Measles-Rubella Mass Immunization Campaign in Albania, November 2000

Author(s): Silvia Bino, Eduard Kakarriqi, Miriam Xibinaku, Nicolae Ion-Nedelcu, Mariana
Bukli, Nedret Emiroglu and Amra Uzicanin
Source: The Journal of Infectious Diseases, Vol. 187, Supplement 1. Global Measles
Mortality Reduction and Regional Elimination: A Status Report (May 15, 2003), pp. S223-
S229
Published by: Oxford University Press
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 SUPPLEMENT ARTICLE

Measles-Rubella Mass Immunization Ca

in Albania, November 2000
Silvia Bino,1 Eduard Kakarriqi,1 Miriam Xibinaku,1 Nicolae lon-Nedelcu,2a Mariana Bukli,3 Nedret
and Amra Uzicanin5

Institute of Public Health, 2American Red Cross Delegation, s Fund

and Office,
3United Tirana,
Nations Albania; 4World Health
Children'
Organization Regional Office for Europe, Copenhagen, Denmark; National Immunization Program, Centers for Disease Con
Atlanta, Georgia

In 2000, Albania resolved to eliminate measles by 2007 by use of a four-step program: by

up" vaccination campaign for all children aged 1-14 years, achieving and sustaining high
among children aged 1 year with the first dose of a measles-containing vaccine, by intr
second dose of measles-containing vaccine for children at age 5 years, and by improving m
This catch-up campaign took place in November 2000: 867,000 doses of measles-rubella va
istered for an estimated coverage of 99%. In all, 231 campaign-related adverse events were
206; allergic reactions, 10; fever, 8; encephalitis/encephalopathy, 2; and aseptic meningitis,
Barre syndrome, anaphylaxis, and arthralgia, 1 each. All resolved without sequelae. This re
status of measles and rubella/congenital rubella syndrome control in Albania before 200
implementation of the catch-up campaign.

Albania is located on the Balkan Peninsula. It isolation,

ternal is 28,748 movement within the country was lim-
ited.
km2 and is administratively divided into 12 Reintegration
prefecturesof Albania into the international
with 37 districts, including the capitalcommunity
city of Tirana.
gradually started in the early 1990s. With
In 2000, Albania'
s population was estimated at 3.41
a per capita gross national income in 2001 estimated
at US S1230
million and the annual population growth rate [2],
at Albania
2% remains one of the most un-
[1]. derdeveloped countries in Europe.
From the end of World War II through the early Pursuant to the World Health Organization (WHO)
1990s, Albania was isolated from neighboring countries. goal of eliminating measles in the European region [3,
From 1948 through 1961, the communist government 4], in 2000 the Ministry of Health of Albania endorsed
maintained political and economic relationships only the National Plan for Measles Elimination 2000-2007
with the Soviet Union, Warsaw Pact countries, and that outlined the following four strategies: conducting
China. Following severance of relations with the Soviet a " catch-up" vaccination campaign for all children aged
Union and China in 1961 and 1977, respectively, total 1-14 years, achieving and sustaining a high coverage
isolation continued until 1988-1989. In addition to ex-
(^95%) among children aged 1 year with the first dose
of a measles-containing vaccine; introducing a second
dose of measles-containing vaccine into the routine
a Present affiliation: Directorate of Public Health, Bucharest, Romania. childhood immunization schedule for children at age
5 years; and improving measles surveillance [5]. To re-
Reprints or correspondence: Dr. Amra Uzicanin, 1600 Clifton Rd., MS E-05,
Atlanta, GA 30333 (auzicanin@cdc.gov). duce the incidence of congenital rubella syndrome
The Journal of Infectious Diseases 2003;187(Suppl 1):S223-9 (CRS) to the European target of ^/100,000 live births
? World Health Organization 2003. All rights reserved. The World Health Organization
has granted the Publisher permission for the reproduction of this article.
per year [3], Albania resolved to simultaneously intro-
0022-1899/2003/1871OS-0034 duce a comprehensive national program for rubella

