WHO-EM/DCD/003/E/G Distribution: General
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
ANNUAL REPORT
2002
WHO-EM/DCD/003/E/G Distribution: General
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
ANNUAL REPORT 2002
Cairo 2003
CONTE NTS
FOREWORD 4
Developing an integrated approach: cross-cutting activities 30 30 32 32 34 36 38 39 40 42 44 44 48 Working with international partnerships Community participation
INTRODUCTION 6 Focusing on cross-cutting activities Capacity-building
Why integration is needed
PA R T 1 Communicable diseases in the EMR 8 Advocacy
Introduction 10 Infection control
Vaccine-preventable diseases of childhood 10 13
Containment of anti-microbial resistance Management of insecticide resistance
Tuberculosis 14 Operational research
Malaria 15 16 17
HIV/AIDS and sexually transmitted diseases
Surveillance forecasting & epidemic management
Emerging and epidemic-prone diseases
Partnership for health Expanding intersectoral collaboration
Tropical and zoonotic diseases
PA R T 2 Challenges 20 22 22 22 24 26
50
National commitment and leadership
Facing realities in the Region and the world Complex emergencies A borderless world
53 53 58
Strengthening health systems
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
A huge task
Building trust
Responding to change: the public-private mix
PAR T 3 Fo c us i ng o n t he p o s s i b l e
60
FOREWORD
Communicable diseases are responsible for the deaths of an estimated 1.3
we are attempting to resolve and the complexities inherent in implementing a new approach in an everchanging environment. It is my wish that all those working for and with the Division of Communicable Disease Control in the Region will succeed in their efforts to move communicable disease prevention and control into a new era of progressive success with every advancing year.
million people in the Eastern Mediterranean Region every year. Most of these
deaths could have been prevented with proper utilization of the available cost-
effective prevention and control measures. Unfortunately, this is not the case,
and millions still die of communicable diseases every year.
It is true that remarkable successes in communicable diseases control have been accomplished and that the
general picture is quite promising; however, this is not enough. It is unacceptable that children are still dying
from diseases for which an effective and safe vaccine is available, such as measles. It is unacceptable, too, Hussein A. Gazairy MD, FRCS Regional Director for the Eastern Mediterranean
that more than 100 000 deaths occur annually from tuberculosis, when treatment under the DOTS strategy
has a success rate of more than 90%. Suffering from malaria and other vector-borne diseases can be greatly
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
reduced by the effective use of insecticide treated bednets. In addition, the lives of people living with HIV/AIDS
can be improved and extended with the use of antiretroviral therapy.
To address this situation, the Regional Office has promoted the concept of integrated disease control, in which
better use of available resources and wider coverage of intervention techniques will lead to improved health
for the people of the Region. The integrated disease control approach was presented in a technical paper to
the Regional Committee for the Eastern Mediterranean in 2002, and the concept generated a great wave of
enthusiasm. This was the beginning of new era of communicable diseases control in the Region. However,
the way is not yet clear. Without a thorough understanding of the many challenges facing us and the obstacles
lying ahead, we may not be able to progress at the pace we would like.
This year’s Annual Report of the Division of Communicable Disease Control is a transparent look at the
difficulties we must overcome and the challenges we face in doing so. It is not a report about the divisional
achievements of the past year; on the contrary, it is a pragmatic analysis of the magnitude of the problems
4
5
INTRODUCTION
Our fight against communicable diseases is far from over. Communicable problem; it lies also in failure to fully comprehend the problem.
Failure to achieve the targets cannot be explained only by failure of the methodology used for tackling the
diseases are still the major cause of premature death in this part of the world.
They are responsible for one-third of the annual deaths in the Region and for The challenges facing communicable diseases control vary greatly among the different countries of the Region. These challenges include lack of national political commitment and leadership to support the control programmes, weak health systems with inequitable distribution of health services, low educational and awareness levels among the general population, ineffective and unplanned decentralization, fragmentation of resources, "brain drain", poverty, political instability and civil strife. In many countries of the Region, health systems are ill equipped to cope with the current or future demands for communicable diseases control. Moreover, while institutional problems which can limit performance of the different communicable diseases control programmes are common, they have been largely neglected by the health authorities in the past. In our battle against communicable diseases, we must constantly strive for better understanding of the factors that affect communicable disease control. This is not an easy task. It requires thorough analysis of the Communicable diseases 32%
32% of the disease burden as measured in disability-adjusted life years.
Moreover, communicable diseases are a major cause of poverty, under-
development and human suffering.
The development of effective treatment and vaccines against priority
communicable diseases during the 20th century should have made a substantial impact on these diseases.
However, this did not occur. The euphoria which arose during the smallpox eradication era gradually dwindled
with the failure to achieve malaria eradication. In the next era, new communicable diseases emerged, such
as AIDS, ebola and more recently, SARS, while others which had been largely forgotten, such as tuberculosis,
malaria and dengue fever, re-emerged as a public health threat.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
In our annual report of last year, we focused on
strengths, weaknesses and challenges facing the control programmes in each country in the Region. This report draws attention to the complexity of the challenges facing the communicable diseases control programmes in the different countries of the Region. It explains how lessons learned from past experiences Maternal conditions 3% Prenatal Conditions 8% Nutritional deficiencies 4%
the situation of communicable diseases in the
Eastern Mediterranean Region. We looked
extensively at the disease burden in general and
failures can guide a more targeted and pragmatic approach to current and emerging challenges and offers strategic directions for tackling these challenges.
specific diseases in particular. We discussed
general prevention and control measures, with
examples of successes and pitfalls. We also
Injuries 11%
admitted that we have not yet achieved all that
is possible and that we are still far from reaching Noncommunicable diseases 42% Dr Zuhair Hallaj Director, Communicable Disease Control
our aim to deliver the people from avoidable
suffering and to save their loved ones from
preventable death. In the same report, we
proposed a new approach, the "integrated approach", to scale up control activities and develop an essential
package of services that can be delivered at the periphery under whatever conditions. We are now on the
way.
In this year’s annual report, we outline the challenges faced in our work. It is clear that even the best approach
will not produce the expected results unless it takes into account the environment in which it will be used.
6
7
PART 1
Communicable Diseases in the Eastern Mediterranean Region
the gap between what is achievable and what is
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
being achieved
Introduction Vaccine-preventable diseases of childhood Tuberculosis Malaria HIV/AIDS and sexually transmitted diseases Emerging and epidemic-prone diseases Tropical and zoonotic diseases
PA R T 1
C o m m u n i c a b l e D i s e a s e s i n t h e E a s t e r n M e d i t e r r a n e a n Re g i o n
COMMUNICABLE DISEASES IN THE EASTERN MEDITERRANEAN REGION
the gap between what is achievable and what is being achieved
INTRODUCTION COUNTRY Afghanistan (AFG) Bahrain (BAH) Cyprus* (CYP) Djibouti (DJI) Egypt (EGY) Iran, Islamic Republic of (IRN) Iraq** (IRQ) Jordan (JOR) Kuwait** (KUW) Lebanon (LEB) Libyan Arab Jamahiriya* (LIB) Morocco (MOR) Oman (OMA) Pakistan (PAK) Palestine (PAL) Qatar (QAT) Saudi Arabia (SAA) Somalia (SOM) Sudan (SUD) Syrian Arab Republic (SYR) Tunisia (TUN) United Arab Emirates (UAE) UNRWA Yemen, Republic of (YEM) 98.08 81.90 95.60 100.00 97.80 60.00 68.30 100.00 97.00 98.00 99.80 74.00 90.00 99.00 ... 92.40 93.50 94.50 98.60 68.50 96.50 96.00 94.70 40.00 64.20 99.00 96.00 94.00 99.00 69.00 ... 98.00 28.80 95.00 95.00 98.00 92.40 93.50 95.00 99.99 70.70 96.50 96.00 94.70 40.00 64.30 99.00 96.00 94.00 99.00 69.00 85.00 74.00 82.00 100.00 99.00 100.00 98.20 96.80 96.80 96.90 96.00 80.00 95.00 99.00 96.00 90.80 96.00 99.00 63.00 93.70 100.00 96.70 45.00 61.80 98.00 94.00 94.00 97.30 65.00 52.04 61.80 61.77 62.07 ... 97.50 97.50 85.50 89.00 ... 96.80 99.00 64.00 95.00 100.00 88.00 90.80 92.00 99.99 18.00 91.70 98.00 97.30 ... ... 98.00 94.00 92.00 99.00 34.00 20.00 98.10 97.90 99.90 98.40 59.20 46.70 48.20 43.70 ... 37.00 58.50 ... 33.46 69.60 35.00 82.00 36.00 ... ... ... 26.00 44.66 55.70 30.00 ... ... 60.00 34.50 40.00 ... ... 98.70 39.00
BCG
DPT3
OPV3
MCV1
HBV3
TT2+
HIB3 ... 98.00 ... ... ... ... ... 95.00 ... ... ... ... 97.00 ... ... 96.00 91.00 ... ... 99.00 ... 94.00 ... ...
For the commonest communicable diseases in the Region, effective strategies for
treatment and/or prevention have been established. Nevertheless, more than one and
a quarter million people in the Region continue to die each year of communicable
diseases. In some countries, disease control programmes have a national reach and
targets for treatment or immunization are being met; in others, there is a vast gap
Progress in immunization is particularly slow in seven countries which account for more than half of the children in the Region.
between these targets and what is actually achieved. As most control strategies focus
on a single disease or group of diseases, we can begin by looking at how these
programmes operate in the Region, and briefly indicate why the targets are not being
met. In Part 2, we take a broader view and look at the common challenges facing all
More than one and a quarter million people in the Region continue to die each year of communicable diseases.
communicable diseases.
