WHO’s regional emergency operations team conducted country support missions to 15 countries in the Region during the year totalling 291 person/days, while our operations support and logistics (OSL) team massively expanded the logistics hub in Dubai from 3000 to 14 000 square metres of warehouse capacity. In 2019 alone, the value of imported products reached US$ 26 million while the value of goods dispatched exceeded US$ 11 million.

OSL staff were deployed to Djibouti, Jordan, Lebanon, Libya, Oman and Yemen to support emergency operations in country offices, share best practice and improve supply chain management, and mobile laboratory containment units were deployed to 13 countries across the Region to enhance preparedness for high-risk pathogens.

We signed three agreements with partners to deliver health services to people in need in different parts of the Region. For example, in 2019 we provided more than 210 tonnes of supplies to health partners operating in northeast Syrian Arab Republic who delivered more than 2500 surgeries, provided life-saving interventions to 5500 seriously wounded patients, supported the chronic disease conditions of a population of 630 000 and provided emergency medicines to a population of 558 000.

WHO’s health emergency information and risk assessment team continued working to enhance capacity to detect and manage public health events, assess risks, and inform the national focal points through the event information site (EIS). The team managed 47 events through the event management system during the year, with 15 risk assessments conducted and 33 updates posted on the EIS.

Activities to improve surveillance and risk monitoring included training sessions to help establish the network of geographical information systems in the Region. Standard operating procedures were developed to support event-based surveillance in Morocco, and the surveillance guidelines for Jordan were expanded to include all hazards.

An incident management leadership course at the end of the year brought together 32 WHO staff from country offices and the Regional Office for training in responding to emergencies using the Organization’s incident management system.

Many countries in the Region are experiencing protracted humanitarian crises. Early Warning Alert and Response Network (EWARN) surveillance systems were maintained in all countries with complex emergencies in order to rapidly detect, verify and investigate any alerts or signals of priority epidemic-prone diseases.

The EWARN network was expanded to eight countries, with Djibouti joining Afghanistan, Iraq, Libya, Somalia, Sudan, the Syrian Arab Republic and Yemen. WHO continues its support to implement, monitor and evaluate these EWARN systems for their improvement and upgrading.

Work to strengthen the network in 2019 also included the initiation of a process to update the evaluation protocol which is used to identify technical and operational gaps in EWARN systems. WHO held a cross- regional workshop in Amman, Jordan, on 21–24 October 2019 to share and discuss countries’ experiences of using the evaluation protocol.

The Eastern Mediterranean was the only region worldwide to detect wild poliovirus (WPV) cases in 2019. Wild poliovirus remains endemic in the Region, and the risk of the international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC). WHO’s team and our Member States are strongly committed to eradicating this global threat.

However, 2019 was a difficult year for the polio programme. Wild poliovirus transmission resurged in 2019 in the two remaining polio- endemic countries, Afghanistan and Pakistan, with a total of 176 cases reported (29 in Afghanistan and 147 in Pakistan; see Fig. 4). Patterns of both human cases and environmental positives indicate that circulation of the virus had expanded from known reservoir areas in both countries. There were also outbreaks of vaccine-derived poliovirus in Pakistan and Somalia.

This is both a disappointing setback and a grave concern. Thanks to the dedication of donors, governments, health workers and partners, the Region – and the world generally – have made incredible strides against polio in recent decades. But as long as wild poliovirus is circulating anywhere, the virus could come surging back.

Three countries in the Region, Somalia, the Syrian Arab Republic and Yemen, are considered at very high risk for polio outbreaks with another four – Djibouti, Iraq, Libya and Sudan – at high risk (see Fig. 5). All have varying degrees of complex emergency and access or security constraints which hamper efforts to maintain high population immunity and sensitive surveillance. WHO is providing technical and logistical support to these countries to implement supplementary immunization and surveillance activities. Ending polio in Afghanistan and Pakistan, closing outbreaks, and increasing routine immunization is a key regional priority.

