Friday, 4th of September 2015 Print



John Maurice

From The Lancet

In high-income countries, measles is generally seen as a mild ailment. An epidemic raging in equatorial Africa proves that the measles virus has not lost its power to kill. John Maurice reports.

Moise Yapi looks out of the window of the WHO country office in Kinshasa, capital of the Democratic Republic of the Congo, and sighs. “This measles outbreak were facing is bad and it could get much worse.” Yapi is the WHO Medical Officer for measles surveillance and control in the DRC. The epidemic started in February and has spread to three of the countrys 11 provinces. Katanga, the countrys southernmost province, bears the brunt of the epidemic. As of Aug 20, 28 506 suspected cases and 386 deaths have been reported but health officials believe this is an underestimate, since many sick people do not seek medical care. “This epidemic”, Yapi said, “could become as dramatic as the last one we had here, which broke out in 2010 and lasted 3 years”. That epidemic caused an estimated 300 000 cases and 5000 deaths. Yapis fear of an explosive escalation of the outbreak is based, he told The Lancet, “on gaps in routine immunisation coverage of the population, on the weakness of the national health system, and on the time it took for the health authorities and humanitarian organisations to respond. The start of the outbreak was confirmed in February. It took about 3 months for the response to get under way”.

What puzzles many health observers is that the epidemic started less than a year after mass vaccination campaigns were done throughout the country. Reasons they invoke include the failure of these campaigns to reach at least 95% of the population, the coverage needed to ensure protection against the infection (the coverage in the DR Congo is currently 84%). The cause of that failure is not hard to find. Yapi cites “poorly trained health personnel, a population constantly on the move, the refusal of some population groups to accept vaccination on religious or cultural grounds, and armed conflicts in several areas”.

A report, dated June 30, from a Médecins Sans Frontières team in Katanga, gives a vivid idea of the difficulty vaccinators are facing in trying to reach about 2·5 million people over a vast area on roads that sometimes degenerate into impassable marshland, and all the while trying to keep the vaccine cool enough to prevent it from being inactivated by the torrid equatorial temperature. The report tells of death rates up to 19% (vs the global average of 1·7%), among the “massive influx of seriously ill patients”, many of them children who not only have measles but also respiratory diseases, malaria, and malnutrition. “This is a huge epidemic. We are facing a genuine epidemic emergency”, the report concluded.

The recent measles epidemics in the DRC come against a backdrop of growing concern among the international health community that efforts to reign in the disease are stalling. In 1980, when measles vaccination was in its infancy, the disease was causing an estimated 2·6 million deaths a year, mostly in young children. By 2000, the death toll had fallen to 544 200, a 79% drop. By 2012, it had fallen a further 78%, to 122 000. The disturbing news is that in 2013 it had climbed back to 145 000. Large measles outbreaks are currently raging in several other African countries—Cameroon, Central African Republic, Nigeria, and Ethiopia—and also in several eastern European countries. In 2013, 70% of measles deaths in the world occurred in six countries—India, Indonesia, Pakistan, Nigeria, Ethiopia, and the DR Congo. These six countries account for 60% of the 21·5 million children in the world who were not vaccinated against measles in 2013 and were at risk of complications, such as pneumonia, diarrhoea, encephalitis, and blindness.

“This disease is a tough enemy”, said Peter Strebel from the Department of Immunization, Vaccines and Biologicals in WHOs Geneva headquarters. “Too many countries at risk of measles epidemics dont realise how tough it is. They are not sufficiently committed to reaching the 95% coverage rate.” Strebel also blames financial shortfalls for the increase in measles mortality figures. In 2007, measles control efforts could count on an annual budget of $150 million. “In 2010, with the global recession under way, we had to make do with $35 million. Since 2012, GAVI has joined the field with an annual investment of $140 million that should boost control efforts.”

Meanwhile, back in DR Congo, the measles epidemic is in full swing, humanitarian teams are in place, and Yapi and other WHO professionals are coordinating the outbreak response, raising awareness among communities of the need to seek treatment and vaccination, and providing treatment kits for the management of acute measles.

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