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1.
Key health interventions
1.1
Tropical diseases | 1.2
Disease surveillance and
control | 1.3 Malaria
| 1.4 Tuberculosis
| 1.5 HIV/AIDS and
sexually transmitted diseases
1.6
Noncommunicable diseases | 1.7
Mental health and substance abuse | 1.8
Reproductive health and
research | 1.9
Making pregnancy safer |
1.10
Immunization and vaccine development | 1.11
Emergency preparedness and
humanitarian action | 1.12
Child and adolescent health (including IMCI)
1.1 Tropical diseases
Tropical diseases
Issues and challenges
Schistosomiasis and soil-transmitted
helminth infections remain a major public health problem
only in Sudan and Yemen where the challenge is to
support the national control programmes to adopt and
properly implement the WHO strategy (repeated, regular
treatment with single-dose anthelminthics of the highest
risk group (school-age children) Another challenge is to
ensure a regular sustainable system of drug delivery to
the target population in these countries. In the
countries with low endemicity (Egypt, Libyan Arab
Jamahiriya, Morocco, Oman, Saudi Arabia and Syrian Arab
Republic), the major challenge is to sustain the
programmes in order to avoid a disastrous and costly
recrudescence.
Sudan is the third most endemic
country in Africa for trypanosomiasis (sleeping
sickness). Only highly toxic injectable drugs are
available to treat it and long treatment courses in
hospital are required. The existence of more than 20%
resistance to melarsoprol in some areas in southern
Sudan constitutes an additional difficulty. The
alternative is to use eflornithine which requires 56
perfusions in 2 weeks for each patient. The initiative
launched by WHO in 2002, in partnership with the private
sector (AVENTIS/SANOFI) and nongovernmental
organizations, brought the disease under control, with
very low prevalence (less than 1%) achieved in almost
all foci. The main challenge are withdrawal of some
important nongovernmental partners, the need to upgrade
all treatment facilities for the newer two-week
treatment regimen and the need for laboratory capacity
to ensure continuous monitoring of Trypanosoma
drug resistance.
Different leishmaniasis entities
occur in the Region, each requiring a specific adapted
control strategy for prevention. Anthroponotic visceral
leishmaniasis due to Leishmania donovani
regularly causes severe outbreaks in Sudan with
thousands of deaths. Anthroponotic cutaneous
leishmaniasis caused by L. tropica is a major
problem in the Syrian Arab Republic and in some urban
foci in Afghanistan, Islamic Republic of Iran and
Pakistan. Zoonotic cutaneous leishmaniasis outbreaks due
to L. major continue to appear periodically in
desert zones in Egypt, Islamic Republic of Iran, Iraq,
Jordan, Libyan Arab Jamahiriya, Morocco, Pakistan,
Syrian Arab Republic and Tunisia. Most of the countries
except Afghanistan, Somalia and Sudan have satisfactory
surveillance/case management systems. The major
challenges regarding these diseases are the absence of
evidence-based validated strategies that prevent or
interrupt transmission, and the high cost of the
diagnostic and treatment tools
Action taken in 2006 and results achieved
The successful countrywide deworming campaign
was continued in Afghanistan, in 28 targeted provinces out of
34, thanks to sustained partnership with UNICEF and WFP and
donations of mebendazole.
In Egypt, the school health programme covered
almost half (30 million) of the total population of the country
and about two-thirds of those living in rural areas. Monitoring
surveys following praziquantel distribution confirmed further
lowering of overall Schistosoma mansoni prevalence in 12
endemic districts to 1.5% and persistence at very low level
(0.2%) of S. haematobium in only one district of the
governorate of Beni Suef. Prevalence and intensity of infection
with soil-transmitted helminths was also reduced in the six
endemic districts. Endemic foci were identified for human
fascioliasis in rural areas for four governorates and control
activities directed toward specific areas are ongoing as
planned, using triclabendazole provided by WHO.
