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Andrianaivoarimanana V, Savin C, Birdsell DN, Vogler AJ, Le Guern AS, Rahajandraibe S, Brémont S, Rahelinirina S, Sahl JW, Ramasindrazana B, Rakotonanahary RJL, Rakotomanana F, Randremanana R, Maheriniaina V, Razafimbia V, Kwasiborski A, Balière C, Ratsitorahina M, Baril L, Keim P, Caro V, Rasolofo V, Spiegel A, Pizarro-Cerda J, Wagner DM, Rajerison M. Multiple Introductions of Yersinia pestis during Urban Pneumonic Plague Epidemic, Madagascar, 2017. Emerg Infect Dis 2024; 30:289-298. [PMID: 38270131 PMCID: PMC10826772 DOI: 10.3201/eid3002.230759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Pneumonic plague (PP) is characterized by high infection rate, person-to-person transmission, and rapid progression to severe disease. In 2017, a PP epidemic occurred in 2 Madagascar urban areas, Antananarivo and Toamasina. We used epidemiologic data and Yersinia pestis genomic characterization to determine the sources of this epidemic. Human plague emerged independently from environmental reservoirs in rural endemic foci >20 times during August-November 2017. Confirmed cases from 5 emergences, including 4 PP cases, were documented in urban areas. Epidemiologic and genetic analyses of cases associated with the first emergence event to reach urban areas confirmed that transmission started in August; spread to Antananarivo, Toamasina, and other locations; and persisted in Antananarivo until at least mid-November. Two other Y. pestis lineages may have caused persistent PP transmission chains in Antananarivo. Multiple Y. pestis lineages were independently introduced to urban areas from several rural foci via travel of infected persons during the epidemic.
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Affiliation(s)
| | | | | | - Amy J. Vogler
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Anne-Sophie Le Guern
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Soloandry Rahajandraibe
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Sylvie Brémont
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Soanandrasana Rahelinirina
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Jason W. Sahl
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Beza Ramasindrazana
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Rado Jean Luc Rakotonanahary
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Fanjasoa Rakotomanana
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Rindra Randremanana
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Viviane Maheriniaina
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Vaoary Razafimbia
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Aurelia Kwasiborski
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Charlotte Balière
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Maherisoa Ratsitorahina
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Laurence Baril
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Paul Keim
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Valérie Caro
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Voahangy Rasolofo
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - André Spiegel
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
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5
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ten Bosch Q, Andrianaivoarimanana V, Ramasindrazana B, Mikaty G, Rakotonanahary RJL, Nikolay B, Rahajandraibe S, Feher M, Grassin Q, Paireau J, Rahelinirina S, Randremanana R, Rakotoarimanana F, Melocco M, Rasolofo V, Pizarro-Cerdá J, Le Guern AS, Bertherat E, Ratsitorahina M, Spiegel A, Baril L, Rajerison M, Cauchemez S. Analytical framework to evaluate and optimize the use of imperfect diagnostics to inform outbreak response: Application to the 2017 plague epidemic in Madagascar. PLoS Biol 2022; 20:e3001736. [PMID: 35969599 PMCID: PMC9410560 DOI: 10.1371/journal.pbio.3001736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 08/25/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
During outbreaks, the lack of diagnostic “gold standard” can mask the true burden of infection in the population and hamper the allocation of resources required for control. Here, we present an analytical framework to evaluate and optimize the use of diagnostics when multiple yet imperfect diagnostic tests are available. We apply it to laboratory results of 2,136 samples, analyzed with 3 diagnostic tests (based on up to 7 diagnostic outcomes), collected during the 2017 pneumonic (PP) and bubonic plague (BP) outbreak in Madagascar, which was unprecedented both in the number of notified cases, clinical presentation, and spatial distribution. The extent of these outbreaks has however remained unclear due to nonoptimal assays. Using latent class methods, we estimate that 7% to 15% of notified cases were Yersinia pestis-infected. Overreporting was highest during the peak of the outbreak and lowest in the rural settings endemic to Y. pestis. Molecular biology methods offered the best compromise between sensitivity and specificity. The specificity of the rapid diagnostic test was relatively low (PP: 82%, BP: 85%), particularly for use in contexts with large quantities of misclassified cases. Comparison with data from a subsequent seasonal Y. pestis outbreak in 2018 reveal better test performance (BP: specificity 99%, sensitivity: 91%), indicating that factors related to the response to a large, explosive outbreak may well have affected test performance. We used our framework to optimize the case classification and derive consolidated epidemic trends. Our approach may help reduce uncertainties in other outbreaks where diagnostics are imperfect. The response to the 2017 plague outbreak in Madagascar was complicated by the lack of a perfect or "gold standard" diagnostic. This study shows how multiple, imperfect diagnostic tests can be used to improve the response to an outbreak.
