Fearsome Plague Epidemic Strikes Madagascar

Face masks were placed on children in Antananarivo, Madagascar, on Tuesday. An outbreak

of plague has killed at least 33 people; the World Health Organization has sent 1.2 million
doses of antibiotics in response.
Madagascar has been struck by a fast-spreading outbreak of plague, creating panic and
prompting the World Health Organization to send 1.2 million doses of antibiotics to the island
nation.

Since August, the country has reported over 200 infections and 33 deaths.

The outbreak is beginning to resemble the early stages of the West African Ebola crisis in 2014:
a lethal disease normally confined to sparsely populated rural areas has reached crowded cities
and is spreading in a highly transmissible form.

Schools, universities and other public buildings have closed so they can be sprayed to kill fleas,
which may carry the infection. The government has forbidden large public gatherings,
including sporting events and concerts.

Fears that the outbreak could spread to other countries are rising. Late last month, plague struck
a basketball tournament for teams from Indian Ocean countries, killing a coach from the
Seychelles and infecting another from South Africa. The players are being monitored,
Malagasy health authorities told the W.H.O.

Madagascar typically has about 400 cases of plague each year between September and April,
but they are usually focused in the nation’s central highlands and spread by fleas living on rats
in rice-growing areas. This outbreak is unusually worrying because most new cases are in cities
and are pneumonic plague, the form transmitted by coughing.

Pneumonic plague kills even faster than the better-known bubonic form, which is transmitted
by flea bites and gets its name from the infected lymph nodes that form large, swollen “buboes”
in the groin, armpits and neck.

Both forms caused the infamous Black Death of the mid-14th century, which is thought to have
killed a third of Europe and caused major social upheavals.
The Madagascar outbreak started in August, when a 31-year-old man originally thought to have
malaria traveled by bush taxi from the central highlands to his home in the coastal city of
Toamasina, passing through the capital, Antananarivo.

Health officials set rat traps at a school in Antananarivo, Madagascar. Rats carry the fleas that
transmit the plague bacterium.
He died en route and “a large cluster of infections” broke out among his contacts, according
to a W.H.O. update issued Oct. 4. Those contacts passed it on to others.

Plague was not confirmed until blood samples collected from a 47-year-old woman who died
on Sept. 11 in an Antananarivo hospital of what appeared to be pneumonia were tested at
Madagascar’s branch of the Pasteur Institute. The samples came up positive on a rapid test for
plague.

The W.H.O. was notified on Sept. 13. Plague is caused by the bacterium Yersinia pestis.
Terrifying as the disease is, it can usually be cured by common antibiotics. Antibiotic-resistant
strains have been isolated in Madagascar but are not thought to be a factor in the latest outbreak.

The W.H.O. calculated that the antibiotics it has shipped, and another 244,000 doses on the
way, will be enough to treat 5,000 patients and protect another 100,000 people who might have
been exposed.

Personal protective gear and disinfection equipment, similar to that used during Ebola
epidemics, also will be sent. Local health workers will be trained to safely treat patients and to
trace all their contacts and offer them prophylactic antibiotics.

The W.H.O. has released $1.5 million from its emergency fund and has appealed for $5.5
million more from donors. In June, prompted by the slow response to the Ebola crisis, the
World Bank issued bonds to create a $500 million “insurance fund” for fighting pandemics.

But the Pandemic Emergency Financing Facility covers only viruses, and only the six viral
families thought to pose the greatest threats, including those that cause Ebola, SARS, pandemic
flus, Lassa fever, Rift Valley fever and Crimean-Congo hemorrhagic fever.

The fund will also have a cash reserve of 50 million euros — about $58 million — that can be
used to fight diseases not covered by the insurance. But the reserve is not due to be available
until next year.