H5N1

China: 2 pneumonic plague cases confirmed in Inner Mongolia

Thanks to Tony Trehy for alerting me to this story. Via Xinhuanet: Two pneumonic plague cases reported in Beijing. The wording could be clearer: the cases were diagnosed in Beijing, but they themselves are under care in Chaoyang, Inner Mongolia.

Two people have been diagnosed with pneumonic plague in Beijing, local health authorities confirmed Tuesday. 

According to the government website of Chaoyang District in Beijing, two patients from north China's Inner Mongolia Autonomous Region were diagnosed with pneumonic plague, which doctors in Beijing confirmed Tuesday. 

At present, the two patients have received proper treatment in relevant medical institution of Chaoyang District and relevant disease prevention and control measures have been taken.

How pandemics shape social evolution

A very interesting review in Nature of Frank M. Snowden's new book Epidemics and Society: From the Black Death to the Present. The reviewer, Laura Spinney, is herself the author of Pale Rider, the definitive history of the Spanish flu: How pandemics shape social evolution. Excerpt:

When will we learn never to declare the end of anything? Only 50 years ago, two prominent US universities closed their infectious-disease departments, sure that the problem they studied had been solved. Now, cases of measles and mumps are on the rise again in Europe and the United States, new infectious diseases are emerging at an unprecedented rate, and the threat of the next pandemic keeps philanthropist Bill Gates awake at night. 

So it’s a shame that to make this point, Epidemics and Society, Frank Snowden’s wide-ranging study on this rolling human reality, repeats the urban myth that in 1969, US surgeon-general William Stewart said, “It is time to close the book on infectious diseases, and declare the war against pestilence won.” Even though Stewart never said this, it’s clear that there was a pervasive, dangerously complacent attitude in the late 1960s. 

International public-health authorities were predicting that pathogenic organisms, including the parasite that causes malaria, would be eliminated by the end of the twentieth century. Snowden’s broader thesis is that infectious diseases have shaped social evolution no less powerfully than have wars, revolutions and economic crises. 

It’s not a new message, but it bears repeating. Snowden, a historian at Yale University in New Haven, Connecticut, has assembled a vast amount of evidence, some the fruit of his own research. His global history spans more than a millennium of outbreaks, covering diseases from bubonic plague to smallpox, malaria, the respiratory illness SARS, Ebola and beyond. He rehashes the long history of scapegoating, violence, mass hysteria and religiosity that have accompanied epidemics, but only to speculate on their longer-term social, political and cultural consequences. 

When cholera struck Paris in 1832 — in an epidemic that eventually killed nearly 19,000 Parisians — a conspiracy theory spread that the unpopular government under King Louis Philippe was poisoning wells with arsenic. The police and army were barely able to contain the violence that ensued. The institutional memory of those events fuelled dread of the “dangerous classes”: poor people. 

That, Snowden argues, might help to explain why the two most egregious examples of class-based repression in the nineteenth century also took place in the French capital. These were the violent crushing of the 1848 revolution and the bloody destruction of the Paris Commune, the revolutionary government that briefly ruled the city 23 years later.

Max Planck-Harvard genome study shows extent, diversity of Roman plague

Via The Harvard Gazette: Max Planck-Harvard genome study shows extent, diversity of Roman plague. Excerpt:

New research on one of history’s most devastating plagues shows that it spread farther than previously believed, reaching post–Roman Britain, and provides new information about the plague bacteria’s evolution during a pandemic that lasted more than 200 years. 

The work, conducted by an interdisciplinary team from Harvard University and the Max Planck Institute for the Science of Human History in Germany, covered 21 archaeological sites across Europe and the Mediterranean that date to the time of the Justinianic Plague, which first struck in 541 A.D. and returned in multiple waves until 750.  

Samples taken from human remains at the sites were examined for the DNA of Yersinia pestis, the bacterium known to cause the plague, which centuries later swept across Europe in perhaps history’s most famous pandemic, the Black Death, which may have killed as many as half of all Europeans. 

