This past weekend, basketball players from island nations across the Indian Ocean converged in Antananarivo, the capital of Madagascar, to face off in the regional championships. But no one was to cheer on the teams. The bleachers were empty — because of the plague.
The modern-day plague is caused by the same bacterium, Yersinia pestis, that caused the Black Death in Europe. It lives in fleas and rodents all over the world and is typically spread to humans by the bite of an infected flea. It is treatable with common antibiotics — but without proper attention it can be deadly.
In some parts of the world, including Madagascar, the plague has become a seasonal scourge. After the rice harvest at the end of summer, rats don't have as much food and their population drops. Around August fleas start looking for new hosts to bite, and that means humans. Madagascar can see between 280 and 600 infections annually.
But only a few weeks into this year's plague season, health officials in the African island are worried that the 2017 outbreak could be different.
As Madagascar's Ministry of Health reported Sunday, 169 people have fallen ill from the plague since August, and 30 of them have died. The prime minister has forbade public gatherings, including at basketball tournaments, to keep infections from spreading. Schools are closed this week in parts of Madagascar, including the capital, so they can be sprayed to kill fleas.
Meanwhile, people are taking steps that are misguided and possibly harmful. They're lining up at pharmacies to buy masks even though the ministry of health has advised against it unless people are interacting directly with plague patients. And they're trying to buy antibiotics despite warnings that only certain courses of medications work and that taking unnecessary antibiotics can help breed drug-resistant bacteria.
Unlike past outbreaks, which have been mostly located in rural, mountainous areas, this one is spreading in cities. Cases have now been reported in 10 cities including the capital and the coastal cities of Toamasina and Mahajanga.
"We are concerned that plague could spread further because it is already present in several cities, and this is only the start of the epidemic season," says Tarik Jasarevic, a spokesman for the World Health Organization.
It's also spreading differently. When the plague is spread by flea bites, it's called bubonic plague, named for the painful lumps, or "buboes," where the bacteria multiply.
That's the most common scenario. But this year, a lot of people in Madagascar are getting the plague from other people.
If bubonic plague is left untreated, the bacterium can travel to a person's lungs, causing pneumonic plague, which spreads and progresses more quickly. It's the most serious kind of infection, and it's the only scenario in which people can pass the bacterium to other people just by coughing. That's the kind of plague Madagascar is grappling with right now.
"More than half of recorded cases are pneumonic plague," says Jasarevic.
The World Health Organization said Sunday it has released $300,000 in emergency funds to "quickly scale up operational efforts" in Madagascar. That includes making sure that health workers know how to isolate and treat infected people and tracking down anyone who may have been in touch with a pneumonic plague patient. WHO is now trying to drum up $1.5 million to beef up its efforts.
According to WHO, this outbreak started in late August 2017 when a 31-year-old man from the eastern port city of Toamasina took a trip inland to Ankazobe, where the plague is established in the rodent and flea populations. While there, he came down with malaria-like symptoms. Four days later, he took a public taxi home, passing through Antananarivo. During that trip, he developed severe respiratory symptoms and died.
Staff at the Moramanga District Hospital prepared his body for a funeral without safety procedures usually used with contagious bodies: involving only trained medical staff who wear personal protective equipment, avoiding traditional rites where relatives touch the body and disinfecting equipment after use. His body was then buried in a village outside Toamasina.
In a statement last week WHO said: "Many of the cases identified are directly or indirectly linked to the first recognized case, which is evidence of person-to-person transmission of pneumonic plague."
But at this stage, Jasarevic says, it's unclear how many of Madagascar's current pneumonic plague cases originated from that one man rather than from other untreated cases that started out as bubonic plague.
Malagasy officials said Saturday that they would organize a campaign to remove trash in the capital and would distribute rat traps, since infected fleas jump from rats to people. The Ministry of Health is trying to track down and treat everyone who may have come in contact with confirmed patients, including anyone who came in contact with the patient up to two days before symptoms set in, anyone who lives in the same home and anyone who came within about 6 feet of a patient.
David Wagner, a biologist at Northern Arizona University who studies the bacterium, says that pneumonic cases have made up a higher proportion of Madagascar's annual plague tally since a military coup in 2009. In the aftermath of the coup, health clinics closed, poverty increased, foreign aid dropped and infrastructure started deteriorating.
A 2015 WHO report noted that the number of plague cases had declined in recent years but more people were dying of the disease — a sign "of the deteriorating fabric of the health system as a result of the recent social and political crisis in the country."
"Health infrastructure is not what it used to be," says Wagner. So it's harder to find and treat people with the plague before their illness progresses.
"We should be spending on understanding infectious diseases and preventing them rather than reacting to an outbreak," he says. "But that's what people do. That's what happened with Zika, that's what happened with Ebola. It's a lesson we don't learn very well."
Other countries do have the plague, including the U.S. "We have plague throughout the western United States," says Wagner. Just this past summer, three people in New Mexico were hospitalized with the plague. All survived.
Rae Ellen Bichell is a science journalist based in Colorado. She previously covered general science and biomedical research for NPR. You can find her on Twitter @raelnb