Download Plague

Public Health and Primary Health Care
Communicable Disease Control
4th Floor, 300 Carlton St, Winnipeg, MB R3B 3M9
T 204 788-6737 F 204 948-2040
www.manitoba.ca
November, 2015
Re: Plague (Yersinia pestis) Reporting and Case Investigation
Reporting of plague (Yersinia pestis) is as follows.
Laboratory:
 All positive laboratory results for Y. pestis are reportable to the Public Health
Surveillance Unit by secure fax (204-948-3044). A phone report must be made to a
Medical Officer of Health at 204-788-8666 on the same day the result is obtained, in
addition to the standard surveillance reporting by fax.
Health Care Professional:
 Probable (clinical) cases of plague are reportable to the Public Health Surveillance
Unit by telephone (204-788-6736) during regular hours (8:30 a.m. to 4:30 p.m.) AND
by secure fax (204-948-3044) on the same day that they are identified. After hours
telephone reporting is to the Medical Officer of Health on call at (204-788-8666). The
Clinical Notification of Reportable Diseases and Conditions form
(http://www.gov.mb.ca/health/publichealth/cdc/protocol/form13.pdf) should be used.
 Cooperation in Public Health investigation is appreciated.
Regional Public Health or First Nations Inuit Health Branch (FNIHB):
 Once the case has been referred to Regional Public Health or FNIHB, the
Communicable Disease Control Investigation Form
(www.gov.mb.ca/health/publichealth/cdc/protocol/form2.pdf) should be completed
and returned to the Public Health Surveillance Unit by secure fax (204-948-3044).
Sincerely,
“Original Signed By”
“Original Signed By”
Richard Baydack, PhD
Director, Communicable Disease Control
Public Health and Primary Health Care
Manitoba Health, Healthy Living and Seniors
Carla Ens, PhD
Director, Epidemiology & Surveillance
Public Health and Primary Health Care
Manitoba Health, Healthy Living and Seniors
Communicable Disease Management Protocol
Plague
Manitoba
Health
Public Health
Communicable Disease Control Unit
Case Definition
Etiology
Confirmed Case: Clinically compatible illness and
one or more of the following:
Yersinia pestis, a gram negative bacillus
• the isolation of Yersinia pestis;
• a four-fold or greater rise in serum antibody titre
to Y. pestis;
• single high antibody titre to Y. pestis in the
absence of history of immunization;
• demonstration of Y. pestis antigen in appropriate
clinical specimens.
Epidemiology
Reporting Requirements
• All Y. pestis positive specimens must be reported
by laboratory.
• All cases must be reported by attending health
care professional.
Clinical Presentation/Natural History
Plague can occur in three primary forms or a
combination thereof. Bubonic plague is characterized
by swollen infected lymph nodes, primarily in the
groin area (buboes), which may suppurate.
Bloodstream infection, which can occur following
Bubonic plague or spontaneously, results in
Septicemic plague. Infection of the lungs resulting in
pneumonia is termed Pneumonic plague.
Signs and symptoms include fever, chills,
prostration, anorexia, nausea, vomiting, myalgia,
sore throat and headache. In the case of pneumonic
plague, symptoms include cough, bloody sputum,
chest pain and shortness of breath. Complications
occur most commonly with Septicemic plague and
Pneumonic plague, and include meningitis,
endotoxic shock, mediastinitis and pleural effusion.
Reservoir and Source: The reservoir is ground
squirrels, wild carnivores, hares and rabbits. The
sources are fleas (animal and in some cases human),
and other persons with Pneumonic plague.
Transmission: Most frequently occurs through
bites from rodent fleas carrying the bacteria. Bites
or scratches, contact with draining lesions or
infected tissues and respiratory droplets of infected
animals, often cats, can transmit plague. Person-toperson transmission can occur through close
contact with a person with pneumonic plague who
coughs out infectious droplets.
Occurrence:
General: Rodent plague occurs in the Western
United States, South America, Africa, Asia, and
Russia. Human plague has occurred in recent
times in Africa, India, China, Indonesia,
Mongolia, Myanmar, Vietnam and Brazil,
among others. North Dakota is known to have
rodent plague.
Manitoba: No cases since at least 1993.
Incubation Period: One to seven days; possibly
longer in immunized persons. Two to four days for
plague pneumonia acquired via the respiratory
route.
