Could a Centuries-Old Ritual Increase the Spread of Plague in Madagascar?

Things may be looking up when it comes to the plague outbreak that has been ravaging Madagascar.

The latest External Situation Report released by the World Health Organization (WHO) indicates that the number of new cases of pneumonic plague continues to decline in number in active areas throughout the country. However, speculation has risen that a centuries-old tradition may increase the risk of the outbreak spreading.

The tradition in question is called famadihana, and, according to Newsweek, it’s also referred to as “the turning of the bones” or “body turning.” In past coverage, CNN delved into the ritual, performed by the Merina tribe in Madagascar’s central highlands.

“In this sacred ritual, which occurs every 5 to 7 years, a number of deceased relatives are removed from an ancestral crypt,” according to CNN. “Living family members carefully peel the burial garments off the corpses and wrap them in fresh silk shrouds.” Then, those involved in the ritual dance with the corpses of their forebears, according to anthropologist Dr. Miora Mamphionona. At the end of the ritual, the bodies are placed back in their tombs and turned upside down.

“If a person dies of pneumonic plague and is then interred in a tomb that is subsequently opened for a famadihana, the bacteria can still be transmitted and contaminate whoever handles the body, “chief of staff in Madagascar’s health ministry Willy Randriamarotia, told Agence France-Presse (AFP).

In order to limit this possibility, rules are in place in the country dictating that individuals who die from plague are “buried within anonymous mausoleums, not in tombs that can be reopened,” according to Newsweek. However, some individuals are hesitant to stop performing the ritual, regardless of the potential risk of catching the disease. One individual reportedly told AFP, “I will always practice the turning of the bones of my ancestors—plague or no plague.”

As of the most recent External Situation Report, a staggering 1309 individuals are suspected of having plague in Madagascar; 93 lives have been claimed by the disease. The number of new cases of pneumonic plague appears to be on the decline, though. In fact, 12 previously affected districts have not reported any new probable or confirmed cases in the past 2 weeks, according to the report.

In total, 235 of the 882 clinical cases of pneumonic plague have been confirmed thus far; 300/882 are probable, and 347/882 remain suspected. Since August 1, 2017, 29 districts reported probable and confirmed cases of the disease; in the past 2 weeks, however, the number has reduced to 17.

WHO, along with several partners, have channeled their efforts into providing an adequate response to the outbreak. Nine treatment centers have been created, and USAID has also provided a total of 6 mobile clinics dedicated to bringing patients to hospitals in Antananarivo—one of the most seriously affected areas. The Institut Pasteur de Madagascar has distributed a total of 2074 rapid diagnostic tests to Tomasina, the Centers Hospitaliers d’Antananarivo, and the Plague Department of the Ministry of Public Health since September 2017.

UNICEF has assisted in the creation of educational materials designed to promote awareness of the plague throughout the country. In total, 69,000 posters and brochures have been created and disseminated to key areas throughout the country.

As for the burial of those who died from the disease? WHO has enlisted help from the Malagasy Red Cross to provide those who died from plague with a “dignified and safe burial.” According to the report, the protocol for this is still in the process of being validated, however, training for these burial teams is ongoing and aims to target 2660 volunteers for 22 affected regions in the country.

With these efforts and many others, the WHO and their partners are working to control the outbreak. As for the potential spread of the plague through famadihana? Although no direct correlation has been cited, according to the European Commission, exposure to dead human bodies is not a serious health hazard in and of itself—only in specific cases. Those who died from plague "are likely to be infested with fleas or lice that can spread disease." Therefore, the EC recommends that only trained medical staff handle these bodies and that they wear appropriate protective materials (such as gloves and face masks). The EC advises that the bodies be placed in body bags before being buried, and that “contact with corpses be minimized and embalming should not be carried out.”

To stay up-to-date on the latest case counts regarding the Madagascar plague outbreak, be sure to check out the Contagion® Outbreak Monitor.