Friday, November 17, 2017

ECDC: Guide To Revising The Influenza Pandemic Preparedness Plan


A decade ago - when H5N1 was looming as a global threat, and before the emergence of the 2009 H1N1 virus - pandemic planning was all the rage.  Every state had, or was working on a plan, and many countries around the world had produced plans, and were actually holding serious preparedness drills.
The military considered pandemic flu a national security issue, and many (mostly large) players in the private sector viewed it as an existential threat, and were developing serious business continuity plans.
While not all of these plans were created equal - some were overly optimistic on pandemic severity, and the local/state/federal government's ability to respond - at least everyone was thinking about how to deal with a severe pandemic.

Two events served to thwart this momentum.  
  • The first being the global economic crisis and downturn in 2008.  While pandemic planning and business continuity are important, it is hard to worry about the creek potentially rising when your building is already on fire. 
  • And the second was the 2009 H1N1 pandemic, which - while far from benign - was considerably less virulent than the three pandemics of the previous century.  The media, which over-hyped the virus in the beginning, then began to dismiss the pandemic as a `non-event' and heavily criticized governments and agencies for over-reacting.
After the 2009 H1N1 pandemic ended, there was a general feeling that `we'd had our pandemic, it wasn't terrible, and it would be decades before the next one hit . . . '.
The problem with that logic being that viruses don't use calendars.  The gap between the 1957 and 1968 pandemics was 11 years, while the inter-pandemic period between the 1775 and 1781-82 outbreaks was only 6 years (cite).
With the rapid growth in novel viruses with pandemic potential over the past 5 years (see Updating the CDC's IRAT Rankings) - including some (H7N9, H5N1, H5N6, MERS) with potential virulence that could exceed the 1918 Spanish Flu - over the past year we've seen  renewed interest in updating pandemic plans around the globe. 

Today it is the ECDC's turn, with their release of a 26-page technical document designed to assist EU member nations as they update and revise their pandemic plans.  Some excerpts follow, but you'll want to download the entire PDF file.
ECDC: Guide To Revising The Influenza Pandemic Preparedness Plan
During the past decade, the 53 Member States of the WHO European Region, 31 of which are part of the European Union/European Economic Area, invested considerably in pandemic preparedness. This came in the wake of global threats posed by (re-)emerging diseases such as avian influenza A(H5N1) and A(H7N9), the SARS outbreak of 2003, and the outbreak of MERS (Middle East respiratory syndrome) which began in 2012. Adequate preparedness is also a national obligation under the International Health Regulations (2005) and the EU Decision on serious cross-border threats to health (No 1082/2013/EU).

The first pandemic since 1968 occurred in 2009, caused by a new strain of influenza A(H1N1) of swine origin. The virus spread rapidly around the globe and caused only mild disease in the majority of cases. However, severe disease and deaths occurred in a significant number of people, mostly in the same groups that are at risk of complications due to seasonal influenza infection, but also in other risk groups and even in previously healthy individuals. It has been estimated that in the first year of the pandemic between 151 000  and 475 000 deaths worldwide were attributable to influenza. Healthcare services, particularly critical care units, were often stretched to their limits, and early recognition and treatment of severe disease could be life-saving.

The 2009 pandemic tested national plans, and in the aftermath many countries and international organisations evaluated their preparedness and response activities. European countries, particularly in the western part of the Region, were generally better prepared for the 2009 pandemic than most countries. But when confronted with a milder pandemic than was expected, even the better prepared countries experienced gaps in their surveillance  and healthcare systems. Their planning assumptions were not flexible enough, they faced difficult communications and logistics issues with respect to pandemic vaccines, and often failed to establish effective communication lines with front-line healthcare responders.

An evaluation performed by the WHO Regional Office for Europe in collaboration with the WHO Collaborating Centre for Pandemic Influenza and Research, University of Nottingham, United Kingdom, showed that pandemic preparedness activities undertaken prior to the 2009 pandemic were useful in the response to the pandemic, and guidance from WHO and ECDC was critical in the preparedness phase. However, a global review of the functioningof the International Health Regulations and the response to the pandemic by both countries and WHO came to the conclusion that the ‘world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.’ 

