On 6 December 2016, the Ministry of Health (MOH) in Madagascar alerted WHO of a suspected plague oubreak in Befotaka district, Atsimo Atsinanana region in the south-eastern part of the country. The district is outside the area known to be endemic in Madagascar. No plague cases have been reported in this area since 1950.
As of 27 December 2016, 62 cases (6 confirmed, 5 probable, 51 suspected) including 26 deaths (case fatality rate of 42%) have been reported in two adjacent districts in two neighbouring regions of the country. 28 cases, including 10 deaths have been reported from Befotaka District in Atsimo-Atsinanana Region and 34 cases including 16 deaths have been reported from Iakora district in Ihorombe Region.
Of the 11 samples tested, 5 were positive for plague on rapid diagnostic test and 6 are now confirmed at Institut Paseur laboratory. Of the total reported cases, 5 are classified as pneumonic plague cases and the remaining as bubonic plague.
Retrospective investigations carried out in those two districts showed that it is possible that the outbreak might have started in mid-August 2016. The investigation in neighbouring villages is still ongoing. On 29 December, an investigation carried out within 25 kilometres of the intial foci in Befotaka district has reported three deaths and is being investigated further for possible linkage to the outbreak.
The affected zone is located in a very remote and hard to reach and highly insecure area (classified as red zone due to local banditry). Despite arrangements made with the local authorities, insecurity slows down the investigations and response activities. In addition, a helicopter has been made available but its use has been limited due to bad weather and financial limitations.