Measles Elimination in Albania * IID 2003:187 (Suppl 1) * S223

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control and CRS prevention that includes a rubella childhood to-door registration of newcomers. Children recorded in the
vaccination program, vaccination strategies to ensure high levels vaccination registries, but permanently absent during the enu-
of rubella immunity among women of childbearing age, and meration due to emigration, were to be excluded from the
routine CRS surveillance. master lists. Health care facilities forwarded finalized master
lists to the District Directorates of Public Health. All districts
The preparations for the catch-up campaign and its imple-
complied with these requirements, except the city of Tirana,
mentation in 2000 were a collaborative effort of several partner
organizations that had assumed clearly defined roles and re-
where the target population estimate was based only on infor-
sponsibilities. The partners included the Albanian health and
mation available in the vaccination registries. From this enu-
education ministries (planning, coordination, and implemen-
meration data, the target population was estimated at 878,000
tation), the Albanian Red Cross (social mobilization), the children aged 1-14 years.
American Red Cross (fundraising, social mobilization, technical Campaign evaluation. In April 2001, an IPH team of
s Fund (UNICEF; fundrais- experts and partner organization representatives evaluated the
support), United Nations Children'
ing, training, logistics support), the WHO and the US Centers
campaign results. The evaluation methodology included a re-
for Disease Control and Prevention (technical support). Here
view of available data on vaccination coverage achieved and an
we describe the status of measles and rubella/CRS control in assessment of the quality of preparatory activities and campaign
Albania before development of the National Plan for Measles services by review of available documents and reports. The
Elimination and report on implementation and immediate im- evaluation team also visited six districts (Tirana City, Tirana
pact of the catch-up campaign. Prefecture, Elbasan, Durres, Kruja, and Shkoder) and con-
ducted detailed evaluations by use of semistructured interviews
with the staff of the District Directorate of Primary Health Care
METHODS
(director and district epidemiologists) and health care facility
staff. Standard questionnaires were developed and used for
Disease surveillance. Physicians report clinically diagnosed
these interviews.
measles and rubella on a simple form to the District Direc-
torates of Public Health; these provide monthly aggregate re-
RESULTS
ports of measles and rubella incidence by age group, sex, and
setting (rural/urban) to the Institute of Public Health (IPH) in
Tirana. We reviewed available reports on measles Measles Control
incidence in in Albania, 1945-2000
Albania during 1945-1990 and analyzed the aggregate IPHbeen a mandatory reportable disease since 19
Measles has
measles and rubella surveillance data for 1991-2001. In 1955, after a large measles epidemic, the Albanian Minis
Routine vaccination coverage. The National Office of the
of Health designated measles as a disease requiring strict qu
Expanded Program on Immunization (EPI) at the IPH in Ti-
antine. The quarantine measures included medical screen
rana annually estimates national vaccination coverage rates for
of people entering Albania for symptoms and signs of mea
all antigens used for routine childhood immunization. The es-
and strict isolation of villages, cities, and even entire distr
when a suspected measles case was identified. No measles
timates are based on quarterly EPI reports on target population
and number of vaccine doses administered as reported by the
were reported in Albania during 1956-1969 (IPH, unpubli
District Directorates for Public Health. data). In 1970-1971, a measles outbreak with 48,156 repo
Campaign coverage. The IPH in Tirana estimated the
cases (overall attack rate, 2293/100,000) occurred, report
campaign vaccination coverage achieved nationwide and in the
after a youth contracted measles while visiting China (I
districts by using the number of vaccine doses administered unpublished
as data). Measles vaccine was first introd
through a mass campaign implemented in response to
numerator and the number of children in the target population
collected through a nationwide enumeration exercise before the
outbreak: About 900,000 ^950Zo) children aged 1-14 years w
immunized in December 1970 with a measles vaccine from
start of the campaign as denominator. The enumeration was
undertaken due to uncertainties about the actual size of the China (IPH, unpublished data).
target population in view of extensive population migrations In 1971, a single dose of the Chinese-produced Beijing 55
strain vaccine was introduced into the childhood immunization
during the 1990s and in the absence of census data since 1989.
In brief, health care facilities were instructed to prepare schedule
a for children aged 9 months. Importation of the Chi-
line-list of children in the campaign target age group currently
nese-produced vaccine continued through 1976, when the IPH
residing in their catchment area by copying the basic demo-
started production of the Beijing 55 measles vaccine. From 1971
graphic data on children aged 1-14 years from the vaccinationto 1990, measles vaccination was conducted in campaigns tak-
ing place each November and targeting children aged 9-23
registries and school registries to the enumeration forms (mas-
months. Routine measles vaccination coverage was reportedly
ter lists) and by supplementing that information through door-

S224 * JID 2003:187 (Suppl 1) * Bino et al.

