Epidemiological characteristic and prevention
of airborne infectious diseases
General epidemiological characteristic.
Actuality of airborne infections in the republic. Epidemiological and socialeconomical impact of airborne infections in the Republic of Moldova.
Spreading
Table 1
Incidence of airborne infections in the Republic of Moldova (2005)
Nosologcal form
Influenza and acute viral
respiratory infections
Tuberculosis
Diphtheria
Pertussis
Measles
Rubella
Mumps
Meningococcal infection
Chicken-pox
Scarlet fever
Total
Incidence
Number of reported
Cases per 100000
cases
population
186821
5178,2
3674
14
5
13
283
62
8071
196
199139
101,8
0,4
0,1
0,4
7,8
1,74
233,7
5,4
5529,5
In the structure of morbidity caused by airborne infections in Moldova
(2005), 93,8 % amount to flue and viral acute respiratory infections.
The rate of morbidity caused by airborne infection in the structure of
general morbidity caused by infectious diseases registered in Moldova in 2005
was 74,1 %, or those 9 of airborne infectious diseases out of total number of 34
infectious diseases registered in 2005 amount to 74,1% of all cases of registered
infectious diseases.
The social-economic impact
- Level of incidence
- Economical prejudice
 direct expenses for treatment
 expenses for realization of antiepidemic and preventing measures
 number of lost working days
 expenses from social fund
- Severity
 chronicising
 complications
 disability
 lethality
- attitude of the public administration bodies, population, mass-media to
infections diseases
- international importance of infectious diseases
General epidemiological characteristic of airborne infections
- aerogenic mechanism of spreading which is realized in 2 ways:
 with liquid aerosols. Liquid particles containing pathogenic agents are
eliminated from the respiratory tract secret of ill persons (carriers of
pathogenic agents) during speaking, coughing, sneezing) in the air and
through it are spread and reaching the respiratory ways of healthy people
with the inspired contaminated air. This way is typical for spreading of
airborne infections whose pathogenic agents are not resistant in the
environment (temperature, dryness) – measles, rubella, mumps, influenza,
chicken-pox, pertussis.
 With solid aerosols. The liquid particles with pathogenic agents suspended
in the air after a certain period of time depending on their size, temperature,
humidity, and the speed of the air are dried and are transformed in solid
particles that get into the airways of healthy people similarly with the liquid
particles. This way is typical for spreading the airborne infections by
pathogenic agents resistant in the environment – tuberculosis, diphtheria,
smallpox.
- Level of incidence of airborne infections (intensity of spreading) is
determined by the protective level of population immunity. Circulation of the
pathogenic agent in an immune population leads to reduction of their virulence and
absence of cases of illness (states of carriers of pathogenic agents can be formed in
some persons). On the contrary, circulation of pathogenic agents within a nonimmune (receptive) population leads to increasing of the pathogenic agent
virulence and registration of multiple cases of manifested illness.
- Ununiform receptivity of population (nonimmune) to different airborne
infections.
Receptivity of population to an infectious disease is determined by the index
of receptivity (contagiousness) which represents theproportion between the number
of ill persons and the number of receptive persons exposed to the risk of getting ill
(had a contact with the source of infection).
Depending on the index of receptivity (contagiousness) the airborne
infections can be divided in 4 groups:
– Infections with absolute receptivity, index of contagiousness is  100%
(measles, chicken-pox, smallpox). The clinical manifestation of the disease is, as
usual, pronounced. States of carriers are not registered.
– Infections with high receptivity, index of contagiousness is 50-70% (flu,
mumps, pertussis, rubella). Manifested, non-manifested clinical forms are
registered, and can be states of carriers.
2
- Infections with moderate receptivity, index of contagiousness is 15-40%
(diphtheria, scarlet fever). Manifested, non-manifested clinical forms are
registered. The main role as the source of infection have the carriers of pathogenic
agents.
- Infections with very low receptivity, the index of contagiousness is
smaller than 1%. More frequent non-manifested forms and states of carriers of
pathogenic agents are registered (meningococcal infection).
