Children wear face masks inside a hospital in the capital Antananarivo, Madagascar. Photo / AP
The deadly plague epidemic that has rocked the island of Madagascar could reach mainland Africa, a respected disease expert has warned.
The outbreak, which has been described the worst in 50 years' and has now reached "crisis" point, has prompted World Health Organization officials to place nine African countries on high alert.
South Africa, Seychelles, La Reunion, Mozambique, Tanzania, Kenya, Ethiopia, Comoros and Mauritius have all been told to brace for potential cases in the coming weeks, reports Daily Mail.
Today Paul Hunter, professor of health protection at the world-renowned University of East Anglia, is the first expert to predict it could reach mainland Africa.
Speaking to MailOnline exclusively, he said: "The big anxiety is that it could spread to mainland Africa, it's not probable, but certainly possible, that might then be difficult to control."
"If we don't carry on doing stuff here, at one point something will happen and it will get out of hand control cause huge devastation all around the world."
An analysis of plague cases by this website has revealed they have spiraled by nearly 40 per cent in less than week, with figures showing that at least 1,800 are now infected with the 'medieval disease' which has claimed 127 lives. The epidemic could strike a further 20,000 people in just a matter of weeks if current trends continue.
Earlier today, amid concerns the plague had reached crisis points, the World Bank released an extra $5 million (£3.8m) to control the deadly outbreak. The money will allow for the deployment of personnel to battle the outbreak in the affected regions, the disinfection of buildings and fuel for ambulances.
Two thirds of cases have been caused by the airborne pneumonic plague, which can be spread through coughing, sneezing or spitting and kill within 24 hours.
Professor Hunter's concerns echo that of dozens of leading scientists, many of whom have predicted the extent of this 'truly unprecedented' outbreak will continue to spiral as pneumonic is a more lethal strain than the one that traditionally strikes Madagascar.
Professor Jimmy Whitworth, an international public health scientist at the London School of Hygiene & Tropical Medicine, told MailOnline earlier this week that this outbreak 'is the worst for 50 years or more'.
And Professor Johnjoe McFadden, a molecular geneticist at Surrey University, said that the plague is "scary" and is predominantly a "disease of the poor".
Speaking exclusively to MailOnline, he also said: "It's a crisis at the moment and we don't know how bad it's going to get.
"It's a terrible disease. It's broadly caused more deaths of humans than anything else, it's a very deadly pathogen.
"It is a disease of poverty where humans are being forced to live very close to rats and usually means poor sewage and poor living conditions.
"That's the root cause of why it's still a problem in the world. If we got rid of rats living close enough to mankind then we wouldn't have the disease."
Professor McFadden warned in countries such as Madagascar "people often need to walk more than a day to receive proper medical treatment".
He also stressed the pneumonic strain of plague which is currently blighting the island off the coast of Africa can still be deadly even with treatment.
Earlier this week MailOnline revealed the "Godzilla" El Niño of 2016 has also been blamed for the severity of this year's outbreak by causing freak weather conditions.
Aid workers have warned the scale of the outbreak could be made worse by crowds who gathered for an annual celebration to honour the dead on Wednesday.
All Saints Day, otherwise known as the "Day of the Dead", is a public holiday which takes place on November 1 each year, sees families often gathering at local cemeteries.
"In that type of situation, it may be easy to forget about respiratory etiquettes," Panu Saaristo, the International Federation of Red Cross' team leader for health in Madagascar, told MailOnline.
Plague season hits Madagascar each year, and experts warn there is still six months to run - despite already seeing triple the amount of cases than expected.
It has started earlier as forest fires have driven rats into rural communities, which has then spread into cities for the first time, local reports state.
The most recent WHO figures dispute claims by Dr Manitra Rakotoarivony, Madagascar's director of health promotion, that the epidemic is on a downward spiral.
He told local radio: "There is an improvement in the fight against the spread of the plague, which means that there are fewer patients in hospitals."
The WHO, which issues a new report into the outbreak every few days, also remains adamant that cases are on the 'decline in all active areas' across the country.
It said on its website: "In the past two weeks, 12 previously affected districts reported no new confirmed or probable cases of pulmonary (pneumonic) plague."
Bubonic plague, which is transmitted by rat flea bites, was responsible for the "Black Death" in the 14th century, which killed 100 million people.
If left untreated, the Yersinia pestis bacteria can reach the lungs. This is where it turns pneumonic - described as the "deadliest and most rapid form of plague"
Health officials are unsure how this year's outbreak began, but local media report that forest fires have driven rats towards rural communities.
This is believed to have been the start of the bubonic outbreak, which then develops into the more virulent pneumonic form which spreads rapidly without treatment.
Concerned health officials have also warned an ancient ritual, called Famadihana, where relatives dig up the corpses of their loved ones, may be fueling the spread.
