Albania’s Plan: Response to COVID-19

The current novel coronavirus (COVID-19) outbreak, which began in December 2019, represents a significant challenge for Albania, as well as for the entire world. This study considers that Albania has prepared several action plans over the years related to pandemic influenza preparedness, health security, and health emergencies. The result shows that sharing information about the preparedness of Albania’s plan has a significant positive impact on the response adequately and in a timely manner, offering protection to the population. This paper first investigates the novel nature of the virus during a pandemic situation in Albania and proposes public protection plans to respond to the coronavirus. In brief, the current main objectives in Albania are to create a protected environment, update information and create response measures for the Albanian population. The results show that the measures taken are helping the health indicators to stay constant and decrease the curve of the pandemic. Keyword: coronavirus, measures, indicators, response, Albanian population


Introduction
Despite lack of data, Albania has been prepared against and affected by several outbreaks including the Spanish flu, Asian flu, Hong Kong flu, etc. Spanish flu, between 1918 and 1919 caused an estimated attributable worldwide excess mortality of 20 -50 million, with a case fatality of around 2% and typically affected children, young adults, and pregnant women. In 1957-1958, Asian flu originating from Southern China was responsible for claiming the lives of 1 to 4 million people with a case fatality of 0.1 -0.2% mainly affecting children. Hong Kong flu started as an emergency also in Southern China between 1968 and 1969 causing a moderate influenza pandemic with an estimated mortality ranging between 1 and 4 million people, with a case fatality of 0.2 -0.4% and affected all age groups. The first pandemic that we possess country data on is the recent AH1N1 outbreak which started in Mexico and caused a mild influenza pandemic with an estimated worldwide attributable excess mortality of around 18'000, and a case fatality of less than 0.025% affecting mainly children, young adults, pregnant women and people with chronic disease. Fortunately, Albania was not affected by Serious Acute Respiratory Syndrome (SARS) outbreak between 2001 and 2002 and from the Middle East Respiratory Syndrome (MERS) that started in 2012, both with high mortality rates of approximately 10% and 30% respectively, affecting middle aged and the elderly. Nonetheless, Albania is affected every year by seasonal flu epidemics which in some instances, such as the 2015-2016 flu season, are more severe than others, affecting individuals across all age groups, but showing a more severe impact on children, pregnant women and people suffering from chronic diseases. To summarize, Albania has a lot of experience in facing outbreaks from having undertaken significant preparedness work for seasonal influenza throughout the years, as well as from outbreaks caused by emergent viruses such AH5N1 outbreak in poultry, Congo Crimean hemorrhagic fever, Hantan hemorrhagic fever, other outbreaks from the past such as cholera and polio, as well as recent occurrences such as last year's measles outbreak. This experience provides the foundation for the effective response to COVID-19, which later on can be adapted according to the situations that arise and to the information that becomes available.

Overview of Albania's national approach
In the face of an outbreak of a serious disease, such as COVID-19, Albania, aim to plan and decide on the measures and steps that ought to be taken and increase their efficacy based on the following principles.
To this day, the COVID-19 situation in Albania remains in Scenario 0, and the steps has taken thus far, summarized below, aim towards having in place a system that allows for timely identification of cases, follow up with their contacts and prevention of spread. The COVID-19 expert committee was established as a decision making body based on medical and scientific analysis of the situation. Furthermore, Albania has established the new coronavirus task force focused on tackling COVID-19 in a cross-institutional fashion, by employing measures to prevent the spread while also reporting and advising the COVID-19 expert committee observations made in the field and steps that might be needed. Case definitions are being updated in real time in accordance with the recommendations from WHO and ECDC. Albania has developed a system to manage the infodemic of misinformation by identifying and addressing rumors spread to create panic in the population. The Institute of Public Health of Albania has prepared guidelines, procedures and plans to early detect and isolate the first case (s) of COVID-19. All local public health agencies and the health inspectorate have worked with border control, port officials and flight carriers to implement and reinforce health measures in all points of entry including temperature control. All guidelines, procedures and plans have been distributed and tested throughout the country. A scheme for cascade training of health care workers with regard to COVID-19 was designed and implemented. Public health units have passed on information to all health professionals on steps needed to be taken in the event of a patient who may have COVID-19. The 127 emergency number, coordinated by national health emergency center in collaboration with public health and health expert teams with trained staff and necessary equipment are able to conduct the triage process and are ready to receive and transport patients providing coverage across the whole country. Upon entering the Albanian territory, all residents and travelers receive a text message on their mobile phones informing them on the importance of calling 127, as a measure to ensure that all people with symptoms are given appropriate advice and tested when appropriate. Public health recommendations with regard to minimizing the chance of transmission of disease have been widely publicized and are updated regularly. Travel advice on what individuals need to know before deciding whether or not to travel and steps to take if they are affected by an outbreak of COVID-19 while travelling has been provided and made public and is continuously updated as the situation evolves. Advice has been provided to first responders, employers, educational institutions, social care institutions and other sectors and business, on identifying and reporting possible cases and taking the necessary precautionary measures. Self quarantine or self isolation is advised for those returning from the affected areas. Guidelines on how to handle individuals under investigation are in place and have been tested. Influenza like illness and severe acute respiratory infections (SARI) surveillance program have been strengthened and adapted to COVID-19.