Though less widely known, the Justinianic plague is believed to have been nearly as deadly. It began during the reign of Emperor Justinian, who ruled the Roman Empire’s eastern portion from his capital in Constantinople (modern-day Istanbul), after the fall of Rome and the western portion of the empire. The pandemic centered on Constantinople and ports around the Mediterranean. Though reports from the time say the first plague outbreak killed half the population, scholars of the era disagree on its impact. Some argue that, though deadly, it played little role in shaping the society and the economy. Others argue that it had the potential for history-altering impacts on a wide array of human activities.  

Such impacts, however, remain unproven and are the subject of active investigation by the research team, which includes historians, archaeologists, and experts in ancient DNA under the auspices of the 20-month-old Max Planck-Harvard Research Center for the Archaeoscience of the Ancient Mediterranean (MHAAM).

In the work, published recently in the Proceedings of the National Academy of Sciences, researchers reconstructed eight new Y. pestis genomes from the samples gathered from sites in modern-day France, Germany, Spain, and Great Britain. The genomes provided further confirmation that it was indeed the plague — known in its various forms as bubonic, septicemic, or pneumonic — that swept the Mediterranean during Justinian’s time. Though the cause of the pandemic had long been debated, plague was confirmed as the likely causative factor in 2013 and again in 2016 when researchers announced they’d identified Y. pestis genomes in graves in Bavaria dated to that period.

Town in Mongolia closed for quarantine after bubonic plague claimed two lives

Via The Siberian Times, an update on a strange story: Town in Mongolia closed for quarantine after Bubonic plague claimed two lives. Excerpt:

The Mongolian Ministry of Health confirmed two people - a 38 years old man and his pregnant wife, 37 - died from plague after consuming raw meat and internal organs of a marmot.  Their deaths left four children as orphans aged from two to 13.   

Dramatic pictures have shown at least one aircraft being met by anti-contamination emergency workers in a bid to prevent spread of the disease.   

The local town of Ulgii (or Ölgii) on the border with Russia was shut for quarantine by Mongolian health authorities and army.  

Several dozen tourists from all over the world had to alter their holiday plans, and are now waiting to hear when they might be allowed to leave the town.

‘Did you think that the plague was something from the Dark Ages? Us too!! We were just about to leave Ulgii to go deeper into Mongolia, but all exits of the town were shut and we were not allowed to leave. Half of the city is closed due to some plague-contaminated marmots!’ wrote traveler Elena Koneva from Kemerovo who is marooned on the border with her husband Timur.  

 ‘This is just so surreal!’   

With a big group of fellow travellers from the US, Netherlands, Sweden, Switzerland, South Korea and Germany, the Russians were besieging the authorities, desperate to leave the town. 

The tragic family that died from plague got infected after eating raw kidneys of a marmot.   

An old Mongolian tradition says that a raw meat and internal organs of freshly killed marmot strengthens health, local media reported.  

The Mongolian Ministry of Health stressed they did not think that the situation with the plague was critical or anywhere near epidemic.   

Yet there was no deadline announced for the quarantine which in the worst case scenario can last as long as 21 days.  

‘We were told to wait for updates on Monday, 6 May’, tourist Timur Konev said. 

Plague advice from the Mongolian Ministry of Health: 'Do not bite marmots'

The Mongolian Ministry of Health has posted this notice on its website. The Google translation and then a comment:

In Dornod soum of Bayan-Ulgii aimag, a potential incidence of marmots was recorded and two deaths per family. At present, these people are eating raw marmots and kidneys.

A quarantine center is established in the Aimag center, and a professional team of the Ministry of Health, State Special Committee and Zoonoses Center are working on the site.

Therefore, the people are sending you the following warnings:

• Must not hunt marmot;

• Purchase of marmot originated raw materials;

• Do not touch dead marmots with slaughter and movement;

• Not to transport marmot raw materials, meat, cities or settlements;

• Do not bite marmots and rodents;

• Immunization of the pandemic;

• To keep the pet dog in constant contact;

• If you have any symptoms such as laryngitis, fever, fever, headache, internal anxiety, facial muscles and sore throat, please call NCCD 70282853 and NCCD 100 immediately.

