Situation in 2012-2016

The public health response to the threats of emerging and other endemic-prone communicable diseases in the Region has remained a constant challenge since 2012. The Region has faced repeated outbreaks from emerging diseases, while the complex humanitarian emergencies and protracted conflicts have heavily damaged already fragile health systems, making communicable disease control and elimination efforts extremely difficult and challenging.

In 2012, communicable diseases were estimated to be still responsible for around a third of all deaths and a third of all illnesses in the Region, seriously hampering health and socioeconomic development in some countries. Of the three remaining polio-endemic countries in the world, two were in the Eastern Mediterranean Region and accounted for most of the reported cases, threatening the gains made in global polio eradication. HIV continued to spread fast, while the burden of malaria and tuberculosis remained high, particularly in group 3 countries. The coverage and quality of HIV, malaria and tuberculosis programmes needed improvement. While new HIV infections in the Region are still increasing, treatment coverage was the lowest among all WHO regions. More than half of all tuberculosis cases were estimated to be unreported. Viral hepatitis was a silent epidemic in some countries.

The Region has experienced a rise in the number of emerging and re-emerging communicable diseases, including avian influenza, brucellosis, cholera, dengue and other viral haemorrhagic fevers, diphtheria, measles, yellow fever, Middle East respiratory syndrome coronavirus (MERS-CoV), West Nile virus and hepatitis A. Immunization and control programmes for vaccine-preventable diseases have faced daunting challenges in several countries, leading to rising rates and incidence of vaccine-preventable diseases. The regional elimination goal for measles faced a major setback owing to the drop in vaccination coverage of susceptible populations.

Health security is a critical concern. Adherence to the core capacities required under the International Health Regulations (2005), an international legal agreement binding on all Member States, remain severely compromised owing to critical gaps in countries’ health systems. As the security situation has worsened, control and elimination efforts for many high-burden communicable diseases have halted and prevention efforts deteriorated. Country capacity for surveillance to detect and respond to outbreaks, evaluate programmes and project future needs was identified as a particular challenge, especially in group 3 and group 2 countries.

Progress 2012-2016

Any examination of the Region’s response to controlling the burden of communicable diseases must take into account the Region’s worsening and perpetual security situation. The fact that outbreaks of communicable diseases have been rapidly contained so that they did not escalate into epidemics or pandemics, and did not spread internationally from the Region, is in itself a measure of considerable success and significant public health achievement. The critical challenges to disease control have been, and remain: widespread displacement of populations, damage and destruction to health care facilities, disruption of essential public health services, and migration of health care workers fleeing violence, decreasing access to health care services including medical supplies and vaccines, and the targeting of health care workers through armed attack.

The Eastern Mediterranean Region is now the only WHO region where polio continues to be endemic. In 2012 Afghanistan and Pakistan implemented national emergency plans, demonstrating high commitment to improving programme performance and accountability. This was supported by a surge in technical support from WHO and international partners, and enhanced advocacy from community and religious leaders to counter disinformation campaigns on the part of some groups. In 2013 outbreaks of polio in the Horn of Africa and in the Middle East were immediately recognized as a serious threat to health security, and a public health emergency of international concern was declared by the IHR emergency committee. A monumental effort ensued by national governments throughout the Region and health partners to drive out the virus. Since 2012, the number of polio cases has dropped significantly. There are still areas in Afghanistan and Pakistan where poliovirus continues to circulate due to vaccination coverage gaps caused by inaccessibility, refusal by parents to have their children vaccinated, and programme operational deficits in accessible areas. Insecurity and attacks on polio workers, and spread of misinformation, also continue to hinder efforts to reach children with vaccines in some areas.

Compliance with the International Health Regulations (2005) has been strongly advocated among Member States and stakeholders as necessary for national, regional, and global health security. Following the outbreak of Ebola in west Africa, and at the request of Member States of the Region, WHO carried out rapid assessments of countries’ capacity to detect and respond rapidly to a case of Ebola. The findings highlighted gaps in the outbreak prevention and control capacities of all countries, including in countries that had previously reported readiness to implement IHR 2005. The assessments carried out by WHO also revealed the limitations of the IHR self-assessment tool, which led the Regional Committee at its 62nd session in 2015 to call for the adoption of an independent assessment and the establishment of a regional assessment commission on IHR to facilitate and provide technical guidance to countries and to oversee the process of independent joint external evaluation. Our region has been leading in harmonizing the IHR assessment tool with the Global Health Security Agenda (GHSA) tool and the development of the Joint External Evaluation (JEE) tool which is now adopted by all WHO regions and the GHSA.

A strategic revamping of IHR implementation with a new monitoring and evaluation framework has been developed with four components: annual self-reports from Member States, after-action reviews in response to outbreaks/crisis, simulation exercises, and independent joint external evaluations. Every Member State has now established an IHR national focal point. Countries have developed plans for IHR implementation, and there has been increasing recognition of the critical importance of strengthening measures at points of entry for managing health threats.

