Five cases of plague confirmed in Tobruk, Libya, 2009

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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

hat-tip Treyfish

This is a Tunisian source, I believe. It contains some shocking claims, including the cases in Algeria. I believe the 60 suspected cases referred to below are suspect H1N1 cases, not suspect plague cases.

http://www.translate.google.com/tra...ouk.com/detailarticle.asp?IDX=143997&IDXRUB=3

Saturday 4 July 2009 at 22:13:48 GMT Tunis

Started in the Tunisian health authorities and the Algerian, Libyan and Egyptian with the World Health Organization moves on many fronts to address the possibility of the spread of infection and transmission of bird flu or swine plague.

To date there are no cases of plague in Tunis, according to sources from the Ministry of Public Health, but said the casualties in Libya in the limited and narrow focus of a small adjacent to the Egyptian border, the Egyptian authorities fear the tourist season, in front of more than one million Egyptian workers in Libya In addition to the vast border between the two countries and more than 1150 km, while extending the border between Tunisia and Libya, 459 kilometers only.

Plague, or the so-called scientific ?Alisina Taonip? (Yersiniapestis) is a bacterium that has emerged in previous decades, disappeared and was shown from time to time in certain spots have emerged in the nineties in India, which is infectious, but less serious epidemic of tuberculosis.
Has contacted the Department of Public Health, confirmed to us by Dr. Mundhir Bedjaoui Kahie Director of the epidemiological surveillance and control of communicable diseases, the ?Epidemiological Alisina? affecting the lymph nodes or the so-called in Tunisia (Alolcic) Balantfaj, the bacterium is moving in the blood, but only in (Alolcic) and can be addressed smooth, less serious than bacterial pneumonia contagious epidemic through sputum and breath .. In the second case Valty easier.

He assured that the siege of the Libyan authorities in connection with the center of the epidemic (which moved some of the infection on to Algeria, through the nomadic particular) said that the World Health Organization in connection with the follow-up is carefully coordinated with the States concerned.

Health system, accurate

The treatment of this epidemic is possible with antibiotics and said that we are following the situation carefully, and appreciated the high proportion of the risk and made sure that small.
Dr. Bedjaoui said that our health system is very strict and we carefully monitor any injury occurred in the form of the intervention would be a speedy and effective as we have adopted a system of surveillance based on the biological and medical and biological laboratories equipped with the latest techniques and technologies, and all suspected cases in which care is carried out the necessary analysis and then identify and address in the form of injury and make sure he said: ?We're prepared for all eventualities and we have all the means and methods to account for the plague of HIV?.
He also said we are the follow-up and control the most serious disease of about twenty that have energy and a contagious epidemic, rapid proliferation and, therefore, ?we have focused a general framework for finding and declaration of disease and the effectiveness of address? said ?We have informed the doctors and we have warned for more vigilance and increase vigilance?.
He denied the existence of any cases of this disease in Tunisia, and there is coordination between the States concerned and the World Health Organization, and even those in tight spots in Libya or Algeria, the control possible.
For the plague that threatened to crawl from the south and Almentsbp him impregnable walls healthy, but how prepared health management in Tunisia of the virus creeping from the north, known as swine flu virus scientific name (H1 N1)?

Visitors from the north

The Tunisian Ministry of Public Health sought approaches or ways to resist the virus, swine flu and the way he named the first Dr. Munther Bedjaoui Our actions to address the prevention of entry, since the virus was in some regions of the world such as Mexico and the United States and Canada ... And the Ministry of Health has tried to monitor the situation after the intensified surveillance in airports, ports and crossing points by focusing on the machines to monitor the heat after using the infrared ray and can monitor the cases infected by the temperature of the body, are also sometimes resort to the measurement of temperature by means of suspected cases regular and known and were monitored carefully to all the entrants officially announced the existence of three cases, is now in the process of follow-up and said there are 60 suspected cases under control, but can not confirm the injury.

Not the most dangerous of the winter influenza

The focus of the Ministry of Health in the central informer Charles Nicolle Hospital, Tunis-finding and analysis of cases and suspected cases in the form of an injury, it is isolated and treated, the official said, we have a sufficient stock of medicines to combat swine flu.
The second phase or the second method, after that changed and how to address the Ministry of Health following the discovery of three people and injuries to entrants prepared all concerned to strictly, and said Our has been shown that it is not serious, not more dangerous than regular winter influenza (uncertainty).
"Some viruses when they appear in the new strain is feared all seriousness, as is the case for the N5 H1 virus known as avian flu, but the proportion of N1H1 fatality (death) when little, so that cases that have emerged in Mexico and Canada was brought under control and there was no longer deals medicine.

WHO emergency

Here the question arises, since the swine flu virus was not serious, then why do all these warnings and alert the world, especially by the World Health Organization, which submitted to the sixth grade and as a global pandemic?
Dr. Mundhir Bedjaoui answer by saying that there are some viruses that are not dangerous in the beginning with no Mujtha first, but later evolve from season to another and be able to adapt to it and become stronger, and the warnings of the World Health Organization is in this context, it is feared that the second wave of this virus and the fear that develops, especially during the coming winter, therefore, must prepare now to meet it.
"We will campaign to raise awareness and distribution of more than 100 thousand of this outstanding issue and said we are ready for a high enough stocks of medicines and reagents minutes.

Fear of the second wave
In the form of the virus in the second Mujth during the coming winter will do what the Ministry of Health?
Ojabna ministry official said in the form of proliferation, we will concentrate on serious cases is expected to be the number of casualties in the coming winter than it is now, which could affect more on the elderly and people living with lung diseases, heart diseases and some chronic diseases, so doctors will be the focus as the level of risk .
"We are ready with ambulances and equipment and we have all the capabilities and means to address, in the form of the existence of injuries, saying it will be isolated so as not to spread infection and possibly more private clinics will be the focus of the injured, but there is an important role as a citizen of the protection begins from home, by isolating the patient and the use of tissue paper and then throw in a special container and wash your hands for sure more than once a day with the adoption of preventive measures, which will be announced in the postings and campaigns rationalization.
Our said that it was no cause for concern or panic, possible prevention and treatment is also available and effective and not a serious disease.

Is it war?
In general, what can be said is that prevention remains the most important geographical location make Tunisia is located in an area between the threat of encroachment Khammash epidemic of avian and swine encroachment from the north and remains an open question to what we hear from time to time epidemics and sophisticated viruses before us on the question of global epidemics and medicine and industry laboratories problematic viruses and bacteria, is the new war? Epidemics and their dirty tactics?

 

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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

What is odd is that several sources OUTSIDE Algeria have reported plague cases in Algeria, but I cannot find any Algerian source reporting this. I don't think Algeria would cover up a plague outbreak, having experienced several before, so something odd is going on here. Does anyone else have any good sources on Algeria to determine whether there is an outbreak there? I'm surprised the ProMed posting didn't draw a quick response either way.

 

[Treyfish]

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

My Algerian searches have not breathed a word so far, but haven't searched for plague today .

 

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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

My Algerian searches have not breathed a word so far, but haven't searched for plague today .

Am I correct that the source you found that I posted above was a Tunisian source? I am skeptical of these reports of plague in Algeria, as I suspect most of them are coming from rehashing the Al Quds source.

 

[Treyfish]

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

No, a libyan news aggregator.

 

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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

No, a libyan news aggregator.

Ok. Then do we think the aggregator was reporting a story that originally appeared in a Tunisian source? That story seems to have Tunisia written all over it.

Update: It was from a Tunisian newspaper called the "Tunisian sunrise" (after going through a translator). We just found it from the Libyan aggregator. That article really has no new information about the suspected "plague" outbreaks.

 

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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

Here is where this gets very odd. The plague outbreaks in that area in the past typically contain fewer than a dozen cases. If the Eurosurveillance article is correct about 5 cases, that is a typical plague outbreak in the area. The 16 to 18 cases originally reported to the WHO would be a very large outbreak. And 50 cases in Algeria would be huge.

If this disease is bubonic plague, there really is no way to import that many cases of the disease. An imported case of bubonic plague would have to have contact with a rat or flea in Libya, and then travel back to Algeria before taking ill, Even one such importation is fairly unlikely. Fifty is less likely than winning the lottery. I'm a little surprised by the fact that there hasn't been an official denial through ProMed yet from Algeria. Usually, a false ProMed posting accusing your country of a plague outbreak would get a pretty quick denial, but not yet this time.

The other possibility is that there is a contagious outbreak of something other than plague that local doctors mistook for plague because plague was seen there before. That would explain both the larger numbers, as well as the fluctuation in counts; cases are being discarded as they test negative for plague. The lack of confirmation after nearly a month now might be a good sign that this might not be plague. The discarding of cases would also explain the discrepancy in exactly who died. The above sources have indicated different numbers of deaths and in different people (a small child, an adolescent male, two friends of the Egyptian suspect, a middle-aged woman, etc.). It is possibly that many deaths are being excluded as they test negative for plague.

The lack of information here is astounding. If the report of 50 illnesses in Algeria is true, this outbreak is NOT plague. ProMed and the WHO need to investigate this quickly.

 

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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

Here is a new source, and a pretty credible one in my opinion. It agrees with the Eurosurveillance report on Libya (up to a possible double counting of the death case - the five cases include the death, and describes the fatal illness as septicemic, not pneumonic plague, which is certainly more believable), but quotes the Al Quds source on 50 cases in Algeria. I don't remember any mention of deaths in the Al Quds source, but this article says that Al Quds claimed two deaths, which is a low fatality rate for 50 cases of plague. I am still suspicious of the reports on plague in Algeria, as no official reports have been issued, and no source from Algeria, even a lone blogger, has mentioned it. Fifty cases would also be a HUGE outbreak.

http://www.irinnews.org/Report.aspx?ReportId=85150

EGYPT: Authorities act in face of plague threat

Photo: Wikimedia Commons
This plague patient is displaying a swollen, ruptured inguinal lymph node, or buboe
DUBAI, 6 July 2009 (IRIN) - The Egyptian authorities have been taking measures over the past couple of weeks to prevent a plague outbreak in neighbouring Libya from reaching Egypt.