- Periodicity (cyclicity)of epidemic process – the multianual incidence by
airborne infections has a cyclic character, caused by the characteristic of
population susceptibility that is the regulating factor of epidemic process
manifestation. Before implementing the immunization of population the periodicity
of incidence in diphtheria, measles, pertussis, mumps, was 3-6 years. Now the
cyclicity changed both in the level of incidence and the duration between cycles,
and in regard with liquidation of the morbidity or registration of single cases of
illness – this peculiarity in vaccine preventable diseases vaccination is not
manifested.
- Autumn-winter (diphtheria) or winter-spring (influenza) seasonality
caused by decreasing the local resistance of the mucous membrane of the
respiratory system organs, being indoors for a longer time and more intensive
realization of transmission mechanism.
- increased incidence through airborne infections in groups of population
with high epidemiologic risk of contamination (in children medium).
Contamination in the first months (years) of life of receptive childrenresulted in
illness and forming of long term postinfectious immunity. In airborne infections
preventable by vaccination this peculiarity has changed – cases of illness are
registered also in adult population (diphtheria, measles, rubella), bat in nonpreventable diseasesthe peculiarity remained until now (chicken-pox, scarlet fever,
meningococcal infection).
- In combating the with airborne infection the main role belongs to
immunoprophylaxis. Out of 10 infections included in NPI, 7 are airborne – TB,
Diphtheria, Pertussis, Measles, Rubella, Mumps and Hib. Airborne infections
controlled by immunoprophylaxis are called “Vaccine preventable infections”.
- in the group of airborne infections there are emergent diseases
(registered for the first time during the last 5 years) – severe acute respiratory
syndrome, avian flu with flu virus A (H5N1) and re-emergent – TB, diphtheria
epidemic outbreak of diphtheria in Moldova in 1994-1996 in Moldova and in the
new independent states and increasing of incidence by TB in 2005  5 times in
comparison with the level of incidence at the end of eighties of the last century.
- according to the epidemiological classification depending on the source
of pathogenic agents, the airborne infections are included into the group of
anthroponoses. For this group of infections the medium of maintaining of
pathogenic agents as a biological species is the human population. In the medium
of human population the airborne infections are spread from one person to another,
causing the appearance of epidemics, epidemic outbreaks, pandemies
3
Diphtheria
An acute infectious disease caused by C.Difteriae, manifested by
membranous inflammation (diphtheric membranes) of uppe respiratory tract
(usually pharynx, but can affect palatine tonsils, nasal cavity, larynx, trachea), and
affecting other organs including myocardium, nervous system, kidneys (by
microbial exotoxins).
Epidemiologic characteristic of pathogenic agent.
Heterogenic population:
- 3 biological types (depending on the morphological, cultural and
fermentative properties) containing about 70 serovariants
 gravis
 mitis
 intermedius
- depending on the capacity to produce the exotoxin all types of
corinebacteria are divided in two groups
 toxicogenic: (all biotypes produce the same exotoxin. The toxicogenity is a
genetically stabile property determined by the presence of the tox + genes
integrated into the corinebacteriua genome). The exotoxin treated with 0,30,4% solution of formalin and maintained at a temperature of +38-400C
during 14 days in a thermostat loses its toxic properties, but keeps its
immunogenic properties. Thus a new preparation is obtained – toxoid
(anatoxin), used for the immunoprophylaxis of diphtheria.
 atoxigenic microorganisms not containing tox+ genes don’t produce
exotoxin and don’t cause a disease.
- pathogenic agents of diphtheria are resistant to the action of different
environmental factors:
 in milk, water – 20 days
 under sunrays resist several hours
 in the temperature of +600 resist 10 minutes
 are resistant to dryness (airborne mechanism of transmission can be realized
both with liquid and solid aerosols)
 are sensitive to the action of disinfectant solutions in usual concentration.
 are sensitive to the action of antibiotics ( erythromycin, tetracycline used
for treatment of patients and sanation of corinebacteria carriers).
Mechanism of epidemic process developing
- source of pathogenic agents
 diseased person – from the epidemiologic point of view, diseased persons
with mild, atypical clinical forms presents a bigger risk for spreading the
diphtheria. At this patients as a rule the diagnosis is establish with delay that
leads to complications. The diseased person eliminates pathogenic agents in
the last 2-3 days of the incubation periods and in the period of clinical
manifestation.
 Carriers of corinebacteria
4
cases per 100000 population
 reconvalescent
 healthy (of toxicogenic corinebacteria)
Duration of the state of carriers can up be to several months (90 days), in
medium – 20-30days.
