Every two to three years, measles outbreaks affect hundreds of thousands of children in Democratic Republic of Congo (DRC).

Last year was no exception, with more than 148,600 cases and 1,800 deaths reported. How can this recurring emergency be explained? And, more importantly, how can we put an end to it?

"We have five emergency teams mobilized almost around the clock to respond to the various measles outbreaks throughout the country,” says Dr Louis Massing, MSF’s medical team lead in DRC.  

“But as soon as we put out a fire here, it flares up on the other side. In 2022, we carried out 45 measles-related emergency interventions; that’s more than three-quarters of our emergency response in DRC.”

The largest measles outbreak ever documented in DRC occurred between 2018 and 2020. At that time, nearly 460,000 children contracted the disease, and 8,000 of them died.

Large-scale vaccination campaigns had been organized by the health authorities, supported by international partners such as Médecins Sans Frontières / Doctors Without Borders (MSF), enabling the number of cases to be drastically reduced by 2021.

"But last year, nearly half of the country's health zones were once again in an epidemic situation,” says Dr Massing.

“And it’s not over. In January 2023 alone, close to 20,000 suspect cases of measles have been notified in DRC and our teams have already responded to measles outbreaks in Tshopo, Maniema, South Kivu, North Kivu, Lomami and Lualaba provinces.”

“There can be no weak links”

Measles is one of the most contagious disease in the world. Fortunately, a vaccine exists and offers almost complete protection when a person is inoculated twice.

Since a person carrying the virus can infect up to 90 percent of the unvaccinated people around them, ensuring maximum vaccination coverage is vital. This requires massive investments in routine vaccination, surveillance and catch-up campaigns.

“The fight against measles is like a chain around the virus: if one link is broken, the virus can escape,” says Dr Massing.

“First, the country must ensure that sufficient quantities of vaccine are available to avoid stock-outs at health facilities.

Unfortunately, many elements of that chain are weak in DRC, and this situation is further aggravated by security constraints, geographic challenges to reach many areas, and the country’s high birth rate, with over 2 million babies born every year who need to be protected from the disease.  

As a result, despite emergency campaigns conducted during each outbreak, immunization coverage remains insufficient. While coverage estimates can vary widely from one source to another, the latest estimates from UNICEF and the World Health Organization (WHO) indicate that by 2021, only 55 percent of children were covered by one dose of measles vaccine.

A minimum coverage of 95 percent with two doses is recommended to prevent the spread of the disease.

“Some areas can only be reached by dugout canoe, or even on foot through the forest," says Alexis Mpesha, logistics manager for one of MSF's emergency teams in DRC.

"It is not uncommon for our teams to be the only ones to reach certain villages because the local health authorities do not have the equipment, fuel or human resources to get there.”

For parents wishing to have their children vaccinated, the distance to a functioning health centre, transportation costs and sometimes consultation fees can be discouraging.

"Care is expensive and our resources are limited," says Anne Epalu, a native of Bangabola village, where MSF responded to a measles outbreak in 2022. "Some children die just because their parents don't have money to pay for treatment."

Boosting immunization is urgently needed

In 2022, MSF emergency teams in DRC vaccinated more than 2 million children in 14 provinces and treated over 37,000 patients with measles.

MSF teams deploy in support of the Ministry of Health to organise vaccination campaigns and set up treatment units when a rapid increase in measles cases is reported in an area and local response capacity is limited or access is difficult.

As well as emergency interventions during outbreaks, MSF also provides logistical support for routine vaccination activities in health facilities in several provinces where our teams are present throughout the year.

But much greater efforts and investments are needed from the health authorities and their partners to increase immunization coverage in DRC and stop the endless cycle of epidemics.

"The implementation of the second dose in routine measles immunization activities needs to be accelerated," says Dr Louis Massing.

"This approach was recently adopted by the authorities and can make a real difference. Offering systematic catch-up vaccination activities during pediatric consultations in health facilities could also help increase significantly the immunization coverage in DRC.”

In the meantime, given the persistence of outbreaks in the country, which put more children at risk every day, it is essential to organize the mass catch-up vaccination campaigns that have been planned since the end of 2022 without delay throughout the country.