Controlling Pneumonic Plague in China

Plague is making headlines again. Pneumonic plague has been reported in China, with 2 deaths, a dozen or so hospitalized, and a small town in total quarantine. How worried should you be? The words "pneumonic plague" are enough to make any microbiologist flinch, but unless China does something monumentally stupid, this will be a local outbreak with a few deaths, not a repeat of the Black Death.

Do the Chinese in that remote area have what it takes to get pneumonic plague under control quickly enough to save the world? Yes, they do, even though there is no effective vaccine. They have isolated the sick and quarantined the rest of the area. That's all it takes.

Dr. Dugald Christie's account of his experience in the 1910 pneumonic plague epidemic in Mukden is a classic example of how to handle plague with limited medical resources. It also has some food for thought for us as the pandemic of H1N1 influenza builds up momentum.

By 1910, when an epidemic of pneumonic plague broke out in Manchuria, the plague bacteria had been identified and it was known that rats and fleas spread plague. What they didn't know then was that plague thrived among wild rodents. One Mongolian rodent, the tarabazan (Marmota sibirica), http://en.wikipedia.org/wiki/Marmota_sibirica was hunted for fur and meat. Changing fashion increased the popularity and price of marmot fur. At the same time railroads made it possible for inexperienced hunters to reach the area.

The local hunters had a strong taboo against killing unhealthy looking or acting marmots, which protected them against being bitten by plague-infected fleas.The new hunters knew nothing of the local taboo, and sick marmots were the easiest to catch or shoot. The inexperienced hunters caught the plague, and it all went to hell in a handbasket in the fall of 1910.

Dr. Christie wrote, "the disease showed itself in the autumn among marmot-hunters and others, crowding in the villages on the railway line on the Siberian side of the border; but as it had been known before as a local visitation, no special notice was taken." We now pay attention to all cases of plague, to stop epidemics when only a few people have it.

""Towards the end of the year we heard terrible accounts of the awful mortality in the Chinese part of Harbin, but the spread of the disease southward was not anticipated by the general public, as many an epidemic rages in the crowded hovels of Harbin, and comes no farther." We should pay more attention to the slums and the poor countries because their epidemic may become your epidemic. Improving their health can save your life, although it also raises your taxes a bit.

"The Viceroy had learned of the deadly nature of the pneumonic form of plague, and was keenly anxious to save Manchuria from its grasp ... Before, however, any preventive measures could even be discussed, a sick man had been taken to the Government Hospital and had died there of plague. Epidemics don't wait for a committee to make a decision. Ready or not, here it comes to your doorstep or airport.

The New Year was coming and thousands of possibly infected people were traveling south from Manchuria for the holiday. The doctors in Mukden persuaded railroad authorities to stop most of the rail traffic. The last train between Mukden and Peking was sent back to Mukden when two passengers died of plague in transit. This fortunately prevented pneumonic plague from reaching Peking and Tsientsin, where the death toll would have been in the millions. "It was a difficult situation. Not one of the isolation stations was ready for use, and no empty building was available. Some of the authorities wanted to let all those coolies who seemed well go free, but that meant carrying infection broadcast through Moukden. Others proposed to make them remain in the trucks till morning, but the temperature during the night had fallen to 25° F. below zero, and many would certainly die of cold. "

Dr. Arthur Jackson, who had come to China from England just ten weeks earlier to help establish a medical school, went to the train station and badgered the authorities to set up quarantine facilities nearby for the 478 passengers. "A small building was set aside for those who had plague, a hospital it could not be called; it was a comfortably warm place to die in. Another house was used for suspicious cases, most of whom were removed to the plague-house one by one. An entire inn was kept for those who had been in close contact with the stricken, and so far as possible the inmates of the various inns were kept apart."

Dr. Jackson and some Chinese assistants stayed inside the quarantine area with. "In five days seventy died. Panic seized the remainder, the military cordon was not very strict, and a number escaped one night, carrying infection into the city. But by that time the worst was over. There was one inn with no deaths; and its sixty occupants were liberated on Monday, the 23rd." The battle at the station was won, but Dr. Jackson fell ill on Tuesday, and died of plague the next day. Despite the death of Dr. Jackson, Dr. Christie had no trouble getting volunteers to work with him.

The remaining two doctors and their Chinese assistants continued to fight the plague in and around Mukden for another three months. They did not have antibiotics, IV fluids or respirators. They had the backing of the Governor and the city police to enforce inspection and quarantine. They had printing presses.

