CONTAGION IN THE CONGO
The race to save young lives in the world's biggest measles outbreak
The Democratic Republic of Congo (DRC) is currently facing the world's biggest measles outbreak.
The epidemic that started in 2018 has now reached the country's 26 provinces.
Since January 2019, more than 288,000 people have contracted measles. Over 5,700, mostly children, have died.
MSF teams are on the ground providing free medical care for measles patients.
Whilst the measles outbreak rages, DRC is also battling another highly infectious virus: Ebola.
With over 3,300 cases, this is the second-worst Ebola outbreak in history. It has claimed more than 2,100 lives.
In areas also affected by Ebola, caring for children suffering from measles and vaccinating those at risk pose additional challenges for health workers.
Vaccination: our only hope
Measles is a highly contagious viral disease that starts with cold-like symptoms before erupting into a blotchy rash.
It's spread by coughing and sneezing, close personal contact or direct contact with infected bodily fluids.
Currently in DRC, one measles patient infects on average two to three other people.
There is no specific treatment once someone contracts measles: our medical teams can only try to manage patients' symptoms.
However, a well-conducted vaccination campaign is extremely effective in preventing new cases.
In areas with low immunisation coverage, an emergency vaccination campaign can cut the number of infants dying of the disease by 50 percent.
Jolie Tabhu Dradheyo knows how quickly and easily measles can spread.
Her two young children contracted the disease, one after the other.
After hearing about MSF, Jolie brought them to Biringi Hospital in Ituri Province, northeastern DRC.
"I first came with one of my children to the hospital because he had measles," she says.
"And when I got home with him, my other child already had the symptoms of the disease.
"He had a fever, cough and pimples: he too had measles.
"Through the community relay, I knew I could bring my children here."
Jolie's youngest child recovered from measles in October. When she spoke to our team in November 2019, her eldest was still being treated.
The evolution of an epidemic
Several factors are contributing to the spread of the current measles epidemic in the DRC.
The immunisation coverage in some regions of the country is extremely low. A lack of vaccines, people trained to administer the vaccine, and access to health facilities all make getting immunised difficult.
On top of this, the vaccine must be kept at the right temperature until injection or it becomes less effective.
In DRC's tropical climate, this and logistical difficulties in getting the vaccines to their final destinations mean real challenges for health teams.
The needs are enormous and DRC's national vaccination programme cannot keep up.
The epidemic shows no signs of slowing: 9,605 new cases were reported in the last week of November, the highest number since the start of the year.
In 2019, the fatality rate was over two percent - twice as high as previous years.
Seventy-three percent of deaths were among children under the age of five.
Surveillance in the jungle
Measles cases remain under-reported across the country.
MSF has set up strategies to identify new areas affected by the epidemic, in order to start interventions as soon as possible. This is known as "surveillance".
In Viadana, in the province of Bas-Uélé, a small team went to assess the situation after a sudden spike in measles cases.
What they found there far exceeded the numbers reported in early December.
In a single school of about 300 children, more than 100 students were ill with measles.
This intervention allowed MSF to immediately start providing medical care for these children and to organise a vaccination campaign.
A similar system has been set up in the four provinces of ex-Katanga, in southeastern DRC, where MSF has created "sentinel" sites and put in place a decentralised laboratory to quickly analyse suspected cases of measles and rubella (a milder viral disease).
Prior to that, samples needing analysis had to be sent to Kinshasa, nearly 570 miles away, which took several months.
“When an epidemic is declared, medical care and vaccination must be combined to stop the spread of the disease," says Alex Wade, MSF's country director in DRC.
Congolese health authorities have been running supplementary immunisation activities since mid-November, while MSF continues to provide free medical care.
"But for now, the epidemic is still several steps ahead of the medical-humanitarian response,” says Wade.
Measles and Ebola
Ebola is a highly infectious virus and one of the world's deadliest diseases.
However, the current measles epidemic has claimed more lives than the ongoing Ebola outbreak.
This is the first time that outbreaks of both diseases have occurred on such a large scale within the same geographical area.
The double outbreak means additional challenges for health workers fighting to save lives.
"In an area affected by Ebola, the vast majority of medical resources are mobilised to prevent the spread of the virus and to care for people with confirmed or suspected cases," says MSF vaccination referent, Dr Nicolas Peyraud.
"When medical staff and equipment are already limited, epidemiological surveillance and medical care for patients may deteriorate for other diseases such as measles. Similarly, preventive activities, such as routine vaccinations, are drastically reduced."
Measles immunisation coverage has declined significantly in Ebola transmission areas since the beginning of the epidemic in mid-2018.
Measles and Ebola patients may also have similar symptoms, which makes diagnosis difficult.
"This can be a significant issue if a measles patient is hospitalised in an Ebola treatment centre and vice versa," says Dr Peyraud.
"Community members can often be reluctant to come to local health centres when they are sick, fearing being identified as a possible Ebola case and then being isolated.
"It is therefore very complicated to manage two outbreaks of this scale at the same time, in the same place."
Despite the many challenges of a double outbreak, MSF teams are finding a way to fight both Ebola and measles in DRC.
Patients are diagnosed and referred to the appropriate unit, where precautions are taken to avoid transmission and they are assessed daily for any appearance of symptoms resembling Ebola.
MSF is also finding a way to prevent more measles deaths, introducing the first measles vaccination campaign in an Ebola-affected area in July 2019.
This required additional infection prevention and control measures and extensive community engagement to ensure families knew their children wouldn't be at risk of contracting Ebola.
"Everything went smoothly and children in several health zones, including Bunia and Ituri, were vaccinated," says Dr Peyraud.
"This has reinforced the message that it is vital to vaccinate against measles even in these contexts, in order to prevent thousands of deaths from complications of the disease."
Measles vaccination activities were carried out several months later throughout the country, taking into account the lessons learned from this first campaign.
This was replicated in eight health zones in Ituri that were at high risk of Ebola transmission at that time.
We must step up the fight
Between January 2018 and October 2019, MSF teams treated 46,870 measles patients and vaccinated 1,461,550 children in 54 health zones.
In collaboration with the Congolese Ministry of Health, we also helped to strengthen measles vaccination activities in areas where the Ebola outbreak continues to spread and, as a result, where vaccination coverage for other diseases has dropped dramatically.
Unfortunately, many regions in DRC are still not vaccinated.
"Supplementary immunisation activities have been launched by the Congolese Ministry of Health, but there are still many health zones where the outbreak continues," says Wade.
"We must wait until the end of these vaccinations to have a better understanding of the evolution of the epidemic.
"However, the current implementation of this campaign suggests that needs will persist, especially for children over the age of five who will not have been vaccinated during this period."
More resources must be urgently committed and targeted to affected areas to help the Ministry stop the measles outbreak.
"Too many children have died from this easily preventable disease," says Wade.