Abstract
Objectives. This report summarizes the results of the Macedonian refugee camps' Expanded Program on Immunization.
Methods. Government agencies and nongovernmental organizations implemented an immunization program consisting of 3 mass vaccination campaigns in each of the 7 camps. Before the second mass campaign, weekly immunization clinics were initiated in each camp. Children younger than 48 months were immunized against 8 antigens according to a schedule established by the Macedonian Ministry of Health.
Results. Immunization coverage rates in the second campaign were 91% in Cegrane and 73% in Brazda. Coverage rates of the weekly clinics averaged 93%.
Conclusions. Initiating an expanded immunization program in the absence of a stable population is problematic.
The long-standing political tension between the majority Albanian population of Kosovo and the Serbian state authorities erupted in military conflict in February 1998. More than a year of violent armed clashes had disastrous effects on the lives of a large number of people. After the escalation of the crisis during the week of March 24, 1999, the North Atlantic Treaty Organization initiated the bombing of select targets in Serbia and Kosovo. Hundreds of thousands of Albanian Kosovar refugees left their homes, seeking safety in Macedonia, Montenegro, and Albania.
Approximately 55 000 refugees were in exile in Macedonia as of March 24, 1999, and an additional 120 000 entered after March 24. To house these refugees, the Macedonian government agreed to build 7 refugee camps: Stenkovec and Brazda (both initially transit camps), Bojane, Neprosteno, Senokos, Cegrane, and Radusa. The number of refugees in Macedonia peaked at an estimated 261 000 in early June 1999, at which time there were more than 110 000 refugees living in the 7 camps (according to United Nations High Commission for Refugees estimates). The remaining refugees were housed with relatives, friends, or volunteer families.
Regardless of their nationality, displaced populations and refugees are vulnerable to dehydration, malnutrition, exposure, injury, and infectious epidemics. If programs are to have an immediate effect on the well-being of refugees and displaced persons, they must provide adequate food rations, an adequate supply of clean water, protective shelter, and some mechanism to ensure physical safety. They must also address reproductive and psychosocial health, prevention of communicable diseases, and provision of primary medical care.1
The refugee situation in Macedonia was different from refugee crises experienced in other parts of the world owing to the overall good health and absence of malnutrition among the Kosovar refugee children. However, the Macedonian situation was similar to other such crises in that there was a risk of vaccine-preventable diseases due to the crowded and often unsanitary conditions of the camps. Experts had identified lowered childhood vaccination coverage rates in Kosovo before the exodus of refugees out of the province. In 1996, World Health Organization data showed that in the first year of life, only 21% of Kosovar children were fully vaccinated (BCG vaccine, the full series of 3 diphtheria–pertussis–tetanus vaccines [DPT3], and the full series of 3 oral polio vaccines [OPV3]). In the second year, 53% were fully vaccinated (BCG, DPT3, OPV3, and measles). These rates were the lowest of any in the former republic of Yugoslavia.
According to data from the Institute of Public Health in Pristina, a participant in the survey, the coverage rates for measles ranged from a low of 67% in 1992 to a high of 84% in 1997. Since the beginning of the conflict in Kosovo in 1998, local health authorities had reported that immunization coverage rates were well below their previous levels and suspected that the rates were even lower among the ethnically Albanian Kosovar children.2 This report summarizes the results of the Expanded Program on Immunization in the Macedonian refugee camps during the initial phase of the Kosovar crisis.
The immunization program in the Macedonian refugee camps was initiated when the International Medical Corps (a nongovernmental organization), in collaboration with the Macedonian Ministry of Health, the Centers for Disease Control and Prevention, and the United Nations Children's Fund, conducted a mass vaccination campaign. This campaign, which took place between April 26 and May 10, 1999, targeted all children younger than 4 years who were living in the 7 refugee camps in the Skopje, Tetovo, and Gostivar regions of Macedonia and whose parents could not present the children's “up-to-date” vaccination cards from the former republic of Yugoslavia. These children were immunized according to a schedule established by the Ministry of Health (Table 1). The campaign employed health care professionals from both the Ministry of Health and the International Medical Corps.
