URGEPI - improving measles prevention and control in the Democratic Republic of Congo
Measles epidemics occur frequently in the DRC and remain a major cause of mortality and morbidity among children. To tackle these epidemics, MSF is deploying a risk-targeted response project in the Katanga region of the Democratic Republic of Congo.
The project was initiated in 2018 by MSF in collaboration with the local MoH to improve prevention and response strategies to measles epidemics in 4 provinces of the Democratic Republic of Congo (DRC) Grand-Katanga Region (Haut Katanga, Haut Lomami, Lualaba, Tanganyika). The project includes an operational component (led by MSF) and surveillance and research components (led by Epicentre) and focuses on the following areas:
- Surveillance strategies: we have implemented an efficient surveillance system in collaboration with the local MoH that allows early detection of outbreaks in need of interventions. As part of this system, we identify outbreaks in need of interventions based on threshold systems, and we developed a decision tool to prioritize outbreaks for interventions.
- Targeted prevention activities: we conduct preventive vaccination activities in identified high-risk health zones (= health zones at high risk of large epidemics).
- Laboratory confirmation: is required for the MoH to initiate reactive vaccination activities; MSF is supporting surveillance activities in the laboratory in Lubumbashi and shipment of samples where necessary.
- Interventions: including case management and vaccination activities.
The project also includes an operational research component to improve the components listed above.
Partenaires
- Ministry of health, DRC
The main findings of the project
Development of measles vaccination strategies tailored to the local context
Methods
Between 2024 and 2025, Urgepi conducted research projects in four HZ. Vaccination interventions were preceded by baseline vaccination coverage surveys (VCS) and mixed-methods studies, which informed health promotion and vaccination strategies. Post-vaccination VCS were conducted immediately after the campaigns to evaluate their impact. National surveillance data were also analysed to assess the long-term effects of the interventions.
Results
Baseline VCS revealed low vaccination coverage across the four HZ, with substantial heterogeneity within each HZ. Mixed-methods studies identified barriers to vaccination at the community, healthcare system, and structural levels. VCS enabled the identification of areas at highest risk for outbreaks, which were subsequently prioritized for vaccination activities, while qualitative findings informed the development of context-specific messages and community engagement strategies. Post-vaccination VCS demonstrated substantial increases in vaccination coverage after the campaigns. In the longer term, vaccination in response to an outbreak effectively halted the outbreak, while preventive vaccination resulted in a reduced number of cases but did not completely prevent outbreaks.
Conclusion
Pre-vaccination research enabled better adaptation of conventional vaccination strategies and strengthened health promotion and community engagement activities through the involvement of multiple stakeholders including parents, community leaders and healthcare workers. However, implementation remained challenging, particularly in moving beyond conventional vaccination practices. Simulation exercises and operationalizable research procedures could help improve implementation. Some of the barriers remains outside the scope of MSF interventions.
Lessons learned from the project, 2021-2022
The Urgepi strategy uses a risk- targeted approach, where more resources are located towards geographic areas at higher risk of large epidemics. As part of the project we previously developed and tested outbreak identification systems, as well as vaccination allocation prioritization approaches. Large parts of the technical proposal are based on the experience gained during the Urgepi project.
Here we capitalize on two of the epidemiological activities that took place before and during a large-scale epidemic in 2021/22: (i) the identification of high-risk health zones (HZ) for preventive activities and enhanced surveillance, and (ii) the prioritization of alerts for interventions.
Methods
To evaluate the selection of high-risk HZ in 2021/22, as well as potential alternative selection approaches, we compared outbreak sizes by risk category based on national surveillance data and evaluated preventive vaccination activities in 9 selected high-risk HZ. We further evaluated the alert scoring algorithm by comparing outbreak sizes by alert score and assessed final operational decisions guided by the score.
Results
Although, the initial selection of high-risk HZ in 2021 allowed the identification of HZ with large epidemics, choosing all HZ with coverage below 40% seems to be the most efficient approach. While a third (3/9) of HZ with preventive vaccination experienced a large epidemic, the proportion was 90% (9/10) among high-risk HZ without preventive/early vaccination. Regarding the evaluation of the alert scoring algorithm, the median size of epidemics and the risk of large epidemics increased with an increasing alert score. Median epidemic durations were shorter in HZ with MSF interventions than in HZ with non-MSF vaccination campaigns or HZ without any vaccination campaigns.
Conclusion
Selecting HZ with low vaccination coverage may be a simple efficient alternative to the current model-based strategy to identify high-risk HZ. The targeted implementing of preventive vaccination probably averted large epidemics in 6 of the 9 vaccinated HZ. The alert scoring algorithm allowed efficient operational decision making during the epidemic in 2021/22, resulting in shorter epidemics in HZ with MSF interventions.
