Re-emergence of the plague in Madagascar

In the fast paced news cycle of modern times, it is all too easy to forget about and miss crucial stories from around the world. One such news item which has failed to gain traction in the media is the spread of the pneumonic plague across the east African island nation of Madagascar.

Pneumonic plague is one of three types of plagues caused by the bacterium Yersinia pestis, each one named after its mode of transmission. The pneumonic plague is a severe lung infection causing fevers, headaches, shortness of breath, chest pain and coughing. It can be treated by antibiotics, however if left untreated leads to a death, with a near 100% mortality rate. Yersinia pestis is perhaps best known as being the cause of Black Death that swept through Asia, Europe and Africa in the 14^th century causing an estimated 50 million deaths.

Yersinia pestis, the bacteria that causes the three forms of this plague, causes endemics in certain locations including the US Southwest. In Madagascar plague season typically runs from September to April with usually around 200 cases.

So what makes this recent plague different from others?

Madagascar typically sees the spread of the bubonic plague which is has a lower fatality rate than the pneumonic plague. Additionally, on average the plague causes 200 cases in the island nation, however in the first six weeks there had already been 680 documented cases.

Patient zero is thought to be a man who died in August of this year, and was believed to have been ill with what was thought to be malaria. In documents released by the WHO (World Health Organisation) he is described as having died whilst travelling by bush taxi, a form of public transport. Plague cases started to appear in large clusters along what appear to be his route. The disease then took off when it reached Antananarivo (commonly called Tana), where schools have been closed and public events cancelled.

So why is this a global health emergency?

Pneumonic plague is thought to be the most contagious and deadliest form of disease which if left unchecked can be expected to spread not only across Africa but throughout the world. This is due to the increased global travel that modern day technologies have allowed us to take, with estimates claiming nearly 2 million people cross a border daily. Currently the WHO lists 9 African countries at high risk of spread due to their close ties to Madagascar (especially due to travel links between the countries and the island nation). The countries currently listed as high risk include Kenya, Ethiopia, South Africa, Mozambique, Tanzania, Reunion, Mauritius, Seychelles and Comoros.

What’s particularly alarming is that the spread of pneumonic plague is airborne e.g. coughing, and the outbreak has reached relatively densely populated urban areas including the capital, Tana. If left untreated the pneumonic plague is fatal is nearly 100% of call cases.

What is currently being done?

The WHO has announced that they would deliver 1.2 million doses of antibiotics to the island nation and authorized £1.5 million in funding to help combat the disease. Additionally, the UK has sent members of its Rapid Response Team along with members from the CDC (Centre for Disease Control) in America to the region.

On the ground treatment centres have bulked up their staff and responders have done extensive contact tracing to break the chain of person to person transmission. Travellers leaving Madagascar are also being currently screened for fevers, those with plague symptoms are not being allowed to travel until they receive treatment and further examination.

The response to this plague has been quick and efficient especially from the WHO which recognized it as a problem soon after the first few cases began to appear in hospital. In the new modern times, we live in currently it is not surprising to see the increase in epidemics with Ebola in 2015 and Zika in 2016. However, it is heartening to see the change in our response to these epidemics, and the increased urgency with which action is taken.