Medical experts from the World Health Organisation (WHO) have revealed cases of bubonic, septicaemic and pneumonic plague have all been found on the Indian Ocean island which is at the centre of a global epidemic alert.
Bubonic plague is the most common form. It is spread by fleas and is characterised by painful swollen lymph nodes.
Pneumonic plague can be caused by breathing in airborne plague bacteria and is a particularly infectious form because it invades the lungs and can spread quickly from person to person, through coughing or in confined spaces.
The septicaemic strain of the terrifying disease is a life-threatening infection of the blood, most commonly spread by bites from infected fleas.
WHO bosses said their Black Death risk assessment was under constant review as the situation evolved.
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A spokesman said: “While the current outbreak began with one large epidemiologically linked cluster, cases of pneumonic plague without apparent epidemiologic links have since been detected in regions across Madagascar, including the densely populated cities of Antananarivo in the central highlands and Toamasina on the east coast.
“Due to the increased risk of further spread and the severe nature of the disease, the overall risk at the national level is considered very high.”
The outbreak began at the start of August and has so far infected more than 1,800 people.
Nine countries and territories, including tourist hotspots like the Seychelles, Mauritius and the French territory La Réunion, have been advised to review their protocols for quarantining infected visitors.
Officials from WHO have been helping countries prepare for the potential spread of the disease.
The spokesman said: “Plague is a preventable and treatable disease; however, untreated pneumonic plague is always fatal.
“Nine countries and overseas territories have been identified as priority countries in the African region for plague preparedness and readiness by virtue of having trade and travel links to Madagascar.
“These countries and overseas territories include Comoros, Ethiopia, Kenya, Mauritius, Mozambique, La Réunion, the Seychelles, South Africa, and Tanzania.”
The British Foreign Office said travel advice “for all countries, including Madagascar” was kept under constant review.
Its latest guidance states: “There is currently an outbreak of pneumonic and bubonic plague in Madagascar.
“Outbreaks of plague tend to be seasonal and occur mainly during the rainy season, with around 500 cases reported annually.
“While outbreaks are not uncommon in rural areas, the latest outbreak has seen an increase in reported cases in urban areas, including Antananarivo.”