Epidemiologic Notes and Reports Imported Bubonic Plague -- District of Columbia

On June 16, 1990, a 47-year-old female mammologist from the United States who was traveling in the area of La Paz, Bolivia, had onset of an acute illness consisting of severe headache, chills, fever, sweating, loss of appetite, pain and swelling in her right axilla, and muscle pains in the lower back and hip. On June 17, she consulted a physician who diagnosed a respiratory infection and treated her with intramuscular ampicillin. The pain and swelling in the axilla gradually increased, and she had difficulty moving her right arm and shoulder.

On the night of June 18-19, she traveled to her home in the District of Columbia; the pain in her right axilla had increased, and she had developed a dry cough. On June 20, she consulted a physician; on examination, her temperature was 38.5 C (101.3 F), and she had an enlarged 2.5-cm fluctuant lymph node in the right axilla with surrounding boggy edema. She was immediately hospitalized with a presumptive diagnosis of bubonic plague.

A lymph node aspiration was performed, and Gram and Wayson stains of the aspirate revealed rare bipolar staining gram-negative organisms suggestive of Yersinia pestis. On June 22, a culture of the aspirate was positive for Y. pestis organisms; the finding was subsequently confirmed by the Plague

Editorial Note

Editorial Note: Although human plague is endemic and occasionally epidemic in South America, Africa, and Asia, reported importations into the United States are rare. The last imported human case reported in the United States occurred in 1966 (CDC, unpublished data), and that case was not documented by cultural isolation of the organism or by positive serologic test results (1). Documented cases of imported plague were last recorded in 1926, in two persons arriving by ship from South America (2). In comparison, during the 1980s, a mean of 18 cases of plague was reported annually in persons exposed in enzootic areas of the southwestern United States (3).

In 1989, 770 human plague cases were reported from 11 countries (4), including 374 cases (49%) from Vietnam and 180 (23%) from Madagascar. Brazil reported 26 cases. Plague has been reported from Bolivia in 7 of the past 10 years (4), and the La Paz area in Bolivia is a recognized endemic focus (5).

The low frequency of imported plague in the United States may be attributed to at least two factors. First, urban plague has been controlled in most parts of the world (6). Second, many persons at high risk (e.g., military personnel and Peace Corps volunteers) are immunized.

Because plague vaccine boosters are necessary to maintain protective immunity, persons at continuing risk should receive booster doses at 1- to 2-year intervals (7). The primary series consists of three immunizations given on days 0 and 30 and 3-6 months after dose 2. The final dose of the primary series should be followed by a booster dose at 6 months and at 1 year.

Reference Diagnostic Laboratory in CDC's Division of Vector-Borne

The patient arrived in Bolivia on May 18 and remained in the vicinity of the rural towns of Ixiamas and Apolo until June 14, when she traveled to La Paz. From May 18 through June 13, she camped intermittently in rural areas and collected small mammals, including rice rats (Oryzomys sp.), for identification purposes. She reported that, because of weight restrictions, she used nembutal injections rather than chloroform for euthanizing animals (nembutal kills the animal but not fleas on the animal; chloroform kills both), and that while skinning rats she crushed some fleas with her fingers. She had received a primary plague immunization series in 1957 but had not received booster immunizations since 1971. Reported by: MS Wolfe, MD, Traveler's Medical Service; C Tuazon, MD, R Schultz, MD, George Washington Univ Hospital, Washington, DC. Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases, Center for Infectious Diseases, CDC. References

1. Caten JL, Kartman L. Human plague in the United States during 1966: case reports. Southwest Med 1968;49:102-8.

2. Link VB. A history of plague in the United States of America. Public Health Monographs 1955;(no. 26):105.

3. Barnes AM. Plague in the U.S.: present and future. In: Davis LR, Marsh RE. Proceedings of the Fourteenth Vertebrate Pest Conference. Davis, California: The Vertebrate Pest Council of the Vertebrate Pest Conference, 1990:43-5.

4. World Health Organization. Human plague in 1989. Wkly Epidemiol Rec 1990;65:321-3.

5. World Health Organization. Human plague in 1982. Wkly Epidemiol Rec 1983;58:265-72.

6. Poland JD. Plague. In: Last JM, ed. Public health and preventive medicine. 12th ed. Norwalk, Connecticut: Appleton-Century-Crofts, 1986:354-9.

7. CDC. Health information for international travel 1990. Atlanta: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8280.

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