Plague

Fact sheets

Key facts

Plague is an acute bacterial infection caused by the bacillus Yersinia pestis.
It is primarily a zoonosis, affecting mainly rodents, wild or peridomestic (rats).
People infected with Y. pestis often show symptoms after an incubation period of 1 to 7 days.
There are 3 main clinical forms: bubonic plague, pneumonic plague and septicaemic plague. The former is the most common and is characterised by a painful swelling of the lymph nodes, the “buboes”.
Plague is transmitted from animals to humans by the bite of infected fleas, by direct contact with infected tissue and by inhalation of infected respiratory droplets.
Plague can be very serious in humans, with a case-fatality rate of 30% to 60% for the bubonic form and is almost always fatal in the pulmonary form if left untreated.
Antibiotic treatment is effective against the plague bacteria, so early diagnosis and treatment can save lives.
From 2010 to 2015, there were 3248 cases of plague worldwide, 584 of which were fatal.
The 3 main endemic countries at present are Madagascar, the Democratic Republic of Congo and Peru.

History

Throughout history, plague has been responsible for widespread pandemics with high mortality. Known as the “black death” in the 14th century, it caused over 50 million deaths in Europe. From 2010 to 2015, there were 3,248 cases of plague worldwide, of which 584 were fatal. Nowadays, plague can be easily treated with antibiotics and prevented by applying standard precautions.

Case definitions

Suspect case:

compatible clinical presentation (sudden onset of fever, chills, headache, severe malaise, prostration and very painful swelling of lymph nodes or cough with bloodstained sputum, chest pain and difficulty in breathing) AND

consistent epidemiological features, such as exposure to infected animals or humans or evidence of flea bites or residence or travel to a known endemic location during the previous 10 days.

Probable case:

Any suspected live or deceased plague case with a Rapid Diagnostic Test (RDT) against F1 antigen or a positive PCR test alone.

Confirmed case:

suspected case confirmed by isolation of Yersinia pestis from blood, aspiration of buboes, specific seroconversion or a rapid diagnostic test that has detected the F1 Ag in endemic areas.

Transmission

The Y. pestis cycle involves three players, rodents, fleas and humans. Rodents form the reservoir of the disease and can be infected or healthy carriers of the bacteria. Some rodents develop the disease and die, while others are resistant. In Madagascar, it appears that the black rat (Rattus rattus) has developed resistance to the plague and acts as the main reservoir.
Fleas, particularly Xenopsylla cheopis, become infected when bitten by infected rodents. Y. pestis then multiplies in the flea’s digestive tract causing a mechanical oesophageal blockage resulting in “blocked fleas” which are more aggressive towards humans and regurgitate large quantities of bacteria. The transmission cycle between rodents and fleas is essential for the persistence of Yersinia pestis in the wild. The most common mode of transmission in humans is via the subcutaneous route by direct bite of the flea. The minimum dose that infects a mammal by the subcutaneous route is considered to be very low, less than 10 bacteria. Fleas that infect humans come either directly from infected rodents or from flea-infested pets.
Other modes of transmission to humans have been described:

Laboratory infection from handling the bacillus
Bites or scratches from infected pets
Handling of infected animal tissue
Inhalation of droplets from infected animals
Inhalation of droplets from patients with pneumonic plague

Signs and Symptoms

Infected individuals usually present with an acute fever and other non-specific systemic symptoms after an incubation period of 1-7 days (sudden onset fever, chills, headache, body aches, weakness, vomiting and nausea).

Diagnosis

Confirmation of plague requires laboratory testing. The best way is to identify Y. pestis in a pus sample from a bubo, in blood or in sputum. There are different techniques for detecting a specific antigen of the bacillus. One of these is a rapid strip test, which has been validated in the laboratory and is now in widespread use in Africa and South America, with the support of WHO.

Treatment

As pneumonic plague can rapidly lead to death if left untreated, early diagnosis and treatment is essential for survival and limiting complications. Antibiotics and symptomatic treatment are effective if the diagnosis is made early. If left untreated, pneumonic plague can be fatal within 18-24 hours of the onset of symptoms, but common antibiotics effective against enterobacteriaceae (gram-negative bacilli) can achieve a cure if given early.

Prevention

Prevention measures include informing the general public of the presence of zoonotic plague in the environment, advising them to take the necessary precautions against flea bites and not to handle animal carcasses. People in general should be advised to avoid direct contact with infected body fluids and tissues. Standard precautions should be applied in contact with potentially infected patients and when collecting specimens.

Vaccination

WHO does not recommend vaccination, except for high-risk groups (i.e. laboratory workers at constant risk of infection and health workers).

Management of plague outbreaks

Find and eliminate the source of infection: identify the most likely source in the area where the human case(s) was exposed, typically looking for clustered areas where small animals have died in large numbers. Implement appropriate procedures to prevent and control infection. Vector and rodent control. Avoid killing rodents before vectors so that fleas do not change hosts.
Protect health workers: inform and train them in infection prevention and control. Those in direct contact with pneumonic plague patients should follow standard precautions and take antibiotic chemoprophylaxis for at least seven days or as long as exposure to infected patients lasts.
Ensure proper treatment: check that adequate antibiotic therapy is given to patients and that there are sufficient stocks of antibiotics locally.
Isolate patients with pneumonic plague. This is necessary to prevent others from becoming infected by airborne droplets. The spread of the disease can be reduced by providing masks to patients with pneumonic plague.
Monitoring: identify and monitor close contacts of pneumonic plague patients and administer chemoprophylaxis for 7 days. Members of a household where bubonic plague patients live should also receive chemoprophylaxis.
Collect samples carefully, using appropriate procedures to prevent and control infection, and send to the laboratory for analysis.
Disinfect: Routine hand washing with soap and water or use of a hydro-alcoholic solution is recommended. Larger parts of the body can be disinfected with 10% bleach (the mixture should be repeated every day).
Practice safe burials: it is not advisable to spray disinfectant on the face or rib cage of a person suspected of having died from pneumonic plague. These areas should be covered with a cloth or absorbent material soaked in disinfectant.

Surveillance and control

Surveillance and control involves studying the species of animals and fleas involved in the plague cycle in the region and developing environmental management programmes to understand the natural cycle of the zoonosis and limit the spread. Prolonged active surveillance of zoonotic outbreaks, combined with rapid response to animal outbreaks, has successfully reduced the number of human plague outbreaks.

In order to manage plague outbreaks effectively, it is essential that health workers (and communities) are informed and vigilant in order to diagnose infection quickly and manage patients promptly, identify risk factors, maintain surveillance, control vectors and hosts, confirm diagnosis with laboratory tests and report test results to the relevant authorities.

