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Emerging Infectious Diseases Detection of Notifiable Diseases Through Surveillance for Imported Plague -- New York, September-October 1994

Recent reports of bubonic and pneumonic plague outbreaks in India (1,2) prompted the New York City Department of Health (NYCDOH) and the New York State Department of Health (NYSDOH), in conjunction with CDC, to develop an emergency response plan to detect and manage suspected cases imported by international air travel. This report describes the surveillance system implemented by CDC on September 27 and supplemental efforts by NYC/NYSDOH to guide and inform physicians about the outbreak, and summarizes clinical findings for 11 travelers who had symptoms suggestive of plague. CDC Surveillance System

The CDC surveillance protocol included instructions to staff of international air carriers to notify U.S. quarantine officials before landing of passengers or crew with illness suggestive of plague. All passengers arriving on direct flights from India were provided a plague alert notice that described the symptoms of plague and urged them to seek medical attention if they developed a febrile illness within 7 days of disembarkation. Once passengers were in the United States, the surveillance system relied on physicians and other hospital staff to report suspected plague cases to local health departments, which would then notify CDC. Supplemental Efforts by NYCDOH/NYSDOH

A primary role of NYCDOH/NYSDOH, in conjunction with CDC, was to determine whether the clinical presentation of persons with suspected cases was consistent with plague and to arrange for immediate hospitalization in facilities with respiratory isolation rooms. In addition, because of the high volume of air travel from India (approximately 2000 passengers arrive daily at John F. Kennedy International Airport on flights from India), NYCDOH/NYSDOH supplemented CDC's surveillance plan by using two approaches to disseminate information to heighten awareness of plague, focusing on emergency department physicians. First, a fact sheet describing the clinical presentation of plague and emphasizing the need to assess travel history among patients with suggestive symptoms was transmitted by fax or electronic mail to emergency department physicians and infection-control practitioners at 102 hospitals in New York City and to all acute-care hospitals and county health departments in the state. Second, a special plague advisory issue of City Health Information, NYCDOH's bulletin, was distributed to 20,000 physicians in New York City within 2 weeks of CDC's plague alert. To directly reach persons who recently may have arrived from India and were at increased risk for plague, leaflets in English and Hindi describing plague symptoms and urging ill persons to seek medical attention were distributed by NYCDOH at a heavily attended Indian cultural fair on October 8 and 9. Clinical Findings for Travelers

As of October 27 (when the plague alert was terminated), 10 persons with suspected plague had been reported to NYCDOH and one to the Albany County Health Department and NYSDOH. None were confirmed as having plague. Patients ranged in age from 31 to 80 years; six were men. All 11 patients reported having recently been in India. One suspected case was recognized by an airline crew member during a flight; two by customs officials in the airport; and one by airline officials at check-in for a connecting domestic flight at a different airport. The remaining seven suspected cases were reported by hospital emergency departments. Nine of the 11 patients were admitted to a hospital isolation unit for observation while awaiting consultation with CDC and/or confirmatory laboratory testing.

Ten patients had clinical presentations that were not consistent with pneumonic plague. One patient, who developed adult respiratory distress syndrome and coma, required serologic and microbiologic testing to rule out plague. The final diagnoses for 10 of the suspected cases were viral syndrome (four patients), malaria (three), concurrent malaria and dengue (one), and typhoid and liver disease (one each); one person had no illness. Reported by: B Mojica, MD, R Heffernan, MPH, C Lowe, MFA, S Matthews, New York City Dept of Health; T Briggs, Albany County Health Dept, Albany; F Guido, E Wender, MD, Westchester County Health Dept, Hawthorne; S Kondracki, G Birkhead, MD, D Morse, MD, State Epidemiologist, New York State Dept of Health. Div of Quarantine, National Center for Prevention Svcs; Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: This report illustrates the ongoing potential for importation of emerging infectious diseases into the United States and the need for prompt reporting of cases to local and state health departments for an appropriate public health response (3). The Institute of Medicine has identified international travel and commerce as a major factor associated with emerging infections (4). The protocols described in this report -- highlighting the close cooperation between federal, state, and local public health officials; the medical community; and the airline industry -- represent the coordinated, comprehensive prevention-oriented response needed to guard against the threat of emerging and resurgent infections. In addition, the evaluation of suspected plague cases in New York revealed limitations in recognizing cases of disease only at the point of disembarkation; in New York, approximately half of the suspected cases were brought to the NYCDOH/NYSDOH's attention by local physicians. The importance of obtaining a travel history when evaluating persons presenting with fever was underscored by the detection of cases of dengue and nationally notifiable disease conditions (i.e., malaria and typhoid) (5).


  1. CDC. Human plague -- India, 1994. MMWR 1994;43:689-91.

  2. CDC. Update: human plague -- India, 1994. MMWR 1994;43:722-3.

  3. Berkelman RL, Bryan RT, Osterholm MT, LeDuc JW, Hughes JM. Infectious disease surveillance: a crumbling foundation. Science 1994;264:368-70.

  4. Institute of Medicine. Emerging infections: microbial threats to health in the United States. Washington, DC: National Academy Press, 1992.

  5. CDC. National notifiable diseases reporting -- United States, 1994. MMWR 1994;43:800-1.

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