- It is not a hidden truth that plagues and pandemics change the course of humanity.
- While thousands of people die, civilizations end, the economy collapses, and such diseases often become difficult to contain, posing a major challenge to the ruling governments across the world.
- Amid COVID-19 or Coronavirus outbreak, India has been hit by many major outbreaks since the 1900s.
- India has witnessed many outbreaks since the 1990s but none of the outbreaks was as widespread and as fatal as COVID-19.
In this article, we will discuss the major outbreaks that India has witnessed since its independence.
“Epidemic” vs. “Pandemic” vs. “Endemic”:
- An epidemic disease is one “affecting many persons at the same time, and spreading from person to person in a locality where the disease is not permanently prevalent.” The World Health Organization (WHO) further specifies an epidemic as occurring at the level of a region or community.
- Compared to epidemic disease, a pandemic disease is an epidemic that has spread over a large area, that is, it’s “prevalent throughout an entire country, continent, or the whole world.”
- Endemic is perhaps most commonly used to describe a disease that is prevalent in or restricted to a particular location, region, or population. For example, malaria is said to be endemic to tropical regions. In this context, it can also be used as a noun: an endemic disease can simply be called an endemic.
- An outbreak is a “sudden breaking out or occurrence” or “eruption.” When referring to an infectious disease, an outbreak is specifically a sudden rise in cases, especially when it is only or so far affecting a relatively localized area.
MAJOR OUTBREAKS SINCE INDEPENDENCE:
Cholera pandemic (1961-1975):
- Cholera has been present in India since antiquity. It is considered to be the first major epidemic of the 19th century in British-colonised India and was described as probably the most terrifying one too. The Indian subcontinent has witnessed seven events of the cholera pandemic.
- Since 1817, Vibrio Cholerae (a type of bacteria) caused six cholera pandemics globally. The seventh pandemic caused by El Tor Vibrio cholerae started in Indonesia (Sulawesi) in 1961 and entered India in 1964. By the end of 1965, it has replaced the age-old classical V. cholerae. Many of the States which never had cholera or were free from it for a long time got infected and became endemic foci of El Tor infection.
- This rapid transmission of the pathogen around the globe in the 20th century can be attributed to the major hub, the Bay of Bengal, the main place from which the disease spread.
- Cholera is an acute often fatal disease of the gastrointestinal tract caused by Vibrio cholerae (V. cholerae) a gram-negative bacterium.
- V. cholerae is a water-borne pathogen. Humans are infected through contaminated water used for drinking or preparing foods. V. cholerae persists indefinitely in aquatic reservoirs and may acquire mobile elements via horizontal gene transfer leading to the emergence of new toxigenic clones.
- El Tor is a particular strain of the bacterium Vibrio cholerae, the causative agent of cholera. Also known as V. cholerae biotype eltor, it has been the dominant strain in the seventh global cholera pandemic.
It has a short incubation period, ranging between two hours and five days.
- profuse watery diarrhoea, sometimes described as “rice-water stools”
- leg cramps.
- restlessness or irritability
- Cholera is easily treated. Death from severe dehydration can be prevented with a simple and inexpensive rehydration solution.
- Oral or intravenous hydration is the primary treatment for cholera. In conjunction with hydration, treatment with antibiotics is recommended for severely ill patients.
- India has encountered a variety of epidemics and pandemics over time. Several accounts of influenza, cholera, dengue, smallpox and several others have been recorded throughout history; while we have been able to eradicate some; many diseases continue to pose a threat to the community. It is not uncommon for sudden and rapid outbreaks to occur in India and many articles direct the cause for this in such developing countries being malnutrition, lack of sanitation and lack of a proper public health system.
- Epidemics is an unusual occurrence in a community or region of disease, specific health-related behaviour or other health-related events clearly in excess of expected occurrence. It is a sudden, severe widespread outbreak of a disease pre-existing in the community. A study by John T. Watson, et all analyses the relationship between epidemics and natural disasters and establishes that there is a rise in the occurrence of epidemics post-disaster though incidence in India has not been emphasized.