Outbreaks summary

Years	Country	All information’s to Plague Outbreak
2022
2021	MADAGASCAR	On 29 August 2021, the Public Health, Epidemiological Surveillance and Response Department of the Ministry of Health, Madagascar received an alert from Arivonimamo health district, Itasy region, regarding a suspected community death and 15 suspected cases of pneumonic plague that occurred in the municipality of Miandrandra. All the cases presented with fever, headache, weakness, shortness of breath, chest pain and cough. Plague is endemic in Madagascar and outbreaks occur regularly, although every outbreak is cause for concern. Furthermore, pneumonic plague is a notifiable disease under the International Health Regulations 2005. By the following day, 30 August, 25 suspected cases of pneumonic plague had been notified to the health authorities from Arivonimamo district, Itasy region, including six deaths (three community deaths and three at Miandrandra health facility), 19 of which were admitted at Miandrandra health facility for treatment. A total of 20 samples (8 sputum and 12 blood) were collected the same day for laboratory confirmation at the Pasteur Institute of Madagascar. As of 15 September 2021, a total of 20 suspected and 22 confirmed cases of plague have been notified. The median age of cases is 36 years (range 3 to 74 years), 22 cases are males and 20 are females. Reported cases are geographically located in two non-bordering regions: Itasy (3 affected municipalities in Arivonimamo district) and Haute Matsiatra (1 affected municipality in Ambalavao district). Both regions are known plague endemic areas, and during the 2017 outbreak they were highly affected with Ambalavao being the main epicenter. Among confirmed cases, 19 have clinically presented as pneumonic plague and three as bubonic plague. Eight deaths occurred among confirmed cases (2 among bubonic plague cases and 6 among pneumonic plague cases) leading to a case fatality ratio of 37% (8/22). Of them, 4 were males and 4 females, 3 occurred in the community level and 5 at health facilities. Overall, 1,064 close contacts of cases have been identified, followed up, and received chemoprophylaxis with cotrimoxazole or doxycycline. Active case finding in the communities was undertaken in all the health districts reporting cases. Health authorities, in collaboration with the Pasteur Institute of Madagascar, carried out animal surveillance in Arivonimamo district during the initial investigation on 30 August. Preliminary results showed a carriage of Yersinia pestis, the causative bacterium, in 1.3% of the rats, exceeding the alert threshold of 1%, while the pulicidal index (the ratio between the total number of fleas collected from rats captured over the total number of rats captured) was 1.7, which did not exceed the alert threshold of more than 5. Analyses were also performed in Faratsiho (Vakinakaratra region) and Besarety (Analamanga region), which are part of the endemic regions, resulting in a pulicidal indexes at 3.1 and 3.2, respectively. Public health response Interventions against pneumonic plague outbreaks are carried out by the local teams at the community level under the supervision of the district and regional teams. These teams are supported by the central level of the Ministry of Health, the Pasteur Institute of Madagascar and a number of partners including WHO. The following are actions taken and activities carried out for the management and control of this outbreak: Diagnosis and case management: Collection of samples from suspected cases; use of rapid diagnostic tests; shipment of samples for further analysis and confirmation to the Pasteur Institute of Madagascar Management of reported cases in healthcare facilities Training of health workers on the management of plague cases Coordination: Activation of plague control committees in areas that have notified cases Epidemiology and surveillance: Active case finding, active search for close contacts with subsequent chemoprophylactic management using cotrimoxazole as first-line and doxycycline in case of contraindication to sulphonamides Strengthening of community surveillance and surveillance at the level of health facilities Animal surveillance Preventative measures: Disinfection of the homes of affected people: spraying the households of cases with HTH (calcium hypochlorite) solution as a disinfectant Vector control and anti-reservoirs measures Community engagement: Sensitization of the population on plague prevention measures in the affected areas, what symptoms to monitor for, and when to seek care in health facilities WHO risk assessment Plague is endemic in Madagascar and cases are reported each year in bubonic and pneumonic forms. The favorable season for transmission of the disease generally lasts from September to April. Cases are usually reported from the central highlands of the country, located at an altitude of over 700 meters, as is the situation with the current outbreak involving the regions of Itasy and Haute Matsiatra. Between 200 and 400 cases of plague are usually notified each year by the Ministry of Public Health, mainly in the bubonic form. The country experienced an epidemic of pneumonic plague in 2017, which was unusual because of its magnitude and its urban character affecting major cities of the country. This form of plague is very severe and almost always fatal if it is not treated promptly. It develops either by inhaling respiratory droplets from an infected person or as a result of untreated bubonic plague after the bacteria have spread to the lungs. Madagascar has a long history of responding to plague outbreaks. It has already adopted several prevention and response plans, such as the National Strategy for the Prevention and Control of Plague. Unfortunately, the weak financial capacity of the country prevents the establishment of an adequate preparedness and response strategy. The existence of other epidemics like COVID-19 and the ongoing humanitarian nutrition and food crisis in the south of the country are straining the health system and reducing the country’s capacity to cope with other crises. The affected areas are geographically close to the capital of the country and the movement of the population increases the risk of spreading the disease to urban areas and other areas of the country. Thus, the risk at the national level is considered high, while at the regional and global levels this risk is low since there is no known history of exporting plague cases to other countries. Additionally, as Madagascar is an island country, the implementation of response measures is particularly effective at preventing the export of cases. WHO advice WHO recommends the following actions for the management of plague outbreaks: Find and eliminate the source of infection: Identify the most likely source in the area where the human cases have been reported, typically looking for clustered areas where small animals have died in large numbers. Put in place appropriate procedures to prevent and fight infection. Control vectors and rodents. Rodent control should only be undertaken after effective disinfection measures have been implemented. Protect health workers: inform them and train them in infection prevention and control. Those in direct contact with patients with pneumonic plague should apply enhanced protective measures (personal protective equipment) and take antibiotic chemoprophylaxis for at least seven days or as long as exposure to infected patients lasts. Ensure rapid and appropriate treatment: check that adequate antibiotic therapy is administered to patients and that there are sufficient stocks of antibiotics locally. Isolate patients with pneumonic plague: patients with pneumonic plague should wear a mask as long as their clinical condition allows. Monitor and protect: identify and monitor close contacts of pneumonic plague patients and administer chemoprophylaxis for 7 days. Depending on the circumstances of the contamination, members of a household where patients with bubonic plague live should also receive chemoprophylaxis as they are also likely to have been bitten by infected fleas. Collect the necessary samples according to the clinical form (blood, pus, sputum) using appropriate procedures to prevent and control infection, and send them as soon as possible to the laboratory for analysis. This procedure should not delay the start of antibiotic therapy. Perform dignified and safe burials: a person who has died of plague, regardless of the form of the disease, presents a risk of contagion. The body should only be handled by personnel trained in this task. Further information Plague fact sheet Plague health topic WHO guidelines for plague management CDC fact sheet REVUE APRÈS ACTION DE LA RÉPONSE D’URGENCE À LA FLAMBÉE ÉPIDÉMIQUE DE PESTE PULMONAIRE, 2 AU 6 JUILLET 2018 – ANTANANARIVO Surveillance of murin plague in the urban areas of Antananarivo https://www.who.int/emergencies/disease-outbreak-news/item/plague—madagascar