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>95% from the beginning of the program in 1971 through Rubella Control and CRS Prevention in Albania, 1960-2000
1989. No measles cases were reported from 1972 to 1988. In Before 2000, rubella-containing vaccines were not used in Al-
April 1989, a large measles epidemic spread from Tirana bania. Rubella has been under routine surveillance as a man-

throughout the country after an alleged measles importation. datory reportable disease since 1960, but there has been no
The outbreak ended in early 1990 with a total of 168,636 re- surveillance for CRS. Rubella outbreaks have occurred every
ported cases (overall attack rate, 5374/100,000 population) and 5-6 years, mainly among children aged ^5 years (table 2).
44 reported deaths [6].
Local production of measles vaccine was insufficient to cover
Catch-up Measles-Rubella (MR) Vaccination Campaign,
the needs for routine immunization in 1990 and it was dis-
November 2000
continued in 1991. Cohorts of children born in 1989-1992
Campaign implementation and coverage. In February 2000,
remained either partially vaccinated or not vaccinated due to
the Ministry of Health established a task force to oversee the
lack of vaccine. Since 1993, UNICEF has supplied all vaccines
preparations for and implementation of the catch-up campaign.
for routine immunization in Albania, including imported
The task force included representatives of all partner organi-
freeze-dried measles vaccine (Schwartz strain).
zations and was chaired by a high-ranking Ministry of Health
During 1994-2000, the routine childhood immunization
official. The IPH was responsible for implementation of the
schedule in Albania included a single dose of measles vaccine
preparatory activities and day-to-day coordination of campaign
administered to children aged 12 months (after the 1st birth-
implementation. Preparation for the campaign included as-
day). Administrative estimates of routine coverage among chil-
sessments of pre-campaign immunization practices (e.g., in-
dren aged 1 year were 76%-95%. In 1999, a national vacci- jection safety), development of technical guidelines, training
nation coverage survey estimated the crude measles coverage
for 4500 health workers in campaign procedures, and a massive
of children aged 18-30 months according to vaccination records
refurbishing of the cold chain system for storage and distri-
and mothers' recollections at 92% and 88^/0, respectively. At of the vaccines at the national, district, and health care
bution
the same time, the proportion of children who received measles
facility levels.
vaccine at the recommended age (i.e., not before the 1st birth-
The campaign was implemented 1-14 November 2000. A
day) was estimated at 66% [7]. combined MR vaccine produced by Serum Institute of India
During the 1990s, measles cases were reported each year
was used to immunize both boys and girls aged 1-14 years,
(table 1). From 1996 to 2001, 90% of reported measles cases
regardless of previous measles immunization or measles and/
occurred among children *c:l 5 years old. The highest age-specific
or rubella disease history. In accordance with current WHO/
attack rates were among children aged ^ year, who wereUNICEF/UNFPA
not policy [8], vaccine was provided "bundled"
yet eligible for measles vaccination. No measles-associated
with auto-disable syringes for vaccine administration, dispos-
deaths were reported during 1991-2000. able syringes and needles for vaccine reconstitution, and safety

Table 1. Measles cases and incidence rate per 100,000 population (IR/105) by age group,
Albania, 1991-2001.

Age group

<5 years 5-9 years 10-14 years ^15 years jota|

Year Cases IR/105 Cases IR/105 Cases IR/105 Cases IR/105 Cases IR/105
1991 _ _ _ _ _ _ _ _ 0 0

1992 _ _ _ _ _ _ _ _ 0 0

1993 3 0.9 2 0.6 1 0.3 1 0.04 7 0.2

1994 9 2.6 15 4.8 5 1.7 0 0 29 0.9

1995 6 1.7 4 1.3 3 1.0 2 0.08 15 0.5

1996 329 95.5 783 250.1 73 24.5 19 0.8 1204 37.1

1997 852 247.3 1080 345.0 148 49.7 306 13.3 2386 73.4

1998 528 153.3 845 270.0 354 119.0 174 7.6 1901 58.5

1999 235 68.2 288 92.0 169 56.8 105 4.6 797 24.5

2000 112 32.5 259 82.7 227 76.3 64 2.8 662 20.4

2001 11a 3.2 4 1.3 2 0.7 1 0.04 18 0.5

a All 11 cases were ^ year old.

Measles Elimination in Alba

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 Table 2. Rubella cases and incidence rate per 100,000 population (IR/105) by age group,
Albania, 1991-2001.

