Re: Illness in Libya (poss. plague) & Ministry of Health in Egypt is Preparing Procedures
Re: Illness in Libya (poss. plague) & Ministry of Health in Egypt is Preparing Procedures
And now the Eurosurveillance has turned into ProMed posting #3:
http://www.promedmail.org/pls/otn/f..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,78198
PLAGUE, BUBONIC - LIBYA (02): (AL BUTNAN)
*****************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Thu 2 Jul 2009
Source: Eurosurveillance edition 2009; 14(26) [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19258>
Plague outbreak in the Libyan Arab Jamahiriya
---------------------------------------------
[Authors: A Tarantola, T Mollet, J Gueguen, P Barboza, E Bertherat]
Plague is circulating regularly in localised areas worldwide, causing
sporadic cases outside Africa and remains endemic or causes limited
outbreaks in some African countries. Furthermore, some notable outbreaks
have been reported in Asia in the last 20 years. A limited outbreak with 5
cases has recently been notified by the health authorities of the Libyan
Arab Jamahiriya.
Introduction
------------
Plague is a zoonosis caused by the bacillus _Yersinia pestis_. This disease
may have caused over 200 million deaths in the history of humanity (1). The
disease is principally transmitted from animal to animal by fleas. Humans
usually become infected through the bite of an infected flea (mainly)
_Xenopsylla cheopis_). The occurrence of bubonic plague cases is therefore
the result of the presence of fleas, rodents, and humans in a given place
at a given time.
Since the 1st description of what may have been a plague outbreak in 430 BC
in Ancient Greece (2), the plague has spread worldwide during the course of
several pandemic waves. Between 1998 and 2008, more than 23 278 cases were
reported including 2116 fatalities (case fatality ratio, CFR, of
approximately 9 per cent) in 11 countries (3). Over 95 per cent of the 23
278 cases, however, were reported in Africa with well-identified endemic
plague foci (mainly in 3 countries: Madagascar, the Democratic Republic of
Congo [DRC], and Tanzania).
The bubonic plague is the most common form of the disease (93 per cent of
plague cases in Madagascar (4) and 81 per cent of plague cases in the
United States (US) (5). Without adequate treatment, the case-fatality rate
of bubonic plague ranges from 50 to 90 per cent. Bubonic plague does not
give rise to direct human-to-human transmission.
Pulmonary plague is not the most frequent form of the disease (3 per cent
of the plague cases in the US, 8 per cent in DRC, sometimes more frequent
in outbreaks with sustained human-to-human transmission), but is deadly in
almost all cases in absence of adequate and timely treatment. This clinical
presentation may give rise to human-to-human transmission through droplet
transmission. Available evidence points to effective prevention of
human-to-human transmission of pneumonic plague through isolation and
treatment of cases and the observance of standard precautions completed by
droplet and contact precautions during healthcare (6,7). There is no
available vaccine for large-scale use.
Outbreak report
---------------
On 14 Jun 2009, the health authorities of the Libyan Arab Jamahiriya
reported suspected cases of bubonic plague (including one death) to the
World Health Organization in compliance with the Revised International
Health Regulations (IHR) [see ProMED-mail post Plague, bubonic - Libya:
(BN) 20090616.2227].
The case definition proposed by the World Health Organization was used (8).
The outbreak occurred in a semi-nomadic setting. Subsequent epidemiological
investigations by an international team ascertained a total of 5 cases. 3
of these occurred in a family cluster in the Tobruk rural area (near the
border with Egypt). The 1st identified case was a child who presented with
pneumonic plague and died. 2 siblings were subsequently identified as
having bubonic plague. 2 other epidemiologically unlinked cases occurred in
young women living in the same district. Confirmatory testing is ongoing.
Rodent control measures have been implemented locally.
The last outbreak reported in the Maghreb to date occurred in Algeria in
July 2008. At that time, the Algerian health authorities reported 4 cases
including 3 fatalities in Laghouat [WHO, unpublished data]. All identified
cases presented with bubonic plague. The last outbreak reported by the
Libyan Ministry of Health occurred in 1984 with 8 cases of bubonic plague
(no deaths) (1). The last deaths due to plague reported in that country
occurred during a 1977 outbreak that affected 11 people (6 deaths).
Discussion and conclusion
-------------------------
The implementation in 2007 of the revised IHR and improved surveillance in
many countries has strengthened communication between countries and WHO.
Regional networks have also emerged which facilitate cross-border and
regional exchange of public health alerts. The Libyan health authorities
have been prompt in describing and reporting the outbreak described here,
thereby enabling speedy confirmation and the implementation of control
measures.
The Maghreb is no longer considered an endemic area for plague (9). The
recent human plague clusters, however, raise the issue of the persistence
of a large focus or of several limited natural foci, which have been
quiescent for decades and remain capable of "re-emergence" at various dates
and locations (Table, Figure [available at the source URL above]). These
clusters of human cases are generally sporadic and limited, but they may
continue to occur despite the necessary extensive rodent control measures,
which will probably be insufficient to eradicate the plague reservoir in
wild animals. Health care workers require training to better recognise
signs of a disease, which is no longer endemic. Informing and increasing
awareness of populations living in and around plague foci, strengthening of
local health systems and targeted public health measures around the cases
remain the key control strategies in plague-prone areas. Improved knowledge
of the natural foci is also a pre-requisite for any rational vector and
rodent control.
