Ala Alwan

Influenza in the Eastern Mediterranean Region: identifying the unknowns for detection and control of epidemic and pandemic threats.

Acute respiratory illnesses and influenza-like illnesses (ILI) are a significant cause of morbidity and mortality worldwide. Data from developed countries reveal that seasonal influenza can affect up to 15% of the population presenting with upper respiratory tract infections and may result in up to 500 000 deaths worldwide annually. Despite their public health importance, little was known about the aetiology of these illnesses in the countries of the WHO Eastern Mediterranean Region (EMR).

Essential public health functions: the experience of the Eastern Mediterranean Region

Early 2012, the WHO Regional Office for the Eastern Mediterranean (EMR) worked with Member States to reach consensus on the key health challenges that would be the focus of joint work over the course of the next five years. Five strategic priorities were identified and were subsequently endorsed by the World Health Organization (WHO) Regional Committee for the Eastern Mediterranean, which is the WHO governing body at the regional level, at its 59th session in October 2012 (1). These were: health system strengthening, maternal and child health, prevention and control of noncommunicable diseases, health security and the unfinished agenda of communicable diseases, and emergency preparedness and response. In close coordination with Member States, WHO undertook a comprehensive situation analysis for each priority area, in terms of the nature and characteristics of the challenges encountered, gaps and barriers to action, as well as opportunities for intervention. This was followed by identifying what had to be done to address these gaps. This is summarized in the report “Shaping the future for health in the Eastern Mediterranean Region: Reinforcing the role of WHO 2012–2016” (2, 3). In addition to the pre-existing challenges in the five priorities, the past five years witnessed major developments that had a considerable impact on the public health landscape in the Region. Political changes, social and economic crises, civil unrest and emergencies, as well as rapid demographic changes, have had a significant impact on health of the Eastern Mediterranean populations. The same period has also experienced the unfolding crises in Iraq, Libya, Syria, and Yemen, in addition to the ongoing protracted emergencies in countries like Afghanistan, Pakistan, Somalia and parts of Sudan. Today, almost twothirds of Member States in the Eastern Mediterranean Region are directly or indirectly significantly affected by crises resulting in unprecedented massive population movements (4-6). A common gap that was identified for all five priority areas is the limited availability of public health capacity (7). Although there has been some progress in public health capacity in the Region over the last two decades, this has not matched the overwhelming public health challenges the Region faces. In fact, some countries did not appear to have made a significant improvement in public health within ministries of health during this period. It was clear in 2012 that competencies in public health are insufficient in tackling the health priorities in many countries of the Region. Thus, strengthening public health capacity was established as a special initiative of the Regional Director and was given a high priority during his five-year term. This was translated through a number of regional initiatives launched since 2012, including: the Leadership for Health programme, health diplomacy initiative, refocusing the Eastern Mediterranean Health Journal as a regional public health journal, and reinforcing national public health institutes and associations. One key component of this initiative focused on the assessment of Essential Public Health Functions (EPHFs) (8).

Closer to a polio-free Eastern Mediterranean Region

After a long hard struggle, the start of this decade saw the fight to eradicate polio from the Eastern Mediterranean Region appearing to bear fruit. In 2011 and 2012, only two countries in the Region were reporting wild poliovirus - Pakistan and Afghanistan, two of the last endemic countries in the world. By the end of 2012, when only 95 cases were reported in total from the Region, it seemed that finally stopping the transmission of poliovirus was just around the corner. The number of cases and countries were at the lowest-ever recorded levels.

Essential public health functions for countries of the Eastern Mediterranean Region: what are they and what benefits do they offer?

Public health refers to organized efforts to prevent disease, promote health and prolong life among the population as a whole (1,2). Good public health is among the primary responsibilities of ministries of health of all countries, and Member States of the World Health Organization (WHO) Eastern Mediterranean Region are no exception. Equally, helping countries improve their capacity to avert, and when needed respond to, public health challenges is among the primary responsibilities of WHO. Noble as it is, good public health requires countries to develop their public health system, establish structures and acquire the necessary resources. One way of doing so is by implementing essential public health functions (EPHFs). These are an indispensable set of actions, under the primary responsibility of the State, that are fundamental to achieving the goal of public health through collective action (3).

Highlights of WHO's work in the Eastern Mediterranean Region.

This report provides highlights on the work of WHO in this Region in 2015 and the early part of 2016. It reflects the achievements made and the challenges encountered as well as the way forward and immediate next steps. It focuses in particular upon the five strategic priorities agreed by Member States in 2012: health systems strengthening towards universal health coverage; maternal and child health; noncommunicable diseases; health security and communicable diseases; and emergency preparedness and response.

World Health Assembly: creating a supportive environment for health.