- Mechanism of transmission. Clinico-epidemiological forms of diphtheria
 with liquid and solid aerosols (airborne, main)
 by food products (water, milk) very rarely
 by contact with objects contaminated with pathogenic agents (underwear,
dishes, books, toys, etc.). Extrabuccal forms are developed; skin diphtheria,
diphtheria of mucous membranes of eyes, genital organs.
- Receptivity of population. In the natural conditions the index of receptivity
(contagiousness) as a rule doesn’t exceed 40%. After disease long term
antitoxic and antibacterial typospecific immunity is developed.
- Manifestations of epidemic process (there are 2 forms – morbidity and
cases of carrier)
- Level of incidence of diphtheria correlates with the level of population
immunity.
Diphtheria is included in the Extended Global Program of Immunization and in
NPI of over 200 countries of the world. In most of the countries the incidence
has now a sporadic character. In the prevaccinal period diphtheria has a global
spreading with a lethality of 10-15%, with increases of incidence once in 6-10
years. In the Republic of Moldova in prevaccinal period the average index of
morbidity was 22 cases at 100 thousand of population (fig. 1 ).
45.00
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
2004
2001
1998
1995
1992
1989
1986
1983
1980
1977
1974
1971
1968
1965
1962
1959
1956
1953
1950
1947
1944
0.00
Fig.1. Incidence by diphtheria in the Republic of Moldova, 1994-2005
In the fifties of the last century in our republic the planned immunoprophylaxis
started and the level of incidence began to degrease dramatically up to sporadic
cases. After a favorable epidemiologic period of over 20 years (1968-1990) when
on average 3 cases per year were registered, at the beginning of nineties the
5
incidence began to grow up, manifested in an epidemic spreading. Thus in 19941996 in the republic a epidemic of diphtheria was registered with 888 cases of
illness, 46 patients (5,2%) died (fig. 2).
cases per 100000 population
12.00
10.00
8.00
6.00
4.00
2.00
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
0.00
Fig. 2 Epidemic outbreak of diphtheria in Moldova in 1994-1996
450
400
350
300
250
200
150
100
50
0
80
60
40
20
0
Nr. of cases of illness
100
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
coverage with vaccination
The epidemics started as a result of deficiencies in immunoprophylaxis due
to insufficient assurance with vaccines in the previous years (that caused the
decrease of the index of coverage with vaccination in 1990-1993 up to 70%,
Fig.3),
DTP3
Diphtheria
Fig. 3 Coverage with vaccination and morbidity by diphtheria in 1990-2005
implementation of imperfect schemes of vaccination, especially for children under
one year – using for primary vaccination of children with some relative
contraindications of DTP-M vaccine which in many cases doesn’t lead to forming
a protective immunity but vice versa, leaded to accumulation of persons with non6
protective immunity. The epidemic spread of diphtheria in the republic was also
conditioned by the influence of diphtheria outbreaks in Russia and Ukraine.
Re-emergency of diphtheria in the republics of the former USSR and in
some European countries, according to WHO conclusions, was conditioned by the
unsatisfactory coverage with vaccination of children and other target groups of
population.
Factors that favoured the re-emergency:
 intensive migration of population
 delayed diagnosing (reduced attention of physicians and population)
 absence of reserves of antidiphtheric serum and antibiotics for
treatment and sanitation of carriers of corinebacterria.
Autumn-winter seasonality, a higher level of incidence in children age group
and other peculiarities of incidence characteristic for epidemic spread are not
registered now.
State of carrier of toxicogenic corinebacteria at immune persons is another form
of manifestation of epidemic process, being especially actual in the period of
registering sporadic cases of disease.
Incidence of states of immune carrier of toxicogenic corinebacteria correlates
with morbidity by diphtheria (tab.2). With reducing the number of cases of disease,
the frequency of registering of states of healthy carriers of toxicogenic
corinebacteria is decreasing.
Table 2
Correlation between the cases of illness and states of healthy carriers of
diphtheric corinebacteria in the republic in 1990-2005
Period of time
1991-1993
1994-1996
1997-2000
2001-2005
Number of cases of
diphtheria
Number of cases
of healthy carrier
of toxicogenic
corinebacteria
Correlation of
cases of
illness/states of
carriers
71
888
78
6
192
1319
88
3
1 : 2,7
1: 1,5
1:1,1
1: 0,5
This peculiarity contributes to maintaining of the favorable epidemiological
situation and further reduction of the risk of diphtheria spreading. At the same time
the existent measures of control of diphtheria don’t allow to put the task of
eradication of diphtheria (maximal realization is liquidation of incidence).