One person has died and five more were infected with bubonic and septicaemic plague in the eastern Libyan town of Tubruq, some 150km from the Egyptian border, according to the World Health Organization (WHO).

“An international [WHO] expert went there and assessed the situation. On 21 June, there were five suspected cases, according to his report; one septicaemic plague who died and four bubonic who recovered,” Dr John Jabbour, emerging diseases specialist at the WHO office in Cairo, told IRIN on 5 July.

Jabbour said the WHO expert in Libya had made recommendations to the Libyan authorities on how to educate communities about the disease and its modes of transmission and how to improve surveillance systems in infected areas. He said a team of international experts was being assembled to provide a wider assessment of the situation.

“What we can say here is that the situation is under control and being very well monitored by the national authorities and there is active surveillance in the area to discover any suspected case of plague,” Jabbour said.

According to London-based newspaper Al-Quds Al-'Arabi, Algeria has reported 50 cases of bubonic plague and two deaths.
Quarantine
Interactive map showing Tabruq in Libya
and Sallum in Egypt


View larger version at Google Maps


The Egyptian government has declared a state of emergency along the Egypt-Libya border and sent two teams of experts to the border town of Sallum, which was already under quarantine for surveillance of the A(H1N1) virus, to set up a field laboratory and isolation facility. Health checks are being conducted on everyone returning from Libya.

“The medical team on the border was supported with more doctors to survey all the cases that come in. No suspected cases have been registered to date and we think the disease was completely controlled on the Libyan side,” Abdel Rahman Shahin, spokesman of the Egyptian Ministry of Health, told IRIN on 6 July.

Shahin said that pest control teams had been sent to the border and were spraying all vehicles coming through Sallum, to kill rodent fleas. “Rodent traps were also put in open areas, while special teams trapped a number of rat fleas and tested them to make sure they are free of the disease. The authorities also got rid of the garbage at Sallum crossing and the exit points of Marsa Matrouh city, which is a very important preventive measure because garbage in open areas can facilitate the reproduction of rodents,” he said.

Bubonic plague epidemiology

According to WHO, infected persons usually start with “flu-like” symptoms after an incubation period of 3-7 days. Patients typically experience the sudden onset of fever, chills, head and body-aches, and weakness, vomiting and nausea.

WHO stresses that rapid diagnosis and treatment is essential to reduce complications. Effective treatment methods enable almost all plague patients to be cured if diagnosed in time.

Clinical plague infection manifests itself in three forms depending on the route of infection: bubonic, septicaemic and pneumonic.

Plague is a bacterial disease caused by Yersinia pestis, which primarily affects wild rodents or rats. It is then spread from rat to rat by fleas. If a human is bitten by an infected flea, he or she would usually develop a bubonic form of plague (a form that enters via the skin), characterized by a swelling of the nearest nymph node to the bite. If diagnosed early, bubonic plague can be successfully treated with antibiotics. It has a case-fatality ratio of 30-60 percent if left untreated.

The septicaemic form of plague occurs when infection spreads directly through the bloodstream without evidence of a "bubo". It may result from flea bites and from direct contact with infective materials through cracks in the skin.

The rare pneumonic form of plague is the most virulent as it can be transmitted from human to human via aerosolized infective droplets without the involvement of fleas or animals.

According to WHO, plague is endemic in many countries in Africa, in the former Soviet Union, the Americas and Asia. In 2003, nine countries reported 2,118 cases and 182 deaths - most in Africa.

ed/cb


Theme(s): (IRIN) Early Warning, (IRIN) Health & Nutrition

 

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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

http://www.algomhuria.net.eg/algomhuria/today/news/detail03.asp

Egypt free of the plague .. والمرض اختفي من ليبيا منذ أسبوع The disease disappeared from Libya a week ago
متابعة: حلمي بدر - نادية السيد - عادل مصطفي Follow-up: Helmy Badr - Mr. Nadia - Adel Mostafa
قنا عبدالحكيم الأمير - الأقصر أحمد السعدي Prince Abdulhakim Qena - Luxor, Ahmed al-Saadi
عقدت غرفة العمليات المركزية برئاسة مجلس الوزراء اجتماعها الدوري أمس بمقر المركز لمناقشة ومتابعة تطورات موقف مرض انفلونزا الخنازير علي المستويين المحلي والعالمي. The central operations room headed by the Council of Ministers at their regular meeting yesterday to discuss the status and follow up the developments of the position of swine flu at the local and global levels.
أشادت الغرفة خلال الاجتماع الي قيام السلطات الطبية بالتعاون مع عدد من الجهات والمنظمات الدولية بالسيطرة تماما علي مرض الطاعون حيث لم تظهر أي حالة جديدة في ليبيا للأسبوع الثاني علي التوالي أما الموقف علي المستوي الداخلي في مصر فلا توجد أي حالة إصابة بمرض الطاعون. During the meeting, commended the room to the medical authorities in collaboration with a number of actors and international organizations to fully control the disease, where the plague did not show any new situation in Libya for the second consecutive week, the situation at the domestic level in Egypt, there are no cases of plague.

