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TOTO
MINOR CREDIT SEMINARMINOR CREDIT SEMINAR
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A SEMINARA SEMINAR
ONON
PLAGUEPLAGUE(Epidemiology and control)(Epidemiology and control)
BYBY--
Dr. RAJESH KUMARDr. RAJESH KUMAR
M.V.Sc. 1M.V.Sc. 1stst YEARYEAR
ROLL NoROLL No--47864786
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INTRODUCTIONINTRODUCTION
Plague is anacute, highly infectious, zoonotic disease causedPlague is anacute, highly infectious, zoonotic disease causedbybyYersinia pestis.Yersinia pestis.
Plaguealso knownas the black death, thegreat pestilence,andPlaguealso knownas the black death, thegreat pestilence,andthe bubonic plague.the bubonic plague.
Disease transmitted to humans and animals by the bite ofratDisease transmitted to humans and animals by the bite ofratflea.flea.
Yersinia pestisYersinia pestis was first isolated by Alexandre Yersinwas first isolated by Alexandre Yersin in 1894in 1894in Hong Kong.in Hong Kong.
Between 1987 and 2001,Between 1987 and 2001, 36876 cases ofplague with 284736876 cases ofplague with 2847deaths were reported todeaths were reported to WHO.WHO.
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HISTORYHISTORY
Plague has produced at least threegreat pandemics andPlague has produced at least threegreat pandemics andmultipleepidemics throughout history.multipleepidemics throughout history.
Threegreat PandemicsThreegreat Pandemics
1.1. 542542--556 B.C.556 B.C. -- Plague ofJustinianPlague ofJustinian
2.2. 13461346--13501350 -- Black DeathBlack Death
3.3. 18941894 -- ModernPandemicModernPandemic
TheThefirst pandemicfirst pandemic knownas theknownas the Justinian plagueJustinian plague inin543543--542 B.C. was believed to have started in Egypt542 B.C. was believed to have started in Egypt
spreading into the Middle East and Mediterranean.spreading into the Middle East and Mediterranean.
killing 100 million people over 60 years.killing 100 million people over 60 years.
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ContCont TheThe second pandemicsecond pandemic knownas theknownas the Black DeathBlack Death began in 1347,began in 1347,
The Black Death had killed approximatelyThe Black Death had killed approximately
OneOne--forth ofEurope populationandforth ofEurope populationand
One thirds ofthe worlds populationsOne thirds ofthe worlds populations
About 30 million people death.About 30 million people death.
TheThe third pandemicthird pandemic began in China in 1860s spreading to Hongbegan in China in 1860s spreading to Hong
Kong in 1890s. Plague was spread by rats transported on ship toKong in 1890s. Plague was spread by rats transported on ship to
Africa, Asia, California,and South AmericaAfrica, Asia, California,and South America
Foci ofinfectionestablished in wild rodents in ruralareas.Foci ofinfectionestablished in wild rodents in ruralareas.
About 20 million dead in Indiaalone between 1889 andAbout 20 million dead in Indiaalone between 1889 and
19501950
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Major plague outbreaksMajor plague outbreaks
YearsYears CountryCountry DeathsDeaths
740740--744744 TurkeyTurkey 200,000200,000
16721672 ItalyItaly 400,000400,000
17111711 Germany, AustriaGermany, Austria 500,000500,000
17921792 EgyptEgypt 800,000800,000
18981898--19081908 China, IndiaChina, India 3 million3 million
19091909--19181918 China, IndiaChina, India 1,335,0001,335,00019201920 IndiaIndia 2 million2 million
19941994 India (Surat)India (Surat) 5656 (WHO)(WHO)
20022002 Shimla ( H.P.)Shimla ( H.P.) 44 (WHO)(WHO)
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Human Plague India (Surat) 1994Human Plague India (Surat) 1994
InIn19941994, total 693 suspected bubonic or pneumonic plague, total 693 suspected bubonic or pneumonic plaguecases were reported tocases were reported to WHO by Government ofIndiaWHO by Government ofIndia..
The outbreak ofsuspected plague diseaselasted fromThe outbreak ofsuspected plague diseaselasted from AugustAugust
26, 1994 to October 18, 1994,26, 1994 to October 18, 1994, that resulted inthat resulted in56 deaths56 deaths..
