Epidemics and Pandemics in India throughout History: A Review Article

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DOI: 10.5958/0976-5506.2019.02328.3
Cite this publication
India has encountered several epidemics and pandemics throughout history. This review article talks about such outbreaks known to have occurred in the 19th-21st century and are arranged in accordance to chronology. For this review, a variety of sources were used by searching through PubMed, NCBI and several others. Different forms of prints such as books, websites, and journals were used as references in this article. The necessity to review this title is because the information is scattered and to source them and compile them into a single article could help the medical practitioners and healthcare workers to understand what this country has been through in the past and what reforms have to be made by them, the community and the government in preventing such outbreaks in the future.
Epidemics and Pandemics in India throughout
History: A Review Article
Swetha G1, Anantha Eashwar V M2, Gopalakrishnan S2
1UG Student, 2Professor, Department of Community Medicine, SBMCH, Chrompet, Chennai
India has encountered several epidemics and pandemics throughout history. This review article talks
about such outbreaks known to have occurred in the 19th-21st century and are arranged in accordance to
chronology. For this review, a variety of sources were used by searching through PubMed, NCBI and several
others. Different forms of prints such as books, websites, and journals were used as references in this article.
The necessity to review this title is because the information is scattered and to source them and compile
them into a single article could help the medical practitioners and healthcare workers to understand what
this country has been through in the past and what reforms have to be made by them, the community and the
government in preventing such outbreaks in the future.
Keywords: epidemics, skin deciencies
India, being a third-world country, has encountered
a variety of epidemics and pandemics through time.
Several accounts of inuenza, cholera, dengue, smallpox
and several others have been recorded throughout
history; while we have been able to eradicate some; many
diseases still 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 [1,2].
According to Park, epidemics is an unusual occurrence
in a community or region of disease, specic health-
related behavior 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 [3]. However, another article by Sen
Corresponding Author:
Swetha G
UG Student, Department of Community Medicine,
SBMCH, Chrompet, Chennai
states those in recent years, cholera outbreaks in India
have been due to the breakdown of sanitation during
natural disasters [4]. A study by Moore, Cristopher, and
Mark displays that the epidemic trends modify when the
transmission exceeds the threshold station the infectious
nature of it [5]. Pandemics, on the other hand, refer to the
worldwide spread of diseases. These are the global health
problems that need to be addressed and treated viciously
along with proper measures to avoid transmission to
other countries. There have been a signicant number
of pandemics throughout history and in many instances;
their control had been difcult because of the lack of
a proper, working global surveillance system [6].
These pandemics show trends of developing microbial
resistance and as a result, the death toll is usually high
in pandemics than epidemics as concluded by the study
comparing the mortality rate of inuenza pandemic and
epidemic [7]. As far as India is concerned, there have
been only two major, signicant pandemics throughout
history. While cholera had been predominant throughout
the 19th century with increasing death tolls every year,
the inuenza pandemic came later on in the early 20th
century [8,9]. The inuenza pandemic was short but
devastating and after a long time, quite recently, came
yet another u pandemic by the H1N1 strain [10].
Though, it is almost impossible to analyze all epidemics
and Pandemics throughout Indian history, effort has
been made to include most of the signicant ones.
1504 Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8
19th Century:
Ist Cholera Pandemic (1817):
This is considered to be the rst major epidemic
of the 19th century in British-colonized India and was
described as probably the most terrifying of all [11]. The
rst case was reported on 23rd August 1817 by a civil
surgeon of Jessore [12].The overall estimation of the
mortality is not available as the data collection in India
began much later, probably in the late 1860s. As for the
geography, it is important to note that the year 1817
had brought a very heavy rainfall leading to ooding
which could have been the cause for such a rapid spread
[13]. While the Europeans living in India then and the
elite were not seriously affected, the slum dwellers and
people in rural poverty were hit the worst [14]. This was
probably due to the differences in living conditions,
personal hygiene and practices.
IInd Cholera Pandemic (1829):
The second outbreak started around 1826 from
Bengal and spread through the rivers to various parts
of northern India. After affecting the United Provinces
(UP), its impact was huge on areas around Punjab and
Delhi but most signicant is its pandemic spread to
countries like China [12,15]. Cholera spread far and
wide, all along the trade routes from China affecting
several cities and villages alike. In each place, it lasted
for a few weeks and killed hundreds of people everyday
IIIrd Cholera Pandemic (1852):
This third cholera pandemic started around 1852
and lasted till the late 1860s. It is signicant in history
because of its spread to countries that were until then not
affected. Though India was not its major area of impact,
in the later phase of pandemic, small spurts of cases
were noted in Bengal. It spread to several other countries
like Persia, Arabia and then to Russia[12,15]. This was
due to the worldwide spread of El Tor serotype of Vibrio
which was initially endemic to India [17].
