'It is a dangerous moment': Madagascar plague death toll reaches 74

The first fatality of Madagascar’s deadly plague outbreak – which has now claimed at least 74 lives – initially went unnoticed.

In late August, according to researchers with the World Health Organization (WHO), a 31-year-old man was visiting the island’s central highlands when he developed what appeared to be the symptoms of malaria.

A few days later, travelling on one of the island’s crowded taxi-brousses (minibus taxis) en route to Tamatave – a journey that took him via the capital, Antananarivo – the unnamed man’s condition worsened, and he died.

No one realised he had been infected by the plague, and his body was prepared for burial without precautions.

In the space of a few days, 31 people who had come into contact with him – either directly or indirectly – were infected. Four of them subsequently died.

Since that first “case zero”, the outbreak of the highly contagious strain of plague has claimed 74 lives over two months, infecting more than 800 people.

Marking the outbreak as doubly dangerous, many cases have also featured the most virulent form of what was known in the Middle Ages as the Black Death – pneumonic plague.

It is initially caused when advanced bubonic plague spreads to the lungs: this slower acting and relatively less contagious form of the disease attacks the patient’s lymphatic system. Pneumonic plague spreads very easily and is deadly if untreated.

Of the 684 cases reported as of 12 October, 474 were pneumonic plague, 156 bubonic and one septicaemic. A further 54 were unspecified.

Although plague outbreaks in Madagascar have been an annual occurrence in recent decades, this outbreak has, unusually, affected urban areas where plague is not normally endemic. This further increases the risk of transmission.

The plague, known as the Black Death, wiped out 30%-60% of the European population in the Middle Ages. Today, the disease is treatable with antibiotics, provided it is caught early.

The Black Death has three forms: bubonic, pneumonic and septicaemic. A person with bubonic plague develops painful swollen lymph nodes or 'buboes' after being bitten by an infected flea.

Around one in 10 people affected with bubonic plague go on to develop pneumonic plague, where the infection gets into their lungs.

Pneumonic plague can be transmitted through coughing.

Septicaemic plague occurs when infection spreads through the bloodstream, following a bubonic or a pneumonic plague.

If left untreated, bubonic plague has a fatality rate of around 30%-60%. The pneumonic and septicaemic forms are fatal without swift treatment.

Between 2010 and 2015 there were 3,248 cases reported worldwide, including 584 deaths.

Another feature of the outbreak that is out of the ordinary has been the timing. Whereas past cases of the disease have generally occurred during the rainy season, between November and March, and were typically of the bubonic variety, this predominantly pneumonic outbreak began in August.

All of this has provoked a climate of fear, even as WHO officials have rushed to attempt to contain the outbreak, delivering 1.2m doses of antibiotics.

The organisation’s efforts have been backed by interventions from health officials, who have set up medical inspections at transport hubs and banned jail visits and public gatherings.

The pneumonic plague outbreak has also hit sectors of society outside impoverished communities, who are typically most at risk.

“Normally, the people who catch the plague … live in poor areas, but in this case we find the well-to-do, the directors, the professors, people in every place in society, catching the disease,” said Dr Manitra Rakotoarivony, Madagascar’s director of health promotion.

As residents of the capital and elsewhere have queued to buy masks or self-medicate, the grim mood was summed up last week by the mayor of Toamasina, one of the towns affected by the outbreak.

“It is a dangerous moment,” Elysée Ratsiraka told the NewsMada website. “You can leave your house today and catch the plague tomorrow. What are we supposed to do today … and tomorrow? That’s the question facing us.”

Others dealing with the outbreak, however, have tried to instil a sense of calm.

“Plague is curable if detected in time. Our teams are working to ensure that everyone at risk has access to protection and treatment. The faster we move, the more lives we save,” said the WHO’s Madagascar representative, Charlotte Ndiaye.

The WHO calls plague a “disease of poverty” caused in part by unsanitary living conditions. Over the course of less than a decade, the country’s plague problem appears to have intensified, driven by a combination of economic and environmental factors.

Madagascar has a per capita GDP of about $400 (£300), and national programmes to control the disease have been “hampered by operational and management difficulties”, according to a report by the European Centre for Disease Prevention and Control.

Plague was first introduced to the island in 1898, when steamships from India brought rats infected with the disease. Within two decades or so, it virtually disappeared from Madagascar for 60 years, only to re-emerge in recent decades.

The black rats that carry plague in the highlands have gradually developed resistance to it. Burial practices that involve touching corpses are another reason the disease spreads, according to a 2015 study by scientists at Madagascar’s Pasteur Institute.