elements must converge in time and place: an agent (the bacterium Yersinia pestis), a vector (the flea Xenopsylla cheopsis), a reservoir (rat or ground squirrel) (May in Meade,1988, p. 77) and a human host.

Reuter's and AP News Service provide daily information from India, and most of the on-site detailed reports from India in this paper are due to their gathering of information and conducting interviews between August and October, 1994. In recent years, hundreds of thousands of poor villagers have migrated to Surat in search of work in the city's silk, and diamond-cutting and polishing industries. Many of the city's 1.5 million inhabitants live outside the Surat city limits in squalid shanty towns. The conditions of these slums in August,1994, were typical of shanty towns all over India: open sewers, tightly clustered shelters made of cement or plastic sheets, rotting animal carcasses, heaps of garbage, and pools of stagnant water fill the alleys. Floods in early August heightened the horror as the human waste and refuse mixed with slush and mud were washed up and left on the riverbank creating ideal conditions for the spread of infection. Cows, dogs and pigs stand on top of high piles of garbage while people sell vegetables from rickety wooden carts alongside: rats thrive in such a setting.

It is highly probable that workers from Maharashtra state traveled to Surat to work after they had become infected. Living in crowded conditions without medical care or money to pay for it, untreated bubonic plague infections progressed systemically to plague pneumonia, and so inevitably commenced the rapid person-to-person spread of pneumonic plague.

A health official blames the outbreak on rats attracted by relief food sent to feed survivors of a September 1993 earthquake in Maharashtra that killed 10,000-12,000 people. Not all of the bodies were recovered, providing an increase of food for rats, making probable an increase in the rat population. Officials maintain that the increasing numbers of rats in the area related to the villagers moving to new homes constructed by the government and converting their old, damaged homes into granaries to store food aid sent last year.

Plague bacillus spread widely due to a lack of preparedness by the public health authorities. Assessment of the situation, first in Maharashtra, then in Surat, was not done, nor were appropriate measures to contain the disease undertaken.

Another factor allowing wide spread of plague bacillus was that broad spectrum antibiotics, required to curb the disease, had been exhausted due to panic- buying of the over-the-counter antibiotics in response to media suggestions. Physicians and pharmacists escaping the city brought large amounts of treatment drugs away with them for their families and friends. Preventive dosing with the essential antibiotic made locating medication for treatment of suspected cases difficult. Supplies were being rushed to Surat from other parts of the country on an emergency basis. Officials raided pharmacies where antibiotics were being hoarded for black-market prices due to scarcity, and turned the antibiotics over to health officials. Insufficient supply persisted because those with adequate resources to buy purchased and hoarded medication, worsening the chances of the poor to have medication available if they became ill.

A counterproductive cultural factor, but one which is a very influential factor in plague, is an old Hindu practice, rat worship, which takes place in many sites in India. In some shrines, tens of thousands of rats race across the floor, feasting on fruit and candy. Many rats leap onto a platform where food has been placed under a golden umbrella by worshipers, while priests chant hymns and play cymbals. In Hindu mythology, the elephant-headed god Ganesh is accompanied by a rat (or a mouse, it is sometimes said) whenever he travels. No Hindu worship is complete without an offering to Ganesh and his small companion.

Hindu residents continue to visit city parks to feed the tens of thousands of rats who live there. Though rats infest much of India, (including farms where they eat nearly one-quarter of the produce) Indians who are Hindu do not kill any animals, including rats, nor will they touch any dead animal. "I do trap a rat when I see one in my kitchen, but I can never kill it. It is a sin to kill the companion of our God," said one Hindu housewife. At daybreak in many towns, villages and cities, Indian men and women are seen carrying rats in traps and releasing them at a distance from their homes. Rarely is one killed.