These cases werefromThese cases werefromSTATESTATE Cases reportedCases reported
MaharashtraMaharashtra 488488
GujaratGujarat 7777
KarnatakaKarnataka 4646
UttarPradeshUttarPradesh 1010
MadhyaPradeshMadhyaPradesh 44
New DelhiNew Delhi 6868
CDC. Human plagueCDC. Human plague -- India,India,1994. MMWR 1994;43:6891994. MMWR 1994;43:689--91.91.
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Discovery ofcausativeagentDiscovery ofcausativeagent
1894: Hong Kong pandemic1894: Hong Kong pandemic
Dr. Alexandre YersinDr. Alexandre Yersin firstfirstisolated and described in detail,isolated and described in detail,Pasteurella pestisPasteurella pestis, the old term, the old termused forused forYersinia pestisYersinia pestis..
Gram negativeGram negative
BacillusBacillus
In 1896, Yersin developed anIn 1896, Yersin developed anantiserum that saved thelife ofantiserum that saved thelife of
an 18 year old Chinese student.an 18 year old Chinese student.
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CAUSATIVE AGENTCAUSATIVE AGENT
YersiniaYersinia pestispestis Family EnterobacteriaceaeFamily Enterobacteriaceae
Gram negative, coccobacillus,Gram negative, coccobacillus,
pleomorphic.pleomorphic.
Aerobic,facultativeanaerobic,Aerobic,facultativeanaerobic,
and facultative intracellular.and facultative intracellular.
Several plasmids and virulenceSeveral plasmids and virulencefactorsfactors
F1, murineexotoxin, LPSF1, murineexotoxin, LPSendotoxin, coagulase, pesticin,endotoxin, coagulase, pesticin,
plasminogenactivatorplasminogenactivator
CDC/ Courtesy ofLarry Stauffer,
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Yersinia pestisYersinia pestis
Destroyed byDestroyed by
SunlightSunlight
DesiccationDesiccation
SurvivalSurvival
1 hour inair1 hour inair Briefly in soilBriefly in soil
1 week in soft tissue1 week in soft tissue
Years whenfrozenYears whenfrozen
Source: Centers for Disease Controland
Prevention, Division ofVector-Borne
Infectious Diseases,Fort Collins, CO
Giemsa, Wright, WaysonGiemsa, Wright, Waysonstainsstains bipolar bipolar safety pinsafety pin""
stainingstaining
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EPIDEMIOLOGYEPIDEMIOLOGY
Geographical distributionGeographical distribution
ReservoirReservoir
VectorVector
Incidental hostIncidental host
Epidemiological Cycles ofPlagueEpidemiological Cycles ofPlague
Mode ofTransmissionMode ofTransmission
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Geographic distributionGeographic distribution
Naturalfoci ofinfection persist onnearly onall continents, theyNaturalfoci ofinfection persist onnearly onall continents, theydo not exist in Australia, New Zealand,and Japando not exist in Australia, New Zealand,and Japan (OIE 2004)(OIE 2004)
WorldwideWorldwide
The WHO document between 1000The WHO document between 1000--3000 cases peryear3000 cases peryear
18,739 cases from 198018,739 cases from 198019941994
2,603 cases in 1999 from 14 countries and 181 deaths2,603 cases in 1999 from 14 countries and 181 deaths
2118 cases in 2003from 9 countries and 182 deaths2118 cases in 2003from 9 countries and 182 deaths
More than 76% ofcases and deaths were reported fromMore than 76% ofcases and deaths were reported fromAfrica.Africa.
There have been recent outbreaks ofplague in India in 2002 andThere have been recent outbreaks ofplague in India in 2002 andAlgeria in 2003.Algeria in 2003.
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Human plague cases : countries having notified to WHO 2004
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AsiaMost cases ofplague worldwide were reported from Asiafrom 1954-80s.
There were outbreaks in Tanzaniaand Madagascar in the 1990s.
Outbreaks occurred in India in 1954, 1963,and thenagain30 years later in 1994.
The plague outbreak in India in 1994 is a result oftheearthquake in September
1993 that disturbed theequilibrium density ofdomestic rodents and theirfleas.
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Maharashtra
Karnataka
H.P
Gujarat
A.P.
T.N.
