EMS Playbook: Pneumonic Plague

You and your partner are dispatched for a 42-year-old male with difficulty breathing and flu-like symptoms at an apartment building you are both familiar with. Upon arrival you find a pale, diaphoretic man sitting upright on the edge of his bed, breathing rapidly, and producing a little bloody sputum with each cough. He reports high fever, severe chest pain, and progressive shortness of breath that began two days earlier. You have had a recent uptick in flu patients, and this patient doesn’t seem any different. As you begin assessing him, he mentions that he returned home two days ago from a business trip to rural Russia…

In the Middle Ages the mere mention of plague would send people into a panic. Plague occurs naturally in the United States.¹ Recently, concerns have been heightened regarding a potential plague outbreak in Russia.² The Centers for Disease Control and Prevention (CDC) specifically tells clinicians to consider plague with compatible illness and residence in or travel to the rural western United States or other plague-endemic areas.

Symptoms and Patient Management

Pneumonic plague is a severe lung infection caused by the bacterium Yersinia pestis. In EMS, we are most likely to encounter person-to-person transmission. Primary infection occurs when infectious respiratory droplets are expelled when a patient with pneumonic plague coughs or sneezes and they are then inhaled by close contacts. Pneumonic plague can also develop as a secondary infection to bubonic or septicemic plague that then spreads to the lungs.^3-6

Symptoms typically appear suddenly and will present as rapidly progressive pneumonia: high fever, chills, headache, weakness, chest pain, shortness of breath, and a cough that may produce bloody or watery sputum. It’s highly contagious through respiratory droplets and, without prompt antibiotic treatment, it’s often fatal within days. The incubation period is between one and three days, but the range may be from one to six days.^3-6

The prehospital PPE⁷ for pneumonic plague includes:

• Surgical mask for routine patient care, but an N95 mask or higher is recommended if you are performing an aerosol generating procedure⁹
• Place a surgical mask on your patient for source control
• Gloves
• Goggles or face shield

Patient management focuses on the treatment of symptoms. Administer oxygen via a non-rebreather or simple face mask to maintain an SpO₂ greater than 95%. Maintain blood pressure above 100 systolic.⁹ Your local protocols or medical director may have more specific direction, but your treatment should follow your usual EMS protocols for hypoxemia, respiratory failure, and shock. Limit or avoid aerosol generating procedures in the back of the ambulance unless they are essential. For nebulized medications and CPAP/BiPAP consider one of the many different types of filters used for exhaled gases. 

Operations and Next Steps After Exposure

Your 9-1-1 telecommunicators should inquire about recent travel outside the United States, or, in areas where plague has been to known to originate in, for example the rural, western, United States, if a request is made for anyone with cold or flu symptoms.

Operationally any patient with high fever, chills, headache, weakness, chest pain, shortness of breath, and a cough should automatically trigger use of PPE.⁷ If this information is available at the time of dispatch, don your PPE prior to entering the residence. If you arrive on scene and find the patient in distress, step back outside and put on your PPE. Use the minimum number of EMS clinicians on scene and in the back of the ambulance to reduce potential secondary exposures. Take a page from the COVID playbook and have one EMS clinician appropriately masked and gowned, make initial patient contact. One recommendation is to try and assess the patient from six feet away.⁷ Remember to clean with an EPA registered disinfectant all your reusable patient care equipment, stretchers, high touch areas, etc., prior to going back into service.⁷ Open windows and use exhaust fans in the back of the ambulance to maintain air flow.

Prior to arrival, notify the receiving the facility that the patient has cold/flu symptoms with recent travel from Russia or from an area that is experiencing an outbreak. When you arrive at the emergency department, prior to removing the patient from the ambulance and bringing them inside, check with triage or the charge nurse to see where they want you to go. They may have a specific entrance or room they want you to use to minimize potential exposures to other patients.

If you have been exposed to a patient, antibiotics are the treatment of choice for people who have been in close contact with a person who has had pneumonic plague in the previous seven days. Doxycycline, ciprofloxacin, moxifloxacin, and levofloxacin are the most effective antibiotics for preventing plague and should be taken for seven days following a known significant exposure.⁸ Close contacts should also measure their temperature twice a day for seven days and see a physician immediately if fever develops.^1-4

Trusted Resources

There is a lot of misinformation that circulates on the internet. Trusted resources for your organization are the Technical Resources, Assistance Center, and Information Exchange (TRACIE), from the Department of Health and Human Services, Administration for Strategic Preparedness and Response (ASPR), the National Emerging Special Pathogens Training and Education Center (NETEC), and the CDC. Your local and state departments of health are also important, trusted resources. They will have more detailed information specific to your region.

Remember to follow local guidance regarding notifications to public health for potential plague patients. Re-affirm the notification process between the hospital infection control personnel and your organizations designated infection control officer. A timely notification for your EMS clinicians is essential to begin treatment before more severe disease develops.

The reality is that the next case of pneumonic plague will probably not arrive with a warning label. It may look exactly like the patient we see every day with flu, pneumonia, or another respiratory infection, until one piece of the history changes the entire picture. EMS clinicians don’t need to make the definitive diagnosis of plague in the field. We need to recognize when something doesn’t fit, ask the next question, and take the appropriate precautions. A surgical mask, gloves, eye protection, good source control, limiting unnecessary exposures/procedures, and an early call to the receiving hospital can protect an entire chain of patients and healthcare professionals. Pneumonic plague may be rare, but preparedness for it is built on skills we should already practice on every call. The lesson is simple: recognize it, protect yourself and your patient, communicate early, and don't become the next patient.

References

1. Centers for Disease Control and Prevention. (2026, April 6). Clinical testing and diagnosis for plague. https://www.cdc.gov/plague/hcp/diagnosis-testing
2. Keaten, J. (2026, October 7). How Russia and the world are responding to a possible case of pneumonic plague after lab worker dies. AP News. https://apnews.com/article/russia-plague-trump-who-irkutsk-5aa82b8bc3d8300c551cd0e1bf91e32c
3. Hinckley AF, Biggerstaff BJ, Griffith KS, Mead PS. Transmission dynamics of primary pneumonic plague in the USA. Epidemiol Infect. 2012 Mar;140(3):554-60. 
4. Kool JL. Risk of person-to-person transmission of pneumonic plague. Clin Infect Dis. 2005 Apr 15;40(8):1166-72.
5. Nelson CA, Meaney-Delman D, Fleck-Derderian S, Cooley KM, Yu PA, Mead PS. Antimicrobial treatment and prophylaxis of plague: Recommendations for naturally acquired infections and bioterrorism response. MMWR Recomm Rep. 2021;70(3):1-27.
6. National Emerging Special Pathogens Training and Education Center. (2026, October 5). Plague. NETEC Resource Library. https://repository.netecweb.org/exhibits/show/plague/plague
7. ASPR TRACIE. (2023). EMS infectious disease playbook (Version 2.0). U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. https://asprtracie.hhs.gov/documents/aspr-tracie-transport-playbook-508.pdf
8. Nelson, C. A., Meaney-Delman, D., Fleck-Derderian, S., Cooley, K. M., Yu, P. A., & Mead, P. S. (2021). Antimicrobial treatment and prophylaxis of plague: Recommendations for naturally acquired infections and bioterrorism response. MMWR Recommendations and Reports, 70(3), 1–27. https://www.cdc.gov/mmwr/volumes/70/rr/rr7003a1.htm
9. National Association of Emergency Medical Technicians. (2024). AMLS: Advanced Medical Life Support (4th ed.). Jones & Bartlett Learning