 

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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

Source: http://www.upi.com/Top_News/2009/07/11/Egypt-reacts-to-Libyan-plague-outbreak/UPI-40391247337067/

Egypt reacts to Libyan plague outbreak

Published: July 11, 2009 at 2:31 PM


CAIRO, July 11 (UPI) -- Egypt has declared a state of emergency along its shared board with Libya over an outbreak of bubonic plague, authorities said.

Since June 21, one person has died and four others were recovering from the outbreak in the eastern Libyan town of Tubruq, about 93 miles from the Egyptian border, Dr. John Jabbour of the World Health Organization said Friday.

Health checks were being conducted on anyone entering Egypt from Libya and pest control teams were spraying all vehicles coming through the border town of Sallum. The plague is spread by fleas on rodents.

WHO specialists were advising Libya about how to contain the outbreak, Jabbour told the IRIN news agency in a story published Saturday.

"What we can say here is that the situation is under control," Jabbour said.

Algeria, which also shares a border with Libya, has reported 50 cases of bubonic plague and two deaths in recent weeks, the London newspaper al-Quds al-Arabi reported Friday.

The plague has an incubation period of three to seven days, with most patients recovering if treated in time, Jabbour said.

 

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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

That UPI article (#211) is a really poor source. It has the wrong date of the outbreak's start (it claims the outbreak started 6/21 when this thread started 6/15). It has the wrong date of the Al Quds article (#188 - and I have been searching Al Quds - there was no second article). And it makes the same errant claim that Al Quds claims two deaths in Algeria (it doesn't - it claims two deaths in Libya, one of which has apparently been discarded or was just rumored).

This story has gone silent for over a week (probably because the outbreak is over), and UPI just now picked it up. This thread might have the highest ratio of posts to illnesses ever, simply because of poor sources. And we can't blame this one on a translator.

 

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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 the "outbreak" in Libya is delcared contained.

http://74.125.93.132/translate_c?hl...le.com&usg=ALkJrhgxaOZ1KlXCJDkzGFITwtMQZJYnFw

Mountain: Libyan actions succeeded in controlling the disease, the plague
الأثنين، 13 يوليو 2009 - 19:41 Monday, July 13, 2009 - 19:41


الدكتور حاتم الجبلى وزير الصحة Dr.
Hatem el-Gabali, Minister of Health
أكد الدكتور حاتم الجبلى وزير الصحة، أن التنسيق الكامل والإجراءات التى اتخذتها وزارة الصحة بليبيا للحد من انتشار مرض الطاعون خلال الفترة الماضية، كان على المستوى المطلوب، وهو ما أدى إلى انحسار المرض فى فترة قياسية، مشيرا إلى أن المرض كان قد ظهر فى منطقة معزولة بليبيا لحالات محدودة. Dr. Hatem el-Gabali, Minister of Health, the full coordination and action taken by the Ministry of Health, Libya, to reduce the spread of plague during the last period, the required level, which led to the decline of the disease in the record, noting that the disease had emerged in an isolated area Libya, for limited cases.

وقال الجبلى إن التنسيق والتعاون المصرى الليبى مستمر فى مواجهة أية أزمات صحية تقع فى أى من البلدين، مضيفا أنه لو لم يكن هناك تعاون واتفاق على تطبيق إجراءات محددة ومشددة لحدث ما لا يحمد عقباه. The mountain that coordination and Egyptian-Libyan cooperation in the face of continuing any health crises occur in any of the two countries, adding that if there was no cooperation and agreement on specific actions and the application of strict credit event does not wants.

كان قد تم الإعلان عن ظهور حالات مصابة بمرض الطاعون بليبيا فى منتصف الشهر الماضى، وقام وقتها الدكتور حاتم الجبلى بإجراء اتصال بنظيره الليبى الدكتور محمد الحجازى للاطمئنان على الموقف هناك بالنسبة للمصابين بالمرض، كما عرض عليه المساعدة وقام بزيارة لمنفذ السلوم لمتابعة الإجراءات والتنسيق بين الجانبين المصرى والليبى. Had been announced as the emergence of cases infected with the plague in Libya in the middle of last month, and then Dr. Hatem a mountain with his Libyan contact Dr. Mohamed Alhijazy to check on the situation for people living with the disease, and offered him assistance and paid a visit to SALLUM outlet for the follow-up action and coordination between the two sides and Libya.

 

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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

Hat-tip IOH. The CDC has released this extensive report confirming 5 cases of plague in Tobruk in this outbreak, resolving one of the longest unsolved outbreaks in FT history.

