Vaccination Campaign for Kosovar Albanian Refugee Children -- Former Yugoslav Republic of Macedonia, April-May, 1999

Extensive ethnic conflict within the Kosovo region of the Federal Republic of Yugoslavia and an organized bombing campaign by the North Atlantic Treaty Organization led to mass population displacement in 1998 and early 1999. In April 1999, approximately 500,000 Kosovar Albanians fled into the Yugoslavian Republic of Montenegro and the neighboring countries of Albania, Bosnia-Herzegovina, and the Former Yugoslav Republic of Macedonia (FYROM) (1). Of the estimated 130,000 refugees who fled to FYROM, approximately 65,000 were housed in seven refugee camps (1). A major public health concern in these camps was the prevention of vaccine-preventable diseases, particularly measles. In response, the FYROM Ministry of Health (MOH) in collaboration with the United Nations Children's Fund (UNICEF) and International Medical Corps, a nongovernmental organization, planned and implemented a mass vaccination campaign. This report describes the first campaign (April 26-May 10, 1999), its results, and follow-up activities.

Vaccination Plan and Administration

Children aged less than 4 years without evidence of full vaccination on a valid vaccination card from the Federal Republic of Yugoslavia were vaccinated according to a schedule established by MOH and approved by the World Health Organization (WHO) and UNICEF. Children aged 0-2 months received Bacillus Calmette-Guerin vaccine, those aged 2-9 months received oral poliovirus vaccine (OPV) and diphtheria and tetanus toxoids and pertussis vaccine (DTP), and children aged 9-48 months received OPV and measles vaccine. The original vaccination plan called for three consecutive mass campaigns each separated by 30 days. After the first campaign, children of the appropriate age were to receive two additional doses of OPV and one additional dose of DTP in subsequent campaigns. This plan was modified to include weekly clinics at each camp.

In each camp, vaccination was preceded by a social mobilization effort that included posters, flyers, loudspeaker announcements, and meetings with camp management and community leaders. The vaccination campaign employed teams of 15-20 MOH and Kosovar Albanian physicians, nurses, and administrators. Physicians from the Republic Institute for Health Protection supervised the campaign teams and the Macedonian Institute for Mother and Child Health physicians coordinated cold chain support with the local health facilities. Continuous vaccination occurred from 9 a.m. to 4 p.m. for 2-4 days, depending on the size of the camp. Children who received vaccines were given vaccination cards created by UNICEF and MOH, and their names were recorded in a MOH registration book. Social mobilization continued during the campaign using volunteers who walked tent-to-tent informing families of the campaign. Vaccination in all seven refugee camps was completed during a 15-day period.

In five of the seven refugee camps, a tent-by-tent survey was conducted on the last day of the campaign to evaluate vaccination coverage. Volunteers and staff visited each tent to count all children aged less than 48 months living in that tent, those children vaccinated in camp (as indicated by a valid camp vaccination card), children with a valid card from the Federal Republic of Yugoslavia, and children not vaccinated because of contraindications. The numerator of the overall coverage rate for each camp was the number of children aged less than 48 months vaccinated in camp plus the number of children with a valid vaccination card from the Federal Republic of Yugoslavia. The denominator was the total number of children aged less than 48 months in a particular camp (Table 1).

Evaluation of the Vaccination Program

Of the 7995 children who presented to the vaccination sites in the seven camps during the initial campaign, 7239 (90.5%) were vaccinated, 260 (3.3%) were not vaccinated because of contraindications, and 496 (6.2%) had up-to-date vaccination cards from the Federal Republic of Yugoslavia (Table 1). In four of the five camps with complete tent-by-tent surveys, coverage rates were greater than or equal to 89%. Vaccine coverage rates decreased during the weeks following the first campaign because of substantial fluctuations in the population. For example, in Brazda camp, 19,697 persons left and 3092 entered the camp during the 21 days between the end of the first vaccination campaign (April 29) and the first weekly clinic (May 20). The arrival of new refugees was greatest during the week between the first and second weekly clinic (May 20 and May 27) when an additional 5599 persons left Brazda camp and 9752 entered. The coverage rate measured during this week was 63%. One case of vaccine-preventable disease was documented in the refugee camps--a laboratory-confirmed case of measles during the first week of June.

Reported by: D Kline, H Dakkak, MD, A Cami, MD, F Abduliahu, International Medical Corps; L Cela, MD, K Venovska, MD, Y Mokuo, M Duprat, MD, United Nations Children's Fund, Skope, Macedonia. D Panev, MD, D Mikic, MD, Z Desovski, MD, Macedonian Institute of Public Health; S Stefanoski, MD, B Ancevska, MD, N Janeva, MD, Macedonian Institute for Mother and Child Health. C Maroto Camino, World Health Organization, Geneva, Switzerland. International Emergency and Refugee Health Br, National Center for Environmental Health; Epidemiology Program Office; and an EIS Officer, CDC.

