Friday, October 27, 2017

WHO Sitrep #6: Plague In Madagascar


Given the `fog factor' that is inherent in nearly any large-scale disaster or epidemic, it is almost inevitable that some of the details we get - even from reputable sources on the ground - will require `adjustment' along the way.  
Over the past week we've seen a lot of conflicting information coming out of Madagascar's plague epidemic. The daily updates from the MOH have become increasingly convoluted, with their numbers running as much as 40% lower than those reported by the WHO
Today, in the latest WHO SitRep, you'll notice a modest rollback in the case (1309) and fatality (96) numbers compared to what was being reported last Monday (1365 cases, 106 deaths). They attribute these changes to :`The figures in this report are based on a rigorous data cleaning, verification and analysis process aimed to give a better understanding of the dynamics of the epidemic'.
Despite the over-the-top coverage by the tabloid press - while the crisis is far from over - the good news is there are some hopeful signs this epidemic may be slowing. 
Some excerpts from today's report follow:

External Situation Report 06

Madagascar Health Emergency Information and Risk Assessment Health 

Date of issue: 26 October 2017

1. Situation update

WHO continues to support the Ministry of Public Health and other national authorities in Madagascar to monitor and respond to the outbreak of plague. The number of new cases of pulmonary plague has continued to decline in all active areas across the country. In the past two weeks, 12 previously affected districts reported no new confirmed or probable cases of pulmonary plague.

From 1 August to 24 October 2017, a total of 1 309 suspected cases of plague, including 93 deaths (7%), were reported. Of these, 882 (67%) were clinically classified as pulmonary plague, 221 (17%) were bubonic plague, 1 was septicaemic, and 186 were unspecified (further classification of cases is in process). Since the beginning of the outbreak, 71 healthcare workers (with no deaths) have been affected.

Of the 882 clinical cases of pneumonic plague, 235 (27%) were confirmed, 300 (34%) were probable and 347 (39%) remain suspected (additional laboratory results are in process). Fourteen strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.

Between 1 August and 24 October 2017, 29 districts have reported confirmed and probable cases of pulmonary plague. The number of districts that reported confirmed and probable cases of pulmonary plague during the last two weeks reduced to 17.

About 70% (3 467) of 4 990 contacts identified have completed their 7-day follow-up and a course of prophylactic antibiotics. A total of seven contacts developed symptoms and became suspected cases. On 24 October 2017, 1 165 out of 1 239 (94%) contacts were followed up and provided with prophylactic antibiotics.

Plague is endemic on the Plateaux of Madagascar, including Ankazobe District, where the current outbreak originated. A seasonal upsurge, predominantly of the bubonic form, usually occurs yearly between September and April. This year, the plague season began earlier and the current outbreak is predominantly pneumonic and is affecting both endemic and non-endemic areas, including major urban centres such as Antananarivo (the capital city) and Toamasina (the port city).

There are three forms of plague, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link

Current risk assessment

While the current outbreak began with one large epidemiologically linked cluster, cases of pneumonic plague without apparent epidemiologic links have since been detected in regions across Madagascar, including the densely populated cities of Antananarivo in the central highlands and Toamasina on the east coast of Madagascar. 

Due to the increased risk of further spread and the severe nature of the disease, the overall risk at the national level is considered very high. The risk of regional spread is moderate due to the occurrence of frequent travel by air and sea to neighbouring Indian Ocean islands and other southern and east African countries, and a limited number of cases observed in travellers. 

This risk of international spread is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures and advice to travellers to Madagascar, and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low.

The risk assessment will be re-evaluated by WHO based on the evolution of the situation and the available information.

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