In spreading of diphtheria in the republic in 1991-2005 the following
manifestations of epidemic process can be outlined:
- aggravition of epidemic situation(1991-1993);
- epidemic spread (1994-1996);
- postepidemic decrease of incidence (1997-2000);
7
- stabilizing of incidence at the most reduced level – single annual cases or
absence of cases (2001-2005).
Antiepidemic measures.
- Early detecting of cases of diphtheria and urgent information about each
case of disease and state of carrier of toxicogenic corinebacteria. Early
detecting and confirmation of cases by laboratory investigation with the
purpose of:
 diagnosing (at persons with suspected diagnoses of diphtheria according to
the definition of standard case).
 epidemiological indication (examination of persons who were in a contact
with people with diphtheria or carriers of toxicogenic corinebacteria).
 preventing (some groups of population with high epidemiologic risk of
spreading are examined – children before admitting to kindergartens,
schools, orphanages, summer camps; patients of psychiatric hospitals, etc.).
- Hospitalization of patients with suspicious diagnosis of diphtheria and
carriers of toxicogenic corinebacteria is mandatory. Treatment with antitoxic
serum and antibiotics as soon as possible after the beginning of the disease.
- Dismissal of patient (carrier) after 3 negative bacteriological examinations.
- Measures of liquidation of the focus of diphtheric infection:
 terminal disinfection with 1-2% solution of chloramine and disinfection in
drying stove.
 medical supervision of people from the focus during 7 days including
thermometry twice per day, consulting by ENT specialist once in three
days.
In case of an epidemic spread of diphtheria, an additional immunization of
population is organized.
Criteria of vaccination according to the epidemiological indications (companies
of immunization) are:
 high rate of toxic forms at patients with diphtheria (15%)
 registering lethal cases among the vaccinated children
 insufficient level of coverage of population with vaccination (70%).
Preventing the diphtheria includes:
Immunization of target groups of population according to NPI (schedule of
vaccination)
 coverage with vaccine of 95% minimum with 4 doses of DTP of children
up to the age of 3 years
 coverage with vaccines of 95% minimum with diphthero-tetanic vaccines of
target groups of children and adults.
The main role in carrying out these activities belongs to the medical
personnel of the primary health care system.
8
Measles
Is an acute infectious disease characterized by fever, cough, conjunctivitis,
rhinitis, maculo-papulous skin eruption and specific enanthema (Koplik
spots)
Complications of measles – are registered in  30% cases of illness more frequent
in children under 5 years and adults (20 years and older).
 Diarrhea (8%)
 otitis media (7%)
 pneumonia (6%)
 encephalitis (0,1%) with a lethality of 15% and different residual
neurological manifestations – 25%
 epileptic seizure (0,6-0,7% with or without fever)
 death (1-2 cases per 1000 patients with higher risk at children older than 5
years and adults. In 60% of cases the death is caused by pneumonia);
 subacute sclerosing panencephalitis (is a rare incurable complication of
the CNS that is supposed to develop due to a long persistence of the
measles virus in the brain on average after 7 years or more after the
disease).
Complications are more frequent registered in patients with chronic diseases,
malnutrition.
Epidemiological characteristic of pathogenic agent
The measles virus is a paramyxovirus, gene Morbillvirus. It was isolated in
the culture by J.Enders and T.Peebles in 1954 in the cell culture of monkey
kidneys and human embryos.
- stable antigenic structure (one serotype)
- sensitive to the action of environmental factors
 dryness
 light (is inactivated in 8-10 minutes)
 temperature (resists at t0 370C up to 2 hours and at 560C – up to 30 minutes)
 acid medium (pH – 2,0-4,0)
Mechanism of epidemic process development
- source of pathogenic agents
 ill person – eliminates pathogenic agents in the last days of the period of
incubation, prodrome (catarrhal) period and period of appearance of skin
eruptions.
Mechanism of transmission – with liquid aerosols
Receptivity of population – absolute. Non-vaccinated persons and without
immunity after a contact with a ill person are getting ill in 100% of cases
independent of age.
