Principal Epidemic Diseases

(Plague)
 Plague Worldwide (WHO)
• Plague epidemics have occurred in Africa, Asia,
and South America but most human cases since
the 1990s have occurred in Africa
• Almost all of the cases reported in the last 20
years have occurred among people living in
small towns and villages or agricultural areas
rather than in larger towns and cities
• Currently, the three most endemic countries are
the Democratic Republic of the Congo,
Madagascar, and Peru
• Plague is transmitted between animals and
humans by the bite of infected fleas, direct
contact with infected tissues, and inhalation
of infected respiratory droplets.
• Plague can be a very severe disease in people,
with a case-fatality ratio of 30% to 60% for the
bubonic type, and is always fatal for the
pneumonic kind when left untreated
 What is plague?
• caused by Yersinia pestis, a zoonotic bacteria
usually found in small mammals and their fleas
• People infected with Y. pestis often develop
symptoms after an incubation period of 1-7
days
• Occurs in many forms
– Enzootically
– Epizootically
– Sporadically
– In epidemics
 Epidemiological determinants
Agent factors
Agent
• Causative agent: Yersinia pestis, gram negative,
non motile, coccobacillus, bipolar staining
• Bacilli occur in great abundance in buboes,
spleen, blood, liver, and other viscera of
infected person and in sputum of pneumonic
plague
• Plague bacilli can survive and multiply in soil of
rodent burrows
Reservoir of infection
• Wild rodents are the natural reservoirs of
plague
• In India, the wild rodent, Tatera indica has been
incriminated as the main reservoir

Source of infection
• Infected rodents
• Fleas
• Cases of pneumonic plague
Mode of exit
• Per-cutaneously
Mode of transmission
• It is transmitted between animals through fleas
• Humans can be infected through:
– the bite of infected vector fleas
– unprotected contact with infectious bodily fluids or
contaminated materials
– the inhalation of respiratory droplets/small particles from
a patient with pneumonic plague
Mode of entry
• Per-cutaneously
Host factors
Susceptible host
• Age and sex
– All ages and both sexes are susceptible
• Human activities
– Hunting, grazing, cultivation, harvesting and
construction activities offer opportunities for flea-
man contact
• Movement of people
• Immunity
– Man has no natural immunity
– Immunity after recovery is relative
Environmental factors
• Season
– In northern India, the “plague season” starts from
September to May
– With the onset of hot weather, the disease tends to die
out
– In south India, there was no definite plague season
– Disease was found active all year round
• Temperature and humidity
– Temperature of 20-25 deg C and relative humidity of
60% and above are favorable
• Rainfall
– Heavy rainfall tends to flood the rat burrows
• Urban and rural areas
• Human dwellings
Vectors of plague
– Most common vector is the rat flea,
Xenopsylla cheopis
– Both sexes bite and transmit the disease
Blocked flea
– A flea may ingest up to 0.5 cu mm of blood which
may contain as many as 5000 plague bacilli
– The bacilli multiply in the gut of rat flea and may
block the proventriculus so that no food can pass
through
– Such a flea is called blocked flea
Flea indices: useful in evaluating the
effectiveness of a spray programme
• Total flea index
• Cheopis index
– more significant than total flea index. If > 1,
indicative of potential explosiveness of situation
• Specific percentage of fleas
• Burrow index
 Human plague
• Most frequently contracted from
– A bite of infected flea
– Direct contact with tissues of infected animal
– Droplet infection from cases of pneumonic plague
• Three types of human plague
– Bubonic plague
– Pneumonic plague
– Septicemic plague
• Bubonic plague
– Most common type
– Infected rat flea usually bite on lower extremities
– Bacilli proliferate in the regional lymph glands
Typical features
– Sudden fever, chills, headache, prostration
– Painful lymphadenitis
– Bubonic plague cannot spread from person to
person because bacilli are locked up in buboes
• Pneumonic plague
– Primary pneumonic plague is rare
– follows as a complication of bubonic and
septicemic plague
• Septicemic plague
– Primary septicemic plague is rare, except for
accidental lab infections
– fever, chills, extreme weakness, abdominal pain,
shock, and possibly bleeding into the skin and
other organs
– Skin and other tissues may turn black and die,
especially on fingers, toes, and the nose.
 Prevention and control
Notification
• Is required by international health regulation
Reporting
• All cases must be reported to the higher authority
by the health person (e.g., HA, TMO)
Early diagnosis and prompt treatment
• During epidemic situations, diagnosis can be made
on clinical grounds
• In other situation, “rat falls” provide useful warning
of possible outbreaks
• Plague suspected humans and rodents must be
examined bacteriologically to confirm the presence
of plague
Treatment
• Antibiotic treatment is effective against plague
bacteria, so early diagnosis and early treatment can
save lives.
• Drug of choice is streptomycin
• 30 mg/kg body weight daily IM in 2 divided doses
for 7 to 10 days
• Tetracycline orally 30-40 mg of body weight daily in
an alternative drug and sometimes given in
combination with streptomycin
• Gentamycin, 2 mg/kg body weight loading dose,
then 1.7 mg/kg body weight every 8 hour IV
• Sulphonamides, used if other drugs are not available
Disinfection
• In situations where there may have been gross
exposure to plague, personal decontamination can
be performed by removing contaminated clothing
and washing exposed skin with soap and water.
Disinfestation
• Control of fleas
– Most effective method to break the chain of
transmission is destruction of rat fleas by insecticides
– DDT (10%) and BHC (3%), used as dust
– In areas of resistance to one or both of these, dust of
carbaryl (2%) or malathion (5%) is used
• Control of rodents
– Continuous mass destruction of rodents is an important
plague preventive measure
Immunoprophylaxis
• Vaccination
• To be effective, vaccination should be carried out at
least a week before an anticipated outbreak and the
vaccine should be given in 2 doses
Chemoprophylaxis
• Highly recommended
• Should be offered to all plague contacts, medical,
nursing, and public health personnel exposed to the
risk of infection
• Drug of choice is tetracycline
• For adult dose is 500 mg, 6 hourly for 5 days
• Cheaper alternative is sulphonamide, 2-3 g daily for
5-7 days
Surveillance
• In areas where natural plague foci exist, or
where there is history of past infection,
surveillance is essential
Health education
• Emphasis must be placed on the need for the
prompt reporting of dead rats and suspected
human cases
• Medical practitioners should keep plague in
mind for differential diagnosis of any cases of
fever with lymphadenopathy, or when multiple
cases of pneumonia occur
Environmental sanitation
• proper storage, collection and disposal of
garbage
• proper storage of food-stuffs,
• construction of rat-proof buildings, godowns
and warehouses
• elimination of rate burrows by blocking them
with concrete.
• Sanitation is essential to permanent control of
rats and mice
References
Park’s textbook of preventive and social medicine
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