# 2019–2020 measles outbreak in the Democratic Republic of the Congo

In 2019, a measles epidemic broke out in the Democratic Republic of the Congo (DRC). The epidemic started in early 2019 in the southeast corner of the DRC and then spread to all provinces. Close to a quarter of a million people have been infected this year alone. The World Health Organization (WHO) says this is the world's largest and fastest-moving epidemic. By June 2019 the epidemic was reported to have exceeded the death toll of the concurrent Ebola epidemic. By April 2020, it had infected more than 341,000 people and claimed about 6,400 fatalities.

## Quotes

* Close to a quarter of a million people have been infected this year alone. The World Health Organization (WHO) says this is the world's largest and fastest-moving epidemic. Measles in DR Congo has now killed more than twice the number who have died of Ebola there in the last 15 months. The Congolese government and the WHO launched an emergency vaccination programme in September that aimed to inoculate more than 800,000 children. But poor infrastructure, attacks on health centres and a lack of access to routine healthcare have all hindered efforts to stop the spread of the disease. Four million children have been vaccinated, but experts warn that this amounts to less than half of the total in the country - and not enough vaccines are available.
** "DR Congo measles: Nearly 5,000 dead in major outbreak". BBC. 2019-11-21. Archived from the original on 2020-02-11. Retrieved 2019-11-22.
* “We’re fighting the measles epidemic on two fronts - preventing infections and preventing deaths,” said UNICEF Representative in the DRC, Edouard Beigbeder. “Along with the government and key partners, UNICEF has been racing to vaccinate children against measles, and at the same time, supplying clinics with medicines that treat symptoms and improve the chance of survival for those already infected.”
** Edouard Beigbeder as quoted in "As measles deaths in the Democratic Republic of the Congo top 4,000, UNICEF rushes medical kits to health centers and vaccinates thousands more children". UNICEF. 2019-10-09. Retrieved 2019-11-22.
* “We’re facing this alarming situation because millions of Congolese children miss out on routine immunization and lack access to health care when they fall sick,” said Beigbeder. “On top of that, a weak health system, insecurity, community mistrust of vaccines and vaccinators and logistical challenges all contribute to a huge number of unvaccinated children at risk of contracting the disease.”
** Edouard Beigbeder as quoted in "As measles deaths in the Democratic Republic of the Congo top 4,000, UNICEF rushes medical kits to health centers and vaccinates thousands more children". UNICEF. 2019-10-09. Retrieved 2019-11-22.
* An outbreak of measles that began in early 2019 in the southeast corner of the Democratic Republic of the Congo (DRC) has now spread to all 26 provinces. Over 180,000 cases and more than 3,000 deaths have been reported. The outbreak has disproportionately affected young children under five years of age. Similar outbreaks occurred previously in the DRC in 2011 and again in 2015. This is the largest and most fatal of the large measles outbreaks across the world this year. These have occurred in the Ukraine, Philippines, Brazil, US, New Zealand, Madagascar and Nigeria. While the details of each individual outbreak vary, the root cause of measles outbreaks is always the same: too few children receive timely and effective vaccination.
** Matthew Ferrari, (2019-10-7). "Outbreaks of measles: compounding challenges in the DRC". The Conversation. Retrieved 2019-11-22.
* Many specific challenges in the DRC compound the already difficult task of vaccine delivery. Years of internal conflict have displaced millions from their homes, limiting their access to preventive health services. The country has an estimated population of 87 million, of which more than half are children. About two thirds live in rural areas and 40% of mothers report distance to health facilities as a challenge when getting health care. In addition, inherent mistrust of government-run programmes prevents some from seeking care. Those who do are met by health-care workers who want to help, but are hampered by stock outages or unstable refrigeration necessary to store vaccines in the prescribed temperature range. Many are understaffed or simply don’t have sufficient vaccines available due to the fragility of cold-storage and supply chain in remote areas.
** Matthew Ferrari, (2019-10-7). "Outbreaks of measles: compounding challenges in the DRC". The Conversation. Retrieved 2019-11-22.
* Even when cases of measles are detected in clinics, limited diagnostic and communication infrastructure can cause significant lags in triggering the outbreak response. The DRC currently has only one reference laboratory that can run the blood tests necessary to confirm a measles outbreak. Transporting and processing samples can take weeks. Add to this the competing demands of a health system combating two Ebola outbreaks in the past two years, and these lags can become larger.