VACCINE-PREVENTABLE DISEASES OF CHILDHOOD
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
The Expanded Programme of Immunization (EPI), supported by WHO and other multilateral
agencies, is administered by ministries of health in all countries of the Region. Yet, in
spite of years of effort, almost 3 million infants in the Region still lack their basic
immunizations each year. While some countries in the Region have achieved a coverage
of over 90% for the combined the DPT3 antigen (for diphtheria, pertussis and tetanus),
Within EPI, measles has been targeted for regional elimintation by 2010; yet there are still around 40 000 cases of measles every year in the Region, and reported immunization coverage varies nationally from 99% to 35%.
others hover around 50%, and the lowest is 18%. In the Region overall, for the past
decade, childhood immunization levels have stagnated at around 80%, and only half
In the Region overall, for the past decade, childhood immunization levels have stagnated at around 80%, and only half of all pregnant mothers are immunized against tetanus.
of all pregnant mothers are immunized against tetanus.
Reported countries’ best estimates for routine immunization coverage (%) 2002
... Vaccine not included in country’s schedule * Data from 2001 ** Data from 2000 Data source: WHO / UNICEF joint form 2002
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Progress in immunization is particularly slow in seven countries which account
TUBERCULOSIS DOTS (directly observed treatment, short-course) is now the national policy for tuberculosis control in all countries of the Region, providing free diagnosis and treatment. The treatment success rate in the Region is 81%, approaching the global target of 85%. Nineteen of the 23 countries had achieved DOTS ALL OVER by the end of 2002, with DOTS available throughout the country. Yet, even a country that has achieved DOTS ALL OVER will not be able to reach every single person who has tuberculosis. The main task now is to expand DOTS to reach all those suspected of having the disease. For, at present, only about one quarter of the people estimated to have tuberculosis are receiving treatment. Unless serious efforts are made, the percentage of treated cases in the Region will barely reach 35% by 2005, half the global target of 70%. Slow expansion of DOTS coverage occurs mainly in two countries: in Pakistan and in war-torn Afghanistan. In many other countries of the Region, case detection also needs to be improved. Other parts of the DOTS programme also need to be upgraded, especially surveillance, laboratory services for diagnosis, and monitoring drug resistance. It is also essential for national programmes to collaborate with the private sector providers, who treat an increasing number of tuberculosis patients. 100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 Case detection rate %
for more than half of the children in the Region. Most of these countries are poor,
some are in a state of complex emergency with only rudimentary health services.
An immunization service designed to reach all children is a complex operation. It
requires a huge supply of vaccines and injection materials, trained staff to administer
the vaccines safely, an efficient record keeping system, and vehicles and cold-chain
equipment to deliver vaccines to the most distant primary health care centers in a
DOTS (directly observed treatment, short-course) is now the national policy for tuberculosis control in all countries of the Region.
timely fashion. Even in what at first sight appears to be an effective national health
system, these requirements may not be met because of poor management and lack
of commitment to the vital task of child immunization.
Within EPI, measles has been targeted for regional elimination by 2010; yet there
are still around 40 000 cases of measles every year in the Region, and reported
Nineteen of the 23 countries had achieved DOTS ALL OVER by the end of 2002.
immunization coverage varies nationally from 99% to 35%. Neonatal tetanus is also
targeted for elimination, defined as less than one new case a year per 1000 live births
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Neonatal tetanus is also targeted for elimination, defined as less than one new case a year per 1000 live births in each administrative district of the country.
in each administrative district of the country. Yet, seven of the poorest countries in the
Region have not achieved this target. In these and several other countries, vertical
programmes including polio are competing for the services of weak health systems.
At the same time, in some countries in the Region new life-saving vaccines have
become available: the hepatitis B vaccine and the Hib vaccine to prevent haemophilus
influenza type b, the most important cause of pneumonia and meningitis among under
fives. But these vaccines are costly, and can only be introduced into countries that AFG REGION PAK UAE SUD YEM Treatment success rate %
already have good immunization coverage. Many countries clearly do not have sufficient
IRQ SOM EGY SYR KUW
capacity or commitment to achieve the goals set for coverage of existing vaccines,
BAH
CYP IRN DJI LIB SAA
JOR
TUN MOR
LEB (153) OMA (107)
let alone new ones.
QAT (101)
The main task now is to expand DOTS to reach all those suspected of having the disease. For, at present, only about one quarter of the people estimated to have tuberculosis are receiving treatment. Unless serious efforts are made, the percentage of treated cases in the Region will barely reach 35% by 2005, half the global target of 70%.
70
80
90
100
Treatment success rate 2001 versus case detection rate 2002 12 13
PA R T 1
C o m m u n i c a b l e D i s e a s e s i n t h e E a s t e r n M e d i t e r r a n e a n Re g i o n
MALARIA giving birth to low-birth-weight infants, who have a high risk of death in the first year of life. However, access to prophylactic and curative drugs is limited in areas which do not have functioning health services, and health facilities may be short of drugs. Thus, in many areas, patients have no choice but to buy substandard or inappropriate drugs from pharmacies or untrained health providers. This situation hastens the proliferation of drug-resistant plasmodia. Moreover, only a small proportion of those in the Region who need insecticide-impregnated bednets are able to obtain them. Overall, integrated vector control strategies have yet to be put into practice in most affected areas.
can prevent malaria and, with it, maternal anaemia. Anaemia increases the risk of
The majority of the people of the Region (around 72%) live in countries in which malaria
is effectively controlled. However, natural conditions throughout the Region are favourable
to the survival of the mosquito vectors. Thus, even countries with no current transmission
need to be committed to maintaining a good surveillance system to prevent the
reintroduction of the disease by infected migrants or travellers.
HIV/AIDS is growing rapidly in the Region, with a three-fold increase in estimated cases between 1999 and 2001, to a current estimate of around 70 000.
HIV/AIDS AND SEXUALLY TRANSMITTED DISEASES HIV/AIDS is growing rapidly in the Region, with a threefold increase in estimated cases between 1999 and 2001, to a current estimate of around 70000. However, only 10 597 cases had actually been reported in the Region until the year 2000; in 2000 fewer cases were reported than in 1999. Because of the lack of national commitment to this disease problem, few countries of the Region have established control programmes. Few of those living with HIV/AIDS are being given treatment or sensitive counselling, which in industrialized countries have been shown to increase their quality of life and ability to function effectively in society. Few of the millions of people in the Region with
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Transmission-free Elimination under way Low to moderate endemicity
High endemicity
Because of the unwillingness to engage in public discussion of sexually related issues, preventive strategies are only slowly being developed and the public in the Region remain unaware of the risk of HIV/AIDS.
Malaria status of countries in the Region 2002
Five countries in the Region–Afghanistan, Djibouti, Somalia, Sudan and Yemen–
contribute 90% of the Region’s estimated 15 million cases a year. Currently available
Five countries in the Region– Afghanistan, Djibouti, Somalia, Sudan and Yemen– contribute 90% of the Region’s estimated 15 million cases a year. Currently available treatment in the home or the health centre can control morbidity and mortality, especially among children, but it needs to be provided within 24 hours of the onset of symptoms.
treatment in the home or the health centre can control morbidity and mortality, especially
among children, but it needs to be provided within 24 hours of the onset of symptoms.
For pregnant women, effective prophylactic drugs given in the second and third trimester
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curable sexually transmitted diseases have received treatment, although sexually
TROPICAL AND ZOONOTIC DISEASES A number of diseases that are not usually fatal seriously disable their victims, resulting in hardship and economic losses for all household members. As many of these diseases are also highly focal, and environmentally related, they also have a serious impact on whole communities. Yet they are often neglected by the health care system, as they occur in remote areas. Leishmaniasis is a neglected disease which today is a greater threat to people of the Region than ever before. It occurs in two main forms: cutaneous leishmaniasis, which is not usually fatal and is the most common and widespread, and visceral leishmaniasis, which is usually fatal within 2 years if it is not treated. Both forms are difficult to control because of their complex ecology which includes many reservoir hosts. Spraying is expensive and unsustainable in the long term and the drugs available for treatment often have serious side-effects or have developed resistance. Thus control depends on a mix of surveillance, early detection, treatment and prevention. The public health significance of schistosomiasis has been reduced significantly in some countries with the introduction of a highly effective single dose oral drug, praziquantel. Jordan, the Islamic Republic of Iran, Morocco and Tunisia, are aiming to achieve the elimination of indigenous transmission. In Egypt, the National Schistosomiasis Control Programme has been responsible for a marked decline in the level of infection in that country.
transmitted diseases are known to be a risk factor for HIV transmission. Because of
the unwillingness to engage in public discussion of sexually related issues, preventive
strategies are only slowly being developed and the public in the Region remain unaware
of the risk of HIV/AIDS. The problem of unsafe injections and poorly protected blood
Leishmaniasis is a neglected disease which today is a greater threat to people of the Region than ever before.
supplies are only gradually being addressed, yet these are likely to be responsible for
an increasing proportion of HIV infections.
