Demographic and spatio-temporal variation in human plague at a persistent focus in Tanzania

Differential pathogenicity and lethality of bubonic plague (1720-1945) by sex, age and place

COVID-19 brought back to the attention of the scientific community that males are more susceptible to infectious diseases. What is clear for other infections-that sex and gender differences influence both risk of infection and mortality-is not yet fully elucidated for plague, particularly bubonic plague, although this knowledge can help find specific defences against a disease for which a vaccine is not yet available. To address this question, we analysed data on plague from hospitals in different parts of the world since the early eighteenth century, which provide demographic information on individual patients, diagnosis and course of the disease in the pre-antibiotic era. Assuming that the two sexes were equally represented, we observe a worldwide prevalence of male cases hospitalized at any age, a result which seems better explained by gender-biased (thus cultural) behaviours than biological sex-related factors. Conversely, case fatality rates differ among countries and geographic macro-areas, while globally, lethality appears slightly prevalent in young females and older adults (regardless of sex). Logistic regression models confirm that the main risk factor for bubonic plague death was the geographical location of the cases and being older than 50 years, whereas sex only showcased a slight trend.

Plague in Tanzania: first report of sylvatic plague in Morogoro region, persistence in Mbulu focus, and ongoing quiescence in Lushoto and Iringa foci

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Six (0.93%) rodents carried antibodies against Yersinia pestis fraction 1 antigens.

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There is evidence of Y. pestis circulation in small mammals in Morogoro.

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Plague continues to persist in small mammals in Mbulu.

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There is ongoing quiescence in Lushoto and Iringa plague foci.

Objectives

Plague has been a threat to human health in Tanzania since 1886. This zoonotic disease has established several endemic foci in the country, posing a risk of outbreaks. This study was conducted to investigate the presence of Yersinia pestis in small mammals in five districts. These districts were selected because of recent (Mbulu), past (40-18 years ago: Lushoto) and historic (>100 years ago: Iringa and Kilolo) human cases of plague. In addition, one region that has not had any reported human cases of plague was included (Morogoro-Mvomero).

Methods

Blood from 645 captured small mammals was screened for antibodies against the fraction 1 (F1) antigen of Y. pestis using indirect enzyme-linked immunosorbent assay (ELISA) and competitive-blocking ELISA.

Results

Specific antibodies against Y. pestis F1 antigens were detected in six (0.93%) animals belonging to Mastomys natalensis. Of these, four animals were captured in the active focus in Mbulu, and two animals were captured from an area with no history of human plague (Morogoro-Mvomero).

Conclusion

These results provide evidence of the circulation of Y. pestis in small mammals in Tanzania. Furthermore, evidence of the circulation of Y. pestis in Morogoro-Mvomero highlights the importance of carrying out plague surveillance in areas with no history of human plague, which can help to predict areas where future outbreaks may occur.

Identifying the spatiotemporal clusters of plague occurrences in China during the Third Pandemic

Plague, a devastating infectious disease caused by Yersinia pestis, has killed millions of people in the past and is still active in the natural foci of the world today. Understanding the spatiotemporal patterns of plague outbreaks in history is critically important, as it may help to facilitate prevention and control of potential future outbreaks. In this study, we explored spatiotemporal clusters of human plague occurrences in China using a machine-learning clustering method and reconstructed the potential transmission pattern during the Third Pandemic (1772-1964). We succeeded in identifying 6 clusters in the space domain (2D) and 13 clusters in the spatiotemporal domain (3D). Our results suggest that there were several temporal outbreaks and transmissions of plague in different spatial clusters. Together with the spatiotemporal nearest neighbor approach (ST-NNA), this method could allow us to have a clearer look at the spatiotemporal patterns of plague.

A Storytelling Approach: Insights from the Shambaa

Narrative medicine explores the stories that patients tell; this paper, conversely, looks at some of the stories that patients are told. The paper starts by examining the 'story' told by the Shambaa people of Tanzania to explain the bubonic plague and contrasts this with the stories told by Ghanaian communities to explain lymphatic filariasis. By harnessing insights from memory studies, these stories' memorability is claimed to be due to their use mnemonic devices woven into stories. The paper suggests that stories can be unpatronising, informative, and appropriate vehicles for communicating medical information to all age groups across all cultures.

