Bollettino epidemiologico nazionale

An Experience in Measles Vaccination in a Gypsy Camp in Rome

MO Trinito¹, I D’Ascanio², C. Zacché², and ME Trillò²

¹Epidemiology and Prevention of Infectious Diseases Service, Local Health Authority Rome C

²Maternal-Child Health Department, Local Health Authority Rome C

The Gypsy population in Italy and elsewhere in Europe is at elevated risk of transmission of infectious diseases because of high mobility and limited access to health services. In 2001, for example, two cases of polio due to wild virus imported from India were reported in Gypsy children in Bulgaria (1). Providing vaccination to this group therefore represents a public health priority.

In Rome, there are 33 Gypsy camps of varying size, of which 12 have full or partial services (water, electricity and sewage systems); 6 of these sites, which have a population of more than 600 children, are within the jurisdiction of the Local Health Authority of Rome C. Vaccine service delivery varies from camp to camp, especially with respect to the interaction between the health services, private agencies, and the camp’s population. In 2001, the sub-group of the Regional Coordinating Group for Immigrant Health (GRIS) working with the Gypsy population, which is made up of representatives from the local health authority and non-governmental social and voluntary services, proposed that a special campaign be conducted for the children living in the camps. As a result, an initiative was launched that involved the Public Health Agency of the Lazio Region’s operative unit on migratory health, the ISS, the 5 local health authorities of Rome, and voluntary associations who provided assistance with cultural mediation and logistic support (Caritas, ARCI, Comunità Capodarco, Opera Nomadi). The Lazio Region lent its support by publicizing the initiative and printing vaccination cards.

It was decided that the campaign should provide immunization against diphtheria, tetanus, pertussis (DTP), polio, hepatitis B (HBV), Hemophilus influenza B (Hib), and measles, mumps, and rubella (MMR).  The campaign was conducted on-site at the Gypsy camps over a three one-week periods (during March, May, and October 2002) using pulse immunization methods, with several vaccinations given simultaneously in order to rapidly achieve high levels of immunization. The program was carried out by persons working in the local health authority and with voluntary groups using the following sequence of steps:

• Census of the children between the age of 0 and 14 years present in the camps

• Determination of their vaccination status on the basis of existing documentation available in various structures of the local health authority (outpatient clinics, public health services, maternal-child health clinics, etc) as well as that maintained by various associations (for example, the school entry vaccine certificates) and vaccination records kept by the families themselves.  The absence of documentation was considered to indicate lack of vaccination.  If initial vaccinations had been conducted but the full cycle had not been completed, the child was considered in need of completion of vaccination (regardless of the time elapsed since the last dose).

• DTP, polio and HBV vaccination was carried out for children between 3 months and 14 years, Hib vaccination for those 3 months to 5 years, and MMR for those 15 months to 14 years of age.

In this article, the experience with MMR vaccination in one of the camps (Tor Pagnotta) during the spring of 2002 is presented.

The first week of vaccinations was conducted simultaneously in all the Gypsy camps in Rome between the 4^th and 9^th of March 2002. In the Tor Pagnotta camp, 43 children between the ages of 1 and 14 years were identified, of whom 34 were 15 months of age or older. None of these children had previously received MMR vaccine. To avoid an approach that might be considered too aggressive by the local population, it was decided to administer a maximum of 2 injections at the same vaccination session, giving priority to DTP and HBV. For this reason, MMR was administered only to 16/34 children (47%) in the <14 year age group; by contrast, 24/34 eligible children were vaccinated against DTP, HBV and polio.  At the end of the vaccination week, a meeting was held with the health personnel who participated in the initiative in the other camps in Rome, many of whom reported that they had observed cases of measles during the week of the campaign.

Given the regional data from the pediatric sentinel surveillance system for vaccine-preventable diseases showing an increase in measles cases, it was therefore decided to undertake a special MMR campaign in the Tor Pagnotta camp on April 12, 20002. On this date, an additional 15 children were vaccinated, resulting in a coverage of 31/34(95%). Mean age of those vaccinated was 6 years, with a range of 19 months to 14 years. Of the 3 unvaccinated children, two were not present in the camp on the vaccination days, and the parents of the remaining child refused vaccination.

Between March 4^th and April 12^th 2002, there were no cases of measles reported in the camp. On the 29^th of April, the two unvaccinated children who had not been in the camp on the day that the vaccination campaign was held developed measles. On the 12^th of May, the parents of the third unvaccinated child, who had initially refused to have their child vaccinated, brought the child to the local clinic to be vaccinated.

We believe that this experience, even though based on only a small sample of the Gypsy population, illustrates several important points. From the standpoint of public health, each case of vaccine-preventable disease represents a failure, especially when the cases happen in a population that is the target of special interventions. In this case, the organization of a second vaccination day specifically to administer MMR resulted in nearly 100% coverage of the target population. Despite this coverage, however, measles is a highly contagious disease and two of the three who remained unvaccinated developed the disease.

The vaccinations were delivered on-site in the camps, which appeared to be an efficient mode of reaching the target population. However, in these situations, every effort needs to be made not to miss a single child but also to avoid disturbing the trust that the target population has in the health care services.

We believe that the vaccination campaign likely prevented a larger epidemic in the Gypsy camp. However, we do not have specific information on the course of events in other camps where targeted vaccination efforts were not conducted. However, given the high levels of viral transmission during the fist half of 2002 in the absence of elevated vaccination coverage, it is likely that there would have been a large number of cases.

References:

1.Nota Ministero della Sanità prot. 400.3/28/1806 del 08.5.2001

2. http://www.spes.iss.it/Report.htm