COVID-19 strategic preparedness and response plan: reinforcing the collective readiness and response in the WHO Eastern Mediterranean Region, 2021 edition

Reinforcing the collective readiness and response in the WHO Eastern Mediterranean Region 2021 EDITION COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN Reinforcing the collective readiness and response in the WHO Eastern Mediterranean Region 2021 EDITION COVID-19 STRATEGIC PREPAREDNESS AND RESPONSE PLAN 4COVID-19 strategic preparedness and response plan – 2021 edition iv WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: COVID-19 strategic preparedness and response plan: reinforcing the collective readiness and response in the WHO Eastern Mediterranean Region, 2021 edition / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2021 Identifier: WHO-EM/CSR/383/E Subjects: COVID-19 - epidemiology | Betacoronavirus | Disease Outbreaks | Disaster Planning | Civil Defense | Health Information Management | Eastern Mediterranean Region Classification: NLM WC 506.4 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Document WHO-EM/CSR/383/E WHO EASTERN MEDITERRANEAN REGION v CONTENTS Foreword from the Regional Director 1. Purpose of the document 2. Global situation 3. Situation in the Eastern Mediterranean Region 3.1 Epidemiological situation 3.1.1 Evolution of the COVID-19 epidemic in the Region 3.1.2 Current situation in the Region (as at 28 February) 3.2 Risk assessment of COVID-19 in the Region 3.3 Operational context 3.3.1 Humanitarian settings and vulnerable groups 3.3.2 Effects on health systems and essential services 3.3.3 Social and economic effects 3.3.4 Public health and social measures 3.3.5 Vaccines 3.3.6 Regional contribution to global research, development and innovation 3.4 Regional collaboration and coordination 4. Key lessons learned for leveraging the COVID-19 response in the Region in 2021 4.1 Partnership and coordination 4.2 Communications (external and internal) 4.3 Operations support and logistics 4.4 Health operations and technical expertise 4.5 Health information management and surveillance 4.6 International Health Regulations and social measures 4.7 Research and knowledge management 4.8 Essential health services and systems 4.9 COVID-19 vaccine 5. Beyond COVID-19 6. Strategic preparedness and response plan for COVID-19 in the Eastern Mediterranean Region in 2021 6.1 Goal 6.2 Regional strategic objectives Areas of work and priority activities for COVID-19 preparedness and response in 2021 7. Budget summary by pillar (2021) 8. Monitoring and evaluation Annex 1. COVID-19 SPRP M&E framework for 2021: Proposed indicators vi 1 2 4 4 4 6 9 10 10 11 12 12 13 14 14 16 16 16 16 17 17 18 18 18 19 20 21 21 21 23 32 33 34 6COVID-19 strategic preparedness and response plan – 2021 edition vi FOREWORD FROM THE REGIONAL DIRECTOR Over the past year, all three levels of the World Health Organization (WHO) have worked with countries to provide guidance and oversight to ensure a streamlined and coordinated response to COVID-19 by national authorities, partners, communities and the private sector. The Organization has built experience and gained insights into what worked best and what did not work so well in the COVID-19 strategic preparedness and response plan for 2020. Looking ahead, and building on this wealth of experience, the regional COVID-19 strategic preparedness and response plan for 2021 lays out the coordinated action required at national and regional levels to overcome challenges, address inequities and work towards ending the COVID-19 pandemic. The revised plan brings together the collective actions needed to suppress transmission, reduce exposure, address misinformation and disinformation, protect the vulnerable through vaccination, reduce mortality and morbidity, and accelerate equitable access to new COVID-19 vaccines and tools. The Incident Management Support Team (IMST) will continue to ensure coordination, planning, financing and monitoring for the response across all countries and at a regional level, providing operational support, including for logistics and supply chains, as well advocating for countries to conduct research and innovation. COVID-19 vaccines are finally within reach. To work towards defeating COVID-19, we need open, fair and equitable sharing of vaccines. But even after we overcome the initial challenges of limited supplies, uneven access and staggered roll-out, a range of well-designed programme strategies will be needed to drive up acceptance and uptake of vaccines in the countries of the Region. Based on the experience of the past year, we will also aggressively scale up fragmented data systems, improve data sharing by countries, and strengthen infection prevention and control policies. This will be key in light of the growing number of variants appearing around the world, which need to be identified and detected. The longer the pandemic goes on, the more such variants are expected to emerge, perhaps undermining the effectiveness of the vaccines we have just started to celebrate rolling out. The coming period in our Region will be challenging for us all, and making sure that we reduce fear, stigma and hesitancy will be critical to our efforts. One year into the pandemic, we understand that COVID-19 fatigue has set in, and that we now face a new threat – not just of misinformation and disinformation, but of communities desperate to go back to pre-COVID-19 times. In addition to the public health risks that the virus presents, we are understandably concerned about the economic, social and political costs of the pandemic. We also should not forget other emergencies in our Region – crises that are characterized by years of conflict, and the consequent social and political disruptions that have further devasted the lives of millions. We cannot defeat COVID-19 as a divided region, or by politicizing the pandemic. Using “Health as a Bridge to Peace” we hope that our shared goal of saving lives and ending the pandemic will allow for countries to come together to work for the common good. COVID-19 has shown us that the virus can only be beaten through solidarity, coordination and collaboration, allowing us to achieve our regional vision of Health for All, by All. Dr Ahmed Al-Mandhari WHO Regional Director for the Eastern Mediterranean

1COVID-19 strategic preparedness and response plan – 2021 edition 1. PURPOSE OF THE DOCUMENT On 30 January 2020, the coronavirus disease 2019 (COVID-19) outbreak was declared a public health emergency of international concern. Four days later, the World Health Organization (WHO) global COVID-19 strategic preparedness and response plan (SPRP) was published, followed by the first edition of the SPRP for the Eastern Mediterranean Region to accelerate regional readiness. The present document is the third edition of the regional SPRP, serving as an update to the July 2020 edition and aligned with the most recent version of the global SPRP, the Region’s Vision 2023, and WHO’s Thirteenth General Programme of Work 2019–2023. Building on successful strategies in 2020 and lessons learned, this document was developed by the WHO Regional Office for the Eastern Mediterranean to help to guide the public health response to COVID-19 in the Region in 2021. It sets the regional strategic priorities that WHO will support in 2021 to reinforce collective readiness and response to the COVID-19 pandemic. The WHO Eastern Mediterranean Region 2WHO EASTERN MEDITERRANEAN REGION 2. GLOBAL SITUATION On 31 December 2019, WHO was alerted to several cases of pneumonia of unknown origin in Wuhan, Hubei province, China. One week later, on 7 January 2020, Chinese authorities confirmed that they had identified a new type of coronavirus as the cause of the pneumonia cluster. The novel coronavirus belongs to the same family of coronaviruses that cause illnesses ranging from the common cold to more severe diseases such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). The illness caused by this novel coronavirus is referred to as coronavirus disease 2019 (COVID-19). Since January 2020, COVID-19 has spread across the world, disrupting even the most resilient health systems and services. Global incidence rates slowed down after the implementation of public health and social measures, but with premature lifting of some social measures and the probable impact of the emergence of variants of concern, incidence increased at the end of 2020 and into 2021. As at 28 February 2021, over 113 million COVID-19 cases have been reported globally, with over 2.5 million reported deaths (case fatality ratio (CFR) 2.2%) (Fig. 1). Of these cases, 44.5% were reported from the Region of the Americas, 34.1% from Europe, 11.9% from South-East Asia, 5.6% from the Eastern Mediterranean, 2.5% from Africa and 1.4% from the Western Pacific. The country most affected is the United States of America with 28 174 978 cumulative cases and 506 760 associated deaths (CFR 1.8%), followed by India which reported a total of 11 096 731 cases and 157 051 associated deaths (CFR 1.4%) and Brazil with 10 455 630 cases and 252 835 associated deaths (CFR 2.4%). The highest incidence rates are reported from Andorra (14 confirmed cases per 100 population), followed by Montenegro and the Czech Republic (both with 13 confirmed cases per 100 population) and Gibraltar (12 confirmed cases per 100 population). The highest CFRs are reported in Yemen (27.7%) followed by Mexico (8.9%), while the lowest CFRs are reported from Singapore (0.05%) and Mongolia (0.08%). Globally, 144 countries have self-reported community transmission while 43 countries have self-reported sporadic or no cases.1 The overall epidemiological data vary among WHO regions, countries and territories, and within countries. The observed trends may not always represent the evolving and real epidemiological situations due to incomplete reporting. Countries have different capacities in detection, confirmation and reporting of COVID-19 cases. The response capacities in terms of case investigation, contact tracing, quarantine, case management and isolation, among other factors, contribute to the varying incidence and mortality rates. 1 WHO coronavirus disease (COVID-19) dashboard (https://covid19.who.int/, accessed 1 March 2021). 0 1000 2000 3000 4000 5000 6000 20 20 _0 1 20 20 _0 2 20 20 _0 3 20 20 _0 4 20 20 _0 5 20 20 _0 6 20 20 _0 7 20 20 _0 8 20 20 _0 9 20 20 _1 0 20 20 _1 1 20 20 _1 2 20 20 _1 3 20 20 _1 4 20 20 _1 5 20 20 _1 6 20 20 _1 7 20 20 _1 8 20 20 _1 9 20 20 _2 0 20 20 _2 1 20 20 _2 2 20 20 _2 3 20 20 _2 4 20 20 _2 5 20 20 _2 6 20 20 _2 7 20 20 _2 8 20 20 _2 9 20 20 _3 0 20 20 _3 1 20 20 _3 2 20 20 _3 3 20 20 _3 4 20 20 _3 5 20 20 _3 6 20 20 _3 7 20 20 _3 8 20 20 _3 9 20 20 _4 0 20 20 _4 1 20 20 _4 2 20 20 _4 3 20 20 _4 4 20 20 _4 5 20 20 _4 6 20 20 _4 7 20 20 _4 8 20 20 _4 9 20 20 _5 0 20 20 _5 1 20 20 _5 2 20 20 _5 3 20 21 _0 1 20 21 _0 2 20 21 _0 3 20 21 _0 4 20 21 _0 5 20 21 _0 6 20 21 _0 7 20 21 _0 8 N um be r of c as es ( in t ho us an ds ) Eastern Mediterranean Region African Region The Americas European Region South-East Asia Region Western Pacific Region Fig. 1. Global and regional trends in COVID-19 cases, 28 February 2021 3COVID-19 strategic preparedness and response plan – 2021 edition For reasons that are not completely understood, males are slightly more affected than females especially in terms of disease severity and case fatality (51% of cases and 57% of deaths). However, females are often disproportionately affected by the social and economic consequences of response measures. Women also suffer from loss or limited accessibility to reproductive and sexual health services, antenatal care and other maternal health services. There are reports from several countries of increased incidence of gender-based violence.2 Regarding age groups, adults aged 25–55 years are the most affected, but disease severity and risk of death are associated with increased age. Elderly populations are more at risk of severe symptoms and death, with over 80% of deaths occurring in individuals aged above 65 years. The COVID-19 pandemic has taken a toll on the mental, social and economic well-being of individuals and communities. It has been estimated that most COVID-19 infections originate from relatively few individuals in high-transmission events or settings.3,4 Transmission mainly occurs among close contacts of infected persons in indoor spaces and can be amplified by poor ventilation. Secondary attack rates are higher in household settings (recent estimates from two meta-analyses5 suggest household secondary attack rate is approximately 17–21%), and outbreaks have been reported from a number of settings, including long-term living facilities, prisons, religious or social events, as well as food processing plants. Data show that about 7.7% of cases worldwide are among health care workers, although there are wide variations among countries, with changes over time. Based on WHO data, in the first three months of the pandemic health care worker infections slightly exceeded 10% of reported cases, declining to less than 5% by early June 2020 and to approximately 2.5% by September 2020. In addition, the heavy burden placed on health workers involved in the response and within the wider health system has had a negative impact on their health and well-being.3 Vaccinations against COVID-19 have started and are ongoing in many countries worldwide. As at 9 February 2021, Our World in Data reported that 134.65 million vaccine doses had been administered globally and at least 65 countries had initiated vaccination campaigns.6 The majority of these countries were in Europe and North America, although vaccination efforts are starting in Africa, South America, South and South-East Asia, and the Eastern Mediterranean (13 countries in the Eastern Mediterranean Region had begun vaccination by 28 February 2021). As SARS-CoV-2 variants have become a significant concern globally, WHO established the SARS-CoV-2 Virus Evolution Working Group to assess the levels of risk and impacts of mutations on public health. Implementing or improving sequencing capacity at the national level has become a priority in this regard. Health systems and delivery of regular health services have been severely affected by the COVID-19 pandemic and financial hardship has increased due to demand for COVID-19-related services. To ensure equitable access to diagnostics, therapeutics and vaccines, health system capacities such as financing, workforce planning, clinical care, logistics and supply chain management must be strengthened. 