In Saudi Arabia, evidence from surveys and
long-term surveillance confirmed that local transmission of
schistosomiasis has ceased in some regions while in others only
cases that were not locally contracted were reported. Jazan
region registered no cases but remains at high risk because of
the movement of people to and from Yemen and the common wadis
that introduce snails into Jazan during floods. The re-emergence
of new cases in Albaha is probably due to the demobilization
that occurred following the achievement of the elimination
targets in 2005 in this area and emphasizes the need to sustain
control activities for a long period.
Sudan started the implementation of mass
treatment of schistosomiasis in two highly endemic localities
(48% prevalence) in Gezira, achieving 30% coverage in one and
60% coverage in the other. In southern Sudan deworming
activities and vitamin A distribution were successfully
integrated with other programmes, especially the poliomyelitis
programme. Two million tablets of albendazole provided by WHO
were distributed during national immunization days.
In Yemen, despite many efforts, there is as
yet no visible impact on morbidity or prevalence. WHO supported
the assessment of the programme and revealed several weaknesses
including the use of costly surveys followed by treatment of
individual detected cases instead of expanding community-based
mass treatment, the use of a praziquantel that was not quality
controlled, and at periphery level the tendency to set up new
independent programmes instead of using already existing systems
in schools.
The WHO team sustained control of sleeping
sickness in all foci of Juba, Kajo-Kegi, Yei, Tambura and Ezo,
except in Maridi and Mundri, two counties of West Equatoria
State where the situation deteriorated following the departure
of MSF-France. Stage 2 treatment is no longer available locally
and patients need to travel far to seek treatment. In this
transition period and to ensure sustainability of control, the
WHO team continued to focus on training, rehabilitation and
coordination including across borders.
An international training course was
conducted in Yei, Central Equatoria State on the use of
eflornithine as first line treatment, with participants from
Angola, Democratic Republic of Congo, Republic of Congo and
Ivory Coast. WHO also organized and sponsored the fourth
sleeping sickness regional meeting in Juba, where the
trypanosomiasis control policy on diagnosis and treatment for
the disease was revised in coordination with border countries.
WHO staff initiated with the Ministry of
Health the development and implementation of a tropical diseases
surveillance system as part of integrated disease surveillance.
WHO supported the rehabilitation of a national reference
laboratory for tropical diseases in Juba, and a 3-month training
for three local laboratory technicians to be able manage the
laboratory, once rehabilitated.
With regard to leishmaniasis, WHO focused on
Sudan where operational support was provided to respond to
outbreaks, and partners were supplied with free drugs and
diagnostic tools. WHO introduced an innovative community-based
approach to control visceral leishmaniasis. The health worker
manual for southern Sudan on community kala-azar health
education, which was developed by WHO in 2005, was updated and
distributed for training to implementing partners. The field
training on community awareness was combined with a refresher
laboratory training concentrating on the use of the dipstick
procedure in the diagnosis of kala-azar in peripheral health
units, and was delivered to staff of nongovernmental
organizations (local and international). Two primary health care
units were rehabilitated as new treatment facilities, located in
Dingkar and Mandeng, to attain more appropriate and more timely
referral. WHO also provided operational support and
capacity-building in several affected countries of the Region
and to the development of new approaches for surveillance,
prevention and control through operational research.
Future directions
A meeting is planned to develop the most
appropriate strategies for elimination of the urinary form of
schistosomiasis. Technical support will be pursued to ensure
continuation of screening of S. mansoni infection and
mass treatment of affected communities in the endemic villages
and hot spots, together with health education activities. WHO
will analyse the lessons learned from the schistosomiasis
control programme and from the 3-year programme of control of
human fascioliasis in Egypt. The partnership with Novartis
Pharma Inc. will be maintained to ensure free availability of
triclabendazole. With regard to sleeping sickness, the
priorities are to re-establish the Maridi and Mundri programmes
by training local personnel in Lui Hospital (Mundri County) so
stage 2 treatment can be available locally, to upgrade the
facilities for trypanosomiasis treatment in Juba and to finalize
the rehabilitation of the national reference laboratory in Juba
for the sleeping sickness programme. A consultation is planned
in order to assess and upgrade the regional and country
programes on leishmaniasis control. WHO will continue its
technical and operational support to respond to leishmaniasis
outbreaks and to promote the development of preventive
strategies for these entities.