WHO Plague Action Plan, Compared with Actions Actually Taken in India to Curb the Epidemic of Plaque

The World Health Organization's (WHO) Plague Manual (Bahmanyar,1976) describes in orderly detail procedures to undertake when cases of plague occur in a given area. For some reason, this information was not promptly utilized in India. Financial, political, and social interests encouraged divergent action from WHO's precise direction. Local leaders in plague-ridden areas of India did not take early action to combat the threat. Since plague is largely a disease of the slumliving poor, the usual stance is to ignore outbreaks of illness caused by living in squalor, since India's middle and upper classes live in walled-off compounds. Mavalankar believes the government seemed to lack correct, concise and practical information (1994, p.1298). A parallel opinion is expressed by Dr. Dominik Wujastyk from Wellcome Institute, in London, on the "Soc.culture.indian" newsgroup on Internet. He says the Indian Express Newspaper "criticized the city for failing to meet with medical experts, parents, teachers or federal officials before making the decisions. . . Evidently, people in authority are unsure of what level of response is appropriate." (Oct. 4,1994). Due to the weaknesses in diagnostic capabilities and communication within the health and political system, the extent of the problem was probably not recognized. Many actions taken were not appropriate to curb the disease, indeed some actions may have encouraged the spread of plague for a longer period of time. This section will compare the suggested and actual procedures, and discuss outcomes which resulted from unadvised procedure. Appendix D shows diagrammatically intervention points to prevent susceptible individuals from becoming plague cases.

Basic foundations of public health infrastructure must include adequate financial resources to provide basic diagnostic laboratory services. Many hospitals and states in India do not have microscopy labs (John,1994, p. 972). Krishnan reminds us that hospitals do not have an uninterrupted supply of power and water (1994, p.1298) limiting their activities. In many cases, no definite lab diagnosis was made, so definite numbers of cases are not known. Economics of cheap treatment with Tetracycline compared with more expensive lab tests indicated the most good could be done by presumptive treatment (that is, presuming that the person with symptoms of plague had it and giving antibiotics without lab testing). Since the poor would not have money to pay for medication or a physician, the few reported cases would indicate a much larger number which were not reported.

India has experienced epidemics of plague several times during this century, the most recent only thirty years ago. The simultaneous incidence of large numbers of cases of bubonic plague in near-by Maharashtra state whence large numbers of factory workers commute should logically have alerted Surat's experienced health officials to watch for the next predictable signs: symptoms of either pneumonic or meningococcal plague due to untreated bubonic disease. Several reported cases of "flu" resulting in death in twelve hours should have prompted first, immediate implementation of quarantine, then testing sputum for plague bacteria. Due to the political pressure to encourage tourist trade as well as exports, such information as existed on plague incidence was overlooked in early stages, and suppressed after the first week of reporting. For the sake of the economy, the fewer cases diagnosed the better.

Step 1: Quarantine, or Cordon Sanitarie

The first step when plague occurs is to set up a cordon sanitaire around infected neighborhoods and/or the field hospital where sick patients are taken for treatment within the restricted area. Isolation wards in hospitals must also be quarantined. This quarantine boundary must be guarded by police or the military, until seven days after the last case is diagnosed.

In India, no quarantine was implemented until a week after the first cases of highly contagious pneumonic plague were diagnosed. Unsanitary hospital conditions encouraged the spread of plague by provoking the flight of plague patients from hospitals. Even Dr. S. J. Rehman, deputy director of the National Institute of Communicable Diseases left the hospital in New Delhi due to unsanitary conditions before he was treated for a high fever and cough. Families of patients who left the hospital stated that the patient received no care and that conditions were very poor in the hospital. Hospital staff went on strike briefly on September 25 due to a clash with the city over the hospital's cleanliness. Many physicians had left the city, and six staff members of the hospital were suspended for not coming to work since the plague epidemic began.

Families who saw that a family member was dying removed the patient from the hospital and brought them home to die, then privately performed the traditional cremation ceremony beside the river. This practice had two effects: increasing spread, as well as making a near accurate count of mortality impossible. On September 25 it was reported that during the first five days of the outbreak (September 19-25) at least 120 suspected plague patients had left Surat Hospital's isolation ward against medical advice and strict instructions had been given to track them down. Unfortunately, it was nearly impossible to locate such patients as they had no address. Crowding in the shantytowns doubtless caused these escaped patients to increase numbers of cases. The neighborhood where cases occurred was never cordoned off by military police to prevent movement of uninfected people into an infected area.