After the first mass campaign, plans were made for a second and then a third campaign, each 1 month apart. During the first campaign, children were vaccinated at all camps from 9 am to 4 pm for 2 to 4 consecutive days. Four teams of 7 people each participated in the first mass campaign (4 International Medical Corps and 3 Ministry of Health personnel composed one team). The vaccination clinics were advertised in the media, and in 5 of the 7 camps, families in each tent were surveyed by International Medical Corps volunteers on the final day of the campaign. The inclusion of all camp tents in the survey meant that the immunization status of each child in the camp could be determined.
Camp volunteers gathered information on the number of people living in each tent, the number of children younger than 4 years living in each tent, and the number of these children who had been immunized (proof of an “up-to-date” vaccination record was required) or had not been immunized. If a parent indicated that his or her child was not vaccinated, the volunteers would direct the parent and child to the vaccination clinic. The data gathered were used to determine overall age-appropriate vaccination coverage rates for each camp.
The populations of Stenkovec and Brazda, in particular, were very unstable throughout the months of April and May 1999. These camps functioned as transition sites before the international relocation of nearly 90 000 Albanian Kosovars. Because of these population fluctuations, there was concern that susceptible children were moving through the camps without receiving protection from vaccine-preventable illnesses. Consequently, a plan was devised to provide weekly mobile immunization clinics for all 7 refugee camps to reduce these “missed opportunities.”
Brazda was the first camp to initiate weekly vaccination clinics for new arrivals and children not immunized in the first campaign; this camp's clinic began operations on May 20, 1999, approximately 21 days after the first mass immunization campaign had been conducted there. The weekly clinics operated in the same manner as the monthly mass campaigns but took place once per week in each camp and lasted a single day (except in Cegrane and Stenkovec, where teams visited 2 times per week to hold clinics). Overall vaccination coverage rates were determined during weekly clinic days, with days and camps randomly chosen (Table 2).
The previously planned second immunization campaign also began in Brazda, on May 27, 1999. The objective of this second campaign was to vaccinate all age-eligible children in the camp, including new arrivals and children from the first campaign requiring revaccination. The second campaign began in each camp on the camp's weekly vaccination clinic day so as not to confuse parents. Campaigns extended for 2 to 4 days as needed (more time was necessary in the larger camps such as Cegrane, Stenkovec, and Brazda). As in the first mass campaign, volunteers collected information on immunization coverage from each tent in 2 of the 7 camps. After completion of the second campaign, the weekly mobile clinics continued.
After the peace agreement was signed on June 11, 1999, and repatriation officially began on July 1, the refugee camp populations quickly decreased. Consequently, there was no need for a third vaccination campaign. The weekly clinics continued into the third week of July, when the camp populations stabilized and the vaccination status (per written record) of all camp children was known.
In the first campaign, overall immunization coverage rates in 4 of the 5 camps were 89% or higher.3 In Cegrane, where a survey was conducted at the end of the second campaign, the coverage rate was 91% (vs 89% for the first campaign). Coverage rates in the Brazda camp fell from 93% for the first campaign to 73% for the second. No changes in the implementation of the vaccination plan occurred between the first and second campaigns. Surveys conducted at the weekly mobile clinics showed that overall immunization coverage rates fell primarily in the mid- to high-90th percentiles (Table 2). It was not possible to calculate an overall coverage rate for the second mass immunization campaign, because fewer surveys took place during this second effort. As a result of personnel shortages, efforts to determine coverage rates for the second mass campaign were concentrated in the 2 largest camps.
In any emergency situation involving movement of a large number of people from their homes, one of the primary health concerns is prevention of communicable diseases. In 1999, an expanded immunization program was initiated in the 7 Macedonian refugee camps to ensure childhood protection against 8 vaccine-preventable illnesses. This effort took the form of 3 monthly mass campaigns, along with the introduction of weekly clinics in each camp to address concerns regarding the large fluctuating populations within some of the camps.