The recommendations of this review have been only partially implemented, and the world has since been confronted with the failure to respond rapidly – and on the scale needed – to prevent the largest outbreak of Ebola ever recorded. As a result, the 69th World Health Assembly agreed to reform the WHO emergency response arrangements. It also agreed that the full implementation of the IHR core capacities by all Member States must be accelerated. In 2016, the new WHO Health Emergencies Programme was established (

A future influenza pandemic is inevitable, although it cannot be predicted when it will happen nor how severe it will be. Since the stress on the non-healthcare sectors was limited during the 2009 pandemic, only limited experience has been gained in multisectoral coordination. Business continuity which will be crucial in a more severe pandemic.

Earlier findings from European assessments and exercises show that there are still weaknesses in those areas. Since 2009, only thirteen countries in the WHO European Region have published revised pandemic preparedness plans (as of July 2017). This document therefore takes into account:

  • the need for all countries to review and revise as necessary their pandemic plans based on the lessons learned from the 2009 pandemic and WHO guidance on pandemic influenza risk management
  • (see: influenza_risk_management_update2017/en/);
  • the need for continuous integration of pandemic preparedness with preparedness for other public health emergencies, in line with the International Health Regulations, Decision No. 1082/2013/EU, and in light ofshrinking resources;
  • the need to develop plans for different scenarios of severity with more emphasis on national risk assessment to inform pandemic response; and
  • the need to revise the ‘WHO/Europe and ECDC Joint European Pandemic Preparedness Self-Assessment Indicators’ and develop a planning document that is useful to all Member States.
Description of the guide
Pandemic planning can be divided into 12 key areas. For each key area, the rationale and a list of good practice requirements for effective pandemic preparedness are provided.

For each key area, or requirement under a key area, countries may:

  • add requirements, indicators or outcomes for determining if a key area or requirement has been covered or implemented, or if progress has been made;
  • indicate changes that have been made to their pandemic plans after the 2009 pandemic;
  • provide to the WHO Regional Office for Europe and ECDC examples of good practice which may be shared with other countries; and
  • include questions to be addressed for each key area.
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Six months ago, in World Bank: World Ill-Prepared For A Pandemic, we saw the latest in a long line of assessments stating that a severe pandemic would test our modern medical system, society, and economy in ways that few can truly comprehend.  
While no amount of planning can fully prepare us for a severe pandemic, every little bit - undertaken by governments, the private sector, and even individuals - can help lessen the impact.
For more on pandemic preparedness, you may wish to revisit a few of these recent blogs.
WHO: Candidate Vaccines For Pandemic Preparedness - Sept 2017
#NatlPrep : Pandemic Planning Considerations

Upcoming Webinar: The Strategic National Stockpile
Are We Prepared to Help Low-Resource Populations Mitigate a Severe Pandemic?

Thursday, November 16, 2017

Italy: IZSV Reports 3 More HPAI H5N8 Outbreaks


The pace of HPAI H5 outbreaks in Italy continues to rise, with 15 outbreaks reported in the first half of November. Nearly as many as were reported in the first half of the year (n=17).

In mid-July we began to see a resurgence in H5N8 in northern Italy, with monthly totals to date running:
Jan-Jun     -  16 Outbreaks
July        -   6 Outbreaks
August      -  13 Outbreaks 
September   -   6 Outbreaks
October     -  23 Outbreaks  
November    -  15 Outbreaks (thru 15th)
In addition to these poultry outbreaks, there have been a number of detections in wild birds as well.  Today, we've three more outbreaks reported by Italy's IZSV (Istituto Zooprofilattico Sperimentale delle Venezie), bringing the total for 2017 to 79.

Highly pathogenic avian influenza (HPAI) in Italy
2016/2017 - H5N5, H5N82016 - H7N72014/2015 - H5N8, H5N12013 - H7N7

2016/2017 – H5N5, H5N8

    Outbreaks | PDF (last update: 15/11/2017)
    Maps | PDF (last update: 15/11/2017)

November 2017

16/11/2017 – On 10 November, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 a laying hen farm in Brescia province (Lombardy region). At the time of confirmation, the farm housed 54,664 birds. The farm is located at approximately 500 m from the duck farm confirmed as positive for HPAI on 3 November (67th outbreak). Samples were taken after observing an increase in mortality on 9 November. The outbreak was extincted on 14 November.

On 10 November, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 a broiler farm in Brescia province (Lombardy region). At the time of confirmation, 13,335 birds were present in the farm. On 10 November, an increase in mortality was observed and reported to the Veterinary Services. The outbreak was extincted on 14 November.