Man-to-man spread is controlled by prompt and on-the-spot isolation and treatment of patients. All family and contacts of patients must be quarantined and treated with preventive antibiotics for seven days. If a field hospital is established, two issues must be addressed. First, the patient may be so ill that he may go into shock if placed in a vertical position. Secondly, transporting the patient with pneumonic plague may cause new cases along the route of transport. Pneumonic plague spreads rapidly due to its associated paroxysmal coughing with large amounts of sputum simultaneously ejected into the air. Preferably the family will be quarantined inside their home . Family members and contacts of the patient must protect themselves from breathing unfiltered air, and health workers should wear goggles to prevent saliva from entering their eyes. Several layers of thin muslin can serve for a mask for mouth and nose in the lack of official masks. Public health personnel must care for the patients, and relatives and visitors should not be allowed within the area of strict isolation until all the patient's symptoms have disappeared.

During the three to four weeks of quarantine, economic problems of the local population will be serious. Consideration for the needs of local people must be managed carefully: allowing usual deliveries to be provided from outside, allowing well people, on preventive antibiotic treatment, access to their fields, water sources and livestock, allowing people inside the quarantined area to send out and sell their perishable products. Lacking this care for the needs of the quarantined people, they will tend to break the regulations, spreading the disease to other areas.

Because quarantine was delayed, thousands of terror-stricken citizens fled Surat. From September 19-22, 1994, there were three straight days of chaos at the Surat railway station and the bus stand. People clambered on any and every vehicle that could take them away. Estimates of 400,000-600,000 people fled to other parts of India (one-fifth of the 2 million population of Surat), some in the incubation phase of the plague infection. More than half of the physicians departed as well. Isolation wards were not set up in major hospitals until days after confirmation of the epidemic (Anonymous, Lancet, 1994, p. 1034).

Officials asked people not to leave, then asked them to return to Surat to avoid spreading the infection. After a three-day exodus, departures slowed, but official sealing of the city was not attempted until September 23, five days after the first pneumonic plague patients had died. Travelers arriving in distant areas from Surat were not registered or monitored until three days after the epidemic was confirmed (Anonymous, Lancet, 1994, p.1034). In Bombay from September 24-26, soldiers went door-to-door checking homes for plague cases (reached 2.8 million of the 12 million population during these three days. On September 25, seven days after the first diagnosed case of pneumonic plague, two companies of Rapid Action Force paramilitary officers began to guard the Surat's Civil Hospital where infectious cases were housed, to prevent any more from leaving.

Uncertainty of government officials on how to proceed with quarantine was illustrated by Delhi's schools reopening only five days after they were closed (Anonymous, Lancet, p. 1034). On September 23, Surat authorities ordered closure of all schools, colleges, cinema halls and public gardens for an "uncertain period." Plague had been rapidly spreading through Surat's slums for nearly two weeks by this time. People walked in the streets with their faces covered by handkerchiefs (probably not effective--as large weave is permeable to the bacillus). Several layers of fine muslin would have been more effective. Industrial units, banks, offices and diamond cutting units were asked to shut down until further notice. A calendar (Appendix C) shows the extent and duration of the outbreak, and the conflicting reports of cases and deaths in the affected districts of India.

Step 2: Provide Antibiotics

The second consideration is obtaining large amounts of the proper antibiotics to treat the ill and administer preventive antibiotics to the health care providers and close relatives. This step was taken, and large amounts of antibiotics were sent to affected areas. The over-the-counter nature of these antibiotics made abuse of the system possible by those who could afford to buy medication for their families in case it was needed, or to take as prevention, even though it was not needed. Pharmacists and physicians bought large amounts of these antibiotics, then left Surat with their families and the medications. On September 27, New Delhi officials raided pharmacies and confiscated antibiotics for sale at high black-market prices, and gave them to the health department for distribution.

To prevent this, the health department could establish procedures for early implementation in the event of another similar outbreak in which government medical officials controlled the dispensing of antibiotics in coordination with medical officials in charge of both isolation units and the area of quarantine. By September 25, seven days into the epidemic, city workers were distributing antibiotics in slum areas while they were clearing heaps of garbage from streets.

Step 3: Elimination of Fleas

The third factor of importance in the case of bubonic plague is elimination of as many fleas as possible. This is not what Surat needed to deal with,-not a single case of bubonic plague was reported in Surat. However, officials had started spraying disinfectant on stagnant water to prevent spread of plague. This is effective for malaria control but not to prevent the spread of plague. However, fleas theoretically may be infected by the patient during the last hours of his life, thereby becoming a source of further bubonic infection (Bahmanyar, 1976, pp. 59-60). In New Delhi, cars coming from Gujarat state (where Surat is) were sprayed on the inside with insecticide before crossing into the new state. In Bombay (Maharashtra state), trucks entering the city from Gujarat state (where only pneumonic plague existed) were being fumigated. Bubonic plague originated in Maharashtra state, so fumigation was cautious, but would not protect from the pneumonic disease spread by people leaving Surat in Gujarat state.