** Matthew Ferrari, (2019-10-7). "Outbreaks of measles: compounding challenges in the DRC". The Conversation. Retrieved 2019-11-22.
* Since the start of 2019, the DRC’s measles epidemic has infected more than 341,000 people and killed some 6,400, taking almost three times as many lives as Ebola over the same period. “The actual mortality rate might be much higher, up to four or five times higher than what we see in official numbers because there are a lot of health structures that are not functioning properly,” said Karel Janssens, Doctors Without Borders’ (MSF) head of mission in the DRC. “So, there’s a lot of community deaths that are not reflected in some of the official reports.”
** Murray, Lisa. "Measles: In Ebola's shadow, a quiet killer is on a rampage in DRC”. Al Jazeera. (7 April 2020). Archived from the original on 10 May 2020. Retrieved 15 May 2020.
* Channelling attention and resources to the Ebola outbreak, donors and government officials were blindsided by the developing measles catastrophe, while the nation’s ailing infrastructure and healthcare system stymied an effective response. And now, the coronavirus pandemic has been unleashed on the world, complicating an already challenging situation. “It’s obvious the priority will be given to COVID-19 in the coming weeks and months,” said Vincent Sodjinou, the head of the World Health Organization’s (WHO) measles response. “The priority [before] was on Ebola, and it wasn’t easy to mobilise funds,” he added. “For measles, it was difficult for us to fight. It was a daily fight.”
** Murray, Lisa. "Measles: In Ebola's shadow, a quiet killer is on a rampage in DRC”. Al Jazeera. (7 April 2020). Archived from the original on 10 May 2020. Retrieved 15 May 2020.
* Last year, the DRC’s Ministry of Health led an effort to vaccinate 18 million children against the measles across the country, using $22m of donor funding – excluding MSF’s contribution. In comparison, USAID alone has spent $569m since the start of the Ebola outbreak, according to the US State Department, while the total funding for the Ebola response is unclear.
** Murray, Lisa. (7 April 2020). "Measles: In Ebola's shadow, a quiet killer is on a rampage in DRC”. Al Jazeera. Archived from the original on 10 May 2020. Retrieved 15 May 2020.
* In countries with advanced healthcare, the measles vaccine works upwards of 85 percent of the time, according to Patricia Tanifum, a measles expert at the WHO. But in remote corners of the DRC, where the health system and road network have suffered decades of conflict, underfunding and neglect, the virus thrives. Some five million children in the DRC are acutely malnourished, which means the effectiveness of the vaccine is reduced. When vaccinated, malnourished children are less able to devel-op the immunoglobulin against measles, leaving them vulnerable, Sodjinou said. Meanwhile, about 1 percent of rural areas have access to electricity from the national grid, making it hard to deliver and store temperature-sensitive vaccines such as measles that need to be kept between 2 and 8 degrees Celsius (35.6 and 46.4 Fahrenheit). “If not kept in the right range of temperature … it would be correct to compare it to a water injection given to children,” said Philippe Mpabenda, MSF’s head of measles response in Boso Manzi.
** Murray, Lisa, (7 April 2020). "Measles: In Ebola's shadow, a quiet killer is on a rampage in DRC”. Al Jazeera. Archived from the original on 10 May 2020. Retrieved 15 May 2020.
* The challenge of transporting an effective vaccine from a factory to a village like Macau is a logistical nightmare. The DRC is about seven times the size of Germany but has less than 0.5 percent of the paved roads compared to Germany. “Sometimes you can find a village which is 100km (62 miles) from the health centre, and they don’t have a motorbike or cold-chain,” said Sodjinou.
** Murray, Lisa (7 April 2020). "Measles: In Ebola's shadow, a quiet killer is on a rampage in DRC”. Al Jazeera. Archived from the original on 10 May 2020. Retrieved 15 May 2020.
* DAKAR (Reuters) - Democratic Republic of Congo’s government has declared an epidemic of mea-sles, which the latest health ministry figures show has now killed at least 1,500 people, more than a hundred more than have died of Ebola. While health officials have focused on the hemorrhagic Ebola virus in Congo’s east, about 87,000 suspected measles cases have been reported across the coun-try so far this year, more than the 65,000 recorded in the whole of last year. Congo’s health minis-try announced the measles figure when it declared the epidemic on Monday.
** "Congo declares measles epidemic after it kills more than Ebola". Reuters. 2019-06-20. Retrieved 2019-11-22.

