title: Where does human plague still persist in Latin America?
abstract: BACKGROUND
  Plague is an epidemic-prone disease with a potential impact on public health, international trade, and tourism. It may emerge and re-emerge after decades of epidemiological silence. Today, in Latin America, human cases and foci are present in Bolivia, Brazil, Ecuador, and Peru.
  
  
  OBJECTIVE
  The objective of this study is to identify where cases of human plague still persist in Latin America and map areas that may be at risk for emergence or re-emergence. This analysis will provide evidence-based information for countries to prioritize areas for intervention.
  
  
  METHODS
  Evidence of the presence of plague was demonstrated using existing official information from WHO, PAHO, and Ministries of Health. A geo-referenced database was created to map the historical presence of plague by country between the first registered case in 1899 and 2012. Areas where plague still persists were mapped at the second level of the political/administrative divisions (counties). Selected demographic, socioeconomic, and environmental variables were described.
  
  
  RESULTS
  Plague was found to be present for one or more years in 14 out of 25 countries in Latin America (1899-2012). Foci persisted in six countries, two of which have no report of current cases. There is evidence that human cases of plague still persist in 18 counties. Demographic and poverty patterns were observed in 11/18 counties. Four types of biomes are most commonly found. 12/18 have an average altitude higher than 1,300 meters above sea level.
  
  
  CONCLUSIONS
  Even though human plague cases are very localized, the risk is present, and unexpected outbreaks could occur. Countries need to make the final push to eliminate plague as a public health problem for the Americas. A further disaggregated risk evaluation is recommended, including identification of foci and possible interactions among areas where plague could emerge or re-emerge. A closer geographical approach and environmental characterization are suggested.
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Maria Cristina
authors: MC
authors: Schneider
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Patricia
authors: P
authors: Najera
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Sylvain
authors: S
authors: Aldighieri
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Deise I
authors: DI
authors: Galan
authors: Unit of Control of Epidemic Diseases, World Health Organization, Geneva, Switzerland.
authors: Eric
authors: E
authors: Bertherat
authors: Department of Global Health, University of South Florida, Tampa, Florida, United States of America.
authors: Alfonso
authors: A
authors: Ruiz
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Elsy
authors: E
authors: Dumit
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Jean Marc
authors: JM
authors: Gabastou
authors: Department of Communicable Diseases and Health Analysis, Pan American Health Organization, Washington, D.C., United States of America.
authors: Marcos A
authors: MA
authors: Espinal
mesh_terms: D006801:Humans; D007843:Latin America / Q000453:epidemiology; D010930:Plague / Q000453:epidemiology*; D011634:Public Health; D012959:Socioeconomic Factors; D013020:South America / Q000453:epidemiology