Author: National Department of Health

Source: National Department of Health

The World Health Organisation (WHO) has confirmed 449 cases of an outbreak of plague in Madagascar, with 48 deaths (case fatality rate 11%). The outbreak is primarily located in the middle third of the island, around the Antananarivo (239 cases and 21 deaths) and Toamasina Province on the east coast (147 cases and 9 deaths).  A single area on the northern coast is affected.

The majority of cases are presenting as pneumonic plague unlike the usual bubonic form. The WHO has classified the outbreak as Grade 2 with the level of risk for local spread being high. Risk to the region is moderate because of frequent air and sea travel, but the global risk is perceived to be low.

There is international concern regarding infection with the bacterium after a South African basketball player who was attending the Indian Ocean Club Championships contracted plague while there.. The basketball player was successfully treated in Madagascar and has returned to South Africa. He and his team members are being followed up – however they do not pose a risk. Currently there are no travel restrictions to Madagascar.
A multi-sectoral national response coordination committee has been established, under the leadership of the Minister of Public Health of that country and with the support of the WHO, to coordinate the response to the plague outbreak. Enhanced contact tracing, improved surveillance and diagnostic capacity, restriction of public gatherings, infection prevention and control and community mobilization are all underway.
Plague is a zoonotic disease caused by a bacterium Yersinia pestis. Where plague is endemic, it is usually found in rodents and is spread by fleas from rodent to rodent, or to other mammals. Humans may acquire plague from persons with pneumonic plague through droplet transmission or from direct contact with infected rodents or through the bite of an infected flea. The incubation period ranges from 2-8 days. Symptoms of pneumonic plague include cough, fever and chest pain.
In order to prevent the importation of plague into South Africa, several measures have been implemented including:

• Alerting all airline companies to remain vigilant for suspected ill passengers
• Port health officials have enhanced their screening measures to detect ill passengers arriving in the country
• All provincial  outbreak response teams have been alerted to enhance preparedness and implement response measures in the event that a case is detected in the country
• Standard operating procedures for the management of a suspected case of plague have been circulated to stakeholder
• The National Institute for Communicable Diseases has the laboratory capacity to diagnose plague and is actively supporting preparedness measures in the country
South African travellers to Madagascar are advised to avoid highly populated areas, and to wear surgical masks while in transit. Liberal application of DEET-containing insect repellent is advised to prevent flea bites. Prophylactic antibiotics are not advised.

All travellers returning from Madagascar must monitor their health for 15 days and seek medical care immediately at their nearest health facility if they develop fever, chills, head and body aches, painful and inflamed lymph nodes, or shortness of breath with coughing and/or blood-tainted sputum. They should tell the doctor about their recent travel and their symptoms. 
There is also a risk of contracting malaria through bites from infected mosquitoes while in Madagascar, making insect bite prevention doubly important. All returning travelers with fever must be tested for malaria. For further information, please visit the NICD website:

The WHO situational report may be found at