In the Macedonian experience, population stability occurred only after most of the refugees had been repatriated. This may be one reason why a discrepancy existed between the coverage rates of the first and second campaigns in the Brazda camp. Cegrane had a relatively stable population throughout the crisis, whereas Brazda did not (Table 3). There was a nearly complete turnover of the Brazda population between the first and second campaigns, with new children arriving throughout the second campaign. Consequently, to avoid a 4-week interval between immunization opportunities, a time during which children would be susceptible to the measles virus in particular, the weekly clinics were initiated. These clinics achieved overall immunization coverage rates above 90%, thereby avoiding any outbreaks.
The coverage rate difference from the first to the second campaign in the Brazda camp cannot be explained by exclusion of more children owing to contraindications in the second effort. The percentage of children in the Brazda camp excluded from the second campaign as a result of contraindications was no different from the percentage excluded from the first campaign. As a result of the large population fluctuations in Brazda, we frequently had new volunteers who helped survey the camp. This personnel problem did not occur in Cegrane and may be another explanation for the discrepancy in coverage rates in Brazda between the first and second campaigns.
We found that there were a number of reasons, falling under the general category of contraindications, why children did not receive vaccinations on the day of the mass campaign or weekly clinic. Most of the time, these contraindications were coughs, runny noses, diarrhea, a slight fever, or skin rashes. A review of the daily clinic numbers showed that 0% to 14% (average: 4%) of children did not receive immunizations owing to contraindications. The Centers for Disease Control and Prevention recommends that in a refugee camp setting, the measles vaccine be given to all children with any of the conditions just mentioned, as well as to children who are undernourished, have HIV, or have active tuberculosis.4 An emphasis on these recommendations can result in a reduction in “missed opportunities.”
There were certain limitations involved in this immunization effort. First, because camp volunteers (individuals who would change from week to week in some camps) were used, no quality control in regard to data collection could be guaranteed. Second, more than half of the Kosovar refugee children were not covered by our immunization efforts. After initial identification of such children, we suggest that a program be undertaken, using existing community services and mobile immunization clinics, to include those not resettled in a refugee camp.
Finally, because all vaccines were included in arriving at overall coverage rates for each camp, we were unable to determine coverage rates for specific antigens. A less costly, more efficient way of monitoring immunization status would be to randomly select a sample of tents in each camp (or a section of a camp) and estimate vaccine-specific coverage rates if concerns exist about possible susceptibility. If, for example, the measles coverage rate were to drop below 85%, a decision could be made to do a more complete surveillance of the camp to identify children at risk and improve this rate.
Measles vaccination is a priority during the emergency phase of any crisis, because measles remains one of the leading causes of childhood mortality in refugee situations. The virus spreads rapidly in crowded refugee camps with large proportions of susceptible individuals. The more malnourished or compromised a child, the greater his or her risk of dying from measles. Experiences in other refugee crises have demonstrated that childhood mortality rates from measles can reach as high as 50%.1, 5, 6
Thus, the standard practice in refugee health care is to vaccinate all children against measles beginning at the age of 6 months. These children should then be revaccinated at 9 months, along with all other children 5 years or younger, regardless of previous immunization status (some experts recommend immunizing up to 12 or 15 years, depending on the circumstances).4 Under ideal circumstances, the efficacy rate of the measles vaccine is 90% to 95%.7 In refugee camps, where cold-chain integrity is always a challenge, the optimum goal is to achieve measles coverage rates that approach 100% to ensure “herd” immunity and prevent an outbreak.8, 9
At present, there are 2 approaches to immunizing children against measles in refugee situations. One is to mass vaccinate the target population at a screening facility upon the population's arrival at the camp. In Macedonia, that would have required that the Kosovar children be vaccinated as they crossed the border into the country or as they stepped off the buses into the camps. The second approach would be to use immunization teams located at a variety of vaccination sites within the camp.10 This approach is most effective when the population of the camp has stabilized.
