Measles returns to the Democratic Republic of Congo: A new predicament amid the COVID‐19 crisis

Abstract

During the coronavirus disease 2019 (COVID-19) pandemic, a measles outbreak resurfaced in the country, owing to the country's inadequate health system, which hampered the development of proper disease responses. Measles is a highly contagious and infectious disease that primarily affects infants, with a global fatality rate of 28,000 cases reported. Democratic Republic of Congo (DRC) is not yet capable of surviving the measles outbreak due to a number of challenges, including the inability to integrate the integrated disease surveillance system (IDSR) into case-based measles surveillance, civil unrest, and a lack of functional cold chain equipment/treatment facilities, among others. The recent measles outbreak, if not treated properly, might result in a new epidemic as well as a co-infection between the two diseases. Measles is a contagious and infectious disease of public health importance that affects infants with a record of 28,000 mortality rate occurring globally1 and can lead to death, chronic complications, and illnesses worldwide.2 Measles mortality is caused generally as a result of certain complications associated with it, thereby making infants and children with nutritional deficiencies at high risk.3 Most measles cases are usually caused by poor health infrastructures especially in low-income countries.1 In recent years, the number of cases of measles has increased in the DRC, necessitating urgent public policy to fight the disease. Poor access to vaccination, accompanied by high birth rates, continues to cause major epidemics in low-income countries. The DRC experiences outbreaks every 2–3 years, with peaks of 182 485 cases in 2005, 133 802 cases in 2011, and 88 381 cases in 2013. The size of the 2019 outbreak, however, was unprecedented, with 311,471 cases reported, far more than in the DRC's history of surveillance.4 Between 2018 and 2020, the country was swept by the worst measles epidemic in DRC history. About 460,000 children were infected with the disease in just 2 years, with almost 8000 of them dying. Three-quarters of them were children under the age of five.5 As in other countries around the world, the burden added by COVID-19 to the public health system has led to a reduction in the epidemiological control of other infectious diseases.6-8 In DRC, the situation was no different. There was a re-emergence of measles outbreak in the country during the COVID-19 pandemic, because the health system is very weak, which had an effect on developing adequate responses to the disease.9, 10 As a result of several challenges faced by DRC, such as the inability to integrate the IDSR into the case-based measles surveillance, civil unrest, lack of functional cold chain equipment's/treatment facilities amongst others, DRC is not yet capable of surviving the measles outbreak except certain actions are put in place to increase accessibility to routine immunization services and effectiveness of the vaccine. In addition to the measles outbreak, there was a substantial setback in terms of coping, detection, and treatment of other diseases, including measles, in 2020, as the maximum capacity of health facilities, such as hospitals, laboratory research, labor, and epidemiological surveillance, was devoted to COVID-19 cases. For example, the Global Vaccine Action Plan initiated by WHO had a solid plan to eradicate vaccine-preventable diseases to a major extent until 2020. The initiative has been mostly successful until the pandemic caused a cessation.11 UNICEF cautioned on May 5th, 2020 that the current decline in vaccination rates in the DRC puts children in the world at risk of contracting deadly diseases like polio, measles, and yellow fever.12 Despite the alerts, the measles outbreak in the DRC has resurfaced. After extensive government efforts, the Minister of Health declared the measles outbreak to be over in August 2020.5 However, several provinces, especially the North and South Ubangi provinces, have seen new rises in measles patients since the end of 2020. Since January 1, 2021, there have been more than 13,000 incidents. The vaccine campaign lowered the number of patients from the previous outbreak in 2020 but it did not break the transmission chain.5 To make things worse, the DRC has been affected by the conflict which brought about an inability to access the roads, limitation of health infrastructure improvement as well as the implementation of the routine immunization schedule. Some WHO guidelines were set for the case definition surveillance for measles but it is yet to be practiced by all provinces in the country.1 If not managed, the recent measles outbreak could result in a new epidemic, as well as a co-infection between the two diseases, as has been observed for COVID-19 and other infectious diseases, such as arboviruses.13, 14 In fact, in September 2020, measles and COVID 19 coinfection were registered. Coinfections can promote genetic exchange and the production of recombinant viruses, influencing viral evolution, antiviral sensitivity, and disease progression which can create havoc in the country.15 To put a stop to it, at the end of 2020, after many provinces began reporting new spikes in patients with measles, Médecins Sans Frontières (MSF) started a vaccination campaign that reached 70,000 children, with an emphasis on those living in difficult-to-reach areas, effectively stopping the disease's spread. MSF's funding also resulted in the treatment of over 1200 patients.5 Their team also provided disease monitoring training to local health workers to enhance the early detection of new measles outbreaks. However, as in many other health zones in the DRC, local health authorities' resources fall well short of what is needed.5 A very high birth rate introduces new children to the disease every day; an under-equipped health system is unable to deliver consistent quality healthcare, and health professionals seeking to reach those regions must resolve ingrained geographic and security difficulties. The urgency is there as they wait for systemic improvements: stop the spread and save lives. Working to tackle these obstacles is critical for long-term measles control. Right now, we must not lose sight of the urgent need for an immediate response, which slows transmission and saves lives.5 Organizations, such as WHO, MSF, CDC, and UNICEF need to underline the importance of eradicating measles, given that the virus can easily be transmitted via air droplets.16 Encouraging NGOs is essential to sustain the measles endemic, it might be beneficial to remind them that there are two coexistence viruses, severe acute respiratory syndrome coronavirus 2, and measles morbillivirus, in DRC. Due to the decline in immunization, over 100.000 children have missed out on their measles vaccination. Immunization programs worldwide should restart, given that measles can be fatal and is easily preventable by vaccination.12 As stated in their National Health Development Plan, a good logistics plan is in order to prevent stockouts and track inventory. Related distributors should be reminded of a possible measles outbreak.17 DRC has received over 1.7 million doses of the COVID-19 vaccine. It might be beneficial to consider vaccinating vulnerable populations' and healthcare professionals' children and grandchildren against measles concomitantly while vaccinating vulnerable populations and healthcare workers.18 The citizens need to be aware of even more at the moment. Brochures and posters can be disseminated explaining both the symptoms and transmission ways of measles and COVID-19. Wearing masks and avoiding crowded settings should be stressed. National public figures should be included, if possible, to increase attention. The authors declare that there are no conflict of interests. Anmol Mohan developed the concept for this letter. Mohammad Mehedi Hasan prepared the outlines of the study. Anmol Mohan, Rabiu Aishat Temitope and Sude Çavdaroğluude Çavdaroğluude Çavdaroğlu wrote the first draft. Mohammad Mehedi Hasan and Ana Carla dos Sude Çavdaroğluude Çavdaroğluantos Costa edited the second draft and improved the manuscript. Mohammad Yasir Essar made the critical comments and revisions. All authors revised and approved the final draft.

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