Bonds, M.H., Ouenzar, M.A., Garchitorena, A., Cordier, L.F., McCarty, M.G., Rich, M.L., et al. (2018). PLOS Neglected Tropical Diseases, 12(1): e0006131.

Introduction:

In August 2017, a 31-year-old man visiting Ankazobe District in the Central Highlands of Madagascar was bitten by a flea that presumably jumped from a cohabitating rat [1]. Within a week, he began to experience malaria-like symptoms as plague-causing bacteria invaded his lymph nodes and then moved to his lungs. En route to the eastern coast, he took a public taxi brousse through the nation’s capital, Antananarivo, and died. The outbreak was officially detected a week later, preceding the infection of more than 2,200 confirmed, probable, and suspected cases as of November 2017, making it one the world’s worst plague epidemics in the past half century. Though curable with antibiotics if detected early, more than 200 people have died.

The response of the international community and the national government brought the epidemic significantly under control after some initial delay. Rapid diagnostic tests (RDTs), antibiotics, and protective gear arrived in the capital en masse and were distributed with a host of international actors. Widespread sensitization campaigns were implemented, patients were identified and treated, and thousands of community health workers (CHWs) conducted contact tracing to prevent the spread. However, supply chains and infrastructure throughout Madagascar are weak, and there have been persistent shortages of needed equipment and materials in exposed regions that are traditionally at low risk of plague. The lack of RDTs at many health facilities meant that many cases went unrecognized or were treated empirically at advanced stages, resulting in unchecked transmissions, including to as many as 70 health workers. The risk of a larger epidemic spreading throughout the country this year is now low, but with the seasonal dynamics typically peaking in December and January, vigilance remains critical.