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Elimination of
lymphatic filariasis, leprosy and dracunculiasis
Issues and challenges
Egypt has achieved elimination of lymphatic
filariasis in the majority of endemic areas through application
of a combination of diethylcarbamazine (DEC) and albendazole.
Mass drug administration (MDA) continued during 2006 in areas
where fewer than 5 rounds of MDA had been applied and in areas
which had still not satisfied the criteria for stopping MDA.
Yemen completed the fifth round of MDA using the ivermectin plus
albendazole combination in all endemic areas. Mapping of
lymphatic filariasis endemic areas in Sudan was less successful
for operational and technical reasons. The remaining challenges
to the national programmes relate to systematic collection of
data to monitor the effect of MDA in Egypt and Yemen, completion
of mapping in Sudan, safeguarding availability of field-friendly
diagnostic tests and sustainable access to funding from
government and external resources.
In 2006, a total of 2839 new cases of leprosy
were reported in the Region. The regional detection rate was 0.8
per 100 000; 633 new cases were registered among females, and
160 new cases among children under 15 years of age; 83% of new
cases had multibacillary leprosy and 33 cases were registered as
relapses. All new cases received multidrug therapy.
Improved access to leprosy diagnosis and
provision of multidrug therapy (MDT) drugs free of charge in all
endemic countries remain the cornerstone of the leprosy
elimination strategy. The prevalence and the number of new
leprosy cases have decreased at the national and regional
levels. The major challenges facing the national programmes
relate to sustaining achievements and further reduction of the
disease burden in countries with low prevalence of leprosy,
accelerating activities in areas with complex emergencies and
achieving the target of leprosy elimination at district level.
The leprosy situation still has to be monitored and remaining
challenges have to be solved at the national level. These
include detection of leprosy among population groups with low
health care coverage, the presence of a significant number of
defaulters, the existence of a high rate of new cases with
disabilities, and difficulties in surveying women and children.
Sudan reported a significantly higher number
of cases of dracunculiasis in 2006 than 2005 as a result of
improved accessibility to areas of southern Sudan, establishment
of an infrastructure for the guinea worm eradication programme
in newly discovered endemic areas and provision of logistical
support to activate surveillance and monthly reporting of
cases.. Challenges facing the national programme include
assessing the status of endemicity in previously inaccessible
areas in southern Sudan, lack of trained personnel to implement
the surveillance and interventions. Other challenges include the
influx of returnees from different parts of the country and from
other neighbouring countries which put great pressure on the
surveillance and intervention needs and require additional
resources. The northern states interrupted disease transmission
in 2003. Surveillance and pre-certification activities in the
formerly endemic areas in northern states should continue until
certification of dracunculiasis eradication in Sudan. The
national certification committee should be established to
support eradication and pre-certification activities.
Action taken in 2006 and results achieved
The national programme in Egypt conducted
surveys in 16 villages in 10 districts, 6 months after
administration of the fifth round of MDA. Results were negative
in 11 sentinel sites, while microfilaria-positive cases were
identified in 5 sites. WHO supplied the national programme with
4000 immunochromatographic card tests (ICT) for a survey of
children in the age groups 2 to 4 years and 6 to 8 years in
villages in districts where results of surveys in sentinel sites
were negative, in order to confirm interruption of transmission
in those areas. Test results were positive in one of two
villages in the Motobos district of Kafr Sheikh Governorate. As
a result, MDA was continued in both villages. In January 2007,
28 villages in 5 governorates with a total population of half of
million received MDA with a combination of DEC and albendazole.
Refresher training courses for drug distribution teams and
social mobilization activities for the population were conducted
prior to the round. The total coverage of the target population
with MDA was 91.1%.
