As of May 19, 2020, Burundi has reported 42 cases of COVID-19 and one death from the disesase, compared with 63 521 cases and 1796 deaths reported across Africa by WHO. Burundi had its presidential election on May 20, and before the election, the foreign ministry asked WHO representatives—who had reportedly expressed concerns over crowded rallies held by politicians—to leave the country, with no explanation provided. Media reports claim that authorities in Burundi have underestimated the risks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and relied on divine protection, instead of adopting specific health measures to contain the pandemic.
However, while Burundi's preparedness and response to SARS-CoV-2 sparks controversy, the country's management of an already ongoing measles outbreak has caused concern among virologists, paediatricians, and public health experts. A WHO statement released on May 6, 2020, reports the measles outbreak started November, 2019, with 857 confirmed cases from Burundi's districts Cibitoke, Butezi, Cankuzo and South Bujumbura, as of April 27, 2020. The outbreak began in a refugee transit camp in the Cibitoke health district, where refugees from measles-affected provinces in DR Congo remained for 21 days, before moving to permanent refugee camps in locations including Butezi, Cankuzo, Muyinga, and Kiremba. The outbreak was only recognised when people living in areas surrounding the refugee transit camp reported suspected measles cases, mainly in children aged 9 months to 5 years. WHO's report states: “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”.
Oyewale Tomori, a professor of virology and former president of the Nigerian Academy of Science agrees with this explanation. “This [measles] outbreak predates the COVID-19 outbreak either in Wuhan or in any part of Africa. It is clear that unvaccinated or inadequately vaccinated refugee children are the source of the outbreak in a poorly vaccinated Burundi population”, he told The Lancet Microbe. He added, “It is obvious that there is also a lack of preparedness [in Burundi] to fight the measles outbreak”.
According to Andrew Noymer, an associate professor of Public Health at the University of California, Irvine (CA, USA), an outbreak of measles is unsurprising where vaccination rates have fallen below about 95%. WHO's statement estimates the vaccination coverage for measles in Burundi, in 2018, to be 88% for the first dose and 77% for the second dose, although these figures do not include data for incoming refugees. “This measles outbreak [in Burundi] is a stark reminder that—even during the COVID-19 pandemic—public health challenges that existed before, have not gone away”, Noymer told The Lancet Microbe. As he pointed out, measles control requires continued vaccination programmes, catch-up campaigns, or both. “[It's] a challenging disease, requiring constant attention from public health authorities”, he comments.
Charles Holmes (Center for Global Health Practice and Impact, Georgetown University Medical Center, Georgetown, WA, USA) told The Lancet Microbe that the estimated case-fatality rate for measles in low-income and middle-income countries is approximately 2%. In Burundi, he notes, the mortality rate for measles would probably be much higher “because of high rates of malnourishment, vitamin A deficiency, and HIV/AIDS—all of which increase the risk of severe complications from measles”. With respect to COVID-19, Holmes believes that, for Burundian children, the risk of severe disease and death from measles is far higher. “And unlike with COVID-19, we have an affordable, effective vaccine [for measles] that could prevent these deaths”, he added. Anish Ray, a paediatrician at the Cook Children's Medical Center (Fort Worth, TX, USA) agrees with the views of Holmes. “COVID-19 and measles—both are communicable diseases, but, measles has a safe and effective vaccine, and there is no vaccine against COVID-19, yet. Burundian children now require proper vaccination coverage for measles and a thoroughly planned approach designed by the country's health authorities, WHO, and other organizations—to tackle the current outbreak”, he told The Lancet Microbe.
According to WHO's report, Burundi's Ministry of Public Health— in partnership with international organisations including WHO, UNICEF, and Médecins Sans Frontières—has devised a comprehensive response plan to the measles outbreak, including the formation a technical committee to monitor its implementation. The plan also includes vaccinating children aged 9 months to 14 years at refugee camps, setting up a vaccination post at the refugee transit camp, strengthening surveillance at affected districts, mobilising financial resources, building health-care provider capacity, and actively searching and vaccinating unvaccinated children. As Noymer points out, the measles epidemic is an indication that a vaccination campaign is required in the most affected provinces and, possibly, nation-wide in Burundi. “The COVID-19 pandemic is serious but neglecting other fatal health conditions during this time would be a mistake”, he points out.
© 2020 Monusco/Abel Kavanagh CC BY-SA 2.0
For cases and deaths in WHO's Africa region see https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200519-covid-19-sitrep-120.pdf?sfvrsn=515cabfb_2
For more on WHO's representatives' expulsion from Burundi see https://time.com/5836654/burundi-who-expulsion-election-coronavirus/
For WHO's statement on the measles outbreak in Burundi see https://www.who.int/csr/don/06-may-2020-measles-burundi/en/