Raw marmot kidney, I presume, is an acquired taste. But not acquired for long. Since fleas infected with Yersinia pestis are the routine vectors for plague, consuming infected animal flesh seems an unusual way to contract the disease.

Alert on Russian border with Mongolia after two deaths from bubonic plague

Mongolian emergency staff check passengers on arrival at Ulaanbaatar. Credit: The Siberian Times

Thanks to Maryn McKenna for tweeting about this story. Via The Siberian Times: Alert on Russian border with Mongolia after two deaths from ‘bubonic plague’. Click or tap through for more photos. Excerpt:

The Mongolian authorities have confirmed the deaths of a husband and wife from suspected bubonic plague in Ulgii district.  

Bayan-Ulgii province's emergency management department said: ‘Preliminary test results show that bubonic plague likely caused the deaths of the two people.’ 

An ‘indefinite quarantine’ period has been declared to prevent it spreading. 

Dramatic pictures showed urgent checks by emergency staff in protective clothing on air passengers arriving in Mongolian capital  Ulaanbaatar on a flight from Bayan, Ulgii and Khovd.

Bayan-Ulgii is outlined in red. Credit: Google Maps.
 

An emergency team from the National Centre for Communicable Diseases and Specialised Border Inspection checked the passengers.  

All passengers from Ulgii were sent to the hospital. Others were examined separately in a sports complex.  

Russian tourists from Siberia and the Urals were affected when a key border crossing was suddenly closed amid suspicion it was related to the plague outbreak.   

Novosibirsk resident Elena told NGS: ‘On the night from 30 April to 1 May the exit from the city of Ulgii was closed because someone died in hospital that night.  

‘This plague is spread by local animals - marmots.’

A group of nine tourists has sought help from the Russian consulate.  

An FSB border control officer in Altai Republic said that the frontier was closed due to the May holidays.  

Reports say the border will be shut until 5 May.  

Reports say a man, aged 38, died on 27 April and his pregnant wife, 37, three days later. Their deaths leave four children as orphans aged from two to 13.   

Dr N.Tsogbadrakh, director of National Centre for Zoonotic Dermatology and Medicine, said: 'Despite the fact that eating marmots is banned, Citizen T hunted marmot. 

‘He ate the meat and gave it to his wife, and they died because the plague affected his stomach.  

 ‘Four children are orphaned.’

 A total of 158 people who came directly or indirectly into contact with the couple are ‘under supervision’.  

The plague is a bacterial disease that is spread by fleas living on wild rodents such as marmots.   

The disease can kill an adult in less than 24 hours if not treated in time, according to the World Health Organisation. 

The plague is believed to be the cause of the Black Death that spread through Asia, Europe and Africa in the 14th century, killing an  estimated 50 million people.

Epidemiological characteristics of an urban plague epidemic in Madagascar, August–November, 2017

Via The Lancet Infectious Diseases: Epidemiological characteristics of an urban plague epidemic in Madagascar, August–November, 2017: an outbreak report. The summary: 

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.

WHO AFRO: Pneumonic plague in Uganda

WHO AFRO has published its Weekly Bulletin on Outbreaks and Other Emergencies for week 10 (March 4-10). It includes this report:

On 5 March 2019, the Uganda Ministry of Health reported two probable cases of pneumonic plague in Zombo District, located in the West Nile sub-region, at the border with the Democratic Republic of the Congo. The event was initially reported to the local district health authority on 1 March 2019 when a 35-year-old woman presented to the local health facility (Warr Health Centre III) with fever, cough with bloody sputum and difficulty in breathing. and she died shortly after arrival. A clinical diagnosis of pneumonia was made, and no specimens were collected.

