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Plague (Yersinia Pestis)

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Plague (Yersinia Pestis) Plague (Yersinia pestis) Septicemic plague: septicemia with or without an 1. Case Definition evident bubo 1.1 Confirmed Case: Primary pneumonic plague: resulting from Clinical evidence of illness* with laboratory inhalation of infectious droplets confirmation of infection: Secondary pneumonic plague: pneumonia Isolation of Yersinia pestis from body resulting from hematogenous spread in bubonic or fluids (e.g., fluid from buboes, throat septicemic cases swab, sputum, blood) OR Pharyngeal plague: pharyngitis and cervical A significant (i.e., fourfold or greater) rise lymphadenitis resulting from exposure to larger in serum antibody titre to Y. pestis fraction infectious droplets or ingestion of infected tissues 1 (F1) antigen by enzyme immunoassay (1). (EIA) or passive hemagglutination/inhibition titre (1). 2. Reporting and Other Requirements 1.2 Probable Case: Laboratory: Clinical evidence of illness* with one or more of All positive laboratory results for Yersinia the following: pestis are reportable to the Public Health Demonstration of elevated serum antibody Surveillance Unit by secure fax (204-948- titre(s) to Y. pestis F1 antigen (without 3044). A phone report must be made to a documented significant [i.e., fourfold or Medical Officer of Health at 204-788- greater] change) in a patient with no 8666 on the same day the result is history of plague immunization obtained, in addition to the standard OR surveillance reporting by fax. Demonstration of Y. pestis F1 antigen by immunofluorescence Manitoba clinical laboratories are required OR to submit residual specimens or isolate Detection of Y. pestis nucleic acid sub-cultures from individuals who tested OR positive for Yersinia pestis to Cadham > 1:10 passive hemagglutination/inhibition Provincial Laboratory (CPL) (204-945- titre in a single serum sample in a patient 6123) within 48 hours of report. with no history of vaccination or previous Submitting laboratories must notify CPL infection of the shipment PRIOR to submission. OR Health Care Professional: Detection of Y. pestis antibody by EIA (1). Probable (clinical) cases of plague are *Plague is characterized by fever, chills, reportable to the Public Health headache, malaise, prostration and Surveillance Unit during regular hours leukocytosis, and is manifest in one or more of (8:30 a.m. to 4:30 p.m.) by telephone the following principal forms: (204-788-6736) AND by secure fax (204- 948-3044) using the Clinical Notification Bubonic plague: regional lymphadenitis of Reportable Diseases and Conditions Communicable Disease Management Protocol – Plague July 2018 1 form MHSU-0013 10 cm in diameter (4). Bacteremia is common in http://www.gov.mb.ca/health/publichealth/ patients with bubonic plague (5). High levels of cdc/protocol/mhsu_0013.pdf on the same bacteremia are often associated with day that they are identified. After hours gastrointestinal symptoms such as nausea, telephone reporting is to the Medical vomiting, abdominal pain and diarrhea (5). Officer of Health on call at (204-788- Untreated bubonic plague has a case fatality of 50- 8666) with a subsequent faxed report form 60% (3). Bubonic plague resulting from the bite MHSU-0013. of an infected flea, accounts for 80-85% of plague cases reported in the United States (6). Regional Public Health or First Nations Inuit Health Branch (FNIHB): Septicemic Plague: The septicemic form of plague can occur subsequent to bubonic plague or Once the case has been referred to without prior lymphadenopathy (primary Regional Public Health or FNIHB, the septicemic plague) (3). The illness progresses Communicable Disease Control rapidly, leading to overwhelming sepsis and organ Investigation Form MHSU-0002 failure within a few days (2). Septicemic plague http://www.gov.mb.ca/health/publichealth/ may be complicated by bleeding and gangrene, cdc/protocol/mhsu_0002.pdf should be especially of the fingers, toes and nose (7). Some completed and returned to the Public patients have gastrointestinal symptoms as well Health Surveillance Unit by secure fax (2). Untreated primary septicemic plague is (204-948-3044). almost invariably fatal (3). Septicemic plague accounts for approximately 10% of plague cases 3. Clinical Presentation/Natural reported in the United States (6). History Pneumonic Plague: Pneumonic plague exists in Plague takes several different clinical forms, two forms, primary and secondary (2). Primary depending in part on the route of exposure (2). pneumonic plague results from the direct Initial signs and symptoms for all presentations inhalation of bacteria into the lungs (2). Patients may be nonspecific, with fever, chills, malaise, experience sudden onset of fever, chills, headache, myalgia, nausea, prostration, sore