EVALUATION OF SURVEILLANCE SYSTEM OF INFECTION DISEASES AND VACCINATION COVERAGE IN ALBANIA

Introduction The Albanian system of epidemiological surveillance for infectious diseases has been and continues to be mandatory: the infectious diseases included in this system should be reported by law. The statutory notification system dates from the years ’50. In spite of small improvements over the time, the essential features of the system remained as before until 1998. Before the years ’98, the surveillance system have had registered a shortage and deficiency on the information flow on infectious diseases due to the non application of active and sentinel epidemiological surveillance, related directly to quantitative and qualitative shortage of the existing form of mandatory reporting of infectious diseases. Today in Albania, the information flow on infectious diseases has been realized and continues to be realized through the monthly reporting form (named-14/Sh). The monthly reporting form of infectious diseases (14/Sh) is compiled by the epidemiological service in the district level and sent to the Department of Epidemiology and Biostatistics at the Public Health Institute (under the direction of the Minister of Health nr.189, dt.08.08.1995, and the approval of the Statistical Institute, 134 letters, dated, 08.25.1995). The monthly data are collected by the departments of epidemiology in the 36 districts from general practitioners, hospitals and laboratories. Surveillance system in Albania has in use 4 cards of notification. Group A (14-1/Sh) includes infectious diseases of the utmost importance to public health, group B / 1 (14-2/Sh) are those for which there is an obligation to notify rapid (within 1-3 days), group B / 2 (14-3/Sh) includes tuberculosis diseases and group B / 3 (14-4Sh) sexually transmitted diseases. Regarding the immunization system has started at the end of the 1950 with diphtheria toxoid and later with DT and DTP in the early 1970s, tuberculosis vaccine (BCG), measles and polio vaccine. After 1993, in the immunization calendar are included other vaccines such as viral hepatitis B, trivalent vaccine (measles, rubella and mumps) and at the end homophiles’ influenza type B which is introduced in 2009. Since 1993, UNICEF started to provide the whole vaccines according to the WHO recommendation for immunization. In 1995, Ministry of Health in Albania introduced also the immunization against hepatitis B for all newborns. After the year 1993 in the immunization calendar have been introduced the following vaccines: 1995 - Viral hepatitis B, 2000 – bivalent vaccine of measles & rubella (MR) 2005 – trivalent vaccine measles, mumps and rubella (MMR) 2009 – penta-vaccine DTP + Hep.B + HiB (influenza hemophilus B). The Research Objectives The evaluation of the current system of infectious diseases surveillance in Albania during the period 1998-2009 in order to identify the critical issues and existing possibilities for improvement This objective will be carrying out through: 1. Evaluation of epidemiological situation of these diseases by focusing attention on: description of the trend of infectious diseases in Albania during the period of study (data from the monthly reporting forms) and the evaluation of the information by the individual form of infectious diseases notification; distribution of the infectious diseases by sex and age; distribution by the regions and the areas (urban and rural); assessment of the vaccine coverage for vaccine preventable diseases in Albania; comparing of the levels of infectious diseases and our surveillance system with those of other European countries. 2. Analysis of the characteristics of the surveillance system (the way of completing the individual forms) in terms of sensitivity of recording the cases of infection, emphasizing the importance of the system and making a balance between the strengths and weaknesses points of the system, in order to implement of the measures to improve the monitoring of infectious diseases and the introduction of surveillance systems for specific diseases. 3. Assessment of the organizational structure of the monitoring system, trying to find out any restrictions on the management of data from local levels of health; 4. Providing a comparison of surveillance system on infectious diseases through the intersection of monthly and individual data to assess and calculate the percentage of cases reported by the monthly reporting forms and individual form and to understand the inadequacy of data with the ultimate goal of improving the current system of surveillance on infectious diseases. The Material and Method It 'was built a database specifically for processing data relating to all infectious disease notifications and conduct an analysis of the criticality of the system in terms of data quality and simplicity of the system according to the criteria of the CDC (2004). There are included all the reported infectious diseases from the monthly reporting system for the period 1998-2009 and there are assessed individual notification forms of infectious diseases which constitute the key point of the system of surveillance of these diseases from which depends and quality and reliability of monthly reporting data. The analysis was based on general information related to the total number of cases from monthly reporting system in order to describe the trends and key variables of infectious diseases under the study, and the data reported by the individual notification forms, so that makes an assessment of the system through cross-analysis of data. Results The main problems found were the poor quality of data and system organization. Individual notification forms consist of the following parts: general information of the patient, the history of the disease, laboratory diagnosis, epidemiological investigation and conclusion. Regarding the individual notification for Measles, Mumps, Rubella, Diphtheria, Tetanus, Pertussis and Poliomyelitis are not completed the individual forms. The diagnosis for these diseases is established only by clinical symptoms. About the quality of data it is concluded that there is a lack of information regarding to: 1. Characteristics of the person (personal data and address) • Diarrheal diseases (typhoid fever, salmonellosis, shigellosis, poisoning) – 40% of cases present lack of the father's name usually indicated in Albania (source of inaccuracy in identifying the subject). • Viral Hepatitits and zoonoses diseases – 20% of them present lack of the father’ name • Pulmonary tuberculosis – 45% of cases present lack of the father’ name; 20% of them present lack of data onset and starting of therapy and 26% of cases present lack of hospital admission; • Other diseases of infectious diseases – present in 40% of cases lack of father’ name and in 20% of them lack of patient address. 2. Characteristics of the disease (laboratory diagnosis) • Diarrheal diseases – in 30% of cases is not complete "laboratory confirmation" field; • Viral hepatitis - in 60% of cases is not complete "laboratory diagnosis" field (especially since 2001 we have confirmed no case for hepatitis A, B and C); in 51% of cases is not shown hospital and in 37% is not complete the evolution of the disease • Zoonoses diseases present in 70% of cases lack of diagnostic confirmation (is not complete the laboratory diagnosis) • Pulmonary tuberculosis – in 45% of cases is “missing” for laboratory confirmation • Regarding the vaccine preventable diseases, data on the subject of previous vaccination is only reported in 63% of cases. • Other infectious diseases – present over 70% of cases lack of laboratory diagnosis 3. Epidemiological investigation The third part presents individual data form about the outbreak nature and infectious origin. Percentages of lack of data are presented as follows: • Diarrheal diseases – in 40% of cases is not complete for outbreak nature and in 8% of them is completed the infectious origin • Viral hepatitis - in 30% of them is not completed the outbreak nature and in 0.6% is completed the infectious origin • Zoonosis diseases – in 60% of cases is not completed the infectious origin field • Pulmonary tuberculosis – present uncompleted field of infectious origin in 20% of cases • Other infectious diseases – in 55% of cases have not information regarding the infectious origin of diseases. 4. Conclusion part of individual notification form Regarding the “Conclusion” part of the individual notification form in the highest percentage the diseases are confirmed, although the laboratory diagnosis is not performed. Conclusion The data produced by the system does not reach a satisfactory quality and is a clear need to revamp the system: the first intervention should be aimed at improving the performance of microbiology laboratories in the laboratory that allows the detection of disease etiology, in addition the system surveillance must be better defined with respect to flows and information tools as well as the timing of data transmission. As part of our analytical work we have already built a new notification card, simplified in some places and made easier to complete, this card will probably be introduced for an initial pilot phase in 6 of the Albanian districts by the end of 2010. This work is also related to the training of operators involved in the reporting of infectious diseases.