The sex-selective impact of the Black Death and recurring plagues in the Southern Netherlands, 1349-1450

Although recent work has begun to establish that early modern plagues had selective mortality effects, it was generally accepted that the initial outbreak of Black Death in 1347-52 was a "universal killer." Recent bioarchaeological work, however, has argued that the Black Death was also selective with regard to age and pre-plague health status. The issue of the Black Death's potential sex selectivity is less clear. Bioarchaeological research hypothesizes that sex-selection in mortality was possible during the initial Black Death outbreak, and we present evidence from historical sources to test this notion.

OBJECTIVE

To determine whether the Black Death and recurring plagues in the period 1349-1450 had a sex-selective mortality effect.

MATERIALS AND METHODS

We present a newly compiled database of mortality information taken from mortmain records in Hainaut, Belgium, in the period 1349-1450, which not only is an important new source of information on medieval mortality, but also allows for sex-disaggregation.

RESULTS

We find that the Black Death period of 1349-51, as well as recurring plagues in the 100 years up to 1450, often had a sex-selective effect-killing more women than in "non-plague years."

DISCUSSION

Although much research tends to suggest that men are more susceptible to a variety of diseases caused by bacteria, viruses and parasites, we cannot assume that the same direction of sex-selection in mortality applied to diseases in the distant past such as Second Pandemic plagues. While the exact reasons for the sex-selective effect of late-medieval plague are unclear in the absence of further data, we suggest that simple inequities between the sexes in exposure to the disease may not have been a key driver.

Patterns of Human Plague in Uganda, 2008-2016

Plague is a highly virulent fleaborne zoonosis that occurs throughout many parts of the world; most suspected human cases are reported from resource-poor settings in sub-Saharan Africa. During 2008-2016, a combination of active surveillance and laboratory testing in the plague-endemic West Nile region of Uganda yielded 255 suspected human plague cases; approximately one third were laboratory confirmed by bacterial culture or serology. Although the mortality rate was 7% among suspected cases, it was 26% among persons with laboratory-confirmed plague. Reports of an unusual number of dead rats in a patient's village around the time of illness onset was significantly associated with laboratory confirmation of plague. This descriptive summary of human plague in Uganda highlights the episodic nature of the disease, as well as the potential that, even in endemic areas, illnesses of other etiologies might be being mistaken for plague.

Probing the spatial cluster of Meriones unguiculatus using the nest flea index based on GIS technology

The nest flea index of Meriones unguiculatus is a critical indicator for the prevention and control of plague, which can be used not only to detect the spatial and temporal distributions of Meriones unguiculatus, but also to reveal its cluster rule. This study used global spatial autocorrelation and spatial hot spot detection methods to describe the relationship between different years and the autocorrelation coefficient of nest flea indexes; it also used a spatial detection method and GIS technology to detect the spatial gathered hot spot of Meriones unguiculatus in the epidemic areas. The results of this study showed that (1) there were statistically significant spatial autocorrelations in the nest flea indexes in 2006, 2012, 2013 and 2014. (2) Most of the distribution patterns of Meriones unguiculatus were statistically significant clusters of high values. (3) There were some typical hot spot regions of plague distributed along the Inner Mongolia plateau, north of China. (4) The hot spot regions of plague were gradually stabilized after increasing and decreasing repeatedly. Generally speaking, the number of hot spot regions showed an accelerated increase from 2005 to 2007, decreased slowly from 2007 to 2008, rapidly increased again after decreasing slowly from 2008 to 2010, showed an accelerated decrease from 2010 to 2011, and ultimately were stabilized after rapidly increasing again from 2011 to 2014. (5) The migration period of the hot spot regions was 2-3 years. The epidemic area of plague moved from southwest to east during 2005, 2007, 2008 and 2010, from east to southwest during 2007 and 2008, from east to west during 2010 and 2011, and from Midwest to east during 2011 and 2014. (6) Effective factors, such as temperature, rainfall, DEM, host density, and NDVI, can affect the spatial cluster of Meriones unguiculatus. The results of this study have important implications for exploring the temporal and spatial distribution law and distribution of the hot spot regions of plague, which can reduce the risk of plague, help support the decision making process for the control and prevention of plague, and form a valuable application for plague research.

