Since December 2017, the province of Ituri in the Democratic Republic of Congo (DRC) has once again been plunged into violence, causing waves of massive population movements towards the safe villages of the Angumu health zone, on the shore of Lake Albert and left bank of the Kakoy River. In February 2019, the emergency team of Médecins Sans Frontières – Operational Center Geneva (MSF-OCG) in DRC carried out an assessment of the humanitarian situation in Angumu health zone and estimated that there were around 29,000 displaced people scattered among host families in the villages and in Internally displaced People (IDP) camps. The under-five mortality rate (U5MR) among IDPs over a 7-month recall period was above the emergency threshold (3.2 deaths per 10,000 persons per day; 95% CI: 2.8–3.6) and the main causes of mortality were respectively malaria (36.6%), anaemia (16.2%) and diarrhoeal diseases (14.9%) (1). To respond to this medical-humanitarian emergency, MSF-OCG has been running the Angumu project since May 2019.
In January 2020, a mortality survey carried out by MSF-OCG showed a crude mortality rate (CMR) above the emergency threshold in the villages and in the IDP camps (respectively 1.53 (95%CI: 1.23–1.82, design effect 4.0) and 1.17 (IC 95% :1.03–1.32, design effect 1.2) deaths/10,000 population/day). The U5MR was also above the emergency threshold in villages with 3.7 (95% CI: 2.61–4.79, design effect 4.4) deaths per 10,000 children per day, and in IDP camps, 3.27 (95% CI: 2.67–3.86, design effect 1.1) deaths per 10,000 children per day. The survey showed that malaria was the main cause of death, particularly among children under 5 years old (2).
Because of its climate, and in particular its rainfall, Angumu is extremely exposed to malaria, which remains present throughout the year. The years 2019 and 2020 have seen the heaviest rainfall for more than a decade. Faced with this dramatic situation, MSF, in collaboration with Ministry of Health (MoH), has increased the population's access to healthcare by supporting eight health centres and setting up 13 community care sites in IDP camps. In addition, impregnated mosquito nets were distributed. However, despite these malaria control interventions, the incidence of malaria remained very high.
In this context of a complex humanitarian crisis, population movement, very high mortality caused by malaria, limited access to care and prevention measures, potentially overcrowded health structures and in the context of the COVID-19 pandemic, the use of mass drug administration (MDA) against malaria was justified in accordance with the recommendations of the World Health Organization (3). The implementation of MDA aims to rapidly reduce malaria mortality and morbidity and has an initial short-term impact. Moreover, by reducing the prevalence of the parasite in the community and among vectors, MDA, if it has good coverage and is carried out synchronously, can, in conjunction with preventive and curative actions, have a longer-term impact due to reduction in transmission level (4).
MDA campaign was launched in September 2020 by MSF and MoH. The whole population living in the villages and IDP camps of 4 health areas (HA), namely Ugudo-Zii, Lanyi and Panyandong and Anzika (Fig. 1), were targeted by three MDA rounds (2 rounds of Artesunate-Amodiaquine (ASAQ) and 1 round of Artesunate-Pyronaridine (Pyramax®)). The door-to-door distribution started in September and ended in December for 3 HA and in January in Anzika HA. All people in the targeted areas were eligible for MDA except children under 2 months of age, pregnant women in the first trimester of pregnancy, severely ill people and those who had taken malaria treatment in the 15 days prior to the distribution.
This was the first MDA for malaria conducted in high malaria prevalence area outside of an Ebola context, in a context of complex emergency and in the midst of Covid-19 pandemic. To document feasibility of the implementation and potential impact, the implementational teams collected routine mass campaign indicators, including monitoring of adverse events; routinely collected malaria morbidity data from the health facilities in areas targeted and not-targeted by MDA were analysed, and a retrospective population-based survey was conducted (Fig. 2). This paper focuses on the survey, for which the main objective was to describe the short-term effect of MDA in Angumu health zone by comparing mortality and morbidity between HAs targeted or not for the MDA, and before and after the MDA took place.