Polio Epidemic (1970-1990):
- India was the worst affected by polio among the developing countries until the late 1990s after which the Expanded Program on Immunization (EPI) was initiated.
|Expanded Program on Immunization (EPI): The World Health Organization (WHO) initiated the Expanded Program on Immunization (EPI) in May 1974 intending to vaccinate children throughout the world.
- The incidence of polio in India was very high in both urban and rural states and the most affected was the state of Uttar Pradesh. Polio (poliomyelitis) mainly affects children under 5 years of age, with 1 in 200 infections leading to irreversible paralysis. Its worst sequel was reported to be post-polio paralysis and in the district of Vellore, about 6/1000 preschool children were affected. It was in 1964 in Bombay and 1965 in Vellore that the oral polio vaccine was introduced. India had a choice between Salk’s IPV and Sabin’s OPV. Even after the introduction of the Oral poliovirus vaccines (OPV) in the Expanded Program on Immunization (EPI), there was no improvement to be noted for 10 years.
- India rolled out the Pulse Polio Immunization Programme on 2 October 1994, when the country accounted for around 60% of the global polio cases. Within two decades, India received ‘Polio-free certification’ from World Health Organization on 27 March 2014, with the last polio case being reported in Howrah in West Bengal on 13 January 2011.
- Emphasis has been laid on maintaining the guard to prevent resurgence. In India, one nationwide NID and two Sub-National Immunization Day (SNIDs) for polio are held every year to maintain population immunity against wild poliovirus and to sustain its polio-free status.
|In 2022, the Government of India has organised the Polio National Immunization Day 2022 (NID) (also known as ‘’Polio Ravivar”) on February 27, 2022, to give two drops of oral polio vaccine (OPV) to every child in the country under the age of five. Over 15 crore children will be covered under the drive across all 36 States and UTs in 735 districts.
- Wild poliovirus cases continue to be reported in neighbouring Pakistan and Afghanistan. As long one child remains infected, children in all countries remain at risk of contracting polio.
- Polio is caused by 1 of 3 types of poliovirus. It often spreads due to contact with infected faeces.
- There are three strains of poliovirus: types 1, 2 and 3. Types 2 and 3 have been eradicated (eliminated), but type 1 still affects people in a few countries.
- Incubation Period:
- The incubation period for nonparalytic poliomyelitis is 3 to 6 days. For the onset of paralysis in paralytic poliomyelitis, the incubation period is usually 7 to 21 days.
- Some people who develop symptoms from the poliovirus contract a type of polio that doesn't lead to paralysis (abortive polio). This usually causes the same mild, flu-like signs and symptoms typical of other viral illnesses; Loss of reflexes; Severe muscle aches or weakness; Loose and floppy limbs (flaccid paralysis).
- There is no cure for polio, only treatment to alleviate the symptoms. Heat and physical therapy is used to stimulate the muscles and antispasmodic drugs are given to relax the muscles. While this can improve mobility, it cannot reverse permanent polio paralysis. Polio can be prevented through immunization.
- There are two vaccines used to protect against polio disease, the oral polio vaccine and inactivated poliovirus vaccine.
Small Pox Epidemic (1974):
- It is known as one of the worst smallpox epidemics of the 20th century. India contributed to about 85% of this epidemic worldwide. This epidemic broke out in three different villages of West Bengal, Bihar and Odisha but it was impossible to establish a connection between the men hence it was treated as three different epidemics. The disease was introduced into different areas by different sources. While over 15,000 people died in this epidemic, thousands of the survived but most of them but most ended up with disfigurement and blindness. Smallpox was eradicated in by the WHO smallpox eradication program. It was the first disease to be combated globally and was declared eradicated by WHO in 1980.
- Smallpox is a serious, life-threatening illness caused by the variola virus. It causes pus-filled blisters (pustules) to develop on the skin.
