Newsdesk
Plague in Madagascar
Madagascar has long been affected by plague, but the latest outbreak is proving unusual in
more ways than one. Talha Burki reports.
As The Lancet Infectious Diseases
went to press, 1554 cases of plague,
including 113 deaths, had been
reported in Madagascar since the
beginning of August. Two-thirds of
the cases were pneumonic plague,
suggesting that the outbreak is
being driven by person-to-person
transmission. Recent figures indicate
that the number of new cases is
declining in all the affected districts of
the country. “This outbreak is under
control, but we have to maintain
vigilance because the plague season in
Madagascar runs from September to
April”, commented Charlotte Ndiaye
(WHO, Antananarivo, Madagascar).
“There have to be sustainable
strategies regarding this disease in
Madagascar.”
Between 2010 and 2015, there
were 3248 notified cases of plague
scattered across 11 countries.
Madagascar accounted for three-
quarters of the global burden.
“Vast areas of the world have
plague in small mammals”, explains
Michael Prentice (University College
of Cork, Ireland). “One does not often
see plague in humans because the
vectors do not tend to be in populated
areas.” Madagascar is an exception to
this rule.
Black rats probably came to
Madagascar with the first human
beings, around 2000 years ago. “Often
when a species invades a country,
they reach a much higher density than
elsewhere because there is nothing
to keep their numbers in check”,
said Matthew Baylis (University of
Liverpool, UK). The rats colonised the
entire island, from pristine forests to
the domestic environment. Worse
was to come: at the end of the
19th century, steamships travelling
from India introduced plague to
Madagascar. The black rat proved
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perfectly designed for spreading
disease (the larger brown rats also
host plague, though they yield fewer
transmission events).
Two flea species are thought to be
crucial to the transmission cycle. One is
the tropical rat flea, which arrived with
the rodent. The other is endemic to
Madagascar. “This flea has parasitised
the black rat very successfully, and
seems to be a strong vector of disease”,
Sandra Telfer (University of Aberdeen,
UK) told The Lancet Infectious Diseases.
Plague in Madagascar usually affects
people living 800 m above sea-level
or higher—the same height at which
the endemic flea is found. The flea
species have opposing seasonal cycles,
meaning that plague can persist
throughout the year.
Madagascar is one of the poorest
countries in the world. Large chunks
of the population live without
good access to health care, and the
mountainous terrain is difficult to
cross. “People may seek traditional
healers before trying to get to hard-
to-reach clinics, so even in normal
years, one can expect a needlessly
high death rate from plague”, notes
Telfer. Bubonic plague, which is
transmitted by the bite of an infected
flea, typically makes up 80–95% of
plague cases. Without treatment,
around half of patients die. If the
infection reaches the lungs, the patient
develops pneumonic plague, which
can be transmitted in the air. Without
treatment, it is fatal.
This outbreak is unusual, both in its
timing and in the fact that it affected
urban areas, including the capital
Antananarivo. Population density
helps facilitate transmission; this
probably explains the preponderance
of pneumonic plague, which requires
close quarters to spread. WHO
has delivered 1·2 million doses of
antibiotics. As yet, there is no sign of
Yersinia pestis developing resistance.
An alert system to detect outbreaks
of plague had been established in
endemic parts of Madagascar, but it is
only effective if the disease hits those
regions. On this occasion, it did not.
“We are pushing the government to
scale up surveillance to all 22 regions
of the country”, said Ndiaye. She urged
the Madagascan authorities to treat
plague as a priority, and to ensure that
communities are made aware that the
disease is preventable and treatable.
WHO has proposed a protocol to help
reduce the stigma associated with
plague. Vector control would also help,
but requires careful planning. “If you
just kill rats at random, the fleas can
jump off and bite humans, so you need
to apply insecticide simultaneously”,
points out Telfer. “Rodent eradication
also needs to happen at specific times
to be effective, depending on breeding
cycles.”
According to WHO, there is an
only moderate chance of the disease
spreading to other countries in the
region. The Madagascan authorities
have established medical inspections
at transport hubs, in conjunction
with WHO under the International
Health Regulations. Pneumonic
plague has an incubation period of
around 24 h, by which time patients
are unlikely to be in any state to
travel. Bubonic plague takes longer
to develop, but transmission requires
abundant vectors. Madagascar,
however, will have to contend with
regular outbreaks of plague for the
foreseeable future. Ensuring that the
public recognises the symptoms and
can readily gain access to antibiotics
should help mitigate the misery it can
cause.
Talha Burki