2 Gender and COVID-19: advocacy brief, 14 May 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/332080/ WHO-2019-nCoV-Advocacy_brief-Gender-2020.1 eng.pdf?sequence=1&isAllowed=y, accessed 21 February 2021. 3 Endo A, Abbott S, Kucharski AJ, Funk S. Estimating the overdispersion in COVID-19 transmission using outbreak sizes outside China. Wellcome Open Res. 2020;5:67. doi:10.12688/wellcomeopenres.15842.3. 4 Koh WC, Naing L, Chaw L, Rosledzana MA, Alikhan MF, Jamaludin SA, et al. What do we know about SARS-CoV-2 transmission? A systematic review and meta-analysis of the secondary attack rate and associated risk factors. PLoS ONE. 2020;15(10):e0240205. doi:10.1371/journal.pone.0240205. 5 COVID-19 strategic preparedness and response plan, 1 February 2021 to 31 January 2022. Geneva: World Health Organization; 2021 (https://www.who.int/ publications/i/item/WHO-WHE-2021.02, accessed 21 February 2021). 6 COVID-19 data explorer: COVID-19 vaccine doses administered per 100 people [online database]. Oxford: Our World in Data; 2021 (https://ourworldindata. org/coronavirus-data-explorer?tab=map&zoomToSelection=true&country=&region=World&vaccinationsMetric=true&interval=total&perCapita=true&smoothin g=0&pickerMetric=total_cases&pickerSort=desc, accessed 10 February 2021). 4WHO EASTERN MEDITERRANEAN REGION 3. SITUATION IN THE EASTERN MEDITERRANEAN REGION The first cases of COVID-19 in the Eastern Mediterranean Region were reported by the United Arab Emirates on 29 January 2020 among travellers coming from Wuhan, China. By the end of February 2020, 11 countries in the Region had reported confirmed cases of COVID-19. In the subsequent weeks, the Region witnessed an increasing number of countries with confirmed cases, and all 22 countries and territories had recorded COVID-19 cases by 10 April 2020. Most of the new cases recorded in the first three weeks of the pandemic were imported and linked to countries/ cities highly affected by COVID-19 outbreaks. When travel restrictions and other mobility measures were imposed by countries in the Region, the proportion of locally acquired infections increased. Most of the Region showed a slow start to the outbreak in the first three months of the pandemic; however, in May 2020 disease transmission accelerated and rapid local and community spread were subsequently observed in many countries.7 This could be attributed to easing of public health and social measures such as travel restrictions and partial or full lockdowns, which were relaxed during the holy month of Ramadan in many countries, and to social gatherings during this month. 3.1 Epidemiological situation 3.1.1 Evolution of the COVID-19 epidemic in the Region 7 Al-Mandhari A, Brennan R, Abubakar A, Hajjeh R. Tackling COVID-19 in the Eastern Mediterranean Region. Lancet. 2020;396(10265):1786–8. doi:10.1016/S0140-6736(20)32349-7. The Region’s cumulative cases surpassed 6.4 million on 28 February 2021. From the first reported COVID-19 case, it took 150 days to reach 1 million cases. From there: On 28 February 2021, COVID-19 deaths reached 144 947. From the first reported death, it took 90 days to reach 10 000 deaths. From there: 1 to 2 million cases 10 000 to 50 000 deaths 50 000 to 100 000 deaths 4 to 5 million cases 3 to 4 million cases 2 to 3 million cases 5 to 6 million cases 72 days 102 days 90 days 38 days 30 days 52 days 42 days 5COVID-19 strategic preparedness and response plan – 2021 edition Fig. 2. Weekly distribution of COVID-19 cases and CFR in the Eastern Mediterranean Region, 29 January 2020–28 February 2021 Fig. 3. Weekly distribution of COVID-19 deaths in the Eastern Mediterranean Region, 29 January 2020–28 February 2021 0 2 4 6 8 10 12 14 16 0 50 000 100 000 150 000 200 000 250 000 300 000 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 2020 2021 CF R (% ) N um be r of c as es Epidemiological weeks Cases CFR (%) 0 1000 2000 3000 4000 5000 6000 7000 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 2020 2021 N um be r of d ea th s Epidemiological weeks Two waves of the pandemic were observed in 2020 across the Region: the first peak was reached in week 25 (starting on 14 June) with 138 844 new confirmed cases and 3435 deaths, followed by a gradual decrease in reported cases and deaths. In week 35 (starting on 23 August) a significant increase in the number of confirmed cases and deaths was observed across the Region. COVID-19 cases increased sharply from mid-October 2020 and reached a peak in mid-November 2020. This increase was initially due to a resurgence of cases in the Islamic Republic of Iran, Jordan and Morocco, surpassing the number of cases reported during the mid-June 2020 peak. The second wave peaked in week 47 (starting on 16 November), where the highest weekly number of cases since the beginning of the pandemic was reported (251 094 cases, 6300 deaths). Then, a gradual decrease in the number of confirmed cases was observed until the end of 2020. Generally, countries in the Region have shown mixed patterns of resurgence, decrease or stabilization in the last six months. The curve has fluctuated in recent weeks, with 12 countries reporting an increase in numbers of cases until February 2021 (Fig. 2). The trend in COVID-19 deaths has shown the same pattern, with a sharp increase since mid- October 2020, declining from mid-November and plateauing since the beginning of 2021. The Islamic Republic of Iran, Lebanon, Tunisia, Pakistan and Egypt have been the main contributors to the number of deaths since the beginning of 2021 (Fig.3). 6WHO EASTERN MEDITERRANEAN REGION The Eastern Mediterranean Region (home to 9% of the world’s population) has the fourth highest number of cases and deaths among the six WHO regions. As at 28 February 2021, a total of 6 421 085 cases of COVID-19 and 144 947 associated deaths (CFR 2.3%) have been reported, representing 5.6% of the cases and 5.7% of the deaths reported globally. Since the beginning of the outbreak, the Islamic Republic of Iran has reported the highest number of cases in the Region (1 631 169 cases; 25.4% of the total for the Region) followed by Iraq (695 489; 10.8%) and Pakistan (581 365; 9.1%). The Islamic Republic of Iran has also reported the highest number of cumulative associated deaths (60 073; CFR 3.7%) followed by Iraq (13 406; CFR 1.9%) and Pakistan (12 896; CFR 2.2%). The highest The trends in incidence and mortality vary across the Region (Fig. 4), in part due to variations in detection, diagnostics, reporting and response capacities of Member States, as well as demographic differences. Moreover, response capacities are most variable at the subnational level, contributing to some uncertainty on numbers of cases reported nationally. The implementation of public health and social measures coupled with their intensity, coverage and public adherence also contribute to this variation. attack rates have been reported from Bahrain (7.2 cases per 100 population), followed by Qatar (5.7 cases per 100 population) and Lebanon (5.5 cases per 100 population); these countries also have among the highest testing rates in the Region. The regional CFR is 2.3%, ranging from 0.2% to 27.7% (median CFR = 1.8%). The highest CFRs are reported by Yemen (27.7%) followed by the Syrian Arab Republic (6.6%). The lowest CFRs are reported by Qatar (0.2%) followed by the United Arab Emirates (0.3%) and Bahrain (0.4%), a result of better quality health care systems, increased testing capacity, adequate hospital and intensive care capacity and trained staff. COVID-19 transmission patterns have evolved over time, with 16 countries currently self-reporting community transmission, five countries (Afghanistan, Bahrain, Djibouti, Egypt, Morocco) self-reporting clusters of cases, and one country self-reporting sporadic cases (Saudi Arabia). 3.1.2 Current situation in the Region (as at 28 February) Afghanistan Pakistan Iraq Syrian Arab Republic Lebanon Jordan EgyptLibya TunisiaMorocco Incidence per million Deaths per million Sudan Occupied Palestinian territory Kuwait Qatar Bahrain Saudi Arabia United Arab Emirates Oman Yemen Somalia Djibouti Islamic Republic of Iran < 100 100–1000 1001–10 000 10 001–50 000 > 50 000 < 50 50–100 101–500 > 500 Fig. 4. COVID-19 cumulative incidence per 100 000 population and total deaths per country, Eastern Mediterranean Region, 28 February 2021 7COVID-19 strategic preparedness and response plan – 2021 edition In terms of testing, a total of 97 602 151 laboratory- confirmed PCR tests have been conducted across the Region since the start of the pandemic, including 3 272 018 tests in week 8 of 2021, which showed a 2% increase compared to the previous week (3 197 386). Countries in the Region have adapted different testing strategies, despite WHO’s recommendation to follow the COVID-19 case definitions8. As a result of different testing strategies and capacities, Jordan, Lebanon and Gulf Cooperation Council (GCC) countries have reported the highest numbers of tests per capita, while countries with complex emergencies such as Afghanistan, Somalia, Sudan, Syrian Arab Republic and Yemen reported the lowest number of tests per capita in the Region. The number of tests per 100 000 population varies from 40 to 310 057, with a regional median of 13 467 tests. The cumulative test positivity ratio is also widely variable, ranging from 1% to 25% with a median of 10.4%. The lowest test-positivity ratio has been reported from Bahrain, Saudi Arabia and the United Arab Emirates, while Afghanistan, Syrian Arab Republic and Tunisia reported the highest positivity ratio. Over the past few months, several SARS-CoV-2 variants of concern (VOC) have been identified and preliminary evidence suggests that they may have increased 8 WHO COVID-19: case definitions: updated in Public health surveillance for COVID-19, published 16 December 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-Surveillance_Case_Definition-2020.2). © W H O /E M RO transmissibility and/or reduced virus neutralization among humans. These variants include the SARS-CoV-2 VOC 202012/01, the VOC linked to infections among farmed mink, the SARS-CoV-2 501Y.V2 and most recently SARS- CoV-2 B1.1.248. Out of 14 countries in the Region with SARS-CoV-2 genome sequencing capacity, 13 have reported VOCs (as at 28 February 2021) including Bahrain, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, occupied Palestinian territory, Oman, Pakistan, Saudi Arabia and the United Arab Emirates. Data from the Region’s case database of 2 015 925 records show that, as is the case globally, males are more affected than females, with a male to female ratio of 1.8 to 1.0. This ratio varies among countries, ranging from 1.1 in Egypt to 4.0 in Qatar. COVID-19 is more prevalent among adults, with about two thirds of COVID-19 cases in the Region being reported among those aged 25–55 years, and the most affected age group being 25–35 years of age. The risk of death increases with age, with the highest frequency of deaths reported among those over 55 years of age. Increased rates of severe and complicated disease, with more adverse long-term outcomes, are also associated with older age. 8WHO EASTERN MEDITERRANEAN REGION The risk of COVID-19 infection among frontline health care workers is higher than in the general population. Early reports suggested that health care workers accounted for 7–10% of all reported infections in the Region during the first three months of the pandemic. However, data on health care-associated infections are limited. In the Region, around 2% of case report forms reported through the regional platform, Eastern Mediterranean Flu (EMFLU), referred to cases among health care workers. Underreporting and lack of appropriate surveillance mechanisms to report infections among the health workforce have likely contributed to an underestimation of health worker infections. The 14 country support missions by WHO during 2020 consistently found deficiencies in infection prevention and control (IPC) governance and practice as one of the most consistent findings. To estimate the burden of COVID-19 in the Region, sero- epidemiological investigations are being conducted in multiple countries to complement surveillance data and guide the public health response, often with WHO support. In 2020, several countries reported their findings in peer-reviewed journals or shared data with WHO. Most nationwide surveys conducted between June and December 2020 in the Region estimated the prevalence of SARS-CoV-2 antibodies at 10%, which is consistent with the observations from global nationwide studies. Notably, low-income countries and countries with complex emergencies have reported