- Incubation Period:
- A person may not look or feel sick for about 7 to 14 days after exposure to the variola virus. This time is called the incubation period. At the end of the incubation period, the first symptoms appear.
- High fever followed with chills.
- Vomiting or nausea.
- A severe headache, followed by other body pains.
- Development of rashes, filled with pus or fluid on the face, legs, hands, arms, etc.
- There is no treatment for smallpox that has been tested in people who are sick with the disease and has proven effective.
- Smallpox vaccination can protect you from smallpox for about 3 to 5 years. After that time, its ability to protect you decreases. If you need long-term protection, you may need to get a booster vaccination.
Surat Plague Epidemic (1994):
Plague cases in Surat were first reported in Sept 1994 and they spread to other cities in India. Fewer than 1,200 people were found positive and it lasted for less than two weeks but it is considered important due to its high fatality and created worldwide repercussions. It is said to have been initially difficult for doctors to diagnose it but when they did, all necessary precautions are taken to contain its spread.
- A plague is an infectious disease that affects animals and humans. It is caused by the bacterium Yersinia pestis. This bacterium is found in rodents and their fleas and occurs in many areas of the world.
- The incubation period is typically 1–6 days.
- Symptoms and signs of the 3 clinical presentations of plague illness are as follows:
- o Bubonic (most common)—rapid onset of fever; painful, swollen, and tender lymph nodes, usually inguinal, axillary, or cervical
- o Pneumonic—high fever, overwhelming pneumonia, cough, bloody sputum, chills
- o Septicaemic—fever, prostration, haemorrhagic or thrombotic phenomena, progressing to acral gangrene.
- To reduce the chance of death, antibiotics must be given within 24 hours of first symptoms.
- Inactivated bacterial vaccines have been used since 1890 but are less effective against the pneumonic plague, so live, attenuated vaccines and recombinant protein vaccines have been developed to prevent the disease.
Plague of Northern India (2002):
The Plague of Northern India broke out in the Shimla district of Himachal Pradesh in February 2002. It was a small and less serious epidemic. Also, as soon as the plague was detected, immediate measures were taken like fumigation, evacuation, and chemoprophylaxis that lead to further control of the epidemic.
Dengue Epidemic (2003):
- In 2003 during September, there occurred an outbreak of dengue haemorrhagic fever (DF/DHF) in Delhi. It reached its peak around October-November and lasted until early December. The mortality rate was around 3%. It became a major outbreak in India despite the widespread preventive measures taken to control DF.
- Dengue fever is caused by any one of four types of dengue viruses. You can't get dengue fever from being around an infected person. Instead, dengue fever is spread through mosquito bites.
- The primary vectors that transmit the disease are Aedes aegypti mosquitoes and, to a lesser extent, Ae. albopictus. The virus responsible for causing dengue is called dengue virus (DENV).
- Dengue begins abruptly after an incubation period of 5–7 days (range, 3–10 days), and the course follows 3 phases: febrile, critical, and convalescent. Fever typically lasts 2–7 days.
- Symptoms include severe stomach pain, vomiting, difficulty breathing, or blood in your nose, gums, vomit or stools.
- There is no specific medicine to treat dengue. Supportive care such as fever reducers and pain killers can be taken to control the symptoms of muscle aches and pains, and fever.
SARS Epidemic (2003):
- SARS (severe acute respiratory syndrome), is considered as the first serious infectious disease outbreak of the twenty-first century. It initially started in the Guangdong province of China in 2003 and spread quickly to about 30 countries across Asia, the Americas and Europe and accounted for a total of 8,439 cases and 812 deaths, within 7 to 8 months.
- SARS was caused by a type of coronavirus (SARS-CoV) and is believed to be an animal virus, possibly transmitted from bats to civet cats to human beings.