Age group

<5 years 5-9 years 10-14 years ^15 years jota|

Year Cases IR/105 Cases IR/105 Cases IR/105 Cases IR/105 Cases IR/105
1991 3 0.9 1 0.3 3 1.0 2 0.08 9 0.3

1992 3 0.9 3 0.9 4 1.3 2 0.08 12 0.4

1993 24 6.7 29 9.3 37 12.4 21 0.9 111 3.4

1994 834 242.1 2403 767.7 162 54.4 33 1.4 3432 105.7

1995 3 0.9 5 1.6 2 0.7 0 0 10 0.3

1996 94 27.3 80 25.6 2 0.7 4 0.17 180 5.5

1997 17 4.9 45 14.4 1 0.3 3 0.13 66 2.0

1998 95 27.6 124 39.6 268 90.1 234 10.2 721 22.1

1999 4 1.2 3 0.9 3 1.0 5 0.2 15 0.5

2000 410 119.0 720 230.0 520 174.8 102 4.4 1752 54.6

2001 5a 1.4 1 0.3 3 1.0 1 0.04 10 0.3

a 3 cases were ^ year old.

boxes for disposal of Overall,

used 231
injection cases of cam
equipment. Tr
supervised by physicians administered
ported, the 15
including vaccine.
hospi
sessions were organized at the primary
(table 3). After health care
the campai
preschool children aged fessor of pediatrics
1-5 years at the
and at primary
children aged 6-14 years. About
case 867,000
reports doses of
on campaign-
cine were administered information
during and prepared
the campaign. The n
paign coverage rate v/as recovered
estimated without sequela
at 99%, while th
coverage in districts the
was UNICEF office,
96%-99.9%. Tirana
Injection safety. An immunization safety su
ducted in
of Other 185
3487 vaccination
Recommended ^/o)
posts
Stratei
overall injection
safety In
rate of 98% [9]. In 14 citie
2001, the routine childh
including Tirana, authorities organized collection
bania was changed to inc
eration of the safety boxes filled with used injectio
vaccine administered at ag
at hospital or industrial incinerators. In rural hea
staff kept filled safety boxes
Table through the end of t
3. Reported adverse
and then burned them in designated places under
(AEFI) with measles-rubell
of doctors, nurses, village elders,
years, or cold
Albania, chain
1-14 co
Novem
Adverse events after immunization (AEFI). Pre
Cases
for the campaign included intensive training on m
AEFI reported Rate/106 doses
and monitoring of AEFI with MR vaccine. All vaccin
Encephalitis or encephalopathy 2 2.30
were provided with emergency kits for managem
Aseptic meningitis 1 1.15
phylactic shock, including adrenaline. Vaccination
Seizure 1 1.15
requested to promptly
report any AEFI to the di
Guillain-Barre syndrome 1 1.15
dinator. In addition,
zero" dailyfrom
reporting " the districts
Anaphylactic reaction 1 1.15
to the IPH was required during the campaign. The
Allergic reaction 10 11.52
surveillance included toxic
shock syndrome, sus
Arthralgia 1 1.15
phylaxis, high fever ^390C), syncope, death or ho
Fever 8 9.22
without other apparent cause, or any other sev
Syncope
event(s) that occurred within 206 237.39
4 weeks of immun
Total 231 266.19
case definitions and case investigation forms for A
lance were developed according to
NOTE. Data are from the Institute WHO
of Public guidelin
Health, Tirana, Albania.

S226 * JID 2003:187 (Suppl 1) ' Bino et al.

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 cases

Figure 1. Measles cases by month of report, Albania, 1996-2001. Source: Institute of Public Health, Tirana, March 2002.

the Ministry of Health Task Group for Measles Elimination
recommended that women of childbearing age in Albania be
immunized with rubella-containing vaccine to ensure high lev-
els of rubella immunity. The group advocated that MR vaccine
be offered through routine health care services to all women
of suspected measles or rubella, 11 had a serum specimen avail-
able and were tested by commercial enzyme-linked immuno-
assay kits for detection of measles- and rubella-specific IgM
antibodies (Enzygnost; Behring); none were confirmed as mea-
sles or rubella.

