Rat fleas are the primary vector for transmitting plague between rats and humans. Fleas live in damp areas and breed quickly. Effective vector control requires first using insecticides to kill fleas on rats before conducting rat control to prevent fleas from jumping to humans. Personal protection measures and public education are also needed when conducting response activities. Proper planning and technical guidance are required for setting up Plague Treatment Centers with adequate water, sanitation and hygiene facilities.

1. WASH
Plague Prevention and Control

2. A note on references contained in this presentation
This presentation relies heavily on information collected from WHO,
the Mentor Initiative, and MSF Belgium. Attribution for the source of
information has been included.
IFRC takes full responsibility for the information contained in the
presentation. However, as explained in the presentation, vector control
for plague response is complicated and we urge all response personnel
to seek technical support before engaging in activities.

3. The Flea
WHO
• Of the 3000 species only a dozen commonly attack humans. The rat
flea is the vector of bubonic plague
• Rat fleas (Xenopsylla species) that normally feed on rats may
occasionally feed on humans and thus spread the disease to them.
When rodents infected with plague die the fleas leave their hosts and
are then likely to attack and infect people.
• Other fleas, such as the human flea, may subsequently transmit the
disease from person to person

4. The Flea
MENTOR Initiative:
• They are wingless, with mouthparts adapted for piercing skin and
sucking blood.
• Fleas are external parasites, living off the blood of mammals including
rats, domestic animals and humans.
• Fleas breed in damp, smelly environments and in houses,
preferentially in piles of old clothing, old shoes and soft furnishings.

5. Before you start
• Rat control is complicated. Rats are hard to kill because they are
cautious about traveling new places and eating new food.
• Rat control when the flea is the vector is even more complicated.
• DO NOT attempt to engage in vector control in plague response
without seeking expert technical support. Poor quality vector control
will make the problem worse.

6. Prevention and Control
• Isolate infected animals
• Limit number of people in contact
• Insect repellant
• Personal protection
• Surgical mask, gloves, eye protection
• Rodent control
• Eliminate rodent habitat around home
• Brush, food sources, firewood, junk
• Undertaken only after insecticide use
• Flea control
• Flea powder
• Proper rat control
• Public health education
• Plague Treatment Centres (PTCs)

7. Control Measures
WHO
• Control measures during epidemics of plague must be effected in two
stages:
(1) insecticidal dusting of rat habitats to kill rat fleas;
(2) rat control.
• A control campaign with the sole aim of killing rodents could result in
increased disease transmission to humans: the deaths of many
rodents could cause large numbers of fleas to leave the dead hosts
and seek alternative sources of blood.

8. Chemical Control Measures
MENTOR Iniative
• Insecticidal powder can be applied in houses using either mechanical
or hand pumps with a fogger to kill adult fleas.
• Insecticidal sprays containing an insect growth regulator such as
pyriproxyfen or methoprene can be used to kill eggs and pupae.
• Borax is sold as a «Natural Laundry Booster» and can also be used at
a household level as a treatment for flea infestations. Borax contains
sodium borate which kills fleas by dehydrating them.

9. Chemical Control Measures
MSF
• The fleas on the rodents must be killed before the rodents otherwise the fleas
will just jump onto another host when the rat is dead.
• Permethrine powder can be dusted along the rat runs and into burrows. It is
probably best to put some quite thick patches of the powder on the run. Try and
put it in areas where it is not accessible to humans and where it is not going to be
swept up or blown away. The idea is that the rat picks up the dust on its paws as
it walks through the powder. Then when it stops to groom and brush itself the
powder will be brushed over its body thus killing the fleas.
• Dust rodent runs, harborages and burrows in and around known or suspected
plague areas with an insecticide labeled for flea control and known to be effective
against local fleas. If nonburrowing wild rodents are involved, insecticide bait
stations can be used. In houses disinfest by dusting the houses, outhouses and
household furnishings; dust the bodies and clothing of all residents in the
immediate vicinity.
• Guidance for chemicals and proper concentration will be shared soon

10. Community Control Measures
MENTOR Initiative
• Maintain good personal hygiene and clean living conditions
• Look out for signs and symptoms (rash, allergic reaction to bites) as
well as for flea-borne diseases
• Treat living spaces with insecticides to eliminate flea infestations Treat
livestock occasionally as well

11. Health Promotion
MSF
• Information should be distributed (posters, radio, person-to –person etc)
to:
• Attempt to mitigate public hysteria. If people have already left it may be a
bit late but it should still be tried with those who remain.
• Ensure that people recognise symptoms and seek treatment quickly and
that those who have been exposed go for prophylaxis.
• Pass basic information about not touching dead rats or other dead animals.
And perhaps not hunting or trying to kill rats at the moment.
• Explain about any vector control going on like dusting of people and
spraying in houses.