higher estimates of prevalence in their populations, up to 25% nationally and 30% subnationally (although these countries have reported the lowest numbers of cases in the Region). The highest rates of antibody prevalence were reported in health care workers and migrant workers (specifically “craft and manual workers”). © W H O /E M RO 9COVID-19 strategic preparedness and response plan – 2021 edition WHO continues to assess the risks of COVID-19 at global, regional, country and community levels. The collection and analysis of epidemiological surveillance data from all countries in the Region has significantly improved over time, and the availability of these data has allowed WHO to conduct risk assessments on a regular basis to inform the public health response. While understanding of the SARS- CoV-2 virus continues to grow regarding the epidemiology, pathophysiology, diagnosis and management of the virus and associated disease, much remains unknown, such as the source, the evolution of the virus over time, the duration of human immunity, the impact of the vaccines on new variants, and the long-term impacts of infection on health. However, the availability of genetic sequencing data has provided valuable information on the biology and evolution of SARS-CoV-2. Combining the sequencing and epidemiological data provides real-time knowledge and understanding of the emergence of new variants and the impact on diagnostics and vaccines. WHO has been working with a global network of public health experts to continuously assess the evolving situation and provide recommendations to Member States. One major public health concern is the reported VOC in recent months. Several SARS-CoV-2 VOC have been identified and preliminary evidence suggests that they may have increased transmissibility or be associated with reduced virus neutralization among humans. Nonetheless, there is no strong evidence to date that these new variants have 3.2 Risk assessment of COVID-19 in the Region major impact on vaccine efficacy, although there is some concern. WHO is working closely with countries in the Region to enhance genomic surveillance in order to detect and monitor mutations and their implications for disease transmissibility, diagnostics, vaccines, therapeutics and overall public health responses. The COVID-19 vaccine roll-out has started in many countries and territories of the Region, and a decrease in cases has been observed in the United Arab Emirates since its deployment. Despite these positive preliminary observations, it is still too early for the vaccination programme to impact COVID-19 transmission considering the challenges it faces, including new variants. Delays in vaccine procurement, distribution and administration could potentially alter the course of transmission at the population level in the months to come. Efforts to ensure rapid and fair vaccine deployment among priority groups are being pursued through the COVAX Facility. Maintaining public health and social measures alongside vaccination is still essential to limit transmission and reduce the morbidity and mortality associated with COVID-19. However, pandemic fatigue could adversely affect the continued acceptance of and compliance with public health and social measures by the population. The regional and country-level risks for COVID-19 remain very high given the evolving situation of COVID-19 across the Region, preparedness and response capacities of Member States and the numerous challenges faced. © W H O /E M RO 10WHO EASTERN MEDITERRANEAN REGION The Eastern Mediterranean Region is home to nearly 600 million people living across 22 socioeconomically and geopolitically diverse countries and territories. Nine countries of the Region are directly impacted by complex humanitarian emergencies, and 43% of people in need of humanitarian assistance globally are located in the Region (101 million people in total). As of 2019, the Region hosted 275 032 asylum-seekers, 11.8 million refugees (half being Palestinian), 18.7 million internally displaced persons and 370 478 stateless persons.9 These populations are often vulnerable to poor health due to the conditions they live in and their limited access to needed quality health care. In addition, those who can access health care services are often faced with financial hardship. Additionally, as at 2019, there are 46 million professional and low-income labour migrants in the Region (of which 22 million are from the Region), with differential access to and coverage of health services.10 Migrants and forcibly displaced populations, refugees in particular, are often excluded from national programmes for health promotion, disease prevention, treatment and care, as well as from financial protection schemes for health, social services and social protection. This exclusion could affect early detection, testing, diagnosis, contact tracing and treatment for COVID-19. In addition, it increases the risk of COVID-19 spreading within these populations, where the outbreak can remain undetected. Moreover, due to limitations imposed by the pandemic, the role of public health and humanitarian partners has been further challenged. In a global survey conducted in November 2020, health cluster partners reported facing increased operational constraints in terms of insufficient funding, human resources capacity and supplies in safely delivering both COVID-19 response activities and essential health services. Existing fragile health systems in the Region have led to suboptimal disease surveillance and preparedness and response capacities, making countries particularly vulnerable to the emergence and rapid transmission of novel pathogens. The COVID-19 pandemic has further exacerbated public health risks and vulnerabilities especially among women and children in emergency countries, requiring concerted efforts to address the double burden of maintaining essential health services in an emergency context and responding to COVID-19 as the pandemic continues to evolve. 3.3 Operational context 3.3.1 Humanitarian settings and vulnerable groups 9 Population statistics [online database]. New York, NY: United Nations High Commissioner for Refugees; 2020 (https://www.unhcr.org/refugee-statistics, accessed 1 March 2021; last update in December 2020). 10 World migration report 2020. Geneva: International Organization for Migration; 2019 (https://publications.iom.int/system/files/pdf/wmr_2020.pdf, accessed 1 March 2021). © W H O /E M RO 11COVID-19 strategic preparedness and response plan – 2021 edition The pandemic has had a major impact on essential health services. Lockdown measures imposed early on in the pandemic, mobility limitations, the fear of getting COVID-19 infection and closure of some services has led to less utilization of and accessibility to essential health services. The supply chain of various essential medicines and vaccines was disrupted, leading to major shortages and further impacting the management of chronic illnesses. Many gaps were highlighted in health system design and implementation, including coordination mechanisms, supportive institutional arrangements, capacities and supportive legislations, funding and equitable financing arrangements, qualified health workforce mix, and access to quality medicines and medical products. WHO has conducted various global surveys to better assess the impact of the pandemic on essential health services. A rapid assessment was conducted in mid-202011 to which 13 countries of the Region responded (59%). The assessment reported frequent disruption of essential health services in the Eastern Mediterranean Region, with an average disruption of 75% – higher than all other WHO regions (PAHO was not included in the survey). An assessment in May 2020 shed light on the impact of the COVID-19 pandemic on services for noncommunicable diseases (NCDs). With responses from 19 (86%) countries in the Region, the most common reasons for discontinuing or reducing services were the closure of outpatient clinics and cancellation of elective care (47%), insufficient staffing (26%) and NCD clinical staff being deployed to provide COVID-19 relief (32%). About half of the countries surveyed had partially or completely disrupted NCD services. Similarly, results of a rapid assessment on mental health and psychosocial services (MHPSS) showed widespread disruption of these services in the Region, despite the mental toll that COVID-19 and associated public health and social measures have taken on individuals. To ensure continuity of services, WHO has established a dedicated pillar on essential health services as part of the SPRP to provide regular and tailored support to countries. Numerous guidance documents and protocols have been published to guide countries in ensuring the continuity of essential care. In this regard, the operational guidance on maintaining essential services serves as the main guidance12,13 alongside capacity-building materials and community-based guidance and assessment tools. Countries in the Region have adopted a range of approaches to ensure continuity of health services, including telemedicine and eHealth, capacity-building, supply chain strengthening, modalities to reactivate and improve access to services at primary and secondary care levels, streamlining health care, and improving IPC across the continuum of health care delivery. 3.3.2 Effects on health systems and essential services 11 Pulse survey on continuity of essential health services during the COVID-19 pandemic: interim report, 27 August 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1, accessed 1 March 2021). 12 Analysing and using routine data to monitor the effects of COVID-19 on essential health services: practical guide for national and subnational decision- makers. Interim guidance, 14 January 2021. Geneva: World Health Organization; 2021 (https://apps.who.int/iris/bitstream/handle/10665/338689/WHO- 2019-nCoV-essential_health_services-monitoring-2021.1-eng.pdf?sequence=1&isAllowed=y, accessed 21 February 2021). 13 Maintaining essential health services: operational guidance for the COVID-19 context. Interim guidance, 1 June 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV-essential-health-services-2020.1, accessed 21 February 2021). © W H O /E M RO 12WHO EASTERN MEDITERRANEAN REGION The COVID-19 pandemic has uncovered and intensified existing social and health inequities. Evidence shows clear socioeconomic inequities in rates of infection and mortality from COVID-19 that reflect existing social, economic and geographic inequities. Moreover, containment measures have had significant effects on health inequities by deteriorating the social determinants of health. In countries of the Region, levels of food insecurity, malnutrition and poverty substantially increased during 2020. In some instances, this was associated with containment measures and related decreases in income due to unemployment, reductions in working hours and inadequate social protection mechanisms to provide sufficient support. The pandemic has also had significant Since the beginning of the COVID-19 pandemic, countries have been implementing public health measures to prevent or slow the transmission of COVID-19, including individual, environmental or community measures in the form of surveillance, response and social interventions. Various social measures have been implemented by countries such as mandating physical distancing, mandating mask-wearing in public places, movement and travel restrictions, banning of gatherings and mass gathering events, closure of schools effects on gender inequalities: violence against women and girls has increased, girls have less access to online education than boys, and women have taken on more unpaid household and caring roles with lockdown measures in place. Mental health disorders have increased for a variety of reasons such as financial pressures, social isolation and anxiety about the pandemic. While the challenges are substantial and increasing, they also enable the identification of gaps to reduce inequities in the future. The Commission on Social Determinants of Health in the Eastern Mediterranean Region has recommended for Member States to position social justice at the heart of decision-making, and to foster a whole-of-society endeavour to improve health and reduce inequities. 3.3.3 Social and economic effects 3.3.4 Public health and social measures and other education settings, and closure of public and social services. Levels of implementation, enforcement and adherence to these measures have varied across countries and territories in the Region. The implementation of such measures can have considerable social and economic costs. Daily monitoring, recording and analysis of these measures show that the implementation of social measures is mostly not based on an objective, evidence-based risk assessment, but rather focuses on the epidemiological and socioeconomic situations. In some countries of the Region, the decision-making process has been skewed towards the socioeconomic situation. The Regional Office for the Eastern Mediterranean will continue to raise awareness and disseminate WHO guidance on performing risk assessments to inform decisions related to public health and social measures. The Regional Office has developed a dashboard that includes three layers of data (public health and social measures, epidemiological data and movement data) extracted from the Google daily monitoring reports in the context of COVID-19. Monitoring, recording and analysing of data from the dashboard, including for modelling purposes, will continue to guide and inform regional and national decisions.