Coping with plague

The latest incidence of plague, in Himachal Pradesh, raises serious questions about the authorities' preparedness to deal with such epidemics and the state of the public health system.

MORE than seven years ago, between August and October 1994, the country saw a major outbreak of plague. Of a total of 5,150 suspected pneumonic or bubonic plague cases reported from eight States, 53 resulted in deaths (Frontline, October 21, 1994). The scourge has returned, on a much smaller scale though. Four persons died in Himachal Pradesh in early February after being infected by Yersinia pestis, the bacillus causing plague.

The latest incidence of pneumonic plague, which knocked the Central government out of its stupor, has drawn attention to larger questions of surveillance, preparedness, awareness and the state of public health in the country. It took almost a week for the government to declare that it was plague, even though doctors at the Indira Gandhi Medical College (IGMC), Shimla, and the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, had indicated that the symptoms of some of the persons being treated in the attached hospitals were similar to those of pneumonic plague.

The first plague-related death this time was that of 35-year-old Randhir Sahuta of Hat Koti village in Rohru subdivision. Sahuta had been on an extended hunting trip in the forests adjoining Kelvi village in Jubbal tehsil since January 21. He is said to have fallen ill after eating meat at the home of his in-laws in Gallu village. He returned to Hat Koti on February 2 and was treated for a viral disease. He died on February 4, and the cremation took place the next day. Soon, Sahuta's wife Sulochana complained of fever, chest pain and breathlessness - symptoms associated with pneumonic plague. Others in the family also had these symptoms. Local people said that as the cold weather worsened, Sahuta's relatives went to the PGIMER to get better treatment. Sulochana and Sahuta's sister Anu died in the hospital. Pushpa, a relative from Banupur in Uttaranchal who had attended Sahuta's funeral, died in her village on February 14.

Twelve people have been treated for pneumonic plague in this area - five at the Civil Hospital, Rohru, six at the PGIMER and one at the IGMC. The condition of one of the patients at the PGIMER was reported to be serious.

The last case of pneumonic plague from Rohru was reported on February 8. As the incubation period for the plague-causing bacteria is seven days, the Health Ministry had concluded that the disease had been contained. However, within 24 hours of the Health Ministry's declaration to this effect, Krishan, a resident of Riyondh Khurd village on the Punjab-Haryana border, succumbed to "pneumonic plague-like symptoms" at the PGIMER. He was attending on a patient at the hospital when the infected persons from Himachal Pradesh were undergoing treatment there. Krishan's wife Karanjit Kaur was admitted to the PGIMER later with similar symptoms on a referral from the Civil Hospital at Hissar. Investigations are being conducted at the PGIMER and the NICD. Karanjit Kaur's condition, according to a PGIMER statement, was stable.

Although Sahuta died on February 4 and reports of a mysterious disease had been appearing in the media since February 12, it was only on February 19 that Union Health Minister C.P. Thakur announced that the deaths had indeed been caused by pneumonic plague. And it was only on February 13 that the State nodal officer for the National Surveillance Programme for Communicable Diseases informed the Director of the National Institute of Communicable Diseases (NICD) in Delhi about the cases. The NICD deputed a medical team to the affected area and started examining patient samples from Chandigarh on February 15. Four days later it declared that it was indeed plague. On February 18, the Prem Kumar Dhumal government submitted a report to the Prime Minister's Office on "plague-like cases".

The disease was confined to three houses in a hamlet in Hat Koti and all the deceased were Sahuta's relatives. The disease did not spread possibly because bad weather prevented people from coming in contact with one another.

Most of Sahuta's relatives went to the PGIMER for two reasons - one, it was only there they could afford treatment and, two, the route to the IGMC remained closed. Sukhdev, an elected member of the local municipal committee, told Frontline that people were in a state of panic because preventive medicines were falling short in the hospitals. This, despite the doctors' independent efforts to convince them that only those who had come in direct contact with the family members of Sahuta should take the medicines. Sukhdev said that people were angry with the government for not having confirmed that it was plague that claimed the lives of Sahuta and some of his relatives. "People were told to stay indoors for seven days. The NICD team came here on February 15 and caught some rats. But there was no mention of the word plague and that added to the confusion," said Sukhdev.