In Yemen, prior to the fifth round of MDA, an
antigenemia survey was conducted in 11 MDA implementation units
among children aged 2 to 4 years using the ICT card test. 50
children in each implementation unit were investigated and all
results were negative. In addition, a microfilaraemia survey was
conducted in each implementation unit in Socotra Island. The
microfilaria positive rate was found to be 3.6% in one
implementation unit. A total population of 111 000 in all
implementation units was covered in the fifth round of MDA using
a combination of ivermectin and albendazole tablets. The total
coverage of the target population was 93%. Nine training courses
for the drug distribution teams were organized with a total of
167 participants.
4000 ICT tests were supplied to the national
programme in Sudan to conduct mapping activities. A total of 22
localities in four states (White Nile, South Kordofan, Khartoum
and Gezira) were surveyed for the prevalence of antigenemia. In
Khartoum State, all 7 localities surveyed were positive within
the range of 1% to 20%. Eight out of 9 localities in South
Kordofan State were found to be endemic for lymphatic filariasis.
Four localities in White Nile State and two localities in Gezira
State were positive with an antigenemia prevalence between 2%
and 10%.
A training workshop on the use of the Health
Mapper technique for mapping of lymphatic filariasis was held in
Nbo, southern Sudan. A map of the distribution of lymphatic
filariasis cases according to payam was prepared.
The Regional Office continued to assist the
national programmes in Egypt, Pakistan and Sudan with
strengthening national capacity in diagnosis and treatment of
leprosy. Regular training of primary health care staff and
dermatologists in diagnosis of leprosy facilitated early
diagnosis and referral of cases to leprosy clinics for MDT
treatment. In addition, training was organized for social
workers in provision of counselling and socioeconomic
rehabilitation to leprosy cases.
All leprosy clinics in Egypt at governorate
level have been integrated with dermatology services. A national
seminar was held in Morocco to discuss restructuring of the
leprosy services within the National Skin Disease Programme. To
maintain sustainability of the leprosy control programme,
Pakistan adopted a strategy of networking with the national
blindness and tuberculosis control programmes and integrated
leprosy into basic dermatology in special action projects (skin
camps) to cover all hyper-endemic areas. The national programme
in Sudan created leprosy master clinics in each state as
reference centres to confirm the diagnosis of any suspected
leprosy case made by primary health care staff. In southern
Sudan, leprosy treatment was integrated into the primary health
care programme in Blue Nile State and efforts are under way to
expand this process to other states. A national seminar on
integration of leprosy services within the general health
services was organized in Yemen.
Support was provided to strengthen community
awareness on leprosy through printing and distribution of health
education and teaching/learning materials on leprosy control and
organization of meetings with community leaders and press media
in major endemic countries, like Egypt, Sudan and Yemen.
Implementation of the national leprosy control strategy in
Somalia was complicated by the insecure situation. Three leprosy
training courses for community health workers in Jilib and one
community sensitization workshop in Labadaad were organized. The
number of leprosy centres in southern Sudan was increased to 30.
The leprosy programme trained 34 health workers from Yambio, Yei
and Rumbek and supported socio-rehabilitation activities for
leprosy patients with assistance from nongovernmental
organizations.
Two national managers from Afghanistan and
Morocco received WHO fellowships for overseas training on
management of leprosy. A WHO consultant was assigned to Morocco
to assist in formulation and implementation of a new leprosy
control strategy integrated with the primary health care system
and to advise on the MDT treatment policy.
A regional meeting of national coordinators
and partners on integrated leprosy control was held in
Alexandria, Egypt The meeting recognized the achievements made
by individual national programmes in sustaining leprosy control
services and emphasized the importance of continuing control
activities in an integrated manner between all partners.
