Measles is endemic in Ethiopia, with cases reported every year. Between 12 August 2021 and 1 May 2023, 16 814 laboratory-confirmed Measles cases and 182 deaths, a Case Fatality Ratio of 1.1%, have been reported nationally. From 2021, the annual number of confirmed measles cases has increased significantly, from 1953 in 2021 to 9291 in 2022 and 6933 in 2023 as of 1 May, according to a press release issued by the World Health Organization on 4 May 2023. Thus, there was, an almost five-fold increase in confirmed measles cases between 2021 and 2022. Low population immunity, combined with concurrent epidemics, conflict, forced displacement, and other humanitarian crises that disrupt childhood vaccinations, are some factors that may explain the increases.
Measles is a highly contagious disease caused by Measles Virus and it is normally passed through direct contact and through the air. The Viirus infects the respiratory tract, then spreads throughout the body. It can lead to major epidemics with significant illness and death, especially among vulnerable people, such as young children. In 2022, 45% of all cases were children under 5 years of age.
There is no specific antiviral treatment for Measles, but an effective and safe vaccine is available for prevention and control. A 95% population vaccination coverage is required to stop Measles circulation.
Since 12 August 2021, all 13 Regional Health Bureaus in Ethiopia have received reports of suspected Measles cases in either host communities, displaced populations, or refugees. Since then, and as of 1 May 2023, 16 814 laboratory-confirmed measles cases and 182 deaths, with a Case Fatality Ratio of 1.1% have been reported nationally.
There are active Measles outbreaks reported in 44 woredas/districts from eight regions: Afar, Amhara, Harari, Oromia, Southern Nations, Nationalities and Peoples Region, South West Ethiopia Peoples’ Region, Tigray and Somali. The number of Measles-affected woredas was 52 (5% of the country’s 1080 woredas) in 2021 and 125 (12%) in 2022.
Between 1 January to 2 April 2023, the Somali region reported 56 laboratory-confirmed and 364 epidemiologically linked Measles cases. In 2022, the nationwide Measles incidence rate was 82 cases per one million population. The highest reported rates were in the Somali region, which reported 540 cases per one million population. The lack of reporting associated with the crisis in Northern Ethiopia (Tigray) hampers an adequate assessment of the Measles situation.
Amongst the confirmed Measles cases, only 36% have received one dose or more of the measles-containing vaccine. According to World Health Organization and UNICEF Estimates of National Immunization Coverage low population immunity (Measles-containing vaccine first dose and Measles-containing vaccine second dose coverage in 2021 was estimated at 54% and 46% respectively), combined with concurrent epidemics, conflict, forced displacement, and other humanitarian crises that disrupt childhood vaccinations, are some of the risk factors identified for the increased spread of the disease. Furthermore, cultural beliefs, insufficient awareness, and behavioral characteristics can be a barrier to seeking early treatment and making use of other management strategies for disease management.
Ethiopia faces various challenges that could exacerbate the situation further, including high rates of malnutrition (nutritional screening during Measles supplemental immunization activity showed that 0.6% of children had severe acute malnutrition 4.7% had global acute malnutrition based on over 15 000 children screened) and, a lack of access to health care in conflict-affected areas increasing the risk of severe disease, displacement and crowded conditions poor hygiene and sanitation access and practices increasing the risk of interpersonal spread. According to the latest predictions by the Intergovernmental Authority on Development Climate Prediction and Applications Centre and National Meteorological and Hydrological Services, certain regions affected by drought, such as Southern Nations, Nationalities and Peoples Region, Oromia, Somali, Afar, and South West Ethiopia Peoples’ Region, have also reported floods, and around 1.7 million people are at risk of flooding, according to preparedness plans, further risking displacement, disruption of vaccination, and a risk of having people move to crowded settlements increasing the risk of Measles circulation.
Measles is caused by a Virus in the Paramyxovirus family. The Virus infects the respiratory tract, then spreads throughout the body. Measles is a human disease and is not known to occur in Animals. It can lead to major epidemics with significant morbidity and mortality, especially among vulnerable people. Among young and malnourished children, pregnant women, and immunocompromised individuals, including those with HIV, cancer or treated with immunosuppressives, Measles can cause serious complications, including ear infection, severe diarrhoea, blindness, encephalitis, pneumonia, and death.