Neither of these 2 approaches were adopted in Macedonia. Instead, at the insistence of the local health authorities, the immunization program began weeks after the refugees crossed the border and had settled in the camps, and it followed the Macedonian national immunization schedule, which included vaccinating children younger than 4 years against all 8 antigens rather than only measles.
Completing an immunization schedule for an antigen that requires 3 inoculations, each separated by a month's interval, in a population that is constantly changing is inefficient and a poor use of resources. Despite the introduction of weekly immunization clinics in the refugee camps, the rapid evolution of the conflict and the significant turnover of the camps' populations created an environment in which children could and did miss opportunities to be vaccinated. By assuming that adequate measles coverage had occurred in Kosovo before March 1999 and by not immediately immunizing the Kosovar children against measles upon their arrival in Macedonia, the Macedonian Ministry of Health risked a measles outbreak. While no measles outbreak or outbreak of any other vaccine-preventable disease occurred in the camps, that may not be the case in future refugee settings.
The standard of early measles vaccination should always be employed emergently in the care of refugee or displaced populations. Other antigens can be administered as opportunities present themselves. In the Macedonian refugee camp experience, we would have recommended that all children 5 years or younger receive a measles vaccination upon their arrival at the camps. Should a similar immunization protocol be used in a future refugee crisis, consideration should be given to providing daily vaccination clinics in each camp, preferably coordinated through a permanent, daily medical clinic. This approach would ensure adequate measles coverage in a dynamic population. As world conflicts continue and populations are displaced, it is essential that public health agencies respond rapidly, yet responsibly, to the threat of all vaccine-preventable illnesses.
Note. OPV = oral polio vaccine; DPT = diphtheria–pertussis–tetanus; MMR = measles–mumps–rubella. aThree total doses separated by 1-month interval. bTwo total doses separated by 1-month interval. aIncludes children with valid vaccination cards. bIncludes children documented as having contraindications and children missed. aTotal population figures used here are from the mornings of the first and second campaigns, respectively. These are official estimates, unlike the head counts of refugees who left or were new arrivals to the camp. This explains the arithmetic discrepancies. bChildren younger than 48 months represented approximately 10% of the total population.
Age Group Vaccine(s) 0–2 months BCG 2–9 months OPV, DPTa 9–47 months OPVb, MMR Children Younger Than 4 Years Children Children Coverage Date Camp Counted in Camp Vaccinateda Not Vaccinatedb Rate, % May 21 Stenkovec 295 263 32 89 May 24 Bojane 61 56 5 92 May 25 Radusa 94 92 2 98 May 28 Senokos 133 120 13 90 June 1 Radusa 127 109 18 86 June 7 Neprosteno 411 384 27 93 June 18 Senokos 245 239 6 98 June 21 Bojane 243 185 59 76 June 21 Neprosteno, section M 54 53 1 98 June 22 Radusa 100 92 8 92 June 22 Cegrane, section N 73 70 3 96 June 22 Cegrane, section L 42 42 0 100 June 25 Senokos 122 121 1 99 June 28 Bojane 61 60 1 98 June 28 Neprosteno 43 42 1 98 June 29 Radusa 30 21 9 70 June 29 Cegrane, section I 59 59 0 100 June 29 Cegrane, section O 47 47 0 100 Camp Total population aat First Campaignb Refugees Leaving New Arrivals Total Population aat Second Campaignb Brazda 27 600 24 816 14 544 19 000 Stenkovec 20 100 11 887 8 894 20 800 Neprosteno 4 700 2 686 1 229 3 800 Bojane 5 500 551 3 929 7 900 Radusa 1 500 811 1 356 2 800 Senokos 2 400 189 3 458 6 800 Cegrane 31 500 3 477 13 082 41 800
We thank D. Kline, MPH, for contributing to the coordination of the program and helping to gather data, F. Abduliahu for helping to gather data and acting as the liaison between the immunization teams and the program coordinator, and E. Azziz-Baumgartner, MD, for helping to gather data.
D. G. Koop, as program coordinator in Macedonia, wrote the paper. B. M. Jackson and G. Nestel contributed to the writing of the paper.