2020	DRC	The health zone of Rethy in Ituri province, the Democratic Republic of the Congo, has seen an upsurge of plague cases since June 2020. The first case, a 12-year-old girl, reported to a local health centre on 12 June experiencing a headache, fever, cough, and an enlarged lymph node. She died on the same day and further deaths from the community due to suspected cases of plague were subsequently reported. From 11 June though 15 July, six out of 22 health areas have been affected within Rethy health zone (11 villages), with a total of 45 cases including nine deaths (case fatality rate: 20%). All nine (9) cases who died presented with signs of headache, high fever, and painful nodes; four (4) out of the nine (9) cases had cough. The health zone team carried out an investigation resulting in five positive rapid diagnostic tests (RDTs). Nine additional samples were taken and shipped to the Institut National de Recherche Biomédicale (INRB) laboratory in Kinshasa. Of the 45 cases reported, two showed signs of septicemic plague; all the other cases were diagnosed as having bubonic plague. According to the available information, it is likely that all three types of plague clinical presentation (bubonic, septicemic and pneumonic) are present. The distribution by sex shows 58% (26/45) are male and 93% (42/45) are greater than five years old. Of the 45 cases reported, nine including four who died, had cough among the symptoms – a sign indicating a potential progression from bubonic plague to pulmonary plague. This was specifically noticed among the deceased. Plague is endemic in Ituri province. Since the beginning of 2020, Ituri Province has reported a total of 64 plague cases and 14 deaths (CFR:21.8%) in five health zones, namely Aungba, Linga, Rethy, Aru and Kambala health zones. This compares against 10 cases and 5 deaths (lethality 50.0%) during the same period in 2019, all in a single zone. The current COVID-19 epidemic affects seven out of 26 provinces in the country. Ituri has also reported cases of COVID-191 that may further interrupt response activities due to lockdown. These are in addition to long standing public health response challenges identified in the region, including a lack of resources and insecurity. Although it has been reported that there is no significant impact of the COVID-19 context on activities taking place in this area, there is limited information available on the current access to health care. This includes whether or not there is a need for the population of Ituri to seek care in Uganda, as well as the availability of human resources, drugs, and personal protective equipment (PPE). Furthermore, the reference laboratory in Bunia, Ituri province is currently not functional, which might delay the confirmation of suspected cases and response efforts. Public health response A national rapid response team (RRT) has been deployed to the affected health zone to conduct an outbreak investigation and implement initial response activities. UNICEF is on the ground responding to the humanitarian situation at Bunia, working on community engagement and safe and dignified burial practices. The WHO guideline for plague, including case definitions, has been disseminated to health facilities to improve the detection of cases. The WHO is supporting plague endemic areas with surveillance, investigation of cases, and training of health workers and community relays in the prevention, early detection and case management of plague. Doxycycline prophylaxis has been administrated to the listed contacts. Intra-household spraying with deltamethrin has been used in some villages. Safe and dignified burials (SDB) have been performed by the health district team. Sensitization of the population on plague prevention measures in the affected villages through local radio. WHO risk assessment Infection with plague can cause severe disease resulting in high mortality in humans, particularly if not identified early. Plague can exhibit in three forms: bubonic, septicemic and pneumonic. If untreated, bubonic plague can evolve to pneumonic plague. Early diagnosis and treatment are essential for survival and reduction of complications. Rethy health zone is endemic for plague and regularly registers cases of enzootic variants of Yersinia pestis, in much of the wild rodent population. Its first outbreak was reported in February 2020 with cases imported from Linga health zone, based in the Godjoka health area. On the security level, there are reports of atrocities and violence linked to the militia CODECO which continues to impact the population of this territory (Djugu and its surroundings). There have been mass population displacements within Djugu and Mahagi Territories. Currently, the Rethy Health Zone has received approximately 112 714 internally displaced persons (IDPs), most of whom have come from the Jiba and Linga Health Zone. The growing insecurity impacts traffic flow between the villages and the willingness of the population to either stay or work in that area. There has also been a deterioration of water, hygiene and sanitation conditions in the reception areas and in the IDP sites. The early detection and reporting of the current outbreak by healthcare workers demonstrate that a functioning surveillance system is in place. Ituri province had a reference laboratory in Bunia which is no longer functional. The Institut National de la Recherce Biomedicale (INRB) laboratory based in Kinshasa/DRC has the ability to conduct laboratory testing for suspected cases. However, delays in shipping samples from Rethy to Bunia and then to Kinshasa, and delays in testing in Kinshasa INRB due to high workload and backload related to COVID-19 samples to be tested, might jeopardize the surveillance and response. Ongoing efforts are required to ensure that any other cases are promptly detected, isolated, and investigated to avoid the establishment of local transmission. The risk at national level is considered to be moderate given: the evolution of the current situation is in danger of deteriorating rapidly (case fatality rate: 20%), the notification of cases of pulmonary plague, the challenges with the surveillance system and delays between sample collection and laboratory confirmation, and the volatile security situation and the existence of other epidemics in progress in the country which prevents the setting up of a more comprehensive response. Furthermore, the health zone currently does not have enough PPE, body bags and materials needed for decontamination. Malteser International, an NGO that supplies the health zone with drugs, has had difficulty getting the products into the zone because of insecurity on the RN27 road. The principles of control are known and have been implemented (early treatment with the recommended antibiotics, isolation of the pneumonic cases, chemoprophylaxis given to the close contacts of the latest ones, rodent and flea control, safe and dignified burials, and the prevention of nosocomial transmission) but the means are limited and the health system is unable to manage the cases in the most appropriate way. The antibiotics used for the treatment of the cases are Doxycycline, Ciprofloxacin and Cotrimoxazole. For the pulmonary or septicemic form case, Gentamycin was administrated. The lack of laboratory confirmation is worrying but the use of rapid diagnostic tests (RDT) on the field ensures a minimum of confirmation among the suspected cases. The RDTs are especially reliable to confirm bubonic plague suspected forms. The risk at regional level is considered low since the epidemic seems to be contained in the Rethy health zone and that it is an isolated region. The risk is considered low globally. WHO advice Bubonic plague is the most common form of plague and is caused by the bite of an infected flea. The plague bacillus, Y. pestis, enters at the bite site and travels through the lymphatic system to the nearest lymph node where it replicates. At advanced stages of the infection, the inflamed lymph nodes can turn into suppurating open sores. There is no inter-human transmission of bubonic plague. Untreated, bubonic plague can advance and spread to the lungs, which is the more severe type of plague called pneumonic plague, the most virulent form of plague. Incubation period can be as short as 24 hours. Any person with pneumonic plague may transmit the disease via droplets to other humans. Untreated pneumonic plague, if not diagnosed and treated early, is almost always fatal. However, the probability of recovery is high if detected and treated in time (within 24 hours of onset of symptoms). Early diagnosis and treatment are essential for survival and reduction of complications. Appropriate diagnostic samples include blood cultures, lymph node aspirates if possible, and/or sputum, if indicated. Drug therapy should begin as soon as possible after the laboratory specimens are taken. Post-exposure prophylaxis is indicated in persons with known exposure to plague, such as close contact with a pneumonic plague patient or direct contact with infected body fluids or tissues. Duration of post-exposure prophylaxis to prevent plague is seven days. Preventive measures include informing people when zoonotic plague is present in their environment and advising them to take precautions against flea bites and not to handle animal carcasses. People, especially health workers, should also avoid direct contact with infected tissues such as buboes, or close exposure to patients with pneumonic plague. Recommended response measures for all forms of plague: Obtain specimens which should be carefully collected using appropriate infection, prevention and control procedures and sent to labs for testing. Confirmation of plague requires lab testing. The best practice is to identify Y. pestis from a sample of pus from a bubo, blood or sputum. A specific Y. pestis antigen can be detected by different techniques Ensure correct treatment: Prompt treatment with the correct medications is critical to prevent complications. Verify that patients are being given appropriate antibiotic treatment such as aminoglycosides, fluoroquinolones, chloramphenicol, tetracyclines sulfonamides and supportive therapy. The antibiotic treatment may need to be adjusted depending on a patient’s age, medical history, underlying health conditions, or allergies. Duration of treatment is 10 to 14 days, or until 2 days after fever subsides. Protect health workers. Inform and train them on infection prevention and control. Workers in direct contact with pneumonic plague patients must wear a full personal protective equipment and use standard precautions for respiratory diseases. Depending on the circumstances, they can also take a chemoprophylaxis with antibiotics such as doxycycline for the duration of seven days or at least as long as they are exposed to infected patients. However, the chemoprophylaxis cannot replace the use of a PPE and the individual physical precautions. Isolate patients with pneumonic plague. Patients with confirmed or suspected pneumonic plague should be isolated so as not to infect others via air droplets. Provide masks for pneumonic patients. Contact follow up: identify, inform and monitor close contacts of pneumonic plague patients and provide them with a seven-day chemoprophylaxis Ensure safe burial practices. Optimal infection prevention and control measures are to be observed during funeral and burial ceremonies. Funeral ceremonies in the houses of plague victims which may involve assembly of people should be discouraged. In order to effectively and efficiently manage plague outbreaks it is crucial to have an informed and vigilant health care work force (and community) to quickly diagnose and manage patients with infection, to identify risk factors, to conduct ongoing surveillance, to control vectors and hosts, to confirm diagnosis with laboratory tests, and to communicate findings with appropriate authorities. Further information ¹As of 16 July 2020, there have been 8 162 confirmed COVID-19 cases including 191 deaths in the Democratic Republic of the Congo. WHO Plague factsheet WHO Plague website https://www.who.int/emergencies/disease-outbreak-news/item/plague-democratic-republic-of-the-congo
