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Tularemia Deaths in the United States

Although tularemia is more common than plague in the United States, the case-fatality rate is higher for the latter.  Deaths reported for both diseases have changed little in five decades, with the number of tularemia deaths similar to the number of plague deaths in most years.  See graphs

Plague Tularemia

Tularemia Deaths


  1. Berger SA. Infectious Diseases of the United States, 2015.  1,208 pages, 483 graphs, 13,730 references. Gideon e-books,

Fatal Plague in Madagascar

Madagascar accounts for most plague deaths in the world – see graph

plague deaths

Plague in Uganda

The following background data on Plague in Uganda are abstracted from Gideon and the Gideon e-book series. [1,2]

The earliest record of plague in Africa was a report by missionaries in Uganda in 1877, and reporting statistics for much of the continent have been documented for more than 100 years.

A series of plague epidemics were recorded in East AFrica during the 1920’s and 1930’s – see graph [3]

31,305 plague deaths were reported in Uganda during 1910 to 1919; 17,410 during 1920 to 1929; 11,387 during 1930 to 1939.

Presumed local reservoirs include the Nile rat, Arvicanthus niloticus.
– Presumed local flea vectors include Xenopsylla cheopis and X. brasiliensis.

Notable outbreaks:
1982 – An outbreak (152 cases, 3 fatal) was reported.
1986 – An outbreak (340 cases, 27 fatal) was reported.
1993 – An outbreak (167 cases, 18 fatal) was reported in Western Region (Nebbi District).
1998 – An outbreak was reported in Arua district.
2001 – An outbreak was reported in Nebbi District.
2004 – An outbreak (4 cases, 1 confirmed, 3 fatal) of pneumonic plague was reported in Kango Subcounty.
2006 – An outbreak (127 cases, 11 fatal) was reported in Arua and Nebbi Districts – including 12 cases of pneumonic plague.
2007 – Outbreaks (179 cases, total) were reported in Masindi District (19 cases, 9 fatal), and in Arua (121 cases, 10 fatal) and Nebbi (39 cases, 9 fatal).
2008 – An outbreak (68 deaths) was reported in Arua and Nebbi.

1. Berger SA. Infectious Diseases of Uganda, 2012. 398 pp, 61 graphs, 1,711 references. Gideon e-books,
2. Berger SA. Plague: Global Status, 2012. 98 pp, 102 graphs, 524 references. Gideon e-books,
3. Gideon graph tool at

Note featured on ProMED

Plague in Madagascar

The following background data on plague in Madagascar were abstracted from Gideon and the Gideon e-book series. [1,2] (Primary references are available on request)

Time and Place:
– Plague was first described in Madagascar in 1898, with cases in the harbor of Tamatave (Toamasina).
– The first epidemic occurred in Majunga in 1902 (142 fatal cases during May to July of that year).
– Subsequent outbreaks were reported in Majunja in 1907 (49 fatal cases), 1924 and 1928.
– The disease reached the central highlands in 1921, and remains endemic to this area at elevations above 800 m.
– Outbreaks of pneumonic plague were reported during 1921 to 1935; and in 1957 (northeast region).
– Plague was first reported in port areas of Madagascar in 1898; with later spread to the high plateau in 1921.
– During 1989 to 1992, 93% of cases were reported from “the plague triangle” located in the Central Highlands and delimited by Ambatondrazaka, Miarinarivo and Fianarantsoa.

Biology and transmission:
– Reservoirs implicated in transmission include the shrews (Suncus murinus) and rats (Rattus rattus).
– Infection has also been identified in hedgehogs (Tenrec ecaudatus).
– Possible flea vectors include Paractenopsyllus pauliani, Synopsyllus fonquerniei and Xenopsylla cheopis.

Two major waves of plague have been reported – with peak incidence in 1932 (3,656 cases) and 1997 (2,863 cases). See graph:

– 10,471 cases were reported during 1935 to 1949 ; 9,227 (448 fatal) during 1957 to 1986; 5,896 (493 fatal) during 1980 to 1997; 11,673 (950 fatal) during 1987 to 2001.
– Of 5,927 suspected cases reported during 1989 to 1995, 1,337 were bacteriologically-confirmed, with a case-fatality rate of 19%.
– 1,702 suspected cases (515 confirmed, 47 fatal) were reported in Mahajanga during 1995 to 1998.
– 91.3% of these cases were characterized as bubonic (67.8% of these involving the inguinal region).

Africa accounts for most of the world’s plague deaths. >=50% of these deaths are reported by Madagascar. See graph:

Seroprevalence surveys:
<1.5% to 15.5% in Majanga City (1997 publication) 0.61% of persons in Mahajanga (anti-F1 antibody, 1999) 3.2% of market vendors in Antananarivo (anti-F1 antibody, 1999) Notable outbreaks: 1982 (publication year) - An outbreak (9 cases) was reported in Tananarive. 1991 - An outbreak was reported in Majunga. 1995 - An outbreak (108 confirmed and presumed cases) was reported in Mahajanga city. 1997 - An outbreak (2,863 cases, 176 fatal) was reported. 1998 - An outbreak was reported in a hamlet in the Ikongo district. 2008 - An outbreak (7 deaths) of pneumonic plague was reported in Toamasina. 2010 - An outbreak (31 cases, 1 fatal) was reported in La Libertad. 2011 - Outbreaks (200 cases, 60 fatal) were reported, including Antananarivo (3 fatal cases) and Antsiranana (16 fatal cases). (outline of Gideon Graph module - see )

1. Berger SA. Infectious Diseases of Madagascar, 2011. 49 pp, 47 graphs, 1,029 references. Gideon e-books,
2. Berger SA. Plague: Global Status, 2011. 95 pages, 101 graphs, 485 references. Gideon e-books,

Plague in Lybia

A recent outbreak in Tobruk belies the fact that only sporadic cases and small outbreaks of plague have occurred in North Africa since 1950. Successive waves of plague were reported in Egypt, Tunisia and Morocco during the first half of the 20th century (See Graph). [1,2]

Plague was relatively rare in Libya, with the exception of an outbreak of 82 cases in 1913 (red arrow).

1. Berger SA. Infectious Diseases of Libya, 2011. 321 pp, 39 graphs, 930 refs. Gideon e-books,
2. Berger SA. Plague: Global Status, 2011. 95 pp, 101 graphs, 485 refs. Gideon e-books,

Fatal Plague in Madagascar

Recent events in Antananarivo highlight the fact that Africa – and particularly Madagascar – have accounted for most of the world’s plague deaths since the 1980’s. See graph of reported plague deaths and graph of rates per 100,000.

Update: Appeared in ProMED, with the following commentary:

Readers should link to the URLs above to observe the reported deaths due to _Yersinia pestis_ from Gideon.

The 1st graph compares worldwide statistics as compared to Africa and as compared to Madagascar. It illustrates that over the years 1994 to 2003, the African continent is the source of most of the world’s reported cases of plague deaths, and since the increased incidence of plague in Madagascar in 1996, a significant percentage of the plague deaths were reported from Madagascar.

The 2nd graph reports plague deaths from 5 African nations, Uganda, Tanzania, Namibia, Congo DR, and Madagascar. In the years 1996-2003, Madagascar reported more deaths than any of the other 4 nations with Congo DR 2nd. In 1996 and 1997, Tanzania reported the 3rd most plague deaths among the 5 nations, but from 1998-2003, Uganda has taken that role. – Mod.LL