Notably, this report does not mention any cases in Algeria in 2009 (only 2008 and 2003), suggesting those reports were indeed false, perhaps for political reasons.

http://wwwnc.cdc.gov/eid/article/19/2/12-1031_article.htm

Research
Plague Outbreak in Libya, 2009, Unrelated to Plague in Algeria
Article Contents
Materials and MethodsResultsDiscussionReferencesFigure 1Figure 2Figure 3Figure 4Figure 5TableSuggested CitationNicolas Cabanel, Alexandre Leclercq, Viviane Chenal-Francisque, Badereddin Annajar, Minoarisoa Rajerison, Souad Bekkhoucha, Eric Bertherat, and Elisabeth Carniel
Author affiliations: Author affiliations: Institut Pasteur, Paris, France (N. Cabanel, A. Leclercq, V. Chenal-Francisque, E. Carniel); National Center for Disease Control, Tripoli, Libya (B. Annajar); Institut Pasteur, Antananarivo, Madagascar (M. Rajerison); University Hospital, Oran, Algeria (S. Bekkhoucha); World Health Organization, Geneva, Switzerland (E. Bertherat)
Suggested citation for this article

Abstract
After 25 years of no cases of plague, this disease recurred near Tobruk, Libya, in 2009. An epidemiologic investigation identified 5 confirmed cases. We determined ribotypes, Not1 restriction profiles, and IS100 and IS1541 hybridization patterns of strains isolated during this outbreak. We also analyzed strains isolated during the 2003 plague epidemic in Algeria to determine whether there were epidemiologic links between the 2 events. Our results demonstrate unambiguously that neighboring but independent plague foci coexist in Algeria and Libya. They also indicate that these outbreaks were most likely caused by reactivation of organisms in local or regional foci believed to be dormant (Libya) or extinct (Algeria) for decades, rather than by recent importation of Yersinia pestis from distant foci. Environmental factors favorable for plague reemergence might exist in this area and lead to reactivation of organisms in other ancient foci.
Plague is a zoonosis caused by the bacillus Yersinia pestis. Rodents are the reservoir and fleas are the vector of this organism. Humans most often become infected by an infectious fleabite, which leads to development of a bubonic form of plague (1). If the bacillus reaches the lungs, the patient will expel the bacteria while coughing, causing another clinical form: pneumonic plague, which is directly transmissible from person to person. Without prompt and efficient treatment, the case-fatality rate is 40%–70% for bubonic plague and ≈100% for pneumonic plague (1).

The plague bacillus is believed to have originated <20,000 years ago in central Asia (2), from which it has spread on multiple occasions and caused 3 well-documented pandemics (1). The first pandemic, known as Justinian’s plague, reached Africa and then Europe during the sixth century. The second pandemic struck the countries surrounding the Mediterranean in 1348 and then spread rapidly throughout Europe. The third pandemic started in Hong Kong in 1894 and reached previously unscathed territories worldwide. These 3 pandemics were extremely devastating and killed millions of persons. Because of identification of the causative agent (3), the reservoir, and the vector of the disease at the end of the 19th century (4) and then the availability of effective antimicrobial drugs, human illness and death caused by plague have been considerably reduced since the middle of the 20th century.

Figure 1


Figure 1. . Locations of plague outbreaks in Oran, Algeria, and Tobruk, Libya, 2009. Upper panels show regions around Oran and Tobruk where plague cases were found.
However, the disease has not been eradicated. Plague-endemic foci persist in Africa (the most affected continent), Asia, South America, and North America (5). Moreover, since the beginning of the 1990s, plague outbreaks have recurred in countries where no cases were reported for decades, and where the disease was believed to have been eliminated. Among the most conspicuous examples is that of India, which experienced a large outbreak of pneumonic plague in 1994 after 30 years with no reports of plague cases (6). Another striking example of plague reemergence is that of Algeria, where the most recent cases were reported in the 1940s. After an absence of >50 years, the disease reappeared in 2003 in a village south of Oran (7,8); and then in 2008, in the Laghouat area (9) (Figure 1). Whether these outbreaks were caused by reimportation of the disease from other countries or by reactivation of organisms in a local quiescent plague focus could not be formally established.

Neighboring Libya experienced several plague outbreaks during 1913–1920, the largest of which resulted in 1,449 deaths in Benghazi in 1917 (10). Other plague epidemics of lower amplitude occurred in 1972, 1976, 1977, and 1984. After an apparent absence of 25 years, plague cases recurred in June 2009 near Tobruk, Libya, close to the border with Egypt (Figure 1). A total of 5 plague cases were confirmed, 3 of which occurred in 1 family and the other 2 in patients living in the same district (11,12). An even more recent plague epidemic that had >21 suspected cases was reported in May 2011 in the city of Tobruk (12). An investigation of this epidemic did not confirm the plague etiology, but the political troubles resulting from the onset of the revolution in February made this investigation difficult.

The purpose of this study was to obtain insights into the origin of the outbreak that occurred near Tobruk in 2009. We analyzed Y. pestis strains that were isolated from patients during this epidemic and determined whether links exist to the recent resurgence of plague in Algeria.

