China

“…..The patient, a herder from Jiuquan’s Subei Mongolian autonomous county, died on Tuesday afternoon despite efforts by medical personnel……. The patient’s gender was not disclosed.

Experts said tests had confirmed at 11 pm that the patient died of septicemic plague that evolved from bubonic plague, which was reported as a suspected plague case at 5:30 pm.

Authorities said they had placed 12 people who had close contact with the patient under quarantine, and no abnormalities had been found……”

WHO

Plague – Madagascar

Since 1 August 2017, Madagascar has been experiencing a large outbreak of plague. As of 10 November 2017, a total of 2119 confirmed, probable and suspected cases of plague, including 171 deaths (case fatality rate: 8%), have been reported by the Ministry of Health of Madagascar to WHO.

From 1 August through 10 November 2017, 1618 (76%) cases and 72 deaths have been clinically classified as pneumonic plague, including 365 (23%) confirmed, 573 (35%) probable and 680 (42%) suspected cases. In addition to the pneumonic cases, 324 (15%) cases of bubonic plague, one case of septicaemic plague, and 176 unspecified cases (8%), have been reported to WHO (Figure 1). Eighty-two healthcare workers have had illness compatible with plague, none of whom have died.

Figure 1: Number of confirmed, probable and suspected plague cases in Madagascar reported by date of illness onset from 1 August through 10 November 2017 (n=2119)¹

¹ Date of onset is missing for 295 cases

From 1 August through 10 November, 16 (out of 22) regions of Madagascar have reported cases. Analamanga Region has been the most affected, reporting 72% of the overall cases (Figures 2 and 3).

Figure 2: Geographical distribution of confirmed and probable pneumonic plague cases in Madagascar from 1 August through 12 November 2017

Figure 3: Geographical distribution of confirmed and probable bubonic plague cases in Madagascar from 1 August through 12 November 2017

As of 10 November 2017, 218 out of 243 (90%) contacts under follow-up were reached and provided with prophylactic antibiotics. Since the beginning of the outbreak, a total of 7122 contacts were identified, 6729 (95%) of whom have completed their 7-day follow up and a course of prophylactic antibiotics. Only nine contacts developed symptoms and became suspected cases.

Laboratory confirmation of plague is being conducted by the Institut Pasteur of Madagascar, National WHO Collaborating Center for plague in Madagascar. Twenty-five isolates of Yersinia pestis have been cultured and all are sensitive to antibiotics recommended by the National Program for the Control of Plague.

The number of new cases and hospitalizations of patients due to plague is declining in Madagascar. The last confirmed bubonic case was reported on 24 October and the last confirmed pneumonic case was reported on 28 October.

Since plague is endemic to parts of Madagascar, WHO expects more cases to be reported until the end of the typical plague season in April 2018. It is therefore important that control measures continue through to the end of the plague season.

Public health response

The Ministry of Public Health of Madagascar is coordinating the health response, with the support of WHO and other agencies and partners.

The Ministry of Public Health of Madagascar has activated crisis units in Antananarivo and Toamasina and all cases and contacts have been provided access to treatment or prophylactic antibiotics at no cost to themselves.

Public health response measures include:

• Investigation of new cases
• Isolation and treatment of all pneumonic cases
• Enhanced case finding
• Active finding, tracing and monitoring of contacts and provision of free prophylactic antibiotics
• Strengthened epidemiological surveillance in the all affected districts
• Disinsection, including rodent and vector control
• Raising public awareness on prevention for bubonic and pneumonic plague
• Raising awareness among health care workers and providing information to improve case detection, infection control measures and protection from infection
• Providing information about infection control measures during burial practices.