"We could only hope to limit the extent of the epidemic, and we directed our plan of campaign accordingly". They set up a plague hospital - a warm place for confirmed cases to die - and isolation camps outside the city. They dug graves so the dead could be quickly buried, and divided the city into inspection districts. "House-to-house visitation was decided upon, that all Plague cases might be promptly discovered and removed, and contacts taken to the isolation stations."

They had the usual problems of rumor and blame-mongering. "The Japanese were credited with encouraging or even causing the epidemic in order to destroy the people and possess the land. It was universally stated that they were poisoning the wells."

The citizens were not cooperative at first, believing that the control measures were useless. "At the beginning there was general disbelief in the necessity or usefulness of preventive measures. Interference with personal liberty was strongly resented, and still more the disturbance of trade and business." "Many threw out their dead and concealed their sick for fear of being taken there (to the isolation houses), and Plague cases were thrust out to die on the streets, especially from inns and lodging- houses."

They had a shortage of trained personnel, and had to use semi-trained students and quickly train the mostly uneducated inspection force what to do. "In looking back we cannot but wonder at the efficiency of the work, considering that hospital students had to act as doctors, and that there was no time to give much practical instruction to the inspectors and police corps."

Because pneumonic plague spreads directly from person to person, their plague control plan minimized the time a sick person spent near healthy persons. They checked every house in the city every day, moved the sick to the plague hospital, and took the rest of the household to an isolation camp. The empty house was disinfected and placed under guard for the 10-day quarantine period.

"When the day's work was over each member of the Plague staff visited a disinfecting station, where he had a bath and left his outer garments to be disinfected." Their ability to keep the medical personnel healthy was a crucial part of their success. Dr. Christie doesn't report any other deaths among his staff, which I find amazing. They had extremely well-aired rooms and spent as little time as possible with the dying. It sounds cruel today, but your chances of surviving pneumonic plague in those pre-antibiotic days were close to zero. Resources were saved for those they could save.

Some citizens decided to do it themselves, with alternatives to modern Western medicine. "The most serious resistance was on the part of some merchants, who determined that their business should not be interfered with. ... They opened their hospital. On one side of the compound were isolation quarters, and on the other rooms for undoubted Plague cases, who were treated by needling and other methods, all under the charge of two native doctors". They were using acupuncture and other traditional Chinese medical treatments. "No proper precautions were taken, no masks were worn. Rapidly the disease spread. Those on the isolation side became infected, and almost all died, including the two doctors. Then in consternation the merchants allowed the police to disinfect and close the place. It had been in use for twelve days, and 251 had died, most of them in the last week." This effectively ended the resistance to the control measures.

They kept the semi-literate population informed to the extent possible before radio. "One important aid in the fight was the posting up of placards all over the city, explaining in the simplest everyday language the dangers of the epidemic, how it spread, and the measures taken against it. A small paper called the "Plague Bulletin," giving a daily official report, was also widely circulated." "Every city and town received copies of placards, instructions for guarding against the entrance of Plague, and stringent orders as to the carrying out of these measures."

After some lapses in quarantine resulted in the deaths of entire villages, the government publicized the details of the deaths and how they could have been prevented. "The instinct of self-defence triumphed over fatalism; the placards and leaflets sent out by the thousand from Moukden were read in every village and homestead; and the people themselves instituted wonderfully effective anti-plague measures." The self-imposed quarantines were often more rigid than the quarantine in Mukden. "In very many places the inns were closed, and no visitor, however intimate, allowed to spend a night in a house. The approaches to the village were guarded, and carters warned to go round outside. Frequently the villagers combined to purchase supplies by the hand of reliable men, who were not allowed to enter an inn or come in touch with any but those absolutely necessary, and who returned home the same day."

Slowly the epidemic burned itself out, with the last case reported in April of 1910. Pneumonic plague seems to be a disease of cold weather and crowded, smoky dwellings. It has returned in smaller outbreaks in China, and in the winter of 1924/25, an outbreak of pneumonic plague in California killed 24 people in a poor Los Angeles neighborhood.

Sources:
China plague outbreak claims second victim by Peter Foster, China Correspondent, The Telegraph.co.uk August 3, 12009

Mirage of Health, by René Jules Dubos; Rutgers University Press, 1987 pp187-188

A Manual of Tropical Medicine, by Hunter, Frye, Swartzwelder; Saunders, 1966

Thirty years in Moukden, 1883-1913 by Dugald Christie, Constable and Company Ltd., 1914