Wüstenschiff

MENINGITIS, MENINGOCOCCAL - NIGERIA (03)
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Date: Thu May 7 2009
Source: Reuters [edited]
<http://in.reuters.com/article/health/id ... R120090506>


A meningitis outbreak in Nigeria is more serious than initially
feared with the death toll rising more than 6-fold over the past 2
months, the Health Ministry said on Wednesday.

Deaths from the epidemic have risen to 2148 since the 1st case was
recorded in December [2008] from 333, announced by the health
minister in early March [2009]. The number of reported cases has
climbed more than 8-fold to 47 902 over the same period. About 2-3rds
of Nigeria's 36 states are affected by the epidemic, the ministry
said. Nigeria is Africa's most populous country with a population of
more than 140 million.

UNICEF said last month [April 2009] that more than 2500 people had
been killed by meningitis this year in West and Central Africa in
what could be the worst epidemic for 5 years. Nigeria, Niger, Burkina
Faso and Chad are considered Africa's high-risk zone.

Meningitis is the inflammation of the tissue surrounding the brain
and spinal cord, and can be caused by viral or bacterial infections.
It spreads mainly through kisses, sneezes, coughs and in close living quarters.

The meningitis death toll in Nigeria since December [2008] is almost
50 times the number of people killed worldwide by the H1N1 swine flu
virus. But the speed with which it has spread underscores the
potential dangers if swine flu reaches Africa. Basic healthcare is
limited in rural parts of Nigeria, where most people live on less
than USD 2.00 a day, despite the country's huge oil resources. Many
Nigerians fear that an outbreak of swine flu would be devastating.
The Health Ministry said no suspected case of swine flu had been
recorded in the country but that it had taken steps to contain any outbreak.

The worst recent meningitis epidemic in West and Central Africa
occurred in 1996-97 when an estimated 100 000 people were infected in
Nigeria and 50 000 in Niger.

[Byline: Camillus Eboh, Tume Ahemba, and Nick Tattersall]

--
Communicated by:
ProMED Rapporteur Brent Barrett

[Numerous cases of meningococcal meningitis are reported in the
African region known as the "Meningitis Belt" each year during the
dry season, between December and June, and every 8-12 years large
outbreaks occur
(<http://wwwn.cdc.gov/travel/yellowBookCh4-Menin.aspx>). The
"Meningitis Belt" extends from Senegal in the west to Ethiopia and
Eritrea in the east, and includes Nigeria
(<http://www.cdc.gov/ncidod/eid/vol9no10/03-0170.htm>).

Nigeria seems to have been hit hardest by the outbreak this year. WHO
reported on 11 Mar 2009 that in Nigeria there were 9086 cases with
562 deaths from meningococcal meningitis (see ProMED post Meningitis,
bacterial - Africa (02): Nigeria, WHO meningitis region
20090313.1038) and that both serogroup A and W135 were involved. The
number of cases of meningococcal meningitis in Nigeria have now
increased 5-fold and the number of deaths, 3.8-fold.

The HealthMap/ProMED-mail interactive map of Nigeria is available at
<http://healthmap.org/promed/en?v=9.6,6.1,6>.
A map of the African bacterial meningitis belt can be found at
<http://www.medic8.com/images/map4-9.gif>. - Mod.ML]

Angola - Darminfektionen
11.05.2009

Risiko für Durchfallerkrankungen landesweit. Epidemische Ausbrüche von Cholera gab es seit 2006 in zahlreichen Provinzen einschließlich der hygienisch schlecht versorgten Viertel der Hauptstadt Luanda mit einem Gipfel jeweils während der Regenzeit. Polio zirkuliert nach einer Pause von 4 Jahren durch Reimporte erneut im Lande. 2007 wurden 8 Erkrankungen nachgewiesen, 2008 stieg die Zahl auf insgesamt 28 Erkrankungen an. Für 2009 wurden bisher 4 Fälle gemeldet. Hygiene und Impfschutz (Polio) beachten. / Quelle: crm
______________________________

Burkina Faso - Darminfektionen
11.05.2009

Risiko für Durchfallerkrankungen landesweit, Cholera wurde in letzter Zeit nicht gemeldet. Polio, 2002 reimportiert, tritt seither sporadisch auf. 2008 wurden 6 Fälle gemeldet, 2009 waren es bisher 8 Fälle. Hygiene und Impfschutz (Polio) weiterhin beachten. / Quelle: crm
_______________________________