Enhanced measures for exit screening have been implemented at the International Airport in Antananarivo. These measures include: filling a special departure form at the airport (to identify passengers at risk); temperature screening of departing passengers, and referring passengers with fever to airport physicians for further consultation; passengers with symptoms compatible with pneumonic plague are immediately isolated at the airport and investigated using a rapid diagnostic test and notified according to the response alert protocol. Symptomatic passengers are not allowed to travel. A WHO GOARN team, consisting of US Centers for Disease Control and Prevention (CDC) and L’Institut de veille sanitaire/ Santé publique France (InVS/SPF), is providing technical support at the airport.

Nine countries and overseas territories in the African region (Comoros, Ethiopia, Kenya, Mauritius, Mozambique, La Réunion (France), Seychelles, South Africa, and Tanzania) have been identified as priority countries for plague preparedness and readiness by virtue of their trade and travel links to Madagascar. These countries are implementing readiness activities, including increased public awareness of plague, enhancing surveillance for the disease (particularly at points of entry), and prepositioning of equipment and supplies.

WHO risk assessment

Since mid-October, the number of new cases of plague, the number of hospitalizations of patients due to plague, and the number of geographic districts reporting plague has decreased. While the declining trend in new plague case reports and reduction in hospitalizations due to plague are encouraging signs, WHO expects more cases of plague to be reported from Madagascar until the typical plague season ends in April 2018.

The decline in case reports suggests that the epidemic phase of the outbreak is ending, however sustaining ongoing operations is critical to minimize bubonic plague infections and human-to-human transmission of pneumonic plague.

The trend in the number of new cases of plague has been declining for more than a month, indicating that measures taken to contain the outbreak have been effective. WHO is working with the Ministry of Health in Madagascar and other partners to maintain ongoing outbreak control efforts, including active case finding and treatment, comprehensive contact identification, follow-up and antibiotic treatment, rodent and flea control, and safe and dignified burials through this outbreak and the plague season into 2018, and to outline a longer term strategy for plague preparedness and control.

Since the beginning of this outbreak, the vast majority of cases, and more than 7000 contact persons, have been treated and have recovered. As of 15 November 2017, only 12 people are hospitalized for plague. There has been no international spread outside the country.

Based on available information and response measures implemented to date, WHO estimates the risk of potential further spread of the plague outbreak at national level remains high. The risk of international spread is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures and advice to travellers to Madagascar, and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low. WHO is re-evaluating the risk assessment based on the evolution of the outbreak and information from response activities.

Advice on prevention and control measures and treatment options has been provided to Madagascar and to priority countries in the region.

WHO travel advice

Based on the available information to date, the risk of international spread of plague appears very low. WHO advises against any restriction on travel or trade on Madagascar. To date, there are no reported cases related to international travel.

International travellers arriving in Madagascar should be informed about the current plague outbreak and the necessary protection measures. Travellers should protect themselves against flea bites, avoid contact with dead animals, infected tissues or materials, and avoid close contact with patients with pneumonic plague. In case of sudden symptoms of fever, chills, painful and inflamed lymph nodes, or shortness of breath with coughing and/or blood-tainted sputum, travellers should immediately contact a medical service. Travellers should avoid self-medication, even if for prophylaxis. Prophylactic treatment is only recommended for persons who have been in close contact with cases, or with other high risk exposures (such as bites from fleas or direct contact with body fluids or tissues of infected animals). Upon return from travel to Madagascar, travellers should be on alert for the above symptoms. If symptoms appear, travellers should seek medical care and inform their physician about their travel history to Madagascar.

Outbreak News

• 1,437 (74%) were clinically classified as pulmonary plague
• 295 (15%) were bubonic plague
• one was septicemic
• 211 were not yet classified (further classification of cases is in process).
• The death count has risen to 143.

