What Ebola can teach us about a new bubonic plague outbreak in Africa
Both outbreaks are unusual, just not for the reasons people may think
While West Africa battles Ebola, another outbreak is striking just across the continent. In Madagascar, cases of plague are erupting in the small village of Mandritsara and the disease is spreading to neighboring communities. The two outbreaks are related by more than simple surface similarities, though. In fact, fighting the first has provided an invaluable blueprint for containing the second.
First off, it's important to note that both outbreaks are unusual, just not for the reasons people may think. What makes them stand out isn't that they're occurring in the first place, but the number of cases involved.
Many Westerners mistakenly assume Ebola and the plague as rare. They're not. The CDC has recorded 35 separate outbreaks (including the current one) of Ebola in West Africa since the discovery of the virus, indicating that the virus is actually endemic to the region. While it remains dormant much of the time, occasionally it resurges, though usually in much smaller and less fatal outbreaks.
Likewise, the plague is endemic in Madagascar, with periodic flare-ups of the disease, usually the result of poor hygiene and inadequate control of food supplies like grain (which draws rodents infected with Yersinia pestis, the bacterium responsible for plague). It's also an issue in some parts of China, Indonesia, and even the American West. The bacterium, in other words, has no plans of dying off any time soon, but there's a silver lining. The aggressive bacterial strain that caused the infamous "Black Death," responsible for killing millions across Europe, is extinct. No matter how serious the Madagascar outbreak becomes, it won't rise to the level of the world's most notorious plague epidemic.
You might not necessarily know that, if you believe the media. The BBC warned of "declining living standards" in the island nation, suggesting that the plague could spread further than it ever had before. The Guardian implied that this outbreak of bubonic plague was identical to the Black Death, despite readily available scientific evidence to the contrary. The Washington Post, via an Associated Press wire, made the same erroneous suggestion.
As with Ebola, false claims about the plague spread quickly and infect body politics around the world. While the World Health Organization doesn't recommend travel bans or trade restrictions, the island has already been tarred for being literally plague ridden. The notoriously gun-shy U.S. State Department hasn't even issued a travel advisory for Madagascar, instead freely admitting that plague is endemic to the region. But that hasn't halted the outbreak of fear.
So one vital lesson learned from Ebola is that scientific literacy is key for the media, to ensure that reporting is accurate and designed to inform, rather than frighten. Making sure scientists are heard is key, which is why many have turned to blogs, Twitter, and other online venues for communicating information about Ebola directly to the public. Before the plague story snowballs, first responders in Madagascar must do the same.
But there are more important lessons that responders are learning on the ground in West Africa, too. These tools aren't just useful for handling the current situation, but also for controlling outbreaks in the future — including, possibly, the ongoing outbreak in Madagascar.
In Madagascar, the plague started in rural villages, and appears to be spreading to the nation's capital, Antananarivo. As with Ebola in West Africa, rapid identification of the infection has been critical to containment, jump-starting data collection and surveillance — i.e., tracking the spread of the disease, including its movement through various connected social circles. Along the way, researchers already determined the identity of patient zero.
Collecting information like this might seem secondary to treating cases, but it's not. As in West Africa, data collection is actually critical to getting in front of a disease, rather than scrambling to clean up after it. While individual patient care is, of course, important, it needs to be paired with aggressive steps to cordon the disease.
That involves rapidly deploying people like doctors, nurses, epidemiologists and, if necessary, law enforcement and soldiers to the affected areas. Creating quarantines around infected communities stamps out flare-ups of disease quickly. Allowing people to pass between villages can facilitate the spread of disease; in the case of Madagascar, for example, a shipment of grain from one village to another could carry infected rats and/or fleas, which would spread the plague even further.
Ideally, quarantines should not be militarized, as this can intimidate and frighten members of a community, some of whom may be reluctant to come forward to ask for treatment and assistance. This has become a persistent problem in West Africa, where the handling of local communities has created fear and resentment — including the belief that aid workers themselves are responsible for the outbreak.
This is an important lesson from West Africa that aid workers need to take into account as they enter Madagascar. It's critical to link up quickly with community leaders and authority figures, especially religious authorities, to reach out to communities and establish positive, friendly relationships that include educating residents. Moreover, aid workers need to understand local habits, traditions, and conventions so they can work with members of the community to increase their safety.
In West Africa, for instance, that included the development of burial techniques that honor traditional practices while still limiting exposure to infected body fluids. In Madagascar, that might include reaching out to local communities to address hygiene concerns, especially for households with fleas and their bacterial payload.
Rapid delivery of medications is also important. Though no antivirals are currently available to treat Ebola, researchers worked quickly to explore alternate treatments, including those derived from the blood of survivors as well as a vaccine and an experimental drug called ZMapp. Meanwhile, they understood the critical importance of supportive medical care, such as replacing lost body fluids and managing infections (an issue in patients with immune systems compromised by fighting Ebola). When supplies weren't delivered, medical teams weren't able to keep up with patients. Madagascar shouldn't be failed in the same way.
Enlisting the global community is a keystone. One of the most stark lessons learned from the Ebola outbreak is that once the virus gains a foothold and begins spreading, it can be extremely difficult to control. The outbreak might have been more manageable if global support for aid workers and regional governments had arrived more quickly to contain it. Nations with expertise in infectious disease, like Germany and the United States, can send in-kind aid such as trained medical personnel, equipment, and supplies. All nations can help with funding.
While money won't solve every problem, it could help teams in Madagascar pay for protective equipment for themselves and the communities in which they work. Funds would also be useful for paying medical personnel and helping aid workers meet staffing gaps. It could also fund supplies like insecticides to kill plague-carrying fleas and aggressive antibiotics to kill infections — rodent traps and better containers for grain could also go a long way toward containing the spread of disease. In addition, funding for patient education and training is necessary to remind people to seek help immediately. The bubonic plague can kill within days if antibiotics aren't administered.
As scientists continue to work in West Africa and new teams of aid workers make their way to Madagascar, one of the biggest lessons learned may be that direct, fast action is critical. Furthermore, outreach and education should follow close behind, ensuring that the global community is informed about and takes an active role in disease control and prevention.
Events in Madagascar aren't going to mirror those in West Africa; there are too many differences between the diseases and regions. But hard-won lessons learned from Ebola will still play an important role.