NICD DELHI
INDIA PLAGUE FOCI
PLAGUE ENDEMIC STATES 6
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RESERVOIRRESERVOIR
Wild and domestic ratsWild and domestic rats Ground squirrelsGround squirrels
Rock squirrelsRock squirrels
Prairie dogsPrairie dogs
Deer miceDeer mice
Field miceField mice
GerbilsGerbils VolesVoles
ChipmunksChipmunks
MarmotsMarmots
Guinea pigsGuinea pigs
Kangaroo ratsKangaroo rats
over 200 identified reservoirs speciesover 200 identified reservoirs species
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VECTORVECTOR
XenopsyllaXenopsylla cheopischeopis The oriental rat flea; nearly worldwideThe oriental rat flea; nearly worldwide
in moderate climatesin moderate climates
OropsyllaOropsylla montanusmontanus United StatesUnited States
NosopsyllusNosopsyllus fasciatusfasciatus Nearly worldwide in temperate climatesNearly worldwide in temperate climates
XenopsyllaXenopsylla brasiliensisbrasiliensis Africa, India, South AmericaAfrica, India, South America
XenopsyllaXenopsylla astiaastia Indonesiaand Southeast AsiaIndonesiaand Southeast Asia
XenopsyllaXenopsylla vexabilisvexabilis Pacific IslandsPacific Islands
~~30 identified fleavectors30 identified fleavectors
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INCIDENTAL HOSTINCIDENTAL HOST
HumansHumans
Domestic and feralDomestic and feral
catscats
DogsDogs Lagomorphs (rabbitsLagomorphs (rabbits
and hares)and hares)
CoyotesCoyotes
CamelsCamels
GoatsGoats
DeerDeer
AntelopeAntelope
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Epidemiological Cycles of PlagueEpidemiological Cycles of Plague
Sylvatic (wild) Cycle ofPlague:Sylvatic (wild) Cycle ofPlague:-- Reservoir (foci) = wild rodents (prairie dogs, rabbits, mice,Reservoir (foci) = wild rodents (prairie dogs, rabbits, mice,dogs)dogs)
Vector = wild rodent fleaVector = wild rodent flea
Urban (domestic) Cycle ofPlague:Urban (domestic) Cycle ofPlague:-- Reservoir = domestic (urban) black ratReservoir = domestic (urban) black rat
Vector = oriental rat flea (Vector = oriental rat flea (Xenopsylla cheopisXenopsylla cheopis))
Human Cycle ofPlague:Human Cycle ofPlague:--
Bubonic plagueacquired from contact with either sylvaticBubonic plagueacquired from contact with either sylvatic
orurban reservoirs orarthropod vector biteand furtherorurban reservoirs orarthropod vector biteand further
transmitted in human population by spread ofpneumonictransmitted in human population by spread ofpneumonic
plague.plague.
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TRANSMISSIONTRANSMISSION
Bites from fleavectors (78%)Bites from fleavectors (78%)
Direct animal contact (20%)Direct animal contact (20%)
With infectious bodyfluids, tissues, scratches, bites whileWith infectious bodyfluids, tissues, scratches, bites while
handlingan infected animal (which can be dead oralive)handlingan infected animal (which can be dead oralive)
Enters through break in skinEnters through break in skin
Ingestion ofraw oruncooked meat from an infectedIngestion ofraw oruncooked meat from an infectedanimal (marmots, prairie dogs,goats, camel)animal (marmots, prairie dogs,goats, camel)
Inhalation ofinfectious droplets,aerosol (2%)Inhalation ofinfectious droplets,aerosol (2%)
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Mode of TransmissionMode of Transmission
Thereareat least 6 potential modes oftransmission:Thereareat least 6 potential modes oftransmission:
1.1. Wild rodentWild rodent FleaFlea Peridomestic rodentsPeridomestic rodents
FleaFlea Domestic rodentDomestic rodent FleaFlea HumansHumans
2.2. Human with pneumonic plagueHuman with pneumonic plague dropletdroplet
infectioninfection HumansHumans
3.3. Wild rodentsWild rodents FleaFlea Humans (whenHumans (when
humans enter theforests etc where thehumans enter theforests etc where thesylvaticsylvatic
cyclecycle is maintained)is maintained)
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ContCont
4. Handling infected rodent tissue (wild / domestic)4. Handling infected rodent tissue (wild / domestic)orany other infected materiale.g. pus fromorany other infected materiale.g. pus from
buboesbuboes
5. Domestic cats eat infected rodents develop5. Domestic cats eat infected rodents develop
pneumonic plaguepneumonic plague Droplet infectionDroplet infection
HumansHumans
6. Plague bacilli6. Plague bacilli BioterrorismBioterrorism HumansHumans
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BUBONIC TANSMISSIONBUBONIC TANSMISSION
Bites from fleavectorsBites from fleavectors
Bites or scratches from infected animals, such asBites or scratches from infected animals, such as
catscats
Direct contact with infected animal carcasses, suchDirect contact with infected animal carcasses, such
as rodents (especially marmots), rabbits, hares,as rodents (especially marmots), rabbits, hares,
carnivores (eg, wild cats, coyotes),and goatscarnivores (eg, wild cats, coyotes),and goats
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SEPTICEMIC TRANSMISSIONSEPTICEMIC TRANSMISSION
Bites from fleavectors whereBites from fleavectors whereY pestisY pestis is insertedis inserted
directly into bloodstreamdirectly into bloodstream
no discernible bubo presentno discernible bubo present
Develops as a complication ofbubonic or 1Develops as a complication ofbubonic or 1
pneumonic plaguepneumonic plague
WhenWhenY pestisY pestis enters the bloodstreamenters the bloodstream
Neither bubonic plaguenor septicemic plagueNeither bubonic plaguenor septicemic plague
spreads directlyfrom person to personspreads directlyfrom person to person
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PNEUMONIC TRANSMISSIONPNEUMONIC TRANSMISSION
Inhalation ofrespiratory droplets from infected animals suchInhalation ofrespiratory droplets from infected animals suchas cats.as cats.