CDC-PHIL

WHO

“……From 1 August to 30 October 2017, a total of 1 801 suspected cases of plague, including 127 deaths (case fatality rate 7%), were reported. Of these, 1 111 (62%) were clinically classified as pulmonary plague, 261 (15%) were bubonic plague, one was septicaemic, and 428 were unspecified (further classification of cases is in process). Since the beginning of the outbreak, 71 healthcare workers (with no deaths) have been affected.
Of the 1 111 clinical cases of pneumonic plague, 257 (23%) have been confirmed, 374 (34%) are probable and 480 (43%) remain suspected (additional laboratory results are in process). Fourteen strains of Yersinia pestis have been isolated and are sensitive to antibiotics recommended by the National Program for the Control of Plague.
Overall, 51 of 114 (45%) districts in 16 of 22 (73%) regions of Madagascar have been affected. Analamanga Region has been the most affected, with 64% (1 149) of all recorded cases.
About 83% (5 357) of 6 492 contacts identified thus far have completed their 7-day follow up and a course of prophylactic antibiotics. A total of nine contacts developed symptoms and became suspected cases. On 30 October 2017, 925 out of 972 (95%) contacts under follow-up were reached and provided with prophylactic antibiotics. ….”

ECDC

Bubonic plague

Bubonic plague is typically caused by the bite of an infected flea, by contact with infected human/animal bodyilyfluids, or by touching or skinning infected animals [1]. Transmission by these routes can result in primary bubonic plague or in septicaemic plague [1]. Healthcare workers (HCW) can become infected during the management of an infected patient or during sample collection (e.g. collection of pus samples from swollen lymph nodes or buboes) [2].

Pneumonic plague

Pneumonic plague can be transmitted via infected respiratory droplets from infected humans or animals [3] [4], or through contact with infected human/animal body fluids [5]. It can also be transmitted by contact with bed linen/clothing contaminated with body fluids of an infected patient [5]. Human-to-human transmission by infected respiratory droplets can occur over a close distance, usually defined as less than two metres. Healthcare workers can become infected during the management of an infected patient or during sample collection (e.g. collection of sputum samples) [6].

Personal protective equipment for the management of possible, probable and confirmed cases of plague

Healthcare workers should be informed and trained on procedures and approaches to prevent and control infection. They should dispose of, disinfect or decontaminate all personal protective equipment (PPE) (disposable or not) used for the management of a plague patient according to the procedures for waste management [7]. They should also wash their hands frequently, particularly before putting on and after removing the PPE.

Bubonic plague

In line with the national and international infection prevention and control recommendations, HCW should wear the following PPE when managing or caring for a patient with possible, probable or confirmed bubonic plague:

• gloves

• long-sleeved gown with tight cuffs (single use/disposable preferable)

• eye protection (face shield or goggles)

• respiratory protection (surgical mask).

The interim guidance on ‘How to safely collect pus samples from buboes of patients suspected to be infected with bubonic plague’ [2] should be followed for the specimens’ collection in case of suspected cases of bubonic plague.

Pneumonic plague

Healthcare workers should apply standard hygiene procedures for the management of the patient. They should isolate the patient [8] [9] and follow Body Substance Isolation (BSI) precautions [10] [11]. If isolation is not possible, they should ensure a separation of at least two metres between patients, and a dedicated bathroom for the infected patient. Health authorities should consider chemoprophylaxis for HCW in direct contact with pneumonic plague patients [9]. Due to the transmission route by droplets, these procedures should be continued for 48 hours after initiation of effective treatment [12].

In line with the national and international infection prevention and control recommendations, HCW should wear the following PPE when managing or caring for a patient with possible, probable or confirmed pneumonic plague:

• gloves

• long-sleeved gown with tight cuffs (single use/disposable preferable)

• eye protection (face shield or goggles)

• respiratory protection (FFP3 filter mask or N-95 particulate).

The patient should wear a surgical mask if it is necessary to move him/her around the hospital; HCW should inform the patient about cough etiquette and respiratory hygiene. They should also follow the interim guidance on ‘How to safely collect sputum samples from patients suspected to be infected with pneumonic plague’ [6] for the specimens’ collection in case of suspected cases of pneumonic plague. Biosafety for the management of specimens All the samples collected for routine testing and cultures should be handled in Biosafety Level 2 (BSL-2) laboratories. Large-scale cultures and activities with high potential for droplet or aerosol production (centrifuging, grinding, etc.) require Biosafety Level 3 (BSL-3) conditions [13] [8].