2019
2018
2017	MADAGASCAR	From the 1 August through 22 November 2017, a total of 2348 confirmed, probable and suspected cases of plague, including 202 deaths (case fatality rate 8.6 %), were reported by the Ministry of Health of Madagascar to WHO. There were 1791 cases of pneumonic plague, of which 22% were confirmed, 34% were probable, and 44% were suspected. In addition to pneumonic cases, there were reports of 341 cases of bubonic plague, one case of septicaemic plague and 215 cases with type unspecified. In total, 81 healthcare workers have had illness compatible with plague, none of whom have died. Since the beginning of the outbreak, cases of pneumonic and bubonic plague have been detected in 55 out of 114 districts (48%), including non-endemic areas and major cities. Analamanga Region has been the most affected, with 68% of the cumulative reported cases. All contacts identified (7289) during this outbreak have completed their course of prophylactic antibiotics. Eleven contacts developed symptoms compatible with plague and were classified as suspect cases. All contacts had completed their follow up. The Institut Pasteur Madagascar has cultured 33 isolates of Yersinia pestis, which were all sensitive to the antibiotics recommended by the National Program for the Control of Plague. Plague is endemic in some areas of Madagascar and additional cases of plague may occur, at least until the end of the plague season in April 2018. It is therefore important that control measures continue through the end of the plague season. Public health response The Ministry of Public Health of Madagascar is coordinating the response, with the support of WHO, the Institute Pasteur Madagascar, and other agencies, stakeholders, and partners. The Ministry of Public Health of Madagascar activated crisis units in Antananarivo and Toamasina to coordinate the outbreak response efforts. All cases and contacts have been provided treatment or prophylactic antibiotics at no cost to themselves. The public health response measures have included: Strengthened epidemiological surveillance in the all affected districts, and enhanced case finding Rapid investigation of new cases Sample collection, referral and testing Isolation and treatment of all pneumonic cases, as well as treatment of bubonic cases Active finding, tracing and monitoring of contacts and provision of free prophylactic antibiotics 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. WHO has coordinated and mobilised regional and global partners in the Global Outbreak Alert and Response Network (GOARN) to support the outbreak response and will continue work with partners to ensure further rapid response support as needed. Working together, the Ministry of Health, WHO, GOARN, and other partners have trained more than 1800 community health workers for contact tracing, about 300 doctors as contact tracing supervisors and has established rapid response teams for case investigation. The IFRC, UNICEF and USAID have supported case management, including establishment of plague treatment centres. Laboratory confirmation of plague cases is conducted by the Institute Pasteur of Madagascar (IPM). WHO and IPM established a system for specimen collection and referral from peripheral areas to the IPM laboratory to strengthen laboratory capacity for testing and confirmation. Enhanced measures for exit screening have been implemented at the International Airports in Antananarivo and Nocibé, to avoid the international spread of pneumonic plague cases. These measures included: 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), provided technical support at the airport to establish exit screening. WHO and partners will support the MOH to re-evaluate the need for continuity of the exit screening and will implement appropriate recommendations. Nine countries and overseas territories in the African region (Comoros, Ethiopia, Kenya, Mauritius, Mozambique, La Réunion (France), Seychelles, South Africa, and Tanzania) had been identified as priority countries for plague preparedness and readiness by virtue of their trade and travel links to Madagascar. These countries have been 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 will support these countries to integrate the plague preparedness and operational readiness activities into their overall multi-hazard preparedness and readiness functions. WHO risk assessment No new cases of confirmed bubonic plague have been notified after 8 November 2017 and no new cases of confirmed pneumonic have been notified since 14 November 2017. All contacts finished follow up on 19 November 2017. However, plague in Madagascar is seasonal and WHO expects additional reports of cases. It is therefore important for the Ministry of Health, WHO, and partners to sustain prevention and response activities until April 2018. A longer term strategy will be needed for plague prevention, preparedness, and response. Based on the current epidemiology and response capacity, WHO estimates the risk of plague at the national level is moderate. The risk at the regional and global levels is low. WHO travel advice To date, there are no reported cases related to international travel. WHO advises against any restriction on travel or trade on Madagascar. WHO recommends that travel measures put in place by neighboring countries in relation to this outbreak be discontinued, given the containment of the pneumonic plague outbreak. International travellers arriving in Madagascar should be informed that plague is endemic in Madagascar, and about the recent plague outbreak. 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. Following the visit of the Secretary General of the World Tourism Organization (UNWTO) on 3 November, the UN body expressed confidence on tourism in Madagascar and echoed the WHO advice against any travel or trade restrictions against Madagascar¹. ¹UNWTO expresses confidence on tourism in Madagascar Information on Plague situation in Madagascar is published on weekly basis and is available at: Plague outbreak situation reports https://www.who.int/emergencies/disease-outbreak-news/item/27-november-2017-plague-madagascar-en 15 November 2017 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. 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). 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. https://www.who.int/emergencies/disease-outbreak-news/item/15-november-2017-plague-madagascar-en 2 November 2017 Since August 2017, Madagascar is experiencing a large outbreak of plague affecting major cities and other non-endemic areas. From 1 August through 30 October 2017, a total of 1801 confirmed, probable and suspected cases of plague, including 127 deaths, have been reported by the Ministry of Health of Madagascar to WHO. Of these, 1111 (62%) were clinically classified as pneumonic plague, including 257 (23%) confirmed, 374 (34%) probable and 480 (43%) suspected cases. In addition to the pneumonic cases, 261 (15%) cases of bubonic plague, one case of septicaemic plague and 428 cases (24%) where the type has not yet been specified, have been reported (Figure 1). As of 30 October, 51 of 114 districts of Madagascar have been affected (Figure 2 and 3). Since the beginning of the outbreak, 71 healthcare workers have had illness compatible with plague, none of whom have died. Laboratory confirmation of plague is being conducted by the Institut Pasteur of Madagascar. Twenty-three isolates of Yersinia pestis have been cultured and all are sensitive to antibiotics recommended by the National Program for the Control of Plague. Since the second week of October 2017, there has been a decline in the number of new cases (Figure 4). There is also a decrease in the number of patients hospitalized due to suspicion of plague. Due to enhanced surveillance and ongoing investigations the cumulative number of cases continues to increase, however, some of the cases are not recently infected. In Madagascar, the number of cases of plague is highest during the period of September through April. It is therefore important that control measures continue through to the end of April 2018. Eighty-three percent of 6492 individuals identified as contacts of a person suspected of having plague have completed follow-up monitoring, which includes a seven day follow-up and a course of prophylactic antibiotics. On 30 October 2017, 95% of the 972 contacts currently under follow-up were reached by field teams and have been provided with antibiotics as precautionary measure. 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. 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 (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 While the declining trend in new plague case reports and reduction in hospitalizations due to plague is encouraging, WHO expects more cases of plague to be reported from Madagascar until the typical plague season ends in April 2018. Sustaining ongoing operations, including active case finding and treatment, comprehensive contact identification, follow-up and antibiotic treatment, rodent and flea control, and safe and dignified burials is crucial during the outbreak and through the plague season as it is critical to minimize bubonic plague infections and human-to-human transmission of pneumonic plague. 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 traveller 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, treatment options have been provided to Madagascar and to priority countries in the region. For further information on plague and the latest information about the plague outbreak in Madagascar please see WHO Plague website and the Madagascar Plague Outbreak Situation Reports website. WHO Plague website Madagascar Plague Outbreak Situation Reports website WHO advice on travel 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 based on the information available. 