Main conclusions and options for preparedness
Madagascar has been experiencing an outbreak of plague since 23 August 2017, and 560 cases and 57 deaths (case fatality rate 10.1%) have been reported as of 12 October 2017. Of these cases, 394 are pneumonic plague, 143 bubonic plague, one is a septicaemic plague and the clinical presentation is undetermined for 22 cases. Cases have been mainly reported in the capital Antananarivo and the port city of Toamasina on the east coast. In addition, sporadic cases of pneumonic plague without apparent epidemiological links to the initial chain of transmission have been reported in several regions across the country.
The update of this risk assessment has been triggered by the continued evolution of the outbreak since the last risk assessment on the ‘Outbreak of plague in Madagascar, 2017’ published 9 October 2017, and by the occurrence of one travel-associated case in the Seychelles with a recent history of travel to Madagascar.
While plague outbreaks in Madagascar are not unexpected, the high proportion of pneumonic plague cases is of concern. The current outbreak is the largest one to occur in the last decade in Madagascar. The risk of further transmission in this country is considered very high until public health prevention and control measures are fully implemented with the support of the World Health Organization (WHO) and international partners working in the country. The risk of regional spread in the Indian Ocean region is considered moderate.
The risk for travellers from the EU or for importation to the EU is considered low. WHO considers the risk for international spread of plague to be very low and advises against any restrictions to travel and trade with Madagascar based on the information to date. There is no restriction of movement in and out of Antananarivo, where cases have occurred, in accordance with the recommendations of the Malagasy authorities.
According to WHO, prophylactic treatment is only recommended for persons who have been in close contact with plague cases, or who have experienced other high-risk exposures such as bites from fleas or direct contact with bodily fluids or tissues of infected animals.
The measures for mitigating the risks for travellers to endemic plague areas include:
• International travellers being informed about the current plague outbreak and that plague is endemic in Madagascar.
• Use of personal protection against fleabites. As Madagascar is a malaria endemic area, the use of mosquito repellents for malaria prevention can protect against flea bites.
• Avoidance of direct contact with sick or dead animals.
• Avoidance of close contact with sick persons and in particular with patients diagnosed with pneumonic plague or patients with symptoms consistent with pneumonic plague.
• Avoidance of crowded areas where cases of pneumonic plague have been recently reported.
• Contacting travel clinics before departure to get information about the current plague outbreak in Madagascar including preventive measures and symptoms of pneumonic plague.
• Seeking immediate medical care if compatible symptoms develop.
If travellers returning from Madagascar present with suggestive symptoms (i.e. fever, painful lymphadenopathy, cough) they should seek medical advice and inform their healthcare provider of their trip to Madagascar.
Individuals with relevant symptoms or signs should be asked about their travel history and activities and assessed for possible exposure to infectious human cases, and also for possible exposure to animal or rodent vectors within the preceding 10 days. If there is any suspicion they should be tested for plague.
Member States should review their preparedness plans for the low but distinct risk of receiving an imported case of pneumonic plague via a direct or indirect flight from Madagascar. Plans should consider the possibility of identification of a suspect case both at the point of entry, and after disembarkation and returning to the community.