WHO-EM/DCD/001/E/G Distribution: General
D DC ANNUAL REPORT 2001
Cairo, Egypt 2002
Fo r e wo r d Communicable diseases are still responsible for one-third of the annual deaths in the Eastern Mediterranean Region. The people still suffer from a wide range of viral, bacterial and parasitic infections, some of which have already been eliminated or efficiently controlled in developed areas of the world. This is happening despite the availability of proven tools of intervention and the tremendous progress in public health practice witnessed in the past century. The problem is much more acute in countries afflicted with poverty, civil strife and disaster, whether natural or man-made. It is true that successes in specific communicable disease control have been accomplished in several countries and that hundreds of thousands of lives have been saved as a result of effective programmes, such as EPI, but in my opinion, and as evidenced by the data available, this is neither sufficient nor acceptable. The problem of communicable diseases should be addressed by a more comprehensive and feasible strategic plan, built on the concept of integrated disease control. An integrated approach will lead to better use of resources, wider coverage of intervention strategies and avoidance of duplication in efforts. It will also help in developing the health system in general, as well as improving health outcome. This first ever report of the Division of Communicable Disease Control of WHO’s Regional Office for the Eastern Mediterranean attempts to show the burden of disease in the Region, the response and the future. It tells of stories of success and of challenges to be met. But beyond all that it tells of our outlook and asks for a solid partnership to be built among all those striving for health, development and equity for the people of this Region and the globe.
Hussein A. Gezairy MD, FRCS Regional Director for the Eastern Mediterranean
O u r Fr a m e wo r k
The
p e o p l e —who we are people people people p e o p l e people people
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Commitment to the
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Burden upon the
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Response of the
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Cour age of the
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R e a l i t y
o f
t h e
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Futur e
for
the
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The people—who we are
“We created you from a single pair of male and female and made you into nations and tribes, that you may know each other” (The Quran)
We are the people of the Eastern Mediterranean Region, living in 23 countries and totalling 478 million. Our Region extends from Morocco to Pakistan spanning an area of 13.9 million square kilometres (Figure 1). The Region is made up of a wide variety of worlds. In nature, it has vast deserts, deltas, rivers and mountains, all with profound significance for the people. But urbanization is sprawling and encroaching on it at an alarming rate. The people live in diverse conditions that represent extreme contrasts. There are people who suffer from drought and famine and people who have plenty. The sting of inequity and injustice is felt daily. There are people whose livelihood is dependent on the earth and sea, yet the fruits of their labour are not equally shared. The ancient and the modern live side by side. Natural and man-made disasters threaten side by side. The foreign and the familiar exist side by side. The people of the Region belong to several different ethnic groups. Each ethnic group has its distinct language, traditions, arts and crafts, history and way of life. Eighteen out of 23 countries have Arabic as their national language. Other main national and vernacular languages spoken in our Region are Urdu (Pakistan), Farsi (Islamic Republic of Iran), Somali (Somalia), Greek (Cyprus), Dari and Pashto (Afghanistan), Amazigi (Morocco) and Kurdish (Iraq). Over the centuries the different groups
Figur e 1. Eastern mediterr anean region of who
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The people—who we are
have influenced one another and contributed to and enriched one another’s culture. Our Region is the cradle of the three monotheistic religions: Islam, Christianity and Judaism, all of which shape our values and are the main basis for global health ethics to this day. The people experience striking socioeconomic disparities. The gross national product (GNP) per capita ranges from less than US$ 180 to over US$ 21 000. Even within countries gaps exist between rich and poor. The percentage of the population below the poverty line ranges from less than 2% in the member countries of the Gulf Cooperation Council to more than 40% in some countries. The countries with the highest disease burden have the least per capita public expenditure on health, amounting to less than US$ 10, while the highest expenditure in some countries is more than US$ 700. Literacy rates also reflect social disparities among the people of the Region: total adult literacy rate ranges from 27% to 94%. There are considerable gender disparities in literacy in some countries, with considerably lower rates among women. Overall, only 47% of women in the Region are literate compared with 68% of men. Life expectancy ranges from below 50 years in the least developed countries to more than 75 years of age in the more privileged countries. According to the Human Development Report 2001, the Human Development Index varies from an extremely low index figure of 0.439 to a relatively high index figure of
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0.877 on a social scale, with 1 being the highest and most desirable. The majority of our People in the Region are young. Children under 15 years of age, who constitute the highest risk for the major infectious disease killers, account for 40.6% of the population. The average population growth rate in the Region is 2.3%, one of the highest in the world. Again, there is substantial variation between countries, from 0.5% to 6.5%. With this diversity, the unifying factors of religion, language, common history and traditions interlink the People to form a unique mosaic called the Eastern Mediterranean Region.
