Madagascar Plague Outbreak: External Situation Report #14 - 4 December 2017

Situation Report
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Due to concerted national and international response the current and unprecedented outbreak of plague in Madagascar, which started on 1 August 2017, has been contained.

On Monday, 27 November the Ministry of Health of Madagascar officially announced the containment of the acute urban pneumonic plague outbreak. However, because plague is endemic in Madagascar and the plague season lasts from September to April, more cases of bubonic and sporadic pneumonic plague are expected to be reported until April 2018.

WHO and other stakeholders will continue to support the Ministry of Health of Madagascar to maintain vigilance and to sustain a strong alert and response system to rapidly detect and respond to new plague cases as they emerge.

From 20 to 26 November 2017, 72 cases of plague (1 confirmed, 6 probable and 65 suspect) were reported to WHO.

The date of onset of the last confirmed bubonic case was 18 November 2017 and the date of onset of the last case of secondary pneumonic plague (primary bubonic form) was 19 November 2017.
From 1 August to 26 November 2017, a cumulative total of 2 417 confirmed, probable and suspected cases of plague, including 209 deaths (case fatality rate 9%), have been reported from 57 of 114 (50%) districts in Madagascar.

Analamanga Region in central Madagascar has been the most affected, with 68% of all recorded cases. Since the beginning of this outbreak, the vast majority of cases have been treated and have recovered. As of 26 November 2017, only 13 people were hospitalized for plague. There has been no international spread outside the country.

The majority of the reported cases (1 854, 77%) have been clinically classified as pneumonic plague, 355 have been classified as bubonic plague (15%), one was septicaemic, and 207 have not yet been classified (further classification of cases is in process). Eighty-one healthcare workers have had illness compatible with plague, none of whom have died.

Of the 1 854 clinical pneumonic cases, 390 (21%) have been confirmed, 618 (33%) are probable and 846 (46%) remain suspected (additional laboratory results are in process). Thirty-three isolates of Yersinia pestis have been cultured and are sensitive to all antibiotics recommended by the National Plague Control Program.

A total of 7 318 contacts identified during this outbreak have been put under a course of prophylactic antibiotics, including 11 contacts who developed symptoms compatible with plague and were classified as suspect cases. On 26 November 2017, 24 of 29 (83%) contacts were followed.
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 than usual. 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 (a port city).

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