Materials and Methods
Bacterial Strains Isolation and Characterization
The Y. pestis strains used in this study are shown in the Table. Y. pestis strains were isolated from biological specimens after streaking them on cefsulodin-irgasan-novobiocin plates (Merck, Schaffhausen, Switzerland) and injection of bacteria into mice. Phenotypic characterization of strains was determined by biochemical reactions on API 20E and API 50CH strips (bioMérieux, Marcy l’Etoile, France) incubated at 28°C, lysis by a Y. pestis–specific bacteriophage, reduction of nitrates, and glycerol fermentation. For further analyses, bacteria were grown in Luria-Bertani broth or on Luria-Bertani agar plates containing 0.002% hemin for 24–48 h at 28°C.

Molecular Typing
Total genomic DNA was extracted by using a Gentra Puregene Cell Kit (QIAGEN, Hilden, Germany) according to the manufacturer’s instructions. Ribotyping was performed as described (13) after digestion of genomic DNA with EcoRI or EcoRV restriction enzymes for 30 min at 37°C. Each profile was classified according to the scheme of Guiyoule et al. (13).

Insertion sequence–restriction fragment length polymorphism (IS-RFLP) analysis was performed as described (14). DNA samples were digested with EcoRI (IS100-RFLP) or HindIII (IS1541-RFLP) for 30 min at 37°C before being loaded onto 0.8% agarose gels and subjected to electrophoresis for 24 h. The IS fingerprints were analyzed by using BioNumerics software version 6.6 (Applied Maths, Kortrijk, Belgium) as described (14). Two IS profiles were considered identical when their percent similarity was >98%.

For pulsed-field gel electrophoresis (PFGE), bacterial genomic DNA was prepared in agarose plugs as described (15) and digested with 50 U of NotI endonuclease in 200 µL of the corresponding buffer for 3 h at 37°C. Electrophoresis was performed as described (16), except that the pulse time ranged from 4 s to 8 s over 42 h in a buffer maintained at 14°C.

Results
Plague Outbreak in Libya
On June 9, 2009, three patients 14, 13, and 4 years of age were admitted to Tobruk Central Hospital because of a severe infectious syndrome. All 3 persons were members of the same family of nomads leaving in Eltarsha, 30 km south of Tobruk. The 13-year-old patient (patient 1) had a septicemic syndrome 2 days after admission and died on June 11 despite intensive care. His 14-year-old brother (patient 2) had a tender left cervical lymph node and a fever of 39.5°C. He received ciprofloxacin and doxycycline before being transferred to Benghazi Hospital on June 11, and he recovered. His 4-year-old sister (patient 3) had signs of severe infection with no visible bubo. She received cefotaxime and metronidazole and then gentamicin before being transferred to Benghazi Hospital, and she recovered. Their father reported having axillary lymphadenitis and indicated that 2 or 3 sudden deaths had occurred in the previous 2 months in the region.

On the basis of clinical manifestations and previous plague cases in the Tobruk area, these 3 patients were considered to have contracted plague. All patients from this area with an infectious syndrome were reported as having suspected cases of plague. All but 1 of these patients received gentamicin at Tobruk Hospital and no additional deaths occurred. On June 13, the Libyan authorities reported 13 cases of plague to the World Health Organization (WHO) and requested technical assistance.

A joint investigation of the outbreak led by WHO and the Libyan National Center for Infectious Disease Prevention and Control concluded that the number of plague cases was overestimated, but it identified 2 additional probable cases. These cases were in a 20-year-old woman (patient 4) and a 24-year-old woman (patient 5) who had an infectious syndrome and a painful inguinal lymph node and were admitted to the Tobruk Hospital on June 16 and 18, respectively. Patient 4 lived in Beer Alashahab and patient 5 lived in Zafrana (Figure 1), ≈60 and 30 km from Eltarsha, respectively. Control measures (chemoprophylaxis of contact persons, insecticide treatment, and rodent control) were implemented, and no additional cases were reported.

Bacteriologic Findings
In Benghazi, blood samples collected from patients 3, 4, and 5 contained gram-negative bacteria resembling Yersinia spp. These blood samples and serum samples from all 5 patients and a bubo aspirate from patient 4 were sent to the WHO Collaborating Center at the Institut Pasteur in Antananarivo, Madagascar, for further analyses. F1 dipstick test (17) results were positive for samples from all 5 patients. A Y. pestis strain was isolated from the blood of patients 3 and 5 and from the bubo aspirate of patient 4, thus confirming the etiology of this outbreak. These 3 strains were then sent to the WHO Collaborating Center at the Institut Pasteur in Paris, France, for further characterization. On the basis of glycerol fermentation and nitrate reduction, the 3 strains were assigned to Y. pestis biovar Medievalis (18).

