At least five people have died of pneumonic plague in Madagascar, public health officials said Friday.
Twenty two others, with suspected cases, are receiving treatment.
"Two people died in the seaport of Toamasina. One of them was a university student," said Dr Raymond Rakotoarimanana, head of public health in the eastern region.
The two had been in contact with a passenger in a public service vehicle who died of the plague en route to Toamasina last month.
Two more people died in the province of Antananarivo.
Madagascar witnesses an outbreak nearly every year since 1980.
In the recent outbreak, some 349 people have been treated for the plague, the health ministry said.
There has been widespread panic in the southeastern Africa island nation especially its eastern region.
People have been spotted lining up at pharmacies for antibiotic drugs with doctors warning of abuse of the medicines.
A resident in Fenoarivo Atsinanana, a city in the eastern region about 100km north of Toamasina, said antibiotics were quickly running out of stock.
"People are queuing at pharmacies to buy Cotrim (an antibiotic used to treat a variety of bacterial infections)," said Ms Marthe Ravonindranto, adding that "the stock is running out".
But Dr Mahery Rarsitorahana, the director of Heath Monitoring and Epidemiologic Surveillance, warned that the drugs should only be used by people receiving treatment.
"They were not for prevention but for treatment," said Dr Rarsitorahana.
Pneumonic plague is a contagious bacterial disease characterised by fever and delirium and sometimes lung infections. It can be fatal if left untreated within 24 hours.
The health ministry, however, assured citizens that the outbreak was under control.
"No death, caused by the infectious disease, has been reported since September 11. However, we have to remain constantly cautious," said Dr Manitra Rakotoarivony, the director of Health Promotion.
The health ministry said beside the eastern region where the plague has been reported, it is also closely monitoring Analamanga - which includes the capital Antananarivo and Vakinankaratra in central Madagascar, as well as Alaotra-Mangoro, Sava and Boeny in the north.
Plagues in the country are attributed to multiple factors including rats fleeing forest fires, poor hygiene and inadequate healthcare.