References
----------
1. WHO. Plague Manual: Epidemiology, Distribution, Surveillance and Control
(WHO/CDS/CSR/EDC/99/2/EN). Geneva: WHO; 1999. Available from
<http://www.who.int/csr/resources/publications/plague/WHO_CDS_CSR_EDC_99_2_EN/en/index.html>.
2. Thucydides. The History of the Peloponnesian War. Book II. 431 BC,
Chapter 47 to 54.
3. Institut de Veille Sanitaire (InVS). Departement International et
Tropical. Peste. Situation mondiale. 8 Jan 2008. [Plague. World situation.
8 Jan 2008]. Paris: InVS; 2008 [in French]. Available from
<http://www.invs.sante.fr/international/notes/peste_final_2007.pdf>
4. Institut Pasteur de Madagascar. Groupe d'Etudes sur la Peste. Atlas de
la peste a Madagascar. [Atlas of the plague in Madagascar]. Montpellier:
Editions IRD; 2006. [In French, available from
<http://www.pasteur.mg/IMG/pdf/Atlas-Peste.pdf>.]
5. Centers for Disease Control and Prevention (CDC). Human plague - four
states, 2006. MMWR Morb Mortal Wkly Rep 2006; 55(34): 940-3. [Available
from <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5534a4.htm>.]
6. Ratsitorahina M, Chanteau S, Rahalison L, Ratsifasoamanana L, Boisier P.
Epidemiological and diagnostic aspects of the outbreak of pneumonic plague
in Madagascar. Lancet 2000; 355 (9198): 111-3. [Abstract available from
<http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(99)05163-6/fulltext>.]
7. Kool JL. Risk of person-to-person transmission of pneumonic plague. Clin
Infect Dis 2005; 40(8): 1166-72. [Available from
<http://www.nycosh.org/workplace_hazards/Biosafety/PlagueArticle4-05.pdf>.]
8. WHO. International meeting on preventing and controlling plague: the old
calamity still has a future. Wkly Epidemiol Rec 2006; 81(28): 278-84.
[Available from <http://www.who.int/wer/2006/wer8128.pdf>.]
9. Mafart B, Brisou P, Bertherat E. Epidemiologie et prise en charge des
epidemies de peste en Mediterranee au cours de la seconde guerre mondiale.
[Epidemiology and management of plague outbreaks in the Mediterranean
during the Second World War]. Bull Soc Pathol Exot 2004; 97(4): 306-10.
[Article in French, available from
<http://www.vitaminedz.com/articlesfiche/0/308.pdf>].
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[The title of the Eurosurveillance article above refers to the plague
outbreak in Libyan Arab Jamahiriya, which is in part the official name for
Libya (officially known as the Great Socialist People's Libyan Arab
Jamahiriya (<http://en.wikipedia.org/wiki/Libya>). Table 1 in the
Eurosurveillance article above lists the occurrence of reported cases of
confirmed or probable plague in Algeria, Egypt, Libya, Morocco, and Tunisia
since January 1945, and the article's figure shows a map of this region of
North Africa (see
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19258>).
Portions of Algeria, Libya, Morocco, and Tunisia between the high ranges of
the Atlas Mountains and the Mediterranean Sea are collectively known as the
Mediterranean Maghreb and share an ecosystem of forests, woodlands, and
scrub with many species of plants and animals in common
(<http://en.wikipedia.org/wiki/Maghreb#Mediterranean_Maghreb>). The region
also shares a culinary tradition; as mentioned in the prior ProMED-mail
post on the current Libyan outbreak (Plague, bubonic - Libya: (BN)
20090616.2227), several of the plague outbreaks in North Africa and the
Middle East have involved pharyngeal plague accompanied by cervical
lymphadenopathy that followed consumption of raw or inadequately cooked
meat from infected animals, such as camels.
The authors of the Eurosurveillance article point out that the recent human
plague cases in this region raise the issue of persistence of unknown
natural reservoirs of plague in wild animals, which may remain quiescent
for decades, but nevertheless are capable of "re-emergence" at various
times and locations when spill-over into the human sphere occurs. - Mod.ML]
[see also:
Plague, bubonic - Libya: (BN) 20090616.2227
Plague, fatal - Algeria (04): NOT 20090206.0534
Plague, fatal - Algeria 20090119.0237
2003
---
Plague - Algeria (Oran) (05) 20030710.1689
Plague - Algeria (Oran) (02): confirmed 20030624.1556
Plague, bubonic - Algeria (Oran) 20030622.1537]
.................ml/mj/sh
.jpg)
.jpg)
.jpg)
.jpg)
.jpg)
.jpg)
ii=19258. Available online: