At least 20 people in Madagascar have died amid an outbreak of bubonic plague, experts have confirmed.
The country faces an epidemic of the disease, known as Black Death, unless it slows its spread, The Pasteur Institute of Madagascar warned.
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But during the political crisis that followed the 2009 coup, living standards in the country have drastically deteriorated, reports the BBC.
In October charities said inmates in the island's rat-infested jails are particularly at risk.
If the plague gets into prisons there could be a "atomic explosion of plague" within the town, they said.
"The prison walls will never prevent the plague from getting out and invading the rest of the town," said the institute's Christophe Rogier.
"A prison is not a sealed place."
Suffering 256 plague cases and 60 deaths last year, Madagascar became the world’s worst-hit country of the disease.
The now rare disease killed an estimated 25 million people in Europe during the Middle Ages.