Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Plague Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Lancet Infect Dis. 2019 May;19(5):537-545. doi: 10.1016/S1473-3099(18)30730-8. Epub 2019 Mar 28.
Madagascar accounts for 75% of global plague cases reported to WHO, with an annual incidence of 200-700 suspected cases (mainly bubonic plague). In 2017, a pneumonic plague epidemic of unusual size occurred. The extent of this epidemic provides a unique opportunity to better understand the epidemiology of pneumonic plagues, particularly in urban settings.
Clinically suspected plague cases were notified to the Central Laboratory for Plague at Institut Pasteur de Madagascar (Antananarivo, Madagascar), where biological samples were tested. Based on cases recorded between Aug 1, and Nov 26, 2017, we assessed the epidemiological characteristics of this epidemic. Cases were classified as suspected, probable, or confirmed based on the results of three types of diagnostic tests (rapid diagnostic test, molecular methods, and culture) according to 2006 WHO recommendations.
2414 clinically suspected plague cases were reported, including 1878 (78%) pneumonic plague cases, 395 (16%) bubonic plague cases, one (<1%) septicaemic case, and 140 (6%) cases with unspecified clinical form. 386 (21%) of 1878 notified pneumonic plague cases were probable and 32 (2%) were confirmed. 73 (18%) of 395 notified bubonic plague cases were probable and 66 (17%) were confirmed. The case fatality ratio was higher among confirmed cases (eight [25%] of 32 cases) than probable (27 [8%] of 360 cases) or suspected pneumonic plague cases (74 [5%] of 1358 cases) and a similar trend was seen for bubonic plague cases (16 [24%] of 66 confirmed cases, four [6%] of 68 probable cases, and six [2%] of 243 suspected cases). 351 (84%) of 418 confirmed or probable pneumonic plague cases were concentrated in Antananarivo, the capital city, and Toamasina, the main seaport. All 50 isolated Yersinia pestis strains were susceptible to the tested antibiotics.
This predominantly urban plague epidemic was characterised by a large number of notifications in two major urban areas and an unusually high proportion of pneumonic forms, with only 23% having one or more positive laboratory tests. Lessons about clinical and biological diagnosis, case definition, surveillance, and the logistical management of the response identified in this epidemic are crucial to improve the response to future plague outbreaks.
US Agency for International Development, WHO, Institut Pasteur, US Department of Health and Human Services, Laboratoire d'Excellence Integrative Biology of Emerging Infectious Diseases, Models of Infectious Disease Agent Study of the National Institute of General Medical Sciences, AXA Research Fund, and the INCEPTION programme.
马达加斯加向世卫组织报告的鼠疫病例占全球病例的 75%，每年有 200-700 例疑似病例（主要为腺鼠疫）。2017 年，发生了一场规模异常的肺鼠疫疫情。这次疫情的规模为更好地了解肺鼠疫的流行病学提供了一个独特的机会，特别是在城市环境中。
临床疑似鼠疫病例向马达加斯加巴斯德研究所中央鼠疫实验室（马达加斯加首都塔那那利佛）报告，在那里对生物样本进行了检测。根据 2017 年 8 月 1 日至 11 月 26 日期间记录的病例，我们评估了这次疫情的流行病学特征。根据 2006 年世卫组织的建议，根据三种诊断检测方法（快速诊断检测、分子方法和培养）的结果，将病例分为疑似、可能或确诊。
报告了 2414 例临床疑似鼠疫病例，包括 1878 例（78%）肺鼠疫病例、395 例（16%）腺鼠疫病例、1 例（<1%）败血型病例和 140 例（6%）临床特征未明的病例。1878 例报告的肺鼠疫病例中，386 例（21%）为可能病例，32 例（2%）为确诊病例。395 例报告的腺鼠疫病例中，73 例（18%）为可能病例，66 例（17%）为确诊病例。确诊病例的病死率高于可能病例（8/32[25%]）和疑似肺鼠疫病例（74/1358[5%]），腺鼠疫也有类似趋势（6/66[9%]确诊病例、4/68[6%]可能病例和 6/243[2%]疑似病例）。418 例确诊或可能的肺鼠疫病例中有 351 例（84%）集中在首都塔那那利佛和主要海港图阿马西纳。分离出的 50 株鼠疫耶尔森菌均对测试的抗生素敏感。
这次以城市为主的鼠疫疫情特点是在两个主要城市地区有大量的病例报告，且肺鼠疫的比例异常高，只有 23%的病例有一项或多项实验室检测阳性。这次疫情中发现的关于临床和生物诊断、病例定义、监测以及应对工作后勤管理的经验教训，对于改进未来鼠疫疫情的应对至关重要。
美国国际开发署、世卫组织、巴斯德研究所、美国卫生与公众服务部、传染病新兴生物学卓越实验室、国家过敏和传染病研究所传染病病原体研究模型、AXA 研究基金以及 INCEPTION 计划。
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