Catching outbreaks wherever they occur

741Bull World Health Organ 2009;87:741–742 | doi:10.2471/BLT.09.031009 News Catching outbreaks wherever they occur A new organization in the Middle East shows how common goals can overcome political differences when it comes to fighting disease and quelling outbreaks. Dale Gavlak reports. Communicable diseases have no respect for boundaries. As pandemic influenza A (H1N1) swept the globe this year, WHO’s Member States could take comfort in the legal requirements of the International Health Regulations (IHR), which were updated in 2005 to require countries to report certain disease outbreaks to the World Health Organization (WHO). But not all parts of the world are or may be parties to the IHR, and where there is a gap in surveillance there is always the possibility that an outbreak can slip through the net. For example, the West Bank and the Gaza Strip – though not party to the IHR – are covered by the Middle East Consortium on Infectious Disease Surveillance (MECIDS). This coordi- nation mechanism of Israeli, Jordanian and Palestinian health officials shares information and takes coordinated action to help detect and respond to infectious disease outbreaks. We have to be aware of what is going on in each country because disease and bacteria know no borders. Dr Assad Ramlawi It is one example of how regional disease surveillance can be achieved in difficult political environments, and also of how such cooperation works to implement the requirements of the IHR. “When WHO declared Phase 6 of the A (H1N1) virus in June, we found we needed an urgent meeting,” says Dr Bassam al-Hijawi, head of the Disease Control Directorate at Jordan’s Ministry of Health. Increasing the capabilities of labora- tories in the region posed one challenge for which it was necessary to hold face- to-face talks, even if it meant travelling to a third location because of political tensions between the sides. “But we suc- ceeded in going to Jerusalem to discuss it,” says al-Hijawi, an epidemiologist, who serves on the executive board of MECIDS. “We started [working according to] the same rules together, even though Israel reported the first A (H1N1) case. This was in compliance with the International Health Regula- tions,” he says. MECIDS was established in 2003, when nongovernmental organizations Search for Common Ground and Washington-based Nuclear Threat Ini- tiative began facilitating regional coop- eration in public health. MECIDS was established as part of those efforts, in which the Ministry of Health of Israel, the Palestinian Authority, and Jordan were initially sharing data on food- borne disease outbreaks. Since then, data sharing has expanded to other disease areas, including vector-borne diseases and pandemic influenza. MECIDS partners have protocols for cross-border collaboration for in- vestigating infectious disease outbreaks, including a bird culling radius across the borders, an automatic system for notifying each other, and tested col- laboration for general preparedness for pandemic influenza. Harmonizing diagnostic and reporting methodologies, sharing training programmes and facilitating cross-border communication between laboratory technicians and public health officials are other important activities. “It’s just not a talking organization. This is a direct action organization,” says Terence Taylor, who is vice-president of Global Health and Security, at the Nuclear Threat Initia- tive, that is helping MECIDS imple- ment its plans. “The idea behind MECIDS is that everybody is equal,” says Dr Alex Leventhal, the director of Israel’s Health Ministry Department of Inter- national Relations and the consortium’s first chair. Leventhal is joined by Dr Adel Belbesi, assistant secretary-general for primary health care at Jordan’s Ministry of Health. Dr Assad Ramlawi, the Palestinian Authority Ministry of Health’s director of primary care and public health, is the third principal and currently holds the year-long rotat- ing post. The three principals are the heads of their respective delegations to MECIDS and they take turns in occupying the rotating chair. “We have to exchange informa- tion and support each other,” Ram- lawi says of the need for health pro- fessionals to protect their respective Co ur te sy o f M EC ID S MECIDS Executive Board. Sitting down (MECIDS principals) left to right, Dr Alex Leventhal (Israel), Dr Adel Belbesi (Jordan), Dr Assad Ramlawi (Gaza and West Bank). Standing, G Mohammad Shyyiab (CMC), Dr Bassam Hijawi (Jordan), Professor Dani Cohen (Israel), Mr Terry Taylor (NTI). 