In 430 BC, a plague struck the city of Athens, which was then under siege by Sparta during the Peloponnesian War (431-404 BC). In the next 3 years, most of the population was infected, and perhaps as many as 75,000 to 100,000 people, 25% of the city's population, died. The Athenian general and historian Thucydides left an eye-witness account of this plague and a detailed description to allow future generations to identify the disease should it break out again. Because of the importance of Thucydides and Athens in Western history and culture, the Plague of Athens has taken a prominent position in the history of the West for the past 2500 years. Despite Thucydides' careful description, in the past 100 years, scholars and physicians have disagreed about the identification of the disease. Based on clinical symptoms, 2 diagnoses have dominated the modern literature on the Athenian plague: smallpox and typhus. New methodologies, including forensic anthropology, demography, epidemiology, and paleopathogy, including DNA analysis, have shed new light on the problem. Mathematical modeling has allowed the examination of the infection and attack rates and the determination of how long it takes a disease to spread in a city and how long it remains endemic. The highly contagious epidemic exhibited a pustular rash, high fever, and diarrhea. Originating in Ethiopia, it spread throughout the Mediterranean. It spared no segment of the population, including the statesman Pericles. The epidemic broke in early May 430 BC, with another wave in the summer of 428 BC and in the winter of 427-426 BC, and lasted 4.5 to 5 years. Thucydides portrays a virgin soil epidemic with a high attack rate and an unvarying course in persons of different ages, sexes, and nationalities.The epidemiological analysis excludes common source diseases and most respiratory diseases. The plague can be limited to either a reservoir diseases (zoonotic or vector-borne) or one of the respiratory diseases associated with an unusual means of persistence, either environmental/fomite persistence or adaptation to indolent transmission among dispersed rural populations. The first category includes typhus, arboviral diseases, and plague, and the second category includes smallpox. Both measles and explosive streptococcal disease appear to be much less likely candidates.In 2001, a mass grave was discovered that belonged to the plague years. Ancient microbial typhoid (Salmonella enterica serovar Typhi) DNA was extracted from 3 skeletons. Because typhoid was endemic in the Greek world, it is not the likely cause of this sudden epidemic. Mt Sinai J Med 76:456-467, 2009. (c) 2009 Mount Sinai School of Medicine.
The plague ravaged large cities and provincial towns in northern and central Italy from 1629 to 1631, killing more than 45,000 people in Venice alone and wiping out more than half the population of cities like Parma and Verona. But strikingly, some communities were spared.
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Ferrara is a picturesque walled city situated along a branch of the Po River halfway between Padua and Bologna, both badly affected by plague in 1630. A UNESCO World Heritage Site, Ferrara is distinguished for having some of the first paved roads in 1375 and a municipal sewer system since 1425.
Starting in the 15th century, Henderson says, large Italian cities like Venice and Florence stayed in constant communication with smaller towns like Ferrara to track the spread of new plague outbreaks. The information was used to set threat levels and coordinate public health responses.
For personal hygiene, the citizens of Ferrara turned to several popular natural remedies prescribed for protection against the plague. But they prized one above the rest: a medicinal oil called Composito. By law, a ready supply of Composito was to be stored in a locked box set into the wall of the municipal palace and only distributed in times of plague.
In September 1994, plague struck Surat, a city in the state of Gujarat in western India. The government officials declared an international public health emergency by reporting an epidemic of pneumonic plague. When compared to the bubonic form, the pneumonic plague spreads rapidly and hence caused widespread panic, both locally and internationally. The plague in Surat was mostly pneumonic, though the bubonic form was found in three villages in Maharashtra preceding the pneumonic outbreak in Surat (Ref 3).
The incidence in Surat had large impacts on other major cities of India like Delhi and Mumbai. In the capital of New Delhi, the lack of public information on how to deal with the spread of the disease resulted in the large scale purchase of surgical masks and tetracycline. As a precaution, the administration ordered the closure of all schools and public entertainment places. The news of the epidemic and these actions taken by the government alarmed many people. Some chose to stay indoors and others who ventured out did so with masks covering their faces. Schools in Delhi reopening only five days after they were closed illustrated the uncertainty of government officials as of how to proceed with the precautionary measures. In eastern states such as Orissa, thousands of kilometers away from Surat initiated steps to check the plague outbreak. Reports from Rajasthan, which borders Gujarat, stated that the villagers launched an intensive drive to kill rats in their regions. Proper instructions as on how to proceed with the preventive measures were not given to the people. Since the disease was already spreading, killing of the flea host (rats) would force them to switch hosts and result in more human cases. The havoc caused by the epidemic was evident (Ref 4,5).