EMERGING AND EPIDEMIC-PRONE DISEASES
A number of communicable diseases have the potential to develop rapidly into epidemics
that could threaten the health and lives of millions. Epidemic-prone diseases in the
Region include meningitis, diarrhoeal diseases (including cholera) and hepatitis. Also
For the control of all these epidemicprone diseases, an effective disease surveillance system is especially important.
having the capacity to develop into epidemics are the emerging viral haemorrhagic
The public health significance of schistosomiasis has been reduced significantly in some countries with the introduction of a highly effective single dose oral drug, praziquantel.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
fevers such as Crimean-Congo haemorrhagic fever and Rift Valley fever, which are little
known to health providers and usually confined to restricted areas.
For the control of all these epidemic-prone diseases, an effective disease surveillance
system is especially important. At the regional and country level, a system for
preparedness and response, supported by a specific budget, drugs, equipment and
trained response teams is also required. The need is especially acute in poor countries
of the Region, which usually have many epidemic-prone diseases, as well as a high
burden of endemic diseases. These countries require external resources from organizations
such as WHO to establish and maintain emergency response systems to prevent and
contain epidemics within the country, and prevent them from spreading beyond their
borders.
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However, in other countries, where the situation has remained stable or deteriorated, public health problem at the national level; this is defined as an overall prevalence of less than one case per 10000 people. However, in countries where higher rates persist in some districts, more action is needed. Multidrug treatment, responsible for an 85% global decline in the prevalence of leprosy over the past 15 years, can now be provided at primary health care centres, or in the home. WHO provides all endemic countries with drugs for leprosy treatment free of charge. Yet because of the stigma associated with the disease, people remain reluctant to come forward for diagnosis and treatment. A number of zoonotic diseases, which have the capacity to spread from animals to humans, are also significant in the Region, such as brucellosis and rabies. Rabies control strategies focus on vaccines for people who may have been bitten by a rabid animal, and control of feral dogs and cats and other reservoir hosts. Collaboration between health and veterinary authorities is essential for the control of zoonotic diseases, but often lacking. As we have indicated above, proven strategies exist for the treatment and control of communicable diseases in the Region. Yet there are many barriers to their full implementation, so they can reach all the people who need them. The main question for communicable disease control is: What are the challenges which urgently need to be overcome in order to strengthen the national response to communicable disease?
All countries in the Region have now achieved the goal of elimination of leprosy as a
no national strategy has been developed.
A number of diseases have been targeted for global eradication (following the precedent
of smallpox in 1976), or elimination, a state in which the disease is no longer recognized
WHO provides all endemic countries with drugs for leprosy treatment free of charge.
as a public health problem. Dracunculiasis (guinea-worm disease) has been the target
of a global eradication programme since the early 1980s. Seventy-five per cent (75%)
of the remaining cases, worldwide, are found in Sudan, mainly in the south of the
country. Here, dracunculiasis eradication faces problems shared with many other
diseases which, in public health terms, are far more devastating for the population and
which cry out for attention. The root of the problem is the decades of civil conflict that
have caused the collapse of health services and vast movements of population; during
the wet season many areas are inaccessible due to flooding. However, there are also
cases in areas of the south within government control, and in the north of the country
Rabies control strategies focus on vaccines for people who may have been bitten by a rabid animal, and control of feral dogs and cats and other reservoir hosts.
which demand attention.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Lymphatic filariasis, endemic in Egypt, Sudan and Yemen, is targeted for global
elimination, i.e. the reduction of transmission to levels below which the disease cannot
sustain itself. Protocols of proven effectiveness, developed by the Global Programme
for the Elimination of Lymphatic Filariasis have already been implemented in Egypt;
Dracunculiasis (guinea-worm disease) has been the target of a global eradication programme since the early 1980s. Seventy-five per cent (75%) of the remaining cases, worldwide, are found in Sudan, mainly in the south of the country.
with annual mass treatment in endemic areas and the promotion of proper disease
management by controlling secondary infection and washing the affected grossly
Collaboration between health and veterinary authorities is essential for the control of zoonotic diseases, but often lacking.
swollen limbs. In Yemen, surveillance activities began in 1999 and in 2002 drug
treatment was offered in eleven endemic areas. However, both in Yemen and in Sudan,
the programme needs to be expanded. In Sudan, where many cases are likely to be
in the south, there have so far been only preliminary attempts to develop an eradication
Lymphatic filariasis, endemic in Egypt, Sudan and Yemen is targeted for global elimination.
strategy and to identify endemic areas.
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PART 2 National commitment and leadership Strengthening health systems A huge task Building trust Responding to change: the public-private mix
Challenges
Developing an integrated approach: cross-cutting activities Why integration is needed Focusing on cross-cutting activities Capacity building Advocacy Infection control Containment of anti-microbial resistance Management of insecticide resistance Operational research Surveillance forecasting & epidemic management
Partnership for health Expanding intersectoral collaboration Working with international partnerships Community participation
Facing realities in the Region and the world Complex emergencies A borderless world
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
PA R T 2
Challenges
CHALLENGES
NATIONAL COMMITMENT AND LEADERSHIP are the age group most vulnerable to communicable diseases. Health systems must reach out to everyone, rich and poor, wherever they live, in remote rural areas or urban slums. To fail to do so endangers the health of all citizens. At the same time, patterns of health provision are changing rapidly, and many services once provided by ministries of health are now provided by parastatal organizations, private for-profit providers and the voluntary sector. In all except the smallest, richest countries of the Region, health services are grossly underfunded. Even though staff are poorly paid, 70%–80% of health allocation goes on salaries. Little is left over for the maintenance of facilities, the supply of drugs and materials, outreach and health promotion, and disease surveillance. Yet, the problem is not only one of shortage of money, but also of commitment, trust and the creative response to changing needs. If the health system is weak, it cannot respond effectively to the needs of the people. If people perceive that the system does not respond to their needs, they will not use its services. The challenge is to strengthen the public health systems in the diverse countries of the Region so that they can provide the essential services needed by their citizens.
National leadership for the essential task of communicable disease control is still weak
in some countries of the Region. National leaders are willing to support programmes
that they know will have a wide appeal but they tend to ignore less popular causes.
Globally, and within the Eastern Mediterranean Region, programmes to vaccinate young
If people perceive that the system does not respond to their needs, they will not use its services.
children receive support because everyone values the lives of young children. The
declining number of cases can be used to demonstrate the impact of these programmes.
Unfortunately, many other communicable diseases that can be relatively easily controlled
often have few powerful advocates. Diseases of the poor, such as tuberculosis, malaria
and AIDS are only now being recognized as targets for international and national
attention. Diseases of poverty contribute the greatest burden on society – on individuals,
the community and the health services. Most sufferers, because they are poor, have
National leaders are willing to support programmes that they know will have a wide appeal but they tend to ignore less popular causes.
no voice in national policy, and are often invisible to policy makers as they live in remote
areas or urban slums beyond the reach of regular health services. National leadership
The challenge is to strengthen the public health systems in the diverse countries of the Region so that they can provide the essential services needed by their citizens.
is essential to support the development and implementation of a health system that
responds to these needs.
Health systems must reach out to everyone, rich and poor, wherever they live, in remote rural areas or urban slums.
STRENGTHENING HEALTH SYSTEMS
A huge task
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
The demands on the public health service are enormous, and ultimately somebody has
to pay for it. Programmes to provide for childhood immunization, and diagnosis and
treatment for diseases such as tuberculosis, malaria and leprosy, should be offered
free, for the benefit of individual sufferers, but more importantly, from a public health
point of view, to prevent other people from becoming infected.
Health services must identify people who suffer from these diseases, and persuade
them to come forward for diagnosis and treatment. They need to expand to reach a
rapidly growing population, in which 40% of the people are under 15 years old, and
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PA R T 2
Challenges
Building trust BUILDING TRUST: HIV/AIDS Lack of transparency is at the heart of the difficulties in tackling HIV/AIDS in the Region. There is a wide discrepancy between the number of cases reported, 12 158 AIDS and 36031 HIV by the end year 2002, and the estimated number of people living with HIV/AIDS, around 750 000. Only a small percentage of the cases diagnosed are actually reported. Government agencies may not be interested in collecting and publishing data on HIV/AIDS as they fear it will reflect badly on their national reputation and deter tourists. There is little motivation for providers to report cases as there is little support in the health system for people who are living with AIDS. Members of the public in the Region are reluctant to submit to a test for HIV because of the stigma attached to the disease. Stigma is related to the general unwillingness to identify and openly discuss issues relating to sexuality. There is a widespread belief among health providers and the public that sex outside marriage is rare, and thus there are few, if any people in their own communities who have HIV/AIDS.
The challenge is to build trust in the health system, so that providers can perform
effectively and give the public access to good services that satisfy their needs for
health and for dignity.
The key concepts here are transparency, integrity, openness and responsibility in the
performance of all the tasks required of the system. To achieve transparency, planners
need to identify priorities, set targets and establish strategies for reaching them. If this
is done, and the responsibilities of the providers are clearly identified, they should be
able to respond effectively to the real needs of the public. If activities are successful,
they can be used to strengthen the commitment of international funding agencies, and
national and regional authorities for the critical task of communicable disease control.
