H5N1

DRC Ebola: Friday night thoughts on the absence of a PHEIC

Today WHO published its Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 14 June 2019. Here's the key passage, with my bolding:

It was the view of the Committee that the outbreak is a health emergency in DRC and the region but does not meet all the three criteria for a PHEIC under the IHR. While the outbreak is an extraordinary event, with risk of international spread, the ongoing response would not be enhanced by formal Temporary Recommendations under the IHR (2005).

A PHEIC declaration in the West African Ebola outbreak had some justification: Two infected Liberians had made it to Lagos, Nigeria, and Dallas, USA. Either case could have triggered serious local outbreaks and further spread. Despite the panicky tweets of Donald Trump and the absurd overreactions of politicians like then-New Jersey governor Chris Christie, American experts contributed greatly to fighting the outbreak at personal cost.

Even more importantly, the Obama administration took its international obligations seriously, throwing a lot of money, health experts, and military people into fighting Ebola on the ground. A similar response from the Trump administration is absurdly unlikely.

 

And in hindsight, much of the international response to West Africa's Ebola was pandemic theatre rather than serious counterattack. Obama sent in military units to build smart new Ebola clinics that never saw a patient.

 

Despite the hard-won expertise of Africans, European and North American health agencies still live in a colonial mindset that expects them to go in to benighted regions and sort out the benighted natives on strictly Western terms. Those terms don't involve saving lives or preventing future recurrences; they involve making us feel good about ourselves.

 

Sure, we learned a little anthropology in West Africa about not violating local cultural attitudes, but the same problems have recurred in the DR Congo, aggravated by the outbreak's occurrence in a zone of chronic violence by armed bands. Evidently we've learned little or nothing since West Africa (and that includes Kinshasa, which seems profoundly unable to understand the northeast provinces of North Kiva and Ituri).

 

So what would a PHEIC accomplish? It sure wouldn't shame Trump into coughing up money or personnel to fight Ebola in a "shithole country" full of black human beings. As it is, the response needs US$98 million to deal with the outbreak, and it's short US$54 million. The European Union, which has ignored the deaths of thousands of African migrants in the Mediterranean, is unlikely to make up the difference.

 

Swarms of Western troops and doctors, descending out of the sky to build and defend new Ebola clinics, would only aggravate the situation in North Kivu and Ituri, providing new targets for Mai Mai militias and the various foreign terrorist organizations operating in the forests and villages along the DRC border. Soldiers, whether UN peacekeepers, African Union forces, or the 82nd Airborne, would deter sick Congolese from going anywhere near a hospital or Ebola treatment centre. More people died in West Africa from malaria, measles, and childbirth complications than from Ebola during the 2013-16 outbreak; they were scared of the whole healthcare system, such as it was. And that was without armed attacks.

 

So a PHEIC would be unlikely to produce a useful Western response. The Congolese, for all their political troubles, know Ebola better than we ever will, and they have been fighting it well with their own skills. The best we can do is to provide some logistic support—vaccines, motorcycles, personal protective equipment, clean water.

 

Such commodities, which we take for granted, are what $54 million could buy. But rich countries like Britain, France, and the US are preoccupied with own internal political problems (Congolese migrants on the Texas border! And in Maine! Build that wall!). We have somehow found the strength to bear the misfortunes of Africa for centuries; the Congolese can't expect us to perform more pandemic theatre unless our governments see some political value in it.

 

Fifty-four million bucks gets laundered through Vancouver in various clever ways every few days. In a multi-trillion-dollar global economy, it's chump change. But the World Health Organization and other health agencies still have to beg for every penny, and every penny has to show a political return on its investment.

 

If a PHEIC can't promise such a return, it would be a waste of effort.

CDC director expects to run out of Ebola vaccine

Via Devex.com: CDC director expects to run out of Ebola vaccine. Excerpt:

WASHINGTON — The director of the Centers for Disease Control and Prevention predicts that responders in the Democratic Republic of the Congo will exhaust the current supply of the Ebola virus vaccine before the pharmaceutical company manufacturing them can produce more.

Robert Redfield, director at CDC, relayed that warning to U.S. lawmakers on Tuesday, just as new reports indicated the number of Ebola virus cases in eastern DRC has climbed past 2,000. While the Ebola vaccine has been helpful in this unprecedentedly difficult response effort, regulatory delays have stalled production of new vaccine stocks, Redfield said in a U.S. House of Representatives hearing.  

