Bubonic plague is endemic in Madagascar. The country typically experiences between 400 and 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, or suspected cases of plague, according to the World Health Organization (WHO).
More than 75% of those 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 bubonic plague, which spreads to humans through infected fleas or rats or through direct physical contact with infected cadavers. Left untreated, pneumonic plague is fatal. However, both bubonic and pneumonic plague are treatable with antibiotics. Therefore, timely case identification is critical for saving lives and controlling the spread of the disease.
As the Madagascar experience shows, effective epidemic control starts in the community. The USAID Mikolo Project in the country worked to support 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 (CHVs) who received mobile telephone credits from the project to alert public health authorities to any suspected cases.
On November 8, 2017, a middle-aged man living in the remote village of Angalampona in Miarinarivo commune, Ambalavao District, died unexpectedly. A week after the man’s death, his 15-year-old son also 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 plague. She alerted the health center in Miarinarivo commune.
The alert triggered an investigation by district health authorities, who travelled to Angalampona on November 23 with members of the Miarinarivo commune watch committee, including the head of the health center, USAID Mikolo staff, and a team from WHO. They arrived in the village with an ambulance, antibiotics, disinfecting equipment, and individual protective equipment. Upon arrival, the head of the village and a CHV brought the team to the household of the deceased. Four family members were experiencing symptoms of pneumonic plague, such as fever; headache; weakness; and rapidly developing pneumonia with shortness of breath, chest pain, cough, and bloody or watery sputum.
The four were rushed to the health center, where two died soon after arrival. Two girls, 5 and 15 years old, stabilized after receiving antibiotic prophylactic treatment. Serological tests at the Pasteur Institute of Madagascar confirmed that both girls had pneumonic plague.
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 and plan and coordinate a response. The plan focused on contact tracing to identify 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, with the head of the health center, mobilized all village heads and CHVs to expand contact tracing and ensure follow-up. A total of 117 people in Miarinarivo commune and 64 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 to respond to the outbreak and other emergencies.
As of December 1, 2017, no new cases had been identified and no additional plague-related deaths had been recorded in Miarinarivo, Mahazony, and Sendrisoa communes. The broad and swift response involved a ready-to-go system featuring strong surveillance and action by local community members. Active contact tracing continued, and the village and commune watch committees, health centers, and district health authorities continued to be supported through the end of plague season in April. Soon, support for this kind of work 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 stories that played out across communities in Madagascar during the pneumonic plague epidemic. USAID Mikolo worked in the 11 most-affected districts and directly supported 220 villages and 30 communes to set up functional epidemic watch committees. The project trained and supported more than 1,100 community health workers, village and other local leaders, and health center staff. At the district and regional levels, the USAID Mikolo Project worked with health authorities to develop and implement response plans and conduct investigations. Project staff also helped develop the national response plan, mobilize resources to implement it, and support the logistics needed for epidemiological surveillance and response.
The combined efforts of the Ministry of Public Health; WHO; USAID and its implementing partners, including USAID Mikolo; the Pasteur Institute of Madagascar; the US Centers for Disease Control and Prevention; the International Committee of the Red Cross; and many others culminated in the containment of the epidemic in less than three months. Without the watch committees, local leaders, and CHVs, this success would not have been possible, and the global community would have faced greater risk of the spread of the deadly disease.