On 10 November, IZSLER confirmed as positive for Avian Influenza A virus subtype H5 another laying hen farm in Brescia province (Lombardy region). The farm is located within 600 metres from 75th outbreak, confirmed as positive earlier on the same day. The farm hosted 17,199 birds at the time of confirmation. On 10 November, an increase in mortality in one shed out of two was observed, together with a slight decrease in feed intake and a marked drop in egg production. On 15 November, the outbreak was extincted.
On 14 November, the National Reference Laboratory (NRL) for Avian Influenza and Newcastle Disease characterised as Avian Influenza A virus subtype H5N8 the viruses isolated in the last three outbreaks.

This heavy persistence of avian flu in Italy over the summer and into the fall - and at much lower levels across other parts of Europe - is in sharp contrast to previous years when H5N8 all but disappeared in Europe and North America once spring ended (see PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl).

As we discussed in Avian Flu: That Was Then . . This Is Now, HPAI H5N8 has undergone dramatic evolutionary changes since 2016, and additional changes in its genetics and behavior are always possible.  

EID Journal: Avian H7N2 Virus in Human Exposed to Sick Cats

NYC Shelter


Eleven months ago the New York City Health Department issued an unusual Statement On Avian H7N2 In Cats at a Manhattan animal shelter. While cats are known to be susceptible to avian (and some novel) flu strains (see Catch As Cats Can) this outbreak was remarkable due to its size (initially involving 45 cats), its location (NYC), and the virus involved - a relatively uncommon avian LPAI H7N2 virus not reported in the United States in years. 
Within a week, the story had escalated when - three days before Christmas - the NYC DOH released a statement announcing a mild Human H7N2 Infection in a  veterinarian who was treating sick cats.   
Additionally, the number of infected cats had doubled to 100, and was reported across multiple animal shelters in the area. Eventually that number would grow to 450 (see January 13th NYC DOH Update On H7N2 In Cats), although no additional human cases were reported. 

Although the risk to human health was believed low, the Health Department offered guidance to those who have had contact with cats in these shelters, and urged people to avoid `nuzzling and close facial contact' with sick cats.

Human infection with LPAI H7N2 has only rarely been reported, with only a couple of cases  on record in the United States (in 2002 and 2003), and 4 people who were presumed to have been infected in the UK in 2007 following local outbreaks in poultry. In all cases, illness was described as mild and self limiting.
While this outbreak was contained, it is worth noting that at the same time this was happening, we were following reports of HPAI H5N6 in cats in South Korea (see Korean CDC Statement On H5N6 In Cats).
Last May, in J. Virology: Virulence Of A Novel H7N2 Virus Isolated From Cats In NYC - Dec 2016,  we saw a follow up report on the NYC outbreak, which found the H7N2 virus will require additional adaptation before it poses a substantial human health threat. 
They did note the virus replicated with increased efficiency in human bronchial epithelial cells over previous H7N2 strains tested, and were better adapted to using a lower pH for HA activation, similar to seasonal flu viruses.
Today's report from the EID Journal builds on these findings, noting the `. . .  acquisition of many genetic changes throughout the genome of the human and cat H7N2 viruses . . . ' that `suggests onward evolution of the virus since it was last detected in poultry and wild birds.'

Among their discoveries, they found the human H7N2 virus bound to both α2,6-linked (mammalian) and α2,3-linked (avian) sialic acids, an important trait for any species jumping avian flu virus to acquire. 
While currently appearing to have only low virulence in humans, H7N2's ability to spread rapidly in cats, and reports of ongoing evolutuionary adaptation to mammals, makes it a virus well worth keeping our eyes on.
I've only included some excerpts, so follow the link to read the Dispatch in its entirety.  When you return, I'll have a brief postscript.

Avian Influenza A(H7N2) Virus in Human Exposed to Sick Cats, New York, USA, 2016

Atanaska Marinova-Petkova, Jen Laplante, Yunho Jang, Brian Lynch, Natosha Zanders, Marisela Rodriguez, Joyce Jones, Sharmi Thor, Erin Hodges, Juan A. De La Cruz, Jessica Belser, Hua Yang, Paul Carney, Bo Shu, LaShondra Berman, Thomas Stark, John Barnes, Fiona Havers, Patrick Yang, Susan C. Trock, Alicia Fry, Larisa Gubareva, Joseph S. Bresee, James Stevens, Demetre Daskalakis, Dakai Liu, Christopher T. Lee, Mia Kim Torchetti, Sandra Newbury, Francine Cigel, Kathy Toohey-Kurth, Kirsten St. George, David E. Wentworth, Stephen Lindstrom, and C. Todd Davis


An outbreak of influenza A(H7N2) virus in cats in a shelter in New York, NY, USA, resulted in zoonotic transmission. Virus isolated from the infected human was closely related to virus isolated from a cat; both were related to low pathogenicity avian influenza A(H7N2) viruses detected in the United States during the early 2000s.