Deinsecting the area is desirable for a second reason: flies may spread organisms from sputum coughed up by the patient to the eyes or mouth of persons taking care of him. City workers were ordered to remove carcasses of cows, dogs, pigs and buffaloes Iying in streets which would tend to decrease numbers of flies, only indirectly a factor in plague. Reports stated this was done in the wealthier neighborhoods, where plague was not presently a problem. The weakness of Surat public health officials' communication and effectiveness showed clearly in their failure to effectively act in the areas of most need: that is, in the periurban slums where the most vulnerable live (Anonymous, Lancet, p.1034). Relief workers in Maharashtra (bubonic plague) correctly sprayed insecticides, distributed antibiotics as well as caught rats in the infected villages.

Step 4: Elimination of Rats

A fourth issue is elimination of rats, essential in case of a bubonic plague outbreak. Surat did not have to deal with this, either. On September 23 Maharashtra state authorities (five weeks after first bubonic plague cases were diagnosed in that area) summoned about 100 tribal Irulas from the southern state of Tamil Nadu to the plague affected areas in Maharashtra to catch rodents by hand. In New Delhi, large numbers of extra city workers were hired to spray inside houses in poor neighborhoods, and trap rats. Large numbers of garbage collectors were hired there, as well. Citizens asked why officials had allowed the conditions to worsen to such a degree as to allow plague to break out. Ecologists had raised an alarm over the spreading of poison on the farm lands to kill the rats. Extra bounties were paid to rat killers to prowl and hunt in the back streets at night. The spraying of insecticide would continue. This killing of first the fleas, then the rats was appropriate. (Killing rats first leaves many hungry fleas looking for a meal, and in the absence of their preferred rats, they will bite humans.)Fortunately, many rodents die in underground burrows, carrying their fleas, so are out of the way, and not likely to infect humans (Dawood, 1993, p.166). However, the next generation of rats may be infected by underground fleas, and start a new epizootic.

The elimination of rats to control plague was correct in the area reporting bubonic disease. Keep in mind, however, the panic in Surat was from Pneumonic plague, spread by airborne droplets from person to person. Bubonic plague was not reported there, so rats and fleas were of secondary importance.

Step 5: Political and Financial Issues

A fifth issue was both a financial and political issue: preventing dissemination of plague through cargo at seaports and by air transport. Transoceanic liners are not usually the issue, as they are rat-proofed when constructed. Small cargo and passenger boats are generally affected, sometimes to the point of being infested. Containers of cargo may contain rats and fleas. Bait boxes in the containers, and strips of insecticide-treated material will kill both rats and fleas within twenty-four hours. Fumigation of ships should be done where ports are infested with rats and fleas. Containers must not be opened in transit after they are closed and sealed (Bahmanyar, 1976, p. 60-61). Caution in watching for rats on the part of travelers and businesses receiving shipments of goods from India in large containers or from ships, was advised.

Airports in areas of endemic plague must effectively control both rats and fleas, by using poison to keep rats from living close to the airport, and putting insecticide in and around rat burrows. Last year Air India, India's international carrier, had to postpone four flights after rats were found in the cockpits of planes. The airline was concerned the rats might have damaged control panel wiring. Employees were reluctant to kill the rats. Preventive rat control in the area of the airports has obviously not been done. Rats on planes should be trapped, rather than poisoned to prevent a dead rat in an inaccessible area where function of the aircraft may be impaired. Aggressive rat control in the environs of the airport should prevent this problem. Action taken in India when airplanes were fumigated after passengers disembarked to prevent spread of pneumonic plague were probably not useful.

Step 6: Control of Plaque in International Travelers

Physicians and nurses checked travelers for plague symptoms before they boarded planes, and emergency clinics were set up in all public transportation stations. People who manifested symptoms of plague could immediately be started on antibiotics and isolated with precautions against airborne spread.