Disclaimer ECDC issued this guidance document in accordance with Regulation (EC) No 851/2004 establishing a European centre for disease prevention and control. In the framework of ECDC’s mandate, the specific purpose of an ECDC guidance is to present different options on a certain matter. The responsibility on the choice of which option to pursue and which actions to take, including the adoption of mandatory rules or guidelines, lies exclusively with the EU/EEA Member States. In its activities, ECDC strives to ensure its independence, high scientific quality, transparency and efficiency.

References

1. Centers for Disease Prevention and Control. Plague Home: Ecology and Transmission [updated 2015 Sept 14; cited 2017 Oct 19]. Available from: https://www.cdc.gov/plague/transmission/index.html. 2. World Health Organization. How to safely collect pus samples from buboes of patients suspected to be infected with bubonic plague 2016 [cited 2017 Oct 19]. Available from: http://www.who.int/csr/disease/plague/collecting-pussamples.PDF?ua=1. 3. Inglesby TV, Dennis DT, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, et al. Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. 2000 May 03;283(17):2281-90. 4. Centers for Disease Prevention and Control – National Center for Emerging and Zoonotic Infectious Diseases – Division of Vector-Borne Diseases – Bacterial Diseases Branch. Protect yourself from plague [cited 2017 Oct 19]. Available from: https://www.cdc.gov/plague/resources/235098_plaguefactsheet_508.pdf. 5. Public Health Agency of Canada. The Plague [updated 2017 Oct 16; cited 2017 Oct 19]. Available from: https://www.canada.ca/en/public-health/services/chronic-diseases/plague.html. 6. World Health Organization. How to safely collect sputum samples from patients suspected to be infected with pneumonic plague 2016 [cited 2017 Oct 19]. Available from: http://www.who.int/csr/disease/plague/collecting-sputumsamples.PDF?ua=1. 7. European Centre for Disease Prevenition and Control. Safe use of personal protective equipment in the treatmentof infectious diseases of high consequence – A tutorial for trainers in healthcare settings 2014 [cited 2017 Oct 20]. 2:[Available from: https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/safe-use-of-ppe.pdf. 8. Stewart CE. Weapons of mass casualties and terrorism response handbook: Jones & Bartlett Learning; 2006. 9. World Health Organisation. Plague. Fact sheet (updated October 2017) 2017 [updated 2017 Oct; cited 2017 Oct 19]. Available from: http://www.who.int/mediacentre/factsheets/fs267/en/. 10. Delaware health and social services – Division of Public Health – Emergency Medical Services. Plague [updated 2007 May; cited 2017 Oct 19]. Available from: http://dhss.delaware.gov/dph/files/plagueems.pdf. 11. Jane D. Siegel MD, Emily Rhinehart RN MPH CIC, Marguerite Jackson PhD, Linda Chiarello RN MS, the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 [cited 2017 Oct 19]. Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf. 12. Ontario Public Health Standards. Infectious Diseases Protocol, Appendix A: Disease-Specific Chapters [updated 2014 Dec; cited 2017 Oct 19]. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/plague_chapter.pdf. 13. US Department of Health and Human Services. Biosafety in Microbiological and Biomedical Laboratories 2009 [cited 2017 Oct 25]. Available from: https://www.cdc.gov/biosafety/publications/bmbl5/BMBL.pdf.

ECDC

Key messages

• Pneumonic plague is transmitted between humans most often by inhaling infected respiratory droplets. The transmission happens at close distance (usually defined as less than two metres) and only symptomatic patients are infectious.

• The infection can cause severe disease in humans but can be successfully treated with antibiotics, especially if antibiotic treatment is insituted early.

