10 Oct 2017

Plague in Madagascar

Outbreak of plague in Madagascar, with an increase in number of reported cases of pneumonic plague Plague in Madagascar

Since 23 August 2017, Madagascar has been experiencing an outbreak of plague. Cases have been reported in 20 central, eastern and northern districts in Madagascar [1]. The capital city Antananarivo is the most affected area, followed by the port city of Toamasina and the rural district of Faratsiho [1, 2].

Plague is endemic in Madagascar and outbreaks are not unexpected; the main season for outbreaks of bubonic plague is September to April, with a seasonal surge in August and September [2, 4]. However, the high proportion of pneumonic plague reported in this outbreak is a concern [1, 2]. As of 9 October 2017, a total of 387 cases (suspected, probable and confirmed) and 45 deaths (case fatality rate 11.6%) have been reported from 27 out of 114 districts in the country. Of these, 277 cases are pneumonic plague (71.6%), 106 are bubonic plague, one is a septicaemic plague and three are unspecified [3].

Two confirmed cases have been reported in international travellers. On 29 September 2017, health authorities confirmed pneumonic plague as the cause of death of a Seychelles basketball coach, who was attending a basketball championship in Madagascar. A South African basketball official also tested positive for plague on 3 October 2017. Risk of further plague cases associated with this tournament is currently being assessed, as all the participants are being monitored [4].

The World Health Organization and Madagascar’s Ministry of Health are working together to implement a rapid response programme, including treatment, monitoring, contact tracing and disinfection [5].

Based on the available information to date, risk international spread of plague appears very low [1, 2].

About plague

Plague is an infectious disease caused by bacteria called Yersinia pestis, usually found in small animals and rodents. It is transmitted between animals and humans by bites from infected fleas, direct contact, inhalation and ingestion. Pneumonic plague is transmissible person to person. There are three different forms, depending on route of infection: bubonic (lymphatic system), pneumonic (lungs) and septicaemic (bloodstream). Incubation period ranges between one to seven days, depending on the type. Symptoms include fever, chills and painful/swollen lymph nodes in the armpits, groin or neck (buboes), shortness of breath and cough [6].

Advice for travellers

Currently, the risk of contracting plague for most travellers to Madagascar is very low [1]. You should use a DEET based insect repellent to protect against flea bites and:

  • Avoid direct contact with sick or dead animals
  • Avoid close contact with anyone who has symptoms or who is diagnosed with pneumonic plague
  • Avoid crowded areas where cases of pneumonic plague have been recently reported
There is currently no vaccine that protect against plague.

Unwell travellers who have been to areas where plague occurs, and who may have had contact with rodents or fleas or anyone with symptoms or diagnosed with pneumonic plague, should seek prompt medical advice with details of their travel history and activities.

Travellers should avoid self-administration with antibiotics and should seek medical advice regarding antibiotic use following a high risk exposure. 

Advice for health professionals

Most travellers are at low risk of plague. Post-exposure antibiotic treatment may however be considered for travellers at higher risk of exposure to plague (e.g. those who may have  close contact with plague cases or direct contact with body fluids or tissues of infected animals) or at higher risk of complications from the disease (e.g. immunosuppressed, chronic medical conditions) following an assessment of their risk. You may wish to seek specialist advice.

If health professionals suspect a case of plague they should discuss this with their local microbiology, virology or infectious disease consultant. Expert advice should be sought from the Imported Fever Service or the Rare and Imported Pathogens Laboratory. The bacterium which causes plague, Y. pestis, can be isolated from bubo aspirates, blood or sputum specimens. Prompt treatment for plague with antibiotics is usually effective.

All forms of plague are statutorily notifiable. Upon suspicion of a plague diagnosis, a notifiable disease form should be completed and sent to the local health protection team.

Resources

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Diphtheria in the Caribbean and South America

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Polio: Public Health Emergency of International Concern

An update on the polio Public Health Emergency of International Concern (PHEIC) Read more

Hepatitis B vaccine shortage and vaccine prioritisation: advising the traveller

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