An important aspect of transparency is the provision of accurate information and its HIV/AIDS is only one of the diseases that patients associate with stigma and the fear of rejection by their families and communities. People suffering from tuberculosis and leprosy are also reluctant to admit that they may have the disease and seek diagnosis and treatment. Cutaneous leishmaniasis, which causes permanent scarring, especially on the face, often results in the social exclusion of infected women. In all these diseases, openness and transparency can encourage people who think they have the disease to report for treatment at an early stage, before it does permanent damage. Health ministries have an important role to play in overcoming stigma by providing education for the public about how the disease is spread (or more importantly, not spread) and what can be done to prevent transmission. At the same time, it can promote a sympathetic atmosphere in health centres that encourages people to seek treatment.
use in decision-making. The right information should be seen to be in the right place,
in the right hands and at the right time. Information provided by health authorities
Information provided by health authorities should be trusted for its accuracy and timeliness, and shared among those who need it for planning and implementing disease control programmes.
should be trusted for its accuracy and timeliness, and shared among those who need
it for planning and implementing disease control programmes.
Transparency means that surveillance systems are consistent and accurate, and that
staff are trained to record data and understand why they are doing it. Transparency
increases the motivation of health providers, who need to know what to do, why to
do it, and have the knowledge and materials to respond to the needs of the community
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
of which they are part.
Transparency and openness in the national health system should provide increased
motivation and opportunity for community members to become more involved in health
related activities.
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Responding to change: the public–private mix The main concern of private providers, whether they are for-profit or run by nongovernmental organizations, is to provide diagnosis and treatment for individual patients. They do not consider that they should be concerned with prevention and surveillance, although this would benefit the whole community. However, because they treat many patients, it is essential for the maintenance of disease control that they be involved in these central activities. How this can be done in ways that do not appear to be cutting into the ability of private providers to make a profit is at present not clear. As yet, there are few, if any, proven strategies for such collaboration and many health planners perceive that the interests of the public and the private sector are far apart. The challenge here is to identify a public–private mix that complements and strengthens overall health performance. When DOTS, the multidrug strategy for treatment of tuberculosis, was first promoted in the Region, in 1996, it was organized through the government health sector, as free treatment was identified as essential to achieve high cure rates and control disease transmission in the community. However, private providers are now treating a growing percentage of tuberculosis patients. Therefore, the Regional Office is promoting partnerships to involve the private sector in DOTS. This faces problems because much Ministry of health and population 19%
Nationally funded health services in many countries are changing rapidly and few still
have the sole responsibility for health sector activities. Other government authorities
have long been responsible for providing health care for schoolchildren, for the military
and for prisoners. Moreover, today, ministries of health are devolving many of their
responsibilities to semi-governmental organizations such as health insurance schemes
for government employees, for schoolchildren and for those on public assistance.
The challenge here is to identify a public–private mix that complements and strengthens overall health performance.
Health ministries are also undergoing reforms, such as decentralization, that they hope
will improve those key services that remain under their direct control. At the same
time, governments have encouraged the expansion of the private sector, both the for-
profit and non-governmental providers. Private health care has also grown in response
to patients’ belief that public sector care does not meet their needs.
Egypt provides a good example of the many different sectors that are now involved
in health care. A study carried out in the 1990s found that the Ministry of Finance
provided only a third of the total funding, of which less than 60% was spent on facilities
administered by the Ministry of Health. Over one-third of all health expenditure was
spent by patients at pharmacies.
Non-governmental organizations1%
Other private 5%
of the private sector remains unregulated, and private providers have only a limited knowledge of tuberculosis.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
The main concern of private providers, whether they are for-profit or run by nongovernmental organizations, is to provide diagnosis and treatment for individual patients. They do not consider that they should be concerned with prevention and surveillance, although this would benefit the whole community. Other public 3% Universities 10%
Pharmacies 36%
Providers 18%
Health insurance organizations 8%
Figure 5 : National health account, Egypt 1997
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Another public-private initiative is being explored, in this instance to control malaria by providing insecticide-treated bednets. Pilot projects, working through the public sector, have shown that these have resulted in a decline in malaria infection, especially among young children, who have not yet acquired partial immunity to the disease. As these projects are extended, the involvement of the private sector in providing bednets for those who can afford them can take advantage of their experience in creating a demand, through social marketing. In Sudan, bednet provision requires the identification of local firms willing to manufacture bednets to specifications, and avoidance of a monopoly situation in which manufacturers can set their own prices. Even if the private sector can provide bednets, the public health service will still need to help to create an enabling environment, by developing guidelines and ensuring that taxes and tariffs on bednets are removed. It will also need to ensure that those who cannot afford to pay are also provided with bednets. In very poor countries and those in complex emergencies public distribution and promotion of bednets may well be the strategy required.
DOTS IN PAKISTAN
In Pakistan, which has a disproportionately large share of tuberculosis cases in the
Region, the private sector now provides 80% of the country’s health services. A WHO-
supported research project found that few private providers knew the correct treatment
regime for tuberculosis or referred cases to the national programme. Proposals for a
public–private partnership are complicated by the plan, introduced in August 2001, to
In very poor countries and those in complex emergencies public distribution and promotion of bednets may well be the strategy required.
decentralize the public sector, moving responsibility for health care to the district level.
If district authorities do not consider DOTS a high priority, the programme will suffer.
Also, weak management and supervision may hinder activities at the provincial and
district levels, especially plans for new partnerships.
DOTS IN EGYPT
A WHO-supported research project found that few private providers in Pakistan knew the correct treatment regime for tuberculosis or referred cases to the national programme. PUBLIC–PRIVATE MIX Why do we need it? • To reach private providers
In Egypt, it is estimated that 30% of tuberculosis patients are treated outside the public
sector and half of the rifampcin supplied by drug companies is sold through private
pharmacies. The National Tuberculosis Programme has established a pilot project in
urban Cairo, in which private providers are given information and notification forms; the
first results indicate an increase in case notification in the pilot areas. In Egypt, it is also
• To include private patients in the surveillance system • To ensure proper care in the private sector How do we achieve it? • Identify strategies that do not threaten the interests of private providers • Provide training and other services for private providers
important for the programme to work with nongovernmental organizations, which have
a significant role in identifying tuberculosis cases among the poor and providing them
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with relatively high quality, low-cost and accessible outpatient services.
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DEVELOPING AN INTEGRATED APPROACH: CROSS-CUTTING ACTIVITIES
Why integration is needed These vertical programmes appeal to physicians trained in the area of communicable diseases who usually consider themselves specialists in particular diseases, or groups of diseases, such as respiratory infections or parasitic diseases. In their capacity as policy-makers at the national level, as managers and as clinicians they think primarily in terms of the control of specific diseases, rather than looking at the broader health picture. Today, they often lack a clear vision of how health staff dealing directly with the public can provide care for the most common diseases, and, at the same time, perform the other essential services for the preservation of health. The challenge is to develop a holistic view of health that looks at all aspects of the situation, rather than thinking in terms of controlling each separate disease.
The focus on primary health care, which began in the 1970s, emphasized community-
based prevention and a range of low-tech approaches to the diseases most commonly
found in poor countries. Economic crisis, including debt repayment, hindered the
development of this policy. Attempts to get poor people to pay for their own health
care foundered because they simply could not afford it. They often went without care
and died young: health services in the poorest countries collapsed.
Vertical programmes were developed outside the regular health structure, which was
The challenge is to develop a holistic view of health that looks at all aspects of the situation, rather than thinking in terms of controlling each separate disease.
considered too weak to support them, in order to maintain essential services such as
The administration of separate programmes leads to a considerable amount of overlap and duplication of effort.
immunization for childhood diseases. Gradually, most international health agencies
came to be organized around such programmes. On the national level, each of these
disease specific programmes has its own specific budget, targets and activities, and
is organized separately at the national and district level. However, at the local level
these separate programmes are usually administered through the network of facilities
and staff that comprise the primary health care system. As presently constituted, the
administration of separate programmes leads to a considerable amount of overlap and
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duplication of effort.
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Focusing on cross-cutting activities CROSS-CUTTING ACTIVITIES
At the same time as developing a holistic view, health services should deliver services SURVEILLANCE, FORECASTING AND EPIDEMIC MANAGEMENT CAPACITY-BUILDING
in the most humane and cost-effective way. As far as possible, formerly separate
disease programmes should be integrated at various levels and between sectors. This
approach is valid even if the diseases are dissimilar, as certain cross-cutting activities DIRECTOR REASERCH ADVOCACY
are used in the control of all diseases. The new structure for the EMRO Division of
Communicable Diseases identifies cross-cutting activities that are common concerns
for all those who plan and implement communicable disease control programmes and
work in the public health system. Focusing on cross-cutting activities can help to forge
The challenge is to strengthen and make full use of these cross-cutting activities to combine programme activities and avoid duplication and waste of scarce resources INFECTION CONTROL & CONTAINMENT OF ANTIMICROBIAL RESISTANCE
cooperation, rather than competition between the various disease sectors.
The challenge is to strengthen and make full use of these cross-cutting activities to DISEASE-SPECIFIC ACTIVITIES
combine programme activities and avoid duplication and waste of scarce resources.
