New Rural Focus of Plague, Algeria

of Hong Kong healthcare workers to accept pre-pandemic infl uenza vaccination at different WHO alert levels: two questionnaire surveys. Initial response of health care institutions to emergence of H1N1 infl uenza: experiences, obstacles, and perceived future needs. To the Editor: Plague is a deadly rodent-associated fl ea-borne zoono-sis caused by the bacterium Yersinia pestis (1). Human plague periodically reemerges in so-called plague foci, as illustrated by the 2003 reemergence of human plague in the Oran area, Al-geria (2,3). We report emergence of a new plague focus in a remote region of Algeria. In July 2008, three patients came to Laghouat University Hospital with signs of severe infection and painful, infl amed, enlarged lymph nodes suggestive of buboes. One additional patient became ill with pneumonia and coma after a bubo appeared. The patients were nomads living in a 24-person camp in Thait El Maa in the Lagh-ouat area, 550 km southwest of Algiers (Figure). Plague was confi rmed by culturing Y. pestis from 1 bubo aspirate. Ten days of oral doxycycline (4 mg/kg/d) combined with oral rifampin (20 mg/kg/d) and intramuscular gen-tamicin (3 mg/kg/d) cured the patients with bubonic plague, but the patient with pneumonic plague died. In January 2009, eight individuals of the rodent species Meriones shawii (Shaw's jird) and 2 Psa-mommys obesus (fat sand rats) were trapped inside nomads' tents (H.P. Sherman Traps, Tallahassee, FL, USA). At time of capture, there was a cold wind with blowing sand, and, after visual inspection of the rodents, efforts to recover fl eas failed. DNA from the rodents' spleens was extracted by using the QIAamp Tissue Kit (QIAGEN, Hilden, Germany) at the Medical Entomology Unit Laboratory , Pasteur Institute, Algiers, and subjected to PCR amplifi cation of the plasminogen activator gene (pla) from 6 M. shawii jirds. Negative controls (DNA extracted from uninfected fl eas maintained as colonies in Medical Entomology Unit Laboratory was used in the absence of negative animal tissue) remained negative. After sequencing, the PCR am-plicons showed 100% sequence identity with Y. pestis reference sequences. Identifi cation was further confi rmed in Marseille, France, by culturing 2 rodent glycerol-negative Y. pestis isolates (Algeria 1 and Algeria 2) and sequencing pla, caf, and glpD genes. The latter sequence was identical to the reference Y. pestis CO92, an Ori-entalis biotype. Multispacer sequence typing found the following combina-a pattern that is typical for all Orienta-lis isolates investigated by this method but does …