Transmission is primarily person-to-person by airborne respiratory droplets that disperse rapidly when an infected person coughs or sneezes. Transmission can also occur through direct contact with infected secretions. Transmission from asymptomatic exposed immune persons has not been demonstrated. The Virus remains active and contagious in the air or on infected surfaces for up to two hours. A patient is infectious from four days before the start of the characteristic morbilliform rash, to four or five days after its appearance. There is no specific antiviral treatment for Measles; most people recover within 2-3 weeks.
An effective and safe vaccine is available for prevention and control. The Measles-containing vaccine’s first dose is given at nine months, while the second dose of the Measles-containing second dose is given at the age of 15 months. A 95% population coverage of both doses is required to stop Measles circulation.
In areas with low vaccination coverage, epidemics typically occur every two to three years and usually last between two and three months. However, their duration varies according to population size, crowding, and the population’s immunity status.
Nationwide measles-preventive supplemental immunization activities have been conducted in Ethiopia from 22-31 December 2022, in all areas except those affected by conflict (all woredas in Tigray, 12 districts in Oromia, and seven in Benishangul Gumuz). A total of 14 579 818 under 5 children were vaccinated out of a target of 15 471 740 resulting in 94.2% coverage. Starting in February 2022, a catch-up Measles vaccination campaign was launched, targeting children aged 9 to 23 months. This campaign was conducted in 55 woredas that are high-risk or have been affected by conflict in the Amhara, Oromia, Southern Nations, Nationalities and Peoples Region, and Somali Regions. The campaign was integrated with vitamin A supplementation and other routine immunization efforts.
There are several challenges that Ethiopia is facing in its efforts to increase national childhood vaccination coverage: conflict, population movement, and an insufficient stock of vaccines at the national level. These challenges are expected to fuel outbreaks and increase the number of cases.
The overall risk at the national level in Ethiopia is assessed as high due to the following factors: (1) Active outbreaks as of 1 May 2023 in 44 woredas in 8 out of 13 regions: Afar, Amhara, Harari Oromia, Southern Nations, Nationalities and Peoples Region, South West Ethiopia Peoples’ Region, Tigray, and Somali; (2) sub-optimal immunization coverage and low population immunity; (3) weak surveillance systems result in late detection of cases and inadequate outbreak investigations, especially at the community level. Furthermore, active surveillance is inconsistently implemented, likely resulting in under-reporting of cases and deaths; (4) poor health awareness in the affected community, resulting in inadequate health promotion and poor healthcare-seeking behavior; (5) inadequate case management skills in handling complicated cases, further exacerbated by referral challenges associated with lack of transportation especially for patients from remote areas; (6) concurrent disease outbreaks (for example, Cholera, Pertussis, Poliovirus) have limited the overall capacity and resources to respond to measles transmission; (7) concurrent complex humanitarian situations from widespread conflict, displacement, and severe and prolonged drought; (8) ifficulty accessing and delivering supplies due to the poor road network and insecurity in western parts of Oromia, Benishangul Gumuz, Tigray, Afar, and Amhara; and (9) the impact of the COVID-19 pandemic on the health system.
The World Health Organization recommends that Ethiopia implements key public health strategies to reduce disease burden and transmission include routine vaccination of children against measles, combined with periodic intensification of routine immunization activities and mass immunization campaigns in countries with high morbidity and mortality rates.
There is no specific treatment for Measles. Case management of Measles focuses on supportive care as well as the prevention and treatment of measles complications and secondary infections. Since Measles is highly contagious, patient isolation is important to prevent the further spread of the Virus.
Oral rehydration salts should be used as needed to prevent dehydration. All children diagnosed with Measles should receive two doses of vitamin A oral supplements, given 24 hours apart, irrespective of the timing of previous doses of vitamin A; 50 000 international units should be given to infants aged under 6 months, 100 000 international units to infants aged 6-11 months and 200 000 international units to children aged 12 months. This treatment restores low vitamin A levels in acute Measles cases that occur even in well-nourished children and can help prevent eye damage and blindness. Vitamin A supplements have also been shown to reduce the number of Measles deaths.
Nutritional support is recommended to reduce the risk of malnutrition due to diarrhoea, vomiting and poor appetite associated with Measles. Breastfeeding should be encouraged where appropriate.
In unimmunized or insufficiently immunized individuals, the Measles vaccine may be administered within 72 hours of exposure to the Measles Virus to protect against disease. If the disease does subsequently develop, symptoms are usually less severe, and the duration of illness may be shortened.
The World Health Organization does not recommend any restrictions on travel or trade to or from Ethiopia.
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