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Commitment to the p e o p l e It has to be admitted that in the field of communicable disease control, we in the Eastern Mediterranean Region have not yet achieved all that is possible for the people and have fallen short of the best we could achieve. What we have done so far to reduce the disease burden is not sufficient, and what we have not done to improve the life of our people is unacceptable. We have a commitment to the people in this Region—to deliver them from avoidable suffering and to save their loved ones from preventable death. As responsible workers in communicable disease control, we have to come up with something more than the conventional responses so as to avail all the people of the activities beneficial to their health. We have to make the best use of resources, interventions and services at all levels, and with input from all partners, to improve the outcome of our programmes. Accordingly, we in WHO’s Regional Office for the Eastern Mediterranean have adopted the concept of an integrated approach to disease control, in addition to our commitment to scaling-up our disease-specific control activities. We have committed ourselves to working with our colleagues in the Member States to develop the methodology, as well as the tools to integrate common cross-cutting control activities, such as surveillance, capacity-building, supervision, drug distribution, environmental management, diagnosis, treatment, patient referral and advocacy. We will also work with them to develop an essential package of services for the prevention and control of priority diseases, which should, and could, be delivered at the periphery under whatever conditions.
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We have committed ourselves to working with other health workers, to ensure that our integrated approach will have a positive impact on the development of the health system, particularly at the periphery. We have committed ourselves to making sure that the implementation of the integrated approach will lead, at the same time, to the scaling-up of disease-specific activities, essential to the control of priority diseases. Our integrated approach should not lead in any way to disruption of programmes already proven to be successful. We have committed ourselves to working with all concerned within and outside the health sector to ensure that the people of the Region will be the focus of our joint endeavour. The division of communicable disease control seeks to advance a common understanding of disease control and a shared sense of urgency in responding to the needs of the people. We present here, to all our partners, a comprehensive strategic approach against which to formulate or re-evaluate, and harmonize their own strategies. It is incumbent upon those with wisdom, clarity of vision and responsibility towards their communities, to seek to prevent, control, eliminate or even eradicate communicable diseases, with all their complexities, in a bold drive towards a new horizon. The people deserve full commitment to help them enjoy a healthy future. This is our commitment to the people of the Eastern Mediterranean Region.
Dr Zuhair Hallaj Director, Communicable Disease Control
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Burden upon the p pe eo op pl le e
Each year 1.3 million people die of communicable diseases in the Eastern Mediterranean Region (World Health Report 2001)
Communicable diseases 32%
Maternal conditions 3%
One out of every three deaths in the Eastern Mediterranean Region is due to a communicable disease: 3500 people every day. When we analyse the disease burden, including mortality and morbidity/disability together, communicable diseases account for 32% of the total burden in DALYs in the Region (Figure 2). The price is paid both in grief and in socioeconomic deterioration (Table 1). Beyond contributing to mortality, infections can also leave people blind, deaf or mentally handicapped. Some, like malaria, tuberculosis and hepatitis B, smoulder into insidious, chronic conditions that steal years of productivity and pleasure. The war against the major infectious killers is the war against poverty and social inequity.