aged 16-35 years (who account for the majority of births), a

target population of an estimated 600,000 women. In addition,
MR vaccination was to be offered to women ^5 years if they
planned to become pregnant. Some 15%-20% of births in Al-
bania are to women ^5 years old. Implementation of the MR
vaccination activities for women of childbearing age started in
September 2001 and continued through 2002.
An enhanced measles and rubella surveillance system with
epidemiologic investigation and laboratory confirmation of all
suspected cases is currently in formation. A national measles
and rubella reference laboratory was established at the Institute
of Public Health in late 2000. From January through December
2001, 18 and 10 physician-diagnosed cases of measles and ru-
bella were reported, respectively, from 6 districts (table 1, table
2). No epidemiological link could be established among these,
nor did they have a history of travel abroad. Of 18 suspected
measles cases, 11 (6^/0) occurred among children aged^ year
who were not eligible for vaccination. Of 10 suspected rubella
cases, 3 (30%) occurred in this age group. All 7 cases of sus-
pected measles aged ^ 1 year had been vaccinated against mea-
sles: 5 received one dose and 2 received two doses of measles-
containing vaccine. Of 7 cases of suspected rubella aged ^1 estimate, uncertainties remain about the data as evi
an extremely high reported coverage (99.0%-99.9%
year, 2 received one dose of MR vaccine. Of 28 reported cases
DISCUSSION
Albania, one of the least developed countries in the
region, successfully implemented a catch-up MR camp
children aged 1-14 years in November 2000 and achi
coverage nationwide and in every district. Quality a
of the campaign were ensured through pre-campai
rations that included refurbishing of the cold chain
ment and dissemination of technical guidelines, ade
vision of vaccine and injection equipment, appr
organized logistics, intensive staff training on safe im
tion practices, and well-organized monitoring and s
during the campaign.
Reported campaign coverage was very high both na
(99%) and in all districts (960Zo-99.90Zo). Based on off
ulation projections, the target population was initially
at about 1 million children aged 1-14 years. Howeve
enumeration of the target populationmaster lists"
through the "
produced an estimate of 877,000. While most nation
believe that the official population projections are a g

Measles Elimination in Albania * JID 2003:187 (Suppl

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(59%) districts. Despite these uncertainties, the immediate im-
pact of the campaign on measles and rubella incidence suggest
that the coverage was sufficiently high to reduce transmission
of measles and rubella viruses to very low levels (figures 1 and
2).
The catch-up campaign in Albania provided high-quality
immunization services and was safe. In the preparatory phase,
the infrastructure for immunization (e.g., cold chain) was im-
proved and immunization practices (e.g., immunization safety)
were strengthened through intensive staff training. Additional
efforts will be needed to sustain the improvements made to
assure high-quality routine immunization services. These in-
clude both ongoing training and supervision to reinforce safe
immunization practices and further improvements of immu-
nization infrastructure, including systems for safe disposal of
injection equipment.
One targets for the Health for All in the 21st Century in the
WHO European Region is to reduce the CRS incidence rate
below 1/100,000 live births [3]. Almost no data concerning
CRS incidence are available in Albania. However, experience
from other developing countries in the absence of rubella vac-
cination suggests that CRS rates during rubella outbreaks may
be as high as 2 per 1000 live births [11]. That means that up
to 120 CRS cases could occur in Albania after a large rubella
outbreak. In 2000, Albania was one of the few countries in the
European region that had not included a rubella-containing
vaccine in the routine childhood schedule. The catch-up cam-
paign offered a unique opportunity to launch a rubella and
CRS prevention program in Albania by targeting with a com-
Figure 2. Rubella cases by month of report, Albania, 1996-2001. Source: Institute of Public Health, Tirana, March 2002.
S228 * JID 2003:187 (Suppl 1) * Bino et al.
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bined MR vaccine 14 cohorts that account for most reported
rubella cases, thus reducing rubella virus transmission to very
low levels.
Some national experts believe that the introduction of strict
quarantine measures for suspected measles cases in 1955 com-
bined with the political isolation of Albania resulted in elim-
ination of indigenous measles during 1956-1969 in the absence
of vaccination; however, there are too few surveillance data
from that period for in-depth examination. A large measles
outbreak in 1970 prompted introduction of measles vaccination
through a large outbreak response vaccination campaign that
was followed by inclusion of measles vaccine into the routine
childhood immunization schedule. These vaccination efforts
were followed by a 16-year period (1972-1988) without re-
ported measles cases. Hence, Albania was, to our knowledge,
the first country in the European region to achieve an apparent
and previously unreported interruption of measles transmission
during a prolonged period of time by implementing a measles
vaccination program.
Absence of reported measles cases from 1972 to 1988 was
possibly due to a combined effect of the 1970 mass vaccination
campaign, subsequent introduction of routine measles vacci-
nation, Albania's external isolation, and limited internal mo-
bility of the population. While concerns regarding the overall
quality and sensitivity of measles surveillance in Albania during
that period may justifiably exist, the extremely high overall
attack rate observed during the 1989-1990 measles outbreak is
consistent with a preceding long period without measles trans-
mission. Liberalization of domestic and international travel
 2. World Bank. Albania at a glance. 2002. Available at: httpV
provided opportunities for measles virus importations and co-
_aag.pdf. Accessed February
worldbank.org/data/countrydata/aag/alb
incided with reestablishment of an endemic measles transmis-
2003.

sion pattern during the 1990s. 3. World Health Organization. HEALTH21-Health for All in the 21st
Albania s borders are open for tourism and trade and a sig- Century. The health for all policy for the WHO European Region.
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