Untreated Bubonic plague has a case fatality of 5060%, while Septicemic and Pneumonic plague are
uniformly fatal if not treated early.
Susceptibility and Resistance: Natural infection
provides some protection but exposure to large
doses of bacteria can result in reinfection.
Immunization is believed to provide immunity,
however exact efficacy is unknown and likely to be
of short benefit (six months), necessitating booster
doses.
Communicable Disease Management Protocol – Plague
November 2001
1
Communicable Disease Management Protocol
Period of Communicability: Fleas can remain
infective for months. Persons with pneumonic
plague should be considered infectious until at least
48 hours following appropriate antibiotic therapy
and a favourable clinical response.
Diagnosis
Alert the laboratory to the suspected diagnosis.
See Case Definitions above. Typical Gram stain
with compatible signs and symptoms is suggestive
but not diagnostic. Serology is available.
• Provide chemoprophylaxis to persons who have
had face-to-face exposure with confirmed or
suspected pneumonic plague (including medical
personnel) cases and observe closely for seven
days. Chemoprophylaxis consists of: tetracycline
15-30 mg/kg or chloramphenicol 30mg/kg daily
in four divided doses until one week after the
last contact.
• Insecticides should be applied to contacts of
Bubonic plague; close contacts may also be given
chemoprophlaxis.
Key Investigations
Management of Environment:
• History of exposure to other potential cases.
• History of international travel.
• History of exposure to fleas, rodents, wild
carnivores or cats.
• History of hunting or trapping.
• History of veterinary medicine as occupation.
• In plague affected areas, discourage rodents from
developing residence in or close by human
dwellings.
• Apply insecticides to reduce population of
rodent and domestic dog and cat fleas.
• Apply insect repellents to skin and clothing.
• Reduce affected rodent populations following
application of insecticides.
• Handle dead animals with gloves.
• Use appropriate biosafety precautions in
laboratories dealing with plague specimens
(special guidelines available from Manitoba
Health or Health Canada).
• Control rats at ports.
Control
Management of Cases:
Treatment:
• Streptomycin is the preferred drug, with
gentamicin, tetracyclines and
chloramphenicol being alternatives.
Public Health Measures:
• If no cough and negative chest X-ray, use
Routine precautions; for those with
pneumonic plague use Droplet
precautions (detailed guidelines available
from Manitoba Health or Health
Canada).
•
Use insecticides on patient clothing and
luggage.
November 2001
2
Management of Contacts:
Management of Outbreaks:
• As per Control measures outlined above.
• The role of Manitoba Health is to:
– develop contingency protocols with
Federal Quarantine Travel Medicine to
allow for rapid conveyance of incoming
affected travellers to appropriate medical
care and isolation;
Communicable Disease Management Protocol – Plague
Communicable Disease Management Protocol
–
identify contacts and recommend
application of insecticides and/or
chemoprophylaxis;
– notify Federal Quarantine Travel
Medicine immediately of any new cases
(613-957-8739).
• The role of Health Canada (Quarantine Travel
Medicine, Medical Services Branch, Department
of Foreign Affairs and International Trade,
Department of Immigration) is to:
– inspect and disinfect aircraft/ship;
– notify Canadian travellers about high-risk
destinations;
– arrange for provision of pre- or post-travel
screening and advice regarding plague
signs and symptoms, for passengers
leaving or arriving from areas affected by
plague;
– obtain contact information on copassengers of suspected cases of plague to
allow follow up by Manitoba Health if
necessary.
Communicable Disease Management Protocol – Plague
Preventive Measures:
• Avoid travel to areas experiencing human or
zoonotic plague.
• If travel cannot be avoided and exposure to fleas
or pneumonic plague is likely, it may be
appropriate to provide travellers with
chemoprophylaxis (detailed information on
appropriate regimens can be sought from
Manitoba Health or Health Canada).
• Avoid rodent burrows during recreational
activities.
• Immunize persons who have frequent contact
with infected rodents (e.g., mammologists in
enzootic areas) or specimens (lab workers).
Additional Resources
For Health Care Professionals
• Recommended Guidelines for Suspected Plague
Case at Winnipeg International Airport.
• Emergency Procedures Plague.
Available from Audiovisual and Publications
Department, Manitoba Health, telephone
(204) 786-7112, fax (204) 772-7213.
November 2001
3