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Plague in Madagascar

On 6 December 2016, theMinistry of Health (MoH) in Madagascar alerted WHO of a suspected plagueoutbreak in Befotaka district, Atsimo Atsinanana region in the south-easternpart of the country. The district is outside the area known to be endemic areain Madagascar. No plague cases have been reported in this area since 1950.

As of 27 December 2016, 62cases (6 confirmed, 5 probable, 51 suspected) including 26 deaths (casefatality rate of 42%) have been reported in two adjacent districts in twoneighbouring regions of the country. 28 cases, including 10 deaths have beenreported from Befotaka District in Atsimo-Atsinanana Region and 34 cases including16 deaths have been reported from Iakora district in Ihorombe Region.

Of the 11 samples tested, 5were positive for plague on rapid diagnostic test and 6 are now confirmed atInstitut Pasteur laboratory. Of the total reported cases, 5 are classified aspneumonic plague cases and the remaining as bubonic plague.

Retrospective investigationscarried out in those two districts showed that it is possible that the outbreakmight have started in mid-August 2016. The investigation in neighbouringvillages is still ongoing. On 29 December, an investigation carried out within25 km of the initial foci in Befotaka district has reported three deaths and isbeing investigated further for possible linkage to the outbreak.

The affected zone is located ina very remote and hard to reach and highly insecure area (classified as redzone due to local banditry). Despite arrangements made with the localauthorities, insecurity slows down the investigations and response activities.In addition, a helicopter has been made available but its use has been limiteddue to bad weather and financial limitations.

Public Health Response

On 6 December, a 15 membermultidisciplinary team from MoH, Institute Pasteur including public healthprofessional, epidemiologist, entomologist and laboratory professional visitedthe affected area for epidemiological investigation and response activities.

Key response activities alreadyimplemented include

Epidemiologicalinvestigations including active case finding and rapid diagnostic testing

Training of communityhealth workers on community-based surveillance and early detection of casesClinical Management ofsuspected cases

Identification, followup and chemoprophylaxis of contacts

Vector and reservoircontrol through the use of Kartman boxes

Sensitization of thepopulation

Strengthening thecommunity based surveillance

Free treatment ofother diagnosed disease such as malaria

Strengthening earlydetection in neighbouring districts


WHO Risk Assessment

Based on the availableinformation to date, the risk of international spread appears unlikely,especially as it is occurring in very remote area. However, the difficulty toreach the affected area hampered prompt investigation and therefore at thisstage the real magnitude of the outbreak is still to be defined and the risk offurther spread in the area and sustained transmission cannot be formally ruledout. WHO continues supporting ongoing investigation and response activities.

WHO Advice

Further ecologicalinvestigations will be needed to understand the occurrence of a plague outbreakin an area which has not reported any cases of plague since 1950 in order toadapt long term surveillance and control measures.

The outbreak impacts ruralcommunities which have already suffered from remoteness and inadequate accessto health services. Staff from MoH are supported by Pasteur Institute ofMadagascar, who are all experienced on control measures. However, localconditions make their implementation complex.

Due to the remoteness of theaffected area and the conditions for getting infected by the disease, thecurrent outbreak does not represent a significant risk for travellers.

Source: http://www.who.int/csr/don/09-january-2017-plague-mdg/en/

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