Plague in Madagascar – Travel advice – 16.10.2017

The outbreak of plague in Madagascar continues. Between 1 August and 12 October 2017, a total of 684 cases (350 suspected, 271 probable and 63 confirmed) including 57 deaths have been reported in 35 out of 114 districts in the country.

Of these, 474 cases were clinically classified as pneumonic plague, 156 were bubonic plague, one case was septicaemic plague, and 54 cases were unspecified. At least fifteen healthcare workers have contracted plague since the beginning of the outbreak. The capital city Antananarivo is the most affected area, followed by the port city of Toamasina and the rural district of Faratsiho.

Plague is known to be endemic on the Plateaux of Madagascar (including Ankazobe District where the current outbreak originated). A seasonal upsurge (predominantly the bubonic form) usually occurs every year between September and April. On 29 September 2017, health authorities confirmed pneumonic plague as the cause of death in a Seychelles basketball player, who was attending the basketball championship “Indian Ocean Club” (23 September – 1 October) in Madagascar. A South African basketball official also tested positive for plague on 3 October 2017. Risk of further plague cases associated with this tournament is currently being assessed, as all the participants are being monitored. On 10 October 2017, the Seychellois Ministry of Health notified of a probable case of pneumonic plague with history of recent travel to Madagascar. The traveler’s contacts are under investigation.

Plague is an infectious disease caused by the bacterium Yersinia pestis, which is usually harbored by small animals, particularly rodents. It can be transmitted between animals and humans through bites of infected fleas, direct contact, inhalation and ingestion of infective particles. Symptoms include fever, chills and painful/swollen lymph nodes in the armpits, groin or neck (buboes), shortness of breath and cough. There are three different forms, depending on the route of infection: bubonic (lymphatic system), septicaemic (bloodstream) and pneumonic (lungs). Incubation period ranges between one to seven days, depending on disease type. Pneumonic plague, in particular, is transmissible from person to person, while the incubation period can be as short as 24 hours.

Advice for travelers

Currently, the risk of contracting plague is very low for most travelers to Madagascar.

Travelers to Madagaskar and Seychelles should be informed about the current plague outbreak and about the endemicity of plague in Madagaskar. However, travelers in rural areas of plague-endemic regions may be at risk, particularly if camping or hunting or if contact with rodents takes place. There is currently no vaccine that protects against plague.

Travelers should:

• Use a DEET based insect repellent to protect against flea bites.
• Avoid direct contact with sick or dead animals.
• Avoid close contact with anyone who has symptoms or who is diagnosed with pneumonic plague.
• Avoid crowded areas where cases of pneumonic plague have been recently reported.

Prophylactic treatment is recommended only for persons who have been in close contact with plague cases, or with other high risk exposures (such as bites from infected fleas or direct contact with body fluids or tissues of infected animals). Travelers should avoid self-administration of antibiotics as prophylaxis, unless recommended by medical professionals.

Travelers returning from Madagaskar are advised:

• To monitor their health for 10 days after return.
• Τo seek medical attention if they develop symptoms (consistent with pneumonic plague i.e. fever, painful lymphadenopathy, cough) during the first 10 days after return and inform their healthcare provider of their trip to Madagascar.