### “Why measles deaths are surging — and coronavirus could make it worse” (07 April 2020)

Leslie Roberts, “Why measles deaths are surging — and coronavirus could make it worse”, (07 April 2020), clarification 09 April 2020), Nature, 580, pp.446-447
* A viral outbreak has killed more than 6,500 children in the Democratic Republic of the Congo (DRC) and is still spreading through the country. The foe isn’t the feared coronavirus, which has only just reached the DRC. It’s an old, familiar and underestimated adversary: measles. Cases began to spike here in October 2018. Children became weak, feverish and congested, with red eyes and painful sores in their mouths, all with the telltale rash of measles. “We have been running after the virus ever since,” says Balcha Masresha, an epidemiologist with the World Health Organization (WHO) regional Africa office in Brazzaville in the neighbouring Republic of Congo. The situation has mushroomed into what WHO experts say might be the largest documented measles outbreak in one country since the world gained a measles vaccine in 1963 (see ‘Measles cases on the rise’). The highly contagious measles virus continues to spread around the globe. In 2018, cases surged to an estimated 10 million worldwide, with 140,000 deaths, a 58% increase since 2016. In rich countries, scattered measles outbreaks are fuelled by people refusing to vaccinate their children. But in poor countries, the problems are health systems so broken and underfunded that it is nigh-on impossible to deliver the vaccine to people who need it. The DRC’s flood of cases shows why measles will keep flaring up despite efforts to control it. And the situation will only worsen with the COVID-19 pandemic: more than 20 countries have already suspended measles vaccination campaigns as healthcare workers scramble to deal with coronavirus.
* The DRC has difficulties on a number of levels. The country has such a high birth rate — 3.5 million children are born each year — that it needs to conduct mass vaccination campaigns every two years. Those campaigns, in which tens of thousands of health workers fan out across this vast country, are a logistical nightmare. First, the government has to get the vaccine from the capital, Kinshasa, to remote villages that can be reached only by helicopter — or through bloody conflict zones in the eastern part of the country. The vaccine must be kept between 2 °C and 8 °C from the time it leaves the warehouse until it is administered — a challenge in a tropical environment where power outages are frequent. Health workers must be trained to inject it safely, a much more difficult task than dropping liquid polio vaccine on a child’s tongue. The vaccine comes as a powder, which must be reconstituted with an accompanying solution of sterile diluent and then used within 6 hours. It also comes in ten-dose vials; worried about wastage, vaccinators are sometimes hesitant to open one when just a few children show up to a session, so the children go unimmunized.
* Money is a major problem. Vaccination campaigns cost around US$1.80 per child in the DRC, says Masresha; international donors foot some of the bill, but the country is expected to pay a share. In 2010, the DRC couldn’t muster the funds and cancelled a scheduled campaign. An outbreak that hit at the end of the year raged for more than 30 months. Further campaigns in 2013–14 and 2016–17 didn’t reach enough children. In June 2019, after cases soared to more than 3,500 a week at the start of the year, the DRC government declared an epidemic, opening the door to further international aid. By the end of the year, 18.5 million children had been vaccinated. The WHO estimates that there have been more than 348,000 cases and 6,500 deaths, but Francisco Luquero, an epidemiologist at Epicentre, the research arm of Médecins Sans Frontières (MSF, also called Doctors Without Borders) in Paris, thinks the outbreak is much worse. The case count reflects only people who go to health centres, he says; many don’t in the DRC. As for the mortality estimates, “they count deaths that happen right after a measles case. They should look out for the next five years,” he says, because of immune amnesia. “The outbreak will have a profound impact on public health.”

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