On 4 March 2019, a 23-year-old cousin of the deceased index case presented to the same health facility with a similar illness. The symptoms of fever, cough and difficulty in breathing started on 3 March 2019. Initial clinical laboratory investigation was positive for malaria on blood smear microscopy. However, because of the clinical presentation raising a suspicion of plague, the Uganda Virus Research Institute (UVRI) Plague Program based in Arua District (a regional hub for West Nile) was called in to review the patient and collect appropriate samples. Preliminary tests on a sputum specimen were positive for plague on rapid diagnostic test (RDT). Additional specimens were collected and transported to the Plague Laboratory in Arua for culture, and the test results are pending.

Blood specimens collected and shipped to the UVRI in Entebbe tested negative for Ebola, Marburg, Crimean-Congo and Rift Valley fever by
polymerase chain reaction. The patient is being managed on antibiotic therapy in Warr Health Centre III and she is steadily improving.

Fifty-five high risk contacts (family members, those who participated in the traditional burial and 11 health workers) have been identified and are under follow up. An additional 59 contacts who attended the burial but did not come into contact with the deceased and/or the current patient have been listed.

Further epidemiologic investigation established that the index case (for the event in Uganda) previously lived in Atungulei village in Mahagi
District, Ituri Province, Democratic Republic of the Congo. She reportedly lost a 4-year-old child in the past days, prompting her relatives from
Uganda to travel to the Democratic Republic of the Congo for the burial. After finding her sick, the relatives (from Uganda) decided to transport
her to Uganda for treatment. In addition, there is information that three other people died of similar illness in the Democratic Republic of the
Congo. Authorities in the Democratic Republic of the Congo have been informed and investigations are ongoing.

PUBLIC HEALTH ACTIONS

 • A national rapid response (RRT) team has been deployed to the affected district, working with the district RRT to conduct outbreak
investigation and implement initial response activities. The two teams are developing an outbreak response plan.

• Case definitions for plague have been disseminated to health facilities to improve case detection.

• The identified high-risk contacts, including 11 health workers, are being followed up daily.

• Health education and community sensitization activities were conducted during the burial of the first probable case. Health education is also being provided to the contacts being followed up.

• WHO has provided personal protective equipment (gloves, face masks and shields, gumboots, aprons, coveralls, etc.), triple packaging specimen materials and spray pumps.

The Black Death may have transformed medieval societies in sub-Saharan Africa

Via Science: The Black Death may have transformed medieval societies in sub-Saharan Africa. Excerpt:

In the 14th century, the Black Death swept across Europe, Asia, and North Africa, killing up to 50% of the population in some cities. But archaeologists and historians have assumed that the plague bacterium Yersinia pestis, carried by fleas infesting rodents, didn't make it across the Sahara Desert. Medieval sub-Saharan Africa's few written records make no mention of plague, and the region lacks mass graves resembling the "plague pits" of Europe. Nor did European explorers of the 15th and 16th centuries record any sign of the disease, even though outbreaks continued to beset Europe.  

Now, some researchers point to new evidence from archaeology, history, and genetics to argue that the Black Death likely did sow devastation in medieval sub-Saharan Africa. "It's entirely possible that [plague] would have headed south," says Anne Stone, an anthropological geneticist who studies ancient pathogens at Arizona State University (ASU) in Tempe. 

If proved, the presence of plague would put renewed attention on the medieval trade routes that linked sub-Saharan Africa to other continents. But Stone and others caution that the evidence so far is circumstantial; researchers need ancient DNA from Africa to clinch their case. The new finds, to be presented this week at a conference at the University of Paris, may spur more scientists to search for it. 

Plague is endemic in parts of Africa now; most historians have assumed it arrived in the 19th century from India or China. But Gérard Chouin, an archaeologist and historian at the College of William & Mary in Williamsburg, Virginia, and a team leader in the French National Research Agency's GLOBAFRICA research program, first started to wonder whether plague had a longer history in sub-Saharan Africa while excavating the site of Akrokrowa in Ghana. 

Founded around 700 C.E., Akrokrowa was a farming community surrounded by an elliptical ditch and high earthen banks, one of dozens of similar "earthwork" settlements in southern Ghana at the time. But sometime in the late 1300s, Akrokrowa and all the other earthwork settlements were abandoned. 

