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Up against an infamous infectious disease: Chasing the Plague

Operational Research News 
Julita Gil Cuesta - Operational Research Support and Documentation Officer
In August 2017, a plague epidemic was reported in Madagascar. Julita Gil, a medical epidemiologist with Médecins sans Frontières’ operational research unit LuxOR, supported the investigation and control of the epidemic on a two week mission in late October and early November.

    The plague historically has a grim and deadly record. Fearfully named the “Black Death” in medieval Europe, epidemics of the infectious plague caused an estimated 50 million deaths in the 14th century. Today, a few hundred cases of plague are still reported every year, but the disease can be effectively treated with antibiotics if diagnosed early.

    Responding to the latest outbreak in Madagascar, MSF together with local authorities and international partners constructed the plague triage and treatment center outside a hospital in the city Tamatave on the eastern coast. The team then helped to diagnose, isolate, and treat patients, and visited surrounding communities explaining essential protective measures.

    In early November, a second MSF-team travelled to Haut Matsiatra and Vakinankaratra to locally support detection and management of the remaining plague cases. 

    You travelled to Madagascar during the plague epidemic. Were you not concerned about your own health?

    I am certainly more alert and vigilant when working in an outbreak setting. However, MSF prioritizes staff safety and always takes all possible protective measures. For Madagascar, we took a prophylactic antibiotic treatment, and were using masks whenever we came in contact with infectious pneumonic patients. 

    In one of our accommodations some bed bugs bit me. Their bites are themselves not harmful, but also not so different from the flea bites transmitting plague. A very disconcerting feeling! Luckily my team’s entomologist helped me to correctly identify and treat them.

    Madagascar reports cases of plague every year. Why did this particular epidemic require an international emergency response?

    Globally about 600 cases of plague are still reported every year, and Madagascar is together with the Democratic Republic of the Congo and Peru one of the endemic countries. This epidemic however showed two alarming anomalies: a majority of cases had the deadly and rapidly infectious pneumonic form of plague, and the outbreak spread through the capital Antananarivo and the largest port town Tamatave, the two biggest cities in Madagascar. 

    The more common bubonic plague is transmitted by fleas from rodents and other animals. Humans can get infected through the bite of an infected flea, or by handling an infected animal. Around one tenth of bubonic plague cases develop pneumonic plague which can spread between humans via infected respiratory droplets. The ecology and transmission of plague is therefore complex and different between urban and rural areas.

    Madagascar is a beautiful country and a popular holiday destination, so containing the outbreak was a major concern for national and international health actors.

    Your mission was to support the investigation and control of the plague epidemic. What activities were you involved in? 

    My initial focus was on better understanding the distribution of plague cases: Which were there areas most affected? How did the disease spread? Which was the most vulnerable age or socioeconomic group? And how reliable are the laboratory results for our diagnosis? To answer these questions, I gathered data from patient files, reports and laboratory results. 

    I worked together with a field coordinator, a doctor, a nurse, a water and sanitation expert, an anthropologist, an entomologist, logistician, and a supply specialist. The multidisciplinary team was supporting the outbreak response already from the beginning of October. They met the local health professionals to assess their needs, from appropriate water supply and sanitation infrastructures to medical equipment, food and support for health promotion activities in the communities.

    With the number of new cases decreasing in Tamatave, we set out on an exploratory mission to the regions of Vakinankaratra and Haut Matsiatra in the highlands. Ambalavao district was the site where we intervened, since it had reported a higher number of plague cases and related deaths. There are cases of bubonic plague reported here every year, so communities and health workers are more aware of the symptoms and how to treat plague. 

    What challenges did the team face working in Tamatave and on your exploratory mission in the highlands?

    At the hospital and treatment center in Tamatave, setting-up a safe and efficient triage system was a major challenge when the MSF-team arrived. The early symptoms of pneumonic plague are fairly unspecific, including fever, headache, weakness, or coughing. This makes it difficult for doctors to use the case definition effectively, and they risk giving the strong antibiotics to patients that may not have plague. It also makes it difficult to determine the real magnitude of the epidemic.

    When initiated early, the different antibiotic treatments are effective and most people recover quickly. It’s however also important to inform affected communities about the symptoms and how to avoid infection.

    What are some early lessons learned and where do you see need for further research? 

    Early detection and treatment of plague cases saves patients’ lives. Especially in more remote areas, community detection and systematic reporting by local health workers need to be strengthened. In cities like Tamatave on the other hand, health professionals are less used to plague cases than their colleagues in the highlands, where bubonic plague cases occur every year.

    Then, there remains one of the core questions of any disease outbreak: how did the pneumonic plague epidemic spread? We would also like to understand whether pneumonic cases in this epidemic showed milder symptoms than in previous ones. We are now analyzing some of the collected routine patient data which may help us find some answers to these questions.
    A positive experience was responding to the outbreak with such a multi-disciplinary team. Combining our different knowledge and perspectives was an advantage that helped containing this epidemic.

    * Main picture: A Doctor in the care center for patients infected with plague in Tamatave helps a little girl put on her protective mask. © RIJASOLO/Riva Press