Avian influenza viruses occasionally cross the species barrier, infecting humans and other mammals after exposure to infected birds and contaminated environments. Unique among the avian influenza A subtypes, both low pathogencity and highly pathogenic H7 viruses have demonstrated the ability to infect and cause disease in humans (1,2).

 In the eastern and northeastern United States, low pathogenicity avian influenza (LPAI) A(H7N2) viruses circulated in live bird markets periodically during 1994–2006 (3) and caused poultry outbreaks in Virginia, West Virginia, and North Carolina in 2002 (4). During an outbreak in Virginia in 2002, human infection with H7N2 virus was serologically confirmed in a culler with respiratory symptoms (5). In 2003, another human case of H7N2 infection was reported in a New York resident (6); although the source of exposure remains unknown, the isolated virus was closely related to viruses detected in live bird markets in the region.

Because of the sporadic nature of these and other zoonotic infections with influenza H7 viruses throughout the world, the World Health Organization (WHO) recommended development of several candidate vaccine viruses for pandemic preparedness purposes, including 2 vaccines derived from North American lineage LPAI viruses, A/turkey/Virginia/4529/2002 and A/New York/107/2003 (7).



The circulation of an influenza A(H7N2) virus at the animal–human interface, especially among common companion animals such as domestic cats, is of public health concern. Moreover, from an epidemiologic perspective, it is essential to understand the current distribution of LPAI A(H7N2) viruses in both avian and feline hosts. 

The US Department of Agriculture and state departments of agriculture have conducted routine avian influenza surveillance in live bird markets; 132,000–212,000 tests for avian influenza were performed annually during 2007–2014 (15), but LPAI A(H7N2) viruses were not detected. 
The acquisition of many genetic changes throughout the genome of the human and cat H7N2 viruses we report, however, suggests onward evolution of the virus since it was last detected in poultry and wild birds. We found that the human virus bound to α-2,6–linked sialic acid receptors, which are more common in mammals, yet retained α-2,3–linked sialic acid binding, indicating that it has dual receptor specificity; this information can be used in pandemic risk assessment of zoonotic viruses.
Although human infections with LPAI A(H7N2) viruses have occurred previously, we know of no other reported instances of direct transmission from a cat to a human.

Dr. Marinova-Petkova is a microbiologist with the Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Her research interests include studying influenza viruses at the animal–human interface, influenza virus evolution, and animal models for risk assessment of zoonotic pathogens.
Until relatively recently (2004) dogs and cats were both viewed as being relatively immune to influenza viruses. That began to change in 2004 and 2005 when equine H3N8 was detected in dogs, and avian H5N1 began to show up in both dogs and cats in Asia.
While we worry primarily about birds or swine producing the next pandemic virus, we can't discount the possibility of being blindsided by a virus coming from another host species.
Dogs, cats, seals (and other marine mammals), horses, bats, and a variety of peridomestic animals (rabbits, skunks, mink, etc.) - even cattle - have all been found to carry flu viruses.

Some recent blogs on influenza infection and evolution among some of these `unusual suspects' include:

Study: Experimental Infection Of Dogs With HPAI H5N1 & HPAI H5N6
J. Infect. Dis.: Molecular, Antigenic & Pathological Features of Canine H3N2 Influenza

That Touch Of Mink Flu (H9N2) - Revisited

Sci Rpts: Avian & Human Influenza Compatible Receptor Cells In Little Brown Bats

Serological Evidence Of Influenza D Among Persons With & Without Cattle Exposure

mBio: A Mammalian Adapted H3N8 In Seals
Report: Skunks and Rabbits Can Catch And Shed Avian Flu

WHO Update: Marburg Virus In Uganda & Kenya

Credit CDC


The Marburg outbreak we began following almost a month ago (see Uganda's Virus Research Institute Confirms 2 Marburg Virus Deaths) appears to have been contained with only 3 confirmed (fatal) cases, although enhanced surveillance activities will continue until December 7th. 
According to the WHO, all three cases were epidemiologically linked and belonged to one family. Several hundred potential contacts have been followed up on, and monitored, but none have developed the disease. 
While small, this is the third outbreak reported by Uganda (15 cases in 2012's outbreak see Here & 1 one in 2014's Here) over the past 5 years, with all three starting in the month of October.