throat, and malaise, and rapidly advancing tachypnea, headache (2). Naturally acquired plague usually dyspnea, hypoxia, chest pain, cough, hemoptysis, takes the form of bubonic plague (3). The global and general signs of toxemia (2). Primary distribution of Y. pestis, ease for its mass pneumonic plague accounts for approximately 2% production, and aerosolized dissemination means of reported plague cases in the United States (8). it is considered to have a high potential for Secondary pneumonic plague is the more common biological weapon use (2, 4). form of pneumonic plague and arises through hematogenous spread of bacteria to the lungs from Bubonic Plague: Bubonic plague results from a bubo or other source (2). Fatality rates are cutaneous exposure (e.g., flea bite) and is influenced by time to initiation of antibiotics, characterized by the sudden onset of high fever, access to advanced supportive care and the dose of chills, weakness and headache (2). A bubo or inhaled bacilli (9). Untreated pneumonic plague is swelling of regional lymph nodes becomes almost always fatal, and mortality is very high in apparent in the groin, axilla, or neck within the persons when treatment is delayed beyond 24 first day (2). The size may vary from one cm to hours after symptom onset (2). Communicable Disease Management Protocol – Plague July 2018 2 Other Forms of Plague: Pharyngeal plague is a (so the dog could appear clinically normal) and rare presentation resembling acute tonsillitis (2). transmission would mainly be via fleas that they Plague meningitis is a rare complication of Y. carry (12). Cases of plague have been reported in pestis (2). people who have butchered or skinned an animal (13). 4. Etiology 5.3 Occurrence: Plague is caused by the gram-negative General: Plague is a disease of poverty in Africa, coccobacillus, Yersinia pestis (3). South America, and India, where commensal rodents are the animal reservoir (10). In other 5. Epidemiology endemic regions such as Peru and the western 5.1 Reservoir and Source: United States, plague is a sporadic disease associated with outdoor occupations and contact Humans are incidental hosts or “dead-end” hosts with infected domestic animals (cats and dogs) (2). The principal animal reservoir differs from (10). Plague does occur in Asia, but is restricted region to region (10). Wild rodents are the natural to breeders and hunters since the reservoir consists vertebrate hosts of plague and maintain the natural mainly of gerbils in the steppe and marmots in the plague cycle by serving as sources of infection mountains (2). Madagascar is the most seriously and amplification for the flea vectors of the affected country in the world (10). Most of the disease (3). Plague bacilli can survive in the soil cases reported in a large 2017 Madagascar plague for prolonged periods and might be a source of outbreak were pneumonic plague (14). Since the infection for rodents (2). 1990s, most human cases have occurred in Africa 5.2 Transmission: (11). Plague is transmitted between animals and Canada: Human cases of plague are very rare in humans by the bite of infected fleas, direct contact Canada with the last case reported in 1939 (15). with infectious body fluids or contaminated Manitoba: No cases of human plague were materials of infected animals or humans, and reported in Manitoba since reporting became inhalation of infected respiratory droplets from a available in 1993. patient with pneumonic plague (11). Person-to- person transmission of pneumonic plague requires 5.4 Incubation: close contact, typically with a patient who is in the The incubation period is usually two to seven late stages of infection and coughing copious days, but can be as short as one day for primary amounts of bloody sputum (2). Human cases have pneumonic plague (2). been linked to handling infected animals and domestic pets, particularly house cats and dogs, 5.5 Risk Factors for Infection: which can carry Y. pestis-infected wild rodent Within endemic areas, elevated plague risk is fleas into homes (3, 8). Domestic cats that eat associated with close contact with rodents and infected rodents are particularly susceptible to their feline and canine predators, harbouring food plague (12) and pharyngeal infection in cats can sources for wild rodents in the vicinity of homes be transmitted directly to humans through and failure to control fleas on pet cats and dogs respiratory droplets, causing primary pneumonic (2). plague (2). Dogs are less susceptible to the plague Communicable Disease Management Protocol – Plague July 2018 3 5.6 Host Susceptibility and Resistance: and effective antimicrobial therapy started immediately after obtaining diagnostic Humans are universally susceptible (3). Immunity specimens (2). after recovery is relative; it may not protect
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