The Madagascar plague is spreading with 449 cases reported as at October 10, as well as three cases of the bubonic strain and one of the pneumonic strain, reported in the Seychelles for the first time. The World Health Organisation rates the risk of spread outside Madagascar as low.
In an October 10 update on the plague outbreak in Madagascar, the number of cases of the lethal bacterial infection had shot up overnight to 449, an increase in 62 cases. Outbreak News Today reports that this is according to the Ministere de la Publique which reported the breakdown of the types of plague as follows: pneumonic or pulmonary plague (322), bubonic (123) and septicemic (1). Three other cases are classified as suspect as of today.
In the capital city of Antananarivo, 239 cases and 21 deaths have been reported. 82% of cases in the city and surrounding suburbs are pneumonic plague.
In Toamasina, 147 plague cases have been reported, including 9 deaths recorded in the city.
The report notes that pneumonic plague is probably the most serious form of plague – it’s when the bacteria infect the lungs and cause pneumonia. It is contracted when the bacteria is inhaled (primary) or develops when bubonic or septicemic plague spreads to the lungs.
Pneumonic plague is contagious and can be transmitted person to person. It is highly communicable under appropriate climate conditions, overcrowding and cool temperatures. Untreated pneumonic plague is frequently fatal.
An update a day earlier (9 October) from the World Health Organisation (WHO) said that over the past 5 days, 23 new suspected plague cases were reported in Madagascar, with the disease spreading to seven more of the country's districts.
And CIDRAP – the University of Minnesota’s Centre for Infectious Disease Research and Policy said that in a related development, the European Centre for Disease Prevention and Control (ECDC) issued its first risk assessment on the outbreak, which said the outbreak's high number of pneumonic cases are concerning, especially since that form of the disease is known to spread in densely populated urban areas, such as Antananarivo and Toamasina, which are some of the main affected areas.
Plague is caused by Yersinia pestis, a bacterium spread by infected rats via flea bites. Human-to-human transmission fuels the spread of pneumonic plague. Of the 239 new suspected cases reported since the WHO's 4 October update, 17 have proved fatal, the WHO said. The new cases lift the outbreak's number of suspected, probable, and confirmed cases to 387 and the number of deaths to 45.
So far, 277 (71.6%) of the illnesses involve the pneumonic form of the disease, while 106 are bubonic, 1 is septicaemic, and 3 are unspecified. The overall case-fatality rate is 11.6%.
Illnesses have been reported from 27 of Madagascar's 114 districts, up from 20 in the WHO's 4 October report. Though plague is endemic in the country, the WHO said illnesses have been reported in two regions where the disease is considered non-endemic: North and Southeast.
At least eight healthcare workers from one district hospital have contracted the disease since 30 September.
Though the outbreak was sparked by one large cluster of pneumonic plague, since then, illnesses without apparent links have been detected in 14 of Madagascar's regions. "Due to the increased risk of further spread and severe nature of the disease, the overall risk at the national level is considered very high," the WHO said, adding that because of frequent travel by air and sea, the regional risk to neighbouring Indian Ocean islands and African countries is moderate.
Overall global risk is low, but the WHO said it would reassess the situation at three organisation levels as the situation unfolds. The organisation has classified the event as a grade 2 emergency, meaning a single or multiple country event that poses a moderate public health threat.
The WHO is scaling up contact tracing training for more than 900 community health workers, Doctors of the World (Medicines du Monde) is setting up five isolation and treatment centres in Antananarivo, and Doctors without Borders has deployed 70 health workers to support the response in Tananative.
The WHO and its partners have started deploying emergency response teams, and as of yesterday, 30 experts were expected to arrive, with 12 more in the process of deploying.
The WHO is also supporting preparedness activities in seven high-risk countries that took part in a recent basketball tournament and have trade and travel connections to Madagascar: South Africa, Mozambique, Tanzania, Mauritius, Comoros, Seychelles, and Reunion. The WHO and Madagascar's health ministry are screening departing passengers at the country's international airport.
The WHO said it has delivered nearly 1.2m doses of antibiotics to Madagascar's health ministry and its partners, enough to treat 5,000 patients and protect 100,000 people exposed to the disease. The WHO has also released $1.5m from its emergency fund, but said $5.5m more is needed to support outbreak response over the next 3 months.
In its overview and risk assessment of the outbreak today, the ECDC echoed the WHO's concerns about the unusually high number of pneumonic cases and said the risk of further transmission in Madagascar is considered high until control measures gain traction.
"The outbreak currently involves several uncontrolled chains of transmission of pneumonic plague and the situation remains unclear at this stage," the ECDC said. "The infection and death of a foreign visitor to the country without a known source of transmission is of concern."
It estimated the regional threat to the region around Madagascar to be moderate, with the threat of imported cases in Europe and to its travelers as very low. "However, Member States should consider reviewing their preparedness plans for imported cases."