Injuries 11%
Perinatal conditions 8% Nutritional deficiencies 4%
Noncommunicable diseases 42%
Figur e 2. Bur den of d i s e a s e i n d a ly s b y cause in the region
Ta b l e 1 . B u r d e n o f 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 r e g i o n Disease Acute respiratory infections Diarrhoeal diseases including cholera Childhood vaccine-preventable diseases* Tuberculosis Malaria HIV/AIDS Meningitis STDs** Tropical diseases*** Hepatitis Other diseases****
Deaths 370 000 286 000 197 000 136 000 47 000 54 000 24 000 12 000 6 000 10 000 148 000
DALYs1 11 399 000 9 173 000 6 997 000 2 951 000 1 945 000 1 786 000 871 000 1 229 000 908 000 254 000 5 325 000
Source: Extrapolated from The World Health Report 2001 * Diphtheria, measles, pertussis, poliomyelitis and tetanus ** Syphilis, gonorrhoea and chlamydia infection *** Schistosomiasis, leishmaniasis, lymphatic filariasis, leprosy and trypanosomiasis **** Others include dengue, leprosy, Japanese encephalitis, and intestinal nematodes
Total
1 290 000 42 838 000
1DALY: disability-adjusted life year. One DALY can be thought of as one lost year of “healthy” life.
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Burden upon the p pe eo op pl le e
Va c c i n e - p r e v e n ta b l e diseases Measles Only 36 480 measles cases were reported to WHO in the year 2000 from 22 countries in the Region while Yemen reported 26 126 cases in 1999. There is considerable under-reporting and the estimated number of deaths from measles could be as high as 80 000 per year. The number of cases reported has been decreasing in the past two decades as measles vaccination coverage has increased. Most cases are reported from countries with relatively low immunity in the population.
Neonatal tetanus In 2000, 3156 cases were reported, 97% of which were confined to 6 countries: Afghanistan, Egypt, Pakistan, Somalia, Sudan and Yemen. During the 1980s, neonatal tetanus was one of the leading neonatal killers, with more than 11 400 cases reported every year in the Region. Since the introduction of immunization of pregnant women with tetanus toxoid (TT) in 1986, and its expansion in 1989 to all women of childbearing age, the number of cases has declined considerably.
Hepatitis B Most countries in the Region are in the category of intermediate to high endemicity of hepatitis B. The prevalence rate for HBsAg carriers is above 2%, and the estimated number of chronic hepatitis B carriers in the Region exceeds 25 million. According to available information 25% of those carriers may eventually develop a fatal liver condition, compounding the size of the problem down the road. Hepatitis B vaccination is now fully integrated into the national Expanded Programme
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on Immunization (EPI) in 18 countries of the Region. These countries account for about 57% of the total infant population in the Region.
Haemophilus influenzae type b (Hib) Severe Haemophilus influenzae infection manifested as pneumonia or meningitis is the most important cause of these diseases in children under 5 years of age. Recently the Regional Office supported activities aimed at assessing the burden of Hib disease using the rapid assessment tool in some countries (Egypt, Islamic Republic of Iran, Oman and Yemen) and a prospective population-based survey in Tunisia. The incidence of severe Hib disease was found to be high, ranging from 138 to 246 cases per 100 000 children under 5 years of age. This translates to 30 000 deaths annually from Hib disease in children under 5 years. Currently only four countries in the Region have introduced the Hib vaccine into their routine EPI (Bahrain, Cyprus, Kuwait and Qatar).
Tuberculosis The burden of tuberculosis is still high in the Region. Onethird of the regional population is infected with the tuberculosis bacilli. It is estimated that every year 630 000 people develop tuberculosis and 136 000 die of it. If the national tuberculosis control programmes do not achieve the global target the annual incidence might increase. Tuberculosis affects socially and economically productive age groups in the community with around 80% of cases occurring in the age group 15–54 years.
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Burden upon the people
Tuberculosis is clearly a public health problem and an obstacle to development.Nine countries (Afghanistan, Egypt, Islamic Republic of Iran, Iraq, Morocco, Pakistan, Somalia, Sudan and Yemen) have a high burden of tuberculosis, and account for 94% of the regional burden (Figure 3). Of these 9 countries, Pakistan and Afghanistan account for 43% and 12% of the regional burden respectively. Pakistan ranks 6th and Afghanistan 20th among the 22 countries in the world with the highest tuberculosis burden.
Yemen Others 3% 6% Egypt 4% Morocco 5% Somalia 6% Islamic Republic of Iran 6% Pakistan 43%
Iraq 7% Sudan 8% Afghanistan 12%
Figur e 3.Bur den of tuberculosis in the region (2000) Based on estimated number of t u b e r c u l o s i s c a s e s b y c o u n t r y. To t a l n u m b e r of cases in the Region is estimated at 630 000.
