There’s new concern over plague in Madagascar, where another six suspected cases were reported this week in the village of Iakora, which saw dozens of fatalities during a seasonal outbreak in 2016.

The deaths all occurred during September, according to local media citing the National Gendarmerie in Ivohibe province. That’s located in the interior southeast of the Indian Ocean island nation, with Iakora located in a remote area that sources said would take a helicopter to access quickly.

Those new cases have not yet been confirmed by the Malagasy Ministry of Health. The ministry said Friday it has accounted for eight confirmed cases since August 1, all in the Ankazobe, Ambalavao, Miarinarivo and Ambatofinandrahana districts.

On Thursday, a United Nations spokesman confirmed the cases. There are now a total of 47 under investigation by humanitarian aid workers, leading to concern that without early action the outbreak could reach emergency levels. Plague is endemic to Madagascar, but last year more than 2,300 cases were investigated – either confirmed, probable or suspect – in what was an unusually severe outbreak. More than 200 people died.

Cases of plague may be pneumonic, a more dangerous form that affects the lungs and can be transmitted from person to person after first originating with rodent and flea bites. Both bubonic and pneumonic plague have been confirmed, and both can be cured using common antibiotics if delivered early, according to the World Health Organization. Antibiotics can also help prevent infection among people who have been exposed to plague.

Image: WHO file