[Alert] Plague Outbreak in Madagascar


13 October 2017


1.            Madagascar has reported a total of 449 cases of plague from 1 Aug to 10 Oct 2017 (322 cases of pneumonic or pulmonary plague, 123 cases of bubonic plague and 1 case of septicaemic plague), with 48 deaths (case fatality rate of 11.6). There has also been a rise in the rate of increase in the number of cases, especially the pneumonic form. Unlike the usual endemic pattern in Madagascar, the plague season begun early this year and the current outbreak has unusually affected major urban centres including typically non-endemic areas. There is also a shift from the bubonic form of plague to the pneumonic form. Pneumonic plague is the most virulent form and can be transmitted through infected droplets. Please see Annex for more details on plague.

2.            While plague has not been detected in Singapore thus far and travel volume from Madagascar to Singapore is low, we remain vulnerable to sporadic importation of the disease. In addition, there is a risk of onward transmission of pneumonic plague in the healthcare setting. MOH would like to remind all physicians to discuss travel history with patients and take the necessary infection control precautions.  

Notification under the Infectious Disease Act

3.            Plague is a notifiable disease under the Infectious Diseases Act, and all cases of suspected and confirmed cases should be reported to MOH within 24 hours. 

Please call the Surveillance Duty Officer of the Communicable Diseases Division at 9817 1463, followed by submission of the MD131 Notification of Infectious Diseases Form through the Communicable Diseases Live & Enhanced Surveillance (CDLENS) system at http://www.cdlens.moh.gov.sg, or by fax to 6221-5528/38.  

4.           Once again, we thank you for your support and co-operation as our first line of care in the community. 


Plague is caused by the bacteria Yersinia pestis, which spreads among rodents through infected fleas. Humans get infected with plague through bites of infected fleas, touching or skinning infected animals, or inhalation of infectious droplets. There are three forms of plague in humans – bubonic, septicaemic and pneumonic. 

The usual incubation period for bubonic plague ranges between 2 and 6 days, while that of pneumonic plague could be between 1 and 3 days. Typically, the pneumonic form is caused by spread to the lungs from advanced bubonic plague. However, a person with secondary pneumonic plague may form aerosolized infective droplets and transmit plague via droplets to other humans. Untreated pneumonic plague has a CFR close to 100% but can be successfully treated with antibiotics.

Key clinical features for the three forms of plague are provided below:

(i)            Bubonic plague may be clinically diagnosed. Key clinical features include:
•         Fever
•         Headache
•         Myalgia
•         Painful acute regional lymphadenopathy (pathognomonic bubo), typically involving the inguinal, axillary or cervical regions

(ii)           Septicaemic plague. Key clinical features include sepsis.

(iii)          Pneumonic plague. Key clinical features includes the following:
•         Severe pneumonia
•         Fever
•         Dyspnea and often haemoptysis

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