On September 23, Surat authorities ordered closure of all schools, colleges, cinema halls and public gardens for an uncertain period. Industrial units, banks, offices and diamond cutting units were asked to shut down until further notice. By this time, plague had been spreading rapidly through Surat's slums for nearly two weeks. People walked in the streets with their faces covered by handkerchiefs, which was not a very effective method because the large weave permitted the entry of bacteria. Several layers of fine muslin would have been a better method.
Though there was much confusion in the beginning, the government successfully stemmed the spread. After identifying the plague cases, antibiotics were given to almost everyone in the neighborhood. Fumigation of cargo, clearing of port areas of rat, dusting of insecticides over vast areas to kill rat fleas, helped to control the spread of the disease (Ref 11).
One of India's major markets (agricultural exports), was jeopardized by a decision by the United Arab Emirates to suspend all cargo transshipment from India. The incident also resulted in the loss of investor confidence. From the exports alone, the total loss suffered was $420 million. In London, Global Depository Receipts crashed after the BBC and CNN media agencies reported the plague situation. In the local stock exchange, the share value of the agricultural products tumbled. An official tour of India by the Mauritian minister for Tourism was postponed. Foreign journalists and tour operators were offered free travel and hospitality to assess the situation, but few responded. More than 45,000 people cancelled their trips to India (Ref 3,5).
Several countries imposed plague-related travel restrictions on Indian travelers. For example, Indians traveling to the United States from plague-affected areas had to fill out special forms upon arrival. As a result of the Surat plague outbreak, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States by modifying the quarantine protocols and providing information to medical practitioners. Aircrafts were fumigated on arrival at airports in Rome and Milan and passengers were subjected to special health checks. In Moscow, authorities ordered six-day quarantines for passengers from India and banned travel to India. In addition, an estimated 25% of the passengers between India and the Gulf region who are job seekers were stranded; many had their visas extended but the delays in their departures resulted in a loss of jobs to nationals from other countries. The plague cost the Indian economy over $600 million (Ref 3,5,6,8).
An international response followed in the aftermath of the Surat plague outbreak. The World Health Organization (WHO) announced plans to establish a Disease Intelligence Unit that would function independently when such outbreaks occur to help diagnose the problem quickly. In addition, WHO asked the International Civil Aviation Organization to tighten its health controls at all international airports and to strengthen quarantine measures. (Ref 3).
The worldwide reaction to the plague outbreaks in India in 1994 reminds us that memories of the sudden spread of disease, from the Black Death onwards are still, understandably, very powerful. The outbreak had severe economic, social, and political impacts. Although the spread of the plague was contained effectively in spatial and temporal terms, societal responses resulted in higher order consequences (Ref 5).
The WHO team which investigated the plague in Surat, did not find any conclusive laboratory evidence of the disease organism. Even though no scientists were able to get pure Yersinia pestis cultures from the infected cases, this was mainly attributed to inadequate facilities and lack of expertise in the hospitals during the period. But there were lot of supportive evidence of the plague organism, blood tests specific to Yersinia showed positive results, antibodies of Yersinia was found in many infected cases and disease symptoms were diagnostic of pneumonic plague (Ref 2, 9,11).
After the Surat plague epidemic in 1994, India took several steps to be prepared for such incidents in future. In response to the outbreak, medical school course work has been revised to address plague in greater detail. The National Institute for Communicable Disease's plague research unit has been modernized to make diagnosis easier. In addition to activating plague control units all over the country, the national government decided to set up a more sophisticated national surveillance system. The recent pneumonic plague outbreak in Himachal Pradesh 2002 was quickly and effectively contained. The government took rapid preventive action and there was better flow of information which prevented the unnecessary panic (Ref 3,10). be457b7860
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