“Operationally, this isn’t really going as effectively as we’d like,” he said. “Vaccine supply is limited, and there’s a need to accelerate that supply,” he said. 

There is currently a global stockpile of about 145,000 doses of the vaccine, while roughly 130,000 people in DRC have been vaccinated so far, according to Redfield. That number of vaccinations represents only about 20% of the number of people that responders would like to be able to reach as they move toward broadening their vaccination plans, he said. 

The current approach is to vaccinate people in “rings.” The first ring includes anyone in contact with someone infected with Ebola. The second ring includes anyone in contact with someone in the first ring. 

“We actually want to vaccinate geographic areas where we can’t function because of the insecurity. Unfortunately, there’s going to be a six to 12-month lag before there’s adequate vaccine supply, so we do project that we are going to run out of vaccine,” Redfield said.

The problem is that the current vaccine’s manufacturer, Merck, closed its facility in Pennsylvania where the first lot of vaccines was produced. They have moved the production facility to Germany, but have been unable to secure the necessary validation for those plants that would allow production to proceed, Redfield told lawmakers. 

“We’re just waiting for the validation of the new plants … The clinical efficacy data, safety data is there. It’s just waiting to prove that the plant that’s going to make the vaccine is going to make it in a reliable way,” he said.

NEJM: The ongoing Ebola epidemic in the Democratic Republic of Congo, 2018–2019

Thanks to Greg Folkers for tweeting the link to this important article in NEJM: The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018–2019. The abstract:

The international response to the evolving Ebola epidemic in eastern Democratic Republic of Congo (DRC) has had interim successes while facing ongoing difficulties. The outbreak has occurred in an area of intractable conflict among multiple armed groups at a time of contentious national elections. Despite porous international borders and considerable population movement, however, transmission has been confined to North Kivu and Ituri provinces. 

Factors potentially contributing to this containment include conduct of about 55 million screenings, surveillance of contacts (12,591 under surveillance currently), testing of 280 samples per day, provision of safe and dignified burials for most deaths, vaccination of high-risk people (112,485 vaccinated as of May 7, 2019), and medical treatment including four investigational therapies. 

Major challenges remain. Since late February 2019, a sharp rise in cases and increased transmission have been observed. These coincide with organized attacks by armed groups targeting response teams, deteriorating security, and the population’s increasing distrust of the response effort. The risk of local and regional spread remains high given the high proportion of deaths occurring outside treatment facilities, relatively low proportions of new patients who were known contacts, ongoing nosocomial transmission, and persistent delays in detection and reporting. 

Stopping this epidemic will require the alignment of the principal political and armed groups in eastern DRC in support of the response.

Karin Huster and Justin Healy: Congo’s Ebola epidemic—a failed response and the need for a reset

Via The BMJ blog: Karin Huster and Justin Healy: Congo’s Ebola epidemic—a failed response and the need for a reset. Excerpt:

Nine months into the second largest Ebola outbreak the world has ever seen—the tenth to hit the Democratic Republic of Congo—and the data are brutally clear: whatever we, Ebola responders, have been doing so far has not been working. The Ebola response in North Kivu and Ituri, the two provinces in the DRC currently affected by the epidemic, is failing. Almost every day seems to bring a new record number of cases—many of which end in deaths in the community—and the overall mortality rate remains well over 60%. 

It was not supposed to be this way. After the 2014 west Africa Ebola outbreak there was a determination that such a catastrophe should not be allowed to happen again. UN agencies restructured their emergency response teams, research teams plowed millions of dollars into new pharmaceuticals, and academic journals were full of new insights and understandings into this previously poorly understood disease. 

When the first cases of this outbreak were reported in August 2018, the Congolese government, WHO, the World Bank, and international medical organisations (including MSF) responded quickly, armed with strong financial support, a promising vaccine, new experimental treatments, and a far deeper understanding of Ebola than in 2014. 

Despite this, the response has failed. In the volatile context of North Kivu—a region where armed groups, distrust of government, and socioeconomic injustices violently intersect—the Ebola response has been met with distrust and violent attacks on health workers and health facilities, the most recent being the killing of Dr Richard Mouzoko.  