Manifestations of epidemic process
9
- Incidence. Despite the decrease of the level of incidence by measles in most
countries of the world and even elimination of measles in USA, Canada,
some countries of Western Europe, this disease remains at the global level
one of the main causes of children death. In the European region in 2004
about 30 thousand cases of measles were registered, and in 2005 – 27
thousand.
In the last 15 years in the European Region the number of registered cases of
measles decreased considerably and its reporting was improved (tab.2).
Table 2
Number of registered cases of measles and the reporting in different zones of
European Region to WHO in 1991 and 2001
Zones
Number of
cases
Western Europe
229447
Central
and
31585
Eastern Europe
New independent
43122
states (NIS)
Total
304184
1991
2001
% of countries Number of % of countries
that reported
cases
that reported
83
16575
96
100
30782
94
100
20402
100
92
67759
96
2004
2000
1996
1992
1988
1984
1980
1976
1972
1968
1964
1960
1956
1952
1948
1600
1400
1200
1000
800
600
400
200
0
1944
cases per 100000 population
Incidence by measles in the Republic of Moldova in prevaccinal period was
maintaining at a high level (560-1400 cases at 100 thousand population) with a
periodicity of 2-3 years (fig. 4).
Fig.4. Multiannual incidence by measles in the Republic of
Moldova 1950-2005
10
After implementing the immunoprophylaxis of measles the character of incidence
has changed: decreased the level of incidence beginning with the sixties and the
duration of cycle increased, especially in the last years.
A peculiarity of multianual incidence by measles is the higher level in the
children medium, but in the year of epidemic increase of morbidity a slight
increase of morbidity in the adult population is manifested too (fig.5).
cases per 100000 population
1200.00
1000.00
800.00
600.00
400.00
200.00
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
0.00
Fig.5. Multiannual incidence by measles in children and adults
in the Republic of Moldova 1979-2005
In 2002, when the last increase of incidence was registered, the adult
population (including children older than 14 years) was more affected than in
previous periodical increases. This peculiarity can be probably explained by the
reduced level of incidence in 1996-2005 and accumulation of receptive population
(children, adults) that favourised the epidemic spread of measles in 2002.
Totally during the epidemics of measles in 2002 were registered 4928 cases
of measles as epidemic outbreaks in schools, institutions of higher education,
colleges and other collectives. From collectives the infection was spread in
families that favourised the illness of over 160 children under 1 year who didn’t
reach the eligible age of vaccination.
In the period of increasing of the level of incidence was characteristic the
winter-spring seasonality although deviations in May-June were registered.
Nosocomial cases of measles were also registered.
The results of analysis of incidence in the last years, WHO
recommendations, were widely used for collaboration and implementation of new
strategies for combating of measles in Moldova.
11
Antiepidemic measures
- early diagnosing and hospitalization of patients;
- urgent information of territorial CPM;
- active detecting of ill persons in the focus;
- evaluation of the state of immunization of population in localities where
cases of illness were registered;
- medical surveillance of people from the focus (who had a contact with the ill
person) during 21 days:
 examining the airways mucous membranes
 conjunctiva
 teguments
 palpation of lymphatic ganglions
 focus visiting by the medical worker once in 3-4 days;
 administrating an additional dose of vaccine in 72 hours after detecting
the patient to persons that had a direct contact with the patient (younger than
20 years, don’t have a measles history, or it is impossible to establish if they
had measles , were not vaccinated or the dates of vaccination can’t be
established, or received a single dose of vaccine more than 6 months ago)
 Vaccination of contacting persons in the focus is indicated beginning with
the age of 10 months
 Administering normal human immunoglobulin in the first 5 days of
contact to persons who have contraindications for vaccination (information
about vaccination and administering the immunoglobulin should be written
in the medical documents of vaccination evidence).
- Establishing the borders of the focus and persons who had contacts with
the ill person (will be done taking into consideration the difficulty of
establishing preventive diagnosis of measles, airborne way of transmission
by aerosols with a high degree of dispersing at a relatively big distance, high
receptivity of non-immune persons. Thus the borders of the focus depending
on the particular situation will comprise the family, block, house, institution,
enterprise, and even some rural localities as a whole).
