Global Health and Herd Immunity: Albania’s Response to the COVID-19

Antea Garo, Princeton University

Covid-19 in Albania

The Albanian government’s initial strategy to the Covid-19 pandemic included a very quick and strict response. On March 8th, 2020, two cases of the virus were reported, and shortly after, on March 10th, 2020, the first lockdown measures were announced: private and public transport was banned in most counties, public gatherings were restricted, and all educational institutions transitioned into virtual learning. An incredibly strict stay at home order was put in place where citizens could only leave the house for an hour each day with the purpose of buying groceries or in the case of a medical emergency. Going outside to exercise or meet other people was prohibited. Albania’s response was relatively more severe than that of other European countries. For example, the United Kingdom (UK) and France went into lockdown on March 16th and March 17th of 2020 respectively, when the UK had 1,399 cases and France had 7,031 cases. Despite these numbers, residents in both countries were allowed to leave their homes for basic needs and exercising outside was allowed without any sort of time restriction. When comparing this to Albania, which enforced a strict lockdown after only two cases had been recorded in the country and extremely limited the citizens personal freedom to leave the home, it raises the question as to why this response was chosen and enforced? Geographically, Albania neighbor’s Italy, and during February of 2020 the virus “disproportionately hit” the northern area of Lombardy. In fact, “[a]s of March 26, it held a grim record of nearly 35,000 novel coronavirus cases and 5,000 deaths in a population of 10 million,” leading to an unprecedented healthcare crisis. Fearing that a similar situation would occur, the government decided to take more serious measures to contain the Covid-19 outbreak, as they did not want Albania’s already strained and poor healthcare system to collapse. The strict lockdown and restrictions were put in place to buy time until more information about this virus was discovered. After approximately three months of strict lockdown, a total of 1,143 cases had been recorded in the country, an estimate that was relatively lower than that of other European countries at the time. However, at this point there was a widespread public demand to ease the covid restrictions put in place because unemployment was rising and the economy was on the verge of collapsing. Due to social and economic pressures, the government decided to open up the country almost entirely, with the only restrictions being a night curfew and limited international travel. This sudden opening of the country increased the number of people drastically, as by August 2020, around 10,000 cases of Covid were officially reported, almost 10 fold the amount that had been declared by the end of May.

SARS-CoV-2 Antibodies and Herd Immunity Study

Due to the fact that Albania went from complete isolation to very sudden freedom in a short amount of time without any gradual transitioning, a study was conducted by the Faculty of Sciences that looked into the rapid increase of SARS-CoV-2 antibodies in Tirana, the capital city of Albania, from June to December of 2020. They were attempting to calculate the “change in the proportion of individuals showing immune response to Covid-19,” and through this they were attempting to understand disease dynamics, specifically herd immunity, a phenomena where “a large portion of a community (the herd) becomes immune to a disease, making the spread of disease from person to person unlikely.” The methodology of the study is as follows: it was conducted in two separate rounds ranging from June 27th until July 3rd 2020 and from December 21st until December 28th, participants of the study “were randomly selected from lists of the inhabitants… [from] four primary health centers in Tirana,” and serological testing “was performed by an ELISA method which determines IgG class antibodies… of SARS-CoV-2 virus.” The results of the study demonstrated that during the first round, from June 27-July 3, the “proportion of individuals classified as seropositive… was 7.5% (95% CI: 4.3%-10.7%).” By the second round of the study, from December 21-28, “the proportion rose sharply… reaching 48.2% (95% CI: 44.8%-51.7%).” Two additional aspects to note in regards to the results are that no statistical significance was discovered between gender and age categories, and the prevalence of seropositive individuals was higher amongst those who reported Covid-19 symptoms. In other words, the study concludes that approximately 7.5% of the population in Tirana had Covid-19 antibodies in late June 2020 and that number increased to 48.2% by December of 2020. The study concluded that “the ratio of total infected cases over confirmed cases was estimated to be higher than 10 to 1 in Albania. The rapid increase [of] SARS-CoV-2 seroprevalence observed in Tirana… may have been facilitated by a number of factors.” These factors, the study concluded, may have been the low disease exposure rate during the strict lockdown from March to May of 2020, followed by the “consecutive high susceptibility” of the population following the end of lockdown.

Behavioral and Anthropological Factors Regarding Rapid Covid-19 Spread in Tirana

As the study itself concludes, there may be a number of factors that led to rapid spread of Covid-19 in Tirana, which caused approximately 50% of the population within the city to have SARS-CoV-2 antibodies according to the study. The two most significant factors that may have led to the spread and the phenomenon of herd immunity within the population can be narrowed down to urban spacing and distrust in the government. Urban spacing was a problem that prevailed in Albania prior to the pandemic; however, this unprecedented public health crisis highlighted just how dire citizen’s living conditions were. They were less than ideal as “43.3% of households in Albania lack high speed Internet, making teleworking and home-schooling difficult.” In fact, many elderly citizens, who continue to remain a large part of family structures in Albania, did not have access to technology that could help them communicate with their loved ones during this time, adding further distress and comfort during an already difficult moment. When restrictions were lifted, families reunited almost immediately to cope with the social isolation they had experienced, without thinking twice about the health danger they may place on themselves and others. In addition to this, Albania has experienced “rapid uncontrolled and unregulated urbanization” since the fall of communism in 1990, and since this urban planning was quite poor it led to the formation of “Slum-like communities” around major cities, particularly in Tirana. This led to overcrowded conditions that further facilitated the rapid spread of Covid from June to December. Besides the living condition concerns, the public also began to distrust the government more than it already had prior to the pandemic, and this is due to the unnecessary fear and severe restrictions placed on citizens during lockdown. Government figures decided to utilize war-like rhetoric to describe how they were handling Covid-19, stating that they had “created a task force” or had gathered an “army of volunteers [who] are working to provide aid” or mentioned that “regions of the country are being blockaded.” This rhetoric was used to convince the population that they should “obey order and do [their] duty” to fight a common enemy, without taking into consideration how these words could have long-term mental health consequences on the population. By the end of May 2020, most of the public had had enough, and began to challenge the severe restrictions that seemed to do more harm than good. Many stopped listening to public health advice, wearing masks, or practicing social distancing, which may factor into the rapid spread of Covid-19 that occurred as the year followed.

Conclusion

The response to the Covid-19 pandemic that the Albanian government undertook is an intriguing case study of how a fast epidemiological response still failed to stop the spread of the disease. Due to a shortage of testing and medical equipment, poor healthcare conditions, economic collapse, and fear-focused rhetoric used in the media, many aspects of the pandemic were unfortunately mishandled. Therefore, despite strict isolation initially, the disease still managed to spread and infect approximately half of the population in Tirana by 2020, demonstrating how herd immunity also played a large role in disease dynamics in the country.