The Regional Office, in cooperation with the
Carter Center, is supporting the national Guinea Worm
Eradication Programme to strengthen its surveillance and
intervention activities. WHO supported the organization of
refresher training courses for village volunteers in formerly
endemic areas in six northern states. Support was provided for
organization of special surveys in selected previously
inaccessible areas in the southern states in Sudan; 25 villages
in two localities situated in Blue Nile State at the border with
Ethiopia were surveyed using the standard guinea worm
questionnaire. Surveillance activities included provision of
advocacy materials to the communities, collection of data about
availability of safe drinking-water and rumour investigation.
All rumours of dracunculiasis cases were investigated and water
filters were distributed in villages where dracunculiasis cases
were identified. In southern Sudan, surveillance and supervisory
structures were fully established in eight out of 10 states. The
status of dracunculiasis in the remaining two states was
assessed alongside the first round of the polio national
immunization days in November 2006. The programme followed up on
reports of suspected cases of dracunculiasis and prepared plans
to assess the status of endemicity in remaining areas. A case
search was also conducted during polio national immunization
days in formerly endemic areas in the northern states.
The first programme review of the South Sudan
Guinea Worm Eradication Programme was conducted in Juba. The
programme reported 20 582 cases of dracunculiasis from 3137
villages in 2006. Three of the ten southern states (East
Equatoria, Waarrab, Jongolei) reported 92% of all cases. The
reporting rate improved to 62% (compared to 51% in 2005), case
containment rate was 49% (compared to 4% in 2005), 47% of
endemic villages had cloth filters in all households (30% in
2005) and 79% of communities had received health education
sessions (76% in 2005). The programme distributed 1.4 million
pipe filters in 2006. Abate larvicide was used in 6% of endemic
villages. A total of 20 042 villages were under surveillance;
16% of villages had at least one source of safe drinking-water;
12 borehole wells were drilled in Kapoeta county. The programme
now has in place more than 13 000 trained village volunteers and
900 area supervisors.
Future directions
Egypt and Yemen will continue to provide MDA
to endemic areas until interruption of lymphatic filariasis
transmission is confirmed. Mapping of lymphatic filariasis in
Sudan will be completed and the plan for MDA in endemic areas
will be prepared. All efforts are needed to sustain further
leprosy control activities at the national and sub-national
levels. Countries have to set operational targets of leprosy
elimination at sub-national levels according to local
situations. The status of dracunculiasis endemicity in remaining
areas in southern Sudan will be identified through active case
search. The national programme will continue to provide endemic
areas with preventive and containment measures. Vigilance will
be continued in the northern states, in order to ensure timely
diagnosis and containment of imported cases and to prevent
re-establishment of local transmission.
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Zoonotic diseases
Issues and challenges
Brucellosis, hydatidosis and rabies remain
the major zoonotic diseases in the Region with a considerable
economic impact in the veterinary and public health sectors. All
these zoonoses require specific actions/programmes on animals to
be prevented or eliminated. This is not happening in most
countries because of the absence of comprehensive multisectoral
programmes. Currently, pathogen surveillance in animals is
usually the responsibility of government departments of
agriculture. Its quality varies greatly among countries and does
not include wildlife. In addition, priority diseases supported
and reported are those of food animals and more particularly
those that affect international trade.
Action taken in 2006 and results achieved
Several Member States responded
positively to the call to participate in the
Mediterranean Zoonoses Control Programme, as requested
by resolution EM/RC50/R.11. The Regional Office also
pursued close coordination with the Mediterranean
Zoonoses Control Programme, particularly in regard to
the organization of joint training workshops and
meetings with the aim of strengthening partnership with
regional and international organizations, such as the
World Organization for Animal Health (OIE) and FAO, in
order to enhance control activities in the Region.
WHO support to countries included
capacity-building in surveillance and management of
human cases in selected zoonoses programmes, such as
rabies in Pakistan and in Yemen. Rabies continues to
constitute a major threat, with cases reported
especially in Afghanistan, parts of Islamic Republic of
Iran, occupied Palestinian territory, Pakistan and
Yemen. Considerable funds continue to be spent by most
of the countries and the Regional Office, in
post-exposure treatment of humans to reduce mortality.
