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Pneumonic Plague Outbreak, Northern Madagascar, 2011 - Volume 21, Number 1—January 2015 - Emerging Infectious Disease journal - CDC

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Pneumonic Plague Outbreak, Northern Madagascar, 2011 - Volume 21, Number 1—January 2015 - Emerging Infectious Disease journal - CDC


Volume 21, Number 1—January 2015


Pneumonic Plague Outbreak, Northern Madagascar, 2011

Vincent Richard, Julia M. RiehmComments to Author , Perlinot Herindrainy, Rahelinirina Soanandrasana, Maherisoa Ratsitoharina, Fanjasoa Rakotomanana, Samuel Andrianalimanana, Holger C. Scholz, and Minoarisoa Rajerison
Author affiliations: Institut Pasteur de Dakar, Dakar, Senegal (V. Richard)Bundeswehr Institute of Microbiology, Munich, Germany (J.M. Riehm, H.C. Scholz)German Center for Infection Research, Munich (J.M. Riehm, H.C. Scholz)Institut Pasteur de Madagascar, Anatananarivo, Madagascar (P. Herindrainy, R. Soanandrasana, M. Ratsitoharina, F. Rakotomanana, M. Rajerison)Ministry of Public Health, Anatananarivo (S. Andrianalimanana)


Yersinia pestis, the causative agent of plague, is endemic to Madagascar, particularly to the central highlands. Although plague has not been previously reported in northern Madagascar, an outbreak of pneumonic plague occurred in this remote area in 2011. Over a 27-day period, 17 suspected, 2 presumptive, and 3 confirmed human cases were identified, and all 15 untreated 20 patients died. Molecular typing of Y. pestis isolated from 2 survivors and 5 Rattus rattus rat samples identified the Madagascar-specific 1.ORI3-k single-nucleotide polymorphism genotype and 4 clustered regularly interspaced short palindromic repeat patterns. This outbreak had a case-fatality rate of 100% for nontreated patients. The Y. pestis 1.ORI3-k single-nucleotide polymorphism genotype might cause larger epidemics. Multidrug-resistant strains and persistence of the pathogen in natural foci near human settlements pose severe risks to populations in plague-endemic regions and require outbreak response strategies.
Yersinia pestis is the causative agent of plague, a severe and life-threatening zoonotic disease. During 3 pandemics, different genotypes of this bacterium spread to various countries and caused millions of deaths (16).Y. pestis genotype 1.ORI3 of the biovar Orientalis was introduced to Madagascar in 1898 during the third pandemic and has persisted there endemically ever since (6,7). Worldwide, an average of 4,000 human plague cases is reported each year. Madagascar is one of the most active plague foci and has an annual average of 1,500 confirmed cases (8,9). The pathogen emerges in multiannual cycles; a peak of pathogen prevalence was observed in Madagascar in 1997 and caused ≈3000 cases, 20 times more than in 1994 (126 cases) (9).
Bubonic plague, the most common form of plague, results from the bite of an infected flea. The infection may spread hematogenously and cause secondary pneumonic plague. If the pathogen is transmitted as an aerosol by droplets or by contaminated dust, primary pneumonic plague may result. After a latency period of 1–5 days, pneumonic plague progresses to the stage of hemoptysis. At this lethal stage of the disease, which lasts ≤3 days, patients are highly infectious (10,11). Plague can be treated with antimicrobial drugs if diagnosed early and if caused by a drug-sensitive strain (9).
Worldwide, only a few pneumonic plague outbreaks have been reported (1215). However, to understand the epidemic potential of Y. pestis, extensive outbreak analyses are essential. In 1997, a pneumonic plague outbreak occurred in Madagascar near the capital of Antananarivo (13). Health authorities responded immediately, and strain cultivation was successful. Three other pneumonic plague outbreaks have been reported, 1 in Uganda (2004) and 2 in the Democratic Republic of Congo with 87 cases (2005) and 117 cases (2006), respectively (14,15). During the 1920s–1930s, valuable descriptions of 2 plague epidemics in Manchuria, China (≈10,000 cases) were reported (10,12).
In this report, we describe an outbreak and highly progressive spread of pneumonic plague in northern Madagascar, a remote region that was supposedly free of Y. pestis, in 2011. We investigated whether Y. pestis might cause larger outbreaks or epidemics with high case-fatality rate within a short period.
Dr. Richard is a scientist in the Department of Epidemiology at the Institute Pasteur, Dakar, Senegal. His research interests are tropical diseases, public health priorities, analysis of surveillance data from sentinel network and cohort studies, and evaluation of emergent risks and antibiotic resistance testing.


We thank Abdou Salam Nasser, Ravoniarisoa Marie Georgette, Noromihaja Randriananja, and Joely Razafilalaintsoa for assistance during the epidemiologic study, and Michaela Projahn and Gabriele Echle for assistance during pathogen typing and laboratory analysis.
This study was supported by the Institut Pasteur de Madagascar, the President’s Malaria Initiative/US Agency for International Development, and the US Department of Homeland Security (project no. DHS-09-ST-108-001/MGN3EL7-01).


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Suggested citation for this article: Richard V, Riehm JM, Herindrainy P, Soanandrasana R, Ratsitoharina M, Rakotomanana F, et al. Pneumonic plague outbreak, northern Madagascar, 2011. Emerg Infect Dis [Internet]. 2015 Jan [date cited]. http://dx.doi.org/10.3201/eid2101.131828
DOI: 10.3201/eid2101.131828

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