Africa has several known endemic foci of plague (Fig. 32.1) and currently contributes over 95% of the burden of plague cases reported globally (Bertherat 2016). Sporadic cases of plague are likely to be under-reported owing to difficulties in recognition and diagnosis but there is also over-reporting during outbreaks. Although the incidence of plague is probably declining, it is very unlikely ever to be eliminated. There is no conclusive evidence that sub-Saharan Africa was affected by plague during the Black Death pandemic in Europe and Asia (1347–1351) but epidemics occurred following introductions via port towns such as those in Madagascar in 1898 and in South Africa in 1901. Since 2000 plague has been documented with foci in Uganda, Tanzania, Zambia, Malawi, Madagascar, Mozambique and Zimbabwe. Since 2010 plague outbreaks in Madagascar and the Democratic Republic of Congo (Ituri province) have contributed 80% and 15%, respectively to the global burden reports, but both the Eastern province of Zambia and the West Nile district of Uganda also reported plague cases occurring in previously known disease foci. Reservoir hosts are widespread and modelling studies have suggested a wide potential for emergence across much of Central, Eastern and Southern Africa (Neerinckx et al. 2008). Thus, there are concerns that ecological change affecting reservoir hosts or the displacement of populations could fuel an emergence of plague from its traditional foci.