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Malaria Malaria is estimated to affect 15 million people and to kill 47 000 people every year in the Region. In total, 60% of the regional population lives in areas at risk of malaria transmission (Figure 4). The burden is, however, unevenly distributed. Countries can be categorized into four groups according to malaria situation. More than 90% of cases occur in five countries: Afghanistan, Djibouti, Somalia, Sudan and Yemen. Of these, Sudan alone accounts for about 50% of the regional burden. Four countries have moderate endemicity of malaria: Islamic Republic of Iran, Iraq, Pakistan and Saudi Arabia. In five countries, malaria is either interrupted (Morocco, United Arab Emirates) or occurs in very limited foci (Egypt, Oman, Syrian Arab Republic). Nine countries have completely eliminated malaria transmission (Bahrain, Cyprus, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Palestine, Qatar and Tunisia).
Transmission-free Elimination under way Low to moderate endemicity High endemicity
Figur e 4. Malar ia bur den in the r egion
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Burden upon the people
H I V / A I D S a n d s e x u a l ly t r a n s m i t t e d diseases At the end of 2000, an estimated 400 000 people were living with HIV/AIDS in the Region, the lowest number of cases among WHO Regions. However, the situation varies widely among the countries, severely affecting Djibouti, Somalia and Sudan. One-third of the reported cases of AIDS in the Region come from only one country, Sudan (3512 reported cases). Sexual contact is the main mode of transmission, responsible for 82% of the reported HIV infections in the Region. However, high-risk behaviour, including injecting drug use, the trend for which is increasing, represents an added threat to the spread of HIV in the Region. Sexually transmitted diseases (STD) constitute a heavy burden that is neither fully recognized nor examined in most of the countries. An estimated 10 million cases of STD occur in the Region every year. Studies in Egypt, Morocco, Sudan and Tunisia show that between 8% and 34% of women have an STD. However, these are only the cases identified among women attending gynaecological and antenatal clinics, so the STD rate in the community is not known. Gonorrhoea and syphilis have declined over the past decade due to the use of antibiotics, while chlamydia infections and trichomoniasis rates are increasing.
E m e rg i n g a n d e p i d e m i c - p ro n e d i s e a s e s Outbreaks in the past decade The Region is challenged by regular outbreaks and epidemics of several communicable diseases (Figure 5). Meningococcal meningitis affects Sudan recurrently. Outbreaks of cholera/epidemic diarrhoea and viral haemorrhagic fevers are reported almost every year in several countries. In 2000, the Region experienced an outbreak of Rift Valley fever in Saudi Arabia and Yemen, the first documented evidence of transmission of the virus outside Africa.
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Meningococcal meningitis Sudan is the only country in the Region that lies in the African meningitis belt, and used to suffer large-scale epidemics every 8–12 years. The last epidemic (December 1998–July 1999) resulted in more than 33 000 cases with a case fatality rate (CFR) of 7.2 %. A second wave of the epidemic occurred in 2000, affecting southern Sudan and resulting in about 4000 cases with a CFR of 8.1%. Meningococcal meningitis is also a concern for Saudi Arabia where millions of pilgrims from all over the world, including pilgrims from the meningitis belt countries, gather each year for a short period of time. In 1987, the largest outbreak of group A Neisseria menigitidis occurred in Saudi Arabia at the beginning of the Hajj, resulting in 1841 cases. During the most recent pilgrimage seasons (2000–2001), there was an increase in the reported number of cases caused by serogroup W135 among pilgrims and their contacts, raising concern regarding its epidemic potential.