To limit the danger of Famadihana, rules enforced at the beginning of the outbreak dictate plague victims cannot be buried in a tomb that can be reopened.
Instead, their remains must be held in an anonymous mausoleum. But the local media has reported several cases of bodies being exhumed covertly.
Despite the serious risks publicised by the authorities, few in Madagascar question the turning ceremonies and dismiss the advice.
Willy Randriamarotia, the Madagascan health ministry's chief of staff, said: "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."
Experts have long observed that plague season coincides with the period when Famadihana ceremonies are held from July to October.
The plague outbreak in Madagascar tends to begin in September and ends in April. Tarik Jaarević of the World Health Organization confirmed it would be no different this year.
He said: "After concerted efforts of the Ministry of Health and partners, we are beginning to see a decline in reported cases but there are still people being admitted to hospital.
"At this time we cannot say with certainty that the epidemic has subsided. We are about three months into the epidemic season, which goes on until April 2018.
"Even if the recent declining trend is confirmed, we cannot rule out the possibility of further spikes in transmission between now and April 2018."
However, this year's worrying outbreak has seen it reach the Indian Ocean island's two biggest cities, Antananarivo and Toamasina.
Experts warn the disease spreads quicker in heavily populated areas. It is estimated that around 1.6 million people live in either city.
The first death this year occurred on August 28 when a passenger died in a public taxi en route to a town on the east coast. Two others who came into contact with the passenger also died.
This year's outbreak is expected to dwarf previous ones as it has struck early, and British aid workers believe it will continue on its rampage.
Olivier Le Guillou, of Action Against Hunger, previously said: "The epidemic is ahead of us, we have not yet reached the peak."
A WHO official added: "The risk of the disease spreading is high at national level... because it is present in several towns and this is just the start of the outbreak."
International agencies have so far sent more than one million doses of antibiotics to Madagascar. Nearly 20,000 respiratory masks have also been donated.
However, the WHO advises against travel or trade restrictions. It previously asked for $5.5 million (£4.2m) to support the plague response, which has now been issued.
Despite its guidance, Air Seychelles, one of Madagascar's biggest airlines, stopped flying temporarily earlier in the month to try and curb the spread.
Schools and universities have been shut in a desperate attempt to contain the respiratory disease, with children known to come into contact with each other more than adults. The buildings have been sprayed to eradicate any fleas that may carry the plague.
Madagascan press reports that the finances and budget minister, Ms Vonintsalama Andriambololona was pleased with the decision to grant an extra $5 million in the fight against plague.
"We are pleased that the Bank has listened to our call. The ministry promises to closely supervise the good management of such resources in order to quickly tame the epidemic," she said.
The unique custom, originating among communities that live in Madagascar's high plateaux, draws crowds every winter to honour the dead and to honour their mortal wishes.
"It's one of Madagascar's most widespread rituals," historian Mahery Andrianahag told AFP at a festival in Ambohijafy, a village outside the capital Antananarivo.
Relatives invite all their fellow villagers to attend the ceremony and to take part in the procession as well as musical and food festivities, but the wrapping of the body is a purely family affair.
The dead may be "turned" more than once but only every five, seven or nine years, and can be wrapped in several shrouds if different parts of the family or loved ones want to honour them.
The customary ritual, rather than a religious rite, is a celebration accompanied by music, dancing and singing, fuelled by alcoholic drinks.
As soon as it is over, the mats on which the bodies are laid are pulled up. Many participants store them under their mattresses in the belief it will bring them good luck, harboring bacteria.
A senior aid worker on the ground in Madagascar has provided MailOnline with an exclusive snapshot of what is happening on the island.
Panu Saaristo, the International Federation of Red Cross' team leader, has revealed thousands of infected adults are unwilling to seek help because they are scared of hospitals.
Mr Saaristo said the cultural stigma associated with seeking medical help was masking the true scale of the problem as it means many of those who are infected are failing to be diagnosed. At the same time there is also a growing shortage of life-saving tests which can provide a rapid diagnosis.
Speaking about the decline in plague cases reported today by Madagascan health officials, Mr Saaristo said he feared this is not really the case and that the true scale of the problem growing. He told MailOnline: "No-one is happier than us, if that is indeed the case".
"Fear of the fact if they get diagnosed with the infection and the long time they would have to spend in hospital' could be a factor in many not seeking treatment because they connect 'hospitals to death'," he added.
"People start avoiding healthcare that may lead to a situation where people start dying." He warned this year's outbreak has been "truly unprecedented", and is "not the plague as usual".
Figures show that at least 1,300 cases of the plague have been reported so far in this year's outbreak, with 93 official deaths recorded. However, UN estimates state the toll could be in excess of 120.
Mr Saaristo warned more deaths are expected unless the urgent shortage of rapid diagnostic tests is immediately addressed, as the majority of plague cases spreading through Madagascar can prove fatal in just 24 hours.
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