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. https://www.who.int/emergencies/disease-outbreak-news/item/02-november-2017-plague-madagascar-en 2 October 2017 From 23 August to 30 September 2017, a total of 73 suspected, probable, and confirmed cases of pneumonic plague, including 17 deaths have been reported in Madagascar. The diagnosis was confirmed by the Institut Pasteur de Madagascar by polymerase chain reaction test or using rapid diagnostic test. The outbreak started following the death of a 31-year-old male from Ankazobe District in the Central Highlands (Hauts-Plateaux), a plague-endemic area. Since then, the Ministry of Public Health of Madagascar enhanced field investigations, contact tracing, surveillance, and monitoring all close contacts. As of 30 September, 10 cities have reported pneumonic plague cases and the three most affected districts include: the capital city and suburbs of Antananarivo (27 cases, 7 deaths), Toamasina (18 cases, 5 deaths), and Faratshio (13 cases, 1 death). On September 27, during the Indian Ocean Champion Clubs Cup (a basketball championship that ran from September 23 to October 1), a Seychellois basketball player died in a hospital in Madagascar from pneumonic plague. The Madagascar Ministry of Public Health immediately launched an investigation and a contact tracing is underway for all persons with whom he was in contact. As a precautionary measure, chemoprophylaxis has been administered to all close contacts.In addition to the 73 cases of pneumonic plague, from 1 August to 30 September, 58 cases of bubonic plague including seven deaths have been reported. One additional case of septicaemic plague has also been reported, and one case where the type is not specified. Public health response The Ministry of Public Health of Madagascar activated crisis units in Antananarivo and Toamasina and all cases have been provided access to treatment at no cost. There are public health response measures which include: Ongoing investigation of new cases Isolation and treatment of all pneumonic cases Active finding and tracing of contacts and provision of chemoprophylaxis Strengthening of the epidemiological surveillance in the affected and surrounding districts Disinsection of affected areas, including rodent and vector control Raising public awareness on prevention Raising awareness among health care workers and providing information to improve case detection, infection control measures Providing information about infection control measures during burial practices WHO risk assessment Plague is an infectious disease caused by the bacteria Yersinia pestis, a zoonotic bacteria, usually found in small mammals and their fleas. It is transmitted between animals from their fleas. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or by inhalation. There are three forms of plague infection, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link below). WHO Plague Fact Sheet Pneumonic plague-or lung-based plague is the most virulent form of plague and can trigger severe epidemics through person-to-person contact via droplets in the air. The incubation period can be as short as 24 hours. Typically, the pneumonic form is caused by spread to the lungs from an advanced bubonic plague. However, a person with secondary pneumonic plague may form aerosolized infective droplets and transmit plague via droplets to other humans. Untreated pneumonic plague is always fatal. Plague is an endemic disease in Madagascar; cases (predominantly bubonic plague) are reported nearly every year, during the epidemic season (between September and April). However, the ongoing pneumonic plague event has been reported in a non-endemic area and in densely populated cities for the first time. A pneumonic plague is a form of plague that is transmissible from person-to-person, with a potential to trigger severe epidemics if inadequately controlled. Detection of this outbreak occurred more than two weeks after the first case died during which cases travelled to different parts of the country, including the capital Antananarivo. Therefore, the overall risk at the national level is high. The overall regional risk is moderate due to frequent flights to neighbouring Indian Ocean islands. The global risk is low. WHO advice Prevention and control measures Preventive measures include informing people when zoonotic plague is present in their environment and advising them to take precautions against flea bites and not to handle animal carcasses. The most rapid and effective method for controlling fleas is to apply an appropriate insecticide formulated as a dust or low-volume spray. People, especially health workers, should also avoid direct contact with infected tissues such as buboes, or close exposure to patients with pneumonic plague. Important prevention and control measures are primarily intended to reduce human transmission and avoid increase in epidemic. These include: Advising the public to take all necessary precautions against flea bites and to not pick up or touch dead animals Implementing measures to control rodents hosts of Yersinia pestis (plague bacillus), especially rats Avoiding direct contact with infected tissues such as buboes, or close exposure to patients with pneumonic plague Early presentation to health care – go to the closest health center in the event of suspicious symptoms Health workers and people who are in direct contact with pneumonic plague patients must wear personal protective equipment Health workers should receive a chemoprophylaxis with antibiotics as long as they are exposed Safe management and burial of deceased cases Treatment Rapid diagnosis and treatment is essential to reduce complications and fatality. Effective treatment methods enable plague patients to be cured, if diagnosed in time. These methods include the administration of antibiotics as Aminoglycosides, Fluoroquinolones, Sulfonamides and supportive therapy. 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 based on the available information. International travellers should be informed about the current plague outbreak and that plague is endemic in Madagascar. Travellers should also be aware that Madagascar is endemic for malaria and should consider the antimalarial prophylaxis recommended by WHO when travelling to Madagascar (see link below). International Travel and Health. List of countries, territories and areas. Vaccination requirements and recommendations for international travellers, including yellow fever and malaria. The risk of infection withYersinia pestis for international travellers to Madagascar is generally low. However, travellers in rural areas of plague-endemic regions may be at risk, particularly if camping or hunting or if contact with rodents takes place. In addition, travellers to previously non-endemic regions from where cases of pneumonic plague have been recently reported should avoid crowded areas, avoid contact with dead animals, infected tissues or materials, and avoid close contact with patients with pneumonic plague.* Travellers should avoid contact with dead animals, infected tissues or materials, and avoid close contact with patients with pneumonic plague. Travellers can protect against flea bites using repellent products for personal protection against mosquitoes, which may equally be protective against fleas and other blood-feeding insects. Formulations (lotions or sprays) based on the following active ingredients are recommended by the WHO Pesticides Evaluation Scheme (WHOPES) : DEET, IR3535, Icaridin (KBR3023) or Picaridin. WHO guidance for control of rodent fleas that transmit bubonic plague can be found here: WHO guidance for control of rodent fleas that transmit bubonic 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. Prophylactic treatment is only recommended for persons who have been in close contact with plague cases, or with other high risk exposures (such as bites from infected fleas or direct contact with body fluids or tissues of infected animals). Travellers should immediately notify health care personnel or authority in case of contact and potential exposure to pneumonic plague patients or other high risk exposures and seek medical advice regarding chemoprophylaxis.** Travellers should avoid self-administration with antibiotics as prophylaxis, unless recommended by medical professionals. Upon return from travel to Madagascar, travellers should be on alert for the above symptoms, and if symptoms appear, they should seek medical care and inform their physician about their travel history to Madagascar. https://www.who.int/emergencies/disease-outbreak-news/item/02-october-2017-plague-madagascar-en 29 September 2017 On 23 August 2017, a 31-year-old male from Tamatave, visiting Ankazobe District in central highlands, developed malaria-like symptoms. On 27 August, he developed respiratory symptoms during his journey in a shared public taxi from Ankazobe District to Tamatave (via Antananarivo). His condition worsened and he died. His body was prepared for a funeral at the nearest hospital, Moramanga District Hospital, without safety procedures. Additionally, 31 people who came into contact with this case either through direct contact with the primary case or had other epidemiological links, became ill, and four cases of them died. The outbreak was detected on 11 September, following the death of a 47-year-old woman from Antananarivo, who was admitted to a hospital with respiratory failure caused by pneumonic plague. The public health authorities Direction de la Veille Sanitaire et de la Surveillance Epidémiologique (DVSSE) immediately launched field investigations. As of 28 September 2017, a total of 51 cases (suspected, probable and confirmed) of pneumonic plague, including 12 deaths were reported in the country. The diagnosis was confirmed by the Institut Pasteur de Madagascar by polymerase chain reaction test and using rapid diagnostic test. In addition to the 51 suspected, probable and confirmed cases of pneumonic plague, and during the same period another 53 cases of bubonic plague including seven deaths have been reported throughout the country. One case of septicaemic plague has also been identified and they were not directly linked to the outbreak. Public health response The Ministry of Health activated crisis units in Antananarivo and Toamasina and all cases have been provided access to treatment at no cost. Active case finding and contact tracing are on-going and all pneumonic cases are being isolated and treated, and all contacts are receiving chemoprophylaxis. There are additional ongoing key public health response measures which include: Ongoing investigation of new cases. Strengthening of the epidemiological surveillance in the affected and surrounding districts, including contact identification, administration of chemoprophylaxis, and monitoring close contacts of pneumonic plague cases. Disinsection of affected areas, including rodent and vector control. Raising awareness of the population about prevention and actions after exposure. Raising awareness among health care workers and providing information including infection control measures, and implementation of safe burial practices. WHO risk assessment Plague is an infectious disease caused by the bacteria Yersinia pestis, a zoonotic bacteria, usually found in small mammals and their fleas. It is transmitted between animals from their fleas. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or by inhalation. There are three forms of plague infection, depending on the route of infection: bubonic, septicaemic and pneumonic. Bubonic plague (known in mediaeval Europe as the ‘Black Death’) is the most common form of plague and is caused by the bite of an infected flea. Plague bacillus, Yersinia pestis, enters at the bite and travels through the lymphatic system to the nearest lymph node where it replicates itself. The lymph node then becomes inflamed, tense and painful, and is called a “bubo”. At advanced stages of the infection the inflamed lymph nodes can turn into open sores filled with puss. Pneumonic plague-or lung-based plague- is the most virulent form of plague. 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 via droplets to other humans. Untreated pneumonic plague is always fatal. Septicaemic plague occurs when infection spreads through the bloodstream, following a bubonic or a pneumonic plague. Plague can be a very severe disease in people, particularly in its septicaemic and pneumonic forms, with a case-fatality ratio of 30–100% if left untreated. The pneumonic form is invariably fatal unless treated early, is especially contagious and can trigger severe epidemics through person-to-person contact via droplets in the air. Plague is an endemic disease in Madagascar; cases of bubonic plague are reported nearly every year, during the epidemic season (between September and April). However, the ongoing pneumonic plague event has been reported in a non-endemic area and in densely populated coastal cities for the first time. Pneumonic plague is a form of plague that is transmissible from person-to-person, with a potential to trigger severe epidemics if inadequately controlled. Detection of this outbreak occurred more than two weeks after the first case died during which cases travelled to different parts of the country, including the capital Antananarivo. Therefore, the overall risk at the national level is high. The overall regional risk is moderate due to frequent flights to neighboring Indian Ocean islands. The global risk is low. WHO advice Prevention and control measures Preventive measures include informing people when zoonotic plague is present in their environment and advising them to take precautions against flea bites and not to handle animal carcasses. The most rapid and effective method for controlling fleas is to apply an appropriate insecticide formulated as a dust or low-volume spray. People, especially health workers, should also avoid direct contact with infected tissues such as buboes, or close exposure to patients with pneumonic plague. Important prevention and control measures include: Find and stop the source of infection. Protect health workers: inform and train them on infection prevention and control. Isolate: patients with pneumonic plague. They should be isolated so as not to infect others via air droplets. Surveillance: identify and monitor close contacts of pneumonic plague patients and give them a seven day chemoprophylaxis. Obtain specimens which should be carefully collected and sent to labs for testing. Ensure safe burial practices. Treatment Untreated plague can be rapidly fatal, so early diagnosis and treatment is essential for survival and reduction of complications. Antibiotics and supportive therapy are effective against plague if patients are diagnosed in time. Travel advice WHO advises against any restriction on travel or trade on Madagascar based on the available information. It is recommended to provide information at the ports of entry (airports, seaports) of Madagascar about the disease and the necessary protection measures required. For more information, please see the WHO plague fact sheet link below: Plague https://www.who.int/emergencies/disease-outbreak-news/item/29-september-2017-plague-madagascar-en 9 January 2017 On 6 December 2016, the Ministry of Health (MoH) in Madagascar alerted WHO of a suspected plague outbreak in Befotaka district, Atsimo Atsinanana region in the south-eastern part of the country. The district is outside the area known to be endemic area in Madagascar. No plague cases have been reported in this area since 1950. As of 27 December 2016, 62 cases (6 confirmed, 5 probable, 51 suspected) including 26 deaths (case fatality rate of 42%) have been reported in two adjacent districts in two neighbouring regions of the country. 28 cases, including 10 deaths have been reported from Befotaka District in Atsimo-Atsinanana Region and 34 cases including 16 deaths have been reported from Iakora district in Ihorombe Region. Of the 11 samples tested, 5 were positive for plague on rapid diagnostic test and 6 are now confirmed at Institut Pasteur laboratory. Of the total reported cases, 5 are classified as pneumonic plague cases and the remaining as bubonic plague. Retrospective investigations carried out in those two districts showed that it is possible that the outbreak might have started in mid-August 2016. The investigation in neighbouring villages is still ongoing. On 29 December, an investigation carried out within 25 km of the initial foci in Befotaka district has reported three deaths and is being investigated further for possible linkage to the outbreak. The affected zone is located in a very remote and hard to reach and highly insecure area (classified as red zone due to local banditry). Despite arrangements made with the local authorities, insecurity slows down the investigations and response activities. In addition, a helicopter has been made available but its use has been limited due to bad weather and financial limitations. Public health response On 6 December, a 15 member multidisciplinary team from MoH, Institute Pasteur including public health professional, epidemiologist, entomologist and laboratory professional visited the affected area for epidemiological investigation and response activities. Key response activities already implemented include: Epidemiological investigations including active case finding and rapid diagnostic testing Training of community health workers on community-based surveillance and early detection of cases Clinical Management of suspected cases Identification, follow up and chemoprophylaxis of contacts Vector and reservoir control through the use of Kartman boxes Sensitization of the population Strengthening the community based surveillance Free treatment of other diagnosed disease such as malaria Strengthening early detection in neighbouring districts Laboratory confirmation WHO risk assessment Based on the available information to date, the risk of international spread appears unlikely, especially as it is occurring in very remote area. However, the difficulty to reach the affected area hampered prompt investigation and therefore at this stage the real magnitude of the outbreak is still to be defined and the risk of further spread in the area and sustained transmission cannot be formally ruled out. WHO continues supporting ongoing investigation and response activities. WHO advice Further ecological investigations will be needed to understand the occurrence of a plague outbreak in an area which has not reported any cases of plague since 1950 in order to adapt long term surveillance and control measures. The outbreak impacts rural communities which have already suffered from remoteness and inadequate access to health services. Staff from MoH are supported by Pasteur Institute of Madagascar, who are all experienced on control measures. However, local conditions make their implementation complex. Due to the remoteness of the affected area and the conditions for getting infected by the disease, the current outbreak does not represent a significant risk for travellers. https://www.who.int/emergencies/disease-outbreak-news/item/09-january-2017-plague-mdg-en
2016
2015	MADAGASCAR	6 September 2015 The Ministry of Health of Madagascar has notified WHO of an outbreak of plague. The first case was identified on 17 August in a rural township in Moramanga district. The case passed away on 19 August. As of 30 August, 14 cases, including 10 deaths, were reported. All confirmed cases are of the pneumonic form. Since 27 August, no new cases have been reported from the affected or neighbouring districts. Public health response The national task force has been activated to manage the outbreak. With support from partners – including WHO and the Pasteur Institute of Madagascar – the government of Madagascar is implementing thorough public health measures, including active case and contact finding, provision of chemoprophylaxis, case and contact management, enhanced epidemiologic surveillance, infection prevention and control (house disinfection), vector control activities, social mobilization, coordination and resource mobilization. WHO risk assessment WHO does not recommend any travel or trade restriction based on the current information available. In urban areas, such as Antananarivo, the surveillance of epidemic risk indicators is highly recommended for the implementation of preventive vector control activities. Background Plague is a bacterial disease caused by Yersinia pestis, which primarily affects wild rodents. It is spread from one rodent to another by fleas. Humans bitten by an infected flea usually develop a bubonic form of plague, which produces the characteristic plague bubo (a swelling of the lymph node). If the bacteria reach the lungs, the patient develops pneumonia (pneumonic plague), which is then transmissible from person to person through infected droplets spread by coughing. If diagnosed early, bubonic plague can be successfully treated with antibiotics. Pneumonic plague, on the other hand, is one of the most deadly infectious diseases; patients can die 24 hours after infection. The mortality rate depends on how soon treatment is started, but is always very high. The current outbreak follows another plague outbreak that occurred in Madagascar between 2014 and 2015, with a peak in November 2014 when over 335 cases and 79 deaths were reported. https://www.who.int/emergencies/disease-outbreak-news/item/06-september-2015-plague-en
