KINSHASA, Congo (AP) — Congo is seeing an upsurge in cases of the plague, as the vast Central African nation also battles outbreaks of COVID-19 and Ebola.

Since June, Congo has recorded at least 65 cases of the plague, including at least 10 deaths, in the eastern Ituri province according to Ituri provincial chief of health Dr. Louis Tsolu.

While the plague is endemic in Ituri province, the number of cases is increasing and has already surpassed the total recorded in 2019 which had 48 cases and eight deaths, according to WHO.

The new plague outbreak appears to have started in June when a 12-year-old girl in the Rethy health zone died with symptoms related to the plague — headache, cough, enlarged lymph nodes, and a fever. More deaths in that area were later recorded with symptoms of the plague, which manifests in three different forms: Bubonic, septicemic and pneumonic.

The transmission of bubonic plague between humans usually occurs when people do not take preventive measures, especially in Congo when they follow traditional burial practices in which they wash and touch the corpses of those who died from the disease, authorities say. The plague is initially transmitted to humans who are bitten by fleas living on rodents. Antibiotics are usually used in treatment.

This year health workers are finding it difficult to assist people in eastern Congo because of insecurity caused by armed militias. The plague cases have also increased while Congo is also fighting COVID-19, which has infected more than 10,100 people and killed at least 260. There is also an Ebola outbreak in the western Equateur province, which has killed 43 people, although in June Congo succeeded in bringing to an end a larger Ebola outbreak in the east that lasted for nearly two years and killed nearly 2,300 people.

The plague is mostly endemic in Congo, Peru and Madagascar, which saw a large outbreak in 2017 with more than 2,300 cases and 202 deaths, according to WHO.