Poverty and ignorance were the outcome of Kashmir’s protracted slavery. Sometimes, the poor hygienic conditions would breed epidemics, killing hundreds. In this 1945 write-up, Dr Noor Hussain wrote about the typhus epidemic that was a resident killer like Cholera and was undone only after 1947
From time to time, the existence of typhus has been recorded in Kashmir. In the winter of 1942-43, an epidemic of typhus occurred in Kashmir, and this paper is based on a study of this epidemic.
Kashmir is a large valley at about 5500 feet surrounded by high mountains 12000 feet high. In the main valley runs the Jhelum River and the tributaries of this river descend from smaller valleys lying at the foot of the high mountains. These smaller valleys are inhabited largely by people called Gujjars. In the summer, they go up the valleys to the mountains for pasturing their cattle and typhus is then little seen. In the winter, however, when the mountains and higher valleys become snow-bound, they live in highly congested huts in villages in the small valleys at the foot of the hills. They are all dirty and louse-infested, and in these circumstances, typhus occurs and spreads.
The Gujjars go to the towns to sell their products and may introduce typhus there; they may also act as a source of infection to other villages in the valleys, which are inhabited by other communities. In Kashmir, the seasonal incidence of typhus, its occurrence mainly in louse-infested people, its epidemiology and mortality, its clinical picture and the results of laboratory tests leave no doubt that the vast majority of cases are of the epidemic louse-borne type. It occurs mainly in the winter. It is confined mainly to the Gujjars and to others who come into contact with them. Whole Gujjar settlements may be affected and whole families in towns or cities.
Fifty Per Cent Mortality
A study of the recent outbreak in Kashmir indicates that the mortality rate varies between 25 and 50 per cent. The clinical picture is that of classical typhus. The typical incubation period, the fever itself, the time of the rash, its distribution, starting on the side of the trunk, spreading and involving the flanks, chest, abdomen and the proximal parts of the extremities, the hands and feet often remaining free, the duration of the fever and its nature, the deaths at the end of the second or beginning of the third week from either pneumonia or Peripheral circulatory failure are all seen.
One hundred and forty-six specimens of blood of suspected typhus cases were examined; 67 showed agglutination with 0X19 and 6 with OXK and none with 0X2. It is frequently found that positives are recorded only at the second or third examination.
Typhus: A Brief Introduction
A scourge for centuries, mankind has recorded typhus first in 1489 during the War of Granada, when the Spanish army reported losing 17,000 men to it. In 1577, an assize held in Oxford (UK) killed over 300 people after infected prisoners were brought into the court and spread the disease to the members. By 1759, nearly a quarter of English prisoners died of jail fever. There were fatal outbreaks during Napoleon’s retreat from Moscow in 1812, during the Irish famine between 1816 and 1819, in Philadelphia in 1837, and all along the Eastern Front during World War I.
During the Nazi occupation (WW-II) of Poland, Jewish residents in Warsaw were forcibly confined to the Warsaw Ghetto. The crowded, unsanitary conditions and meagre food rations led to a deadly outbreak of typhus fever in 1941. However, social distancing, self-isolation, and public awareness prevented mass deaths.
Known as “jail fever” and “gaol fever”, Typhus outbreaks were frequent visitors to areas with bad sanitary conditions and densely packed populations like prisons and ghettos. Now, the disease is rare – thanks to the antibiotics, even though there is no vaccine against this. The last recorded outbreak was in Los Angeles homeless population in 2018 and 2019.
People infected by typhus experience sudden fever and accompanying flu-like symptoms, followed five to nine days later by a rash that gradually spreads over the body. If left untreated with antibiotics, the patient begins to show signs of meningoencephalitis (infection of the brain)—sensitivity to light, seizures, and delirium, for instance—before slipping into a coma and, often, dying. Lice are the fundamental disease vectors.
The 1944 Epidemic
Savoor (Haffkine Institute, Bombay) studied typhus in Kashmir in March 1944 and found agglutination for 0X19 only. Guinea-pig inoculations carried out by him showed no Neil-Mooser faction.
For many years typhus has been considered as occurring in Kashmir but accurate records are very few. A mention is made by Lawrence in his book The Valley of Kashmir published at the end of the last century. Epidemics have apparently occurred from time to time but no accurate records are available.
The 1927 Epidemic
In 1927, the epidemic was reported on either side of Singhpore Pass, and I visited the place and saw numerous cases among the Gujjars. In some fatal cases a suppurative parotitis was seen. The difficulty was then experienced in discerning the characteristic rash partly because of the dark skin of the Gujjars but partly due to lack of careful observation.
In the epidemic of 1943-44, the characteristic rash has been seen by me in many cases. Some cases have occurred among attendants on patients.
In one hospital at Baramulla, a lady doctor, a mother superior, and four nurses acquired the infection from patients, and three of them died
The recent epidemic has occurred in the following areas: Khurhama in Lolab valley, an area notorious for typhus in the past; Kishtwar in Dachhan, Udil in Chenab valley, in Sikh villages in Baramulla and Handwara tahsils, in Uri tahsil adjoining Poonch jagir, in Poonch itself, in the Sindh valley near Ganderbal, in Anantnag tahsil near Kishtwar (Singhpore Pass), at Banihal in Udhampur district. In some places, infected blankets were suspected of harbouring the infection. Altogether the number of cases reported to us was 1,526 and 408 deaths occurred, but these figures are probably very incomplete.
The 1943 Winter
In the winter of 1943- 44, the disease reappeared and this time involved not only the old localities but fresh ones. Badgam tahsil in Baramulla district was the chief focus. Nine hundred and forty-six cases were reported with 320 deaths. During this period immunization against typhus with vaccines was introduced on a limited scale. Among 252 persons inoculated, 16 cases occurred, but in all these cases there was evidence that the infection had been acquired before inoculation; moreover, nine persons had not received the third injection recommended, six having received only one. Two cases occurred in persons fully inoculated but both these attacks were mild with recovery. During the same period, 106 cases and 20 deaths occurred in the un-inoculated.
The anti-typhus work consisted mainly of delousing garments by boiling or by heating in a delousing hut where heat was generated between 80 and 100 degrees C; bathing and delousing of people was also done. Some work was also done with DDT and pyricide 20. Naphthalene was not found of much use in delousing clothes.
(Noor Hussain was the Deputy Director of Public Health and Chemical Examiner in the government of Maharaja Hari Singh. This write-up appeared in The Indian Medical Gazette in March 1945.)
