Rapid Risk Assessment: Outbreak of plague in Madagascar, 2017 (9 October 2017)


Main conclusions and options for response

Since 23 August 2017 Madagascar has been experiencing an outbreak of plague, and as of 3 October 2017, 194 cases and 30 deaths (case fatality rate 15.5%) have been reported. Of these cases, 124 cases are pneumonic plague including 21 deaths, 68 are bubonic plague, including nine deaths, one is a septicemic plague and one is an undetermined plague case. The cases are from 20 central, eastern and northern districts in Madagascar.
While plague outbreaks in Madagascar are not unexpected, the high proportion of pneumonic plague is of concern. The risk of further transmission in Madagascar is considered high until public health prevention and control measures are fully implemented with the support of the World Health Organization (WHO) and international partners. 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 very low. However, Member States should consider reviewing their preparedness plans for imported cases. 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 preventive measures for travellers to endemic plague areas include:

• 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 are developed.

If travellers returning from Madagascar present with suggestive symptoms (fever, painful lymphadenopathy) they should inform their healthcare provider of their travel to Madagascar. They should also be investigated for possible exposure to animal or rodent vectors within the preceding 10 days and tested for plague in case of suspicion.