• A case of pneumonic plague can be suspected on aircraft or ships when a traveller (passenger or a crewmember) leaving an affected area has fever associated with persistent coughing and/or impaired breathing.

• The training of crewmembers and the increase in their awareness should reduce the risk of transmission on-board.

• A surgical mask and standard infection control precautions can be used to effectively reduce the spread of droplets from a suspected patient, if isolation measures are not possible.

• A surgical mask can be used to protect travellers (passengers and crewmembers) from infection by a suspected pneumonic plague case.

• Local authorities of the arrival airport/mooring port of call should be kept informed immediately after the identification of a suspected case of pneumonic plague on-board, in order to plan for mitigating the risks of further spread.

• All passengers should be advised about self-monitoring of plague compatible symptoms in case of an onboard event; collection of passenger contact details is crucial for further contact tracing.

• Early post-exposure prophylaxis should be considered for passengers and crewmembers who came into close contact with the ill passenger.

• After disembarkation, disinfection measures should be considered which comply with relevant national and international recommendations.

WHO

“…From 1 August to 24 October 2017, a total of 1 309 suspected cases of plague, including 93 deaths (7%), were reported. Of these, 882 (67%) were clinically classified as pulmonary plague, 221 (17%) were bubonic plague, 1 was septicaemic, and 186 were unspecified (further classification of cases is in process). Since the beginning of the outbreak, 71 healthcare workers (with no deaths) have been affected….”

CIDRAP

• An increase of 448 since its previous update.
• Of the total, 846 (65.2%) are pneumonic plague infections.
• The number of deaths rose to 102, up 35 since the last report.
• The case-fatality rate remained at 7.9%.

WHO

“Madagascar is experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017.

Between 1 August and 15 October 2017, a total of 849 cases (suspected, probable and confirmed) including 67 deaths (case fatality rate 7.9%) have been reported from 37 (32.5%) out of 114 districts in the country. Of these, 568 cases (67%) were clinically classified as pneumonic plague, 155 (18.3%) were bubonic plague, one case was septicaemic plague, and 125 cases were unspecified. At least 39 healthcare workers have contracted plague since the beginning of the outbreak.

Of the 849 reported cases, 78 (9.2%) were confirmed, 304 (35.8%) were classified as probable after testing positive on rapid diagnostic tests (RDT) and 467 (55%) remain suspected. Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.

Eighteen (81.2%) out of 22 regions in the country, including traditionally non-endemic areas, have been affected. The district of Antananarivo Renivohitra has been the most affected, accounting for 57.1% of the reported cases. As of 16 October 2017, a total of 3745 contacts were identified, 79.2% (2 967) of them were followed up on the day of reporting…..”

WHO

Seychelles – Suspected Plague (Ex- Madagascar)

Disease outbreak news
15 October 2017

Madagascar is experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. This outbreak caries a moderate risk of spread to neighbouring Indian Ocean islands. This risk has been mitigated by the short incubation period (the time from exposure to onset of symptoms) of pneumonic plague and the institution of exit screening measures at the airport and other major ports. For more information, see the latest situation report available from:

• Plague outbreak situation reports

On 10 October 2017, the Seychellois Ministry of Health notified WHO of a probable case of pneumonic plague. The probable case is a 34-year-old man who had visited Madagascar and returned to Seychelles on 6 October 2017. He developed symptoms on 9 October 2017 and presented to a local health centre. Based on a medical examination and reported history of recent travel to Madagascar, pneumonic plague infection was suspected and he was immediately referred to hospital where he was isolated and treated.

A rapid diagnostic test (RDT) performed within the country on 11 October on a sputum sample was weakly positive. Since then he has been treated as a probable case until confirmation by a WHO plague reference laboratory is completed. The specimen is being sent to Institut Pasteur in Paris, France for confirmation. The patient continues to be hospitalized in isolation until completion of the antibiotic treatment. He is currently asymptomatic and in stable condition.