2015	Zambia	On April 10, 2015, the Zambian Ministry of Health was informed by the Eastern Province Medical Office of possible cases of bubonic plague in Nyimba District. Eleven patients with acute fever and cervical lymphadenopathy had been evaluated at two rural health centers between March 28 and April 9, 2015; three patients died. To confirm the outbreak and develop control measures, the Zambia Ministry of Health Field Epidemiology Training Program (ZFETP) conducted epidemiological and laboratory investigations in partnership with the University of Zambia Schools of Medicine and Veterinary Medicine and provincial and district medical offices. Twenty-one patients with clinically compatible plague were identified, with symptoms occurring between March 26 and May 5, 2015. The median age was 8 years, and all patients were from the same village. Blood samples or lymph node aspirates from six (29%) patients tested positive for Yersinia pestis by polymerase chain reaction (PCR). https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a4.htm
2014	Madagascar	https://wwwnc.cdc.gov/eid/article/20/8/13-0629_article 21 November 2014 On 4 November 2014, WHO was notified by the Ministry of Health of Madagascar of an outbreak of plague. The first case, a male from Soamahatamana village in the district of Tsiroanomandidy, was identified on 31 August. The patient died on 3 September. As of 16 November, a total of 119 cases of plague have been confirmed, including 40 deaths. Only 2% of reported cases are of the pneumonic form. Cases have been reported in 16 districts of seven regions. Antananarivo, the capital and largest city in Madagascar, has also been affected with 2 recorded cases of plague, including 1 death. There is now a risk of a rapid spread of the disease due to the city’s high population density and the weakness of the healthcare system. The situation is further complicated by the high level of resistance to deltamethrin (an insecticide used to control fleas) that has been observed in the country. Public health response The national task force has been activated to manage the outbreak. With support from partners – including WHO, the Pasteur Institute of Madagascar, the “Commune urbaine d’Antananarivo” and the Red Cross – the government of Madagascar has put in place effective strategies to control the outbreak. Thanks to financial assistance from the African Development Bank, a 200,000 US dollars response project has been developed. WHO is providing technical expertise and human resources support. Measures for the control and prevention of plague are being thoroughly implemented in the affected districts. Personal protective equipment, insecticides, spray materials and antibiotics have been made available in those areas. Background Plague is a bacterial disease caused by Yersinia pestis, which primarily affects wild rodents. It is spread from one rodent to another by fleas. Humans bitten by an infected flea usually develop a bubonic form of plague, which produces the characteristic plague bubo (a swelling of the lymph node). If the bacteria reach the lungs, the patient develops pneumonia (pneumonic plague), which is then transmissible from person to person through infected droplets spread by coughing. If diagnosed early, bubonic plague can be successfully treated with antibiotics. Pneumonic plague, on the other hand, is one of the most deadly infectious diseases; patients can die 24 hours after infection. The mortality rate depends on how soon treatment is started, but is always very high. WHO recommendations WHO does not recommend any travel or trade restriction based on the current information available. In urban areas, such as Antananarivo, the surveillance of epidemic risk indicators is highly recommended for the implementation of preventive vector control activities. https://www.who.int/emergencies/disease-outbreak-news/item/21-november-2014-plague-en
2013	Madagascar	From November 2013 to January 2014, Madagascar reported 427 suspected and 45 confirmed cases of plague (bubonic and pneumonic) in 4 districts. Here we report rodent-associated flea species and those collected from human dwellings in Mandritsara District where plague occurred (Technical Appendix Figure). Four villages in the district were surveyed one month after the end of the human plague outbreak and after an insecticide-based vector control intervention had taken place. Fleas were collected, either from rats or from candle traps set inside houses, and preserved in 70% ethanol (online technical appendix, table). Rats were trapped alive inside houses and on cropland. https://wwwnc.cdc.gov/eid/article/22/12/16-0318_article
2012
2011	Madagascar	https://wwwnc.cdc.gov/eid/article/21/1/13-1828_article
2010
2009	Lybie	https://wwwnc.cdc.gov/eid/article/19/2/12-1031_article
2008	Madagascar	Plague was introduced to Madagascar in 1898 from rat-infested steamboats that had sailed from the affected areas (2). Today, Madagascar is one of two countries in Africa that have reported cases of human plague every year since 1991 (3). From January 2008 to January 2013, the number of reported human plague cases in Madagascar ranged from 312 to 648 per year. Of these, 61.8% to 75.5% were laboratory confirmed (Ministry of Health National Plague Laboratory, personal communication). Most (>83%) of the confirmed cases were cases of bubonic plague, which most often results from flea bites, suggesting that flea bites were the most common mode of transmission of Y. pestis. In Madagascar, Xenopsylla cheopis fleas are known to be the main vector of plague in urban areas, while Synopsyllus fonquerniei fleas are usually involved in plague transmission in rural areas (2). In January 2013, a total of 9 suspected cases of bubonic plague, 3 of which were confirmed, were reported in Soavina, a rural area in Ambatofinandrana District, Madagascar. Household fleas were collected with candle traps inside 5 houses during 3 nights (Table). Fleas were also captured on small mammals trapped inside houses and outside in sisal fences and rice fields (Table). A total of 319 fleas belonging to 5 species in 5 genera were collected inside and outside the houses, an average of 44 per house (maximum 71) : Pulex irritans, Echidnophaga gallinacea, and Ctenocephalides canis fleas were collected inside the houses (244, 76.5%), and S. fonquerniei and X. cheopis fleas were collected outside (75, 23.5%). The human flea, P. irritans, was the most collected flea species (233, 73.3%), followed by S. fonquerniei (62, 19.4%), X. cheopis (13, 4.1%), E. gallinacea (10, 3.1%) and C. canis (1, 0.3%). https://wwwnc.cdc.gov/eid/article/20/8/13-0629_article
2007	Tanzania	Since the beginning of December 2010, the Tanzanian authorities have reported an outbreak of bubonic plague in the Manyara region (north central Tanzania), close to national parks. At least seven cases have been reported, with no deaths. Mbulu District experienced plague outbreaks last year and in 2007 (72 suspected cases, including 9 deaths between January and June 2007, also in Manyara Region). https://www.mesvaccins.net/web/news/902-peste-bubonique-en-tanzanie
2006	DRC	7 November 2006 As of 29 September 2006, WHO received reports of a suspected pneumonic plague outbreak in 4 health zones in Haut-Uele district, Oriental province in the north-eastern part of the country. The local authorities have now reported 1174 suspected cases including 50 deaths. More than 50 samples have been collected and analysed; however, the diagnosis of plague has not been finally laboratory confirmed. A 5-person team from WHO and the Ministry of Health will return to the field to re-assess the situation with the local medical staff and international nongovernmental organizations working in the affected areas. https://www.who.int/emergencies/disease-outbreak-news/item/2006_11_07-en 13 October 2006 WHO has received reports of a suspected pneumonic plague outbreak in 2 health zones in Haut-Uele district, the majority reported from Wamba health zone in Oriental province in the northern part of the country. Six hundred and twenty-six suspected cases including 42 deaths have been reported from 31 July to 8 October. However, the low case fatality ratio is unusual for pneumonic plague which suggests that the number of suspected cases may be an overestimation. Preliminary results from a rapid diagnosis test in the field found three samples positive, out of eight. Additional laboratory confirmation is under way. A team from the Provincial Health Authority, WHO and Médecins sans Frontières (MSF Switzerland) carried out an initial investigation. Disease surveillance is being strengthened and case management, contact tracing, and sensitization of the affected population are being implemented. https://www.who.int/emergencies/disease-outbreak-news/item/2006_10_13-en 14 June 2006 As of 13 June 2006, WHO has received reports of 100 cases of suspected pneumonic plague, including 19 deaths in Ituri district, Oriental province. Suspected cases of bubonic plague have also been reported but the total number is not known at this time. Preliminary results from rapid diagnostic tests in the area confirm pneumonic plague. Additional laboratory analysis, including tests by culture, is ongoing on 18 samples. Ituri is known to be the most active focus of human plague worldwide, reporting around 1000 cases a year. The first cases in this outbreak occurred in a rural area, in the Zone de Santé of Linga, in mid-May. A team from Médecins sans Frontières (Switzerland), WHO and Ministry of Health has been in the area to assess the situation and provide support to the local health authorities. Isolation wards have been established to treat patients; close contacts are being traced and receiving chemoprophylaxis. However, control measures have been difficult to implement because of security concerns in the area. For more information. See fact sheet on plague . https://www.who.int/emergencies/disease-outbreak-news/item/2006_06_14-en