Major and widely threatening infectious diseases that were investigated and rapidly contained over the past five years include yellow fever in Sudan; hepatitis A in Iraq and Jordan; cholera in Iraq; epidemic influenza in Iraq, Jordan, Kuwait, Libya, Egypt, Tunisia, Yemen and Pakistan; avian influenza A (H5N1) infection in Egypt; Middle East respiratory syndrome (MERS) in Saudi Arabia and other countries; and dengue fever in Pakistan, Yemen and Sudan. Timely and effective response efforts helped avert major international health emergencies from these threats. An early warning, alert and response network system was established and rapidly expanded for early detection and response to health threats in all the countries affected by the Syrian crisis and other emergencies. The value of establishing this network was exemplified by the fact that major epidemics were averted. A regional network of experts and technical institutions was established to facilitate support for international outbreak response.

Surveillance systems for influenza-like illness and severe acute respiratory infections were established to build local capacity for early detection, recognition and response to any novel influenza virus with pandemic potential. A total of 16 national influenza centres have been established in the Region for influenza virus isolation, sequencing and antiviral resistance testing. In addition, the Pandemic Influenza Preparedness Framework, a unique publicprivate partnership initiative, was rolled out to strengthen the capacity of countries for detection and response to influenza with pandemic potential and to increase access to vaccines and other pandemic-related supplies. Laboratories for disease prevention, detection, and control have also been strengthened.

Despite the continuing challenges, regional average of DTP3 coverage was maintained at 82% and 14 countries maintained DPT3 routine vaccination coverage above 90% in 2014. Despite outbreaks in several countries, overall, the number of reported measles cases fell by half between 2011 and 2014. Measles campaigns were implemented in 12 countries during 2015, reaching over 65 million children with measles-containing vaccine. Considerable progress was made in capacity-building and planning and evaluation for immunization programmes and national immunization technical advisory groups now established in almost all countries. A new regional vaccine action plan was endorsed for implementation by the Regional Committee in 2015. In crisis zones where health facilities were damaged, destroyed or nonexistent, including camps for displaced persons, innovative mobile and community-based approaches to care were implemented with success. Such innovations resulted in closing the gaps in immunization coverage, including for measles.

A regional operational framework has been developed to implement the global action plan for combating anti-microbial resistance in the Region. Data and evidence has been generated on the burden, scale and magnitude of the threat of antimicrobial resistance in the Region and public health actions have been harmonized with the animal health sector for an integrated and coordinated approach to combat this emerging threat to mankind.

Treatment coverage for HIV care nearly doubled from 2011 to 2014, although overall coverage for antiretroviral therapy of eligible people is still below 20%. A steady increase in notification of new TB cases has occurred since 2012, while the treatment success rate improved, reaching 91% in 2015, well above the global target of 85%. The estimated incidence and death rates due to malaria decreased from 2010 to 2015.

Way forward

In addition to stepping up response efforts to control communicable disease outbreaks, action must be focused on health security, namely, full compliance by all countries with the International Health Regulations (2005). Capacities that are required under the IHR (2005) must be achieved. Although self-assessments indicated fairly high implementation levels with the regulations, subsequent assessments in response to potential importation of Ebola found many critical gaps in countries. These gaps, such as the absence of operational coordination structures, emergency operating centres and real-time monitoring of acute health threats, need to be filled through concerted efforts by Member States. WHO, with Member States, has defined specific steps countries must take and provided technical support and capacity building to support full IHR (2005) compliance. Using the new harmonized Joint External Assessment and working jointly with the Global Health Security Agenda, IHR core competencies will be assessed in all countries. We have set a target of 10 countries to be assessed in the remaining part of 2016, starting with Pakistan which completed the assessment in early May 2016.WHO and countries need to roll out the strategic framework for prevention and control of emerging diseases, and develop a framework for integrating the early warning system for disease outbreaks in countries affected by humanitarian crises. The network of trained experts and technical institutions will be expanded to provide support to Member States in outbreak detection, field investigation and response. WHO’s institutional readiness must be enhanced for rapid and comprehensive response to emerging health threats.Border coordination between countries must also be strengthened. Combating the growing threat of antimicrobial resistance will be a major priority.

Immunization programmes provide significant contribution to safeguarding public health and promoting overall health and socioeconomic development. While government contribution to immunization programmes has increased in all countries, the level of funds available through global donors can be expected to decrease in coming years and countries need to step up efforts to ensure that comprehensive immunization programmes are adequately funded.

The persistence of violence, civil disruption, displaced persons and humanitarian crises in many countries in the Region may have delayed the ability to eradicate certain communicable diseases, instead temporarily changing the focus to containing them. However, comprehensive, evidence-based plans remain in effect for the ultimate goal of eradication, which will be attained through continued collaboration among all parties.