Plague in India: A New Warning from an Old Nemesis

The main outstanding problem of the Black Death, or indeed of the plague in any era, is … what it is which provokes an epidemic of the air-borne pneumonic variant of the disease [1].

A recent Institute of Medicine report, “Emerging Infections: Microbial Threats to Health in the United States” [2], called attention to the complacency that has developed regarding infectious diseases, highlighted the risk for importation of diseases that develop in remote parts of the world, and stressed the need to strengthen national and international infectious disease surveillance. The report cites the introduction of plague from other continents into Europe in the 14th century and into North America in the late 19th century. The recent epidemic of plague in India highlights the concerns expressed in this report.

In August 1994, an outbreak of bubonic plague was reported from the Beed district, a known plague-enzootic region [3] in Maharashtra State in western India. In late September, news came of an explosive epidemic of suspected primary pneumonic plague in the city of Surat in neighboring Gujarat State [4]. Hundreds of suspected cases and more than 50 deaths were reported from Surat. Press accounts described a mass exodus of hundreds of thousands of persons from this industrialized port city of nearly 2 million inhabitants [5]. By early October, more than 6300 suspected cases of plague had been reported from 12 Indian states, including Delhi, but only a few were considered laboratory confirmed, primarily by unvalidated serologic techniques [6].

Preliminary results of subsequent studies, done by the Indian government and an independent World Health Organization team, provided presumptive evidence of bubonic plague cases and enzootic plague activity in Maharashtra State (Gage KL, Chu MC, Centers for Disease Control and Prevention [CDC]. Personal communication). In Surat, reviews of clinical …