ECDC: Management Of Suspected Plague Cases On Ships & Aircraft

#12,865

The reality of life in this 21st century is that we live in an increasingly mobile society where millions of people cross oceans and borders every day, and invariably, some number of them will be carrying communicable diseases. 

Given the 2 to 14 day incubation period of most diseases, the likelihood of some cases being asymptomatic, and the ability to fly to nearly any destination in less than 24 hours and you have all the ingredients for the efficient global spread of an infectious disease.

While the carriers are unknown, this is probably how West Nile Virus arrived to New York City in 1999, how Dengue returned to South Florida after an absence of nearly 70 years in 2010, and how both Zika and Chikungunya made their way to the Western Hemisphere over the past 5 years (see Not Without Warning - The Return Of Mosquito Disease Threats).

Among non-vector borne disease threats, a few standouts include:

• In 2003, we saw the SARS virus cross the Pacific on a flight taken by a 78-year-old woman who fell ill in Toronto after returning from Hong Kong, and before that outbreak was contained, 251 people in Canada had been infected, and 44 died (see SARS And Remembrance).
• The H1N1 pandemic virus of 2009 spread rapidly via international air travel, as does seasonal influenza every year (see Vietnam Discovers Passengers Beating Thermal Scanners).
• In 2014 we saw a couple of brief introductions of Ebola to the United States (see CDC Updates Traveler’s Movement & Monitoring Guidance For Ebola), along with several European countries.
• And in 2015 a Korean national - after visiting four Middle Eastern countries - returned home carrying the MERS virus. Once he became symptomatic he visited several hospital ERs, where the virus quickly spread, sparking a major health crisis (see Superspreaders & The Korean MERS Epidemiological Report).

The list goes on. In recent years we've seen rare reports of imported Lassa Fever both here in the United States (link), and in Europe (link).  Imported CCHF in the UK (link).  And  imported cases of avian H5N1 and H7N9 in Canada .  To name a few. 

Simply put, a disease outbreak anywhere has the potential to arrive anywhere in the world in a matter of days, if not hours, thanks to our highly mobile society.

While airport surveillance may catch some of these cases prior to boarding, study after study has shown that a significant percentage of infected individuals will invariably get through (see EID Journal: Evaluating Border Entry Screening for Infectious Diseases in Humans).

Despite these challenges, aircrews and ship's personnel must remain vigilant for signs of illness among passengers, and know what to do if they suspect a communicable illness.

With the recent high profile outbreak of pneumonic plague in Madagascar, the ECDC has published guidelines for the management of suspected plague cases on ships or aircraft.

I've only posted some excerpts, so follow the link to read the document in its entirety, after which I'll return with a postscript.
 

Key messages

 • The common route of transmission of bubonic plague to humans is the bite of an infected flea. The disease can be transmitted between humans by contact with infected bodily fluids; humans can be also infected by touching or skinning infected animals. 

• The infection can cause a severe disease in humans but can be successfully treated with early administration of antibiotics. If bubonic form is not treated, the infection can spread through the bloodstream to the lungs, resulting in pneumonic or septicaemic form of plague.

• A case of bubonic plague can be suspected on aircraft or ships when a passenger or a crew member leaving an affected area has a fever associated with swollen lymph nodes.

• The presence of trained crew members and their awareness of the disease could help reduce the risk of on-board transmission. 

• The main risk of transmission on aircraft and ships lies in infected fleas infesting a passenger and/or his/her belongings. The transmission by bodily fluids (e.g. the fluid from the buboes) requires exposure to infected material through a break in the skin; this can be considered unlikely on aircraft and ships, but it cannot be excluded.

 • Members of the cabin crew assisting an ill passenger should wear gloves; the ill passenger and the crew member assisting him/her should follow standard infection control precautions.

 • Local authorities at the arrival airport/mooring port of call should be informed immediately after the identification of a suspected case of bubonic plague on board so they can plan mitigation measures aimed at reducing the risk of further spread. 

• If there is a suspected plague case on board, passengers should be informed about how to self-monitor for plague-compatible symptoms; the collection of passenger contact details is crucial for further contact tracing.

 • Physicians should consider early post-exposure prophylaxis for passengers and crew members who have come in direct contact with body fluids of the ill passenger. 

• Arrangements for post-event disinfection and disinsection procedures for the aircraft and the ill passenger’s belongings should be considered after disembarking.

 • On a ship, the WHO’s International medical guide for ships suggests that the patient’s quarters and all other passenger quarters should be treated with insecticide powder in order to ensure the extermination of fleas.

 • After disembarking from a ship, the sickbay and/or the cabin where the ill passenger was isolated should be disinfected and disinsected. All biohazard materials should be disposed of properly and in accordance with the relevant national and international rules and recommendations.

(Continue . . . .)

One of the great challenges of the 21st century is how we will deal the international spread of infectious diseases.  While the headlines today center on plague, or avian flu, the reality is nature can serve up a bounty of new and unexpected disease threats at any time.

It has been more than a decade since the World Health Organization enacted their IHR (International Health Regulations) - which requires countries to develop mandated surveillance and testing systems, and to report certain disease outbreaks and public health events to WHO - but at last report less than half of all countries reported compliance (link).

Two years ago, in TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections, we looked at an issue brief prepared by TFAH (Trust for America’s Health) along with UPMC Center for Health Security and the IDSA (Infectious Disease Society of America) on the actions the United States needs to take to prepare for the arrival of MERS and other emerging infections.

A couple of weeks later, we saw the HHS Launch A National Ebola Training & Education Center to help prepare medical facilities to deal with Ebola, along with other highly pathogenic viral diseases.

Reminders that every health care facility – large and small - needs to plan, train and equip themselves for the possibility that the next patient that comes through the ER entrance could be carrying something considerably more exotic and dangerous than seasonal flu.