TREATING THE SCOURGE: The Government went into overdrive to check the outbreak

In normal times, residents of the sparsely populated, affluent apple-growing belt of Jubbal-Kotkhai in Himachal Pradesh only worry about infections that plague their orchards. But last fortnight, it was their own health they were worried about. The fear of getting infected by the dreaded disease appeared all too real.

This is not the first time plague has afflicted the region. In September 1982, on the eve of the Asian Games being held in Delhi, the National Institute of Communicable Diseases (nicd) diagnosed the "mystery" fever that had gripped the region as bubonic plague, but the matter was suppressed. Union Health Minister C.P. Thakur doesn't deny that the episode was kept under wraps since it could have had serious repercussions on the games. The official death count was eight, though an nicd official puts the toll at 23.

This time, however, preventive action taken much before the disease was even officially diagnosed as "pneumonic plague" checked the outbreak from reaching epidemic proportions-there were only four deaths, three in Himachal and one in neighbouring Uttaranchal. In fact, Thakur uttered the "P" word only on February 19-it claimed its first victim on February 4-after experts seemed convinced that the bacteria had outlived its incubation and infectivity cycle.

The outbreak, despite the preventive relief measures, has yet again exposed not only the vulnerability of the Indian population to epidemics, but also the glaring lack of a disease surveillance system. Himachal Pradesh does not have a surveillance unit, and observations by nicd and other agencies are at best sporadic even in areas where plague is endemic. "We have just one surveillance unit in Karnataka under the aegis of the nicd. There was another unit in Maharashtra but the state government thought it was not needed and disbanded it in the early 1980s," says K.K. Datta, former director, NICD.

"Plague is not a serious threat in India. There are other worrisome diseases." C.P. Thakur Union Health Minister

Seemingly wise after the event, the Centre has now decided to put in place a nationwide Integrated Disease Surveillance Network for generating real-time information on highly contagious infections. According to Thakur, the upcoming National Health Policy will have provisions for setting up such a network in the next five years. Much of the groundwork has already been done by the successful implementation of a pilot project in 45 scattered districts in the country. Now, the network will extended to all the 593 districts in the country.
A similar outbreak claimed 200 lives in Surat, Gujarat, in 1994. But, unlike the 1982 outbreak when investigation was suppressed or the Surat episode where identification of the plague bacteria was doubtful, this time the culprit was beyond the realm of any controversy. A series of biochemical and molecular tests by the Post-Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh, nicd and Defence Research and Development Organisation (DRDO) confirmed the presence of the plague bacteria, Yersinia pestis.

HEALTH

ABOUT THE PLAGUE > This is not the first time plague has afflicted Himachal Pradesh. In 1982, it claimed eight lives, though the episode was suppressed. > Himachal Pradesh, parts of Uttar Pradesh, Maharashtra, Karnataka, Tamil Nadu and Andhra Pradesh are endemic plague foci regions. > There is only one plague surveillance unit in India in Karnataka. Another unit in Maharashtra was closed in the early 1980s. > The exact source of the recent outbreak is yet to be ascertained.

The epicentre of the outbreak was Hat Koti, a hamlet in the scenic Pabbar valley on the Shimla-Rohru road. Randhir Singh Sautha, a farmer, was the first to show symptoms of pneumonic illness-respiratory distress and vomiting-on February 2, a day after his return from a hunting trip to the nearby Kelvi forest. According to the villagers, Sautha ate the meat of a dead animal that he found buried in the snow. Investigation by NICD epidemiologists revealed that he was "exposed to a heavy dose of the plague bacteria through his respiratory tract". An infected flea bite causes swelling in the groin and results in the bubonic form of plague. In Sautha's case, it was an "accidental infection". He was not bitten by wild rodents or rat flea, the known hosts and carriers of the bacteria which sustains itself in animal bodies for generations, especially in the wild. The nicd experts who caught the rodents in the affected area did not find plague bacteria on them, suggesting that it was not bubonic plague but pneumonic plague that Sautha had contracted.

Sautha died within 48 hours of being taken ill. But not before infecting his 12 family members, including a woman from Uttaranchal who attended his funeral. Though the patients displayed symptoms of pneumonia, the first suspicion of it being plague came from the "rather unusual" clustering of infection. Other pneumonic illnesses are not known to have such a high secondary attack rate.

The plague alarm came from the doctors at an under-equipped civil hospital at Rohru. Senior Medical Office Ram Lal, who was a witness to the 1982 outbreak, informed the state Government which in turn asked the Union Health Ministry. While an nicd team arrived with mouse traps to trace the origin of the infection, the state Government went into prevention overdrive. The "index cases"-the first victims-were confined to two houses on the village outskirts, the locals who came in contact with the infected family were identified, the affected areas quarantined and more than four lakh antibiotic tablets administered to the people. "They did not wait for the exact diagnosis," says S.K. Sharma, director, pgimer. "That was the key to nipping the outbreak in the bud." Nature also played a crucial roadblock in checking the epidemic. Heavy snowfall restricted the people's movement.

Meanwhile, experts at the research laboratories at pgimer, nicd and drdo searched for definite microbiological finger prints of the culprit. It involved dogged efforts in the form of multi-disciplinary testing. "Unravelling the identity of the bacteria was like a police detection job," says pgimer microbiologist Pallab Ray, who led the biochemical investigations. For once, pgimer, nicd and drdo acted in unison to conclusively establish the characteristics of the bacteria as per international guidelines.

"Though the course of infection and the patient's symptoms fitted the classic textbook description case of pneumonic plague, we wanted to be doubly sure," says Subhash Verma, head of internal medicine at pgimer, who headed a "core committee" on diagnosis and treatment of suspected cases. Experts were able to zero in on two possibilities of the infection being either pneumonic plague or tularaemia, one of the most infectious pathogenic bacterial infection known and considered to be a potential biological weapon because of its extreme infectivity. During the investigation period, pgimer experts also dutifully browsed the Internet for more information on the bacteria.

The crucial breakthrough came on February 14-48 hours after the patients' admission at pgimer when a culture of their infected sputum and blood showed the growth of bacteria colonies. The bacillus was fastidious and slow-growing because of the presence of antibiotics in the samples. By February 17, not only was the bacteria isolated but also identified as a plague agent after a series of biochemical tests. A bacteriophage susceptibility test by drdo confirmed the pgimer's finding. But, the Union Health Ministry held back the final word for another two days awaiting the results of the polymerase chain reaction tests and dna sequencing by nicd, which had taken the bacteria isolated at pgimer. Though Thakur claimed that molecular testing by nicd was necessary as the "ultimate confirmation" of plague as per the World Health Organisation criteria, pgimer experts dispute this, citing the guidelines set by the Atlanta-based Centre for Diseases Control which proscribes biochemical test for plague identification. "Molecular testing is needed only when the bacteria is not isolated," says a pgimer expert.

Incidentally, nicd officials allege that they were informed of the epidemic only on February13 though the first death took place on February 4. This, points out a former nicd official, shows the lackadaisical attitude of the Government even though the state is vulnerable to the deadly disease. In other words, the scare of the dormant plague bacteria will continue to haunt the hill people till it decides to surface at the place and time of its choice.

-with Prerna Singh Bindra