The social and political dynamics at play in North Kivu are complex, and there is no magic bullet to this crisis. It’s clear that the local community has lost what little trust it had in the ability of national and international organisations to respond to the epidemic, but what’s less evident is the next steps we can take to solve this problem. Based on our experience of working in North Kivu, these are some concrete suggestions of where we could go next.  

Normalising Ebola 

Of all the suspect cases admitted to Ebola centres, only a small minority (less than 10%) of patients end up having the disease, which reinforces the idea that Ebola is not real. Integrating Ebola into the regular system of care would help overturn this perception that these Ebola centres are part of a wider conspiracy against the population. Decentralising the isolation and testing of suspect patients and allowing them to remain at a facility they trust in their community would go a long way in increasing acceptance of the disease. 

However, this can only be successful if we simultaneously re-institute sound triage practices, which isolate and test only those patients who respond to the standardised Ebola case definition. This would ensure that health centres (or Ebola centres) wouldn’t unnecessarily be overwhelmed with false suspect cases held for three days awaiting their results—at risk of getting Ebola, and at risk of not getting the care they need. 

Improving access to diagnostics  

One of the frustrating aspects of working in this epidemic has been the limited access to diagnostics. One of the most significant developments during the 2014 outbreak was the use of GeneXpert machines to improve the turnaround time of tests, but the full potential of this technology has not been reached during this outbreak. The complete oversight of laboratory results by the government, as well as the limited hours of operation of laboratories, has meant unnecessarily long waits for lab results. Delays in sample transportation has meant that patients (or the families of deceased persons) were often kept waiting overnight for a result that should have been available within four hours. 

Humanising Ebola 

One of the characteristics of this epidemic has been the aggressive attitude to finding new suspect cases. There have been reports of patients being forced into Ebola centres by the authorities. This is not only an affront to basic ethical principles, but it is also utterly counterproductive as it promotes anger and distrust amongst the communities we need to partner with.

Canadian scientists create stable, affordable way to transport fragile vaccines

Via The Globe and Mail: Canadian scientists create stable, affordable way to transport fragile vaccines. Excerpt:

A breakthrough by researchers at McMaster University could save lives around the world by making it easier and far cheaper to deliver fragile vaccines for deadly viruses such as Ebola and influenza to remote communities in developing countries.  

The innovation is almost as easy “as stirring milk and sugar into coffee,” said Matthew Miller, an assistant professor in McMaster’s biochemistry department, who was part of the interdisciplinary team that worked on the project. The process involves combining sugars used for other purposes with the drugs, turning the temperature-sensitive vaccine into a lightweight sugary gel that can travel for long periods through harsh climates.  

Globally, nearly 20 million children are vulnerable to preventable diseases because they don’t get vaccines, with one-quarter living in three countries: Afghanistan, Nigeria and Pakistan. 

Transporting and storing vaccines is complicated because they need to be kept at low temperatures to remain viable – a system of constant refrigeration known as the “cold chain.” Warm weather and rough roads don’t just increase the risk the vaccines will fail, they also raise the price tag – in some cases, transportation alone accounts for 80 per cent of the cost of a vaccine program, Dr. Miller said. 

Solar-powered, mini-refrigerators that can travel on the back of camels or wagons, have been one solution, says Vincent Leung, a chemical engineer at McMaster and the lead author of the paper published today in the journal Scientific Reports. But these are expensive and heavy, the units break down and they can only carry so much of the vaccine. 

At McMaster, a team of engineers and infectious-diseases scientists decided to look for a lighter, more travel-friendly solution. They had one already: an edible coating that had been previously created by chemical engineers at the university to extend the shelf life of fruit.  

As researchers discovered, the same two ingredients – a pair of sugars called trehalose and pullulan, which are used to make the jelly coating on breath strips – could do the same for a delicate vaccine. Combine, stir and dry, and their work suggests that a vaccine would be able to travel safely and relatively cheaply in the sugary gel, protected from the heat for months.  

“It is extremely simple,” said Dr. Miller, using the coffee milk-and-sugar analogy. The process, he said, can be easily adopted by any facility that can manufacture vaccines. Upon arrival at the destination, saline water would be added to restore the vaccine to a liquid state so that it can be administered.  

