Shadow of the third pandemic: a review of the epidemiology, microbiology, ecology, clinical features, molecular diagnosis and treatment of plague

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Yersinia pestis has caused three plague pandemics. The third pandemic created a legacy of disease in 16 countries with The Democratic Republic of Congo and Madagascar most affected. Phylogenetically, Y. pestis gained pathogenicity and the ability to spread via fleas due to the acquisition of plasmids Pst and Fra. Recently, contaminated soil has been implicated as an additional transmission route. In well resourced settings, plague diagnosis was transformed in the 2000s by PCR and ELISA. More recently, matrix assisted laser desorption/ionization time-of-flight has enabled species identification within 6 min. However, these innovations have had little impact on the rural, resource poor settings, in which plague is most prevalent. Here, the F1 dipstick has been a more effective method of field diagnosis. A new plasminogen activator protease dipstick is currently being validated. The emergence of two antibiotic resistant strains and potential for bioweaponization has stimulated vaccine development with the F1-LcrV vaccine most promising in animal models.

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