Measles Epidemics in Romania: Lessons for Public Health and Future Policy

Measles is a highly infectious viral disease that remains endemic in Romania. This paper presents a synthesis of the available information about measles in Romania, looking at recent outbreaks, some of their underlying factors, and specific control measures. It illustrates the successes and failures of national public health strategies and possible solutions to limit the impact of future epidemics. Because similar issues are being faced in other countries, the management of measles in Romania may offer lessons for researchers and policymakers elsewhere.

Although the disease burden caused by measles had decreased substantially in Romania by the beginning of the current millennium, there have been epidemics in 2004-2007, 2011-2013, and the one that began in 2016. The latter outbreak resulted in more than 15,500 cases, with a total of 59 deaths by the end of 2018. Furthermore, the primary cases of some recent outbreaks in Ireland, Greece, Bulgaria, and Belgium were either of Romanian nationality or had traveled to Romania before becoming infectious, thus making the control of measles in Romania relevant at an international level.

As reported here, low vaccine uptake is a particular issue in vulnerable communities, which is exacerbated by challenges associated with communicating with and offering healthcare to vulnerable subsets of the population. For example, members of the Roma and Sinti minorities were involved in the transmission of the Romanian measles strain in at least 10 other European countries from 2005 to 2007. Similarly, from 2016 onwards, many transmission chains in Europe involved members of these minority groups. With this in mind, if public health strategies were to take into account specific socio-cultural factors and be directed in a more targeted manner toward vulnerable communities, the severity of future outbreaks could be diminished.

These problems are further exacerbated by an inadequate implementation of public health measures, such as the absence of a legislative framework concerning immunisation. As such, even if the government provides the vaccines that are part of the national immunisation programme (including the measles, mumps, and rubella (MMR) vaccine) free of charge, parents can still opt out without having to legally justify this action. The worry is that, if the social, economic, and cultural factors are not evaluated appropriately, legal enforcement of vaccination may lead to public unrest and the inability to deliver the desired outcomes.

A study carried out in 2017 found that, overall, the majority of the Romanian public (83%) believes that immunising children as part of the national vaccination strategy is beneficial. Furthermore, 87% of the surveyed individuals considered that the benefits of vaccination outweigh potential side effects. However, a key element that potentially adds to the ineffectiveness of measles control in Romania is the belief that the healthcare system is unable to provide efficient services. As such, 40% of individuals consider that this is a direct cause of the frequent changes of health ministers, while another 40% believe that the recent national shortage of vaccine supplies is due to the Ministry of Health being unable to handle the situation. Another Romanian study revealed that only about one-third of those surveyed had a high trust in the effectiveness of state-funded healthcare facilities. The individuals cited corruption, insufficient staffing, and the inadequate supply of medication as some of the problems afflicting the national healthcare system. Cumulatively, these perceptions may impact the effectiveness of all public health programmes in Romania, including the management and control of vaccine-preventable diseases (VPDs).

Religious arguments have also been used against vaccination. According to a 2011 census, more than 85% of the population identified as Orthodox Christian. A collaboration protocol was established between the government and the Orthodox Church in 2008 in order to provide "spiritual and medical assistance" to the public, including access to and information about vaccines. However, the Church reportedly often ignores the association of its name with most events or campaigns that advocate against immunisation, and many religious officials actively encourage parents to refuse the vaccination of their children.

Furthermore, in Romania, the increase in the number of books, websites, social media pages, and even public appearances of individuals that are against vaccination are a reflection of the same phenomenon occurring on an international scale. Media coverage of anti-vaccine advocates further enhances public mistrust and detrimental attitudes toward healthcare officials who are involved in immunisation activities. It is suggested here that analysis of anti-vaccine blogs and other types of social media coupled with conducting surveys that inquire about vaccination issues might prove to be useful when designing national public health campaigns. In addition, assessing the main factors that are presented as arguments against vaccination could help shape strategies concerning both immunisations and raising awareness. This information may also facilitate the identification of specific subsets of the population, thus enabling more targeted measures for maximising the efficiency of national public health programmes.

Past experience indicates that a structure exists to support future communication programmes around measles in Romania. The county branches of the Romanian National Institute of Public Health (INSP) regularly offer medical practitioners training sessions that aim to provide them with skills in vaccine delivery and in communicating with patients. Furthermore, in the case of an ongoing epidemic, strategies exist for disseminating information to the community. For example, during the 2016 outbreak, advertisements with widely-known public figures, such as actors and musicians, were aired on television, presenting information about VPDs and their associated burdens. Similarly, the Romanian Ministry of Health developed an official website that presents what is meant to be accessible information about immunisation and explains why achieving a high vaccination coverage is beneficial for society as a whole. Moreover, campaigns were carried out in which posters, leaflets, and other informative materials were provided to healthcare practitioners and the general population. (See, e.g., the video below.)

Looking ahead, "the outcomes of public health measures in Romania will strictly depend on the way in which current and future policies will be implemented. The results will be contingent on thorough evaluations of existing methodologies, efficient public awareness campaigns, adequate intervention strategies, and more targeted measures toward vulnerable subsets of the population....[U]nderstanding why people are hesitant about, or actively opposed to vaccination may provide invaluable insights for designing tactics to address...problems."