To make sure they were on the right track, the team at McMaster tested their theory with two of the hardest vaccines to transport, one for the herpes virus, and another for influenza A. “This was the extreme end of testing,” Dr. Miller said. “Now that we know it works there, it can be employed with any vaccine.” 

For instance, he said, it could work with the Ebola vaccine created by a lab in Winnipeg, which is difficult to transport to hot spots in remote parts of Africa. Being able to transport vaccines more easily will also help eradicate “smouldering fires” of preventable illnesses such as polio in regions that are difficult to reach.

Struggling with Scale: Ebola’s Lessons for the Next Pandemic

Via ReliefWeb, a report from the Center for Global Development by Jeremy Konyndyk: Struggling with Scale: Ebola’s Lessons for the Next Pandemic. Click or tap through to download the full report. The summary:

The next global pandemic is a matter of when, not if. Preparing for this inevitability requires that policy­makers understand not just the science of limiting dis­ease transmission or engineering a drug, but also the practical challenges of expanding a response strategy to a regional or global level. Achieving success at such scales is largely an issue of operational, strategic, and policy choices—areas of pandemic preparedness that remain underexplored. 

The response to the 2014–2015 Ebola outbreak in West Africa illuminates these challenges and highlights steps toward better preparedness. Ebola was a known disease whose basic transmission pathways and con­trol strategies were understood. Yet traditional Ebola control strategies were premised on small, non-urban outbreaks, and they rapidly proved inadequate as the disease reached urban environments, forcing policy­makers to develop new strategies and operational plat­forms for containing the outbreak, which generated unique policy challenges and political pressures. Lack­ing a blueprint for controlling Ebola at scale, response leaders scrambled to catch up as the disease began threatening the wider West African region. 

This report explores the lessons of the Ebola outbreak through the lens of the US and UN policymakers who were forced to construct an unprecedented response in real time. It tells the story of their choices around four major policy challenges: 

1. Operationalizing the US government response  

2. Balancing the politics and the science of travel restrictions 

3. Defining the role of a reluctant military  

4. Coordinating complex international partnerships 

The report draws on interviews with 19 high-level US and UN policymakers, a desk review of after-action reports, and the author’s own experiences while lead­ing the response efforts of the US Agency for Interna­tional Development (USAID).

Uganda: Refugees in the time of Ebola

Via ReliefWeb, a short report from European Commission's Directorate-General for European Civil Protection and Humanitarian Aid Operations: Uganda - Deterioration of the humanitarian situation (DG ECHO, UN, INGOs, media) (ECHO Daily Flash of 08 May 2019). Like most countries hosting huge numbers of refugees, Uganda is both poor and uncomplaining. 

It's the Europeans, North Americans, and Australians, who can best afford to handle such numbers, who behave like babies "making strange." Babies, after all, have no sense of the wellbeing of anyone but themselves.

Uganda is hosting over 1.2 million refugees, 332,000 of which are from the Democratic Republic of the Congo (DRC). Since January 2019, 16,195 new arrivals were registered. In April, a 33% increase was reported compared to previous month.  

Due to a recent increase in armed attacks since 30 March in Beni (North Kivu), tens of thousands of people were forced to flee their homes. The UN Refugee Agency (UNHCR) anticipates an imminent massive influx of up to 20,000 refugees to Uganda. 

Services for refugees and their host communities are overstretched in Uganda. The 2019 response plan for Congolese refugees in Uganda is only 2% funded. The World Food Programme (WFP) warns of an imminent break to food and cash pipelines. The looming drought could further aggravate the food insecurity of the refugees and their host communities.  

To scale up preparedness efforts for the influx, UNHCR Uganda is calling on international non-governmental organisations and actors to step up their response.

DRC Ebola: 14 new cases, 13 deaths (6 in community/hospital)

The Ministry of Health has a long update today: EBOLA DRC - Evolution of the response to the Ebola outbreak in the provinces of North Kivu and Ituri to Tuesday, April 30, 2019. We could see 1,000 deaths before the end of the week. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Tuesday, April 30, 2019   

The epidemiological situation of the Ebola Virus Disease dated 29 April 2019:   

• Since the beginning of the epidemic, the cumulative number of cases is 1,480, of which 1,414 are confirmed and 66 are probable. In total, there were 970 deaths (904 confirmed and 66 probable) and 412 people cured. 

