Plague is spreading at an alarming rate in Madagascar. Yes, plague.

By Julia Belluz

The Indian Ocean island has already seen 500 plague cases and 54 deaths — and it’s early in the season.

People in Madagascar are scrambling to get their hands on antibiotics and face masks, while public gatherings have been canceled, as a rare pneumonic plague epidemic spreads quickly across the country.

Plague is the deadly flea-borne bacterium you might associate with the Middle Ages, when the “Black Death” killed 50 million people, wiping out most of Europe’s population. But it’s still around today, even in the United States.

In some countries, particularly Madagascar, plague is endemic, and flare-ups cause public health emergencies on an almost annual basis — but the epidemic that’s quietly brewing there right now appears to be exceptionally worrying.

As of October 11, 500 plague cases have been identified, as well as 54 deaths. At least twenty of Madagascar’s 114 districts are now affected by the epidemic. Madagascar typically sees about 400 cases each year, when the disease surfaces from September all the way to April. So it’s really early to see such a high burden of illness.

Plague has also now spread through the capital to coastal cities, “which we have not seen before,” World Health Organization spokesperson Tarik Jašarević told Vox. There’s already been one case of international spread, too, to nearby Seychelles.

Also unlike previous outbreaks, this year’s involves mostly pneumonic plague, a more dangerous form of the disease than the much more common bubonic plague.

Pneumonic plague attacks the lungs and spreads from person to person through droplets from coughing, like a cold, while bubonic plague spreads only from fleas to humans.

“So it’s a worrying situation because it’s in an urban setting, and it’s transmissible from human to human,” Jašarević added. “We need to act quickly — to trace the contacts of those infected and put people on a preventive treatment.”

Some 30 to 60 percent of people with bubonic plague die. Untreated pneumonic plague is always deadly, typically within 24 hours of disease onset. A timely antibiotics dose can, however, save lives, and that’s why the WHO delivered an emergency stockpile of nearly 1.2 million doses of antibiotics to the Indian Ocean island nation.

The rick plague keeps spreading in Madagascar is high, but the risk of international spread is still low

 RIJASOLO/AFP/Getty Images
Doctors and nurses from the Ministry of Health and officers of the Malagasy Red Cross staff a “health care checkpoint,” trying to inform passengers leaving Antananarivo about plague and to potentially detect suspected cases.

Health officials traced Madagascar’s current outbreak back to a 31-year-old man from Toamasina, a coastal city in Madagascar. On August 27, the man used public transport to travel about 500 miles, through Madagascar’s capital, Antananarivo, and died while en route.

Public health workers found out that many people he was in contact with had come down with plague, and they had spread the disease to others too. Since then, cases have been popping up elsewhere around the country.

A traveler was also diagnosed with the disease in Seychelles, a chain of Indian Ocean islands, after returning from Madagascar — raising fears that this may be the first of more to come, the New York Times reported.

Plague is caused by the bacterium Yersinia pestis. Wild rodents — chipmunks, mice, squirrels — can carry the bacteria. Fleas feed on the rodents and pick up plague, in turn spreading it to other mammals, including humans, through bites.

When people talk about plague, they’re usually talking about bubonic plague, the type that causes about 80 percent of infections in the US every year. Bubonic plague infects the lymphatic system, causing the lymph nodes to swell up and feel tender. These swellings, known as buboes, typically pop up in the groin, neck, and armpits. A blackish pustule will also arise at the site of the flea bite, and hemorrhaging can occur underneath the skin, causing it to blacken — part of the reason the plague is called “Black Death.”

When bubonic plague is left untreated, it can spread into the lungs to become pneumonic plague, or into the bloodstream to become septicemic plague. These types of plague are more rare — and more dangerous — because unlike bubonic plague, they can spread from person to person.

And again, it’s pneumonic plague that’s affecting Madagascar right now.

For now, the WHO believes there’s a very low risk that plague will spread internationally from Madagascar — though the risk that it’ll continue to brew within the country is high.

That’s a situation worth keeping an eye on, as infectious diseases expert Crawford Kilian warned on his blog. “Pneumonic plague in a big city is like Ebola in a big city: better to prevent it than suppress it, and prevention now seems out of the question.”

In much of the world, plague is associated with poverty

 Henitsoa Rafalia/Anadolu Agency/Getty Images
Houses in Antananrivo, Madagascar, on October 2, as plague spreads rapidly in cities across the country.

As this study in PLOS Medicine reports, poorer countries with bad sanitation and other risky practices can help spread the infection:

Africa is particularly at risk for a number of reasons. Poor rural communities typically live in close proximity to rodents, which are widely hunted and eaten in many plague-endemic areas. Superstitions, lack of money, and distance from health facilities often lead to delays in seeking health care and receiving treatment. The public health system in large parts of Africa is poorly organised and equipped, and political crisis and social disorganisation impede improvements.

So it’s not surprising that on the global scale, plague is most common in poorer countries, such as Madagascar, where the per capita GDP is only $1,500. Plague turned up on the island in 1898 through trade routes, and outbreaks have popped up nearly every year since 1980. (For the past two decades, …read more

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