Côte d’Ivoire (Elfenbeinküste) - Darminfektionen
11.05.2009

Risiko für Durchfallerkrankungen landesweit, größere Cholera-Ausbrüche wurden in letzter Zeit nicht bekannt. Polio wurde 2009 zum ersten Mal seit 5 Jahren wieder nachgewiesen. Bisher wurden 5 Erkrankungen registriert. Hygiene und Impfschutz (Polio) weiterhin beachten. / Quelle: crm
________________________________

Kongo, Republik - Gelbfieber
11.05.2009

Wie inzwischen labortechnisch bestätigt wurde, erkrankte im Januar ein 55-jähriger Mann an Gelbfieber. Eine Gelbfieberimpfkampagne wurde in der Region initiiert. Impfschutz beachten. / Quelle: crm
________________________________

Liberia - Gelbfieber
11.05.2009

Wie inzwischen labortechnisch bestätigt wurde, erkrankte im März eine 32-jährige Frau an Gelbfieber. Eine Gelbfieberimpfkampagne wurde in der Region initiiert. Impfschutz beachten. / Quelle: crm

Nigeria - Meningokokken-Meningitis
11.05.2009

Bis Mitte April wurden landesweit mehr als 47.000 Erkrankungen und 2.148 Todesfälle registriert. Während der Trockenzeit (Dezember-April) kommt es in den Ländern des „Afrikanischen Meningitisgürtel“ regelmäßig zu Meningokokken-Epidemien. Impfschutz beachten. / Quelle: crm

TRICHINELLOSIS, WARTHOG HAM - FRANCE ex SENEGAL
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Date: Thu 21 May 2009
From: Jean Dupouy-Camet <jean.dupouy-camet@cch.ap-hop-paris.fr>


Trichinellosis, smoked warthog ham from Senegal
-----------------------------------------------
A small outbreak of at least 3 proven cases of trichinellosis was
identified in early May 2009 in France. The 3 patients, living in
different regions, were infected after consumption of smoked warthog
ham. There were no remains of the warthog ham that could be examined.

All patients were accommodated around mid February [2009] in the same
hotel of St Louis du Senegal. The usual clinical and biological signs
and symptoms (fever, facial and limb oedema, myalgia, and high
eosinophilia) appeared around mid March [2009].

All cases had a positive serology (ELISA and western blot) and in one
case seroconversion was observed. No cardiac or neurological
complications occurred. Only one patient was hospitalized and all
patients were treated with albendazole.

No other outbreaks related to warthog have been reported so far. The
hotel in which the French patients were infected, welcomes guests
from different European countries. If you are informed of related
cases, please contact the French National Reference Center on trichinellosis.

[Trichinellosis] has already been reported in Senegal when an
outbreak involving 9 persons occurred in the 60s. Subsequent
veterinary studies (Gretillat & Chevalier, 1970) reported a 4 percent
prevalence of trichinellosis in 450 Senegalese warthogs. Pozio et al
identified isolates from the neighbouring Guinea as belonging to the
species _Trichinella britovi_, but could not find _Trichinella_ in
any of the 10 examined warthogs.

References
----------
1. Gretillat S, Chevalier JL [Preliminary note on the epidemiology of
trichinosis in wild animals in Western Africa] Bull World Health
Organ. 1970; 43: 749-57 (in French, available at
<http://whqlibdoc.who.int/bulletin/1970/ ... 43-766.pdf>)
2. Pozio E, Pagani P, Marucci G, Zarlenga DS, Hoberg EP, De Meneghi
D, La Rosa G, Rossi L: _Trichinella britovi_ etiological agent of
sylvatic trichinellosis in the Republic of Guinea (West Africa) and a
re-evaluation of geographical distribution for encapsulated species
in Africa. Int J Parasitol 2005; 35: 955-60 [abstract available at
<http://www.ars.usda.gov/research/public ... 115=177339>].

