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Plague spreads in India but is “under control”

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6959.897 (Published 08 October 1994) Cite this as: BMJ 1994;309:897
  1. G Nandan

    India's epidemic of plague spread across several more states last week, but health authorities in New Delhi say that the situation is now “under control and improving.” The number of patients with suspected plague in hospitals across the country had risen to 4 000 by Monday. But laboratory tests showed that a large number of them did not have plague. Gujurat and Maharashtra - the states that first reported the outbreaks last month - account for 3 300 patients. At least 400 patients are in the Infectious Diseases Hospital in Delhi, and the rest are distributed over seven other states.

    Although health authorities have attributed the spread of the infection to the exodus of people from Surat, where pneumonic plague first surfaced two weeks ago, epidemiologists are still puzzled by the patterns of incidence across the country. Maharashtra has reported 2 100 cases of bubonic plague, while other states have been struck by the more serious pneumonic variety.

    One reason for the high influx of suspected cases at the Infectious Diseases Hospital is that doctors have been referring many patients with high fever, cough, and chest pain to the hospitals reserved for cases of plague. Staff suspect that a large number of patients with other illnesses, including tuberculosis, pneumonia, and even malaria, have arrived in such hospitals. “It is becoming clear that all patients admitted here do not have plague,” said a doctor at the Infectious Diseases Hospital.

    The National Institute of Communicable Diseases has so far confirmed only 21 cases of bubonic plague in Maharashtra and 30 cases of pneumonic plague in Delhi and 28 in Surat. Officials of the Directorate General of Health Services say that the epidemic is likely to subside over the next two weeks.

    The standard response has been to admit patients with “plague-like symptoms” to hospital and begin treatment with tetracycline and streptomycin. On Monday the number of people who had died of plague stood at 50 - all but four from Surat. Health authorities say that all the patients who had died had not received adequate treatment. Patients' response to treatment with tetracycline seems to be good, and the government has made arrangements to distribute an extra 10 tonnes of tetracycline hydrochloride, the raw material for the antibiotic, to drug manufacturers across the country.

    Doctors are, however, concerned at the lack of information on the micro- organisms that are believed to be responsible for the outbreak. Tetracycline might not be the best drug available today to combat Yersinia pestis, but there are no data on the efficacy of the new range of antibiotics. “Culturing this micro-organism and testing its sensitivity needs top priority,” said Ashok Rattan, a microbiologist at the All India Institute of Medical Sciences in New Delhi. Tests of drug sensitivity will take another week.

    The epidemic has also brought into focus the role of India's private medical sector in a health emergency. Although private doctors have increasingly been participating in public education campaigns over the past week, some doctors joined the exodus when the epidemic first broke out in Surat. Residents burnt down some private clinics abandoned by doctors, and this week a local voluntary organisation field a criminal case against 70 doctors accusing them of abandoning the population.