- In collectives with a high degree of contact and risk of spreading of
measles during 21 days after isolating the last patient, new persons who
didn’t have measles or are not vaccinated against measles are not admitted.
- In collectives with a high spreading risk of measles (institutions of
education, sanatoriums, summer camps, army, etc.) persons younger than
35 years are not admitted without medical documents where information
about vaccination against measles is included.
- Antiepidemic measures in the measles focuses are done by the medical
personnel of the primary health care institutions and the medical personnel
of the respective collective.
12
Measles prevention
In the Republic of Moldova the prevention of measles now is done in
accordance with the Global Strategic Program of measles prevention approved by
the WHO in 2001.
The goal of the Global Strategic Program is liquidation of measles. In
accordance with the Global Program, the European Bureau of the WHO defined
the strategic goal of the measles prevention program in the countries members of
WHO of the European region –
Interrupting the epidemic transmission (spread) of measles in the European
region (eliminating the measles from the European region)
This activity in the Republic of Moldova is done according to the National
Plan of eliminating the measles, combating the rubella and mumps, preventing
the congenital rubella for 2002-2007 years.
Carrying out the activities foreseen by the National plan has the goal
creating of a immune protective layer among the whole population (not only
children).
Beginning with January 2002 in our republic the vaccine MMR is used and
the vaccination against this infection is done with two doses (at 12 months and 6-7
years) according to the NPI for the years 2001-2005. (For a long time in the
Republic of Moldova one dose of mono-vaccine was used for anti-measles
vaccination in comparison with the European countries and NIS, where 2 doses
were used).
The company of immunization against measles (and rubella) started in
November 2002 and was carried out in two steps:
- The first step with the duration of 2 weeks foreseen the immunization of
persons of the age of 7-22 with the vaccine MR.
- The second step with the duration of 3 months immediately after the first
step foreseen immunization of women of the age of 23-29 with a rubella
vaccine.
Objectives of the company:
 Assuring the coverage with the vaccine MR of persons of the age of 7-19
years at a 98% level.
 Assuring the coverage with the vaccine MR of persons of the age of 20-22
years at a 90% level.
 Assuring the coverage with the vaccine MR of persons of the age of 23-29
years at a 90% level.
In general lines the strategy of eliminating the measles is based on:
- vaccine coverage of children over 95% with two doses (at the age of 12
months and 6-7 years);
- setting up and functioning of an efficient surveillance and control system
(implementing the standard case definition for a complete detection of the
infection) and strict antiepidemic measures in the focus (enumerated
before).
Indexes of qualitative epidemiologic surveillance of measles for carrying out
the program of measles elimination.
13
 Rate of incidence by measles beginning with 2009  1 confirmed case at
1000000 population.
 Rate of registration of suspected cases of measles 2 cases at 100000
population at the national level and  1 case at 100000 population at the
level of administrative territory.
 Laboratory confirmation – carrying out laboratory examinations of adequate
blood samples in 80% of suspected cases. (The adequate blood sample is the
blood sample collected in the period of 4-28 days after appearing of
eruptions, in the volume of 3-5 ml, with the serum collected separately
(without hemolysis) stored and transported at a cool temperature, noncontaminated and accompanied by the approved statistical form.
 Transportation of 80% of samples for examination to the territorial CPM in
the day of collecting.
 Transportation of 80% of samples for examination to the NSPCPM
(reference laboratory) in the first 24 hours after their arrival to the CPM
laboratory.
 Registration of 80% of samples registered at NSPCPM in 24 hours after the
day f their arrival to the laboratory.
 Final classification of suspect cases of measles in the first 60 days after
eruptions appearing (after 60 days this indicator should be zero).
 Determining the possible place of contamination in  80% of confirmed
cases of measles (classification of case in: imported case, case
epidemiologically linked with an imported case, case with local
contamination, etc.).
 Presenting monthly reports to the NSPCPM in time  80% (before the date
of 5 of the next month the CPM will present a month report – form nr.2).
 Presenting - before the date of 25 of the next month by the NSPCPM to the
ERB WHO a month report  80% .
 Epidemiological investigation of the suspect cases of measles in the first 24
hours after registering the urgent information  80% of focuses.
 Investigation of epidemic outbreaks of measles (5 and more cases
epidemiologically linked) with laboratory examination of not less than 5
patients  90% of outbreaks.
14