Black Death refers to a disease outbreak in Europe and parts of North Africa in the 14th century. Over four years from 1347-51, this outbreak is said to have killed between 75 million and 200 million people.

Bubonic plague, said to be responsible for the Black Death, is the most common of three types of plague. It gets its name from the buboes or inflamed and painful lymph nodes that are a characteristic sign of bubonic plague (interestingly the word bubo comes from the Greek word for groin; the most common site for the appearance of the first bubo in patients). The other symptoms of bubonic plague include fever, chills, muscle pain, headaches, nausea and vomiting.

Bubonic plague is one of three types of plague—the other two are septicaemic plague and pneumonic plague. Bubonic plague affects the lymphatic system, septicaemic plague occurs when the plague bacteria enter the bloodstream and pneumonic plague occurs when the bacteria infect the lungs. Bubonic plague is the most common of the three and the least deadly.

The bacteria that causes plague is called Yersinia pestis after Alexandre Yersin, the scientist who first identified and described the bacteria in 1894. In the mid-1900s, scientists finally found a way to treat the plague with antibiotics. Today the condition is treatable, provided it is diagnosed in time. Diagnosis of bubonic plague may be done by physical examination and tests such as a blood test and testing the fluid from a bubo.

India saw a massive outbreak of bubonic plague in 1855/57; the disease is said to have claimed 10 million lives at the time. In 1994, an outbreak of bubonic and pneumonic plague across Maharashtra, Gujarat, Delhi, Karnataka, Uttar Pradesh and Madhya Pradesh reportedly caused 56 deaths in less than two months. A committee found that the 1993 Latur earthquake and flooding in Surat were the precipitating events for the outbreak.

To understand this link between a plague, an earthquake and a flood, it is necessary to know how plague spreads, the difference between bubonic and pneumonic plague and their connection to each other. Read on for more:

  1. Black Death transmission: how plague spreads
  2. Black Death symptoms
  3. Black Death causes
  4. Black Death disease type
  5. Bubonic plague prevention
  6. Diagnosis and treatment of bubonic plague
Doctors for Black death

Depending on its mode of transmission and which part of the body the plague bacteria infects, plague can be of three types:

Bubonic plague spreads through the bite of flea (often the Oriental/tropical rat flea or Xenopsylla cheopis) infected with Yersinia pestis bacteria. These fleas commonly infest rodents like rats, squirrels and rabbits—though they have been found on over 200 mammalian species by some accounts.

In bubonic plague, the bacteria use the lymphatic system to get around—the bacilli quickly move from the bite site to the nearest lymph nodes (usually in the armpits or groin) where they multiply rapidly causing the node to fill up with bacteria and appear swollen. This swollen mass is called a bubo.

Bubonic plague can also be transmitted by coming in contact with the dead bodies of plague victims (human and animal). It can also be transmitted through close contact with buboes—the bacteria-filled nodes. Human fleas (Pulex irritans) and body lice can also spread the disease from one person to another.

Septicaemic plague occurs when Yersinia pestis reaches the bloodstream. The bacteria can travel with the fleas (carried into households and other human-populated areas by rats, squirrels and other common rodents), or by coming in contact with the dead bodies of people and animals who died of the plague, or they could enter the bloodstream through an open wound to cause this type of plague. The lymphatic system is connected to the bloodstream through the subclavian vein—research has suggested that this route may be one way in which the bacteria reach the bloodstream.

Pneumonic plague occurs when Yersinia pestis affects the lungs. This is the most fatal type of plague. Human-to-human transmission of pneumonic plague is possible through respiratory droplets: when an infected person coughs, sneezes or talks loudly, they can release droplets into the air. Most of these droplets travel a short distance before falling to the ground. Some of these droplets remain airborne for longer and cover more distance. If these droplets enter the nose, mouth or eyes of a healthy person, they can transmit the infection. There are a few more things to keep in mind when it comes to pneumonic plague: if bubonic plague reaches the lungs, it can turn into pneumonic plague—which is much more deadly and acts even faster.

In February 2002, 16 cases of pneumonic plague (including four deaths) were reported from a village in Simla, Himachal Pradesh. The outbreak was contained by giving prophylactic antibiotics (chemoprophylaxis) to people who had come in contact with the patients, to the residents of the villages (Hat Koti) and the neighbouring village and to doctors and health workers. Both villages, all patient transport vehicles, etc., were also fumigated.

Pneumonic plague is so deadly that it typically kills the patient before he/she can transmit the disease to many people—the R-naught, or how many people can be infected by a diseased person on average, for pneumonic plague is around 1.3.