IVth Cholera Pandemic (1863):
This began around 1863. While some suggest that the
major cholera epidemic in 1865 was brought to Mecca
by the Haj pilgrims from India,others disagree stating
that it was a just a recrudescence [18,15]. However, it is
agreed that it was from Mecca that the infection spread to
several countries [19,20]. The Kumbh Mela at Hardwar
in April 1867 has been considered to be responsible for
the epidemic spread of cholera in northern India [11].
The Madras Presidency in 1877 was the worst hit and
the cholera epidemic was responsible for about 10% of
the annual mortality then [21].
Vth Cholera Pandemic (1881):
The fth cholera pandemic was considerably less
fatal as compared to the previous four. It was during this
pandemic (1881-1869) that Robert Koch proved that
cholera was transmitted through the fecal-oral route,
after studying the outbreaks in Calcutta and Egypt [22].
It spread to United Provinces and Punjab after which it
spread to other countries like Afghanistan, Persia, parts
of Russia and then to Europe[23].
Bombay Plague Epidemic (1896):
This plague began in September 1896 in colonial
Bombay creating a lot of social and political frenzy. The
rapid growth of commerce in Bombay led to an increase
in population and thereby overcrowding. The anti-plague
campaign was started to battle this epidemic and it was
based on the belief that the focus of the infections was
from the slums. The plague killed thousands and many
people were forced out of the city [24].
VIth Cholera Pandemic (1899):
The sixth cholera pandemic began around 1899 and
major outbreaks were noted in Bombay, Calcutta, and
Madras [8]. While the infection throughout the 20th
century was caused by O1 serotype of Vibrio cholera
and conned mostly through the Asian subcontinent,
the sixth cholera pandemic brought about surprising
challenges. This cholera infection was caused by an
unknown, non-O1 serotype of V.cholera and spread to
many distant countries including the United States [25].
The sixth cholera pandemic lasted for about 25 years
20th Century
Inuenza Pandemic (1918):
This is also known as the Spanish Flu of 1918-19.
This has been known to have caused around 20- 50 million
deaths worldwide and is considered most devastating
[27]. This was caused by the H1N1 strain of Inuenza
and was severe. The rst episode of the disease began
Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8 1505
in early 1918 and later in autumn, it began to spread all
around the world, India considered to be the foci [28].
The second wave of the attack began in Bombay in 1918
and spread to other parts of northern India and Sri Lanka
from where it spread worldwide [29]. Improvement in
the virulence and velocity of the virus strain and the
monsoon bringing humidity are considered to be the key
factors in increasing the severity and spread [28].
Polio Epidemic (1970-1990):
India was the worst affected by polio among the
developing countries until the late 1990s after which the
EPI was initiated [30]. 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 [31]. Its worst
sequel was reported to be post-polio paralysis and in the
district of Vellore, about 6/1000 preschool children were
affected [32]. It was in 1964 in Bombay and 1965 in
Vellore that the oral polio vaccine was introduced [33].
India had a choice between Salk’s IPV and Sabin’s OPV.
Even after the introduction of the OPV in EPI there was
no improvement to be noted for 10 years [33]. But with
improvement in surveillance, the desired results were
achieved and India was declared polio-free status in
January 2011 and emphasis has been laid on maintaining
the guard to prevent resurgence [30].
Small Pox Epidemic (1974):
It is known as one of the worst small pox 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 Odissa
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 disgurement and blindness
[34, 35]. Small pox was eradicated in by the WHO
small pox eradication program. It was the rst disease
to be combated globally and was declared eradicated by
WHO in 1980 [36].
Surat Plague Epidemic (1994):
Plague cases in Surat were rst reported in Sept
1994 and which it 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 difcult for doctors to
diagnose it but when they did, all necessary precautions
are taken to contain its spread [37].
21st Century
Plague of Northern India (2002):
The Plague of Northern India broke out in 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 [38].
Dengue Epidemic (2003):
In 2003 during September, there occurred an
outbreak of 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 in spite of the widespread preventive
measures taken to control DF [39].
SARS Epidemic (2003):
SARS (severe acute respiratory syndrome), is
considered as the rst serious infectious disease out
break of the twenty-rst century. It initially started in the
Guandong province of China in 2003 and spread quickly
to about 30 countries across Asia, Americas and Europe
and accounted for a total of 8,439 cases and 812 deaths,
within 7 to 8 months [40,41].
Meningococcal Meningitis Epidemic (2005):
In early 2005, a sudden surge had been noted
in meningococcemia and meningococcal meningitis
cases in India. Cases were reported from Delhi and the
surrounding states of Uttar Pradesh and Maharastra.
Around 430 cases of meningococcal meningitis were
reported as of June 2005 [42]. Case management, early
detection through surveillance was aimed at prevention
of spread [43].