In February 2002 a meeting at EMRO reviewed the regional strategy on integrated
COORDINATOR
COORDINATOR
communicable disease control. Representatives of national programmes of communicable AIDS & SEXUALLY TRANSMITTED DISEASES ROLL BACK MALARIA STOP TB
disease surveillance and control in Pakistan, Sudan and Yemen discussed the different
strategies for cross-cutting activities, and concluded that integration would lead to a
In February 2002 a meeting at EMRO reviewed the regional strategy on integrated communicable disease control and it was concluded that integration would lead to a better outcome for health plans and an optimum use of resources. EMERGING & EPIDEMIC DISEASES
better outcome for health plans and an optimum use of resources.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Capacity-building
VACCINE-PREVENTABLE DISEASES & IMMUNIZATION
PARASITIC & ZOONOTIC DISEASES
Capacity-building is the first of these cross-cutting activities. It involves upgrading facilities. Laboratories for diagnostic studies are especially important for the public health services, as they are not supplied in the private sector, which regards them as unprofitable. All facilities need up-to-date equipment and to ensure a regular flow of supplies.
A new structure for DCD : Cross-cutting activities to promote effective communicable disease control
Health systems depend on clinical staff responsible for the day-to-day delivery of services, as well as trained policy-makers and managers who can identify and solve problems, make decisions and carry them out.
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Challenges
benefits for the public at large, rather than just for individuals. Clinicians, and the many national-level health officials who were trained as clinicians, need to be convinced of the value of this, as their training orients them towards the care of individuals rather than the community-wide approach. Another important objective of advocacy programmes is to change attitudes among the general public. This is especially important for stigmatizing diseases and for emerging diseases that are new, unfamiliar and hence particularly frightening. Activities need to extend beyond globally observed national days, such as those for HIV/AIDS, tuberculosis and malaria, and keep up the momentum. At the local level, follow-up activities need to be supported by local health centres, schools and community organizations, where local people can initiate further dialogue. Success in communicable disease control for one disease at the national level can be used in advocacy at the local level for the control of other diseases. Local level advocacy will alert local people to disease risks of which they were previously unaware.
For example, important decisions about charges to patients require a comprehensive, holistic assessment of the burden of disease on individuals and their ability to pay for care, as well as of the risk of continued transmission in the locality. In the case of malaria, drugs for treatment and insecticides for mosquito control, needed by the poorest people in the poorest countries, are expensive. A country that hopes to solve the problem by charging patients may simply make the problem worse by driving them away and taking their infective bodies with them. Poor patients, who treat themselves and delay coming to the health centres, risk their own life and health, and burden hospital services when they are finally admitted.
CHARGING FOR MALARIA TREATMENT IN SUDAN?
In Sudan’s White Nile State, which has relatively good health care facilities, the proportion
of severe and complicated falciparum malaria being treated in hospitals is increasing.
This is likely to be happening because patients cannot afford to pay for malaria diagnosis
and medication, and thus delay seeking treatment until they are seriously ill. In such
settings, cost sharing strategies are under continual review.
Advocacy ADVOCACY Why do we need it? • To build support for programmes at international, national, regional and local levels How can we achieve it? • Outreach at all levels: international, national, district and local • Using all media—television, radio, newspapers—as well as face-to-face activities at the local level
Advocacy programmes for communicable disease control initiatives need to ensure a
consistent targeted approach. They need to enlist the support of national governments,
health ministries, and the general population. Advocacy can work in a variety of ways;
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
at the highest level through governments and ministries, and through mass media and
community-based activities to reach the general public. They need to focus on the
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Challenges
Infection control Many countries in the Region need support and encouragement to develop infection control strategies to protect the blood supply and ensure injection safety. The Eastern Mediterranean Region is the first WHO region to develop a regional strategy for immunization safety, to encourage Member States to develop their own programmes. During 2002, Egypt developed national guidelines for infection control in heath care settings. In Sudan, the Regional Office reviewed immunization and other infection control practices and assisted in developing a national programme.
Infection control, including injection safety, is a major emerging concern in the Eastern
Mediterranean Region. It has been suggested that up to 70% of new cases of hepatitis
B, 80% of new cases of hepatitis C and 6% of new cases of HIV infection in the Region
are transmitted by unsafe injections. These may be administered at health centres or
by untrained injection providers in the community.
Injection safety is especially important as all antigens used for childhood immunizations,
except for polio, are injected. In July 2002 WHO conducted a review of injection INFECTION CONTROL Why do we need it? • To prevent the transmission of communicable diseases to patients through contaminated blood or body fluids, in the health care setting • Unsafe injections are a risk for providers, users and community members How do we achieve it? • Rigorous monitoring of activities in health centres • Staff training and motivation • Provision of equipment and materials such as syringes, needles and gloves • Monitoring the blood supply • Educating the public
procedures in the Region. This study suggested a high risk to patients from non-sterile
The Eastern Mediterranean Region is the first WHO region to develop a regional strategy for immunization safety, to encourage Member States to develop their own programmes.
injections; only 74% of injections were administered safely. A week’s supply of auto-
disable injection equipment was available in over 80% of health facilities visited, but
shortages did occur, and reuse of injection equipment was not uncommon.
Risks for providers were also identified; half of health care workers admitted to having
had needle-stick injuries. Although WHO-approved safety boxes for sharps (discarded
It has been suggested that up to 70% of new cases of hepatitis B, 80% of new cases of hepatitis C and 6% of new cases of HIV infection in the Region are transmitted by unsafe injections.
needles) have been introduced in most countries of the Region, sharps were found in
unprotected, open containers in 71% of health facilities.
For all community members, the careless disposal of used sharps poses a serious risk.
Sharps waste is rarely disposed of safely; it is either dumped in the open, or burned.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Sharps were found on the ground around almost half of the health facilities surveyed.
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Challenges
Containment of anti-microbial resistance Management of insecticide resistance Insecticide resistance occurs when a single insecticide is used against disease vectors, such as mosquitoes; hardy specimens reproduce themselves, and new generations of insects develop that are almost entirely immune to the insecticide. The most noted example occurred with DDT, used very widely in the 1960s against malaria. Today, resistance has been reported in many countries of the Region, mostly due to organophosphates and organochlorines used in agriculture. It is not yet known if mosquitoes in the Region are resistant to pyrethroids, a relatively effective and environmentally safe group of insecticides. Because of the risk of malaria in remaining endemic countries, and the possibility of resurgence in other areas, there is an urgent need to identify strategies to prevent the development of insecticide resistance, such as using insecticides in rotation. It is also important to develop strategies to detect, monitor, map and manage insecticide resistance. The possibility of the development of entirely new insecticides is limited, as there is little commercial incentive for companies in the industrialized countries to develop new products for malaria. The development costs are high and the demand is largely from poor countries that cannot afford to buy expensive new products.
The development of resistance in disease pathogens to commonly used drugs is the
result of inappropriate treatment by providers. It also occurs when patients fail to
complete a course of treatment under the guidance of a trained health provider, or
treat themselves with drugs purchased on the open market. Multidrug treatments for
tuberculosis, leprosy and malaria, if properly administered, can largely avoid this
problem.
There is an urgent need to identify strategies to prevent the development of insecticide resistance, such as using insecticides in rotation.
The high rate of drug resistance in the Islamic Republic of Iran among Afghan refugees
with tuberculosis illustrates the complexity of this challenge. The refugees have a rate
of resistance three times that of Iran’s resident population. Many refugees came to
Iran after a short course of treatment or self-treatment in Afghanistan; others discontinue
treatment when they return to their home country. The emergence of pathogenic
Multidrug treatments for tuberculosis, leprosy and malaria, if properly administered, can largely avoid this problem.
immunity imperils the whole existing system of multidrug treatment.
CONTROL OF MICROBIAL RESISTANCE
Why do we need it?
• To prevent the development of resistance in disease pathogens which destroys
the ability of existing drugs to treat communicable diseases CONTROL OF INSECTICIDE RESISTANCE Why do we need it? • To ensure the continued effectiveness of existing insecticides against insect vectors of communicable diseases How can we achieve it? • Rigorous monitoring • Use of more than one insecticide • Identifying alternative ways to control insect vectors, such as biological control
How can we achieve it?
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• Rigorous enforcement and monitoring of multidrug treatment
• Development of new drugs
• Education for the public on safe use of drugs
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Operational research RESEARCH Why do we need it? • To fill knowledge gaps • To identify possible innovative control strategies How do we achieve it? • Support and strengthen locally-based operational research directed towards specific problems
The Small Grants Scheme for Operational Research in Tropical and Communicable
Diseases has been supported by WHO Regional Office for the Eastern Mediterranean
since 1992. The programme was originally funded by TDR (UNDP/WORLD BANK/WHO
Special Programme for Research and Training in Tropical Diseases) and covered three
of the TDR priority diseases, malaria, leishmaniasis and filariasis. In 2002 it expanded
to cover other diseases, including tuberculosis, meningitis, viral haemorrhagic fevers
and vaccine-preventable diseases. For the first time, in 2002, there were applications
for research on HIV/AIDS.
Research capability in many parts of the Region is weak. The regional office is in a
position to be able to identify major applied research gaps, and each year invites
research proposals in those areas. The Small Grants Scheme for Operational Research
in Tropical and Communicable Diseases supports researchers at all stages—from the
preparation of the application, through the research process, to the dissemination of
results. The next stage is to help successful research teams to apply for larger grants,
based on the experience they have already gained.
RESEARCH ON LEISHMANIASIS
Past research projects on visceral leishmaniasis, a serious disease with a high
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
mortality rate if left untreated, have included: GIS (geographic information systems)
mapping of risk in southern Sudan, and the development of a reliable, rapid and
sensitive diagnostic test for the disease. Another project studied the epidemiology
of the less serious cutaneous leishmaniasis in the Palestinian district of Jericho.