Like with Ebola viruses, bats are believed to be the primary reservoir host for Marburg, although it isn't known what other hosts might carry the virus.  Human infection is often attributed to the consumption of bush meat.

Excerpts from yesterday's update follow:

Marburg virus disease – Uganda and Kenya

Disease outbreak news

15 November 2017

On 17 October 2017, the Ugandan Ministry of Health (MoH) notified WHO of a confirmed outbreak of Marburg Virus Disease in Kween District, Eastern Uganda. The MoH officially declared the outbreak on 19 October 2017. As of 14 November, three cases have been reported including two confirmed cases, and one probable case. All three cases have died, resulting in a case fatality rate of 100%. The cases were epidemiologically linked and all belong to the same family.

Chronologically, the first case (probable) was a 35-years-old herdsman who frequently hunted near the area of Kaptum, known for its bat-infested caves. He was admitted to hospital on 20 September with Marburg-like symptoms and died five days later. The first confirmed case was the sister and caretaker of the first case. The second confirmed case was the brother of the first two cases, who died on 26 October 2017 and had a safe and dignified burial on the same day.

Prior to his death, the second confirmed case travelled to Kenya where he visited his relatives in West Pokot County, as well as a traditional healer in Trans Nzoia County. On 29 October 2017, the Ugandan MoH notified WHO and the Kenyan MoH of these high-risk contacts. The traditional healer tested negative for Marburg virus disease on repeated blood specimen analyses performed at the Kenyan Medical Research Institute (KEMRI) in Nairobi. She and her family were monitored for 21 days. The two relatives from West Pokot, as well as other contacts in the same county, also completed their 21 days of follow up.

Active case search, death surveillance, safe and dignified burials and community mobilization are ongoing in Kween and Kapchorwa districts. In Uganda, of the 339 contacts listed, 283 have completed 21 days of follow-up and 56 are still being monitored. Contact follow-up is ongoing in Kween for the 56 contacts, while In Kapchorwa District, all the listed contacts have completed the 21 days follow-up period. All remaining contacts are expected to complete 21 days of follow up on 16 November 2017. Enhanced surveillance activities will continue until 7 December 2017.

Public health response
  • The Ugandan MoH continues to proactively respond to the outbreak with support from WHO and partners. 
  • Contact tracing and active case search in health facilities and at the community level are ongoing. On 14 November 2017, 56 contacts were still under follow up. Reported deaths are also investigated for Marburg before burial and suspicious deaths are buried according to safe and dignified burial protocols. 
  • Two Marburg treatment centers have been set up in Kapchorwa hospital and Kaproron with logistical support from Médecins Sans Frontières (MSF) France, UNICEF and WHO. 
  • Social mobilization and risk communication are ongoing. Over 12 000 community members have received information on Marburg virus disease with the support from Red Cross volunteers, UNICEF and WHO communication experts.
  • Psychosocial support specialists have been deployed to Kween and counselling sessions are being conducted for family members of the deceased Marburg cases, health workers, and other community members.
  • Guided tours of the Marburg treatment units in Kapchorwa and Kaproron were organized in order to dispel fear of the treatment centers and rumours of wrong practices by healthcare workers that cause deaths among admitted patients.
  • On 7 November 2017, a cross-border meeting between Uganda and Kenya health authorities was organized to strengthen cross-border surveillance in Kapchorwa, and cross-border surveillance activities are ongoing.
  • The Kenyan Marburg virus disease outbreak contingency plan and the public health Emergency Operations Center have been activated and preparedness measures have started. 
  • Two thousand Personal Protective Equipment (PPE) kits have been dispatched by WHO and shipped to Trans Nzoia County, Kenya.
  • A temporary treatment center (Kaisangat Health center) has been identified and the Kenya Red Cross Society is recruiting and re-orienting nurses to manage the Marburg Virus Disease treatment centre.
  • UNICEF is assisting with communication activities and community engagement.
WHO risk assessment

Marburg virus disease is an emerging and highly virulent epidemic-prone disease associated with high case fatality rates (CFR: 23 to 90%). Marburg virus disease outbreaks are rare. The virus is transmitted by direct contact with the blood, body fluids and tissues of infected persons or wild animals (e.g. monkeys and fruit bats).