However, the incubation period of one to seven days for pneumonic plague was not considered: names and addresses of travelers boarding planes in India were not taken, nor was written information provided about symptoms to be aware of, with directions to report immediately for medical care if such symptoms occurred within the next week. The rapidity of spread and diagnosed cases in areas all over the country in one to two days caused international airlines to place restrictions on receiving passengers from India. Some flights were not allowed to land and had to turn back and return to India.

Tourist trade was severely and negatively effected by the outbreak, so actual numbers of cases were distorted and deflated as much as possible; widely varying statistics were released on any given day. Authorities made it seem like "business as usual," and wanted conferences and family holiday visits to continue as planned. The social segregation of the poor in slums (where plague largely occurred) may have been somewhat protective to those of higher socioeconomic status and the tourists and business travelers. The embarrassment to India was that the eyes of the world focused on the squalor which allowed the plague outbreak. " . . [T]he poor are for once being seen as what they are, a direct threat to the rich. In India it has been said that the poor have finally taken their revenge in the only way they know-by dying" (Anonymous, 1994, Lancet, p. 1034-5).

After two weeks, the number of cases had diminished greatly. Theaters and schools again opened, and hotels cut their rates in half to attract tourists.

Prevention from exposure for Local Residents

Persons going to visit, work, or live in India or other plague-endemic countries may take a few specific actions to protect themselves from exposure to plague. If rats are sharing the roof under which you live, apply insecticide to floors and around the outside of the dwelling. If rat burrows are obvious, insecticide generously applied within five feet of them (fleas jump four feet) and also inside the burrows is effective. Then trap the rats. DEET-containing insect repellents on exposed skin and insecticide containing permethrin on clothing will protect people from flea bites (Benenson,1990, p. 327). If these two steps (killing first fleas, then rats) are reversed, plague will spread more rapidly.

A "rat fall" (dead rats or rodents lying about) is alarming in areas where plague is endemic. Public health authorities want such information quickly in order to take protective action. A rat fall occurs when a population of rats has not been previously exposed to plague. The introduction of the bacteria frequently causes large numbers of vulnerable animals to die quite rapidly. The fleas which spread the disease from animal to animal will be seeking food, and although a second-best choice, humans are utilized for a blood meal, and plague crosses over from an animal-to-animal problem, to a disease which can kill people (Appendix A). Persons with pet cats or rabbits who live in plagueendemic areas need to be familiar with symptoms of plague in animals. Several cases of cats with plague pneumonia infecting their owner have occurred in the USA (MMWR, 1992, 41, p.738; Doll, 1994, p. 109). House cats, ground squirrels, and rabbits can transmit plague to people (Benenson, 1990, p. 325).

Some individuals are at high risk for exposure to plague, and would be wise to take preventive antibiotics. Such people may deliver medical care to plague victims or trap rodents in plague-endemic areas. People who handle dead or sick animals, including pets, risk exposure to plague, and may choose to take tetracycline, or sulfonamides for children, until seven days after the last exposure to plague (Bahmanyar, 1976, p. 59).

Researchers working with Yersinia pestis bacillus may also choose to take plague vacci although it is not for sale in the United States due to its lack of effectiveness. It may make bubonic symptoms milder, but does not protect from the infection progressing to pneumonic plague (PDR, 1992, p. 15841585).

Policy Options and Conclusions

Plague, which has existed in India for hundreds of years, is usually confined to rodents. Unfortunately, conditions in India persist which allow for continuing outbreaks in human populations. The 1994 outbreak provided lessons and examples which India and the other nations at risk for plague would be wise to note.

T. Jacob John (Lancet, 1994, p. 972) states the key problem in India's response to the plague epidemic was a "lack of epidemiological alertness, skill and interventions." Eswar Krishnan (Lancet, 1994, p. 1298) focuses on "the failure of administration to support scientific staff." A conspicuous absence of public health funding for epidemiological facilities to diagnose and track local health problems leaves India open to repeat a similar plague experience to that of 1994. Absence of basic laboratory facilities would eliminate any possible early response to plague cases and isolation of an area before the disease has spread. Financing health education for professional and local health care providers would allow individuals in all areas of India to receive basic sanitation information. Practical activities to prevent spread of infection could be taught, which may decrease hysteria. Health providers who have education as a priority in their job can teach vigilance to the poor when specific situations (such as rat-fall) are indicated as important to report. Sanitarians and sanitary workers could be educated and paid to do surveillance and clean-up in slums and city streets.