Each of these three types of plague has slightly different symptoms and outcomes. Read on for more.

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The incubation period of the plague is between one and seven days—that is, it takes up to a week after exposure to the bacteria for symptoms to show. Bubonic plague, or the plague that caused Black Death and the 1994 outbreak in India, has the following symptoms:

  • Fever
  • Chills
  • Myalgia (muscle pain)
  • Nausea and vomiting
  • Headaches

Buboes, the characteristic sign of bubonic plague, are inflamed and painful lymph nodes, usually in the armpit and groin area (though they can be present in lymph nodes anywhere in the body).

The symptoms of septicaemic plague (fever, chills, weakness, stomach ache, shock and possible bleeding) and pneumonic plague (fever, weakness, shortness of breath, chest pain, cough and blood in mucus) are different from bubonic plague in some important respects.

How to recognise a bubo

Bubo comes from the Greek word for groin (boubon). Here’s what to look for in a bubo:

  • An inflamed (red and swollen) bump
  • The bump in no bigger than five centimetres in diameter
  • The bump could be in the groin area, armpits, or in the lymph nodes behind the knee, above the collar bones, in the neck region (cervical lymph nodes), etc.

The bacteria that causes bubonic plague (Yersinia pestis) infects fleas which in turn infest roughly 200 mammalian species, including rats, squirrels, rabbits, wild rodents, prairie dogs and cats.

The fleas get infected when they bite an animal with the plague bacteria. The bacteria now grow in the food pipe (oesophagus) of these fleas, until the bacteria completely block the fleas' food pipe. Now, the fleas can’t feed without vomiting up the bacteria into a new host first. Once the flea bites a human host, the bacteria travel to the lymph nodes where they grow exponentially.

There are over 131 types of fleas that commonly spread the bubonic plague; chief among them is the Oriental rat flea.

Symptoms start showing up one to seven days after the flea bite. A person with bubonic plague is most infectious towards the end of the disease period (as opposed to pneumonic plague where the person’s condition could worsen suddenly, and the patient could die within 24 hours after contracting the bacterial infection).

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Black Death specifically refers to an outbreak of bubonic plague in the Middle Ages—1347-51 (some science historians say it went on till 1353). Here’s what we need to know about the bubonic plague today:

  • Black Death or bubonic plague is a bacterial infection.
  • It is a zoonotic disease, meaning that it jumped from animals to people at some point in history. Scientists say that this point in history could be anywhere from 5,000 to 10,000 years ago. The Plague of Justinian in 541-542 AD may have been the first plague epidemic—it is said that 25-50 million people may have died in this outbreak, most of them in Constantinople—then a powerful empire—and parts of North Africa.
  • Bubonic plague is also a vector-borne disease. Which means that it has a carrier that transmits the infection—the flea. As this flea can feed on roughly 200 species of mammals, it can get around quite quickly. That said, bubonic plague is most commonly associated with rats (those who de-skin infected rabbits and squirrels without gloves can also be infected). Since rats can get into homes, on-board ships and practically everywhere, the plague can travel with them.
  • Bubonic plague is a fulminant disease, meaning it sets in quickly and can be severe and even lethal. Left untreated, 30-60% of patients with bubonic plague die (the mortality for pneumonic plague is even higher at nearly 100%; remember than bubonic plague can travel to the lungs and become pneumonic plague).
  • Bubonic plague bacteria enter the body through the skin’s dermis layer. Most of the bacteria doesn’t go beyond the skin. A small fraction of “dissemination competent bacteria” escapes from the skin into the lymph vessels “immediately after inoculation”. According to research published in Trends in Microbiology, a peer-reviewed journal, Yersinia pestis bacteria possibly reach the lymph nodes too quickly for the immune system to put up an adequate response. Next, the bacterium multiplies “at remarkably high rates”. The bacteria then leave the lymph node and enters the bloodstream (possibly when lymph nodes burst or via the subclavian vein) and cause sepsis and septicaemic plague.
  • Bubonic plague is endemic to India and countries like the Democratic Republic of Congo, Madagascar, Peru and China even today. Between 2010-15, the World Health Organization received reports of 3,248 confirmed cases of bubonic plague across the world. However, an outbreak in Madagascar in 2017 saw cases rising over 2,000 within weeks.

Scientists have argued that bubonic plague outbreaks are linked to:

  • Historical events like the beginning of agriculture settlements when people started clearing forests for farming and making granaries to store grain. Wild rodents that lost their habitat and mice in search of food started living closer to human settlements and domesticated animals, making people more prone to the disease.
  • International travel, especially for war and trade, contributed to the spread of the plague bacteria to nearly all part of the world.
  • Disasters like floods, earthquakes and famine do two things: bring more rodents to human settlements in search of food. Some disasters kill off rats and other rodents—some scientists have proposed that with fewer rats and rodents to feed on, fleas turn to humans for their blood meals, thereby causing a spike in infections.