Inhalation ofrespiratory droplets from a person with primaryInhalation ofrespiratory droplets from a person with primary
or secondary pneumonic plague.or secondary pneumonic plague.
HandlingHandlingY pestisY pestis cultures in thelaboratory.cultures in thelaboratory.
Bubonic and 1Bubonic and 1 septicemic spread plague bacillisepticemic spread plague bacilli
hematogenously to thelungs.hematogenously to thelungs.
Theability to cause infection byaerosoland the seriousTheability to cause infection byaerosoland the serious
nature ofpneumonic plague makenature ofpneumonic plague make Y pestisY pestis aapotentialpotential
biological weapon.biological weapon.
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Manner in which fleas transmit plagueManner in which fleas transmit plague
Flea feeds on Y. pestisFlea feeds on Y. pestis--infected bloodinfected blood
Y. Pestis enters fleas midgut & multiplies logarithmicallyY. Pestis enters fleas midgut & multiplies logarithmically
Clump of Y. pestis forms in the midgut, blocking fleasClump of Y. pestis forms in the midgut, blocking fleasforegutforegut
During next meal, blood cannot enter the midgut & fleaDuring next meal, blood cannot enter the midgut & flea
gets very hungrygets very hungry
Flea bites vigorously & regurgitates the contents of itsFlea bites vigorously & regurgitates the contents of itsmidgut into the next woundmidgut into the next wound
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Disease in humanDisease in human
3Forms ofthe disease3Forms ofthe disease
1. Bubonic Plague.1. Bubonic Plague. 8080--95%95%
Painfullymph node swellings,Painfullymph node swellings, buboesbuboes
2. Septicemic Plague.2. Septicemic Plague. 1010--20%20%
Also called Also called blood poisoningblood poisoning,attacked the,attacked the
blood systemblood system
3. Pneumonic Plague.3. Pneumonic Plague. rarestrarest
Attacked the respiratory systemAttacked the respiratory system
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Bubonic PlagueBubonic Plague
Incubation: 2Incubation: 2--6 days6 days Clinical signsClinical signs
Fever, chills, malaise, muscleaches, headacheFever, chills, malaise, muscleaches, headache
Regionallymphadenitis (buboes)Regionallymphadenitis (buboes)
1.1. Swollen,very painfullymph nodesSwollen,very painfullymph nodes
2.2. Typically inguinal (most common),Typically inguinal (most common),
femoral,axillary, or cervicalfemoral,axillary, or cervical
3.3. Swellings expandinguntil they burstSwellings expandinguntil they burst death followingdeath following
soonaftersoonafter
-- ss vomiting,abdominal pain,nausea, petechiaevomiting,abdominal pain,nausea, petechiae
Mortality (untreated):30Mortality (untreated):30 --75 %75 %
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Painfullymph nodePainfullymph node
swelling, called buboesswelling, called buboes
Dark blotches = acralDark blotches = acralnecrosisnecrosis Black Death!Black Death!