This study identified the seasonality of transmission, highest from October to
January, and found the disease more prevalent among young Palestinians camping
on the outskirts of the town and among Bedouin women and farmers’ wives. The
next step is to apply this knowledge to control in the local setting.
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Challenges
Surveillance forecasting & epidemic management reporting schedules. Under-reporting of disease morbidity and mortality and epidemics is especially common in remote areas and in areas with complex emergencies. Outbreaks of disease among poor people, migrants and nomads are also often under-reported. Yet, these are the areas and people in the greatest need. As many countries in the Eastern Mediterranean Region do not yet have contingency plans for epidemic-prone diarrhoeal diseases, a regional strategy to ensure epidemic preparedness was developed and endorsed by the Regional Committee for the Eastern Mediterranean in 2002. The target is for all countries to have the capacity for early detection and rapid and effective response to outbreaks of diarrhoeal disease by 2005.
A surveillance system must provide effective and timely information for detecting and
controlling disease outbreaks. It also assists in planning and implementing health
policies at international, national and local levels. Such activities can only be performed
through a public health system; if this system is weak, surveillance will be weak.
A public health system must have the capacity to track epidemic-prone diseases and
respond rapidly when they do occur. This requires an effective surveillance system, a
supply of essential drugs and insecticides, and trained staff ready to respond and able
A regional strategy to ensure epidemic preparedness was developed and endorsed by the Regional Committee for the Eastern Mediterranean in 2002.
to reach the affected areas. Yet, in the Region, the areas most prone to epidemic
outbreaks are those that are least able to maintain effective monitoring and response
systems.
The areas most prone to epidemic outbreaks are those that are least able to maintain effective monitoring and response systems. SURVEILLANCE Why do we need it?
In most national health services, the existence of a number of vertically organized
disease programmes means that different surveillance systems exist for each disease
or group of diseases. This duplication is wasteful of trained personnel, time and money.
• To provide information about communicable diseases & their distribution, & early warning of epidemics • To facilitate rapid and appropriate responses to disease crises How can we achieve it? • Upgrading and coordinating recording systems • Training staff • Monitoring • Feedback
Health information published by WHO and its regional offices depends on data submitted
Inaccurate data makes proper planning difficult and hinders effective disease control.
by Member States. These in turn depend on reliability of regional and local recording
systems operating through national health ministries.
Inaccurate data makes proper planning difficult and hinders effective disease control.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Inaccurate figures may be the result of inconsistent case definitions for the various
diseases, poorly designed reporting systems, and a failure of staff to adhere to regular
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PARTNERSHIPS FOR HEALTH
Expanding intersectoral collaboration Intersectoral collaboration at all levels needs to be seen as mutually beneficial, rather than as an encroachment on the domains of long established bureaucracies. Disease control requires collaboration between health specialists and a range of other governmental authorities, such as those responsible for communications and education, in order to reach the public. Collaboration with education authorities can reach primary school children; they are receptive targets for health messages, and can also influence their siblings, and even their parents, about health risks in the community. Young children can also be reached through schools for treatment for parasitic infections, as they have higher rates of infestation than other population groups. Collaboration between the health and veterinary services is needed for the control of zoonotic diseases, which are spread from animals to humans. Human brucellosis cannot be tackled without controlling the livestock disease, a task for the veterinary department. In the case of cutaneous leishmaniasis, collaboration with the pest control units in the ministries of agriculture is needed to facilitate early detection and prevention through surveillance programmes to monitor rodent population explosions that are likely to precede outbreaks in humans. Collaboration achieved in an emergency situation, as in the recent outbreak of leishmaniasis in Afghanistan, needs to be established on a regular basis.
Achieving good health for the population of the Region is a task not only for the health
sector. Health ministries need to collaborate with the ministries responsible for water
and sanitation, housing, agriculture, irrigation and the environment, to help to establish
and implement strategies that will improve the health of all the people of the Region.
As health and poverty are inextricably intertwined, health issues need to be incorporated
into programmes of poverty alleviation, for example literacy programmes and employment
creation activities, such as small loans for women to establish craft, trading or animal
raising enterprises. These cannot be carried out if the skills, knowledge and needs of
The challenge is to foster more effective cooperation between the health sector and other relevant sectors, at the national and local levels.
the poor are neglected.
The challenge is to foster more effective cooperation between the health sector and
other relevant sectors, at the national and local levels.
Many government bureaucracies in the Region remain highly centralized, with each
Collaboration between the health and veterinary services is needed for the control of zoonotic diseases.
ministry operating independently and maintaining a chain of command down to the
local level. Today, the trend in health and local government reform is towards
decentralization, with decisions being made at the district and local level, where it is
hoped that they can reflect local needs. At the local level there is great scope for
cooperation among the different sectors of the bureaucracy. For it is at this level that
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Intersectoral collaboration at all levels needs to be seen as mutually beneficial, rather than as an encroachment on the domains of long established bureaucracies. Disease control requires collaboration between health specialists and a range of other governmental authorities.
communicable diseases are transmitted, and are usually treated, and where they can
most effectively be prevented.
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Challenges
Collaboration with local authorities responsible for water, sanitation and irrigation is SCHISTOSOMIASIS CONTROL IN EGYPT In Egypt, the National Schistosomiasis Control Programme, organized through the Ministry of Health and Population, provides free diagnosis and treatment with praziquantel. Other aspects of the integrated control programme are vector control, and health promotion to encourage people to go for treatment and to avoid contact with canal water. Collaboration with the relevant authorities to provide safe water and sanitation is also part of the integrated programme but, in practice, it receives less attention. Recently, the national programme has had to provide diagnosis and treatment through the Health Insurance Organization, a parastatal organization independent of the Ministry of Health and Population which provides services for 16 million schoolchildren, as well as all government employees.
essential because many communicable diseases in the Region are water-related. The
absence of safe water, sanitation and adequate drainage creates conditions for the
transmission of diarrhoeal diseases, schistosomiasis and dracunculiasis. Mosquitoes
that breed in open water are vectors for malaria, dengue fever, yellow fever and
lymphatic filariasis. Working together, health ministries and ministries responsible for
providing domestic water, sanitation and irrigation can identify priorities and effective
strategies for providing safe water and sanitation, upgrading the quality of water in
rivers and irrigation canals, and limiting the amount of stagnant water that might
provide breeding sites for insect vectors.
Schistosomiasis is a disease that is transmitted by human activities associated in one
way or another with water. Those who are infected, through contact with canal water
during farming, recreation or domestic activities, can be successfully treated with
praziquantel. However, they are likely to be reinfected if they do not change their
behaviour, and if no improvements in water and sanitation are made to prevent the INTERSECTORAL COLLABORATION Why do we need it? • Because the health of the population is adversely affected by poverty, lack of safe water and sanitation, poor housing, illiteracy, unsafe and unhygienic environments How do we achieve it? • Collaboration based on shared concerns, especially at the local level
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Working together, health ministries and ministries responsible for providing domestic water, sanitation and irrigation can identify priorities and effective strategies for providing safe water and sanitation.
contamination of canals.
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Challenges
Working with international partnerships international partnerships, because they have the capability to sustain scientific research and to provide urgently needed drugs and vaccines. However, it is important to remember that these companies are run with a market-driven system and need a profit from the sale of drugs and recompense to recoup the cost of research. One important challenge is therefore to ensure that for-profit companies continue to work in partnerships and provide drugs and vaccines to the poorest countries of the world, and in the same spirit which motivates these alliances and the objectives for which it was initiated. An alternative approach to obtaining much needed drugs at affordable price, is for poor countries to negotiate with individual pharmaceutical companies based in Europe and North America. New drugs, especially antiretrovirals, that improve the quality of life of those living with AIDS are now available for patients in industrialized countries; treatment can also prevent the transmission of HIV from mothers to infants in almost 70% of cases. However, the price of such drugs constitute a heavy burden on the already depleted financial resources available to the ministries of health. For their part, pharmaceutical companies recognize that they can benefit from preferential pricing agreements with countries that would otherwise not be able to purchase the drugs. With the assistance of the Regional Office, Lebanon, Morocco and Tunisia have reached agreements with pharmaceutical companies to supply health ministries with antiretroviral drugs at much reduced prices. Other countries in the Region are preparing to negotiate with drug companies for access to affordable antiretroviral drugs.
Today, international programmes to tackle communicable diseases in the Region involve
more partners than ever before. These new partnerships have the potential to supply
much needed funding for disease control, to support the development of new tools
such as drugs and vaccines, and to build up the capacity of health systems to deliver
existing and new tools. However, the concept of partnership needs to be clearly
understood, for it requires mutual trust and openness in order to plan and carry out
joint programmes. These new partnerships face problems similar to those of the various
different government sectors; each partner has its own agenda and its own way of
thinking about its own particular concerns.
With the assistance of the Regional Office, Lebanon, Morocco and Tunisia have reached agreements with pharmaceutical companies to supply health ministries with antiretroviral drugs at much reduced prices.
Partners increasingly recognize the complexity of the task that lies ahead. It is generally
possible to take a comprehensive view of these health problems at the international
level, where most partnerships are initiated. But it is more difficult to translate these
The concept of partnership needs to be clearly understood, for it requires mutual trust and openness in order to plan and carry out joint programmes.
ideals into action at the national level, and ultimately to contribute to the delivery of
services at the local level.