Molecular Characteristics of Strains from Libya
Figure 2


Figure 2. . NotI pulsed-field gel electrophoresis patterns of Yersinia pestis strains of biovar Medievalis obtained during plague outbreak in Libya, 2009. A) Pattern of three 2009 isolates from Libya. Lane M, low-range...
Figure 3


Figure 3. . Insertion sequence–restriction fragment length polymorphism profiles of 3 Yersinis pestis strains obtained during plague outbreak in Libya, 2009. Genomic DNA of strains IP1973 (lane 1), IP1974 (lane 2), and IP1975...
The 3 strains exhibited identical NotI PFGE profiles (Figure 2, panel A), and all had ribotype O (EcoRI.4 + EcoRV.5) according to Guiyoule et al. (13) and identical IS100 and IS1541 hybridization patterns (Figure 3). These results are consistent with a single Y. pestis strain as the origin of the cases that occurred in distinct places in the Tobruk area.

Figure 4


Figure 4. . IS100 and IS1541 restriction fragment length polymorphism patterns of 70 Yersinia pestis isolates of worldwide origin. A) Medievalis branch. B), ancient strain from Algeria (IP1867); C) other strains from Algeria...
Ribotype O is commonly associated with biovar Medievalis strains (13). When the IS100 and IS1541 profiles were combined (2IS-RFLP), the isolates from Libya clustered with other biovar Medievalis strains (Figure 4) in our database (14). Moreover, the chromosomal location of some IS100 sequences determined by PCR was typical of this biovar (19). Therefore, our results demonstrate unambiguously that the Y. pestis strain that caused the plague outbreak in Libya in 2009 belongs to the biovar Medievalis lineage, a lineage typical for strains that originated in central Asia.

The 2IS-RFLP dendrogram suggested that strains from Libya were closely related to but different from those from Kurdistan and more distantly related to the biovar Medievalis strain from Turkey (Figure 4). A comparison of the NotI PFGE profile of an isolate from Libya with those of 5 other biovar Medievalis strains confirmed this observation: all isolates had similar but different profiles (Figure 2, panel B), and the similarity was more pronounced with strains from Kurdistan than with the strain from Turkey. Thus, strains from the 2009 outbreak in Libya are genetically close to those isolated in the Iranian part of Kurdistan.

Y. pestis Strains that Caused the Plague Outbreak in Algeria in 2003
Because Y. pestis strains were isolated from patients during the outbreak that occurred in the region of Oran in 2003 (7) (Figure 1), we performed the same analyses on these strains and compared them with isolates from Libya. Biochemical characterization of the 5 strains from Algeria indicated that they belonged to biovar Orientalis. They were of ribotype B (EcoRI.1 + EcoRV.2), which is found only in biovar Orientalis strains (13). Their IS100 + IS1541 profiles also included them in the biovar Orientalis group (Figure 4). Therefore, the strains that caused the 2003 plague outbreak in Algeria belong to the biovar Orientalis lineage.

Figure 5


Figure 5. . NotI pulsed-field gel electrophoresis patterns of Yersinia pestis isolates from plague outbreak in Algeria, 2009. Lane M, low-range DNA marker (New England Biolabs, Ipswich, MA, USA); lane 1, IP1860 (Kehailia);...
Four of these strains had identical IS100 + IS1541 profiles, but the IS1541 profile of the strain from Hamoul (IP1862) displayed 1 additional band. The NotI PFGE patterns of the 5 strains from Algeria were highly similar but differed by a few bands (Figure 5). The 2 strains from Ain Temouchent (IP1863 and IP1864) had an identical NotI pattern, which was different from that of the strain from Hamoul (IP1862), which also slightly differed from the NotI profile of the strains from Kehailia (IP1860) and Hama Ali (IP1861). Thus, these results suggest that the 2003 outbreak in Algeria was caused by closely related, but not identical, strains.

Two Y. pestis strains isolated in Oran in 1944 and 1945 from bubonic plague patients were available in our collection and were used for comparison with the 2003 strains. These 2 more ancient isolates also belonged to biovar Orientalis. However, the strain isolated in 1945 (IP1867) had ribotype E, a ribotype found in strains from Saigon, Vietnam. This strain also clustered with an isolate from Saigon (IP532) in the 2IS-RFLP dendrogram (Figure 4), which suggested an epidemiologic link between these 2 foci. In contrast, the strain isolated in 1944 (IP1866) had ribotype B and was found in the same cluster in the 2IS-RFLP dendrogram as that containing the 2003 strains from Algeria (Figure 4). This cluster grouped all other strains from northern Africa (Morocco and Senegal). These data support a local or regional origin of the strains that caused the 2003 plague outbreak in Algeria.

Discussion
After decades of no plague cases, human plague cases have recently recurred in countries surrounding the Mediterranean Sea. New cases occurred in Saudi Arabia in 1994 (20) where no human cases of plague had been reported for ≥40 years, in Jordan in 1997 (21), where no cases had been reported during the past 70 years, in Algeria in 2003, where no cases had been reported for 50 years (7), and more recently in Libya in 2009, where the last plague case was reported 25 years ago. Recent reappearance of plague cases in this area could have been caused by regional spread of organisms from a single focus, reimportation of strains from distant areas by land or sea transportation, or reactivation of the organism in local foci that had been apparently dormant for years.