Bushmeat and Emerging Infectious Diseases: Lessons from Africa

Zoonotic diseases are the main contributor to emerging infectious diseases (EIDs) and present a major threat to global public health. Bushmeat is an important source of protein and income for many African people, but bushmeat-related activities have been linked to numerous EID outbreaks, such as Ebola, HIV, and SARS. Importantly, increasing demand and commercialization of bushmeat is exposing more people to pathogens and facilitating the geographic spread of diseases. To date, these linkages have not been systematically assessed. Here we review the literature on bushmeat and EIDs for sub-Saharan Africa, summarizing pathogens (viruses, fungi, bacteria, helminths, protozoan, and prions) by bushmeat taxonomic group to provide for the first time a comprehensive overview of the current state of knowledge concerning zoonotic disease transmission from bushmeat into humans. We conclude by drawing lessons that we believe are applicable to other developing and developed regions and highlight areas requiring further research to mitigate disease risk.

Effects of land use on plague (Yersinia pestis) activity in rodents in Tanzania

Understanding the effects of land-use change on zoonotic disease risk is a pressing global health concern. Here, we compare prevalence of Yersinia pestis, the etiologic agent of plague, in rodents across two land-use types-agricultural and conserved-in northern Tanzania. Estimated abundance of seropositive rodents nearly doubled in agricultural sites compared with conserved sites. This relationship between land-use type and abundance of seropositive rodents is likely mediated by changes in rodent and flea community composition, particularly via an increase in the abundance of the commensal species, Mastomys natalensis, in agricultural habitats. There was mixed support for rodent species diversity negatively impacting Y. pestis seroprevalence. Together, these results suggest that land-use change could affect the risk of local transmission of plague, and raise critical questions about transmission dynamics at the interface of conserved and agricultural habitats. These findings emphasize the importance of understanding disease ecology in the context of rapidly proceeding landscape change.

We are connected: flea–host association networks in the plague outbreak focus in the Rift Valley, northern Tanzania

Context Plague is a serious health problem in northern Tanzania, with outbreaks since 2008 in two districts located in Rift Valley. There is dearth of knowledge on diversity of small mammal and flea fauna occurring in this plague focus. Knowledge on interactions between fleas and rodent species that harbour the plague bacterium, Yersinia pestis, is important for developing strategies for control and prevention of plague. Aims This study aims to show how rodents and fleas are associated with each other in the plague focus. Methods Animals were trapped bimonthly from 2009 to 2012 in different habitats. The fur of animals was brushed to collect fleas, which were identified and quantified. Network analysis methods, randomisation and rarefaction curves were used to show how hosts and fleas are associated. Key results Thirteen species of rodents were associated with 26 species of fleas of which Dinopsyllus lypusus, Xenopsylla brasiliensis and X. cheopis are confirmed efficient vectors of Y. pestis. Randomisation and rarefaction curves established that Lophuromys flavopunctatus had significantly higher flea species richness (n = 9) than did all other hosts, whereas Xenopsylla cheopis and Dinopsyllus spp. showed greater host species richness than did other species of fleas. There was no significant correlation between host sex and flea abundance (χ2 = 0.8, d.f. = 6, P = 0.371), but significant differences between reproductive states (adults had more fleas than did subadults) were observed, which probably reflected typical positive correlation between size and flea abundance (χ2 = 4.1955, d.f. = 1, P = 0.040). Conclusions The plague outbreak focus in northern Tanzania has a diverse fauna of rodents and fleas with multiple patterns of association and connectivity. Implications Existence of diverse populations of rodents associated with a large number of flea species, some of which are efficient plague vectors, increases the potential for persistence and transmission of plague to humans in northern Tanzania.

Influence of satellite-derived rainfall patterns on plague occurrence in northeast Tanzania

Background

In the tropics, rainfall data are seldom accurately recorded, and are often discontinuous in time. In the scope of plague-research in northeast Tanzania, we adapted previous research to reconstruct rainfall patterns at a suitable resolution (1 km), based on time series of NDVI: more accurate satellite imagery was used, in the form of MODIS NDVI, and rainfall data were collected from the TRMM sensors instead of in situ data. First, we established a significant relationship between monthly rainfall and monthly composited MODIS NDVI. The established linear relationship was then used to reconstruct historic precipitation patterns over a mountainous area in northeastern Tanzania.

Results

We validated the resulting precipitation estimates with in situ rainfall time series of three meteorological stations located in the study area. Taking the region's topography into account, a correlation coefficient of 0.66 was obtained for two of the three meteorological stations. Our results suggest that the adapted strategy can be applied fruitfully to estimate rainfall variability and seasonality, despite the underestimation of overall rainfall rates. Based on this model, rainfall in previous years (1986) is modelled to obtain a dataset with which we can compare plague occurrence in the area. A positive correlation of 82% is obtained between high rainfall rates and plague incidence with a two month lag between rainfall and plague cases.