12. Plague Treatment Centres (PTCs)
• WASH will have a key role in PTCs
• Infection Prevention and Control and WASH are related but different
activities within the RC RC Movement.
• There are overlaps and WASH personnel are excellent candidates for
IPC roles.
• However, as we are not solely a medical organization and the vast
majority of our WASH work is service delivery to community
focussed, we distinguish between WASH and IPC

13. WASH Tasks in PTCs
• Waste incineration High Risk Area (HRA)
• Waste management Low Risk Area (LRA
• Preparation & quality monitoring of:
• 0,5% chlorine solution line
• 0,05% chlorine solution line
• “Safe water” line (0,3 mg/l free chlorine)
• Chlorine control and storage
• Water pipes repairing and maintenance
• Construction for new PTCs and expansion

14. Water in PTCs
The following overview comes from Ebola Treatment Cetnres and guidance
will be modified over time:
• Plan for 100 litres per patient per day for larger PTCs and 150 litres for
smaller (less than 30 beds).
• Plan for 0.5 to 1 kg of chlorine per patient per day (HTH or NaDCC). Similar
for household disinfection in the community.
• Water storage should include a buffer stock of two to three days.
• To avoid additional spread of plague, water borne diseases in staff and
patients need to be avoided as much as possible. If possible provide
bottled drinking water.
• Local procurement of chlorine should be avoided if possible due to quality
concerns. Actual strength of chlorine stock should be regularly tested.

15. Drainage and Toilets PTCs
The following overview comes from Ebola Treatment Cetnres and guidance
will be modified over time:
• Drainage of handwashing water is less of a priority due to the high chlorine
content. Focus on rainwater not flooding latrine pits.
• Latrine pits are usually covered after filling. However, toilets in PTCs in
urban areas may require desludging.
• Squatting is better than sitting for disinfection purposes. It is preferable
but very difficult to disinfect between uses).
• Chlorine will interfere in the decomposition in the pits.
• Latrine cubicles should be larger, as patients may collapse or die inside and
need to be removed by staff.
• Septic tanks and other more advanced technical options are not advised as
decommissioning is complicated.

16. Specific considerations for PTCs
• IPC in a PTC will largely resemble Ebola protocols
MSF
• Bed nets can be used to prevent fleas. Make sure that all people
living in the PTC have access to them (particularly guards etc who are
sleeping on or near the floor).
• Mattresses should not be placed on the floor but should be on bed
frames as fleas are often on the floor and can only jump about 30cm.
• Patients with bubonic plague or who have had bubonic plague should
be de-flead as they come into the health centre. If there is fear that
there is an infestation of fleas in the health centre then the floors can
be sprayed with insecticide.

17. Personal Protection in Vector Control
WHO: People working in the field may protect themselves by dusting
their clothing with insecticidal powder, using impregnated clothing, and
using repellents on a daily basis.
People entering houses for spraying purposes
should wear high rubber boots and/or
insect repellent on their lowers legs, ankles
and hands.

18. Additional Topics Forthcoming
• Guidance on chemicals and methodology for household disinfection
• Guidance on control strategy for this plague outbreak
• Desludging guidance for urban PTCs

19. Additional Resources
• WHO Vector Control for Individuals and Communities:
http://www.who.int/malaria/publications/atoz/9241544945/en/
• MENTOR Integrated Vector Control Toolkit:
http://thementorinitiative.org/wp-content/uploads/2016/11/IVM-
Toolkit_English_17Nov_2016.pdf
• CDC - Division of Vector-borne Infectious Diseases:
https://www.cdc.gov/plague/resources/235098_plaguefactsheet_50
8.pdf
• CDC - Plague information: www.bt.cdc.gov/agent/plague/index.asp
Center for Food Security and Public Health, Iowa State
University, 2011