Emerging Infectious Diseases
Detection of Notifiable Diseases Through Surveillance for Imported
Plague -- New York, September-October 1994
Recent reports of bubonic and pneumonic plague outbreaks in
India (1,2) prompted the New York City Department of Health
(NYCDOH) and the New York State Department of Health (NYSDOH), in
conjunction with CDC, to develop an emergency response plan to
detect and manage suspected cases imported by international air
travel. This report describes the surveillance system implemented
by CDC on September 27 and supplemental efforts by NYC/NYSDOH to
guide and inform physicians about the outbreak, and summarizes
clinical findings for 11 travelers who had symptoms suggestive of
plague.
CDC Surveillance System
The CDC surveillance protocol included instructions to staff
of international air carriers to notify U.S. quarantine officials
before landing of passengers or crew with illness suggestive of
plague. All passengers arriving on direct flights from India were
provided a plague alert notice that described the symptoms of
plague and urged them to seek medical attention if they developed
a febrile illness within 7 days of disembarkation. Once passengers
were in the United States, the surveillance system relied on
physicians and other hospital staff to report suspected plague
cases to local health departments, which would then notify CDC.
Supplemental Efforts by NYCDOH/NYSDOH
A primary role of NYCDOH/NYSDOH, in conjunction with CDC, was
to determine whether the clinical presentation of persons with
suspected cases was consistent with plague and to arrange for
immediate hospitalization in facilities with respiratory isolation
rooms. In addition, because of the high volume of air travel from
India (approximately 2000 passengers arrive daily at John F.
Kennedy International Airport on flights from India), NYCDOH/NYSDOH
supplemented CDC's surveillance plan by using two approaches to
disseminate information to heighten awareness of plague, focusing
on emergency department physicians. First, a fact sheet describing
the clinical presentation of plague and emphasizing the need to
assess travel history among patients with suggestive symptoms was
transmitted by fax or electronic mail to emergency department
physicians and infection-control practitioners at 102 hospitals in
New York City and to all acute-care hospitals and county health
departments in the state. Second, a special plague advisory issue
of City Health Information, NYCDOH's bulletin, was distributed to
20,000 physicians in New York City within 2 weeks of CDC's plague
alert. To directly reach persons who recently may have arrived from
India and were at increased risk for plague, leaflets in English
and Hindi describing plague symptoms and urging ill persons to seek
medical attention were distributed by NYCDOH at a heavily attended
Indian cultural fair on October 8 and 9.
Clinical Findings for Travelers
As of October 27 (when the plague alert was terminated), 10
persons with suspected plague had been reported to NYCDOH and one
to the Albany County Health Department and NYSDOH. None were
confirmed as having plague. Patients ranged in age from 31 to 80
years; six were men. All 11 patients reported having recently been
in India. One suspected case was recognized by an airline crew
member during a flight; two by customs officials in the airport;
and one by airline officials at check-in for a connecting domestic
flight at a different airport. The remaining seven suspected cases
were reported by hospital emergency departments. Nine of the 11
patients were admitted to a hospital isolation unit for observation
while awaiting consultation with CDC and/or confirmatory laboratory
testing.
Ten patients had clinical presentations that were not
consistent with pneumonic plague. One patient, who developed adult
respiratory distress syndrome and coma, required serologic and
microbiologic testing to rule out plague. The final diagnoses for
10 of the suspected cases were viral syndrome (four patients),
malaria (three), concurrent malaria and dengue (one), and typhoid
and liver disease (one each); one person had no illness.
Reported by: B Mojica, MD, R Heffernan, MPH, C Lowe, MFA, S
Matthews, New York City Dept of Health; T Briggs, Albany County
Health Dept, Albany; F Guido, E Wender, MD, Westchester County
Health Dept, Hawthorne; S Kondracki, G Birkhead, MD, D Morse, MD,
State Epidemiologist, New York State Dept of Health. Div of
Quarantine, National Center for Prevention Svcs; Bacterial Zoonoses
Br, Div of Vector-Borne Infectious Diseases, National Center for
Infectious Diseases; Div of Field Epidemiology, Epidemiology
Program Office, CDC.
Editorial Note
Editorial Note: This report illustrates the ongoing potential for
importation of emerging infectious diseases into the United States
and the need for prompt reporting of cases to local and state
health departments for an appropriate public health response (3).
The Institute of Medicine has identified international travel and
commerce as a major factor associated with emerging infections (4).
The protocols described in this report -- highlighting the close
cooperation between federal, state, and local public health
officials; the medical community; and the airline industry --
represent the coordinated, comprehensive prevention-oriented
response needed to guard against the threat of emerging and
resurgent infections. In addition, the evaluation of suspected
plague cases in New York revealed limitations in recognizing cases
of disease only at the point of disembarkation; in New York,
approximately half of the suspected cases were brought to the
NYCDOH/NYSDOH's attention by local physicians. The importance of
obtaining a travel history when evaluating persons presenting with
fever was underscored by the detection of cases of dengue and
nationally notifiable disease conditions (i.e., malaria and
typhoid) (5).
References
CDC. Human plague -- India, 1994. MMWR 1994;43:689-91.
CDC. Update: human plague -- India, 1994. MMWR 1994;43:722-3.
Berkelman RL, Bryan RT, Osterholm MT, LeDuc JW, Hughes JM.
Infectious disease surveillance: a crumbling foundation. Science
1994;264:368-70.
Institute of Medicine. Emerging infections: microbial threats to
health in the United States. Washington, DC: National Academy
Press, 1992.
CDC. National notifiable diseases reporting -- United States,
1994. MMWR 1994;43:800-1.
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