In 1994, the flooding in Surat brought the rats out of the open drains. In part, this is what triggered the outbreak in parts of the western, central and northern parts of India that year.

The World Health Organization recommends the following steps to prevent and contain the spread of bubonic plague and manage any future outbreaks:

Prevention of bubonic plague

Prevention of bubonic plague

Bubonic plague is endemic to India, among other countries like Madagascar, Congo, Peru, China, Malawi and Zambia (endemic regions are those where a particular disease exists continually, though the number of cases may be low in most years). The best ways to prevent this disease are:

  • Keep your surroundings clean to prevent rats and fleas entering your home and offices
  • Do not to handle animal carcasses. If you must handle dead animals for any reason, wear proper protective gear (gloves, mask, goggles, etc.) first.
  • Do not touch an infected person’s body fluids and tissues. If you are a primary caregiver or healthcare professional, follow all the precautions while handling the patient, suspected patient and any blood or sputum samples collected from them for testing.
  • Vaccines for bubonic plague are available, but the WHO only recommends their use for high-risk groups like healthcare workers and people who work with this bacteria in a lab.
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Management of bubonic plague

The WHO follows a time-sensitive procedure for the management of bubonic plague:

  • Contact tracing helps to find the contacts of the first (index) patient, to give them medicines prophylactically (to prevent disease).
  • WHO and the local government agencies work together to find and address the source of the infection, and ensure proper treatment with antibiotics.
  • Patients and all their contacts are monitored for at least a week, to check if anyone develops symptoms.
  • All precautions need to be taken while drawing samples for testing and transporting them to the labs.
  • Hand hygiene (washing hands with soap and water or using alcohol hand rub) and disinfecting surfaces with household bleach that has been diluted to 10% and made fresh each day, can help reduce transmission risk.
  • Care needs to be taken while handling, cremating or burying dead bodies as they continue to be infectious. In case of burial, WHO recommends covering the area with a cloth or any absorbent material soaked in disinfectant.

Bubonic plague is treatable with antibiotics, provided it is diagnosed early. This may sometimes be difficult as the early symptoms of plague can be quite generalised. However, buboes are a characteristic feature of bubonic plague. If you experience painful swelling in your lymph nodes, you should see a doctor without losing any time.

The doctor will do a physical examination. If you live in an area (or have recently travelled to an area) where the bubonic plague is endemic or if your doctor wants to confirm or rule out the bubonic plague, he/she may recommend a sputum test or blood test. Fluid from the swollen lymph node may also be tested.

The doctor may start antibiotics quickly (sometimes before the test results come back), if he/she suspects infection with Yersinia pestis. Some of the antibiotics used for treating bubonic plague are:

  • Septromycin
  • Gentamicin
  • Doxycycline
  • Ciprofloxacin
  • Levofloxacin
  • Moxifloxacin
  • Chloramphenicol

Please note that you should not take any antibiotics without a prescription from a doctor.

Dr Rahul Gam

Dr Rahul Gam

Infectious Disease
8 Years of Experience

Dr. Arun R

Dr. Arun R

Infectious Disease
5 Years of Experience

Dr. Neha Gupta

Dr. Neha Gupta

Infectious Disease
16 Years of Experience

Dr. Anupama Kumar

Dr. Anupama Kumar

Infectious Disease


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  2. Anisimov A.P. and Amoako K.K. Treatment of plague: promising alternatives to antibiotics. Journal of Medical Microbiology, 2006); 55: 1461–1475.
  3. Gonzalez R.J. and Miller V.L. A deadly path: bacterial spread during bubonic plague. Trends in Microbiology, April 2016; 24(4): 239-241. Epub 12 February 2016. PMID: 26875618.
  4. Keeling M.J. and Gilligan C.A. Metapopulation dynamics of bubonic plague. Nature, 19 October 2000; 407: 903-906.
  5. Centres for Disease Control and Prevention [Internet]. Plague. CDC, U.S. Department of Health & Human Services
  6. Gupta M.L. and Sharma A. Pneumonic plague, northern India, 2002. Emerging Infectious Diseases, April 2007; 13(4): 664-6. PMID: 17561574.
  7. Encyclopædia Britannica, Inc. [Internet]. Black Death.
  8. World Health Organization, Geneva [Internet]. Plague, 31 October 2017

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