© W H O /E M RO 13COVID-19 strategic preparedness and response plan – 2021 edition Alongside public health and social measures to slow the spread of the virus and reduce transmission, safe and efficacious vaccines are a powerful tool to rapidly control the pandemic if a large proportion of the global population is vaccinated against COVID-19. Through the global solidarity initiatives, WHO has brought together public and private sector donors, pharmaceutical and research companies, and other experts to rapidly invest and support the development of COVID-19 vaccines. Within a few months of the pandemic, several vaccines had reached phase 3 clinical trials and were showing promising results. By December 2020, the first vaccine was approved by regulatory authorities in different countries and showed a high efficacy rate. Safe and effective vaccines for COVID-19 are now available and are already proving to be powerful tools in the global effort to control the pandemic. All 22 countries and territories of the Eastern Mediterranean Region have joined the COVAX Facility and committed to global coordination for the fair and equitable distribution of COVID-19 vaccines. Of these countries, 11 were considered self-financing countries (high-income countries) and 11 were eligible for the Advanced Market Commitment (AMC) funded through official development assistance ( low- and middle-income e countries, according to the World Bank classifications). By 28 February 2021, 15 countries in the Region had completed their readiness assessment using the COVID-19 Vaccine Introduction Readiness Assessment Tool (VIRAT/ VRAF 2.0). Eleven AMC countries had submitted their vaccine request form to the COVAX Facility and outlined their needs with respect to technical assistance, but none had reported readiness regarding the ultra-cold chain. Development of a national deployment and vaccination plan (NDVP) had started in 14 countries in the Region and WHO is providing technical assistance in finalizing the plans. Twenty-one countries had provided emergency use authorization for at least one vaccine. Thirteen countries had started COVID-19 vaccination and more than 11 million doses had been administered to target populations. As many countries in the Region are facing humanitarian crises, populations in fragile, conflict and vulnerable settings are prioritized and included in the NDVPs. However, the inclusion of migrants could be challenging due to limited accessibility to vaccines. A monitoring mechanism to evaluate the implementation of the NDVPs should be ensured. Eligibility, target groups and review processes are yet to be developed in collaboration with humanitarian organizations. Formal approval of Gavi is ongoing for allocation of the 5% buffer stock for humanitarian use. The regional working group on COVAX has organized several orientation webinars and virtual trainings targeting the Regional Immunization Technical Advisory Group, the national immunization technical advisory groups, WHO country offices, programme managers, and the Expanded Programme on Immunization (EPI) focal persons. Furthermore, the Regional Review Committee, consisting of WHO and UNICEF regional staff members, headquarters staff members and partner organizations, with four to five people per country panel, was established to review applications to COVAX. Several challenges have been identified in terms of concerns regarding the delay of COVAX vaccines compared to other vaccines, public acceptance of vaccine, and logistics support particularly in low-capacity and disrupted health systems. 3.3.5 Vaccines © W H O /E M RO 14WHO EASTERN MEDITERRANEAN REGION In line with the COVID-19 Research and Development Blueprint, countries in the Region have continued to accelerate innovative research to help contain the pandemic, facilitate care for those affected and contribute to global research platforms. Ten of the 22 countries and territories in the Region have joined the global quest for an effective treatment: the WHO Solidarity trial. For vaccine development, more than four countries have been involved in independent vaccine trials in collaboration with manufacturers. For diagnostics, all countries in the Region have been using commercial PCR tests and providing regular feedback on their effectiveness. This role has been further amplified since the emergence of the new variants and their detection. Three countries have also contributed to the evaluation of rapid immunoassay tests through sero- epidemiological studies. Moreover, eight countries have formally enrolled in the global Unity Studies initiative to further the understanding of transmission patterns, severity, clinical features and risk factors for infection. Other countries also continue to conduct epidemiological research and publish in peer-reviewed journals. The Region has also been a hub of technological innovation, including the development of mobile applications for contact tracing, the creation of home-made cloth masks, the use of robots for IPC in hospitals, innovative biomedical equipment, and the use of digital health applications to maintain essential health services. Additionally, the development and use of mathematical models for decision-making on public health and social measures, as well as to assess their epidemiological impact, has been a highlight innovation throughout the COVID-19 response. 3.3.6 Regional contribution to global research, development and innovation Supported by WHO, all 22 countries and territories of the Region have activated a national multisectoral coordination mechanism to facilitate efficient and comprehensive response activities, with the active engagement of local partners and donors. Many countries have established a dedicated multidisciplinary committee to lead the coordinated response reflecting, in most instances, a whole- of-government approach. Health clusters are utilized in nine countries and lead the response with humanitarian partners in the field to ensure adequate COVID-19-related service delivery and to ensure the continuity of essential health services. In the WHO Eastern Mediterranean Region, the Regional Director closely engages with ministers of health on a daily basis to update countries on new guidance and global and regional concerns, build consensus and foster evidence- based decisions, in addition to sharing experiences across countries. The Regional Director has established mechanisms for engaging experts from the Region and beyond, as well as other United Nations agencies, academia and the media. The Regional Director also engages with United Nations resident/humanitarian coordinators in the Region through regular meetings to ensure their support to the COVID-19 response at the country level. In agreement with ministers of health, a Ministerial Group on COVID-19 was established consisting of seven countries (Egypt, the Islamic Republic of Iran, Lebanon, Morocco, Oman, Saudi Arabia and Somalia). A dedicated technical working group held a series of consultative meetings, during which countries shared country-specific experiences highlighting successes, challenges and lessons learned on COVID-19 response. As a result, key recommendations were provided to guide strategic plans for 2021 to strengthen preparedness and response in the Region. 3.4 Regional collaboration and coordination 15COVID-19 strategic preparedness and response plan – 2021 edition A regional network of 35 technical and operational partners was established that convenes virtually on a biweekly basis to coordinate support for country-level responses and exchange updates. WHO has also continued to act as the health cluster lead in the response to the pandemic at global, regional and national levels. In addition, WHO continues to leverage the capacities of the Global Outbreak Alert and Response Network (GOARN) and emergency medical team initiatives to support country operations across the Region and globally. Within WHO’s Regional Office, the regional Incident Management Support Team (IMST) was established in January 2020 and rapidly expanded to involve all departments and expertise to tailor and address the regional needs to curb and prevent further spread of COVID-19. The IMST has provided and continues to provide a management and coordination platform to escalate areas of concern across the Region, tailoring the required support needed to overcome challenges and address needs. For 2021, the IMST has revisited its structure to improve internal coordination across its different response pillars and improve monitoring and reporting. A vaccine pillar has been added to IMST as pillar 10. This has fostered the integration and internal coordination between vaccine-preventable diseases and immunization (VPI), research, vaccine safety and risk communication and community engagement (RCCE) components of the pillar. Pillar 10 will promote a comprehensive and integrated approach to COVID-19 response and facilitate the uptake of COVID-19 vaccines in different countries. © W H O /E M RO 16WHO EASTERN MEDITERRANEAN REGION 4. KEY LESSONS LEARNED FOR LEVERAGING THE COVID-19 RESPONSE IN THE REGION IN 2021 • Coordination mechanisms were in place in many countries to support the response, including accountable whole-of-government approaches to decision-making. The most effective mechanisms were those in which the highest levels of government were fully engaged and followed the evidence-based guidance provided by public health experts. However, these mechanisms need to be better structured, maintained and strengthened through adjustments to their structure and operations using the lessons learned, such as optimizing the use of emergency operations centres. • Governance arrangements and capacities demonstrated gaps in delivering essential public health functions including gaps in coordination, oversight and regulations, as well as in preparedness and response • The production of clear credible information and messaging, alongside ensuring its wide dissemination via social media platforms and improving coordination with the media, is critical to fight misinformation/ disinformation and empower individuals, communities and populations to adapt appropriate risk-reducing behaviours and improve knowledge, perceptions and practices. to ensure accountability, responsiveness and equitable access to quality health care. Furthermore, building trust between governments and communities at both national and subnational levels needs improvement, as demonstrated by non-compliance to public health measures. Collaborative governance and promoted leadership skills and capacities in health decision- making need to be strengthened for a whole-of- government and whole-of-society approach. • There is a need to better identify and acknowledge specificities of the response in fragile, conflict and vulnerable settings. This will allow guidelines, response mechanisms and funding to be better tailored to enable adequate and timely response to COVID-19, and future pandemics, in areas already affected by crises. • Maintaining regular, timely and proactive communications to highlight WHO’s position to key stakeholders on key platforms raised the Region’s profile, increased the number of followers, generated media coverage and established the Regional Office as a credible source of information, including by other WHO regions who use our materials on their platforms. 4.1 Partnership and coordination 4.2 Communications (external and internal) • Maintaining a pre-positioned repository of essential health commodities proved critical to the acute phase of the response and enabled WHO to immediately and rapidly distribute personal protective equipment (PPE) and other essential medicines. • The increased supply chain management requirements associated with the COVID-19 response revealed the need to have qualified logistics/supply coordinators based in all WHO country offices to facilitate the delivery of medical supplies. • Increasing the visibility of supply chain data including financial commitments, physical locations and expected delivery dates, as well as technical details such as quantities, weights, volumes and expiry dates, is critical to WHO’s response. • Expanding logistics capabilities across the Region, in coordination with Member States, is required to maintain current service delivery levels and to improve national-level distribution of supplies. • The digitalization of the COVID-19 Supply Chain System, established to centralize procurement and distribution to help to overcome acute shortages of essential supplies caused by the pandemic, should be explored to enhance WHO’s resilience to future health shocks. 4.3 Operations support and logistics 17COVID-19 strategic preparedness and response plan – 2021 edition • IPC: – insufficient IPC governance and capacities at country and facility levels have highlighted the importance of establishing/enhancing national IPC programmes, improving the supply chain for PPE, and strengthening the monitoring of implementation of IPC measures to reduce transmission of COVID-19 and other emerging infectious diseases. • Clinical management: – improved skills of health care providers in the clinical management of COVID-19 has reduced the length of hospital stays and reduced death rates in severely and critically ill patients; – innovative and novel approaches for managing COVID-19 patients have contributed to reduction in complications and mortality associated with the disease. • Laboratory diagnostics: – expansion of national laboratory networks for COVID-19 testing has scaled up capacity for detection, characterization and response to the pandemic; however, further decentralization and strengthening of the laboratory network is crucial at both central and subnational levels; – lack of supply planning and forecasting at the country level has led to supply shortages for diagnostic testing, especially in complex emergency settings; – forecasting and quantification is needed at the country level to ensure an uninterrupted supply for the programme; the quantities can be used for pool procurement at regional level to support emergency countries. 