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International Notes
Human Plague -- India, 1994
Since August 26, 1994, outbreaks of bubonic and pneumonic
plague have been reported in south-central, southwestern, and
northern India. Because most of the reports are unconfirmed, the
extent of the outbreaks is unclear. On August 26, following reports
of a rat die-off, the first human cases were reported in Bir
district, Maharashtra state, approximately 300 km east of Bombay.
On September 22, cases of pneumonic plague were reported from the
city of Surat, Gujarat state, approximately 200 km north of Bombay.
As of September 26, several hundred pneumonic plague cases and
numerous deaths have been reported from Surat. On September 26 and
27, cases were reported from Bombay and Calcutta, and on September
27, cases of pneumonic plague were reported from Delhi.
Reported by: Div of Quarantine, National Center for Prevention
Svcs; Bacterial Zoonoses Br, Div of Vector-Borne Infectious
Diseases, National Center for Infectious Diseases, CDC. Editorial Note
Editorial Note: Plague is caused by infection with Yersinia pestis,
a bacterium carried by rodents and transmitted by fleas commonly
found in parts of Asia, Africa, and North and South America (1,2).
Sporadic human cases associated with epizootics in wild rodents
occur annually in the western United States (3); however, no
pneumonic plague cases resulting from person-to-person spread have
been reported in the United States since 1924 (1). In India, large
plague outbreaks occurred during the first half of the 20th
century; however, the last laboratory-confirmed human cases were
reported in 1966 (4,5). In 1992 (the most recent year for which
complete data are available), human plague cases were reported from
nine countries (Brazil, China, Madagascar, Mongolia, Myanmar, Peru,
the United States, Vietnam, and Zaire) (5).
Most human plague is the bubonic form, which results from the
bites of infected fleas; however, plague also can be transmitted to
humans by handling infected animals or by inhaling infectious
aerosols from persons with pneumonic plague. The incubation period
for plague ranges from 1 to 7 days, and manifestations of the
illness include rapid onset of fever, chills, headache, malaise,
myalgias, and prostration, often with nausea. In particular,
bubonic plague is characterized by painful swelling of lymph nodes
(buboes) in the inguinal, axillary, or cervical regions; pneumonic
plague is characterized by cough and dyspnea; and septicemic plague
may result in fulminant gram-negative shock without localized signs
of infection (2,6). Multiple clinical presentations can occur in
one patient.
Travelers to India and other plague-endemic countries are at
low risk for infection with Y. pestis. To reduce risk, travelers
should avoid areas with recently reported human plague cases.
Persons who must travel to these areas should 1) avoid rat-infested
areas -- especially areas where dead rats have been observed; 2)
apply insect repellents to ankles and legs, and apply repellents
and insecticides to clothing and outer bedding as directed by the
manufacturer; 3) avoid handling dead or sick animals; and 4) if the
risk for exposure is high, take prophylactic antibiotics. For
adults, the preferred antibiotic for prophylaxis is tetracycline or
doxycycline, and for children aged less than or equal to 8 years,
sulfonamides (2). Because maximal antibody responses from plague
vaccine require administration of multiple doses over several
months, plague vaccine is not recommended for immediate protection
during outbreaks.
International travelers should be advised to report
immediately to a physician any febrile illness beginning within 7
days after leaving India. Although imported cases are expected to
be rare, physicians should be alert for evidence of plague in
persons who have traveled to plague-endemic areas and who developed
a febrile illness within 7 days after leaving the area. All
suspected plague patients should be hospitalized and isolated,
specimens should be obtained from patients for laboratory
diagnosis, chest roentgenogram should be performed, and antibiotic
therapy should be promptly initiated. For all suspected cases,
appropriate diagnostic specimens include blood for culture and
serum antibodies; for suspected pneumonic cases, sputum samples;
and for suspected bubonic cases, aspirates from affected lymph
nodes. Streptomycin is the preferred drug for treatment of plague,
but gentamicin, tetracyclines, and chloramphenicol also are
effective (2,7). Prompt treatment can reduce overall plague
mortality from 60%-100% to 10%-15%.
Prophylactic antibiotic treatment should be administered to
all persons who have had face-to-face contact or who have occupied
a closed space with a person with pneumonic plague. Household
contacts of bubonic plague patients also should receive
prophylactic antibiotic treatment.
Suspected human plague cases in international travelers should
be reported through state and local health departments to CDC's
Division of Quarantine, National Center for Prevention Services,
telephone (404) 639-8107 or (404) 639-2888 (nights, Sundays, and
holidays). Specimens for confirmatory testing can be submitted
through state health departments to CDC. Inquiries about the
availability of streptomycin should be directed to Pfizer, Inc., *
telephone (800) 254-4445. Additional information about plague is
available to physicians and the general public from the CDC Voice
Information System, telephone (404) 332-4555, and to physicians and
laboratory personnel from CDC's Division of Vector-Borne Infectious
Diseases, National Center for Infectious Diseases, telephone (303)
221-6453.
References
Barnes AM. Surveillance and control of bubonic plague in the
United States. In: Edwards MA, McDonnel U, eds. Animal disease in
relation to conservation. New York: Academy Press, 1982:237-70.
Poland JD. Plague. In: Hoeprich PD, Jordan MC, eds. Infectious
diseases. Grand Rapids, Michigan: JB Lippincott, 1989:1296-1306.
CDC. Human plague -- United States, 1993-1994. MMWR 43:242-6.
World Health Organization. Epidemiology and incidence of plague
in the world, 1958-79. Bull WHO 1982;60:165-9.
World Health Organization. Human plague in 1992. Wkly Epidemiol
Rec 1994;2: 8-10.
Hull HF, Montes JM, Mann JM. Septicemic plague in New Mexico. J
Infect Dis 1987;155:113-8.
Medical Economics Data Production Company. Physicians' desk
reference. 48th ed. Montvale, New Jersey: Medical Economics Data
Production Company, 1994:1610-1.
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| Erratum: Vol. 43, No. 38
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| SOURCE: MMWR 43(41);763 DATE: Oct 21, 1994
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| In the article "Human Plague -- India, 1994," on page 689,
in |
| the second paragraph of the editorial note, the first sentence
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| should read "Most human plague is the bubonic form, which
results |
| from the bites of infected fleas; however, plague also can be
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| transmitted to humans by handling infected animals or by direct
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| exposure to large respiratory droplets from persons with
pneumonic |
| plague."
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