Meningococcal Meningitis Epidemic (2005):
- In early 2005, a sudden surge had been noted in meningococcaemia and meningococcal meningitis cases in India. Cases were reported from Delhi and the surrounding states of Uttar Pradesh and Maharashtra. Around 430 cases of meningococcal meningitis were reported as of June 2005. Case management, and early detection through surveillance were aimed at preventing of spread.
- Bacteria called Neisseria meningitidis cause meningococcal disease. About 1 in 10 people have these bacteria in the back of their nose and throat without being ill. This is called being a carrier.
- 2-10 days (average 3-4 days)
- Common symptoms of meningococcal meningitis include sudden fever, headache, and stiff neck.
- Other symptoms may include nausea, vomiting, increased sensitivity to light, and confusion. Children and infants may show different signs and symptoms, such as inactivity, irritability, vomiting, or poor reflexes.
- Currently, a third-generation cephalosporin (ceftriaxone or cefotaxime) is the drug of choice for the treatment of meningococcal meningitis. Vaccines can help prevent meningococcal disease.
Chikungunya Outbreak (2006):
- Around 3.4 million cases of Chikungunya were reported in Ahmedabad in 2006 with 2,944 deaths estimated. The mortality rate in the 2006 epidemic was substantially increased when compared with that in the previous four years.
- In December, there occurred another epidemic in South India where the states of Andhra Pradesh, Karnataka and Tamil Nadu were affected. The volatile nature of this epidemic was attributed to the herd immunity to the then isolated genotype. Major efforts were taken for mosquito control and several awareness campaigns were initiated by the television and print media.
- Chikungunya is a viral disease transmitted to humans by infected mosquitoes. It is caused by the chikungunya virus (CHIKV).
- The majority of people infected with the chikungunya virus become symptomatic. The incubation period is typically 3–7 days (range, 1–12 days).
- The most common symptoms are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash.
- There are no specific drugs to treat chikungunya; doctors simply recommend rest and plenty of fluids. Symptomatic treatment will help ease fever and joint pain.
Dengue Outbreak (2006):
- The outbreak began in early September of 2006 and the first case was reported from Delhi. By the end of September, it began to spread to other states like Rajasthan, Kerala, Gujarat, Chandigarh and Uttar Pradesh. The ministry of health set up a control room to monitor the outbreak and provide technical assistance that led to the efficient management of the disease.
Gujarat Jaundice epidemic (2009):
- Modasa town in Gujarat witnessed the outbreak of hepatitis B in 2009. This is of significance because almost all outbreaks of viral hepatitis in India were considered to be due to hepatitis E which is transmitted by the fecooral route. It was a long-lasting epidemic and control was achieved by mass public awareness and health actions.
- Out of six different types of viral hepatitis known (A, B, C, D, E, and G), the hepatitis E virus (HEV) is the agent responsible for the hepatitis outbreak.
- Infections of the liver from a virus (hepatitis A, hepatitis B, hepatitis C, hepatitis D, and hepatitis E) or a parasite. Use of certain drugs (such as an overdose of acetaminophen) or exposure to poisons.
- It is caused due to the accumulation of bilirubin in the blood and body’s tissues. Bilirubin is a waste product that is generated when red blood cells break down. It is then transported to the liver through the bloodstream where it is then combined with a digestive fluid called bile
- The incubation period ranges from 2 weeks to 2 months, usually 1 month to 45 days.
- Jaundice is a condition in which the skin, whites of the eyes and mucous membranes turn yellow because of a high level of bilirubin, a yellow-orange bile pigment. Yellow-tinted skin and eyes characterize jaundice.
- Liver Transplant
- Opening of bile duct
H1N1 Flu Pandemic (2009):
- The H1N1 flu pandemic began in May 2009 and spread globally by July 2009. By August 2010, it was declared a pandemic and around 18,500 deaths were reported from all around the world. Three strains of influenza viruses were circulating then of which the Inf A (H1N1) and Inf A (H3N2) viruses were largely replaced by the pdm H1N1 strain.