Sukhdev said that when plague-like symptoms were reported from Tangnu village of Rohru subdivision in 1983, the doctors had said that the area was prone to plague. They also suggested then that the State government constitute a body equivalent in status to the NICD. Even two days before Thakur's announcement, medicines for plague were being given to patients.

Ram Lal, Senior Medical Officer at the Rohru Civil Hospital, told Frontline that since February 12, prophylactic treatment with a broad range of antibiotics had been given to all who had come in contact with the plague-afflicted persons. The suspected cases were put in the isolation ward. He said that anti-rodent measures should be taken as the disease could recur.

The NICD team has issued elaborate guidelines to the local health administration. These include quarantining the affected village; administering chemoprophylaxis (using drugs such as doxycycline and tetracycline) to people who come in close contact with the patients, to the residents of affected villages and neighbouring areas and to doctors, paramedics and health workers; fumigating affected villages and vehicles with formaldehyde; conducting a campaign to reassure people, telling them not to panic and report to the health authorities immediately if they notice symptoms such as fever and cough; and door-to-door interaction with the people in the affected and neighbouring villages to dispense antibiotics, obtain information about new cases and educate them about plague. Similar guidelines were also issued to the Uttaranchal government as Pushpa (Sahuta's relative) died in that State. Strangely, all this was done while keeping information about the latest incidence of plague under wraps.

Very few laboratories in the country have the equipment and expertise to culture and isolate the plague-causing bacterium. And most of the plague surveillance centres and plague control units in the country have been closed. According to Om Prakash, a doctor with the Himachal Gyan Vigyan Samiti at Shimla, some surveillance had to be carried out in the higher reaches where wild rodents abounded. He said that when plague occurred in 1983, Jaidev Ratola, the Chief Medical Officer of the Rohru Civil Hospital, had warned the authorities about the possibility of its recurrence and that there was no response. Scarcity of paramedics was a major problem in Himachal Pradesh, especially in its rural and interior areas.

Perhaps responding to the criticism about the absence of any surveillance mechanism in Himachal Pradesh, Thakur announced the inclusion of Shimla in the National Integrated Surveillance Programme (NIDSP) and the setting up of a regional laboratory at the IGMC to investigate various diseases.

Om Prakash said that the health priorities of the State depended on the funding it received. Of late, there was hardly any focus on the prevention of contagious and infectious diseases such as diarrhoea. Mira Shiva, head of the Public Policy Division at the Voluntary Health Association of India (VHAI), said that a strong public health system that would not only follow up on previous outbreaks and trends but also could provide early diagnosis and effective treatment was the need of the hour. Shiva said that falciparum malaria was a bigger killer, especially of women and children, and that despite its large-scale occurrence in various parts of the country, including Jharkhand and the northeastern region, health policy planners did not seem to have given serious attention to it. Ghanshyam Shah, former Director, Centre for Social Studies, Surat, and now a Professor at the Centre for Social Medicine and Community Health, Jawaharlal Nehru University, said that the medical education system needed to be updated in line with the priorities of the community. The surveillance system for plague had been gradually dismantled since the mid-1960s.

There was a crisis of confidence in the authorities in the case of the Surat epidemic, he said. In his book Public Health and Urban Development: The Plague in Surat, Professor Shah wrote that "not only the well-to-do but also the poor did not believe in the information given by the government sources, and they doubted the capabilities and sincerity of the authorities in meeting the situation". Just as in the case of Rohru, in Surat there were conflicting statements from the government with "one spokesperson saying it was plague and another at a different level saying it was not plague". Results of clinical and laboratory tests were kept a "secret" in Surat. The bureaucratic approach of the Health Department at the State and national levels further eroded the government's credibility, he said.