4.4 Health operations and technical expertise • One of the most common findings of WHO country support missions was fragmentation of disease surveillance and health information management systems; this fragmentation complicates data collection, analysis and reporting, and constrains response efforts. Establishing integrated disease surveillance and consolidated health information management systems are important priorities for the Region, moving forward. • New and emerging epidemic diseases surveillance was not integrated in many existing national surveillance systems and therefore ad hoc COVID-19 surveillance had to be implemented in the majority of countries. Countries need to reinforce the early warning function of surveillance systems to detect emergence of a new disease or changes in disease patterns. • Standardized interactive and electronic tools (e.g. data management platforms, dashboards) are useful to improve the collection, management, analysis and communication of surveillance data in a timely manner. • Modelling tools are useful to support countries for planning and decision-making by estimating the burden of COVID-19 on health systems, in addition to enabling studies of the impact of different public health and social measures on the evolution of the outbreak. • Contact tracing capacities have been unable to cope with the increasing number of cases; thus, use of innovative techniques and deployment of new technologies are required to scale-up contact tracing measures. 4.5 Health information management and surveillance 18WHO EASTERN MEDITERRANEAN REGION • Accelerating efforts to enhance preparedness and operational readiness in countries in line with in line with International Health Regulations (IHR, 2005) requirements is important to rapidly respond to consecutive waves and peaks of the pandemic. • Building strong capacities for screening and management at points of entry (PoE) using standardized and simplified procedures, including proper risk assessment to inform decisions related to international travel, is important to early detect and manage imported cases. Sharing information about additional measures with WHO is needed to comply with IHR requirements. • Ensuring that social restriction measures are informed by risk assessments is vital to controlling the pandemic and to minimizing the social and economic impacts. 4.6 International Health Regulations and social measures • RCCE: – The RCCE workforce requires strengthening through capacity-building to address community fatigue resulting from strict social measures and to raise public awareness and compliance. – Coordinated, localized and participatory approaches to build systems for risk communication and engage communities will help to accelerate the COVID-19 response and ultimately reduce the negative impacts of the pandemic. – With vaccine availability, further RCCE-related challenges will arise such as vaccine hesitancy and increased misinformation and disinformation. Shifting towards community engagement to build trust and enhance social cohesion will help to counter these challenges. • Science and innovation played an important role in advancing the emergency response to the pandemic. It was very unique to see the collaboration between governments, scientists and private sector across the Region in search of new vaccines, diagnostics and drugs, and this collaboration needs to continue and should be leveraged for other public health emergencies. • Many countries of the Region do not have a designated focal point or structure for maintaining essential health services in their COVID-19 response. Governance structures and policies need to place much greater focus on essential health services as part of the response. • Health workers are at the forefront of the COVID-19 response. It has proved critical to mobilize and scale up capacities both quantitatively and qualitatively, with regular and timely updates on developments. Equally, ensuring a safe and secure working environment is a top priority. • Rapid diagnostic tests (RDTs) can be a useful tool for field epidemiological studies, particularly in countries with complex humanitarian emergencies. However, further studies are needed to assess their performance in different settings using standardized protocols and ensuring close quality control. • Many countries are suffering from a lack of information about maintaining essential health services. There is a need to create and maintain a dashboard of key indicators to monitor changes in the availability/use of essential services and the potential impact of service disruption on health outcomes. It is critical to better document the current status of essential health services in order to inform policy decisions and pandemic mitigation measures. 4.7 Research and knowledge management 4.8 Essential health services and systems 19COVID-19 strategic preparedness and response plan – 2021 edition • Global solidarity and innovation have accelerated vaccine development in a historically unprecedented manner. • Well-informed national regulatory and legal authorities have a powerful role in promoting faster and more efficient acquisition and use of vaccines during the COVID-19 response. • Decisions on prioritization and setting up of allocation schemes are critical to promote equitable access to COVID-19 vaccines. Measures have to be taken to prevent any tendency to deviate from this during the implementation phase. • Lack of political understanding of signing indemnification and liability agreements with vaccine manufacturers might hinder the timely delivery and deployment of vaccines. • Lack of clarity and the uncertainty regarding vaccine characteristics during the planning phase of deployment results in difficulties in anticipating needs. 4.9 COVID-19 vaccine © W H O /E M RO 20WHO EASTERN MEDITERRANEAN REGION 5. BEYOND COVID-19 Despite COVID-19 hitting health systems and populations on an unprecedented scale, the lessons learned from previous or ongoing outbreaks such as on accessibility to therapeutics (HIV), vaccine deployment (H1N1), IPC measures (MERS-CoV) and surveillance systems (influenza) have helped anticipate and adapt country responses to COVID-19. Therefore, assessing the achievements, challenges and areas of improvement of the COVID-19 response since the start of the pandemic is essential to improve readiness for any future outbreaks. Ensuring equitable access to COVID-19 vaccines and to high-quality health care services, expanding research on therapeutics, maintaining a strong supply chain system, and implementing large-scale diagnostic testing and effective contact tracing today will mitigate the consequences of the pandemic tomorrow. Strengthened health systems would be able to better manage the ongoing pandemic, while also building a foundation for potential future outbreaks. Multisectoral collaboration and a whole-of-government approach are needed for effective action at national and subnational levels. Beyond the health systems in place, emergency financial, material and human resources should be allocated and ready for possible future outbreaks. Strong partnerships and interconnectedness would allow for better prediction and detection of emerging diseases. For this, expanding of existing surveillance and early warning systems is essential. Furthermore, tackling the “infodemic” and educating the population on cough etiquette and other protective measures is necessary to build resilience and preparedness at the community level. Countries in the Eastern Mediterranean Region have implemented surveillance systems for timely data collection and dissemination for communicable diseases; however, their capacity for detection of high-threat pathogens in a timely manner for effective response is still limited. This is even more pronounced in humanitarian settings, where routine surveillance systems have collapsed and the early warning and alert response network (EWARN) has been implemented. To ensure real-time surveillance and response, efforts should be pursued to enhance surveillance systems, build the capacity of surveillance staff and adopt innovative technical solutions to ensure timeliness and completeness of data collection. Long before the COVID-19 pandemic, the WHO Regional Office worked with partners and Member States to strengthen the emergency preparedness and response operations at regional, national and subnational levels. All countries and territories in the Region have trained rapid response teams at the national level to investigate and rapidly respond to high-threat pathogens. However, capacity at subnational levels remains low and only 15 countries (68%) have rapid response teams at subnational levels ready to respond to local disease events. In responding to COVID-19, countries scaled up capacity of rapid response teams through decentralization and strengthening and empowering teams at different levels. Well trained and properly equipped rapid response teams are essential to combat outbreaks and epidemics at national and subnational levels. The COVID-19 pandemic demonstrated the effective utilization of an integrated public health response approach, whereby field-based polio programme personnel and assets were rapidly mobilized alongside rapid response teams and EPI teams to support the COVID-19 response and serve the most vulnerable communities. Going forward, there is a unique opportunity to turn the concept of integrated public health teams (IPHTs) into practice to ensure prompt response to any public health threat or alert, especially in fragile countries where national health workforce capacity is low or limited. 21COVID-19 strategic preparedness and response plan – 2021 edition 6. STRATEGIC PREPAREDNESS AND RESPONSE PLAN FOR COVID-19 IN THE EASTERN MEDITERRANEAN REGION IN 2021 • Maintain strong and well-coordinated pandemic planning and response through partnerships with government institutions, civil society, private sector, local communities and international agencies. • Strengthen country capacities to prevent or suppress community transmission and to control the occurrence of sporadic and clusters of cases through the use of evidence-based public health and social measures. • Minimize the risk of exposure through intensive community awareness campaigns, addressing misinformation, engaging and empowering local communities to adopt risk-reducing and appropriate health care-seeking behaviours, protecting vulnerable groups and promoting IPC best practices. • Ensure equitable, timely and affordable access to vaccines and other lifesaving COVID-19 tools and interventions (diagnostic tests, therapeutics and PPE) to all countries in the Region, including low-income/ AMC countries, and protect the most vulnerable people including refugees, displaced people, migrants, the elderly and hard-to-reach populations. • Reduce mortality and morbidity through improved health promotion and disease prevention, strengthened diagnostic capacities and quality clinical care, while ensuring the continuity of essential health services and systems and the provision of essential medicines and medical supplies. 6.2 Regional strategic objectives To continue supporting countries in the Region to leverage and sustain an effective response to suppress transmission, reduce exposure and minimize the impact of the COVID-19 pandemic, while exploring options to build resilient health systems for improved preparedness and response. 6.1 Goal 22WHO EASTERN MEDITERRANEAN REGION THE ROAD AHEAD Strengthen multisectoral partnerships Strengthen intensive care unit/critical care capacity to manage severe cases Enhance data generation, collection, management, analysis, and sharing for decision-making Support vaccine deployment and follow up Maintain and strengthen engagement with media professionals Strengthen infection prevention and control at national and facility levels Perform risk assessments to inform social and travel- related measures Support health workers in maintaining or restoring essential health services Deploy medical supplies rapidly Maintain and expand quality PCR testing and genomic surveillance capacity Engage and empower communities Enhance knowledge for action through priority research 23COVID-19 strategic preparedness and response plan – 2021 edition Areas of work and priority activities for COVID-19 preparedness and response in 2021 Area of work Activities Budget (US$) Partnership 1. Strengthen and support multisectoral, multi-partner coordination mechanisms with international and regional health partners, stakeholders and donors to ensure a whole-of-government approach to country preparedness and response to COVID-19, with particular focus on graded emergencies and fragile and vulnerable settings in the Region. 2. Establish and maintain a network of partners at regional level to ensure coordination of COVID-19 preparedness and response at regional and country levels. 