EPI (Expanded Programme on Immunization), one of the longest established international
health programmes, has failed to reach global targets in many countries of the Region,
and elsewhere. One of the challenges is how to make the best use of the Global
Alliance for Vaccines and Immunization (GAVI), to improve the situation. We also need
to determine how best the Global Fund to Fight AIDS, Tuberculosis and Malaria, launched
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
in January 2002, can coordinate efforts among its many partners to control the three
most serious diseases in the Region.
As many of these partnerships are arranged within UN agencies, they can be regulated
by the policies and procedures established by the UN agency concerned. But in the
case of new partners, especially private for-profit pharmaceutical and consulting
companies, innovative approaches are needed in reaching and sustaining agreements.
Private for-profit companies have been included in the Global Fund, GAVI and other
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PA R T 2
Challenges
Community participation Studies in the Region show that women often neglect their own health, and may not be allowed by their husbands or fathers to visit health centres on their own. Also, women’s health needs are different from those of men. Many primary health care workers in the Region are women, and are thus well placed to reach out to other women. However, currently they make little attempt to encourage women to be involved in activities related to their own health, and the health of their families. There are few examples in the Region of poor people being involved in health issues in partnership with the public health system or nongovernmental organizations. The poor, who comprise a third or a half of the population in some countries of the Region, are the most vulnerable to communicable diseases. They live in social and economic isolation from other members of the society. They are often beyond the reach of the health system. Some may be nomadic or semi-nomadic, seeking out a living on the edge of agricultural settlements. Large numbers of poor people live in crowded squatter settlements in and around the mega-cities of the Region (such as Cairo with 16 million, Karachi 12 million, and Teheran with 10 million people). They are usually beyond the reach of urban health and municipal services, such as water, sanitation and garbage collection. The overcrowding and poor sanitation are favorable conditions for increasing susceptibility to infection and fostering spread of diseases.
Community participation is a neglected aspect of Health for All. Without it, people will
not be aware of the existence of protective services and will not use them. Members
of the public need to express what they perceive are their health needs, and contribute
towards meeting these needs.
The challenge is to involve all sections of the community—women, men and children,
rich and poor—using their skills and knowledge, recognizing their needs, and working
with them to identify and overcome local health risks.
Women are usually responsible for the health of family members, especially young
children who are most vulnerable to communicable diseases. They are thus well placed
The challenge is to involve all sections of the community— women, men and children, rich and poor—using their skills and knowledge, recognizing their needs, and working with them to identify and overcome local health risks.
to be involved in the services offered by local health facilities. However, outreach
programmes in the Region are usually weak.
In some parts of the Region, mothers do not understand that their children need immunizations. Instead they tend to think that this is something forced on them by the government.
In some parts of the Region, mothers do not understand that their children need
immunizations. Instead they tend to think that this is something forced on them by the
government, which can enforce its will by requiring immunization certificates for children
before they start school. To overcome this idea, the government can involve local
women in the programme, rather than see them as passive acceptors of services.
They can train local women to immunize children safely, keep records and persuade
There are few examples in the Region of poor people being involved in health issues in partnership with the public health system or nongovernmental organizations.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
their peers to participate in immunization programmes.
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PA R T 2
Challenges
Outbreaks of diarrhoea and spread of acute respiratory infections are quite often Complex emergencies Many people in the Region live in areas of complex emergency, often without a functioning government. In Afghanistan, Iraq, Palestine, Somalia and southern Sudan, war and civil disorder, the displacement of population, the collapse of protected water supplies, communication and travel difficulties, and shortages of food, combine to create serious health crises. In these areas, health services are limited or nonexistent. Health staff are demoralized because they are paid late, or not at all, and the health facilities that do exist lack essential drugs and equipment. Many health staff have left government service, some to find employment outside their home country. In many areas, the only available health services are those provided by nongovernmental organizations and international agencies, such as WHO and UNICEF. Many special health programmes face serious difficulties in these areas as they depend for their effectiveness on regular activities, such as daily treatment for tuberculosis and leprosy, regular immunizations for infants and prompt treatment for malaria. The challenge is to extend existing government health services as conditions stabilize, and, at the same time, to develop innovative ideas to ensure the effectiveness and sustainability of health services operating in areas not covered by this sector.
FACING REALITIES IN THE REGION AND IN THE WORLD
observed in mega and other large cities. This unhealthy environment poses health risks
for the people living in these areas. Environmental awareness is growing in the Region.
There is a need to build on existing activities of nongovernmental organizations working
with poor people to help them achieve a healthier life and safer employment conditions.
COMMUNITY PARTICIPATION
Why do we need it?
• To ensure the appropriateness of public health services
• To ensure the use of public health services
• To ensure sustainability of health programmes
How do we achieve it?
• Build working partnerships between health centres, local nongovernmental
organizations and local people.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
• Recognize the skills, knowledge and concerns of local people.
In Afghanistan, Iraq, Palestine, Somalia and southern Sudan, war and civil disorder, the displacement of population, the collapse of protected water supplies, communication and travel difficulties, and shortages of food, combine to create serious health crises.
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PA R T 2
Challenges
Southern Sudan experiences serious health problems, including malaria, HIV/AIDS and are displaced within the country and over 2 million Afghan refugees live in Pakistan. At least one-third of the population of Afghanistan is without access to primary health care. Here too, the national tuberculosis programme had ceased to operate. DOTS was provided by the few surviving government health facilities and by nongovernmental organizations without national or regional coordination. Activities urgently need to be expanded; by the end of 2001 DOTS covered only about 20% of the population. In Afghanistan, special efforts need to be made to reach women with tuberculosis. Official figures indicate that more women are infected with tuberculosis than men. This is due to a lethal combination of poor access to health care, to malnutrition, and to the transmission of the disease in crowded household settings. Because they cannot travel to health facilities, and there are few women health workers, women delay seeking treatment and thus risk infecting other women in the house. When they do seek care they tend to attend the cheaper public facilities, whereas men are more likely to attend private providers, who rarely register their patients. In 2002 both Afghanistan and Somalia suffered from outbreaks of cholera/acute watery diarrhoea; these outbreaks are directly related to the lack of a safe water supply, the large proportion of the population who are displaced, and the absence of health services. WHO has assisted in providing supplies, such as oral and intravenous rehydration fluids, and has trained health workers in proper case management. Efforts are also being made to chlorinate wells, and to provide health education to forestall future outbreaks.
tuberculosis. Here problems of war and civil disturbance are combined with difficulties
of access because of seasonal flooding. There is also an urgent need for surveillance
for epidemic-prone diseases. In areas outside government control, the Early Warning
and Response Network, started in 1998–9, now includes all epidemic-prone and
vaccine-preventable diseases. However, little is known about the extent of many
communicable diseases, such as leishmaniasis, HIV/AIDS and trypanosomiasis, which
affect thousands of people in this area.
Somalia has been ravaged by war since 1990 and the health infrastructure seriously
damaged. In 1993, UN agencies, and multilateral and bilateral agencies organized a
working group to coordinate the activities of partners involved in various sectors,
including health. Tuberculosis was identified as a priority. In the absence of a health
infrastructure that is usually regarded as essential for the delivery of DOTS, a control
programme was started in 1995. WHO provided drugs and laboratory equipment, and
helped to develop treatment guidelines and a surveillance system. In 2001, DOTS
services were provided at 27 centres run by 17 international and local nongovernmental
organizations. However, only 42% of those estimated to suffer from tuberculosis are
included in the DOTS programme. New challenges in Somalia include the increasing
The challenge is to extend existing government health services as conditions stabilize, and, at the same time, to develop innovative ideas to ensure the effectiveness and sustainability of health services operating in areas not covered by this sector.
number of HIV-positive patients who have tuberculosis, and the threat of drug resistance.
Afghanistan has suffered from almost 25 years of war, foreign invasion and internal
disorder. In addition, in a country where conditions for agriculture are always marginal,
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
there have been four consecutive years of drought. As a result, over 1.2 million people
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PA R T 2
Challenges
In Iraq, international sanctions imposed since 1991 made it difficult for the authorities Cholera (1998-2003)
CCHF (1998-2002) High case fatality
to obtain medicines and equipment. During 2002, bombing in the extreme north and
south of the country disrupted administration and normal patterns of communication
and transport. The result has been a disruption in health service provision and a large
increase in infant deaths; at least a quarter of all children are malnourished and
thousands have died unnecessarily. There has also been a resurgence of malaria since
1991 and the introduction of sanctions that affected the import of vital supplies such Cholera (1998-2002) RVF (2003)
as insecticides and spraying equipment; severe epidemics occurred in 1994 and 1995.
Infections are mainly due to Plasmodium vivax, a form that is not usually fatal but which
prevents children and pregnant mothers from digesting their food, hence causing
malnourishment. There is a continuing danger of the introduction of P. falciparum in the RVF (2000) Meningitis (1999) Dengue fever (2002 - 2003) Yellow fever (2003) RVF (1997 - 1998) Cholera (1995-2001) Cholera (2000)
south, and of the extension of the area affected by P. vivax as displaced people moved
In Iraq at least a quarter of all children are malnourished and thousands have died unnecessarily.
between high and low risk areas.