Conclusions

We conclude that the obtained results are satisfactory in support of the human plague research in which this study is embedded, and that this approach can be applied in other studies with similar goals.

Susceptibility to Yersinia pestis experimental infection in wild Rattus rattus, reservoir of plague in Madagascar

In Madagascar, the black rat, Rattus rattus, is the main reservoir of plague (Yersinia pestis infection), a disease still responsible for hundreds of cases each year in this country. This study used experimental plague challenge to assess susceptibility in wild-caught rats to better understand how R. rattus can act as a plague reservoir. An important difference in plague resistance between rat populations from the plague focus (central highlands) and those from the plague-free zone (low altitude area) was confirmed to be a widespread phenomenon. In rats from the plague focus, we observed that sex influenced plague susceptibility, with males slightly more resistant than females. Other individual factors investigated (weight and habitat of sampling) did not affect plague resistance. When infected at high bacterial dose (more than 10⁵ bacteria injected), rats from the plague focus died mainly within 3-5 days and produced specific antibodies, whereas after low-dose infection (< 5,000 bacteria), delayed mortality was observed and surviving seronegative rats were not uncommon. These results concerning plague resistance level and the course of infection in the black rat would contribute to a better understanding of plague circulation in Madagascar.

Predicting potential risk areas of human plague for the Western Usambara Mountains, Lushoto District, Tanzania

A natural focus of plague exists in the Western Usambara Mountains of Tanzania. Despite intense research, questions remain as to why and how plague emerges repeatedly in the same suite of villages. We used human plague incidence data for 1986-2003 in an ecological-niche modeling framework to explore the geographic distribution and ecology of human plague. Our analyses indicate that plague occurrence is related directly to landscape-scale environmental features, yielding a predictive understanding of one set of environmental factors affecting plague transmission in East Africa. Although many environmental variables contribute significantly to these models, the most important are elevation and Enhanced Vegetation Index derivatives. Projections of these models across broader regions predict only 15.5% (under a majority-rule threshold) or 31,997 km(2) of East Africa as suitable for plague transmission, but they successfully anticipate most known foci in the region, making possible the development of a risk map of plague.

Geographic distribution and ecological niche of plague in sub-Saharan Africa

BACKGROUND

Plague is a rapidly progressing, serious illness in humans that is likely to be fatal if not treated. It remains a public health threat, especially in sub-Saharan Africa. In spite of plague's highly focal nature, a thorough ecological understanding of the general distribution pattern of plague across sub-Saharan Africa has not been established to date. In this study, we used human plague data from sub-Saharan Africa for 1970-2007 in an ecological niche modeling framework to explore the potential geographic distribution of plague and its ecological requirements across Africa.

RESULTS

We predict a broad potential distributional area of plague occurrences across sub-Saharan Africa. General tests of model's transferability suggest that our model can anticipate the potential distribution of plague occurrences in Madagascar and northern Africa. However, generality and predictive ability tests using regional subsets of occurrence points demonstrate the models to be unable to predict independent occurrence points outside the training region accurately. Visualizations show plague to occur in diverse landscapes under wide ranges of environmental conditions.

CONCLUSION

We conclude that the typical focality of plague, observed in sub-Saharan Africa, is not related to fragmented and insular environmental conditions manifested at a coarse continental scale. However, our approach provides a foundation for testing hypotheses concerning focal distribution areas of plague and their links with historical and environmental factors.

Plague and the human flea, Tanzania

Pulex irritans fleas were more common in villages with high plague incidence.

Domestic fleas were collected in 12 villages in the western Usambara Mountains in Tanzania. Of these, 7 are considered villages with high plague frequency, where human plague was recorded during at least 6 of the 17 plague seasons between 1986 and 2004. In the remaining 5 villages with low plague frequency, plague was either rare or unrecorded. Pulex irritans, known as the human flea, was the predominant flea species (72.4%) in houses. The density of P. irritans, but not of other domestic fleas, was significantly higher in villages with a higher plague frequency or incidence. Moreover, the P. irritans index was strongly positively correlated with plague frequency and with the logarithmically transformed plague incidence. These observations suggest that in Lushoto District human fleas may play a role in plague epidemiology. These findings are of immediate public health relevance because they provide an indicator that can be surveyed to assess the risk for plague.