Candidate experimental therapeutics are being reviewed for potential clinical trials.
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Wednesday, November 15, 2017

Smithsonian `Next Pandemic' Webinar Now Available Online


For those who were unable to watch the live webinar held on Monday by Smithsonian Magazine and Johns Hopkins (see Upcoming Smithsonian Livestream: “The Next Pandemic: Are We Prepared?") the full 2 hour and 34 minute presentation is now available on the Smithsonian Magazine Youtube Channel.
Between scheduling a 3-hour block of time out of a workday, and some reported streaming problems (my iPad feed had low volume, and a lot of buffering), not everyone who wanted to see this livestreamed event was able to do so. 
The Smithsonian Magazine has an overview of Monday's presentation, along with the embedded video on their website:
When the Next Pandemic Hits, Will We Be Prepared?
The question isn’t whether a pandemic will strike—it’s how it will play out.
         (Continue . . . )

Or you can watch it on Youtube at the following link:
Although I haven't viewed it all (yet), from what I was able to see on Monday, this is well worth your time to view.

WHO SitRep #10: Plague In Madagascar


While you wouldn't guess it by the breathless coverage in the tabloids, the news out of Madagascar continues to be encouraging, although the WHO is quick to point out the crisis is far from over. Even in normal years plague cases on the island can be reported well into April, and this year has been anything but normal. 
In this latest WHO Sitrep - with numbers updated through the 10th of November - a cumulative total of 2,119 confirmed, probable and suspected cases of plague, including 171 deaths (CFR of 8%), have been reported.

The number of new cases continues to slow (see epi curve above), leading to the following updated Risk Assessment.
The number of new cases of pneumonic plague has steadily declined since mid-October. From 7 to 10 November 2017, 73 pneumonic and 9 bubonic cases of plague have been reported to WHO. While the number of new cases and hospitalizations of patients due to plague is declining in Madagascar, WHO anticipates additional cases to be reported until the typical plague season ends in April 2018.

Based on available information and response measures implemented to date, the potential risk of further spread of plague at national level remains high. The risk of international spread is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures and advice to traveller to Madagascar, and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low.
WHO is re-evaluating the risk assessment based on the evolution of the outbreak and information from response activities.
Some excepts from the latest Situation Update follow:
Date of issue: 14 November 2017

WHO continues to support the Ministry of Public Health and other national authorities in Madagascar to monitor and respond to the outbreak of plague. From 7 to 10 November 2017, 86 confirmed, probable and suspect cases of plague were reported.

From 1 August to 10 November 2017, a cumulative total of 2 119 confirmed, probable and suspected cases of plague, including 171 deaths (case fatality rate 8%), have been reported from 55 of 114 (48%) districts in Madagascar.

Analamanga Region has been the most affected, with 72% of all recorded cases.Since the beginning of the outbreak, 1 618 (76%) of reported cases have clinically been classified as pulmonary plague, 324 (15%) as bubonic plague, one was septicaemic, and 176 have not yet been classified (further classification of cases is in process). A total of 82 healthcare workers (with no deaths) have been affected.

Of the 1 618 clinical cases of pneumonic plague, 365 (23%) have been confirmed, 573 (35%) are probable and 680 (42%) remain suspected (additional laboratory results are in process). Twenty-five isolates of Yersinia pestis have been cultured and are sensitive to all antibiotics recommended by the National Plague Control Program.

About 95% (6 729) of 7 122 contacts identified thus far have completed their 7-day follow up and a course of prophylactic antibiotics. Since the beginning of the outbreak, a total of eleven contacts developed symptoms and became suspected cases. On 10 November 2017, 218 out of 243 (90%) contacts under follow-up were reached and provided with prophylactic antibiotics.

Plague is endemic on the Plateaux of Madagascar, including Ankazobe District, where the current outbreak originated. A seasonal upsurge, predominantly of the bubonic form, usually occurs yearly between September and April. This year, the plague season began earlier and the current outbreak is predominantly pneumonic and is affecting both endemic and non-endemic areas, including major urban centres such as Antananarivo (the capital city) and
Toamasina (the port city).

There are three forms of plague, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link