742 Bull World Health Organ 2009;87:741–742 | doi:10.2471/BLT.09.031009 News communities from the outbreak of infectious diseases. “We have to be aware of what is going on in each country because disease and bacteria know no borders.” “Political tensions are one issue and disease intervention is another,” he added, preferring not to be drawn into a discussion about the often tense situ- ation between Israel and the Palestinian Authority. Global Health and Security’s Taylor says the secret to MECIDS’s success is the trust between the partners. “It’s the three principals that really make this work,” Taylor says, referring to Belbesi, Leventhal and Ramlawi. MECIDS was formed to discuss all of these practical issues. People know each other well and this is a key issue for success in time of emergencies. Dr Guenael Rodier Al-Hijawi believes MECIDS co- operation would be stronger if it were not for tensions between Israel and the Palestinians. “There was tension during the Gaza military incursion. We didn’t meet for several months. This is very bad because we are dealing with health issues,” he says. “But all MECIDS members have decided that it is very important and there must be strengthening.” “But even in the case of Gaza, they know who to call. They have principals who are senior enough in their administration to carry this thing forward. That’s part of the trick,” Taylor says. Mahmoud Daher, a WHO officer working in Gaza, says that coopera- tion between Israel and the Palestinian Authority was “very crucial” to imple- ment the IHR because Israel controls the borders and surveillance. WHO’s mediating role between Israel and Palestinian health authorities has become even more critical due to the tensions between the two. “WHO brings supplies, notifies about disease and advocates for the need of the health authorities in Gaza,” he added. Despite the political divide, there have been extraordinary cases of coopera- tion between Israel and the health au- thorities in the Gaza Strip with WHO assistance. With the outbreak of avian flu in the Gaza Strip three years ago, WHO initiated contact with the Israeli authorities to coordinate interven- tion activities and the provision of equipment and anti-viral drugs for the coastal strip. “We managed to hold a meeting between senior profession- als from Gaza and Israel to talk about surveillance. They understand that communicable diseases don’t respect borders and they work in accordance with the situation,” Daher says. Dr Guenael Rodier, who heads IHR coordination at WHO headquar- ters in Geneva, says that in the IHR, “public health sometimes overlaps with national security”, adding: that “imple- menting the IHR in the area means that you must also take into account the numerous operational constraints due to security issues as well as the physical separation” between Israel, the West Bank and Gaza. “MECIDS was formed to discuss all of these practical issues. People know each other well and this is a key issue for success in time of emergencies,” he says. “There is a lot of good sense of common purpose.” The influenza pandemic drills in September 2008 are a practical example of their cooperation. Political tensions meant that the partners decided to hold a regional “tabletop” simulation exercise for pandemic influenza in Istanbul, Turkey. MECIDS members discussed their plans for a possible pandemic, including steps to be taken at each stage, including cross-border collabo- ration. The exercise was preceded by local exercises. Little did they know they had already laid the important groundwork to respond quickly and efficiently to the A (H1N1) outbreak just a few months later. “This has paid dividends be- cause here we are in the middle of a pandemic,” Taylor says. “It’s not just a health issue. It’s also about agricul- ture, immigration, foreign affairs and security.” ■ Recent news from WHO • Road accidents, suicide and maternal conditions are the leading causes of death in people aged 10–24 years, according to a WHO- supported study of global mortality patterns. The study, which was published in the Lancet on 12 September, shows that 2.6 million young people die each year around the world, with 97% of these deaths occuring in low- and middle-income countries. • On 11 September, WHO issued new advice on measures that can be undertaken in schools to reduce the impact of the A (H1N1) influenza pandemic. Recommendations include those on school closures, isolation of students and staff who become ill, promotion of hand-washing, respiratory etiquette as well as proper cleaning and ventilation, and measures to reduce crowding. • On 28 August, WHO advised countries in the northern hemisphere to prepare for a second wave of pandemic influenza A (H1N1). Countries with tropical climates, where the pandemic virus arrived later than elsewhere, also need to prepare for an increasing number of cases. Countries in temperate parts of the southern hemisphere are advised to remain vigilant. Experience has shown that localized “hot spots” of increasing transmission can continue to occur even when the pandemic has peaked at national level. For more about these and other WHO news items please see: http://www.who.int/mediacentre