1998–2001 High case fatality
1998–2000 1999 33 000 cases 2400 deaths
Meningitis RVF Cholera CCHF 1997–1998 The largest epidemic ev er reporte d 1995–2001
2000 First epidemic outside Africa 2000
F i g u r e 5 . M a j o r o u t b r e a k s i n t h e r e g i o n 19 9 5 – 2 0 0 1
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Burden upon the p pe eo op pl le e
Cholera/epidemic diarrhoea During the past decade (Figure 6), cholera was reported from Afghanistan, Djibouti, Islamic Republic of Iran, Iraq, Pakistan and Somalia. Unofficial reports indicate that cases of cholera occur in other countries also. Somalia, in particular, has been severely hit since 1994 by seasonal outbreaks with high CFR (7.5%). In 1998 more than 60 000 cases 70 000 were reported in the Region, with 60 000 outbreaks occurring in Afghanistan, Djibouti, Islamic 50 000 Republic of Iran, Iraq and 40 000 Somalia. In 1999 around 66 000 cases were reported from the same 30 000 countries. The number of cases 20 000 dropped to about 15 000 in 2000. The CFR differed significantly 10 000 among countries, ranging from 0 less than 1% in the Islamic 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Republic of Iran to more than 7% in Somalia. Outbreaks of F i g u r e 6 . Re p o r t e d c h o l e r a c a s e s i n t h e r e g i o n 19 9 0 – 2 0 0 0 gastroenteritis, severe diarrhoea, and “summer diarrhoea” were reported from other countries that did not officially refer to them as cholera outbreaks, although all the epidemic features indicated that they were cholera. The lack of transparency in such reporting is mainly due to fear of economic loss.
Viral hepatitis Viral hepatitis is one of the most frequently reported communicable diseases in the Region. Studies indicate that all five viruses (A, B, C, D, E) are endemic in the Region (Table 2). It is estimated that 4000 people die of
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Ta b l e 2 . E t i o l o g y o f a c u t e v i r a l h e p a t i t i s i n selected countries of the region HAV (%) 89.8 34.3 39 14 48 60 0.0 25 71
Country Bahrain Kuwait Tunisia Egypt Jordan Pakistan Children Adults Saudi Arabia Syrian Arab Republic * Non-A, non-B hepatitis
HBV (%) 9.3 27.3 36 21 39 10 23 15 24
HCV (%) 0.9 27.3 21 65* 13* 30* 77* 60* 5*
HEV (%) 0.0 11.1 4
acute viral hepatitis every year in the Region. However, the burden of chronic infection from some types of viral hepatitis is much more alarming.
Hepatitis A Hepatitis A is highly endemic in all countries in the Region and most infections occur asymptomatically early in life. Recently there are indications of a shift in age in the occurrence of infection towards higher age groups, with more complications.
Hepatitis C The estimated number of people infected with HCV in the Region is around 21.3 million. Egypt has one of the highest prevalence rates of hepatitis C in the world. According to available information between 50% and 80% of HCV cases will develop chronic liver conditions, and of these 50% will eventually develop liver cirrhosis and cancer. This is another indicator of the severe potential of HCV for the disease burden in the Region.
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Burden upon the p pe eo op pl le e
Hepatitis E Seroprevalence surveys indicate high rates of HEV infection in many countries. Studies in Egypt and Pakistan indicate that it is the major cause of non-A, non-B hepatitis and accounts for 15%–25% of persons with acute jaundice. HEV usually occurs in association with outbreaks of faecally contaminated drinking water. Such outbreaks have been reported from Djibouti (1993), Iraq (1986 and 1994), Jordan (1999), Morocco (1994) and Pakistan (1994). HEV has a relatively high fatality rate among pregnant women who contract it.
Viral haemorrhagic fevers Viral haemorrhagic fevers (VHFs) are important emerging diseases in the Region. Crimean-Congo haemorrhagic fever (CCHF) occurs in sporadic form or as localized outbreaks in several countries. In the past 2 years outbreaks of CCHF have been reported with an increase in number of cases from Afganistan, Islamic Republic of Iran and Pakistan. Iraq reported 48–65 cases of CCHF yearly from 1992 to 1996. Thanks to prevention and control measures, currently 8–12 cases of CCHF are reported yearly in Iraq. Sudan and Somalia are the only two countries within the infected zone of yellow fever. However, they did not report any cases since decades. The first reported outbreak in the world of Ebola haemorrhagic fever in the world occurred in southern Sudan, in 1976, followed by a second outbreak in 1979. Since then no Ebola cases have been reported in the Region. Outbreaks of the Ebola virus have occurred in several sub-Saharan African countries, and the virus remains a threat to the Region.