- The only known drug to work against H1N1 (Tamiflu) was not sold in general medical stores, to prevent the virus from developing antibiotic resistance due to excessive use. The government feared that people would pop in pills for no reason, thereby making the virus resistant to its only known cure.
Odisha Jaundice Epidemic (2014):
- The outbreak began in November 2014 in Kantalbai, a remote village in Odissa. This led to a district-level investigation and it was confirmed to be jaundice caused by the Hepatitis E virus. This 2014 Odisha Jaundice epidemic was one of the many outbreaks in Odisha and the most common cause was the Hepatitis E virus. This has affected several people, especially those of the low socioeconomic category. Surveillance for clean water and sanitation was proposed as the control measure.
Indian Swine Flu Outbreak (2015):
- The H1N1 virus outbreak had previously occurred in India during the 2009 flu pandemic and was still present as of March 2015. This outbreak in 2015 is considered a resurgence of the infection and the most plausible reasons are considered to be low temperature, decreasing host immunity and failure of vaccination campaign after 2010. According to the NCDC data in India, Rajasthan, Maharashtra, and Gujarat were the worst affected states in India during this pandemic.
Nipah Outbreak (2018):
- The virus was first noted in the late 1990s in Singapore and Malaysia. The natural host for this disease is the fruit bat and transmission is from direct person to person contact. This Nipah virus outbreak began in May 2018 in Kozhikode District, Kerala.
- This is the first Nipah virus outbreak reported in Kerala and the third known to have occurred in India, with the most recent previous outbreak being in 2007. Spread of awareness about this infection, isolation of the infected and post-outbreak surveillance led to the control of this outbreak.
- Early detection of the outbreak and prompt isolation of cases along with strengthening of infection control practices and barrier nursing helped in containing the outbreak.
- Nipah virus (NiV) infection is a zoonotic disease that is transmitted from the natural hosts- fruit bats- to humans either directly, or indirectly through other hosts like pigs. Direct transmission occurs by consumption of fruit or date sap contaminated by infected fruit bats.
- The incubation period is 5 to 14 days.
- Infection with the Nipah virus is associated with encephalitis (inflammation of the brain). After exposure and an incubation period of 5 to 14 days, the illness presents with 3-14 days of fever and headache, followed by drowsiness, disorientation and mental confusion.
- There are currently no drugs or vaccines specific for Nipah virus infection although WHO has identified Nipah as a priority disease for the WHO Research and Development Blueprint. Intensive supportive care is recommended to treat severe respiratory and neurologic complications.
- COVID-19 is a type of viral respiratory infection caused by a coronavirus (known as SARS-CoV-2). Cases were first reported in Wuhan in China in December 2019, and since then it has spread around the world, becoming one of the deadliest pandemics in history.
- Infection with severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, causes coronavirus disease 2019 (COVID-19).
- The time is taken for the symptoms to first appear on an infected individual. The incubation time for COVID-19 ranges from 1-14 days, most commonly being around 5 days.
- Fever or chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; Headache; New loss of taste or smell; Sore throat; Congestion or runny nose; Nausea or vomiting; Diarrhoea.
- Treatment for COVID-19 depends on the severity of the infection. For milder illnesses, resting at home and taking medicine to reduce fever is often sufficient.
- Antiviral drugs (Remdesivir) may be prescribed by a doctor if a patient is eligible.
- Monoclonal antibody Treatment
- Convalescent Blood Plasma Therapy
- Coronavirus COVID-19 Vaccines
Take-aways from the COVID-19 pandemic:
- Although India has witnessed accomplishments in every sphere, including healthcare, the pandemic has been an eye-opener. It has pinpointed the swift improvement areas in our public health system and compelled everyone to focus on its betterment.
- The management of the COVID-19 pandemic has strongly demonstrated to the world the power of a "strong political will, self-reliant nation which is also empowered by technology. shared goals and collaborative efforts through a 'whole of government and whole of society' approach".