--
Jean Dupouy-Camet, MD, PhD
Centre National de Reference des _Trichinella_
<http://monsite.wanadoo.fr/cnrdestrichinella/>
Hopital Cochin, Descartes University
27 rue du Fbrg St Jacques, 75014
Paris
France
<jean.dupouy-camet@cch.ap-hop-paris.fr>

[_Trichinella_ infections in humans and animals were reported from
Senegal in the 1960s (Gretillat & Chevalier. Receptivity of the
warthog (_Phacochoerus aethiopicus_) to the West African strain of
_Trichinella spiralis_ [in French]. C R Acad Sci Hebd Seances Acad
Sci D. 1969 Dec 15; 269(24): 2381-3). A recent survey from 2005
identified _T. britovi_ from guinea (Pozio E et al. _Trichinella
britovi_ etiological agent of sylvatic trichinellosis in the Republic
of Guinea (West Africa) and a re-evaluation of geographical
distribution for encapsulated species in Africa. Int J Parasitol.
2005; 35: 955-60, abstract available at
<http://www.ars.usda.gov/research/public ... 115=177339>).
The smoked warthog ham was probably imported to France without an
investigation for trichinellosis. - Mod.EP]

Kenia - Darminfektionen
28.05.2009

Risiko für Durchfallerkrankungen landesweit. Aus 14 Provinzen werden seit März lokal begrenzte Cholera-Ausbrüche gemeldet. Bis Mitte Mai erkrankten mehr als 1.000 Personen, von denen 55 verstarben. Hygiene beachten, Impfschutz für Risikoreisende. / Quelle: crm

HEPATITIS E VIRUS - UGANDA (03): (KITGUM)
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Date: Fri 29 May 2009
Source: Daily Monitor [edited]
<http://www.monitor.co.ug/artman/publish ... 5594.shtml>


Hepatitis E kills 2, leaves 60 infected in Kitgum
-------------------------------------------------
Latest statistics in Kitgum District indicate that the deadly hepatitis E
[virus infection] has killed 2 people and left 60 others infected in the
last 2 weeks. The figure now brings the total number of infections in the
district to 1010, while the death toll stands at 160, since the disease
broke out last year [2008].

During the district's review meeting on Tuesday [26 May 2009], Mucwini,
Amida, Lukung, Matidi, Palabek Gem, town council and Padibe sub-counties
were singled out among the high risk areas with special treatment units
opened for patients.

The district secretary for health, Mr Tony Blair Toolit, told journalists
that the continued infections were due to the people's negative attitude
towards the preventive measures. "It's unfortunate that we still continue
to lose people to this disease that can easily be avoided. We appeal for
better health practices in homes," Mr Toolit said. He explained that the
district has now introduced a new strategy to ensure compliance to health
standards in homes which include levying a fine of 5000 Ugandan shillings
[USD 2.24] on every homestead found without a proper latrine or a minimum
of 3 months in prison among other penalties. According to Mr Toolit, most
returning IDPs [Internally displaced persons] have prioritised building
huts [rather than] latrines, increasing the risks of oral-fecal infections.

Meanwhile, the district has also introduced exchange visits for
sub-counties hit by the disease to enable them to learn better practices
from their counterparts that have no reports of the disease. Hepatitis E
has since spread to other districts like Pader, Amuru, and Yumbe in West
Nile, killing hundreds there.

[byline: James Eriku]

--
communicated by:
ProMED-mail rapporteur Brent Barrett

[Since the last report on 6 May 2009 the death toll in Kitgum district has
risen by 4. The number of new cases does not appear to be declining and the
spread of the disease has not been halted. The provision of adequate
latrines and supply of clean water remain the principal restraints on progress.

A map of Uganda showing the location of Kitgum district in the north of the
country can be accessed at
<http://www.lib.utexas.edu/maps/africa/u ... l_2005.jpg>. The
HealthMap/ProMED-mail interactive map of Uganda is available at
<http://healthmap.org/promed?g=443346&v=1.5,36,5>. - Mod.CP]

HEPATITIS E VIRUS - UGANDA (04): (KITGUM)
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Date: Sat 30 May 2009
From: Hugh Nelson
<hugh19480915@gmail.com>


A comment
---------
It is a mistake to blame the lack of latrines for hepatitis E, which is
transmitted primarily by animal feces, not human feces. It means that the
water supply is not being well protected from contamination and the
authorities should address that rather than fining individuals without
latrines.

It can also mean that people are eating salad vegetables -- that have been
fertilized with animal feces -- raw.

We have seen multiple cases of hepatitis E in wealthy expatriates in China
who ignore the old rule: "Peel it or Cook it or Forget it."