2006	Uganda	A total of 127 cases of plague, with onset dates between July 19 and December 30, 2006 (Figure 1), were identified in Arua and Nebbi districts of northwestern Uganda (Figure 2). Of the 102 patients with documented symptoms, 90 (88%) had bubonic plague and 12 (12%) had pneumonic plague. Two or more cases of plague were reported from nine different villages, including four villages that reported 10 or more cases (Nave, 18; Kestro, 18; Andosi, 17; and Yiapi, 10). The median age of patients was 14 years (range: 2 weeks–65 years); 65 patients (51%) were female (Table). https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5828a3.htm
2005	RDC	Plague remains a concern in several countries, particularly in Africa (8-12). The war-torn Democratic Republic of Congo (DRC) is the most active plague hotbed in the world. In the northeastern region of Ituri, more than 1,000 suspected cases are reported each year (7,12,13). In January 2005, an outbreak of highly lethal pneumonia occurred in a diamond mining camp in a remote area of Orientale Province (Figure 1), 25 km from the village of Zobia, Bas-Uele (13,14). The clinical signs and rapid spread of the disease raised suspicion of pneumonic plague. No previous cases of plague had been reported in this area, which has a history of serious security problems and where, at the time of the outbreak, a United Nations peacekeeping operation was underway. In August 2006, an outbreak of a similar nature occurred in a camp for gold miners located 200 km from Zobia camp, near Bolebole, in Haut Uele (15) https://wwwnc.cdc.gov/eid/article/17/5/10-0029_article 15 March 2005 As of 14 March 2005, the team has reported a total of 130 suspect cases, including 57 deaths in Zobia, Bas-Uélé district, Oriental province. These figures are based on the current situation and a retrospective analysis of cases since 15 December 2004. No cases of bubonic plague have been detected. Laboratory analysis of specimens and contact tracing is continuing. To date, a total of 363 contacts have been followed up. Suspect cases are being treated in isolation treatment centers. https://www.who.int/emergencies/disease-outbreak-news/item/2005_03_15-en 9 March 2005 The multidisciplinary team (see previous report) has reported a total of 114 cases (110 suspect cases, 4 probable cases), including 54 deaths in Zobia, Bas-Uélé district, Oriental province. These figures are based on the current situation and a retrospective analysis of cases since 15 December 2004. Laboratory analysis of specimens is continuing. An isolation treatment centre has been set up by the Ministry of Health with support from Médecins sans Frontières – Belgium. Contact tracing and follow up of 214 contacts is underway and social mobilization activities are taking place in surrounding areas. https://www.who.int/emergencies/disease-outbreak-news/item/2005_03_09-en 18 February 2005 As of 15 February 2005, WHO has received reports of 61 deaths of pneumonic plague in Bas-Uele district, Oriental province in the northern part of the country (see map below). The total number of cases is still not known. Preliminary results from rapid diagnostic tests in the area confirm pneumonic plague, and the cases had clinical features compatible with this disease. Forty samples have been taken and will be tested by culture and serology at the Institut de la Recherche Biomedicale, Kinshasa. No cases of bubonic plague have been reported to date. The cases have occurred in workers in a diamond mine in Zobia where c. 7000 people work. The mine was re-opened on 16 December 2004 and the first case occurred on 20 December. A team from Médecins sans Frontières (Belgium and Switzerland), Medair, WHO and Ministry of Health have been in the area to assess the situation. An additional multi-disciplinary team will be leaving for the Democratic Republic of the Congo on 19 February. If humanitarian access is possible given the security concerns in the area, the team will go to the affected area to provide technical support in case management and treatment of cases, intensive surveillance and tracing of possible contacts and further epidemiological investigations. https://www.who.int/emergencies/disease-outbreak-news/item/2005_02_18-en
2004	Tanzanie	In Tanzania, a persistent outbreak of human plague was discovered in 1980 in the Lushoto district in the northeast of the country. By 2004, 7,603 cases had been reported from this area (3). The distribution of plague cases in Lushoto is limited to an area of ≈1,200 km2, and a high variation in plague frequency and incidence is observed among villages in this area (3). Although evidence of Y. pestis infection has been observed in several species of rodents and wild fleas, the actual reservoir in which the infection survives between outbreaks has not yet been identified, and the ecology of the infection and the source from which humans acquire the infection are poorly understood (4-8). In Lushoto District, frequent plague outbreaks occur in some villages, but the disease is rare in other villages in the same vicinity. A study is underway to compare ecological conditions in villages with frequent outbreaks with those in villages where plague is relatively rare, with the aim of understanding, predicting, and ultimately controlling human plague. Comparison of host and vector communities is an important component of these studies. https://wwwnc.cdc.gov/eid/article/13/5/06-1084_article
2003	Algérie	En Algérie, les archives font état d’épidémies de peste dès le XIVe siècle. Ces épidémies touchent principalement les ports, notamment celui d’Oran en 1556 et 1678 (3 000 morts). En 1899, après une absence de près de 100 ans, la peste réapparaît dans le port de Philippeville (aujourd’hui Skikda). Trois grandes épidémies ont ensuite été signalées en 1921 (185 cas), 1931 (76 cas) et 1944 (95 cas), ainsi que 158 cas sporadiques. Tous les cas sauf 2 sont survenus dans des ports (3,4). Aucun foyer naturel de peste n’avait jamais été décrit en Algérie (5). Nous décrivons une épidémie de peste bubonique survenue en 2003 en Algérie, où le dernier cas humain rapporté est survenu à Oran en 1946 (6). https://wwwnc.cdc.gov/eid/article/13/10/07-0284_article https://wwwnc.cdc.gov/eid/article/19/2/12-1031_article 10 July 2003 Disease Outbreak Reported As of 9th July, the Ministry of Health, Algeria has reported a total of 10 laboratory confirmed cases and 1 probable case of Plague in Oran district (see previous report). A joint WHO and Ministry of Health team investigated this outbreak and the preliminary findings are being used for control measures. Further investigations will be needed to identify and describe a possible natural focus, unknown so far in Algeria, as well as to identify the mechanism of the spread of the causative organism, Yersinia pestis in this area. https://www.who.int/emergencies/disease-outbreak-news/item/2003_07_10-en 3 July 2003 Disease Outbreak Reported As of 2 July, the Ministry of Health, Algeria has reported a total of 10 cases of which 8 have been laboratory confirmed (see previous report). These include 8 cases of bubonic plague and 2 of septicemic plague, of which one was fatal. Eight additional cases are under investigation. A team from WHO and the Institut Pasteur, Paris, France, a partner in the Global Outbreak Alert and Response Network is working with the Ministry of Health to carry out epidemiological investigations and assist with vector control measures. https://www.who.int/emergencies/disease-outbreak-news/item/2003_07_03b-en 24 June 2003 (revised 26 June 2003) Disease Outbreak Reported “As of 23 June, the Ministry of Health, Algeria has reported a total of 10 cases, 8 cases of bubonic plague and 2 of septicemic plague, one of which was fatal, in Tafraoui, on the outskirts of Oran. Cases have been treated with antibiotics and preventive measures have been taken. To date, no new cases have been officially reported. WHO is working with the Ministry of Health to provide rapid diagnostic tests and technical support in liaison with two WHO Collaborating Centres who are both partners in the Global Outbreak Alert and Response Network:Institut Pasteur, Paris, France, and Kazakh Scientific Centre for Quarantine and Zoonotic Diseases, Almaty, Kazakhstan. https://www.who.int/emergencies/disease-outbreak-news/item/2003_06_24a-en
2002	Madagascar	Plague, caused by the bacterium Yersinia pestis, has caused some of the most devastating epidemics in human history and is endemic in parts of Asia, the Americas and Africa. Africa accounts for more than 90% of human plague cases worldwide, and most cases are reported in Madagascar and the Democratic Republic of Congo (1). The plague was introduced to Madagascar in 1898 in the port of Toamasina and reached the capital (Antananarivo) in 1921. It is endemic to the central and northern highlands (altitude >800 m). The main reservoir is the black rat (Rattus rattus), and 2 main species of fleas (Xenopsylla cheopis, a cosmopolitan species, and Synopsyllus fonquerniei, an endemic species) are involved in transmission. S. fonquerniei fleas have a higher transmission efficiency (2,3). The restriction of the plague mainly to the highlands is probably due to the absence of S. fonquerniei fleas at altitudes <800 m (4). https://wwwnc.cdc.gov/eid/article/25/2/17-1974_article
2002	MALAWI	05 June 2002 Disease Outbreak Reported As of 27 May 2002, the Malawian Ministry of Health has reported a total of 71 cases of bubonic plague in the district of Nsanje since the onset of the outbreak on 16 April 2002. The outbreak has so far affected 26 villages, 23 in the Ndamera area, 2 in Chimombo and 1 village in neighbouring Mozambique. There is good cross border collaboration between Malawian and Mozambican health teams. WHO is assisting the Malawian Ministry of Health surveillance unit and the Nsanje district health staff in their efforts to contain the outbreak by providing supplies and technical support, including the training of health workers. https://www.who.int/emergencies/disease-outbreak-news/item/2002_06_05e-en