Chikungunya Outbreak (2006):
Around 3.4 million cases of Chikungunya were
reported in Ahmedabad 2006 with 2,944 deaths
1506 Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8
estimated. The mortality rate in 2006 epidemic was
substantially increased when compared with that
in the previous four years [44]. 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 [45].Major efforts were taken for mosquito
control and several awareness campaigns were initiated
by the television and print media [46].
Dengue Outbreak (2006):
The outbreak began in early September of 2006
and the rst 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 [47]. The ministry of health set up a control
room to monitor the outbreak and provide technical
assistance that led to the efcient management of the
disease [48].
Gujarat Jaundice epidemic (2009):
Modasa town in Gujarat witnessed the outbreak of
hepatitis B in 2009[49] This is of signicance because
almost all outbreaks of viral hepatitis in India were
considered to be due to hepatitis E which is feco-orally
transmitted [50]. It was a long-lasting epidemic and
control was achieved by mass public awareness and
health actions.
H1N1 Flu Pandemic (2009):
The H1N1 Flu pandemic began in May 2009 and
spread globally by July 2009. By August 2010, it was
declared pandemic and around 18,500 deaths were
reported from all around the world [51, 52]. Three strains
of inuenza viruses were circulating then of which the
Inf A (H1N1) and Inf A (H3N2) viruses were largely
replaced by the pdm H1N1 strain [53,54].
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 conrmed to be jaundice
caused by the Hepatitis E virus [55]. This 2014 Odisha
Jaundice epidemic was one of the many outbreaks in
Odisha and the most common cause being HEV [56].
This is transmitted enterically and has affected several
people, especially of the low socioeconomic category.
Surveillance for clean water and sanitation was proposed
as the control measure [57].
Indian Swine Flu Outbreak (2015):
It refers to the outbreak of the 2009 H1N1 u
pandemic in India which was still present as of March
2015. This outbreak in 2015 is considered as 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
[58]. According to the NCDC data in India, Rajasthan,
Maharastra, and Gujarat were the worst affected states in
India during this pandemic [59].
Nipah Outbreak (2018):
The virus was rst 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 [60]. This Nipah virus outbreak
began in May 2018 in Kozhikode District, Kerala. This
is the rst Nipah virus outbreak reported in Kerala and
the third known to have occurred in India, with the most
recent previous outbreak being in 2007 [61]. Spread of
awareness about this infection, isolation of the infected
and post-outbreak surveillance led to the control of this
outbreak [62].
India has stood strong through several epidemics
and pandemics. Good medical care and efcient
researches have made it possible to ght every infection
and luckily, we have been able to even eradicate a few. It
can be established that throughout time, many infectious
diseases have become widespread due to the mere lack
of sanitation and crowded environment. The tropical
climate and the seasonal rains in India is yet another
important factor contributing to several vector-borne
infections outbreaks in the past and many more to come.
Though it has been difcult to compile all the epidemics
and pandemics due to lack of sufciently available data
and errors in data preservation, sincere efforts have been
put into including most of the important, notable ones.
This is written with a hope that it may help medical
Indian Journal of Public Health Research & Development, August 2019, Vol. 10, No. 8 1507
professionals understand where they had gone wrong in
controlling an outbreak in the past or how they succeeded
to lead by example. It is also a sad truth that India will
have to face several more such outbreaks in the days
to come but preparedness has to be given immense
importance and control of spread should be the number
one priority of the doctors and other health care workers.
Ethical Clearance- No ethical clearance was
necessary for this research work
Source of Funding- Self funded project
Conict of Interest – Nil
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    What is cholera? How and where did it start? How did and does it spread? There is a lack of agreement about the early history of cholera. Confusion arose because it was difficult to define cholera precisely (which has a broad clinical spectrum) and to distinguish it from many other diseases associated with diarrhea and vomiting.
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    Background: The 1918-19 'Spanish' Influenza was the most devastating pandemic in recent history, with estimates of global mortality ranging from 20 to 50 million. The focal point of the pandemic was India, with an estimated death toll of between 10 and 20 million. We will characterize the pattern of spread, mortality, and evolution of the 1918 influenza across India using spatial or temporal data. Methods: This study estimates weekly deaths in 213 districts from nine provinces in India. We compute statistical measures of the severity, speed, and duration of the virulent autumn wave of the disease as it evolved and diffused throughout India. These estimates create a clear picture of the spread of the pandemic across India. Results: Analysis of the timing and mortality patterns of the disease reveals a striking pattern of speed deceleration, reduction in peak-week mortality, a prolonging of the epidemic wave, and a decrease in overall virulence of the pandemic over time. Conclusions: The findings are consistent with a variety of possible causes, including the changing nature of the dominant viral strain and the timing and severity of the monsoon. The results significantly advance our knowledge of this devastating pandemic at its global focal point.
