China! The plague! A city quarantined! It sounds like a dismal new episode of the new 24: Live Another Day. But this time it’s true.
Yumen, a town of 30,000 in northwest China, has been “sealed off” because a young man there died of the plague, an infectious disease caused by the bacteria Yersinia pestis. In addition, 151 people in Yumen have been placed under “quarantine,” probably because they were directly exposed to the patient and so are at some risk for acquiring the plague.
Famous for the three great pandemics that have shaped human history over the centuries, including the Black Plague in the 14th century that killed more than half of Europe, cases of the plague still occur, including in the United States. Now, the disease is curable with antibiotics if caught early; plus its spread is readily preventable by giving exposed but still-uninfected persons common antibiotics such as doxycycline or ciprofloxacin.
In China, the sad story is that of a 38-year-old man who died of the infection after apparent contact with a diseased marmot, a small squirrel-y looking mammal. The patient has been described by some reports as having “bubonic” plague and by others as having developed the “pneumonic” form. Though the words may sound and scan the same, there is a world of difference in threat each poses to others.
“Bubonic” plague is the simple version. A flea, Xenopsylla cheopis, from an infected little mammal—usually a rat—can hop from the dying rat onto a human and bite it. A small mark can be visible where the bite occurs, but anatomically upstream, toward the heart, in that mat of lymph nodes we have in our groin or underarms or neck, a “bubo” may form. (Ergo “bubonic.”) The bubo, Greek for a swelling in the groin, may successfully contain the infection locally but in the majority of people, Yersinia pestis infection overwhelms this local control and enters the bloodstream to cause “septicemic” (blood-borne) plague.
(Note: A town or city where a rat population is dying off fast is a town or city where one should run for the hills even faster. The likely cause of the die-off is not effective municipal pest control but rather a first-wave epidemic of the plague that kills the little mammals first, then the people. The only historical exception to this rule is that which surrounds the Pied Piper of Hamelin, who was said to be able to play his pipe so beautifully that the still-living rats would follow him out of towns and thus remove the plague risk hygienically.)
The second form of plague, the septicemic, causes the signs and symptoms that give the “Black Plague” its name—toes, fingers, and the tip of the nose turn black from clogged blood supply and fall off. The duskiness—from bacteria affecting small blood vessels—soon may progress to involve hands, feet, then arms and legs till a person dies a literally black death.
But that’s still not the worst of it, at least from a public health perspective. As the bacteria riots through the bloodstream, it may settle in the lungs, causing the “pneumonic” plague, the third and by far the most contagious form of the disease. A coughing person with pneumonic plague may infect anyone he comes into contact with, leading to the sort of galloping epidemics and pandemics that fill the history books.
The pneumonic plague also has given rise to the entire world of protective masks, gowns, and gloves so common these days in hospitals. The bird-like “plague suit” worn by plague doctors since at least the 16th and 17th centuries demonstrates both how resourceful denizens were when confronted with possible cases and also how panic-stricken. The key part of the costume, beyond the head-to-toe fabric, was the beak. This typically was filled with something that had a strong aroma, to neutralize the deathly smell of the plague and (per then-modern belief) prevent disease transmission to the wearer.
The appearance of the plague also challenged doctors of the era to determine who came first: the sick patient or the doctor himself. This complex ethical issue still surfaces as new contagious diseases such as AIDS, SARS, and Ebola appear that place the health-care worker at risk. Most groups, such as the AMA, articulate an obligation to treat that has replaced the advice of a 14th-century physician (who advised young physicians to inform families of plague patients that “you will be leaving town shortly and cannot take the case”). Thankfully, taking readily available antibiotics is sufficient to prevent plague for today’s worried health-care worker.
The most impressive aspect of the news out of China is that health authorities there have moved so quickly to report and clamp down on the case. This is in contrast to concerns many Western public health experts have had about a lax approach in China to reporting and controlling SARS and influenza. It is uncertain whether the new way of doing business is indeed a new way of doing business, or perhaps reflects a papering-over of a much worse problem than now reported.
I fear the latter, given the draconian governmental measures over a single case, but time will tell. Perhaps we should give China a break: It may be ungenerous just now to second-guess any country’s handling of a potential outbreak of the disease caused by Yersinia pestis. After all, this is a problem so much easier to control than the situations that plague us in the Middle East and Ukraine that are caused by man’s undying inhumanity to man.
