Plague reports in India

Two outbreaks of plague were reported in Maharasha and Gujarat states in the western India in September 1994. In Marharasha state, the first case of bubonic plague was detected in Beed district on Aug. 26. In neighboring Gujarat state, the first case of pneumonic plague was diagnosed in Surat on Sept. 19. Subsequently, cases of pneumonic plague were detected in five other states and in Delhi. Intensive surveillance had detected 4,780 suspected cases by Oct. 4. Of these, 147 were confirmed and 56 died. By Oct. 9, the cumulative number of suspected cases reached 6,291. Only 3% of suspected cases have been confirmed serologically and a smaller number have been confirmed bacteriologically.[1]

In the first half of the 20th century, India was burdened with the largest share of reported plague in the world, with an estimated total of 10 million deaths. In the 1950s, two-thirds of the world plague cases reported to the World Health Organization were from India; the number gradually decreased until cases ceased to occur in India in 1967.[2] More plague was experienced in Vietnam in the 1960s, with as many as 10,000 deaths a year. In 1992, the most recent year with complete date, human plague was reported from nine countries: Brazil, China, Madagascar, Mongolia, Myanmar, Peru, the United States, Vietnam and Zaire.[3]

Fleas transmit plague between wild rodents and thus maintain plague in a sylvatic cycle of transmission in enzootic foci in Asia, Africa, North America and South America. Sporadic human plague cases may occur in association with plague epizootics in wild rodents. Plague may break out of this pattern and produce epidemics under two conditions: first, when plague epizootics affect domestic rats in close association with human habitation, and second, by person-to-person spread of pneumonic plague.

The most common clinical form is acute regional lymphadenitis, also known as bubonic plague, which may lead to complications of septicemic or pneumonic plague. Mortality is high in untreated cases (60%400%), but antibiotic treatment administered early in the course of the disease markedly reduces fatalities to 10%15%.

Prevention of human plague rests on surveillance to detect sporadic cases of pneumonic plague before human-to-human spread begins and to detect outbreaks associated with domestic rats. Surveillance measures include rapid notification of suspect cases, confirmation, isolation and treatment. The drug of choice for plague treatment is streptomycin, 2 grams per day for 10 days. To prevent secondary spread of pneumonic plague, persons occupying the same house or a closed space or with face-to-face contact with pneumonic plague patients should be provided as cheinoprophylaxis tetracycline, 2 grams daily. Plague outbreaks associated with domestic rats (urban plague) may be controlled with insecticide to kill fleas, followed by rat control.[4] Because wild rodent reservoirs of sylvatic plague are widespread and diverse, control of sylvatic plague is not practical.

The World Health Organization advises travelers arriving from potentially infected areas that any illness presenting within seven days of leaving the area should be brought to the attention of a physician for diagnosis. If plague is suspected, contacts need to be notified and, if necessary, receive prophylaxis or treatment.

In addition, Saudi Arabia has taken several measures to prevent extension of the epidemic into the Kingdom. Initially, persons arriving from India were given a medical examination and placed under surveillance for six days. Those who developed symptoms compatible with plague were placed in isolation. When the outbreak extended from Surat to other areas of India, travel to and from 'India was restricted. All health facilities were prepared to meet the demand for diagnosis and treatment of plague. International health regulations to keep ships and ports free of rodents and ectoparasites were applied to ships arriving from India.