Concurrent type 2 and type 3 circulating vaccine-derived poliovirus (cVDPV) outbreaks continued in Somalia in 2019, and a type 2 vaccine- derived virus outbreak was detected in Pakistan. A total of 25 cases of cVDPV were reported across the Region in 2019 (22 in Pakistan and three in Somalia).

Patterns of both human cases and environmental positive samples indicate continued circulation of the virus in known reservoir areas in both countries.

The continued detection of cVDPVs in Somalia reflects a significant population immunity gap primarily due to the large number of inaccessible children in areas controlled by non-state armed groups.

During 2019, the polio programme developed a new global strategy to target cVDPV outbreaks. As part of the strategy, the programme will roll out a new oral vaccine designed to tackle vaccine-derived outbreaks, possibly as early as June 2020. This decision was supported by the WHO Executive Board in February 2020.

Meanwhile, the Syrian Arab Republic remained polio-free a year after the closure of a serious vaccine-derived outbreak in December 2018. The polio programme alongside regional partners successfully ended an outbreak of cVDPV that had taken hold in conflict-affected areas of the Syrian Arab Republic, paralysing 74 children. Amid ongoing insecurity and huge population movement, the programme worked throughout 2019 to maintain and increase levels of immunity among the under-5 population. This included running regular vaccination campaigns with the help of United Nations partners in camps of internally displaced populations. Environmental surveillance continues in the country to test for poliovirus.

The polio programme is committed to collaborating with routine immunization programmes and forming new partnerships with broader health initiatives. In 2019, Gavi, the Vaccine Alliance, was welcomed into the polio partnership to provide expertise to this project, especially in the endemic countries of Afghanistan and Pakistan.

The Polio Eradication Hub has a dedicated function for strengthening services beyond polio in Afghanistan and Pakistan, spearheaded by UNICEF and supported by WHO and other partners. Work so far focuses on strengthening broader immunization services by providing technical support, increasing services in under-resourced areas, and building capacity, including by supporting training for health workers.

In several countries in the Region, staff funded by the polio programme support the WHO Health Emergencies Programme and national EPIs. A study in Sudan in early 2019 found that national medical officers supported by the polio programme spent up to 45% of their time working to support other health projects.

Gender is an important determinant of health, impacting both those delivering and those receiving health services. The polio programme is the first disease-specific programme within WHO to develop a dedicated gender strategy. In 2019, the programme launched its gender strategy and is now working towards integrating a gender lens across all workstreams. At a regional level, this includes collecting gender-disaggregated data on immunization coverage and delivery and conducting analysis to further strengthen the reach of vaccination services. Action plans have been developed to realize gender equality strategic objectives. Within the Region, indicators show that boys and girls under 5 years of age have very similar immunization status for polio vaccination and are generally equally well represented in surveillance. Major progress has been made in Pakistan, and some in Afghanistan, with respect to recruiting local female community vaccinators and supervisors to strengthen the capacity to reach every child in house-to-house immunization activities. 

Significant progress was made in 2019 to contain type 2 polioviruses, in line with the WHO Global Action Plan (GAP III) to minimize risks associated with poliovirus facilities after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine use. All countries that destroyed or removed VDPV2 materials documented the destruction processes.

Three facilities in the Eastern Mediterranean Region have been designated as polio essential facilities. In both countries where the facilities are located (Islamic Republic of Iran and Pakistan), national authorities for containment have been nominated to ensure strict implementation of containment measures. WHO is assisting both countries to prepare for pre-audit within the certification process and to achieve other containment targets.

Meanwhile, several countries across the Region initiated surveillance to detect children with primary immune deficiencies (PIDs), a group of diseases caused by genetic defects of the immune system. Certain types of PIDs are associated with a risk of prolonged excretion of poliovirus, and thus a risk of its spread. This is a real threat for the polio programme after eradication, as population immunity levels will wane after vaccine use is eventually phased out. Sensitive surveillance will allow the timely detection of poliovirus excretion from any PID patient, thereby creating opportunities for preventive public health measures and treatment of patients.