ContCont
Source:CDC NVBID
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Septicemic PlagueSepticemic Plague
Systemic spread (BloodSystemic spread (Blood-- Poisoning)Poisoning)
Clinical signsClinical signs::
1.1. Similar to bubonic, plus Prostration, circulatory collapse,Similar to bubonic, plus Prostration, circulatory collapse,
septic shock, organfailure, hemorrhage,septic shock, organfailure, hemorrhage,
2.2. Skin turns dark purple,almost black =Skin turns dark purple,almost black = The Black DeathThe Black Death..
due to DIC (disseminated intravascular coagulation)due to DIC (disseminated intravascular coagulation)
3.3. Necrosis ofextremitiesNecrosis ofextremities
4.4. Microthrombi blocking capillariesMicrothrombi blocking capillaries
5.5. Victims died the same day symptoms appeared.Victims died the same day symptoms appeared.
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ContCont
Only pneumonic form ofplague is spread personOnly pneumonic form ofplague is spread person--toto--personperson
Mortality Rate (untreated) : 90Mortality Rate (untreated) : 90--95%95%
RadiographyRadiography usually patchyusually patchy
bilateral infiltrates, consolidationbilateral infiltrates, consolidation
Photograph by Ken Gage,Ph.D., Centers ofDisease Controland Prevention,Fort Collins, CO.
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Disease in animalsDisease in animals
Manyfound serologically positiveManyfound serologically positive
Bears, bobcats, badgers,fox, ringtails, skunks, deer,Bears, bobcats, badgers,fox, ringtails, skunks, deer,
Mountainlion, Africanelephant, African buffalo, camel,Mountainlion, Africanelephant, African buffalo, camel,
coyote, more coyote, more
RodentsRodents
Most rodent die readilyfrom infectionMost rodent die readilyfrom infection
Farm animals and dogsFarm animals and dogs
Very resistant to diseaseVery resistant to disease
May be incubatingat time ofslaughterMay be incubatingat time ofslaughter
Human riskHuman risk
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Cats and PlagueCats and Plague
No human cases from cats prior to 1977No human cases from cats prior to 1977
In 1998, 23 cases reported amongIn 1998, 23 cases reported among -- 5 fatal5 fatal
Cats develop severe illnessCats develop severe illness
Signs mimic human illnessSigns mimic human illness
Bubonic, septicemic, pneumonic and dieBubonic, septicemic, pneumonic and die
Can transfer disease to humansCan transfer disease to humans
Owners,veterinarians or staffOwners,veterinarians or staff
Pneumonic,fleas, bite, scratchPneumonic,fleas, bite, scratch
Hundreds ofcases ofdomestic cats reported with plague.Hundreds ofcases ofdomestic cats reported with plague.
In U.S cats have been sours ofinfectionforabout 5% case ofIn U.S cats have been sours ofinfectionforabout 5% case ofplague in manplague in man
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Dogs and PlagueDogs and Plague
Rarely show signsRarely show signsFever,lethargy, orallesions,Fever,lethargy, orallesions,
lymph nodelesionslymph nodelesions
May seroconvertMay seroconvert
May carry infected fleasMay carry infected fleas
Cats and dogs arenow recognized as sources ofCats and dogs arenow recognized as sources of
infectionfor humans.infectionfor humans.
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Laboratory diagnosisLaboratory diagnosis
Theappropriate specimens for diagnosis ofbubonic, pneumonic,Theappropriate specimens for diagnosis ofbubonic, pneumonic,and septicaemic plagueare,and septicaemic plagueare,bubo aspiratebubo aspirate,,sputumsputum,and,andbloodblood
respectively.respectively.
Giemsa smear (Giemsa smear (bipolar staining)bipolar staining) withwithGrams stain (Grams stain (gramgram--negative)negative)
A characteristic growth is seen inA characteristic growth is seen in
nutrient broth such asnutrient broth such asbrainbrain--heartheart--infusioninfusion
Y pestis cultureat 48 h inY pestis cultureat 48 h in
brainbrain--heartheart--infusion broth at 26infusion broth at 26CC
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YersiniaYersinia--specificspecific CIN agarCIN agarcan becan be
usefulfor culture ofcontaminatedusefulfor culture ofcontaminatedspecimens, such as sputumspecimens, such as sputum
Rapid diagnosis is possible by detection ofRapid diagnosis is possible by detection ofY.pestisY.pestis F1 antigenF1 antigenby Immunofluorescenceby Immunofluorescence
PCR testPCR test
4 fold increase inantibody titres against F1 antigen4 fold increase inantibody titres against F1 antigen
(byPHA tests)(byPHA tests)
Isolation ofthe bacteria by cultureand phagelysis.Isolation ofthe bacteria by cultureand phagelysis.