Analysis of the 3 strains isolated in Libya in 2009 showed that they were identical by 2IS-RFLP and PFGE, which suggested that a single strain caused this outbreak and that a single focus was the source of infection for different human patients. Phenotypic and genetic analyses indicated that this strain belongs to the biovar Medievalis lineage. Thus, as for other strains of this lineage, the strain from Libya most likely originated in central Asia. To our knowledge, no biovar Medievalis strains have been reported in Africa. However, this finding might reflect a lack of reporting rather than a true absence of these strains in countries in Africa near Asia.

Camel caravans travel through central Asia and the Middle East, and consumption of infected camel meat were shown to be responsible for human plague cases in Libya in 1976 (22), in Saudi Arabia in 1994 (20), in Jordan in 1997 (21), and in Afghanistan in 2007 (23). Thus, infected camels could have been a means of importing new Y. pestis strains into Libya. However, because camels are highly susceptible to plague, it is unlikely that sick animals could travel long distances. Furthermore, dead rats were found in the vicinity of a sick camel in Libya (22), Y. pestis strains were isolated from rodents and fleas in the corral where a camel died of plague in Saudi Arabia (20), and dogs had antibodies against the plague bacillus in Jordan (21). These observations suggest that plague was already present in these countries and that camels were not the mode of transmission.

Resurgence of plague in Libya in 2009 could most likely be attributed to reactivation of established and permanent local plague foci resulting from ancient importation from central Asia. Strengthening this hypothesis are the numerous plague outbreaks that occurred in Libya during the 20th century. In the Tobruk area, human cases were reported in 1976–1977 and in 1984 (24). This finding and the fact that the recent epidemic involved persons living 30–60 km from each other are highly evocative of reactivation of organisms in a local plague focus in 2009. Comparison of strains from past epidemics in Libya with the strain from 2009 would have helped answer this question, but such strains were not available in our collection.

The sudden resurgence of plague cases in the Tobruk region >2 decades after the last reported case might be linked to unusual climatic conditions. The outbreak was preceded by a particularly humid winter, which favored flea proliferation, and exceptionally good harvests, which supported rodent multiplication. The effect of climatic changes on human plague has been documented (25,26) and further emphasizes the need to take into consideration the effect of global warming on infectious diseases that have a nonhuman reservoir.

Although Libya and Algeria have a common border, our results demonstrate that the plague outbreaks that occurred recently in Algeria were not caused by spread of organisms from the focus in Libya. Phenotypic and genetic analyses of 5 strains isolated from patients in Algeria in 2003 demonstrated that they belong to biovar Orientalis. Similarly, the strains that caused the plague episode in Laghouat (550 km south of Algiers) in 2008 had a multispacer sequence type typical for biovar Orientalis strains (9). This lineage is distinct from the biovar Medievalis lineage of strains from Libya. Thus, the plague foci in Algeria and Libya are not linked.

Several plague outbreaks in Oran have been attributed to importation of infected rodents or fleas by marine shipping, e.g., during World War II military operations (27). Ribotyping and 2IS-RFLP analyses of the Y. pestis strain isolated from a bubonic plague patient in the Oran area in 1945 fully support this point and suggest that this strain was imported from southern Vietnam (Saigon). In contrast, Y. pestis isolates from 1944 and from 2003 in Oran cluster together by 2IS-RFLP. They also cluster with the other strains from northern Africa (Morocco and Senegal) isolated in the 1940s. These results are consistent with reactivation of organisms in a local or regional plague focus and argue against importation of infected materials or animals from a distant plague-infected region.

Also arguing for existence of an active local reservoir was detection of Y. pestis DNA in fleas collected near Oran 1–2 years after the 2003 outbreak (8) and in native rodents trapped in the Laghouat area a few months after the 2008 plague cases (9). The fact that 3 similar but distinct NotI patterns were observed among the 5 Y. pestis strains isolated in Oran in 2003 also argues against importation of a foreign strain and suggests emergence of variants from a local common ancestor. If true, this suggestion would also imply that it was not organisms in 1 focus but organisms in several adjacent foci that were reactivated at the same time in the Oran region. Climatic and environmental factors may have played a critical role in this resurgence because they have been shown to be predictors of human risk for exposure to plague in other foci in Africa (28).

Our results indicate that adjacent but independent plague foci coexist in Algeria and Libya. Plague outbreaks that occurred in these 2 countries are most likely the result of reactivation of organisms in local foci that were believed to be dormant (Libya) or extinct (Algeria). Recent reemergence of these independent foci suggests that climatic and environmental changes in northern Africa may be favorable for the Y. pestis epidemiologic cycle. Thus, other countries in northern Africa that have had plague foci may also be at risk for plague outbreaks in the near future.

Mr Cabanel is a research technician in the Yersinia Research Unit at the Institut Pasteur in Paris, France. His research interests are strain characterization and molecular typing of Y. pestis.