International Notes Human Plague -- India, 1994

Since August 26, 1994, outbreaks of bubonic and pneumonic plague have been reported in south-central, southwestern, and northern India. Because most of the reports are unconfirmed, the extent of the outbreaks is unclear. On August 26, following reports of a rat die-off, the first human cases were reported in Bir district, Maharashtra state, approximately 300 km east of Bombay. On September 22, cases of pneumonic plague were reported from the city of Surat, Gujarat state, approximately 200 km north of Bombay. As of September 26, several hundred pneumonic plague cases and numerous deaths have been reported from Surat. On September 26 and 27, cases were reported from Bombay and Calcutta, and on September 27, cases of pneumonic plague were reported from Delhi. Reported by: Div of Quarantine, National Center for Prevention Svcs; Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Plague is caused by infection with Yersinia pestis, a bacterium carried by rodents and transmitted by fleas commonly found in parts of Asia, Africa, and North and South America (1,2). Sporadic human cases associated with epizootics in wild rodents occur annually in the western United States (3); however, no pneumonic plague cases resulting from person-to-person spread have been reported in the United States since 1924 (1). In India, large plague outbreaks occurred during the first half of the 20th century; however, the last laboratory-confirmed human cases were reported in 1966 (4,5). In 1992 (the most recent year for which complete data are available), human plague cases were reported from nine countries (Brazil, China, Madagascar, Mongolia, Myanmar, Peru, the United States, Vietnam, and Zaire) (5).

Most human plague is the bubonic form, which results from the bites of infected fleas; however, plague also can be transmitted to humans by handling infected animals or by inhaling infectious aerosols from persons with pneumonic plague. The incubation period for plague ranges from 1 to 7 days, and manifestations of the illness include rapid onset of fever, chills, headache, malaise, myalgias, and prostration, often with nausea. In particular, bubonic plague is characterized by painful swelling of lymph nodes (buboes) in the inguinal, axillary, or cervical regions; pneumonic plague is characterized by cough and dyspnea; and septicemic plague may result in fulminant gram-negative shock without localized signs of infection (2,6). Multiple clinical presentations can occur in one patient.

Travelers to India and other plague-endemic countries are at low risk for infection with Y. pestis. To reduce risk, travelers should avoid areas with recently reported human plague cases. Persons who must travel to these areas should 1) avoid rat-infested areas -- especially areas where dead rats have been observed; 2) apply insect repellents to ankles and legs, and apply repellents and insecticides to clothing and outer bedding as directed by the manufacturer; 3) avoid handling dead or sick animals; and 4) if the risk for exposure is high, take prophylactic antibiotics. For adults, the preferred antibiotic for prophylaxis is tetracycline or doxycycline, and for children aged less than or equal to 8 years, sulfonamides (2). Because maximal antibody responses from plague vaccine require administration of multiple doses over several months, plague vaccine is not recommended for immediate protection during outbreaks.

International travelers should be advised to report immediately to a physician any febrile illness beginning within 7 days after leaving India. Although imported cases are expected to be rare, physicians should be alert for evidence of plague in persons who have traveled to plague-endemic areas and who developed a febrile illness within 7 days after leaving the area. All suspected plague patients should be hospitalized and isolated, specimens should be obtained from patients for laboratory diagnosis, chest roentgenogram should be performed, and antibiotic therapy should be promptly initiated. For all suspected cases, appropriate diagnostic specimens include blood for culture and serum antibodies; for suspected pneumonic cases, sputum samples; and for suspected bubonic cases, aspirates from affected lymph nodes. Streptomycin is the preferred drug for treatment of plague, but gentamicin, tetracyclines, and chloramphenicol also are effective (2,7). Prompt treatment can reduce overall plague mortality from 60%-100% to 10%-15%.

Prophylactic antibiotic treatment should be administered to all persons who have had face-to-face contact or who have occupied a closed space with a person with pneumonic plague. Household contacts of bubonic plague patients also should receive prophylactic antibiotic treatment.

Suspected human plague cases in international travelers should be reported through state and local health departments to CDC's Division of Quarantine, National Center for Prevention Services, telephone (404) 639-8107 or (404) 639-2888 (nights, Sundays, and holidays). Specimens for confirmatory testing can be submitted through state health departments to CDC. Inquiries about the availability of streptomycin should be directed to Pfizer, Inc., * telephone (800) 254-4445. Additional information about plague is available to physicians and the general public from the CDC Voice Information System, telephone (404) 332-4555, and to physicians and laboratory personnel from CDC's Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, telephone (303) 221-6453.

References

1. Barnes AM. Surveillance and control of bubonic plague in the United States. In: Edwards MA, McDonnel U, eds. Animal disease in relation to conservation. New York: Academy Press, 1982:237-70.

2. Poland JD. Plague. In: Hoeprich PD, Jordan MC, eds. Infectious diseases. Grand Rapids, Michigan: JB Lippincott, 1989:1296-1306.

3. CDC. Human plague -- United States, 1993-1994. MMWR 43:242-6.

4. World Health Organization. Epidemiology and incidence of plague in the world, 1958-79. Bull WHO 1982;60:165-9.

5. World Health Organization. Human plague in 1992. Wkly Epidemiol Rec 1994;2: 8-10.

6. Hull HF, Montes JM, Mann JM. Septicemic plague in New Mexico. J Infect Dis 1987;155:113-8.

7. Medical Economics Data Production Company. Physicians' desk reference. 48th ed. Montvale, New Jersey: Medical Economics Data Production Company, 1994:1610-1.

• Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

+------------------------------------------------------------------- -------+ |             | | Erratum: Vol. 43, No. 38 | |             | | SOURCE: MMWR 43(41);763 DATE: Oct 21, 1994 | |             | | In the article "Human Plague -- India, 1994," on page 689, in | | the second paragraph of the editorial note, the first sentence | | should read "Most human plague is the bubonic form, which results | | from the bites of infected fleas; however, plague also can be | | transmitted to humans by handling infected animals or by direct | | exposure to large respiratory droplets from persons with pneumonic | | plague."   | |             | +------------------------------------------------------------------- -------+

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