The Health Assembly agreed some key reforms for the Organization. The most important for our region was the agreement on a new health emergency programme. This will change the way WHO provides support to countries during outbreaks and emergencies to ensure faster, more efficient and more effective response. It will also provide much needed support for preparedness, strengthening the capacity of first responders in countries and in WHO country offices. The changes are the result of intensive discussions among and with Member States over the past 18 months and in light of the report of the Review Committee on the Role of the International Health Regulations in the Ebola Outbreak and Response (Ref A/6921).

Strengthening national health information systems: challenges and response

A well-functioning national health information system (HIS) is a prerequisite for the provision of reliable and timely health-related information. This information is essential for: 1) policy development and evidence-informed decision-making; 2) proper health management and rational resource allocation; and 3) monitoring and evaluation of health systems and other related social services performance. National HIS draw upon multiple data sources, including civil registration and vital statistics systems, census, population-based surveys, routinely generated data from health facilities and administrative information systems. These are supported by governance structures, human and financial resources infrastructure and information, communications technology, quality assurance procedures, data management and standards, and clear plans for dissemination, use of the information and evidence generated from the system.

Food safety in the Eastern Mediterranean Region: time to act.

Unsafe food is linked to the deaths of an estimated 2 million people annually – many of whom are children (1). World Health Day 2015 in April focuses on food safety under the slogan “From farm to plate, make food safe” in order to draw attention to the importance of this issue, particularly in view of the global nature of food production and supply, and highlight the need for everybody to play a role in ensuring food safety: governments, manufacturers, retailers and the public.

Paying tribute to health care workers on the frontline.

The cover of this month’s EMHJ shows a candle. This candle was lit on 18 May in the main hall during the first day of the World Health Assembly in memory of all health workers who lost their lives in the service of health in 2014-2015. Lighting of the candle was followed by a moment of silence. It was a poignant moment which reminded those present that we all depend upon the dedication of health workers at some point in our lives. Too often we take that dedication for granted, both in the clinical setting and in the public health setting. In the past year we have lost precious lives to Ebola and MERS-CoV, to politically motivated attacks, and to conflict.

Preventing the introduction of Ebola virus into the Eastern Mediterranean Region: enhanced preparedness is the key.

1Regional Adviser, Pandemic and Epidemic Diseases, Department of Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo Egypt (malikm@who.int). 2Director, Department of Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo Egypt. 3Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo Egypt. The current outbreak of Ebola virus disease (EVD) in West Africa is unlike any of the previous outbreaks caused by the disease because of the unprecedented speed with which it is evolving. A number of countries in western Africa are currently affected – Guinea, Liberia, Sierra Leone and Democratic Republic of Congo. All these countries have now reported laboratory-confirmed cases. The outbreak, which probably began as an event of acute febrile illness associated with a high case fatality rate, was first identified in December 2013 in the Guéckédou region of Guinea– Conakry, a remote region of southeast Guinea bordering Sierra Leone and Liberia (1). It soon escalated with rapidly increasing numbers of cases reported from these three countries, possibly due to constant movement of people across their porous borders, raising a high public health alert across the continent. The World Health Organization was officially notified of an outbreak of EVD on 23 March 2014 (2). The exponential increase in cases from this EVD outbreak and its unprecedented size, pace and scale led WHO on 8 August 2014 to declare this event a public health emergency of international concern (PHEIC) under the International Health Regulations (2005) (3). More recent incidents include the travel-associated spread of EVD to Nigeria and Senegal and the identification of Ebola transmission in the Democratic Republic of Congo, although the molecular data suggest that this event is unrelated to the ongoing outbreak in West Africa (4). Being a zoonotic pathogen, the circulation of Ebola virus among humans is uncommon. Transmission of Ebola virus to humans probably originates from an animal reservoir, possibly involving additional intermediary species, and occurs through direct contact with tissue or bodily fluids of an infected animal (5). This explains the intermittent and unpredictable nature of outbreaks of EVD. In most previous outbreaks, the virus emerged in geographically restricted, rural regions and the outbreaks were contained through routine public health measures such as case identification, contact tracing, patient isolation and quarantine to break the chain of virus transmission. None had spread beyond East and Central Africa (6). The current epidemic is not only by far the largest and most persistent outbreak of the disease reported in its 38-year history, it is also the first ever multi-country outbreak (2,6). After recording cases for almost 10 months, there have been 8033 cases of EVD (confirmed, probable, and suspected) and more than 3879 associated deaths reported from this outbreak as of 8 October 2014 (7); this is more than in all previous Ebola outbreaks combined. What’s more, these numbers are likely to be underestimates, given the limitations of case identification and possible weakness in contact tracing and laboratory identification. In a recent report, a conservative projection has been suggested of close to 20 000 cases by early November 2014 (2), an ominous sign that the epidemic is continuing to expand.