Measles crisis in Africa amidst the COVID‐19 pandemic: Delayed measles vaccine administration may cause a measles outbreak in Africa

Even though a vaccine is available, measles still poses a risk in many parts of the world,1, 2 including Africa.3 The disease is caused by a highly contagious virus that spreads from person to person via airborne transmission including breathing, coughing, and sneezing. Among other symptoms, infected individuals often experience rash, high fever, cough, runny rose, and irritated red, watery eyes. Contagious people can spread the disease up to 4 days before and 4 days after the presence of a rash, with the highest infectivity during symptomatic stages involving fever, cough, and runny nose. Sadly, measles can lead to serious health complications, such as pneumonia and even death.3 Though measles is highly preventable through vaccination, the emergence of the coronavirus disease 2019 (COVID-19) pandemic has provoked countries to shift attention away from standard healthcare leading to neglect of routine immunization plans for major infectious diseases. When the COVID-19 pandemic was first declared in February 2020 in Africa, governments moved on to impose stringent measures to curb the spread of COVID-19. Most of these policy actions primarily focused on limiting COVID-19-related cases and deaths with insufficient attention to the larger indirect impacts of the pandemic, as evident with the lack of appropriate response measures across other health needs.4 Among the visible consequences of such measures is the increase in the number of reported measles cases in countries such as the Democratic Republic of Congo (DRC), Nigeria, Central African Republic, and many others.3 Reduced attention to routine non-COVID-19 vaccination protocol has ignited fear among many health experts, as a continuation of such laxity in vaccination administration may harmfully progress to increased risk of developing measles outbreaks in different countries and to potential loss of many lives. As African countries continue to record confirmed cases of COVID-19, disease outcomes still remain variable with disparities in the numbers of active cases, recoveries, and mortalities. Of luck, the death toll in Africa is not as severe as in other continents. Nevertheless, the less developed healthcare systems in Africa have uncovered difficulties in obtaining healthcare equipment, funding, and workforce training in addition to supporting standard health programs including routine immunizations.5 Underfunding and negligence to healthcare systems in Africa have significantly contributed to the extreme challenges across the World Health Organization (WHO) six pillars of effective service delivery.6 Human resources are inadequate, and countries’ budgetary allocation still falls under the agreed Abuja declaration of 15%. The emergence of the COVID-19 pandemic has further exposed the weaknesses of such health systems. The COVID-19 catastrophe has revealed the unpreparedness of most health sectors to adequately respond to such major outbreaks. As a result of governments directing attention toward the fight against the COVID-19 pandemic, most routine programs are either being suspended or postponed. Specifically, in a preliminary examination of 14 countries assessing the five key essential health service indicators of outpatient consultation, inpatient admission, skilled birth attendance, treatment of confirmed malaria cases, and provision of the combination pentavalent vaccine, WHO noted a drastic decline in these measures between January and September 2020 as compared with the 2 previous years.7 The gaps were markedly widest in May, June, and July of 2020, corresponding to when many countries had put in place and enforced movement restrictions and other social and public health safety measures to check the spread of COVID-19. During these 3 months in particular, services in the five monitored areas dropped on average by more than 50% in the 14 countries in comparison to the same time period in 2019.7 Routine immunization against major infectious diseases of children under 5 years of age has also been heavily affected in most African countries. About 1.37 million children across the African region missed the Bacillus Calmette–Guerin (BCG) vaccine and an additional 1.32 million children under 1 year old did not receive the first dose of the measles vaccine between January and August 2020 as compared with vaccine administration during the same time interval in 2019.7 Immunization campaigns covering measles, yellow fever, polio, and other diseases were postponed in at least 15 African countries in 2020 when the COVID-19 pandemic struck.8 Measles, Bird flu, Malaria, and Ebola outbreaks are among the recent outbreaks that occurred in some African countries.3, 9-11 The introduction of new vaccines has been halted and several countries have reported running out of vaccine stocks. Such laxity in adherence to routine immunization programs is a threat to the resurgence of a vaccine-preventable outbreak of highly contagious diseases such as measles. To have measles eliminated, countries need to maintain a high vaccination coverage percentage.12 WHO-UNICEF estimates of immunization reporting show that global coverage of the first dose of measles vaccine has stabilized at 85% from 2015 to 2019. In 2000, 17 countries in the WHO African and Eastern Mediterranean regions had measles vaccine coverage below 50%, and although all increased coverage to a median of 60% by 2019, percentages remained far below levels needed for elimination.7 Importantly, this percentage still remains low for most African countries, and due to the COVID-19 pandemic, the situation has worsened as most countries have seen an amplified number of measles cases. For instance, countries such as DRC have witnessed an upsurge of measles with more than 13,000 cases reported since January 2021.8 Health officials also fear that a number of African countries could experience an outbreak of measles following interrupted administration of vaccination against this very infectious disease.12, 13 In 2020, only eleven countries in Africa reached the target surveillance level to track measles, demonstrating a sharp fall in monitoring measles to its lowest point in the past 7 years.14 The recent rise in measles cases may be attributed to the inattention afforded to routine immunization programs as a result of the COVID-19 crisis.15 If such negative trends continue, other vaccine-preventable diseases may see a noticeable escalation in the coming future. As the fight against the COVID-19 pandemic continues, health systems need to enhance attentiveness and resources to essential medical services including life-saving vaccination facilities. Governments need to invest more in their health system and establish suitable preparedness plans against major disease outbreaks. Additionally, it is worthwhile to promote outreach and community-based engagement through local, cultural, religious leaders and community health workers and enable risk communication in local languages to rapidly encourage citizens to participate in measles vaccination programs. The overlapping crisis of the COVID-19 pandemic should be seen not only as a challenge but also as an opportunity for countries across Africa to strengthen their healthcare system and to create robust immunization programs that can efficiently and effectively run, regardless of any catastrophe. We have not received any financial support for this manuscript. All the authors declare that there are no conflicts of interest. Olivier Uwishema: Conceptualization, Project administration, Writing-review, and Designing. Tania Torbati: Reviewed, edited the first draft, and made critical comments. Helen Onyeaka: Reviewed and edited the second draft. Manuscript writing: Olivier Uwishema and Lubanga Focus Adriano. Final approval of manuscript: All authors.