Between 9 and 11 October 2017, eight of his contacts developed mild symptoms and have been isolated. Two other suspected cases, without any established epidemiological link to the probable case, have also been identified isolated and are on treatment.

In total 10 laboratory specimens have been collected from the probable case, his contacts and the two suspected cases and are being shipped to Institut Pasteur in France for testing.

October 13 was the last day of monitoring of over 320 contact persons of the probable case, including 41 passengers and seven crew from the flight, 12 close family members, and 18 staff and patients from the health centre visited by the probable case. All were provided a prophylactic course of antibiotics to prevent the disease.

In addition, 577 children and 63 teachers in potential contact with one of the individual identified by contact tracing were given antibiotics as a prophylaxis precautionary measure. Thus contact tracing is done thoroughly.

Currently only eleven (11) close contacts and one foreign national who was not in contact with the probable case but recently arrived from Madagascar, are hospitalised as precautionary measure and will remain in the hospital on treatment although they do not present signs of respiratory distress.

Public health response

A Crisis Emergency Committee was established on 10 October, and has since then, been meeting daily to coordinate surveillance, contact tracing, case management, isolation and supplies.

A hotline was revived on 12th October.

The Government has allocated funds to support the Committee interventions, enabling the setting up of a temporary isolation ward (whilst the existing ward is expanded), procurement of key supplies, contact tracing, and expanded contact tracers training next week, etc.

Air Seychelles flights to-from Madagascar were stopped from 8 October to reduce likelihood of further importation of cases from Madagascar.

WHO does not recommend restrictions on travel and trade, based on the currently available information.

On 10 October 2017, Madagascar Ministry of Health, with support from WHO, has implemented exit screening at the international airport in Antananarivo to prevent international spread. Further support from WHO and partners is being planned to strengthen measures at points of entry to avoid international spread.

WHO has deployed three epidemiologists and one risk communication officer to support the Country Office and Ministry of Public Health in responding to the current situation.

WHO risk assessment

Plague is an infectious disease caused by the bacteria Yersinia pestis, a zoonotic bacterium, usually found in small mammals and their fleas. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or animals or by inhalation.

There are three forms of plague infection, depending on the route of infection: bubonic, septicaemic and pneumonic.

Pneumonic plague is the most virulent form of plague and can trigger severe epidemics through person-to-person contact via droplets in the air. Incubation period can be as short as 24 hours. Typically, the pneumonic form is caused by spread to the lungs from advanced bubonic plague. However, a person with secondary pneumonic plague may form aerosolized infective droplets and transmit plague to other humans. Plague is treatable disease; however, untreated pneumonic plague is always fatal.

Plague has never been reported in Seychelles, and at this stage, no cases have been definitively confirmed. The case reported above being considered as probable until final classification according to the laboratory results that will be performed at Institut Pasteur in Paris.

The Seychelles Government has established precautionary measures including, enhanced surveillance, isolation and treatment of suspect cases, contact tracing and prophylactic treatment of potential contact.

The risk of further spread in the Seychelles (should the case be confirmed) is considered as low and the overall regional and global risk levels as very low.

WHO travel advice

At this stage, there is a very low risk international travellers would come into contact with plague in Seychelles. WHO advises against any restriction on travel or trade on Seychelles or Madagascar based on the available information.

On 3 October 2017, WHO published advice for international travellers in relation to the outbreak of plague in Madagascar, which should also be followed for travellers to Seychelles.

• Plague – Madagascar
  Information for international travellers

On 11 October, the Ministry of Health announced several measures against pneumonic in a press release on its website. As many of these measures significantly interfere with international traffic, on 13 October, the Ministry of Health informed WHO that it will provide the scientific evidence and public health rationale for these measures, as required by Article 43.3 of the International Health Regulations (IHR, 2005).

• Measures reinforced to contain pneumonic plague
  Ministry of Health, Republic of Seychelles
• International Health Regulations (2005)

For further information on plague, including prevention measures, please visit the WHO Plague website.

• Plague