Antananarivo - The little footbridge near Justin Rakatoarivony's home is submerged in a murky green liquid the texture of sewage.But he has no choice but to cross it every day on his way to work in Antananarivo, the capital of Madagascar. The filthy conditions in his area, the southern Ampefiloha district, make him worry that he will be the next victim of the plague outbreak sweeping the country.His fear is far from unfounded: the disease has already killed 21 people in Antananarivo since August, according to the health ministry."The plague is a disease that comes from the filth, because the filth attracts rats, and rats carry fleas which transmit the plague to humans," said Rakotoarivony, 45."I fear getting the plague here, but I don't have any choice, I have to cross this bridge every day, so I do it at speed."Rakotoarivony is one of many on the Indian Ocean island nation who are increasingly fearful of the unusually virulent outbreak that has so far killed 48 people nationwide and infected 239 in the capital and its outskirts.Everyone who crosses the bridge puts on a brave face despite the flow of brackish water and domestic rubbish beneath."The plague can kill in 12 hours," Edmond Rakotondrasoa, 46, a used-phone salesman, told AFP."But I'm not scared because I'm a believer and God wrote in the Bible, 'I will protect you from all epidemics'."Scrap-metal merchants do business beside the accumulated detritus near the canal without a thought for the unhygienic surroundings.Madagascar's outbreak includes bubonic plague, in which the germ Yersinia pestis is spread by infected rats via fleabites, and pneumonic plague, a particularly dangerous form which spreads from person to person via airborne droplets.One of the traders there has already been diagnosed as a carrier of pneumonic plague.The individual was hospitalised in a specialist clinic in Antananarivo - but discharged himself before completing his treatment.'Spitting blood'"Following our efforts to raise awareness about the plague, a group brought in a 24-year-old man who was spitting blood," said Rabenjaminahobianintra Harimanana, head doctor at the Isotry Central health clinic."Tests [for plague] came back positive, so after being given initial treatment he was sent to the Ambohimiandra Anti-plague Clinic."But he escaped from the centre and was seen once again trading in the market."Authorities sought to reason with him, but he fled again.He was declared a wanted man, but is still at large."He was scared because he was a repeat offender who had been released from prison," said Harimanana."We alerted the police so they can return him to hospital if they find him."Hanitra Randrianarison, a senior medical official in Antananarivo, said "this fugitive patient risks spreading the disease very quickly to anyone who gets within 2m of him".President Hery Rajaonarimampianina on Tuesday described tackling the plague in military terms."We are at war... and today I think we have the weapons and munitions to fight this epidemic," he said in his first public comments on the crisis as he visited affected areas.The current crisis was sparked on August 28 after a single fatality in the central town of Ankazobe. The victim, a passenger in a public taxi, passed away as the vehicle travelled across the country.They infected two other passengers who died at the beginning of September in Tamatave, a town on the island's east coast that had gone for 100 years without a single recorded instance of the plague. Now almost 450 cases of plague have been identified nationwide, prompting authorities to take drastic measures.'A baseless rumour'Passengers at Antananarivo's transport hubs are subject to medical inspections, infected areas have been fumigated to kill fleas, public gatherings are banned, and schools and universities have been shut. "Local health inspectors are working to identify people infected with the plague and to inform people about the importance of hygiene and cleanliness," said Randrianarison."All of the local communities in Antananarivo have been taking part in a city-wide clean-up drive."This week, the health ministry trained 384 local health inspectors to deal with plague in Antananarivo.Among them was Norosoa Raharimalala, who works in Ivandry district in the capital's north. Unlike some of those who live and walk alongside the filthy Andriantany canal, the people of Ivandry have been panicked by the plague outbreak, according to Norosoa.They no longer shake hands to greet one another, and avoid standing close to each other."It takes a plague for people in our area to appreciate cleanliness and hygiene," said Raharimalala.