- Despite the large population combined with geographical and sociological diversities, India has set global standards of vaccination. India's vaccination drive is a testament to the capabilities and power of the people without whom this journey, and this high level of vaccine coverage, would not have been possible. Vaccine hesitancy was prevented through mass communication. Procurement and logistics were solved through robust cold chain ecosystem development.
- India has not only produced quality and affordable vaccines; we have exported medicines to more than 150 countries on humanitarian grounds. The Vaccine Maitri programme of the government has been lauded globally.
Lessons learnt from the outbreak and areas to bolster:
- Increased focus on medical infrastructure and facilities in Tier 2 and 3 cities
- Increased investment for better monitoring
- Improved coordination with other nations
- Continual progress in biomedical science innovation
- Government policies
Prevention from Future pandemics:
- The spread of infectious diseases is thus expected to increase due to human activities and their effects on the environment. Epidemics and pandemics will also occur more frequently and will represent new challenges for public health.
- To control the transmission of water-borne pathogens such as V. cholera, the WHO has launched a water, sanitation and hygiene (WASH) program in developing countries. The WASH program was reported to increase safe drinking water access, safe sanitation services and basic handwashing facilities with soap and water at home to 71%, 45% and 60% of the global population, respectively.
- Vector control is the primary tool to control vector-borne diseases such as malaria, Dengue virus, Chikungunya virus and Zika virus. These methods can target either the immature stages (by the use of predator species and chemical or biological larvicides or by the modification of the habitat) or the adult vectors (by the use of nets, topical repellents, insecticides and spraying).
- Furthermore, novel vector control methods are under development such as the genetic manipulation of mosquitos, bacterial infection of vectors and eave tubes with insecticide-laden electrostatic netting. However, the development of novel vector control tools is still needed.
- The implementation of global surveillance programs for the rapid detection of pathogen spill over from animals to the human population is of prime importance.
- Genome-Mapping of the Virus: India has some of the best genome labs in the world. It has to establish a better correlation among its labs and continue its genomic surveillance to prevent the situation from getting worse and developing new strains of the virus.
- Spread of False Information: Social media platforms play a major role in spreading information related to Covid-19, circulation of this false information is still quite successful at creating panic among people and hesitancy towards getting tested or vaccinated.
- One Health concept promotes optimal health for humans, animals and the environment. The environmental effects resulting from land use, urbanization and climate changes may increase the risk of pathogens spill over from animals to humans and emphasize the importance of a One Health integrative approach for the surveillance of zoonosis. Such integrative approaches are used to implement surveillance programs for the prevention and control of emerging and re-emerging infections in developing countries. These multidisciplinary efforts could have positive impacts in these countries as they are the most afflicted by the effects of zoonoses.
|The father of modern pathology, Rudolf Virchow, emphasised in 1856 that there are essentially no dividing lines between animal and human medicine. ‘One Health’ vision derives its blueprint from the agreement between the tripartite-plus alliance comprising the Food and Agriculture Organization of the United Nations (FAO), and the World Organisation for Animal Health (OIE).
- Cross-cultural depth to the study of pandemics provides insight to investigate the social and health impacts of stress and stigma attached to pandemics and ethical issues. As COVID-19 is unlikely to be the last global pandemic, stronger involvement of pandemic studies and public health policy and research is vital.
- The time of onset and the pathogen that will cause the next pandemic is unpredictable. Therefore, pandemic preparedness plans emphasize that non-pharmaceutical interventions should be implemented first to control the human-to-human transmission of the pathogen.
- Insights from past pandemics can strengthen the knowledge base and inform the study of current and future pandemics. There are distinctive social and epidemiological features of a pandemic affecting differently to people from different races, gender, and indigeneity; including pre-existing health and disability.
- India has stood strong through several epidemics and pandemics. Good medical care and efficient research have made it possible to fight every infection and luckily, we have been able to even eradicate a few.