Editorial Note:

Vaccination against measles is a major public health priority in the acute phase of any emergency involving large-scale displacement of a population (2). In past emergencies, up to 50% of deaths were attributed to measles (3). In contrast, outbreaks of other diseases prevented by routine Expanded Program of Immunization (EPI) vaccinations have not caused excess mortality in other refugee crises. Guidelines for vaccination in emergencies recommend that all children aged 6 months to 12 years be vaccinated against measles and receive an age-appropriate dose of vitamin A as soon as possible, often on camp entry (4). In addition to measles vaccine, WHO recommends that OPV be administered when a national immunization day* had not been conducted in the affected community during the previous 9 months (5).

Several factors raised concerns that risks for vaccine-preventable diseases might have been increased among Kosovar Albanian refugee children. First, camps were overcrowded, a condition strongly associated with increased risk for measles infection (3). Second, many refugee children were incompletely vaccinated because of the ethnic conflict in the region since 1990 (6,7). These factors, and the history of a poliomyelitis outbreak in 1996 in Kosovo, made the implementation of a mass vaccination campaign for Kosovar Albanian refugees a primary concern for relief personnel in Macedonia.

Although the situation in Macedonian refugee camps was similar to previous refugee experiences, the vaccination plan differed in a number of ways. First, the vaccine schedule included more antigens (i.e., BCG and DTP) and targeted fewer children than other protocols for refugee emergencies. The additional antigens were administered because the Macedonian MOH requested that a vaccination schedule similar to EPI be adapted for use in the refugee camps. The MOH limited the campaign to children aged less than 4 years because coverage rates for children vaccinated in Kosovo before 1996 were thought to be adequate. Second, vitamin A supplementation was not included because this population was considered well nourished. Third, children were not vaccinated immediately on entering Macedonia because of lack of access to refugees at the border and the concern that vaccination would be psychologically traumatic. Access problems included the relatively short stay of refugees at the border and the unpredictable timing of their arrival and movement into Macedonia. Finally, the vaccination program in Macedonia was planned as an EPI in which children would be revaccinated every 30 days according to the schedule. Under this plan, no provision was made to vaccinate new refugees who arrived between campaigns.

The results of vaccination activities after the first mass vaccination campaign for refugees in camps in Macedonia demonstrate that rapid population turnover can substantially reduce camp-specific coverage rates in a short period. In addition, between the first campaign and the second week of weekly clinics, 44,417 refugees left Macedonian camps and 46,492 refugees arrived. Had the original vaccination plan been followed, coverage rates would have been much lower and newly arrived children would have been susceptible to measles for up to 1 month before being vaccinated.

The lack of vaccine-preventable diseases was most likely a result of a combination of factors, especially the relatively good health and nutritional condition of the refugees. Future refugee populations might be different, and existing recommendations for vaccinating displaced populations should be followed. Relief workers should attempt to vaccinate all eligible children against measles as soon as possible after camp entry to sustain a high measles vaccine coverage rate. Specific situations may dictate whether it is feasible to implement recommended protocols fully or to modify these protocols. However, any adaptations of recommended protocols must not hinder measles vaccination efforts.

References

1. United Nations High Commissioner for Refugees. Kosovo Crisis Update. Available at http://www.unhcr.ch. Accessed June 1, 1999.
2. CDC. Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR 1992;41:(no. RR-5).
3. Toole MJ, Steketee RW, Waldman RJ, Nieburg P. Measles prevention and control in emergency settings. Bull World Health Organ 1989;67:381-8.
4. McConnan I. The SPHERE project. Geneva, Switzerland: Steering Committee for Humanitarian Response, 1998.
5. World Health Organization/Europe. Criteria and scheduling for immunization after a disaster. Copenhagen, Denmark: World Health Organization Regional Office for Europe, 1999.
6. United Nations Children's Fund. FR Yugoslavia 1996: Multiple Indicator Cluster Survey. Belgrade, Yugoslavia: Institute of Public Health of Serbia, Institute of Public Health of Montenegro, and United Nations Children's Fund, 1997.
7. McBurney R, Ogden K, Silverman P, Maxhuni B. Nutritional anthropometric, child health and food security survey, Kosovo, FR Yugoslavia. Pristina, Yugoslavia: Action Against Hunger, Mercy Corps International, and United Nations Children's Fund, 1999.

* Mass campaigns over a short period (days to weeks) in which two doses of OPV are administered to all children in the target age group (usually aged 0-4 years) regardless of previous vaccination history, with an interval of 4-6 weeks between doses.

TABLE 1. Results of the first vaccination campaign in seven refugee camps -- Former
Yugoslav Republic of Macedonia, April 26-May 10, 1999
====================================================================================================
                                                                          Children
                  Estimated                                Children      with valid
                    target      Children    Children     with contra-    vaccination
Camp             population*    examined   vaccinated    indications        cards      Coverage
-----------------------------------------------------------------------------------------------
Brazda                2623        2547         2291             108            148        93%
Stankovec II          1755        1431         1257              62            112        78%
Neprosteno               +         388          361               4             23         --
Bojane                 248         233          219               6              8        92%
Radusa                   +         154          125              19             10         --
Senokos                315         314          295               5             14        98%
Cegrane               3227        2928         2691              56            181        89%

Total                   --        7995         7239             260            496         --
-----------------------------------------------------------------------------------------------
* Derived from tent-to-tent survey on last day of campaign.
+ Survey not completed.
====================================================================================================

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