Despite support from WHO and other sources, Pakistan did
not yet achieve the shift from the production of
sheep-brain vaccines to tissue culture vaccines. Morocco
was supported to assess its actual epidemiological
status in regard to hydatidosis and the control
programme was revised.
Future directions
WHO will continue to reinforce coordination
with the Mediterranean Zoonosis Control Programme, and other
regional and international organizations, such as OIE and FAO,
in order to enhance multisectoral technical support to the
countries in control activities, expand implementation of a
regional control programme of brucellosis and strengthen
capacity-building in zoonoses control.
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Vector control
Issues and challenges
The burden of vector-borne disease continues
to be a major public health problem in the Region, expanding
geographically and seasonally, and yet the coverage of key
vector control interventions remains low in some countries. In
such countries the choices of interventions are limited and the
availability of the infrastructures and national capacity
required to deliver the few interventions available is a big
challenge. This has also been compromised by the detection of
vector resistance to insecticides––including pyrethroids––the
current group of insecticides of choice. This not only limits
the choice of insecticides but also increases the financial
burden on already constrained programmes. Following the
endorsement of integrated vector management (IVM) by Member
States (resolution EM/RC52/R.6), nine countries have seriously
embarked on implementation of this approach. This represents
almost 80% of the high-risk countries.
Action taken in 2006 and results achieved
The Regional Office finalized and also
translated into French, the tools for carrying out vector
control needs assessment. The tools were administered in the
countries of the Region that were supported by UNEP/Global
Environment Facility (Djibouti, Egypt, Islamic Republic of Iran,
Jordan, Morocco, Sudan, Syrian Arab Republic and Yemen).
Analysis of the assessment reports identified gaps and
opportunities for the implementation of vector control,
especially the incorporation of IVM in the national health
policies in the areas of policy, institutional frameworks,
scaling up of interventions, intersectoral coordination and
community mobilization. These gaps and opportunities were used
to develop national IVM plans in the nine countries. This
process is planned for the remaining countries of the Region in
2007, especially in Pakistan and Somalia.
A consultation involving regional and global
partners was held for establishment of a postgraduate degree
course in entomology and vector control. Two venues for the
course were identified, Ain Shams University for the course work
and the University of Gezira for the field work. A detailed
one-year course curriculum was developed. This curriculum was
modified for adoption at country level for short national
training courses to run parallel with the postgraduate course.
Manuals were developed for indoor residual
spraying and ITNs/LLINs and the latter was field-tested in
Sudan. Furthermore, analysis of data received from countries
implementing these strategies revealed weaknesses in accurate
reporting and/or supervision.
Insecticide resistance monitoring continued
in countries to guide the selection of insecticides and to
develop management strategies to delay and mitigate its
consequences. In Morocco, the main malaria vector species
Anopheles labranchiae was reported resistant to DDT and a
national policy to switch to pyrethroids was advocated. In parts
of Al-Dahira region, Oman, An. Stephensi was reported
resistant to temephos and suitable alternative insecticides for
biological control are under consideration. In Sudan, for the
first time in the Region, the local malaria vector species
An. arabiensis was reported resistant to pyrethroids, the
insecticides of choice for indoor residual spraying and for ITNs/LLINs.
In the same area the vector is also resistant to DDT and to
malathion, an organophosphate. Change to bendiocarb, a carbamate,
is not only expensive per house structure sprayed, as it
requires two cycles of spraying, but it also cannot be used to
treat bednets.
Future directions
Vector control capacity will be strengthened,
especially through the proposed postgraduate degree programme in
entomology and vector control. Adoption of the regional
curriculum for use by countries for short courses will be
supported. Scaling up of appropriate vector control
interventions and the judicious use of vector control products,
including entomological surveillance for disease mapping and
targeting of interventions, will also be continued. Coordination
with partners will continue as will advocacy for mobilization of
resources for effective implementation of IVM as the regional
strategy for the control of vector-borne diseases.
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