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The bubonic plague wiped out tens of millions of people in Europe in the 14th century - gaining the grim label the Black Death. In 2024, a handful of cases arise each year in the United States and around the world - though the disease is far less common and far more treatable.
Last week in the United States, a rare case of human plague was confirmed in rural Oregon, according to Deschutes County Health Services. The unnamed individual is likely to have been infected by a pet cat, which had symptoms, health officials said. The case was identified and treated early, “posing little risk to the community,” and no additional cases have emerged.
In recent decades, an average of seven human plague cases are reported each year, according to the Centers for Disease Control and Prevention. The bubonic plague is the most common form of the plague and is characterized by painful, swollen lymph nodes known as “buboes.” While not totally eradicated, “human to human transmission of bubonic plague is rare,” according to the World Health Organization.
“It’s a popular misconception that it’s an ‘old’ medieval disease,” Steve Atkinson, associate professor of molecular and cellular bacteriology at the University of Nottingham in Britain, told The Washington Post by email Tuesday. “In reality it’s still around and is endemic in rodent populations in many parts of the world including the USA, parts of South America, Africa, Asia.”
“One key hotspot is Madagascar,” Atkinson said, adding that the island nation had a prolonged epidemic in 2017 for three months starting in August, with 2,417 confirmed cases and 209 fatalities. “There are still cases every year throughout the world,” he added.
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Here’s what to know about the disease in modern times.
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What is the bubonic plague and how is it transmitted?
The bubonic plague is an infectious disease caused by the Yersinia pestis bacteria. The zoonotic bacteria can infect small such mammals as rodents, other animals and humans, according to the CDC.
Humans who contract the disease have usually been bitten by a flea that is infected by the bacteria. Another way is from “direct contact with infected tissues or fluids while handling an animal that is sick with or that has died from plague,” according to the CDC. The bacteria can also be picked up by inhaling respiratory droplets after close contact with cats or humans with pneumonic plague - the “most serious form of the disease,” according to the CDC, and the only way plague can spread from person to person.
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How common is the bubonic plague?
Between 1900 and 2012, there were 1,006 confirmed or probable human plague cases in the United States, according to the CDC. Bubonic plague accounts for over 80 percent of U.S. plague cases. Since the 1990s, plague cases have mostly occurred in Africa, according to the WHO. “The three most endemic countries are the Democratic Republic of Congo, Madagascar, and Peru,” it says.
“Plague has killed millions of people and is often considered a disease of the past. But plague is far from being eradicated,” said Sophie Jullien, a pediatrician who has worked with the WHO to develop a manual for plague surveillance and prevention. “The main reasons are because the bacteria causing plague live and survive in the ground and in animal reservoirs. … They can survive under the ground for years.”
Jullien said it is “challenging” to fully eradicate plague bacteria. However, she added, “great advances” in antibiotics made a “huge difference.”
“Now, we know how to treat the disease and how to prevent the spread of the disease in humans,” she said.
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What are the symptoms of the plague?
People with the bubonic plague normally develop a fever, headache, chills and have swollen, painful lymph nodes. The “classic buboes” are neck and groin swellings, Atkinson said, and are “popularly depicted in almost every medieval painting of the disease.” The bacteria multiply in a lymph node near to where the bacteria entered the human body following a flea bite and can spread in the bloodstream if untreated.
Symptoms of the plague usually begin in humans two to eight days after exposure to an infected animal or flea, according to the Deschutes County Health Services: “If not diagnosed early, bubonic plague can progress to septicemic plague (bloodstream infection) and/or pneumonic plague (lung infection). These forms of plague are more severe and difficult to treat.”
According to the CDC: “If plague patients are not given specific antibiotic therapy, all forms of plague can progress rapidly to death.”
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How do you treat the plague, and is there a vaccine?
Usually, patients will have blood and other samples, such as sputum or pus, taken from a bubo. If the plague is identified, then antibiotics are administered as the usual treatment and the patient may be medically isolated. “Early diagnosis and early treatment can save lives,” according to the WHO.
There is no commonly available vaccine for the plague. Although improved sanitation, better living conditions and health care have helped temper the disease, Atkinson said, “the disease itself is just the same as the one that swept through Europe during the Black Death outbreak.”
He said antibiotic resistance was a future concern: “A plague strain that was resistant to the front line antibiotics used for treatment would pose significant clinical challenges if it were to be transmitted [through] the human population.”
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Tips to avoid the plague
The Deschutes County Health Services and WHO suggest some best practices to avoid the plague - primarily by avoiding all contact with rodents and their fleas. “Pet cats are highly susceptible to plague,” according to the Deschutes County Health Services. “If possible, discourage their hunting of rodents,” it advises. Treating pets with flea control products can also help - as well as avoiding feeding squirrels, chipmunks or other wild rodents in campgrounds and picnic areas, and applying insect repellents.