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Affiliation(s)
- Quirine ten Bosch
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
- Quantitative Veterinary Epidemiology, Department of Animal Sciences, Wageningen University and Research, Wageningen, the Netherlands
- * E-mail:
| | | | | | - Guillain Mikaty
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | | | - Birgit Nikolay
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
| | | | - Maxence Feher
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | - Quentin Grassin
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | - Juliette Paireau
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
| | | | - Rindra Randremanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | - Feno Rakotoarimanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | - Marie Melocco
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | | | - Javier Pizarro-Cerdá
- Yersinia Research Unit, Institut Pasteur, Université Paris Cité, CNRS UMR 6047, F-75015 Paris, France
- National Reference Laboratory for Plague and other Yersiniosis, Institut Pasteur, F-75015 Paris, France
- World Health Organization Collaborating Center for Plague FRA-140, Institut Pasteur, F-75015 Paris, France
| | - Anne-Sophie Le Guern
- Yersinia Research Unit, Institut Pasteur, Université Paris Cité, CNRS UMR 6047, F-75015 Paris, France
- National Reference Laboratory for Plague and other Yersiniosis, Institut Pasteur, F-75015 Paris, France
- World Health Organization Collaborating Center for Plague FRA-140, Institut Pasteur, F-75015 Paris, France
| | - Eric Bertherat
- World Health Organization, Health Emergency Programme, Department of Infectious Hazard Management, Geneva, Switzerland
| | - Maherisoa Ratsitorahina
- Direction, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- Directorate of Health and Epidemiological Surveillance, Ministry of Public Health, Antananarivo, Madagascar
| | - André Spiegel
- Direction, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Laurence Baril
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | | | - Simon Cauchemez
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
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10
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Randremanana R, Andrianaivoarimanana V, Nikolay B, Ramasindrazana B, Paireau J, Ten Bosch QA, Rakotondramanga JM, Rahajandraibe S, Rahelinirina S, Rakotomanana F, Rakotoarimanana FM, Randriamampionona LB, Razafimbia V, De Dieu Randria MJ, Raberahona M, Mikaty G, Le Guern AS, Rakotonjanabelo LA, Ndiaye CF, Rasolofo V, Bertherat E, Ratsitorahina M, Cauchemez S, Baril L, Spiegel A, Rajerison M. Epidemiological characteristics of an urban plague epidemic in Madagascar, August-November, 2017: an outbreak report. Lancet Infect Dis 2019; 19:537-545. [PMID: 30930106 PMCID: PMC6483974 DOI: 10.1016/s1473-3099(18)30730-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/01/2018] [Accepted: 11/21/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Madagascar accounts for 75% of global plague cases reported to WHO, with an annual incidence of 200-700 suspected cases (mainly bubonic plague). In 2017, a pneumonic plague epidemic of unusual size occurred. The extent of this epidemic provides a unique opportunity to better understand the epidemiology of pneumonic plagues, particularly in urban settings. METHODS Clinically suspected plague cases were notified to the Central Laboratory for Plague at Institut Pasteur de Madagascar (Antananarivo, Madagascar), where biological samples were tested. Based on cases recorded between Aug 1, and Nov 26, 2017, we assessed the epidemiological characteristics of this epidemic. Cases were classified as suspected, probable, or confirmed based on the results of three types of diagnostic tests (rapid diagnostic test, molecular methods, and culture) according to 2006 WHO recommendations. FINDINGS 2414 clinically suspected plague cases were reported, including 1878 (78%) pneumonic plague cases, 395 (16%) bubonic plague cases, one (<1%) septicaemic case, and 140 (6%) cases with unspecified clinical form. 386 (21%) of 1878 notified pneumonic plague cases were probable and 32 (2%) were confirmed. 73 (18%) of 395 notified bubonic plague cases were probable and 66 (17%) were confirmed. The case fatality ratio was higher among confirmed cases (eight [25%] of 32 cases) than probable (27 [8%] of 360 cases) or suspected pneumonic plague cases (74 [5%] of 1358 cases) and a similar trend was seen for bubonic plague cases (16 [24%] of 66 confirmed cases, four [6%] of 68 probable cases, and six [2%] of 243 suspected cases). 351 (84%) of 418 confirmed or probable pneumonic plague cases were concentrated in Antananarivo, the capital city, and Toamasina, the main seaport. All 50 isolated Yersinia pestis strains were susceptible to the tested antibiotics. INTERPRETATION This predominantly urban plague epidemic was characterised by a large number of notifications in two major urban areas and an unusually high proportion of pneumonic forms, with only 23% having one or more positive laboratory tests. Lessons about clinical and biological diagnosis, case definition, surveillance, and the logistical management of the response identified in this epidemic are crucial to improve the response to future plague outbreaks. FUNDING US Agency for International Development, WHO, Institut Pasteur, US Department of Health and Human Services, Laboratoire d'Excellence Integrative Biology of Emerging Infectious Diseases, Models of Infectious Disease Agent Study of the National Institute of General Medical Sciences, AXA Research Fund, and the INCEPTION programme.
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Affiliation(s)
- Rindra Randremanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | - Birgit Nikolay
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, UMR 2000, CNRS, Paris, France
| | | | - Juliette Paireau
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, UMR 2000, CNRS, Paris, France
| | - Quirine Astrid Ten Bosch
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, UMR 2000, CNRS, Paris, France
| | | | | | | | - Fanjasoa Rakotomanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Feno M Rakotoarimanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | - Vaoary Razafimbia
- Directorate of Health and Epidemiological Surveillance, Ministry of Public Health, Antananarivo, Madagascar
| | - Mamy Jean De Dieu Randria
- Department of Infectiology, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | - Mihaja Raberahona
- Department of Infectiology, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | - Guillain Mikaty
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | - Anne-Sophie Le Guern
- Yersinia Research Unit, National Reference Laboratory for Plague, WHO Collaborating Centre, Institut Pasteur, Paris, France
| | | | | | | | | | - Maherisoa Ratsitorahina
- Directorate of Health and Epidemiological Surveillance, Ministry of Public Health, Antananarivo, Madagascar
| | - Simon Cauchemez
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, UMR 2000, CNRS, Paris, France.
| | - Laurence Baril
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - André Spiegel
- Institut Pasteur de Madagascar, Antananarivo, Madagascar
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