3. Work with regional network of partners to adapt technical guidance on COVID-19 to local settings and study the secondary impact of the pandemic on health and other related sectors to ensure timely and appropriate recovery. 4. Ensure use of the concrete actions across all seven accelerator themes of the Global Action Plan on Healthy Lives and Well-being in addressing COVID-19, as per the Regional Joint Workplan 2020–2021, to strengthen health systems’ resilience and sustainability to prevent and mitigate the impacts of COVID-19. 5. Collaborate with and facilitate the work of international and national partners including local nongovernment organizations, academia, donors and Red Cross/Red Crescent societies to cover gaps in COVID-19 preparedness and response. Coordination 1. Strengthen the regional IMST to monitor regional and country-level activities, to facilitate coordination with counterpart teams of regional partners and with incident managers from other WHO regions, headquarters and country offices, and to mobilize resources. 2. Support WHO country offices to develop and activate national public health emergency management mechanisms including planning, operations, logistics and finance, with a whole-of-government approach and in cooperation with partners. 3. Support countries to update and implement their national COVID-19 preparedness and response plans, incorporated in their country preparedness and response plan for 2021 or their humanitarian response plan for 2021, as applicable, in estimated resource requirements (human, financial, supplies, etc.). 4. Facilitate capacity assessment and risk analysis, including gender analysis and proper mapping and inclusion of vulnerable populations in fragile and conflict-affected settings (including internally displaced persons, refugees, ethnic minorities, women, survivors of violence, people with disabilities, older people and populations in areas not under government control), for the implementation of the national plan including fair and equitable share of COVID-19 response resources and activities including vaccines. 5. Establish and maintain the regional network for receipt of inquiries from Regional Office technical leads, country offices and regional partners; coordinate country-support technical review or assessment missions; provide appropriate support or guidance, or escalate inquiry to the relevant country support team mechanism; and provide closed-loop communication of answers in a timely manner. 6. Lead the regional operational review/intra-action review process to monitor WHO’s progress, working together with partners, in implementing country preparedness and response activities to capture lessons learned and inform appropriate course corrections. Partnership and coordination 2 074 491 24WHO EASTERN MEDITERRANEAN REGION Area of work Activities 1. Proactively engage with the media through press briefings, pitching of interviews and ensuring availability of updates and information on hot topics. 2. Ensure regular monitoring and evaluation of the impact of communications and adjust the approach as the situation evolves to ensure relevance of messaging for key audiences and stakeholders. 3. Develop a COVID-19 communications toolkit for country communications officers and support roll out of toolkits to countries. 4. Enhance communications capacity of technical staff in the Regional Office and communications staff at country level and scale up internal communications on COVID-19 for staff across the Region. 5. Develop and disseminate internal communications including media talking points, briefing notes and other documentation for senior management and staff. 6. Support the development of a training-of-trainers manual for communications staff at regional and country levels. 7. Engage a regional advertising agency to support implementation of the regional vaccine communications plan. 8. Organize and support thematic mass media campaigns to promote vaccines and other COVID-19 response tools and interventions, and develop digital content with tailored messaging for key audiences. 9. Proactively counter misinformation and disinformation by building resilience to online disinformation, managing the infodemic, scaling up media and social media monitoring for misinformation and harmful rumours, and guide messaging to address health misinformation. 10. Conduct media, social media and audience landscape analysis. 11. Conduct training for the media on issues related to COVID-19 to increase understanding and awareness for more responsible coverage. 12. Identify and nurture a network of champions to advocate use of preventative measures by the public, as well as use of vaccines. 13. Promote content in Arabic, English and French on aggregation/influencer sites to further expand reach and visibility of correct information on COVID-19. 1. Forecast and identify demand for essential supplies for COVID-19 response and source, allocate and deliver supplies to where they are needed most at national and subnational level. 2. Maintain a pre-positioned reserve of emergency medical supplies/health kits to ensure a rapid response to critical needs and the evolving situation at country level, as per IMST priorities. 3. Support WHO country offices with the submission of requests into the global COVID-19 Supply Chain System. 4. Facilitate tracking of requests from WHO country offices and coordinate consolidation of supplies at the WHO logistics hub in Dubai. 5. Develop and disseminate procurement and supply planning guidance while deploying technical assistance for procurement and supply planning to priority countries. 6. Conduct regular assessments of operations support and logistics in the Region and identify key gaps in resources (financial and human); develop guidance on addressing these gaps to enhance management of supplies. 7. Facilitate the emergency deployment of logistics staff to priority countries and implement supply chain controls (supply planning, consolidation of procurement requirements, warehousing, tracking of distribution). 8. As COVID-19 vaccines are rolled out, support countries to enhance their supply chain management capacities and maintain the cold chain for storage and safe distribution, especially in humanitarian and low-capacity settings. 9. Distribute supplies to support vaccination efforts including ultra-cold-chain freezers, ancillary vaccination equipment and PPE. 10. Facilitate better communication with countries by drafting medical supply reports to be shared with country support teams. 11. Implement a comprehensive dashboard to track and record distributions from WHO’s logistics hub in Dubai. 12. Organize webinars with biomedical engineers to facilitate the selection of biomedical devices at the facility level. 13. Routinely share guidance and information on PPE, diagnostics and biomedical devices with WHO country offices, country support teams, IMST and partners. 14. Coordinate stock rotation and replenishment of other regional hubs to increase access to medical supplies globally. Communications (external and internal) Operations support and logistics 239 790 2 951 363 Budget (US$) 25COVID-19 strategic preparedness and response plan – 2021 edition Area of work Activities 1. Support the further expansion and decentralization of laboratory testing capacities to ensure accessibility of testing at district and community levels, especially for hard-to-reach vulnerable groups and in humanitarian settings. 2. Support countries to review and optimize their national testing algorithms and strategies, including the use of antigen-detecting rapid diagnostic tests (Ag-RDTs), based on transmission dynamics and available resources. 3. Continue to monitor the testing strategies implemented by countries and assist them in optimizing the introduction and use of new diagnostic kits. 4. Conduct virtual and on-site training for laboratory staff on the use of Ag-RDT kits and develop a system for mentoring non-laboratory health workforce (nurses, doctors) on Ag-RDT use, including fit-testing and waste disposal. 5. Organize and facilitate quality assurance for COVID-19 testing in countries through participation in WHO’s External Quality Assessment Programme (EQAP); evaluate assessment outcomes and take actions to address the gaps. 6. Develop and train laboratory workforce on diagnostic methods and procedures, through workshops or in-service training. 7. Organize and support trainings to strengthen capacities for specimen collection, packaging and transportation both within and outside the country. 8. Support technology transfer and troubleshooting through mentoring and supervision visits by national reference laboratory staff to subnational laboratories. 9. Expand the COVID-19 Genomic Surveillance Regional Network and encourage countries to share genetic sequence data and virus materials, including national public health laboratories, academia and the private sector. 10. Develop a training programme on genome sequencing and bioinformatics and upload sequences in international databases. 11. Support and enhance the capacity of the two regional genome sequencing laboratories to better support other countries that currently lack sequencing capacity. 12. Support countries to develop supply chain plans for procurement and distribution to ensure timely and sustained access to testing kits and other laboratory supplies. 13. Procure and pre-position stocks of essential laboratory supplies in WHO’s logistics hub in Dubai to enable a faster and more efficient regional response. 1. Continue to enhance IPC capacities and foster establishment/strengthening and implementation of IPC programmes both at national and facility level. 2. Support national authorities to review and update the IPC pillar within their national COVID-19 preparedness and response plans for 2021. 3. Disseminate new/updated WHO IPC guidance to national authorities on a regular basis regarding health care and community strategies to prevent the spread of SARS-CoV-2 in public and private settings. 4. Support review, updating and implementation of national IPC guidance for prevention of COVID-19 in health care, long-term care facilities and community settings. 5. Conduct regional IPC webinars, in collaboration with the WHO Collaborating Centre for IPC and Antimicrobial Resistance in Saudi Arabia, on updates in IPC guidance to control COVID-19 in health care and community settings. 6. Conduct tailored IPC trainings for high-vulnerability settings that favour the spread of COVID-19 (camps, migrant dormitories, etc.) to reduce the risk of outbreaks. 7. Conduct country-specific IPC training courses according to needs, with a special focus on IPC training of health workers involved in the delivery of COVID-19 vaccination programmes. 8. Ensure that countries with no national IPC programme establish a national core group of well-trained IPC persons to cascade the training forward to hospital IPC teams and frontline health workers. 9. Provide technical support to countries to develop and implement national programmes for the protection of health workers from COVID-19, including prevention, identification, management and monitoring. 10. Support priority countries to implement a national plan for the WHO/UNICEF Hand Hygiene for All initiative in health care and community settings. 11. Support countries to monitor priority IPC indicators to assess implementation of IPC best practices in selected health care facilities. 12. Promote evidenced-based water, sanitation and hygiene measures in communities, homes, schools, marketplaces and health-care facilities. Laboratory diagnostics Infection prevention and control 1 799 543 763 754 Budget (US$) 26WHO EASTERN MEDITERRANEAN REGION Area of work Activities 1. Support countries in effective management of mild and moderate COVID-19 cases to ensure judicious use of antibiotics to decelerate the development of antimicrobial resistance. 2. Develop and implement a training package on basic intensive care/critical care for resource-limited settings and support countries to deliver the training, on demand, including direct missions to countries to conduct training. 3. Support the development of country-specific clinical management trainings on demand-led topics such as critical care, systematic screening/ triage/referral of suspected cases at health facilities, and optimal use of biomedical supplies and equipment. 4. Support the recruitment of national doctors skilled in clinical management for emergency deployment, surge missions and long-term support in resource-limited countries, as per need. 5. Support countries to develop post-COVID-19 rehabilitation programmes at national level. 6. Continue to contribute to the development of WHO clinical management guidance, treatment protocols and recommendations, and ensure timely dissemination, updates and alerts to countries. 7. Support countries in conducting clinical research related to management of patients with severe respiratory infection and other COVID-19- associated complications. 8. Continue support for innovation in biomedical equipment in countries and support the WHO-led biomedical consortium. 9. Support countries and health facilities to access adequate treatments through enhanced and rapid procurement of therapeutics, medical oxygen, biomedical supplies and equipment. 10. Promote and enhance collaboration between pre-hospital and critical care services across the three levels of WHO and partners on development of training packages, regional referral system, procurement of biomedical supplies and equipment, and research activities. 11. Build a network among intensive care/critical care professionals and academic institutions in the Region to further collaborative efforts and support resource-limited countries through the network. 