ANTANANARIVO, Madagascar—In September, David Ranaivo woke up with a high fever and felt very weak. He went to a nearby hospital, but was so depleted he could barely answer the doctor’s questions.

Around 24 hours later, the doctor returned with a diagnosis: the plague.

“I was totally devastated,” said the 31-year-old businessman. “I was thinking, ‘I am going to die.’”

Madagascar, the tropical island nation off Africa’s southeast coast, is scrambling to contain its worst outbreak of plague in at least 50 years. The country’s health ministry reported 2,119 probable cases from Aug. 1 to Nov. 10, including 171 deaths.

Although the plague—also known as Black Death, the disease that decimated Europe’s population in the 14th century—is endemic in Madagascar, it has struck some of the islands’ nonendemic areas and densely-populated cities for the first time. The vast majority of the cases have been pneumonic plague, which is the most virulent form of the bacterial disease and can quickly and easily spread from one person to another through droplets in the air.

At a treatment center in Toamasina, Madagascar, patients affected with plague are quarantined in tents on Oct. 25, 2017. Photo: rijasolo/Agence France-Presse/Getty Images

In Madagascar, “pneumonic plague had never occurred in big cities with an overcrowded population,” said Richard Fotsing, a coordinator with the World Health Organization based in Madagascar’s capital, Antananarivo. “In high density areas, the spread of pneumonic plague is very rapid, leading to large-scale outbreaks.”


While the number of new cases has slowed during the past month, government officials and the World Health Organization are still on high alert, conducting surveillance, warning the public, and leading massive cleaning campaigns to keep the bacterial disease from spreading further. They are also conducting screening measures at the country’s borders to prevent international spread. Plague season normally runs August through April.

Workers are cleaning out garbage-filled open drains in poor neighborhoods. Health workers’ and visitors’ shoes are washed with chlorinated water at Antananarivo’s Centre Hospitalier Anti-Pesteux d’Ambohimiandra, or Chapa, where plague patients are treated—a brick building located off a dirt road and sealed by a large red gate.

Transmitted by fleas that have bitten rats or other rodents infected with a bacteria called Yersinia pestis, plague thrives in poor sanitary conditions and places with inadequate health services—which abound in Madagascar, one of the world’s poorest countries. The Democratic Republic of Congo and Peru, along with Madagascar, are the three most endemic plague countries in the world today.

Plague comes mainly in two forms: bubonic, which causes swollen lymph nodes; and pneumonic, which affects the lungs and has an incubation period as short as 24 hours. If detected early on, both forms of plague are curable with antibiotics. Untreated, pneumonic plague is always fatal.


The outbreak comes at a destabilizing time in Madagascar—a nation of 25 million famed for the thousands of indigenous species found nowhere else on earth—with presidential and parliamentary elections expected next year. Panic-stricken city-dwellers have pulled children out of school, while neighbors now regard each other with fear.

Health ministry workers sprayed pesticide against fleas, which carry the plague bacteria, in a primary school in Andraisoro, a district of Antananarivo, on Oct. 2, 2017. Photo: rijasolo/Agence France-Presse/Getty Images

The current outbreak started in late August, when a 31-year-old man from a coastal city traveled to a district in the country’s central highlands, a plague-endemic area. After developing malaria-like symptoms, he took a shared public taxi, passing through the capital of Antananarivo and on to the coastal city of Toamasina. He died shortly after arriving, and 31 people who came into contact with him subsequently became ill—four of them died.

It was more than two weeks later, when a 47-year-old woman from Antananarivo was admitted to a hospital with respiratory failure brought on by pneumonic plague, that the outbreak was identified and field investigations launched.

For eight days, Mr. Ranaivo, the businessman, remained hospitalized at Chapa, while doctors clad in blue and turquoise surgical gowns and face masks administered antibiotics orally and by injection. Mr. Ranaivo estimates he received about 36 jabs.


“After that eight days of hospitalization, thank God, the doctor gave me an exit bill,” Mr. Ranaivo said.

“I thought that plague could not be treated by a doctor,” he said. “It is curable, and we should not be afraid and ashamed of it.”