• 279 suspected cases under investigation; 

• 14 new confirmed cases, including 6 in Katwa, 2 in Musienene, 2 in Butembo, 1 in Mabalako, 1 in Beni, 1 in Kayna and 1 in Kalunguta;  

• 13 new confirmed case deaths, including 

º 6 community / hospital deaths, 2 in Katwa, 2 in Musienene, 1 in Kayna and 1 in Beni; 

º 7 CTE / CT deaths, including 4 in Butembo and 3 in Katwa; 

• 1 new healed from the CTE of Butembo.    

 /! \  The data presented in this table are subject to change later, after extensive investigations and after redistribution of cases and deaths in their health areas.

News of the response   

Establishment of multisectoral Ebola Response Committee 

• Considering the persistence of the Ebola epidemic in the provinces of North Kivu and Ituri and on the instructions of the President of the Republic at the meeting of 27 April 2019, Prime Minister Bruno Tshibala Nzenzhe and the Minister of Health, Dr. Oly Ilunga Kalenga, signed on Tuesday, April 30, 2019, the decree establishing, organizing and operating the multisectoral committee for the response of the Ebola virus disease in the Democratic Republic of Congo. 

• This Committee's mission is to: 

1. Oversee the multi-sectoral response to the current Ebola virus disease in the provinces of North Kivu and Ituri; 

2. Formulate the necessary measures to be taken at government level; 

3. Collaborate with institutions at central, provincial and decentralized territorial entities to prevent the spread of the epidemic;  

4. Propose the allocation of resources needed for the response to end the epidemic;  

5. Ensure an optimal link between the overall response strategy and sectoral policies. 

• The Committee meets once a week and whenever necessary, when convened by its Coordinator. He reports to the President of the Republic, once a week, and keeps him fully informed of the work, interventions and evolution of the epidemic.  

• The Committee is composed of the Prime Minister, who is the Coordinator, the Deputy Prime Minister, Minister of the Interior and Security, the Minister of the Budget, the Minister of Defense, the Minister of Finance, the Minister of Health who is the Secretary of the Committee, the Minister of Communication and Media, the Minister of Humanitarian Action and National Solidarity, the Minister of Social Affairs, and a representative of the Cabinet of the President of the Republic. Each member of the Committee is responsible for the response in their area of ​​activity. 

• Each member of the Committee invites the experts and partners in the work of his sector of activity whenever necessary. These experts and partners will be able to integrate the technical commissions and take part in the work of each sector of activity. 

• As a reminder, for the health pillar of the Ebola response, the Ministry of Health has created nine commissions, each led by a Ministry program or directorate. These nine commissions are:  

1. Surveillance (General Directorate for Disease Control, DGLM) 

2. Port of Entry Surveillance (National Hygiene Program at the Borders, PNHF) 

3. Medical care (National Program of Emergencies and Humanitarian Actions, PNUAH, and the National Institute of Biomedical Research, INRB) 

4. Logistics 

5. Vaccination (Expanded Program on Immunization, PEV, and INRB) 

6. Laboratory (INRB) 

7. Infection Prevention and Control (Health Directorate of the DGLM) 

8. Psychosocial care (National Mental Health Program) 

9. Communication and Community Engagement (National Program for Communication and Health Promotion) 

World Health Organization High-Level Mission in Butembo 

• WHO Director-General Dr Tedros Adhanom Ghebreyesus and WHO Regional Director for Africa Dr Matshidiso Moeti concluded their visit to Butembo on Tuesday, 30 April 2019. This high-level visit took place only ten days after the murder of Dr. Richard Mouzoko, a WHO epidemiologist from Cameroon.  

• Click here to read the WHO communiqué on this mission.