12. Monitor and evaluate the implementation and effectiveness of case management procedures and protocols, and address gaps as necessary. 13. Assess clinical management capacity in referral hospitals managing COVID-19 patients and provide technical support to address the gaps. 14. Work with the Science Information and Dissemination team at the Regional Office to conduct clinical research on therapeutic options and clinical management of COVID-19 patients. Clinical management 1 281 076 Budget (US$) 27COVID-19 strategic preparedness and response plan – 2021 edition Area of work Activities 1. Strengthen detection capacity at the regional and country level by cascading the available procedures and tools (e.g., online signal module, Epidemic Intelligence from Open Sources (EIOS), epitweetr). 2. Enhance detection and monitoring of SARS-CoV-2 variants of concern and develop a mechanism for related information management processes. 3. Support countries to enhance capacities in data collection, analysis and information generation, as well as data sharing in a timely manner; and specifically monitor health system capacities including hospitalization rates and hospital occupancy. 4. Enhance country capacities to collect and upload the required data to the EMFLU-COVID-19 platform. 5. Perform comprehensive and timely epidemiological and social science data analysis to identify trends, needs and gaps, and to inform risk assessment and decision-making to guide or adjust the COVID-19 response. 6. Encourage countries to pool their resources to implement integrated disease surveillance, and to engage communities for establishing/enhancing event-based surveillance within integrated disease surveillance systems. 7. Develop and disseminate regional guidance on contact tracing in the context of community transmission and provide support for its implementation. 8. Develop/build new indicators to better understand the evolution and impact of the pandemic and implement mechanisms to collect and monitor the indicators. 9. Pursue dialogue with WHO country offices and ministries of health for improving data collection and sharing in a timely manner. 10. Continue to update the regional COVID-19 SPRP monitoring and evaluation framework, in coordination with WHO headquarters and country offices, and support the development of national monitoring and evaluation frameworks. 11. Streamline the use of information technology platforms for COVID-19 data management and dashboards at the regional and country level and support adaptation and deployment of the DHIS2 digital data package for COVID-19 surveillance. 12. Conduct in-depth epidemiological analysis of possible risk factors contributing to COVID-19 morbidity and mortality, particularly in countries with high case fatality rates. 13. Strengthen the modelling capacities at the regional and country level and support countries in running statistical modelling at national and subnational levels. 14. Scale-up the use of GIS and spatial analysis to inform decision-making and produce cartographic maps to visualize and conceptualize the spread of the virus, burdens of caseloads and mortality, and response activities and their impact. 15. Promote and support the use of existing surveillance systems such as influenza systems (SARI and ILI sentinel sites) and EWARN to identify COVID-19 cases at community and peripheral levels. 16. Provide additional support required to document, monitor and track COVID-19 vaccination safety. 17. Support continuing training and capacity-building of national and subnational rapid response teams/integrated public health teams (IPHTs) for COVID-19 outbreak and case investigation and management, laboratory sample collection, contact tracing, RCCE and IPC. 18. Develop and disseminate protocols to enable rapid response teams/IPHTs to collect and analyse subnational data for assessing levels of local transmission and health system response capacity, so as to assign a “situation level” and to inform implementation of public health and social measures. 19. Conduct landscape analysis and needs assessment to identify rapid response team capacities in the Region and identify gaps, challenges and strengths for improved COVID-19 response. Health information management and surveillance 1 696 453 Budget (US$) 28WHO EASTERN MEDITERRANEAN REGION Area of work Activities Preparedness and operational readiness 1. Support countries to fully operationalize public health emergency operations centres (PHEOC) through assessment of national PHEOC and capacity- building of staff; identify gaps in the incident management system and PHEOC operations, develop operationalization plans, and provide software solutions to facilitate PHEOC operational management. 2. Support emergency care system assessments (pre-hospital and hospital services) to identify gaps and implement corrective measures, and build capacity of hospital managers and relevant staff on emergency management of COVID-19. 3. Support countries to establish and deploy emergency medical teams for COVID-19 response, and facilitate and support the process of attaining WHO global classification. 4. Support countries to conduct intra-action reviews of their COVID-19 response and ensure proper documentation for the development/review of response plans. PoE, travel and mass gatherings 1. Enhance operational capacities at PoE by supporting country assessments of PoE premises and operations and the modification/restructuring of physical premises; develop guidance to support strategic directions at PoE, provide technical trainings, perform exercises and drills for COVID-19 preparedness, and develop contingency plans and standard operating procedures (SOPs). 2. Strengthen PoE surveillance and screening systems through enhanced multisectoral coordination between national authorities and PoE stakeholders. 3. Foster collaboration among PoE stakeholders by expanding the interagency PoE working group (comprising the International Organization for Migration (IOM), the International Maritime Organization (IMO) and the International Civil Aviation Organization (ICAO)) to coordinate support to countries. 4. Support countries to conduct risk assessment of international travel and public health measures, provide training on WHO’s guidance for risk assessment related to international travel and provide technical support on the potential role of vaccination in navigating international travel under the aegis of the IHR. 5. Foster cross-border collaboration on COVID-19 and other public health threats and provide technical and strategic support to enhance information sharing between countries; develop memoranda of understanding and SOPs for joint surveillance and response, and support joint trainings and assessments. 6. Encourage documentation of best practices and lessons learned on cross-border collaboration for use in scientific studies and case-studies. 7. Maintain the regional Travel Measures platform and follow up with countries on weekly entering of data; share additional measures implemented by countries with the IHR Secretariat for dissemination on the Event Information Site. 8. Scale up capacities for mass gathering events in the context of COVID-19 by providing technical trainings and support countries to: conduct risk assessments to inform contingency plans and operational SOPs; develop travel requirements for specific events; ensure legacy generation and sharing of country experiences; produce technical materials/guidance on strategic directions for mass gatherings. One Health 1. Strengthen multisectoral coordination mechanisms between public health and animal health sectors: conduct a stakeholder mapping exercise to identify national One Health committee/hub members from government authorities and nongovernmental organizations, and support countries to identify roles and responsibilities for each sector/stakeholder. 2. Strengthen/establish an integrated zoonotic disease surveillance system, including for COVID-19, by supporting countries to review existing integrated surveillance structures at national level and undertake strengths, weaknesses, opportunities and threats (SWOT) analysis; identify key stakeholders and their role in implementation of surveillance activities and develop an information-sharing mechanism for stakeholders. IHR and social measures 452 945 Budget (US$) 29COVID-19 strategic preparedness and response plan – 2021 edition Area of work Activities Social measures 1. Ensure daily data collection and monitoring of social measures implemented in countries, including mobility and epidemiology data, maintain the Social Measures dashboard and produce a weekly summary report on social measures implemented in the Region. 2. Conduct in-depth analysis (such as time series analysis) to understand the impact of social measures on the epi curve in each country and develop policy briefs guided by the findings to inform decision-making at country level. 1. Strengthen country capacities to institutionalize RCCE systems, mechanisms and processes to support planning and implementation of public health and social measures for the COVID-19 response. 2. Support countries to implement the regional guiding framework for RCCE for the COVID-19 response. 3. Strengthen existing RCCE coordination mechanisms including expansion of membership, collaboration and activities of the Regional Interagency RCCE Working Group; institutionalize and reinforce the mandate and role of existing national RCCE interagency groups and provide joint WHO/ UNICEF support for country analysis of RCCE activities using common tools adapted to national contexts. 4. Increase coordination for RCCE through the subregional task force to improve alignment with other United Nations organizations and regional and international partners. 5. Build/strengthen country capacities to manage the COVID-19 infodemic by providing supporting materials that address concerns, translate science and communicate risks in order to promote resilience to misinformation and disinformation. 6. Develop a social and behavioural insights dashboard and support countries to conduct national surveys on behavioural insights to inform targeted policies, interventions and communications and to address gaps. 7. Support countries to conduct landscape analysis of civil society organizations to map opportunities for community engagement, including enablers and barriers, and use analysis to inform polices and plans for building resilient communities for COVID-19 response and beyond. 8. Develop an advocacy plan/materials and build capacity for social mobilization and community engagement to create and maintain demand for COVID-19 vaccines and to address community concerns and vaccine hesitancy. 1. Identify and support COVID-19-releated innovation (including digital health innovations) in response to country needs, in collaboration with relevant teams at all levels of the Organization. 2. Support priority research on COVID-19 in countries through open calls for research proposals linked to the announced global or regional priority topics. 3. Support ethical conduct of research and conduct ethical reviews of WHO-supported COVID-19 research at regional or national levels. 4. Provide operational and technical support to conduct WHO Unity Studies in countries. 5. Conduct or support priority research on vaccine effectiveness, infodemiology, clinical management of disease and other related areas, as required by country need and/or regional IMST. 6. Support the development of a regional COVID-19 Health System Response Monitor platform to generate a monitoring report on COVID-19 response in countries, through collaboration between the WHO Eastern Mediterranean Regional Health Observatory and other WHO observatories. 7. Assess and support national COVID-19 evidence-informed policy-making processes and national decision-making processes, and how these were affected by the pandemic. 8. Support sharing and dissemination of peer-reviewed knowledge and evidence with the WHO community, partners involved in the COVID-19 response, and wider academic and policy-making circles. RCCE Research and knowledge management 530 210 1 942 318 Budget (US$) 30WHO EASTERN MEDITERRANEAN REGION Area of work Activities 1. Lead technical cooperation to develop and implement country-specific roadmaps for maintaining essential health services during COVID-19 and beyond, as per WHO’s operational guidance on maintaining essential health services. 2. Coordinate technical support for essential health services with relevant United Nations agencies and other humanitarian and development partners, under the umbrella of the Regional Health Forum and the Global Action Plan for SDG 3. 3. Provide technical support to health workers for maintaining/restoring essential health services and facilitate the development of national occupational health programmes for health workers. 4. Enhance hospital readiness for response to COVID-19 and develop and implement IPC, patient safety and quality improvement strategies. 5. Provide technical support to improve regulatory and supply chain management readiness for maintaining essential health services. 6. Provide technical support to enhance financial access to essential health services, with a focus on vulnerable populations. 7. Provide technical support to strengthen health governance, including strengthening the role of the private sector and improving institutional arrangements for coordinating and maintaining essential health services. 