Burundi has been experiencing an increase in the number of confirmed cases of measles since November 2019. This outbreak initially started in a refugee transit camp (Centre de transit de Cishemere, Cibitoke Health district), whose inhabitants had arrived from measles-affected provinces of the Democratic Republic of Congo. Refugees spend 21 days in the Transit Camp of Cishemere before they are sent to permanent camps in Nyankanda and Bwagiriza refugee camps in Butezi, Kavumu camp of Cankuzo, Garsowe camp of Muyinga and Mulumba camp at Kiremba.
The outbreak was identified when suspected measles cases had been reported by the local residents in the surrounding areas, highlighting pockets of under-vaccinated populations. According to WHO/UNICEF 2018 estimates, measles first dose vaccination coverage is relatively high (88%), and slightly lower for the second dose (77%). However, this does not reflect the vaccination coverage of incoming refugees.
As of 27 April 2020, 857 confirmed measles cases have been notified from four districts, including: Cibitoke (624 cases), Butezi (221 cases), Cankuzo (6 cases) and South Bujumbura (6 cases). Of the measles cases in Cibitoke, 601 cases were epidemiologically linked, 20 cases were laboratory confirmed, and three were clinically diagnosed. In Butezi district, 27 were laboratory confirmed, 192 were epidemiologically linked, and two were clinically diagnosed. In Cankuzo, all six cases were laboratory-confirmed, whereas in the district of South Bujumbura three were laboratory confirmed and three were epidemiologically linked. Children aged 9 to 59 months were the most affected age group, with 80% of cases in children aged 9 years or younger.
Table 1. Distribution of confirmed cases of measles by age and sex
No new cases have been reported in South district of Bujumbura and Cankuzo since December 2019. The last cases were reported in Butezi on 2 March 2020.
The outbreak in Cibitoke is ongoing. The last case in the Transit camp of Cishemere was reported on 14 January 2020). Globally, the total cases reported in Cishemere Transit Camp and Cibitoke health district are 67 and 557 respectively.
Measles circulation in a population with low immunity is the cause of this outbreak. The majority of cases (77%) were either unvaccinated or unsure of their vaccination status.
Public health response
The Ministry of Public Health of Burundi, with partners including WHO, UNICEF, Doctors Without Borders (MSF) and Gruppo di Volontariato Civile (GVC), have developed a comprehensive measles outbreak response plan which includes the following public health measures:
- Establishment of a technical committee responsible for developing and monitoring the implementation of the plan, under the chairmanship of the Director-General of Health Services and the Fight against AIDS;
- Vaccination response by targeting children aged 9 months to 14 years in the camps including Cishemere transit center in Cibitoke, Nyankanda and Bwagiriza refugee camps in Butezi; and Kavumu camp of Cankuzo;
- Strengthening the vaccination program for children in refugee camps and affected districts with the establishment of a vaccination post at the Cishemere refugee transit camp;
- Strengthening surveillance in the affected health districts with an emphasis on active case finding extended to all the districts sheltering the refugee’s camps of Garsowe (Muyinga) and Mulumba (Kiremba).
- Resource mobilization is underway to finance the national response plan, validated by the Ministry of Public Health and Fight against AIDS;
- Capacity building of health care providers on case management and surveillance;
- With support of community health workers, active search, and vaccination of children who are not previously vaccinated with a first and second dose of measles-containing-vaccine (MCV).
WHO risk assessment
WHO estimates that the current measles epidemic represents a high risk for Burundi for the following reasons:
- Increase in the number of cases reported since November 2019;
- The epidemic is spreading from refugee camps to the community;
- The lack of infrastructure, insufficient inputs and resources to ensure free care and staff capable of ensuring clinical management of complications of measles infection;
- Suboptimal immunization coverage- 88% for MCV 1 and 77% for MCV 2 (according to the 2018 WHO / UNICEF joint estimate);
- Large population movements between localities and concomitant measles epidemics in the neighbouring Democratic Republic of Congo.
In addition to low immunity, gaps in measles-rubella surveillance in the country, confirmed by the 2019 measles risk analysis, showed that 63% of districts (29/46 health districts) were at high risk, including 13 districts at very high-risk of measles outbreak. This shows that the country’s surveillance system might not be able to detect outbreaks of measles if it is not strengthened.
WHO advice
Measles is a vaccine-preventable disease and two doses of MCV are recommended to ensure immunity. Conducting targeted reactive vaccination campaigns and strengthening routine vaccination are essential for effective control of the epidemic. The administration of Vitamin A, particularly in the context of malnutrition, can reduce morbidity and mortality from measles.
WHO urges all Member States to:
- Ensure routine measles vaccination for children combined with mass immunization campaigns in countries with high case and death rates to reduce deaths due to measles.
- Achieve and maintain at least 95% coverage with the first and second doses of MCV.
- Vaccinate at-risk populations, including refugees, internally displaced persons, young children, pregnant women, health workers, people working in tourism and transportation and international travellers.
- Strengthen epidemiological surveillance of fever and rash cases for timely detection of all suspected cases of measles in public and private healthcare facilities and ensure that samples are promptly received by laboratories.
- Ensure vitamin A is integrated into the response, in line with recent WHO guidelines.
WHO does not recommend any restriction on travel and trade to the Burundi based on the information available on the current outbreak.