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Rift Valley fever (RVF) Since its discovery, RVF has been endemic in many countries of subSaharan Africa. The first time it spread out of the endemic areas was to Egypt in 1977, resulting in more than 18 000 cases and 600 deaths. In 1993 a smaller outbreak was also reported from Egypt. The largest ever reported epidemic occurred in East Africa in 1997–1998 in which Somalia suffered more than 250 deaths. RVF spread out of the African continent for the first time in 2000, producing outbreaks in Yemen (1328 cases; 166 deaths) and Saudi Arabia (882 cases; 124 deaths). This outbreak highlighted the threat of further RFV spread outside Africa.
Zoonotic Diseases Information about the incidence of zoonotic diseases is often incomplete, although for some countries in our Region these diseases constitute important public health problems.
Brucellosis (Malta fever or Mediterranean fever) Brucellosis has been recognized in the Region since antiquity; however, the real incidence is still not known. The annual notifications vary from less than 1 per 100 000 to more than 20 per 100 000 population. Official figures (45 000 notifications per year) do not fully reflect the real magnitude in humans. It is estimated that the real incidence could be 10 to 25 times higher. Animal studies have shown that brucellosis is common among herds in most countries of the Region.
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Burden upon the people
Rabies In spite of the wide use of post-exposure prophylaxis in the Region, 150 deaths due to rabies were reported in 2000. The economic burden of rabies far exceeds this relatively limited number of deaths. Rabies remains a public health problem, particularly because of the large financial resources spent by the public health sector and the community in preventing the disease among human cases exposed to animal bites. Several countries experienced an outbreak of wild rabies among red foxes during the 1990s.
Leishmaniasis Leishmaniasis is an important public health problem in the Region due to its high morbidity and its epidemic potential. The zoonotic cutaneous type is found in the majority of countries and the anthroponotic cutaneous leishmaniasis is highly endemic in urban foci in Afghanistan, Islamic Republic of Iran, Pakistan and the Syrian Arab Republic. The more severe visceral leishmaniasis is found in some countries, particularly Iraq and Sudan. Epidemics of visceral leishmaniasis can lead to significant mortality if not properly treated. Displaced populations and those living in areas with new agricultural and industrial projects are at high risk of leishmaniasis outbreaks.
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Pa r a s i t i c a n d t r o p i c a l d i s e a s e s Schistosomiasis Schistosomiasis is one of the oldest recorded parasitic diseases in the Region. Despite all efforts to control the disease, there are still an estimated 20 million infected people in the Region and more than 60 million living at risk of infection. Two types of the disease (intestinal and urinary) are found in the Region. The peak intensity of schistosomiasis infection is in 10–14 year-old children. Currently, urinary schistosomiasis is endemic in 10 countries and intestinal schistosomiasis in five countries.
Lymphatic filariasis Lymphatic filariasis is endemic in three countries of the Region (Egypt, Sudan and Yemen). It is estimated that 35 million people are living at risk of infection in these countries. The disease constitutes a major risk for disability in chronically infected individuals.
Dracunculiasis (guinea-worm disease) Sudan, particularly southern Sudan, continues to be the only country in the Region with endemic foci of dracunculiasis. The total number of cases reported by Sudan in 2000 was 54 890; southern Sudan accounts for approximately 73% of reported dracunculiasis cases worldwide, making it the main source of imported cases in the northern part of the country. The disease was eradicated in Pakistan in 1997. In Yemen, no cases have been reported since 1997.
Leprosy Prevalence of leprosy has declined dramatically in the Region in the past decade. The total number of registered cases decreased from almost 100 000 in 1989 to 8924 in 2000. The majority of leprosy cases were reported from Egypt (2986 cases), Islamic Republic of Iran (588), Morocco (370), Pakistan (2221), Sudan (1859) and Yemen (560). It is expected that during the next 10 years the number of cases will continue to decrease, especially after initiation of an intensified elimination strategy at the district level in endemic countries.