8. Provide technical support for health systems strengthening to improve access to integrated quality essential health services during the COVID-19 pandemic and beyond. 9. Assess the use of digital health solutions in maintaining essential health services across the Region during the COVID-19 response and beyond. 10. Operationalize WHO’s COVID-19 MHPSS response framework to integrate MHPSS in health and social services, increase access to care, strengthen community-based interventions and address the needs of specific populations. 11. Identify essential nutrition services for mothers and children to mitigate the economic impacts of COVID-19 and subsequent effects on household incomes and food supplies. 12. Provide technical support to countries to enhance access to essential health services for migrants and refugees. 13. Monitor continuation, disruption and restoration of essential health services at the country level. Essential health services and systems 3 336 234 Budget (US$) 31COVID-19 strategic preparedness and response plan – 2021 edition Area of work Activities 1. Expand technical support for vaccine introduction, communications and advocacy, supply chain and logistics, microplanning, vaccination verification, and monitoring of immunization and safety. 2. Engage with regional and global partners to identify new financing platforms to support priority countries in scaling up access to COVID-19 vaccines. 3. Support countries to develop and implement their national deployment and vaccination plans (NDVPs). 4. Establish and lead a regional COVID-19 review committee to manage and oversee NDVPs and provide guidance to countries. 5. Manage and disseminate information and knowledge related to COVID-19 vaccines to ensure that WHO country offices and national health authorities are fully informed. 6. Organize regional, subregional and in-country virtual events to support and monitor vaccine deployment and implementation processes. 7. Develop/adapt tools for country readiness assessments and trainings, as well as for monitoring and evaluation, and support countries in utilizing these tools and materials. 8. Support countries to enhance the knowledge and skills of health care workers and managers in COVID-19 vaccination and reporting of adverse events. 9. Advocate for inclusion of conflict-affected, fragile and humanitarian settings in vaccination roll-out and work with partners to reach the most vulnerable groups. 10. Support the national regulatory authorities to enable faster and more efficient regulatory approvals and regulatory oversight of the vaccines. 11. Ensure regional and national immunization technical advisory groups and other relevant stakeholders are fully involved in vaccine introduction, regulatory processes, policy recommendations and implementation processes. 12. Promote demand generation and community uptake, and address vaccine hesitancy. 13. Provide necessary technical support to countries for: - decision-making related to COVID-19 vaccine deployment; - assessment of country readiness to identify gaps and guide planning process; - prioritization of target groups; - preparation of applications/proposals for COVID-19 vaccine purchase, deployment and monitoring; - monitoring and evaluation, including data analysis and evaluation on the safety and effectiveness of vaccines; - establishing a system for vaccine safety monitoring, including adverse events following immunization. 14. Support and engage countries in collection, management, analysis, use and sharing of vaccine-related information. 15. Provide technical support on using innovative technologies for microplanning, monitoring, gap analysis and impact evaluation. 16. Develop and maintain a regional dashboard for COVID-19 vaccine deployment and follow up on regional and global core indicators. 17. Conduct post-deployment evaluations and document lessons learned in the Region. 18. Ensure collaboration between the three levels of the Organization and partners at international, regional, national and subnational levels. COVID-19 vaccine 2 941 209 Total budget US$ 20 009 386 Budget (US$) 32WHO EASTERN MEDITERRANEAN REGION 7. BUDGET SUMMARY BY PILLAR (2021) Pillars Budget (US$) Pillar 1. Partnership and coordination Pillar 2. Communications (external and internal) Pillar 3. Operations support and logistics Pillar 4. Health operations and technical expertise – Laboratory diagnostics – Infection prevention and control – Clinical management Pillar 5. Health information management and surveillance Pillar 6. International Health Regulations and social measures – Risk communication and community engagement Pillar 7. Research and knowledge management Pillar 8. Essential health services and systems Pillar 9. COVID-19 vaccine Total for the WHO Regional Office for the Eastern Mediterranean 2 074 491 239 790 2 951 363 1 799 543 763 754 1 281 076 1 696 453 452 945 530 210 1 942 318 3 336 234 2 941 209 20 009 386 33COVID-19 strategic preparedness and response plan – 2021 edition 8. MONITORING AND EVALUATION The regional COVID-19 monitoring and evaluation (M&E) framework was developed to monitor implementation of the COVID-19 SPRP for the Eastern Mediterranean Region. The regional framework is aligned with the global COVID-19 M&E framework. The objectives of the regional COVID-19 M&E framework are to: • provide key performance indicators that enable monitoring of COVID-19 response activities at the regional and country level; • enable the Regional Office to identify the specific support and interventions needed by countries; • support transparent resource allocation to the countries in the Region; • document operational reviews/after-action reviews and lessons learned. The regional M&E framework has been revised for 2021 to include an updated list of indicators, taking into account the lessons learned from implementation of the SPRP 2020 and the evolution of the pandemic, as well as changes in the IMST structure. The regional M&E framework for 2021 includes a list of 43 indicators that cover the activities of the all pillars under the new IMST structure, and these indicators should be collected weekly, monthly, quarterly or annually (refer to Annex 1). These indicators will be complemented by data collection and visualization tools. Training on the data collection tools has been provided to focal points at WHO country offices to ensure proper data collection and reporting. A progress report will be generated and periodically shared by the M&E working group with the IMST and other senior management at the Regional Office. Progress reports will highlight the strengths, weaknesses and gaps in implementation of activities and make recommendations for adjustments to the Region’s COVID-19 preparedness and response. The M&E working group will provide technical support to WHO country offices and Members States of the Eastern Mediterranean Region to strengthen monitoring of the response activities. © W H O /E M RO 34WHO EASTERN MEDITERRANEAN REGION Annex 1: COVID-19 SPRP M&E FRAMEWORK FOR 2021: PROPOSED INDICATORS No. Indicator Type Target Source Frequency Pillar 1: Partnership and coordination Pillar 2: Communications (external and internal) Pillar 3: Operations support and logistics Pillar 4: Health operations and technical expertise Laboratory diagnostics Infection prevention and control 1 2 4 5 6 7 8 9 10 11 12 3 Proportion (%) of countries with an active multisectoral, multi-partner coordination mechanism to support preparedness and response Proportion (%) of countries reporting modifications to planned mass gathering events due to COVID-19 (cancelled, postponed) Proportion (%) of countries requesting PPE from the global system that received stockpiles within 6 weeks Proportion (%) of requested supply volume disaggregated by type (PPE, biomedical equipment, diagnostics) that has been shipped to countries Number of countries experiencing stockout of critical items Proportion (%) of laboratories with COVID-19 testing capacity in the country Proportion (%) of laboratories in the country performing SARS-CoV-2 molecular testing that are participating in External Quality Assessment for SARS-CoV-2 Proportion (%) of subnational laboratories with 80% performance in WHO’s COVID-19 External Quality Assessment Programme Number and proportion (%) of countries supported by COVID-19 SPRP investments for IPC through WHO country offices Number of users that completed OpenWHO IPC modules Percentage of countries with a functional national IPC programme Number of country press releases Process Output Output Output Output Outcome Process Outcome Output Outcome Output Output 100% 50% 85% 85% NA NA 100% 75% 60% NA All countries with WHO country offices NA Country offices Country offices Dubai hub OSL database Dubai hub OSL database Country offices Country offices WHO headquarters (influenza programme) & COVID-19 laboratory team WHO headquarters (influenza programme) & COVID-19 laboratory team WHO headquarters WHO HQ Regional office Country offices Quarterly Quarterly Monthly Monthly Monthly Monthly Biannually Biannually Quarterly Monthly Biannually Monthly 35COVID-19 strategic preparedness and response plan – 2021 edition No. Indicator Type Target Source Frequency Clinical management Pillar 5: Health information management and surveillance Pillar 6: International Health Regulations and social measures Pillar 7: Research and knowledge management Risk communication and community engagement (RCCE) 13 14 15 16 17 18 25 26 19 20 21 22 23 24 Proportion (%) of hospitals designated to treat COVID-19 cases Number of health workers trained on case management of COVID-19 cases Proportion of inpatient bed (designated for COVID-19) occupancy rate (%), nationwide Proportion (%) of COVID-19 cases who are health care workers Proportion of ICU bed (designated for COVID-19) occupancy rate (%), nationwide Number of countries with trained multi-disciplinary rapid response team at subnational level Proportion (%) of funded research proposals for COVID-19-related topics completed according to plan Proportion (%) of randomized control trials on COVID-19-related topics conducted by countries, and have minimum sample size of 1000 participants Percentage of PoE with public health emergency contingency plans inclusive of a risk communication strategy (i.e. for travellers, media/public) Proportion (%) of PoE with public health emergency contingency plans and SOPs for managing respiratory illnesses at specific PoE Proportion (%) of PoE equipped to generate real-time (electronic) data from suspect passengers Proportion (%) of countries with a RCCE coordination mechanism formally activated (e.g., multisectoral RCCE team, working group, task force) Proportion (%) of countries with an active mechanism in place to capture community feedback (e.g., community meetings, hotlines, health volunteer networks, social listening, surveys, etc.) Proportion (%) of countries that monitor disinformation, misinformation and rumours deemed harmful to public health Output Output Output Outcome Output Input Output Output Input Input Process Process Outcome Outcome NA NA NA NA NA 100% 100% 100% 100% 100% 100% 100% 100% 50% Country offices Country offices Country offices Country offices Country offices Country offices Regional Office Regional Office Country offices Country offices Country offices Country offices Country offices Country offices Monthly Monthly Monthly Weekly Weekly Quarterly Annually Annually Biannually Biannually Quarterly Quarterly Quarterly Quarterly 36WHO EASTERN MEDITERRANEAN REGION No. Indicator Type Target Source Frequency 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Proportion (%) of vaccine effectiveness studies completed according to plan Proportion (%) of countries that received technical and financial support to implement at least one sero-epidemiological investigation using WHO Unity Studies protocols Number of countries that received technical and financial support to implement at least one WHO Unity Study Number of countries submitting all-causes mortality on weekly bases Proportion (%) of countries which agreed to participate in WHO Solidarity trial that have started trials DTP3 vaccination coverage in children under 12 months of age Institutional delivery Proportion (%) of countries where at least one VPD- immunization campaign was affected (suspended or postponed, partially or fully) due to COVID-19 Outpatient attendance Hospital admissions OR discharges Proportion (%) of stockouts of essential medicines or supplies Total doses of COVID-19 vaccine administered per country Proportion of targets vaccinated with 1st dose Proportion of targets vaccinated with 2nd dose Proportion (%) of surge deployments filled and timely from requests received by country office and IMST Percentage of funds distributed (against planned cost) Percentage of funds utilized (against funds distributed) Output Outcome Process Process Process Outcome Outcome Outcome Outcome Outcome Output Output Output Output Output Process Output 100% 40% 100% 100% NA NA NA NA NA NA NA NA NA NA NA 100% 100% Regional Office Regional Office Regional Office Regional Office Country offices Regional IMST Regional IMST WHO headquarters (Immunization, Vaccines and Biologicals programme) Country offices Country offices Country offices Country offices Country offices Country offices Regional Office Regional Office Regional Office Annually Quarterly Quarterly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Weekly Weekly Weekly Monthly Monthly Monthly Pillar 8: Essential health services and systems Pillar 9: COVID-19 vaccine Cross-cutting functions Programme management © W H O /E M RO