Containment of the infection
Albania is now in its 9th week of the Covid 19 pandemic as the first cases were recorded on 8th of March in 2 people coming from Italy. Data show that the spread of infection has been contained; (i) the epidemic curve was 'flattened' with infection circulating in clusters only; the number of cases in need of hospitalizations never threatened the stability of health care; (iii) the mortality rate is kept at low levels.

Daily diagnosed cases of Covid 19 in Albania
In the 9 th week of the Covid 19 pandemic, Albania recorded only thirty-one covid related deaths. At the same time, are only thirty-eight patients in two covid hospitals in the country, with only seven of them in intensive care. From 9.806 tests 842 were confirmed positive, with more tests being carried out. Since mid April, the number of recovered cases is higher than the number of active cases and the trend continues. Although the disease has affected most districts of Albania at various degrees, there are still many municipalities with no confirmed cases. There are still active clusters in many regions of the country, and new cases are being identified every day, but the trend during the last two weeks of May, has been on decrease.

Measures taken
Albania has inherited good public health structures from the past and has passed a new bill on control of infectious diseases quite recently. After the Wuhan situation in January, before covid, Albania started to prepare a strategy to respond to an eventual pandemic. Laboratory was equipped with new tests, new epidemiology protocols were developed, and staff in districts was trained. Albania, observed with attention and concern the surge of cases in Northern Italy in late February and drew valuable lessons about the extent and intensity of the measures which would be needed. Alertness was increased to maximum and special measures were introduced for all travelers from Italy. Albania reacts with nationwide measures, starting with schools which were closed on Mars. One day later all flights from Italy were suspended and on Mars 14 th -15 th all national borders were closed. Self quarantine was required for all those who entered the country in the first week of Mars. Some services and activities were closed since 10 th of Mars. From Mars 12 th to Mars 18 th all travel between main cities was limited or banned. On second week of Mars government introduced first limits of moving out of home. Then on third week, all essential activities were limited to 05:00-13:00 o clock. During weekends there was almost total curfew strictly enforced. There has been massive compliance by the public. Also, religious communities of the country supported the measures taken by authorities and suspended their ceremonies or carried them out without public. Since 15 th of Mars measures were introduced to minimize contact with health services, while planed surgeries were postponed and private health services were requested to adapt to the emergency rules. Since 10 th of Mars strict rules were introduced to avoid contagion of residential institutions. On 24 th of Mars Government raised the emergency situation to the highest possible catastrophe. The existing emergency is coupled with the earthquake emergency which left without homes almost 20 000 people.

Adaptation of measures and the normalization strategy
While the measures are being very effective to contain the circulation of the virus and suppress the effect in health of the population and health system, the situation has been hitting the economy and society as whole. After successfully controlling the pandemic during March and April, Albania is adapting gradually and carefully the measures to the epidemiologic situation. Since 25 th of April, Albania has announced the establishment of "green zones". The Ministry of Health and Social Protection of Albania, in collaboration with other ministries, has developed a comprehensive strategy to guide the country through normalization in four (4) phases. This strategy assures that the steps forward be gradual and cautious, accompanied with other measures and intensive monitoring, while health system is continuously strengthened: (i) it is being gradual and cautious; (ii) every decision for lifting some of the measures is followed by two weeks periods of monitoring the indicators; (iii) a system of alerts is put in place and Albania is ready to stop the 'normalization' if indicators start to worsen; (iv) activities are categorized in green, yellow and red, in terms of public health risk, based on a score from one (1) lowest risk to five (5) highest risk. Risk is estimated based on the number of potential contacts, intensity of contacts, geography of contacts etc. Health risk is prevailing over economic rationale.

Recommendation
The activities and businesses with highest public health risk will be normalized the last.
The gradual normalization of activities is being accompanied with extra sanitary measures to be applied during the phases. A list of eight sanitary protocols for a range of businesses is prepared to assure that social distancing is maintained risk of infection is minimized; (ii) health system will continue to be prepared for all scenarios; a new quarantine hospital will be ready in May, stocks of equipments will continue to be increased, and health services normalization will be centrally planned during the phases; (iii) public health and epidemiology capacities for case finding and testing will be strengthened, with new serologic testing already starting. Tests will continue to be carried out intensively to assure good control of infection community spread; (iv) vulnerable categories and risk populations will continue to be specifically protected. Albania has been effective not allowing outbreaks in its residential institutions and will continue to keep in place the measures for protecting its elderly, during all normalization phases; (v) strategy of normalization will be dynamically adapted as international data and knowledge on Covid 19 improves.