Cont
http://www.cdc.gov/ncidod/dvbid/plague/p4.htm
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PlaguePlague -- TreatmentTreatment
Isolation:Isolation:--
Patients Isolationfor thefirst 48 hours after the initiation ofPatients Isolationfor thefirst 48 hours after the initiation oftreatment.treatment.
Patients with pneumonia must be isolated at least 4 days ofPatients with pneumonia must be isolated at least 4 days ofantibiotic therapy.antibiotic therapy.
Antibiotic Therapy:Antibiotic Therapy:--
Str eptomycinStreptomycin (drug ofchoice)(drug ofchoice)--1515--30 mg/kg IM bid x 10 days30 mg/kg IM bid x 10 days
GentamicinGentamicin-- 2 mg/kg IV then 1.02 mg/kg IV then 1.0--1.5 mg/kg q8h or 5 mg/kg IV1.5 mg/kg q8h or 5 mg/kg IVq24h x 10 daysq24h x 10 days
DoxycyclineDoxycycline -- 200 mg IV then 100 mg bid x 10200 mg IV then 100 mg bid x 10--14 days14 days CiprofloxacinCiprofloxacin -- 400 mg IV q12h x 10 days400 mg IV q12h x 10 days
ChloramphenicolChloramphenicol-- 25 mg/kg IV q6h (Max. 4 Gm/day)25 mg/kg IV q6h (Max. 4 Gm/day)
Avoid in children < 2 year oldAvoid in children < 2 year old
Avoid streptomycin in pregnant womenAvoid streptomycin in pregnant women
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Prevention and ControlPrevention and Control
Two things that could limit the spread ofdisease:Two things that could limit the spread ofdisease:--1. Epidemic plague is best prevented by controlling rat population1. Epidemic plague is best prevented by controlling rat population
in ruraland urbanareas.in ruraland urbanareas.
2. Close surveillance ofhuman plagueassociated with plague in2. Close surveillance ofhuman plagueassociated with plague in
rodents and use ofeffective insecticidefor controlling rodentsrodents and use ofeffective insecticidefor controlling rodentsflea.flea.
Some other measures taken to control plagueare:Some other measures taken to control plagueare:--
1.1. Prophylactic antibiotic therapyas recommended by CDC forProphylactic antibiotic therapyas recommended by CDC forpeople who have beenexposed topeople who have beenexposed to--
Plague outbreak/flea bitesPlague outbreak/flea bites
Handled infected animalHandled infected animal
Close contact with plague caseClose contact with plague case
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Preferred postPreferred post--exposure prophylaxis:exposure prophylaxis:
Doxycycline 100 mgPO BIDDoxycycline 100 mgPO BID
Ciprofloxacin 500 mgPO BIDCiprofloxacin 500 mgPO BID
Duration ofprophylaxis: 7 daysDuration ofprophylaxis: 7 days
2.2. Plague VaccinePlague Vaccine Liveand killed vaccine developedLiveand killed vaccine developed
Killed vaccine preventsKilled vaccine prevents bubonicbubonic plagueplague
Primaryvaccination: 0, 1Primaryvaccination: 0, 1--3, & 53, & 5--6 months6 months
Boosters: 12, 18, & 24 mo., thenevery 1Boosters: 12, 18, & 24 mo., thenevery 1--2 years2 years
ContCont
Vaccination is oflimited useand is ineffectiveagainstVaccination is oflimited useand is ineffectiveagainst
pneumonic form ofplague.pneumonic form ofplague.
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ContCont
3.3. Environmental sanitationEnvironmental sanitation
Removingfood sources used by rodents.Removingfood sources used by rodents.
Rodents proofing homes, buildings.Rodents proofing homes, buildings.
Eliminate rodent habitat around homeEliminate rodent habitat around home
Applying chemicals to killfleaand rodents.Applying chemicals to killfleaand rodents.
4.4. Treatment petsTreatment pets
Such as dogs and cats for properflea control.Such as dogs and cats for properflea control.
5.5. Public health educationPublic health education
Risks, transmission, prevention.Risks, transmission, prevention.
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VaccinesVaccines
TheThekilledkilled--wholewhole--cellvaccinecellvaccinediddid notnotprotect againstprotect against
primary pneumonic plague.primary pneumonic plague.
TheThelivevaccineslivevaccines were illwere ill--defined and retaineddefined and retained
enoughenough virulencevirulence to beunsuitablefor current use.to beunsuitablefor current use.
A subunit vaccine protects miceagainst respiratoryA subunit vaccine protects miceagainst respiratoryinfection withinfection with Y pestisY pestis is in clinical trials.is in clinical trials.
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