--
Dr Hugh Nelson MBBS DCH DTM&H
Expatriate Medical Adviser
International SOS Tangguh LNG
West Papua, Indonesia
<hughnelson@pobox.com>

[While it is true that identification and characterization of swine
hepatitis E virus in several countries and their close relationship to
locally characterized human hepatitis E virus isolated in the same areas
indicates that it is a zoonotic virus, it is still likely that transmission
in human communities in Africa is predminantly waterborne. In background
data derived from the Gideon Database (see: Hepatitis E virus - Sub-Saharan
Africa 20080305.0909) hepatitis E virus infection was considered to be
water-borne in 4 of 10 countries in sub-Saharan Africa.

Construction of efficient latrines is an essential factor in the provision
of clean water supplies. - Mod.CP]

RABIES, CANINE, HUMAN - ANGOLA (07): (UIGE)
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Date: Thu 4 Jun 2009
Source: ANGOP [in Portuguese, trans. & summ. Mod.TY, edited]
<http://www.portalangop.co.ao/motix/pt_p ... 07b03.html>


Of 830 people bitten by dogs in the city of Uige from January to 4 Jun
of this year [2009], 6 died, the supervisor of the municipal Expanded
Program of Vaccination, Pedro Guilherme Fernando, reported today,
Thursday [4 Jun 2009]. He asked the population to go urgently to the
nearest health unit as soon as one is bitten.

--
Communicated by:
ProMED-PORT
<promed@promedmail.org>

[Apparently, a significant rabies outbreak, with human fatalities,
continues in Angola. In the 1st 3 months of this year (2009), 93
children died of rabies in the capital, Luanda (see ProMED archive no.
20090314.1051). Now cases are occurring in the nearby province of
Uige. Failure to obtain timely post-exposure treatment may be due, in
part, to scarcity of the vaccine and anti-rabies immunoglobulin and
their relatively high cost. The most effective measure to prevent
human cases such as these is to maintain the canine population rabies
virus immune through a continuous vaccination program.

A map showing the location of Uige city in Uige province in northwest
Angola can be accessed at
<http://www.lib.utexas.edu/maps/africa/angola.gif>
The HealthMap/ProMED-mail interactive map of Angola can be accessed at
<http://healthmap.org/promed/en?v=-12.3,17.5,5>.
- Mod.TY]

Angola - Tollwut
08.06.2009

In Angola ist es dieses Jahr zu einer deutlichen Zunahme der Tollwut-Todesfälle gekommen. Die Stadt Uige (NW) meldete bis Anfang Juni 6 Todesfälle. In der Hauptstadt Luanda sind zuvor bis Mitte März bereits 93 Personen an der Tollwut verstorben. Bei der Mehrzahl handelt es sich um Jungen die von streunenden Hunden gebissen worden sind. Die Regierung hat im Rahmen einer großangelegten Impfaktion 111.000 Tiere (Hunde, Katzen und Affen) immunisiert. Bei entsprechenden Kontakten sofort einen Arzt aufsuchen, bei vorhersehbarem Risiko und längerem Aufenthalt wird eine vorbeugende Impfung empfohlen. / Quelle: crm

Libyen - WHO untersucht Fälle von Beulenpest in Tobruk
16.06.2009

Die libyschen Behörden haben einen Ausbruch der Beulenpest in der Mittelmeer-Küstenstadt Tobruk bekanntgegeben und ein Expterenteam der Weltgesundheitsorganisation WHO soll vor Ort die Verbreitung untersuchen, erklärte die WHO am 16. Juni 2009. Erstmals seit mehr als zwei Jahrzehnten sind 16 bis 18 Fälle der hochgradig ansteckenden Infektionskrankheit in Libyen festgestellt worden, darunter verstarb eine Person, erklärte der WHO-Spezialist Dr. John Jabbour in Kairo. Es wird derzeit berichtet, dass es sich um Beulenpest handelt, so Jabbour und fügte hinzu, das es noch kein genaues Bild der Situation gibt. 2008 gab es zuletzt Fälle in Madagaskar und Uganda. / Quelle: Libyen-Aktuell

PLAGUE, BUBONIC - LIBYA: (AL BUTNAN)
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Date: Tue 16 Jun 2009
Source: Reuters [edited]
<http://www.reuters.com/article/healthNe ... 2820090616>


Libyan authorities have reported an outbreak of bubonic plague in the
Mediterranean coastal town of Tubruq, and the World Health
Organization (WHO) was sending a team to investigate, a WHO official
said on Tuesday [16 Jun 2009].