Resistance of Y pestis to antibiotics seems limited, and experts monitor circulating strains to gauge antimicrobial susceptibility, the ECDC said. Increasing resistance of fleas, which transmit the bacteria from rodents to people, is a concern. And Madagascar's national plague control program, in place for several decades, has been hampered by operational and managerial difficulties, the agency added.
The US Centres for Disease Control and Prevention (CDC) on 6 October issued a level 2 travel notice based on the developments in Madagascar, urging people traveling to the country to practice enhanced precautions.
"Although bubonic plague occurs nearly every year in Madagascar, an unusual outbreak of plague pneumonia is occurring in geographically widespread areas, including in heavily populated cities of Antananarivo (the capital city and its suburbs) and Toamasina."
The CDC added that local officials are working to control fleas and are cancelling mass gatherings, given that the pneumonic form of the disease can spread from person to person in close contact.
Those traveling to Madagascar should use insect repellent to avoid flea bites, avoid close contact with sick and dead animals, and avoid close contact with sick people, especially those with cough or pneumonia.
Health officials in Seychelles have, meanwhile, confirmed that 3 people have tested positive for the bubonic plague, says a eTurbo News report. A Seychellois basketball coach died from the pneumonic plague late last month in a hospital in Antananarivo, the capital of Madagascar. The coach, Alix Allisop, was assisting the Seychelles men’s reigning champion of the Beau Vallon Heat in Madagascar during the Indian Ocean Club Championship.
The report says the government of Madagascar has confirmed that the death of Allisop was due to the pneumonic plague. The other members of the Seychellois basketball delegation, who were in close contact with Allisop, have been under observation since they returned to the country. They are now at the military academy at Perseverance, a reclaimed island on the outskirts of Victoria.
According to the WHO pneumonic plague, or lung-based plague, is the most virulent form and can trigger severe epidemics through person-to-person contact via droplets in the air, as well as flea bites from infected mammals. The incubation period can be as short as 24 hours.
The report says the Seychelles’ Ministry of Health has advised all airlines and travel agents to discourage people from traveling to Madagascar due to the plague outbreak. Additional health measures at Seychelles’ main airport have also been put in place.
Jude Gedeon, Seychelles’ public health commissioner, is quoted in the report as saying that officials have put in place walk-through and temperature scanners at the international airport to detect cases. A form is also being given to disembarked passengers to state if they have any symptoms similar to those brought on by the plague. Additionally, as a precaution, all schools in Seychelles are closed for the next 6 days as it is not yet confirmed that contact was made with any of the teachers.
BBC News reports that there has recently been criticism of the government's perceived slow reaction to the outbreak. And, a specialised hospital in the capital Antananarivo is struggling to cope with the influx of ill people, local media reported, with long queues outside for face masks and medicine.
The report says this year urban areas have been affected, a development that has worried aid agencies in a country not renowned for a robust healthcare system. "Plague is curable if detected in time. Our teams are working to ensure that everyone at risk has access to protection and treatment. The faster we move, the more lives we save," WHO Madagascar representative Charlotte Ndiaye is quoted in the report as saying.
Two regions are particularly hit by the outbreak. The first is in eastern Madagascar – where the first death was recorded on 28 August – and the other is the central part of the island, mainly in Antananarivo. "The risk of the disease spreading is high at national level… because it is present in several towns and this is just the start of the outbreak," a WHO official said.
The report says on 30 September, Prime Minister Olivier Mahafaly Solonandrasana announced that all public gatherings would be banned in Antananarivo to prevent the spread of the disease. In addition to school closures across the country, authorities on 5 October ordered the closure of the country's two main universities in the eastern port of Toamasina and Antananarivo for disinfection purposes. Sports events have also been cancelled.
There have been concerted efforts to set up rat traps and spray insecticides in several neighbourhoods to prevent the spread of the disease. The government has also established a toll-free number to report any new cases.
The Ministry of Health in addition has also taken measures against social media users who it accuses of spreading "false news" on the disease to create panic. A Facebook user was arrested and investigated on 3 October for publishing a report which did not correspond to the toll given by the ministry.
Plague is endemic to Madagascar, where around 400 cases of – mostly bubonic – plague are reported annually. Contrary to past outbreaks, this one is affecting large urban areas, which increases the risk of transmission. The number of cases identified thus far is higher than expected for this time of year.
Bubonic plague is spread by infected rats via flea bite, pneumonic by person-to-person transmission. The current outbreak includes both forms of plague. Nearly half of the cases identified so far are of pneumonic plague.
Plague is a disease of poverty. It thrives in places with poor sanitary conditions and inadequate health services. It can kill quickly if left untreated, but can also be cured by common antibiotics if delivered early.
The last reported outbreak in December 2016 was mainly bubonic plague occurring in remote area.Outbreak News Today report Madagascar Ministry of Public Health communique CIDRAP material WHO situation update ECDC risk assessment CDC travel notice eTurbo News report BBC News report World Health Organisation material