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Troops battle to contain India's outbreak of plague

India's first epidemic of human plague in 28 years has broken out in two western states of the country, creating panic and sending health authorities scrambling to control its spread. The National Institute of Communicable Diseases (NICD) in New Delhi last week confirmed two outbreaks - one of bubonic plague in a region of Maharashtra state that was devastated by an earthquake last year, the other of pneumonic plague in the industrial town of Surat in Gujurat state. There were reports earlier this week, however, that the number of new cases in Surat was falling, although epidemiologists are uncertain whether the disease has been contained. Two patients in Delhi who had passed through Surat were being investigated for the disease after presenting with symptoms of plague.

Indian security forces have been sent into Surat to prevent people who are known to have the disease from leaving the town. There were reports that 100 patients with the disease left hospital before they had been adequately treated. Health authorities in Surat have reported 42 deaths from pneumonic plague. At least 400 people are being treated in city hospitals. So far no deaths have been reported in the villages hit by bubonic plague in Maharashtra, where an estimated 70 people have the disease.

The epidemic in Surat has triggered a mass exodus of residents. At least 600 000 out of a total of two million people have left the town since the epidemic struck two weeks ago. "This exodus could lead to satellite outbreaks in other parts of the country," said Dr Kamal Datta, director of the NICD.

Surat is an industrial town with a high number of migrant workers who work in diamond cutting plants and textile mills. Many are fleeing to their native states. State authorities across the country have asked doctors to be extra vigilant. Patients with symptoms of plague have already been detected in four other towns in Gujurat and in neighbouring states. Surat is 200 km north of Bombay, and health authorities are concerned that the plague could spread to Bombay, which has a population of 10 million.

The epidemic has turned the spotlight on India's disease surveillance system. State authorities are being criticised for having ignored warnings of a rise in the rodent population. Although India's last case of human plague was recorded in 1966, animal foci of plague continue to exist in the wild. In periodic surveys over the past three years India's Plague Surveillance Unit in Bangalore reported a gradual rise in the number of rats found to be seropositive for plague.

A meeting of the National Plague Coordination Group in 1993 urged states with a high rodent population to strengthen their systems for controlling plague. Maharashtra dismantled its plague control unit in 1987.

Health authorities have not yet established a link between the epidemics in the two states. Both types of plague are caused by Yersinia pestis. Infection can result in lymphadenitis with suppuration (bubonic plague) or necrotising pneumonitis (pneumonic plague). "It is possible that infected individuals from villages in Maharashtra carried it to Gujurat," said Dr Datta. Epidemiologists say that independent outbreaks could have occurred at both sites.

In villages in Maharashtra hit by earthquakes crumbled houses have been used as granaries - encouraging an increase in the rat population. In Surat, floods about three weeks ago disrupted municipal services. People have complained that accumulated rubbish and carcases of animals killed by the floods were left rotting in the street - creating conditions that attracted rats.

The NICD has confirmed the infectious agent as the bacillus Y pestis and is now testing the strains for drug sensitivity. "The response to standard tetracycline seems good," said Dr Datta. The government has air lifted 10 million capsules of tetracycline and other antibiotics to the affected areas and ordered a house to house search for infected people in the most severely hit zones. Local authorities have launched intensive measures to control fleas through the use of pesticides. Hospitals throughout India are being asked to keep stocks of tetracycline. The epidemic, however, has sparked off panic buying by the public.

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