"There was a deep, structural change in settlement patterns," Chouin says, just as the Black Death ravaged Eurasia and North Africa. With GLOBAFRICA funding, he has since documented a similar 14th century abandonment of Ife, Nigeria, the homeland of the Yoruba people, although that site was later reoccupied.

Events in the 14th century also transformed the site of Kirikongo in Burkina Faso, where Daphne Gallagher and Stephen Dueppen, archaeologists at the University of Oregon in Eugene, recently excavated. Starting around 100 C.E., people there farmed, herded cattle, and worked iron. The settlement steadily grew for more than 1000 years. Then, sometime in the second half of the 14th century, it suddenly shrank by half. There's no evidence of food stress, conflict, or migration. 

"We don't see it coming," Gallagher says. Stone says the sudden changes at Kirikongo and Akrokrowa resemble those seen in the British Isles during the Justinian Plague in the sixth to the eighth centuries C.E. 

New hints are also turning up in historical records. Historians have found previously unknown mentions of epidemics in Ethiopian texts from the 13th to the 15th centuries, including one that killed "such a large number of people that no one was left to bury the dead." It's not clear what the disease was, but historian Marie-Laure Derat of the French National Center for Scientific Research in Paris found that by the 15th century, Ethiopians had adopted two European saints associated with plague, St. Roch and St. Sebastian.

WHO: Measles – Madagascar

WHO has published Measles – Madagascar. Excerpt:

WHO is supporting the Ministry of Public Health of Madagascar to respond to an unusually large measles outbreak. Madagascar last experienced measles outbreaks in 2003 and 2004, with reported number of cases at 62 233 and 35 558, respectively. Since then, the number of reported cases had sharply declined until the current outbreak. From 4 October 2018 to 7 January 2019, 19 539 measles cases and 39 “facility-based” deaths (case fatality ratio: 0.2%) have been reported by the Ministry of Public Health (MoH) of Madagascar. Cases were reported from 66 of 114 total districts in all 22 regions of Madagascar. 

Among the 19 539 measles cases, 375 have been laboratory confirmed (all are IgM+) and 19 164 were confirmed by epidemiological link. Cases confirmed by epidemiological link are those who presented clinical symptoms based on the case definition and had been in contact with another laboratory confirmed or epidemiologically linked case. The outbreak has spread to densely populated urban cities including Toamasina, Mahajanga, Antsirabe, Toliara and the capital city Antananarivo. Most cases were reported from Analamanga (61%) and Boeny (20%) regions. 

The highest attack rates were observed in Antananarivo-Renivohitra district (714 per 100 000 inhabitants), and Ambato-Boina district (668 per 100 000 inhabitants), in Analamanga and Mahajanga regions, respectively. These rates are considerably higher compared to the national attack rate of 108 per 100 000 inhabitants.  

In the current epidemic, children aged 1 to 14 years account for 64% of the total number of cases. The age distribution in this group is as follows: under five years at 35%, 5-9 years at 22% and 10-14 years at 19%. Both sexes are equally affected with a male to female ratio of 1.04. The national immunization programme recommends routine measles immunization for children aged nine months. 

According to WHO and the United Nations International Children’s Emergency Fund (UNICEF), the estimated measles immunization coverage in Madagascar was 58% in 2017. More than half of the cases (51%) reported during the current outbreak have not been vaccinated or have unknown immunization status. Madagascar has the highest proportion of malnutrition among children under five (47%) in the African region which can increase children's risk of serious complications and death from measles infection. 

The circulating genotype for the current measles outbreak in Madagascar is B3, usually found in Africa and Europe. No measles cases with travel history to Madagascar, however, have been reported in neighboring countries and initial investigations in Madagascar have not shown any link with cases from countries with measles outbreak in the Africa region or Europe.  

The measles outbreak has occurred concurrently with the resurgence of plague in the country—which reoccurs seasonally—straining the public health response.