The cases, approximately 16 to 18 have been reported, would be the
1st in more than 2 decades in Libya of the disease known in medieval
times as the Black Death, according to John Jabbour, a Cairo-based
emerging diseases specialist at WHO.

"It is reported as bubonic plague," Jabbour said, adding WHO still
didn't have "a full picture" of the situation. "It is officially
reported by Libya... Tomorrow [17 Jun 2009], the WHO is deploying a
mission to Libya to investigate the whole situation, to see how many
of the cases are confirmed, or not confirmed."

He said preliminary information from Libyan authorities showed 16 to
18 reported cases including one death, and that Tripoli had asked for
assistance from the global health body.

Tubruq, where the new cases were reported, is approximately 125 km
[78 miles] from the Egyptian border and was the scene of previous
plague cases decades ago, Jabbour said. Egypt, already fighting to
contain an outbreak of the H1N1 flu virus, said it had no reported
cases of plague.

Globally the WHO reports about 1000 to 3000 plague cases each year,
with most in the last 5 years occurring in Madagascar, Tanzania,
Mozambique, Malawi, Uganda and the Democratic Republic of Congo. The
USA sees about 10 to 20 cases each year.

[Byline: Cynthia Johnston]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Tobruk or Tubruq is a town, seaport, and peninsula in northeastern
Libya, near the border with Egypt, in North Africa. It is the capital
of Al Butnan District (formerly Tobruk District). Its location can be
found on a map at:
<http://en.wikipedia.org/wiki/Tobruk>

Consumption of the meat of an infected camel has been reported to
cause plague in Libya in 1976 (1). The abstract of the paper is:
"In 1976, in a small, remote Libyan village, an apparently sick camel
was slaughtered and skinned, and the camel meat was distributed for
human comsumption. A few days later, 15 villagers suffered a severe
febrile illness. Of the 5 individuals who had participated in the
killing and dispensation of the camel, all were dead within 4 days.
When samples of serum from 9 of the remaining patients were examined,
7 were found to be positive for plague as determined by the passive
hemagglutination test. Another 6 persons became ill after killing 2
goats, and the serum of one goat contained antibodies to _Yersinia
pestis_. Because all of the remaining patients except one were
treated early enough, they recovered. These incidents confirm
previous reports that the camel and the goat are susceptible to
naturally occurring plague infection and have a significant role in
the dissemination of human plague."

Two more recent outbreaks in the Arab world have been reported in
2005. In Saudi Arabia (2), a cluster of 5 plague cases were reported
including 4 with severe pharyngitis and submandibular lymphadenitis.
These 4 case-patients had eaten raw camel liver. _Yersinia pestis_
was isolated from bone marrow of the camel and from jirds (_Meriones
libycus_) and fleas (_Xenopsylla cheopis_) captured at the camel
corral. In Jordon (3), a 1997 outbreak of plague was reported,
associated with cervical lymphadenopathy and fever, occurred in the
Jordanian village of Azraq ad-Druze, 50 km [31 miles] west of the
border with Saudi Arabia. The 12 cases who presented at hospital were
initially assumed to have tularaemia, and all were successfully
treated with gentamicin. But all 12 were found to have anti-_Y.
pestis_ IgM. 11 of the 12 patients reported that, 2-4 days before
their symptoms appeared, they had eaten the meat cut from the carcass
of the same camel, either raw (10 cases) or cooked (one case). All 12
patients were diagnosed as cases of pharyngeal plague (the 1st cases
of plague reported in Jordan for more than 80 years), caused by _Y.
pestis_ that most had acquired when they ate raw meat from a camel
that was infected with the pathogen.

The source of the cases of bubonic plague in northeastern Libya is
not reported in this posting but may be related to camels and camel
fleas.