Vaccination

• Since the beginning of vaccination on August 8, 2018, 108,175 people have been vaccinated , including 29,182 in Katwa, 23,177 in Beni, 13,355 in Butembo, 6,973 in Mabalako, 4,862 in Mandima, 3,335 in Kalunguta, 3,070 in Goma, 2,729 in Oicha, 2,699 at Komanda, 1,915 at Vuhovi, 1,889 at Masereka, 1,748 at Kyondo, 1,630 at Kayina, 1,487 at Bunia, 1,357 at Karisimbi, 1,313 at Lubero, 1,047 at Musienene, 1,025 at Biena, 772 at Mutwanga, 690 at Rutshuru, 557 in Rwampara (Ituri), 527 in Nyankunde, 496 in Mangurujipa, 420 in Mambasa, 355 in Tchomia, 342 in Kirotshe, 333 in Lolwa, 254 in Alimbongo, 250 in Mweso, 245 in Kibirizi, 161 in Nyiragongo, 97 in Watsa (Haut-Uélé) and 13 in Kisangani.

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018.

WEEKLY SUMMARY OF EPIDEMIOLOGICAL DATA

Week 17 (April 22-28, 2019)

For the week of April 22-28, 2019, we recorded:

• 1,588 suspected cases investigated and tested in the laboratory

• 126 new confirmed cases :

• The city of Butembo remains the main focus of the epidemic. Together, the two areas of the city, namely Butembo and Katwa, reported half of the new cases (64 cases out of 126, or 50.8%).

• 83 deaths of confirmed cases:

• The town of Butembo is also the main focus of confirmed case fatalities reported last week. The health zones of Butembo and Katwa together reported 53 of the 83 new confirmed case deaths, or 63.9%;

• Of the 83 deaths, 47 were community deaths, or 56.6%, and 36 occurred in an ETC.

• 24 new healed people left the CTE.

Rain grounds Mozambique aid flights as cyclone death toll hits 38

Via Thomson Reuters: Rain grounds Mozambique aid flights as cyclone death toll hits 38. Excerpt:

Rains grounded aid flights in northern Mozambique for a second day on Monday, hampering efforts to reach survivors of Cyclone Kenneth as the death toll there jumped to 38. 

Rescuers managed to use a brief break in the downpours to send one helicopter packed with aid to the island of Ibo, where hundreds of homes were flattened by the second cyclone to hit the country in less than six weeks. 

But rains started again and conditions were too dangerous for the next flight to take off, the United Nations said. Roads to rural districts further north were swamped and impassable after torrential rains on Sunday. 

"Unfortunately the weather conditions are changing too fast and threatening the operation," said Saviano Abreu, a spokesman for the United Nations' humanitarian arm OCHA.  

Cyclone Kenneth slammed into the Comoros and then Mozambique's province of Cabo Delgado on Thursday with storm surges and winds of up to 280 kph - stretching resources in a region still recovering from Cyclone Idai which struck further south in March. 

The storm knocked out power and communications. Some rural communities were reduced to mounds of jumbled wood, with only the occasional structure and coconut tree left standing. 

Four people died in the Comoros, the United Nations said. Mozambique's National Institute of Disaster Management said its death toll stood at 38 on Monday - up from an earlier estimate of five - and just over 168,000 people had been affected. 

After the first hit, heavy rains pounded Mozambique's north, an area prone to floods and landslides. Information about the scale of the flooding in more remote districts remains scant.

Donkeys deliver vaccines in Mali as diseases spike with violence

Via Thomson Reuters: Donkeys deliver vaccines in Mali as diseases spike with violence. Excerpt:

DAKAR, April 17 (Thomson Reuters Foundation) - With spiralling ethnic violence exposing more children in Mali to fatal diseases, health workers are using donkeys and boats to deliver life-saving vaccines, charities said on Wednesday. 

In the central Mopti region - where 157 people died in one attack last month - suspected measles cases rose five-fold in one year to 98 in 2018, U.N. children's agency UNICEF said, due to a four-fold jump in unvaccinated children to 70,000.  

Motorcycles, which health workers used to reach remote villages, have been banned to reduce militant activity, forcing them to use traditional means like horses, it said. 

"The problem of vaccination is directly linked to the current conflict," said Patrick Irenge, medical coordinator for the charity Medecins Sans Frontieres (MSF), which is using cars and boats as mobile clinics to reach cut off communities.  

"If there is a lull in the violence, a small window that opens, we organise a vaccination campaign." 

Last month's massacre was the deadliest to date in a conflict between Dogon hunters and Fulani herders which has displaced tens of thousands of civilians in the West African country since it escalated last year.  

Pneumonia is one of the top killers of children in Mali and it can be prevented with vaccines - as can measles - but it is too dangerous for many parents to venture out with children.