Yesterday, WHO Director-General Dr. Tedros Adhanom Ghebreyesus declared the Ebola outbreak in the Democratic Republic of the Congo (DRC) a Public Health Emergency of International Concern, calling for renewed international commitments to the response. However, the Director-General also recognized that there have been several other outbreaks occurring in the country, some of which have case counts and mortality statistics that match or exceed the current ongoing Ebola epidemic. He surmised “Even as we focus on ending the [Ebola] outbreak, we must look beyond it. An outbreak of measles in DRC has killed almost 2000 children since January – more than Ebola in less time – and yet it gets little international attention.”
According to UNICEF, nearly 2,000 children have died from measles as of July 11 this year with nearly 115,000 suspected cases as of June 23. WHO also reports 12,247 suspected cases and 279 deaths from cholera this year as of June 9. Outbreak Observatory has written multiple posts on the current Ebola outbreak in DRC, the most recent of which can be found here. In this post, we will be discussing the outbreaks concurrently occurring with the Ebola outbreak and how they are complicating the country’s response strategies.
Measles is a highly contagious, vaccine preventable systemic disease, and in recent years there has been a rise in measles epidemics occurring globally. Outbreak Observatory has covered multiple measles outbreaks in the past, occurring in countries such as Venezuela, the United States, Ukraine and Madagascar.
On June 10, 2019, DRC officially reported an outbreak of measles. This outbreak has already far surpassed last year’s 65,098 suspected cases in 18 of DRC’s 26 provinces of which 2,908 were confirmed and 961 were fatal. This year’s outbreak is affecting all 26 provinces in the country with nearly double the amount of suspected cases compared to last year. According to the WHO, 905 cases have been lab-confirmed as of July 10, 2019, but the WHO also says this data may be a poor representation of the current situation as there are large gaps in measles surveillance in DRC. Children under 5 made up two thirds of the 1,981 deaths reported this year. DRC has faced multiple issues that contribute to measles transmission including low immunization coverage, low vaccine supply, poor surveillance, limited logistical means to maintain cold chain needed for vaccines, armed conflict, displacement as well as financial and geographical barriers that impede access to health facilities. DRC health officials even had to temporarily suspend measles vaccination campaigns in June due to insecurity in the northeastern part of the country.
The Measles & Rubella Initiative and Gavi, the Vaccine Alliance have been collaborating with the DRC Ministry of Health to implement vaccination campaigns and prevent further spread of measles. A mass immunization campaign occurred in April reaching 2.1 million children. An additional nationwide mass immunization campaign targeting 18 million children aged 6 to 59 months will be conducted in October 2019.
Cholera is a vaccine preventable food- and water-borne disease that causes severe diarrhea and dehydration. While effective treatment including antibiotics and fluid replacement can reduce the case fatality rate from 50% to 0.2%, lack of safe water sources and sanitation can contribute to explosive outbreaks. Outbreak Observatory has written previously about past outbreaks affecting countries such as Mozambique, Zimbabwe, and Yemen.
DRC is no stranger to cholera. The disease repeatedly reappeared in DRC throughout the 1970’s, becoming endemic in eastern DRC by 1978. Now, DRC makes up approximately 5-14% of annual cholera cases worldwide. In 2017, there were 53,037 cases and 841 deaths. In 2018, there were 29,304 suspected cholera cases and more than 930 deaths. According to literature, complex emergencies in eastern DRC have enabled cholera to continue its spread along the banks of the Great Lakes and into surrounding areas due to water supply interruptions, high population densities and population movement. The 2019 outbreak is affecting 20 of DRC’s 26 provinces, particularly Haut-Katanga, South Kivu, Tanganyika, Haut-Lomami and North Kivu.
In response to the outbreak, DRC is rolling out the biggest ever oral vaccination campaign against the disease. WHO, Gavi, the Vaccine Alliance and the Global Task Force on Cholera Control collaborated with the DRC Ministry of Health to implement the project. During Phase 2 this month, approximately 1.2 million people are being targeted in four provinces in central DRC. As of June 1, 2019, nearly 350,000 people have been vaccinated for cholera with support from the WHO and Gavi, the Vaccine Alliance. Sanitation and water quality control have also been implemented in affected areas.
Overlap with the Ebola Outbreak
Concerningly, the initial stages of Ebola mimic the symptoms of measles, cholera and malaria. DRC has the second largest number of cases and deaths due to malaria globally. With approximately 15.2 million presumed and confirmed cases of malaria in the country per year, that creates tough decisions for clinicians who want to isolate suspected Ebola cases.
In settings in DRC where outbreaks of these diseases overlap, case management and prevention activities can become complicated. For example, the measles outbreak and the Ebola outbreak overlap in Ituri, a province that contains up to 400,000 displaced individuals and 35 camps which experience overcrowding and unsanitary conditions that can create dangerous settings for transmission. Health workers are now rolling out a vaccination campaign of 67,000 children in the province where 5,400 cases and 500 deaths due to the disease have been reported. To avoid Ebola infection, measles vaccinators have to wear surgical gowns to protect themselves and hire additional staff to check temperatures, oversee handwashing and refer suspected Ebola cases, putting an additional strain on limited resources.
It is unknown if similar issues are present in North Kivu where the cholera and Ebola outbreaks overlap. Phase 1 of the cholera vaccination campaign occurred in the province in May with approximately 800,000 people vaccinated.
There is also a concern that failing to fully address outbreaks other than Ebola may contribute to mistrust already present in DRC communities, therefore further complicating the Ebola response and other response activities. The MSF emergency coordinator in DRC echoed this statement, saying “it is not possible to gain the trust of the population if you are not addressing all of their key health needs. We need to be looking at not just Ebola but the other things that are killing people.”
With DRC battling Ebola, measles, cholera and malaria all at once, it is more important than ever to step up response activities. Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance best summarized the current situation: “The DRC is confronted with an unprecedented combination of deadly epidemics. While the Ebola outbreak continues to cause untold misery in the East, measles and cholera epidemics are claiming the lives of thousands of people throughout the country. That’s why we are stepping up our response through this cholera vaccination campaign, through ongoing measles vaccinations in health zones affected by measles outbreaks, as well as through our continued support for Ebola vaccinations in both the DRC and neighbouring countries. We cannot allow this needless suffering to continue.” Hopefully, as the international community increasingly draws attention and funding to issues and outbreaks both including and beyond Ebola, we will see a benefit for all responses.
Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.
Photo courtesy of CDC Public Health Image library (https://phil.cdc.gov/Details.aspx?pid=20184)