Emergencies preparedness, response

Plague outbreak in remote Madagascar puzzles investigators

Plague, though terrifying, is nothing new in Madagascar, where around 600 cases are reported annually. But there was something different about a suspected plague outbreak reported last December. The outbreak’s location was far away from recent outbreaks and implied plague had spread to new parts of the island nation, but health officials couldn’t explain it.


WHO/E. Bertherat

One of the oldest identifiable diseases known to man, plague remains endemic in many natural foci around the world. It is still widely distributed in the tropics and subtropics and in warmer areas of temperate countries. Essentially a disease of wild rodents, plague is spread from one rodent to another by flea ectoparasites and to humans either by the bite of infected fleas or when handling infected hosts. Recent outbreaks have shown that plague may reoccur in areas that have long remained silent.

Untreated, mortality - particularly from pneumonic plague - may reach high levels. When rapidly diagnosed and promptly treated, plague may be successfully managed with antibiotics such as streptomycin and tetracycline, reducing mortality from 60% to less than 15%.

Plague is an infectious disease caused by the bacteria Yersinia Pestis, a zoonotic bacteria, usually found in small mammals and their fleas. It is transmitted between animals and humans by the bite of infected fleas, direct contact, inhalation and rarely, ingestion of infective materials.

Plague can be a very severe disease in people, with a case-fatality ratio of 30%-60% if left untreated. In 2015 there were 320 cases reported worldwide, including 77 deaths. Historically, plague was responsible for widespread pandemics with high mortality. It was known as the "Black Death" during the fourteenth century, causing an estimated 50 million deaths, approximately half of them in Asia and Africa and the other half in Europe, where a quarter of the population succumbed.

People infected with plague usually develop “flu-like” symptoms after an incubation period of 3-7 days. Typical symptoms are the sudden onset of fever, chills, head and body-aches and weakness, vomiting and nausea.

There are 3 main forms of plague infection, depending on the route of infection: bubonic, septicaemic and pneumonic.

Bubonic plague is the most common form of plague and is caused by the bite of an infected flea. Plague bacillus, Y. pestis, enters at the bite and travels through the lymphatic system to the nearest lymph node where it replicates itself. The lymph node then becomes inflamed, tense and painful, and is called a "bubo". At advanced stages of the infection the inflamed lymph nodes can turn into suppurating open sores. There is no inter human transmission of bubonic plague.

Septicaemic plague occurs when infection spreads through the bloodstream Septicaemic plague may result from flea bites and from direct contact with infective materials through cracks in the skin. Advanced stages of the bubonic form of plague will also lead to direct spread of Y. pestis in the blood.

Pneumonic plague-or lung-based plague- is the most virulent and least common form of plague. Typically, the pneumonic form is caused by spread to the lungs from advanced bubonic plague. However, a person with secondary pneumonic plague may form aerosolized infective droplets and transmit plague via droplets to other humans. Untreated pneumonic plague has a case-fatality ratio close to 100%.

Diagnosis and confirmation of plague requires laboratory testing. The best way to confirm that a patient has plague is to identify Y Pestis in a sample of fluid from a bubo, or blood or sputum. Rapid dipstick tests have been validated for field use to quickly screen for Y. pestis antigen in patients. Specimens should be collected and safely forwarded to laboratories for plague testing.

Untreated plague can be rapidly fatal so early diagnosis and treatment is essential for survival and reduction of complications. Antibiotics and supportive therapy are effective against plague if patients are diagnosed in time. Pneumonic plague patients must be isolated and cared by trained medical staff with personal protective equipment.

Preventive measures include informing people when zoonotic plague is active in their environment and advising them to take precautions against flea bites and not to handle animal carcasses in plague-endemic areas. In plague endemic areas and during bubonic plague outbreaks, flea and reservoir (usually rodents) controls must be implemented.

Pneumonic plague is highly contagious. Close contact persons must be kept under medical surveillance and must receive a prophylaxis with antibiotics during 7 days.

Plague vaccines were widely used before the antibiotics era. The current vaccines have not been shown to be very effective against pneumonic plague and are not recommended by WHO out of for high-risk groups (e.g. laboratory personnel who are constantly exposed to the risk of contamination).

Epidemiological information

Technical information

Geographical distribution

Plague is most common in Madagascar, Democratic Republic of the Congo and Peru. However, potential plague natural foci are distributed worldwide.

General information

Contact information

Department of Pandemic and Epidemic Diseases
World Health Organization
Avenue Appia 20
1211 Geneva 27, Switzerland
Email: edpln@who.int