Routine healthcare has been severely disrupted in communities hit hardest by Ebola in Congo, where fear of infection and pressure on hospitals are stymieing pediatric immunizations and discouraging patients from seeking maternity and other basic care.

Use of seven essential health services fell 42% between April and June in four major Ebola hotspots in Ituri province, the outbreak’s epicenter, according to an analysis published by ACAPS, an independent humanitarian research group. Childhood vaccination in the same areas fell by more than half.

The disruption points to a widening toll from an epidemic that has already grown to more than twice the size of Congo’s previous biggest Ebola outbreak — and spread through more than twice as many health zones. The Central African nation reported 8,067 confirmed cases across 63 health zones in seven provinces through Sept. 26.