Personal Protective Measures for Travel in Plague-Endemic Areas

• Keep food in closed containers
• Burn or bury garbage
• Insect repellent on skin
• Permethrin insecticide on clothing, bedding
• Spray/dust insecticide on floors inside and outside home
• Dust pets with insecticide
• Trap or poison rats
• Don't camp near rodent burrows
• Report rat-fall to health authorities
• Don't handle sick or dead rodents

Funding for such traditional epidemiological techniques as "definition of size and location of the problem, surveillance and case reporting, rat-fall counts, isolation and treatment of cases--to clean up the rat-infested environment at the foci of infection" (Anonymous, Lancet,1994, p. 1034) must be established by law as a political and financial priority in the case of another plague epidemic. The huge slums in India's major cities where conditions allowing such a disease of squalor to exist are an embarrassment to a nation encouraging both financial and educational interaction with nations of varying levels of development.

Ashok Rattan, microbiologist, at the All India Institute of Medical Sciences in New Delhi, advises culturing and testing of Y. pestis for drug sensitivities of new antibiotics for efficacy (Nadan,1994, p. 897) to provide possible better alternatives to Tetracycline, Streptomycin (which must be given intravenously) and Chloromycetin (which has unpleasant side effects). Improved epidemiological procedure in the early stages of an outbreak of plague would allow identification of the specific organism causing the illness, therefore, better care for those infected, and a more rapid control of the disease.

Another area to develop is that of authoritative, accurate and prompt directions delivered to health care providers for dealing with disease outbreaks. Continuing medical education of physicians in India to inform them of early and aggressive techniques to manage the occurrence of disease outbreaks at the first hint of a potential problem would both prevent such rapid spread of disease, and give them known techniques of epidemiological steps with which to proceed. Government support for such programs is essential to the health of the citizens of India. The exodus of physicians with the rest of the escaping population undermines citizens' trust in public health structure and effectiveness. Communication networks need to be established to provide physicians with accurate information, diagnostic laboratories, medication, and practical instruction for directing local public health activities. Public health education must extend to local neighborhoods and villages. Midwives are trained as health educators in many countries. Plague management education and certification with compulsory review and recertification every year or two would provide status and give authority to midwives in teaching cleanliness and health. More important, this certification would establish a system of communication and outreach from villages back to central authorities of surveillance information, and from authorities to the villages in case of need for information distribution, epidemic control or immunization.

Public health authorities worldwide have little, if any, personal experience with control of a pneumonic plague epidemic in today's world of rapid transportation. World Health Organization has written directions which should be at hand in airports, shipyards, and train stations around the world for instant reference (Anonymous, 1969, 1983). Directions must be clear, brief, and provide health authorities instant and proper actions to maintain the respect and trust of their citizens for protection of public welfare. Annual review and certification should be required for employees and managers of transportation centers. In time of need, employees need current information about location of the plague management manual, and prevention and containment procedures to follow in a calm and orderly fashion.

One cultural aspect of plague control which is difficult to change is the custom of the "bribe." When exit from a contaminated area is desired, when the person who wishes to leave has money to pay the local militia or train conductor, with a smile and a nod the money is pocketed and the person is allowed quietly to pass by. This ability to buy passage through any impediment to a desired objective would make difficult a cordon sanitaire, or the holding of hospitalized patients with suspected pneumonic plague in an isolation unit.

The tradition of rat worship, and the religious opposition to the taking of any animal's life, make plague in India a nightmare. If health authorities collected rats trapped overnight by householders, perhaps at least the custom of releasing trapped rats the next day could be adapted to public health needs. To attempt to change a culture where feeding rats in the park is an afternoon diversion, and the worship customs include feeding them in temples seems overwhelming. Perhaps to cage them and control the numbers while still allowing the customs to persist, but within state control, would be acceptable. Certainly the increase in amounts of farm produce available to feed people would be very welcome if numbers of rats were diminished.

Considerable misunderstanding on the part of officials exists in emergency situations due to a lack of funding for epidemiological stations and microbiological laboratories, and the lack of a communication system to quickly notify officials of health problems and provide direction to the public. Since financial support is lacking for public health (funding for professional and public education, and communication systems to transmit information regarding location, cause, diagnosis, and control of contagious diseases), future outbreaks are likely.

Appendix A
Appendix B
Appendix C
Appendix D

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