Is this a case of 'here we go again'?
Mongolia and China
It was reported on 06 July 2020 that health officials in China had confirmed cases of Bubonic Plague in Mongolian Herdsmen in Inner Mongolia. The WHO advised they were monitoring the case but it was not high risk. By the 26 August cases were reported in 17 of 21 provinces and by 29 Sep the disease had spread across the border to Menghai county, Yunnan in China where a three year old boy was reported to have contracted the disease.
Chinese authorities have declared a level 3 emergency response in an attempt to prevent another pandemic. This is the second lowest alert level and "forbids the hunting and eating of animals that could carry plague and asks the public to report any suspected cases of plague or fever with no clear causes, and to report any sick or dead marmots". It is understood that Russia has also now taken steps to prevent spread across its borders and have vaccinated tens of thousands of people in the border regions of Tuva and Altai.
Context
Plague is one of very few diseases that can create widespread panic following the discovery of even a small number of cases so it’s important put this outbreak in context. For example only, from 2010 to 2015 there were 3248 cases reported worldwide, including 584 deaths. Currently, the three most endemic countries are the Democratic Republic of the Congo, Madagascar, and Peru. Close monitoring and actions to contain the disease are important.
What is Plague?
Bubonic plague is a bacterial disease spread by fleas that live in wild rodents. It can kill adults in less than 24 hours if not diagnosed and treated early. It can also transfer between animals and humans. The disease killed about 200m people in the 14th Century but advances in living conditions, public health and antibiotic therapy reduce the likelihood of natural pandemics. Some of the recent cases of bubonic plague are thought to have been caught through the eating of Marmot; hunting Marmots is illegal but Marmot is thought by some to be a delicacy and so the practice continues.
The WHO Fact Sheet on Plague can be found here. There are two main forms of plague infection, depending on the route of infection: bubonic and pneumonic.
Bubonic plague is the most common form of plague and is caused by the bite of an infected flea. Plague enters at the bite and travels through the lymphatic system to the nearest lymph node where it replicates itself. The lymph node then becomes inflamed, tense and painful, and is called a ‘bubo’. At advanced stages of the infection the inflamed lymph nodes can turn into open sores filled with pus. Human to human transmission of bubonic plague is rare. Bubonic plague can advance and spread to the lungs, which is the more severe type of plague called pneumonic plague.
Pneumonic plague, or lung-based plague, is the most virulent form of plague. Incubation can be as short as 24 hours. Any person with pneumonic plague may transmit the disease via droplets to other humans. Untreated pneumonic plague, if not diagnosed and treated early, can be fatal. However, recovery rates are high if detected and treated in time (within 24 hours of onset of symptoms).
How it is spread
Humans can be contaminated by the bite of infected fleas, through direct contact with infected bodily fluids and materials, or by inhalation of infected respiratory droplets. Plague can be a very severe disease in people, with a case-fatality ratio of 30% - 100% if left untreated.
Symptoms
Plague has an incubation period of 1-7 days. Common symptoms include:
Swollen lymph nodes possibly leading to open sores; and,
Sudden onset of fever, chills, head and body aches, and weakness, vomiting and nausea.
Treatment
Confirmation of plague requires lab testing. Today Bubonic Plague can be easily treated with antibiotics and the use of standard preventative measures. Untreated pneumonic plague can be rapidly fatal so early diagnosis and treatment is essential for survival and reduction of complications.
Antibiotics and supportive therapy are effective against plague if patients are diagnosed in time. Pneumonic plague can be fatal within 18 to 24 hours of disease onset if left untreated, but appropriate common antibiotics can effectively cure the disease if they are delivered early. National Authorities should:
Ensure correct treatment: Verify that patients are being given appropriate antibiotic treatment and that local supplies of antibiotics are adequate.
Isolate patients with pneumonic plague. Patients should be isolated so as not to infect others via air droplets. Providing masks for pneumonic patients can reduce spread.
Surveillance: identify and monitor close contacts of pneumonic plague patients and give them a seven-day chemoprophylaxis. Chemoprophylaxis should also be given to household members of bubonic plague patients.
Specimens should be carefully collected using appropriate infection, prevention and control procedures and sent to labs for testing.
Disinfection. Routine hand-washing is recommended with soap and water or use of alcohol hand rub. Larger areas can be disinfected using 10% of diluted household bleach (made fresh daily).
Ensure safe burial practices. Spraying of face/chest area of suspected pneumonic plague deaths should be discouraged. The area should be covered with a disinfectant-soaked cloth or absorbent material.
Face to face contacts. People with household or face-to-face contacts with known pneumonic cases should immediately initiate antibiotic prophylaxis and, if exposure is ongoing, should continue it for seven days following the last exposure.
Advice to Overlanders, Travellers and Expatriate Residents
A global Plague pandemic is not likely as it can be treated with existing antibiotics. However where these antibiotics are not available, it could spread rapidly through communities and has the potential to cause multiple fatalities.
Avoid non essential travel to and within areas known to be infected with Plague. If travel is essential then:
1. Monitor appropriate websites such as WHO, NathNac, CDC, UK Foreign Office and US Department Of State, and Australian DFAT travel advice.
2. Monitor the local situation closely and follow regional and national government advice.
3. Seek medical advice regarding inclusion of Plague vaccine in pre travel health inoculations to support essential travel to infected areas.
4. Register planned travel with your ‘in country’ national Embassy and monitor associated travel health and safety alerts. Follow advice as appropriate.
5. Ensure you are covered under the terms and conditions of your travel insurance policy
6. Take steps to prevent insect bites. Wear sturdy footwear and keep limbs, head and face covered. (Insect repellent and mosquito nets may help).
7. Do not handle animal carcasses.
8. Avoid direct contact with infected body fluids and tissues.
9. When handling potentially infected patients and collecting specimens, standard precautions should apply.
10. Maintain social distance (2m) where possible. Avoid crowded areas.
11. Wear facemasks where social distance cannot be maintained or in poorly ventilated areas.
12. Maintain good personal hygiene. Wash hands thoroughly and regularly (washing duration should last for the equivalent of 2 x verses of ‘Happy Birthday’!)
13. Clean work spaces and other surfaces at regular intervals.
14. Consider wearing of gloves in busy public or other common areas.
For those travelling in remote infected areas and where local access to antibiotics is not available, travel first aid kits should include an appropriate prescribed antibiotic for use if the traveller is diagnosed with Plague and to be taken when advised by a medical practitioner as part of a prescribed preventative treatment. Emergency response plans should take into consideration travellers becoming stranded due to the sudden closure of regional and national borders and / or being swept into local and national government quarantine schemes.
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