Madagascar Plague Response: Epidemic Control Starts in the Community

Bubonic plague is endemic in Madagascar. Typically, the country experiences 400 to 600 cases of the disease each year. However, in 2017 the plague also took the pneumonic form. Between August 1 and November 26 there were 2,417 confirmed, probable, and suspected cases of plague, according to the World Health Organization (WHO). More than three-quarters of the cases were clinically classified as pneumonic. Spreading from person to person through the air, pneumonic—or pulmonary—plague is much more virulent and contagious than the bubonic plague, which spreads to humans through infected flea bites or direct physical contact with infected cadavers. Left untreated, pneumonic plague is fatal. However, both bubonic and pneumonic plagues are treatable with antibiotics. Therefore, timely case identification is critical for saving lives and controlling spread of the diseases. This story illustrates how effective epidemic control starts in the community. 

Outbreak

On November 8, 2017, a middle-aged man living in the remote village of Angalampona in Miarinarivo commune died unexpectedly.  At the time of his death, the USAID Mikolo Project, funded by USAID Madagascar and led by Management Sciences for Health (MSH), had been supporting local health authorities to establish two local plague watch committees—in Miarinarivo and Mahazony communes—and five village watch committees as part of the national response to the ongoing plague epidemic. The village watch committees included the village head and two community health volunteers who received mobile telephone credit from the project to alert public health authorities to any suspected cases.

A week after the man’s death, his 15-year-old child died. The head of the village, who had received training on recognizing signs of plague, suspected that the boy and his father had died of the disease. She then informed the head of the health center in Miarinarivo commune.

The alert triggered an investigation by the district health authorities, who travelled to Angalampona on November 23 along with members of the Miarinarivo commune watch committee, including the head of the health center, USAID Mikolo Project staff, and a team from WHO. They arrived in the village with an ambulance, antibiotics, disinfecting spray equipment, and individual protective equipment. Upon arrival, the head of the village and a community health volunteer brought the team to the household of the deceased. Four family members were experiencing symptoms of pneumonic plague. These can include fever, headache, weakness, and rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery sputum.

The family members were rushed to the health center, where two of them soon died. Two girls, aged 5 and 15 years, were stabilized upon being administered antibiotic prophylactic treatment. Serological tests at the Pasteur Institute of Madagascar confirmed both girls had pneumonic plague.

Broadening the Response

Four days later, a second investigative team of district health authorities and USAID Mikolo and WHO staff met with 32 local health and community leaders from Miarinarivo commune to review the situation, plan, and coordinate a response. The plan included a focus on contact tracing, or the identification of those who were in contact with the suspected/infected persons, continued education on preventive practices, and systematic spraying of houses to disinfect and help control the outbreak.

The project then expanded its support to the neighboring commune of Sendrisoa, and mobilized, with the head of the health center, all village heads and community health volunteers to expand contact tracing and ensure follow-up. A total of 117 people in Miarinarivo commune and 64 people in Sendrisoa were identified as potential contacts, and all were started on preventive antibiotic treatment.

USAID Mikolo staff worked with the health centers in the three communes to ensure that they had sufficient supplies of antibiotics so they were prepared to respond to the outbreak and other emergencies.

Controlling the Epidemic

As of December 1, 2017, no new cases have been identified and no more plague-related deaths have been recorded in the three communes of Miarinarivo, Mahazony, and Sendrisoa. The broad and swift response involved a ready-to-go system featuring strong surveillance and action by local community members. Active contact tracing is ongoing, and the community and commune watch committees, the health centers, and the district health authorities will continue to be supported throughout the end of the plague season in April. Soon, that support will include a mobile health application developed by the USAID Mikolo Project to facilitate the real-time capture and analysis of case data.

The story from Angalampona is one of many similar stories that played out across communities in Madagascar during the pneumonic plague epidemic. The USAID Mikolo Project worked in the 11 most-affected districts, directly supporting 220 villages and 30 communes to set up functional epidemic watch committees. The project has trained and supported 1,101 community health workers, village and other local leaders, and health center staff. At the district and regional levels, USAID Mikolo works with health authorities to develop and implement response plans and conduct investigations. Project staff also helped develop the national response plans and mobilize the resources to implement it and support the logistics needed for epidemiological surveillance and response.

The combined efforts of the Malagasy Ministry of Public Health; WHO; USAID and its implementing partners, such as the USAID Mikolo Project; and the Pasteur Institute of Madagascar, US Centers for Disease Control and Prevention,  International Committee of the Red Cross, and many other partners culminated in the containment of the epidemic in less than three months. Without the community watch committees, local leaders, and community health volunteers, this success would not have been possible, and the global community would have faced greater risk of the spread of the deadly disease.