  • Article
    Cholera is a global health problem as several thousands of cases and deaths occur each year. The unique epidemiologic attribute of the disease is its propensity to occur as outbreaks that may flare-up into epidemics, if not controlled. The causative bacterial pathogen Vibrio cholerae prevails in the environment and infects humans whenever there is a breakdown in the public health component. The Indian subcontinent is vulnerable to this disease due its vast coastlines with areas of poor sanitation, unsafe drinking water, and overcrowding. Recently, it was shown that climatic conditions also play a major role in the persistence and spread of cholera. Constant change in the biotypes and serotypes of V. cholerae are also important aspects that changes virulence and survival of the pathogen. Such continuous changes increase the infection ability of the pathogen affecting the susceptible population including the children. The short-term carrier status of V. cholerae has been studied well at community level and this facet significantly contributes to the recurrence of cholera. Several molecular tools recognized altering clonality of V. cholerae in relation with the advent of a serogroup or serotype. Rapid identification systems were formulated for the timely detection of the pathogen so as to identify and control the outbreak and institute proper treatment of the patients. The antimicrobials used in the past are no longer useful in the treatment of cholera as V. cholerae has acquired several mechanisms for multiple antimicrobial resistanceantimicrobial resistance . This upsurge in antimicrobial resistance directly influences the management of the disease. This chapter provides an overview of cholera prevalence in India, possible sources of infection, and molecular epidemiology along with antimicrobial resistance of V. cholerae.
  • Article
    The incidence of emerging infectious diseases in humans has increased within the recent past or threatens to increase in the near future. Over 30 new infectious agents have been detected worldwide in the last three decades; 60 per cent of these are of zoonotic origin. Developing countries such as India suffer disproportionately from the burden of infectious diseases given the confluence of existing environmental, socio-economic, and demographic factors. In the recent past, India has seen outbreaks of eight organisms of emerging and re-emerging diseases in various parts of the country, six of these are of zoonotic origin. Prevention and control of emerging infectious diseases will increasingly require the application of sophisticated epidemiologic and molecular biologic technologies, changes in human behaviour, a national policy on early detection of and rapid response to emerging infections and a plan of action. WHO has made several recommendations for national response mechanisms. Many of these are in various stages of implementation in India. However, for a country of size and population of India, the emerging infections remain a real and present danger. A meaningful response must approach the problem at the systems level. A comprehensive national strategy on infectious diseases cutting across all relevant sectors with emphasis on strengthened surveillance, rapid response, partnership building and research to guide public policy is needed.
  • Article
    In September 1896, a virulent plague epidemic broke out in the colonial port city of Bombay. Central to existing interpretations of the epidemic has been the pervasive assumption that colonial policies aimed at suppressing the disease were principally informed by etiological doctrine. However, this article argues that long-standing etiological theories continued to exercise a critical influence over colonial policies. It thereby highlights the explicit bias that informed the colonial state's anti-plague offensive, which was largely directed at the urban poor.
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    India's success in eliminating wild polioviruses (WPVs) has been acclaimed globally. Since the last case on January 13, 2011 success has been sustained for two years. By early 2014 India could be certified free of WPV transmission, if no indigenous transmission occurs, the chances of which is considered zero. Until early 1990s India was hyperendemic for polio, with an average of 500 to 1000 children getting paralysed daily. In spite of introducing trivalent oral poliovirus vaccine (tOPV) in the Expanded Programme on Immunization (EPI) in 1979, the burden of polio did not fall below that of the pre-EPI era for a decade. One of the main reasons was the low vaccine efficacy (VE) of tOPV against WPV types 1 and 3. The VE of tOPV was highest for type 2 and WPV type 2 was eliminated in 1999 itself as the average per-capita vaccine coverage reached 6. The VE against types 1 and 3 was the lowest in Uttar Pradesh and Bihar, where the force of transmission of WPVs was maximum on account of the highest infant-population density. Transmission was finally interrupted with sustained and extraordinary efforts. During the years since 2004 annual pulse polio vaccination campaigns were conducted 10 times each year, virtually every child was tracked and vaccinated - including in all transit points and transport vehicles, monovalent OPV types 1 and 3 were licensed and applied in titrated campaigns according to WPV epidemiology and bivalent OPV (bOPV, with both types 1 and 3) was developed and judiciously deployed. Elimination of WPVs with OPV is only phase 1 of polio eradication. India is poised to progress to phase 2, with introduction of inactivated poliovirus vaccine (IPV), switch from tOPV to bOPV and final elimination of all vaccine-related and vaccine-derived polioviruses. True polio eradication demands zero incidence of poliovirus infection, wild and vaccine.