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Response of the people
“To every disease there is a remedy” (Hadith)
The burden of communicable diseases in the Region is tremendous and millions of people are suffering, while effective control strategies exist. Immunizing a child against the six deadliest diseases costs less than US$ 1.5. There are no excuses. Strategies vary in their effectiveness and in their aim. Some strategies are targeted at eliminating or eradicating diseases where that is feasible. Other strategies are aimed at controlling diseases so that public health is protected. The people in the Region are actively responding, working together to ensure that effective disease control strategies are available, accessible and affordable to all. Gener al str ategies for communicable disease control Communicable disease surveillance Surveillance is an essential tool for communicable disease control. Surveillance is needed for priority-setting, policy decision-making, planning, implementation, evaluation and monitoring of communicable disease. Surveillance is also a tool for prediction, forecasting and early detection of epidemics, where information needs to be rapidly disseminated throughout communities. Effective disease surveillance is still underdeveloped in many countries of our Region. Prioritization is needed. Proper analysis of data is missing at all levels. Reporting and feedback of information is not timely. The data generated are neither properly used nor translated into action. Upgrading and strengthening surveillance is a regional priority. Steps to make national surveillance systems effective are in process. Nine countries have national surveillance guidelines. Only a few countries have laboratorybased sentinel surveillance of specific communicable diseases but 14 countries have taken steps to consolidate laboratory capabilities for
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Response of the people
surveillance. Geographic Information Systems (GIS) technology has been introduced as a surveillance tool in six countries, and investment in human resource development is playing a critical role. As a result, communicable disease surveillance is now fully functioning in seven countries.
Epidemic preparedness and outbreak response To avoid the impact of epidemics, establishment of a functioning early warning system is critical. In addition, countries need to have an epidemic preparedness plan, a sufficient stock of supplies and equipment, and logistical management capability. Currently, the gap between epidemic occurence and response in the Region is too wide. This is mainly due to the inability of health personnel to detect an epidemic, under-reporting of real situations by health authorities for fear of economic loss, lack of political will to invest resources and to enforce policy, and overall lack of intersectoral collaboration. Some countries have taken action. For example, in response to annual disease outbreaks, the National Institutes of Health (NIH) of Pakistan, with WHO support, initiated the Disease Early Warning System (DEWS) in 1997. Fifteen priority diseases were selected for the system, including cholera, viral haemorrhagic fever, dengue, viral hepatitis (including hepatitis A and E), malaria and meningitis. These diseases are monitored weekly using a simple chart and form. DEWS will be expanding to rural, epidemicprone areas of Quetta and Hyderabad. Since 1998, DEWS has been instrumental in controlling over 134 outbreaks. In countries with complex emergencies, the Regional Office initiated the development of task forces for epidemic preparedness for specific diseases. For example, task forces were established for cholera in Afghanistan and Somalia, and for meningitis in Sudan. In south Sudan, the Early Warning and Rapid Response Network (EWARN) was initiated by WHO and UNICEF in 1999. A support response team was established in Lokichoggio, Kenya, with a radio-based reporting system. The support response team was able to detect and rapidly respond to several outbreaks of malaria,
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meningitis and relapsing fever in 1999 and 2000. In addition, a Regional Rapid Epidemic Response System was established at the Regional Office in 1998 in collaboration with NAMRU-3, Egypt, and the Centers for Disease Control and Prevention, USA. The regional system aims to support countries in epidemic investigation and appropriate response.