1. Christie AB, Chen TH, Elberg SS. Plague in camels and goats: their
role in human epidemics. J Infect Dis 1980;141: 724-726.
2. Bin Saeed AA, Al-Hamdan NA, Fontaine RE: Plague from eating raw
camel liver. Emerg Infect Dis. 2005;11: 1456-1457.
3. Arbaji A, Kharabsheh S, Al-Azab S, et al: A 12-case outbreak of
pharyngeal plague following the consumption of camel meat, in
north-eastern Jordan. Ann Trop Med Parasitol. 2005;99: 789-793.
- Mod.LL]

Libyen - Pest
22.06.2009

In der Stadt Tubruq wurden Beulenpestfälle diagnostiziert. Bei ca. 15 Personen besteht die Verdachtsdiagnose. Die WHO hat ein Team nach Libyen gesendet um die Erkrankungsfälle zu untersuchen. Es handelt sich um die ersten Pesterkrankungen in Libyen seit 25 Jahren. Die Küstenstadt Tubruq liegt im Nordosten des Landes ca. 125km von der ägyptischen Grenze entfernt. / Quelle: crm

Madagaskar - Chikungunya
22.06.2009

Seit März 2009 werden in Madagaskar wieder vermehrt Chikungunya-Erkrankungen registriert. Betroffen ist v.a. die Stadt Toamasina (O). Schutz vor der Überwiegend tagaktiven Überträgermücke beachten. / Quelle: crm

PLAGUE, BUBONIC - ALGERIA: REQUEST FOR INFORMATION
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Date: Mon 29 Jun 2009
Source: Free Republic, The Media Line report [edited]
<http://www.freerepublic.com/focus/f-chat/2281642/posts>


Countries in North Africa are boosting precautionary measures in heightened
efforts to prevent bubonic plague from spreading to their territories.
According to the London-based Al-Quds Al-'Arabi, Algeria has documented 50
cases of the plague, some within 15 kilometres (9 miles) of the border with
Libya, where 2 people have died of the disease. As a result, Algiers has
tightened medical surveillance on its borders with Libya.

Officials there fear that Bedouin are crossing the borders from the Illizi
province into Libya and passing the disease back into Algeria, according to
local Algeria and Moroccan press.

Rodents in the area have been seen [found? - Mod.LL] bearing the disease,
Aphaluck Bhatiasevi, a spokeswoman for the World Health Organization (WHO),
told The Media Line. "But it hasn't infected people for 25 years," she
said. "They're still investigating the cause. It's likely exposure to
fleas. It's not pneumonic plague, which can be transmitted from one person
to the other. It stops at the person who gets infected."

Health authorities in Egypt, Tunisia, Algeria, and Morocco are also taking
extra measures to contain the disease, Al-Quds Al-'Arabi reported. Earlier
in June 2009, Egypt closed its border with Libya following confirmed
reports that around 13 people were infected with the bubonic plague in the
Libyan coastal city Tubruq, 93 miles (150 km) from the Egyptian border.

The Libyan media reported between one and 3 fatalities from the disease,
and Bhatiasevi said the Libyan authorities were being extremely supportive,
cooperative and open with the investigation. She added that they have also
launched awareness campaigns in the area.

Algeria and Libya share a border 982 kilometres (610 miles) long, and a
large, unsupervised passage of people and goods flow through the border daily.

Some believe the outbreak could be connected to the consumption of camel
meat or caused by camel fly bites. Outbreaks connected to the consumption
of contaminated camel meat were reported in the past in Libya, Jordan, and
more recently in Saudi Arabia in 2005.

[byline: Rachelle Kliger]

--
communicated by:
ProMED-mail rapporteur Susan Baekeland

[Earlier this year (2009), ProMED-mail followed a possible outbreak of
plague in Algeria that apparently was not. We would appreciate more
information documenting this bacterial infection in Algeria and if the
disease has spread from eastern to western Libya. - Mod.LL

An administrative map of Algeria is available at
<http://www.lib.utexas.edu/maps/africa/a ... dmin01.jpg> and the
HealthMap/ProMED-mail interactive map at <http://healthmap.org/r/009O>. -
Sr.Tech.Ed.MJ]

PLAGUE, BUBONIC - LIBYA (02): (AL BUTNAN)
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Date: Thu 2 Jul 2009
Source: Eurosurveillance edition 2009; 14(26) [edited]
<http://www.eurosurveillance.org/ViewArt ... leId=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/public ... 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/ ... l_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/lance ... 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 ... le4-05.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/ViewArt ... leId=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#Me ... an_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]