In Palestine, the crisis situation continued, indeed deteriorated. During 2002, many
health centres and the headquarters of the Ministry of Health were destroyed in crossMeningitis Yellow fever Rift valley fever (RVF) Dengue fever Cholera Crimean-congo haemorrhagic fever (CCHF)
border incursions, making it extremely difficult, by the year’s end, to support health
services for the population. For example, the high rates of immunization coverage,
which in 2001 covered 97% for DPT (diphtheria, pertussis and tetanus) and 98% for
measles, were threatened. The coverage rate for DOTS is currently only 12%, and
information on treatment outcome is not available. The UN Relief and Works Agency Disease outbreaks in the Region
for Palestinian Refugees in the Near East (UNRWA) continues to do its best to support
health—as well as education and social services—for the approximately 4 million
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Palestinian refugees in Jordan, Lebanon and the Syrian Arab Republic, and in the West
Bank and Gaza.
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PA R T 2
Challenges
A borderless world and transit camps, which often lack safe water and sanitation, exacerbate the situation. The leishmaniasis epidemic that broke out in Afghanistan in 2000 affected around 200 000 people in the capital, Kabul, and 70 000 elsewhere, mainly in camps. In spite of a collaborative effort to control the disease, it spread as refugees crossed the border into the North West Frontier Province of Pakistan. Here, it was also transmitted to the indigenous population. As most of this population is non-immune, outbreaks can quickly flare up. Physicians in Pakistan are often unfamiliar with the disease and do not know how to diagnose or treat it. Viral haemorrhagic fevers are usually highly focal, but when they occur as epidemics they may cross an international boundary and appear in a country for the first time. The first cases of Rift Valley fever reported outside the African continent appeared in 2000 in Saudi Arabic and Yemen. The disease is likely to have spread from Kenya and Somalia, where there were major epidemics in the previous 2 years. The disease could expand in the Region wherever there are appropriate mosquito vectors. Millions of people travel each year to the holy cities of Mecca and Medina in Saudi Arabia, for the Muslim pilgrimage, the hajj. Crowded conditions among the millions of pilgrims facilitate disease transmission. During 2000 and 2001, Saudi Arabia reported outbreaks of meningitis due to a new strain, serogroup W 135, and required all pilgrims to be vaccinated with a vaccine that includes serogroup W 135. However, because this serogroup has only recently been recognized as responsible for meningitis epidemics, there was a shortage of the vaccine that includes this group.
In an age of mass air travel, the Eastern Mediterranean Region serves as a crossroads
and a destination for millions of people each year. As a result of international air travel
communicable diseases spread rapidly, as with the spread of cholera from Asia to
Africa and South America in the 1970s, and most recently with SARS (Severe Acute
Respiratory Infection). Whether facing an entirely new disease, such as SARS, or one
that appears in the area for the first time, a surveillance system is essential. Countries
need to collaborate in establishing cross-border surveillance and checks at airports.
WHO and organizations such as the Centers for Disease Control and Prevention in the
USA coordinate reports, publish global alerts and send out special response teams to
epidemic areas.
The movement of refugees across international borders spreads disease, as refugees are invariably malnourished and have low disease resistance; poor conditions in refugee and transit camps, which often lack safe water and sanitation, exacerbate the situation.
The challenge is to develop and maintain effective national and cross-border surveillance
Whether facing an entirely new disease, such as SARS, or one that appears in the area for the first time, a surveillance system is essential.
systems and to link these to the international surveillance network.
In some member countries of the Gulf Cooperation Council up to 80% of the labour
force comes from other countries, most often from south and south-east Asia, especially
India and the Philippines. These migrants may bring in unfamiliar communicable diseases
that then spread among the migrant and local population, and which may not be easily
recognized and treated by local health providers. Many migrants return home before
they have completed their DOTS treatment for tuberculosis; this is reflected in the
comparatively low treatment completion rate for DOTS in some member countries of
The challenge is to develop and maintain effective national and crossborder surveillance systems and to link these to the international surveillance network.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
the Gulf Cooperation Council.
The movement of refugees across international borders spreads disease, as refugees
are invariably malnourished and have low disease resistance; poor conditions in refugee
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PART 3
Focusing on the Possible
There are success stories in the Region that can be used to infuse new spirit into moribund health systems, dispirited health staff, and apathetic communities. Success stories such as these can be used to demonstrate to national governments, health ministries, and the public that with adequate commitment and focused activities, the health of people in the Region can be improved.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
PA R T 3
focusing on the possible
CONCLUSION
focusing on the possible
We already know which tools are needed to effectively control most of the communicable water pipes which were creating mosquito breeding sites. Existing legislation to eliminate mosquito breeding sites was also reviewed and updated, and more fully enforced by local authorities. Success is attributable to national and state level commitment, the many partners who agreed on cooperation, and on very focused local level activities. In Yemen, a malaria elimination initiative began in mid-2000 in the remote, poor Socotra Island, involving effective collaboration between health, agriculture and environment sectors. Its success demonstrates the possibility of achieving a high level of malaria control in other parts of the country. The risk of HIV/AIDS is still largely unrecognized in the Region. However, a few Member States are committed to activities directed towards hard-to-reach stigmatized groups, such as men who have sex with men, sex workers and injecting drug users. In the Islamic Republic of Iran, injecting drug users, a group stigmatized by the general public and neglected by health and social services, are now officially recognized as having a high rate of HIV/AIDS. A pioneering Ministry of Health and Medical Education programme is reaching out to this group. It provides free needles (to prevent the transmission of blood borne pathogens including HIV), treatment with anti-retrovirals, and vaccination against hepatitis B. The ministry programme also offers patients and family members counselling. A good practice document has been written based on the Iranian experience, with the intention that it will be shared with other countries in the Region. Success stories such as these can be used to demonstrate to national governments, health ministries, and the public that with adequate commitment and focused activities, the health of people in the Region can be improved. Healthier populations are in a far better position to contribute constructively to their communities and to society as a whole than are the sick and demoralized who feel helpless in the face of epidemic emergencies and who stoically endure diseases that are, in fact, preventable and unnecessary.
health and water supply sectors which organized the repair of thousands of leaking
diseases found in the Region. We also have well-developed plans of action to put these
tools into effect. Yet, in many countries in the Region, effective control has not been
achieved. We need the courage to ask ourselves why this is so and to set about
improving our performance by learning from our successes and our failures.
In Pakistan, the continuing low level of EPI coverage suggests that the strategic
approach depending on outreach teams is not working. New support from GAVI should
spark greater commitment to provide the effective oversight the programme requires.
Healthier populations are in a far better position to contribute constructively to their communities and to society as a whole than are the sick and demoralized.
In southern Sudan, where civil strife has caused a breakdown in many essential health-
related services, we need to take advantage of any windows of opportunity which
present themselves in order to achieve the eradication of dracunculiasis. Dracunculiasis
is only one of the many health problems in Sudan, but because of the prospect of
global eradication, it demands priority.
This means focusing efforts on what is possible, what is applicable to the local situation, and what is acceptable to local health staff and the local population.
At all levels, policy-makers need to think creatively in order to overcome the constraints
imposed by weak health services. This means focusing efforts on what is possible,
what is applicable to the local situation, and what is acceptable to local health staff
and the local population. For example, in Afghanistan and Somalia, where central
government control in many rural areas is tenuous at best, national tuberculosis
programmes collapsed. Treatment of the disease now relies largely on nongovernmental
organizations and international donors working at the district level. Here, it has been
necessary to build on existing district and local level activities, without waiting for the
emergence of an effective national health service.
There are success stories in the Region that can be used to infuse new spirit into
moribund health systems, dispirited health staff, and apathetic communities. In 2002,
in Sudan the malaria-free initiative in the capital, Khartoum, has resulted in a 50%
decline in new cases among the largely poor and ethnically diverse urban population.
DCD DIVISION OF COMMUNICABLE DISEASE CONTROL
Among activities supported was a task force consisting of representatives from the
62 63
DCD Staff Frank Mahoney Vaccine-preventable diseases
Zuhair Hallaj Mojtaba Haghgou Vaccine-preventable diseases
Samiha Baghdady
Director
Stop TB
Jihane Tawilah Raef Bekhit Vaccine-preventable diseases
John Jabbour
AIDS and sexually transmited diseases
Stop TB
Hany Ziady Riadh Ben Ismail Parasitic and zoonotic diseases
Laura Gillini
AIDS and sexually transmited diseases
Stop TB
Joumana Hermez Nikolai Neouimine Parasitic and zoonotic diseases
Hassan El Bushra
AIDS and sexually transmited diseases
Emerging and epidemic diseases
Hoda Atta Amal Bassili Research
Nadia Teleb
Roll back malaria
Emerging and epidemic diseases
Abraham Mnzava Samar Ibrahim Advocacy
Said S. Youssef
Roll back malaria, Vector Control
Vaccine-preventable diseases
Akihiro Seita
Ezzeddine Mohsni
Stop TB
Vaccine-preventable diseases
Written by
Susan Watts
Editing by
Jane Nicholson
Photographs
Cassandra Nelson / Mercy Corps WHO photo library
Designed by
CU Creative Advertising
For more information contact Division of Communicable Disease Control World Health Organization Regional Office for the Eastern Mediterranean Address: Abdul Razzak El Sanhouri St P.O. Box 7608 Nasr City. Cairo 11371, Egypt. Tel.: (202) 670 25 35 - Fax: 670 24 92/4 e-mail: dcd@emro.who.int web site: www.emro.who.int