It seems like something out of ancient history: from a time of uncleanliness and backward medical practices.  In reality, the plague is not an extinct threat.

The plague is a bacterial infection shared by animals and humans.  It is generally spread to people by being bitten by a rodent flea carrying the bacteria, or by handling or consuming another animal that is infected with the disease.   The most common causative agent is Yersinia pestis, but there are also two other strains: Yersinia enterocolitica and Yersinia pseudotuberculosis.  These two forms of the bacteria are transmitted from person to person by the fecal–oral route. Although modern antibiotics can fight the plague, if the disease goes unrecognized or is not treated promptly within the first 24 hours, death can still result. 

The last epidemic in the United States occurred in Los Angeles in 1924-25.  Since then, outbreaks have been minimal and centered on rural areas.  An average of 10 to 15 people die each year from the plague within the United States.  Most cases in the United States occur in two regions: 1. northern New Mexico and Arizona and southern Colorado, or 2. California, southern Oregon and western Nevada.  However, the World Health Organization reports that there are 1000-5000 cases of the plague every year world wide.  Areas carrying the highest risk are Africa, Asia and South America, with Africa generating the highest number of outbreaks.

Scientists are becoming worried that recent climate changes may cause an increase in the number of plague cases seen each year.  Another great concern is that Yersinia pestis has recently shown an ability to acquire antibiotic resistance.  The emergence and spread of multi-resistant strains of Y. pestis creates the potential for a major threat to human health.  It also can not be discounted as a bioterrorism threat.  Therefore, how does the medical community prepare for such an almost forgotten threat?  Since it is impossible to eliminate the rodents, the best line of defense to reduce the risk of complications and death is early recognition and rapid treatment.

Nurses working in one of the high risk areas, or in an environment where a lot of international traffic comes through, should be aware of the signs and symptoms of this flu-like disease.  With an incubation period any where from two to seven days, infection by Yersinia pestis can present itself in three different forms of the plague depending on the route of exposure.  These three types are: bubonic, septicemic, and pneumonic.

Bubonic plague is the most common form which results from the bite of a flea infected with Yersinia pestis.  It is an infection of the lymph nodes causing the tonsils, adenoids, spleen and thymus to become inflamed.  Other symptoms include high fever, aches, malaise, chills, tender lymph glands, severe headache and seizures.

Septicemic plague occurs when the bacteria multiply in the blood stream.  This septic response includes fever, chills, abdominal pain, diarrhea, nausea, vomiting, low blood pressure, abnormal blood clotting, shock, bleeding under the skin or other organs, and organ failure.  But, septicemic plague can also result in death before any recognizable symptoms occur.

Pneumonic plague is an infection of the lungs.  The bacteria are transmitted directly from human to human by inhalation of infected respiratory droplets and causes pneumonia.  Resulting symptoms include difficulty breathing, a severe cough, and frothy, bloody sputum. The incubation period for this type of infection can be as short as a few hours. Pneumonic plague requires isolation of the patient to avoid further transmission.  Contact and droplet precautions must be used by the nurse when caring for these patients.  People coming in unprotected contact with the patient prior to isolation are watched very closely for symptoms and generally given prophylactic antibiotics.  This is also the type most likely to be used as a bioterror agent.

Recent developments now allow for a rapid diagnostic test, where in the past laboratories required a four day wait to isolate and identify the bacteria.  This allows for faster positive identification and a method of monitoring and tracking the disease.  It is critical that treatment begin within the first 24 hours of the disease.  Standard antibiotic treatments include: streptomycin, tetracyclines, and sulfonamides.  Gentamicin and fluoroquinolones can be considered as alternatives when needed.  Oxygen, IV fluids and respiratory support may also be considered as needed.  As with most disease processes, cleanliness and proper hand washing are also essential for containing the threat of the plague.

 

References:

Division of Vector-Borne Infectious Diseases.  Plague.  Center of Disease Control. December 11, 2007.

Stenseth NC, Atshabar BB, Begon M, Belmain SR, Bertherat E, et al. (2008) Plague: Past, Present, and Future. January 15, 2008. PLoS Med 5(1): e3

US National Library of Medicine.  Plague.  Medline Plus.  Updated January 23, 2008.

 

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