Infection control and containment of antimicrobial resistance The essential components of infection control include surveillance, legislative national policy, organizational structure and guidelines, monitoring of compliance to infection control, and education and ongoing training of health personnel and the community. Antimicrobial resistance is a complex issue, and requires extensive measures. These measures range from establishment of antimicrobial resistance surveillance, to rational use of antimicrobial drugs by medical professionals. Infection control remains a major problem in the Region. Political commitment along with a strong accreditation system is needed. Issues in the private health sector need careful management and the role of the community needs to be identified. Blood transfusion services need quality control systems to be put in place at all levels in each country. Antimicrobial resistance surveillance is functioning in a limited number of countries. Not all countries have policies and regulations on rational use of antimicrobial drugs, and even when they do, their enforcement is not ensured. In the private health sector, antimicrobial drugs are widely available without any regulation or control, and there is poor compliance with national treatment guidelines. Most countries in the Region do not yet have comprehensive infection control programmes. Measures are currently being taken to initiate programmes in some countries to set a standard for others. Egypt has started a comprehensive programme in two governorates, with the aim of covering the entire country in 6 years. Safe injection practice has been assessed in several countries, and these countries have introduced appropriate measures either partially (through EPI) or fully. Quality
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Response of the people
control to ensure safe blood and blood products is in place in a majority of the countries to prevent transmission of blood-borne pathogens. However, some of the highly populated countries have not yet introduced the appropriate measures for blood safety. There is a clear understanding in the Region of the importance of monitoring, preventing and controlling antimicrobial drug resistance. Countries, with the assistance of the Regional Office, have developed a regional laboratory network to monitor the magnitude and trend of the resistance. Surveys to measure the resistance to anti-tuberculosis and anti-malarial drugs have been conducted in several countries.
Operational research The Regional Office has, in recent years, effectively promoted operational research on tropical diseases (TDR) through the Small Grants Scheme (SGS). Since its inception in 1992, 113 proposals have been funded. The SGS was created in response to the weak research capabilities in the Region. Initially the Arab Fund supported the SGS. Currently, the SGS is jointly supported by WHO headquarters as well as the Regional Office with funds totalling US$ 150 000 annually. For 2000–2001, the Roll Back Malaria Programme also contributed funds to the scheme. Research on the following diseases has been funded: 1992 leishmaniasis; 1993 schistosomiasis; 1994–1995 malaria; 1996 all tropical diseases; 1997 insect-borne diseases; 1998–1999 leishmaniasis, schistosomiasis, malaria; 2000 leishmaniasis, tuberculosis and malaria; and 2001 leishmaniasis, filariasis, tuberculosis and malaria. Inclusion of other communicable diseases in the scheme is now being looked at. Research studies on cost-effectiveness of DOTS have
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been carried out in Egypt and the Syrian Arab Republic, the results of which were influential in obtaining political commitment to provision of tuberculosis drugs free of charge. Studies in Sudan are under way to improve household treatment of malaria as well as to promote community involvement in malaria case management.
Human resources development The Regional Office supports strengthening of research capacity in the countries of the Region through research methodology workshops. In 2001, a research proposal development course was held in Cairo that attracted participants from all 23 countries. A tuberculosis management course was held in 2000, and national training activities on advance preparedness and epidemic management are continuously supported throughout the Region. At least two master trainers from each country, have been trained on the principles of epidemic preparedness, response and management, including resource mobilization. Training courses on rabies for different groups of professionals (health and veterinary) in epidemiological surveillance, application of appropriate diagnostic techniques, and measures for prevention and control of the disease have been invaluable to communities and the health system of many countries. Following the Regional Director’s expression of the urgent need to integrate the surveillance training activities of all the disease control programmes, using funds for training on general and specific disease surveillance in a synchronized way, a training package on communicable disease surveillance, aimed mainly at district health officers, and easily adaptable for local use, was developed. It consists of a 3-day basic surveillance training module and a 3-day specific programme surveillance requirement module. Regional training courses were conducted accordingly on an integrated communicable disease surveillance system.
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Response of the people
Advocacy and health education World AIDS Day, World TB Day and African Malaria Day have all been widely promoted and celebrated throughout the Region. Malaria calendars and bumper stickers, an HIV/AIDS media kit for World AIDS Day under the slogan “Your Move ... Your Choice” and DOTS advocacy documents are just some of the materials that have been produced in both Arabic and English to raise awareness in the Region. Individual web pages have been set up on the Regional Office web site for each of the technical units within the Division of Communicable Disease Control in both Arabic and English and reflect up-to-date countryspecific activities. Since health personnel in any category below university level seldom speak English or French, learning materials and health information sources are needed in Arabic and other national languages. Among the activities of the Regional Office to support this need, 18 UNAIDS documents were translated into Arabic by the AIDS Information Exchange Centre (AIEC) in 2000–2001 in order to keep an up-todate library for all countries to access.
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The role of the community is key to communicable disease control. From filariasis to malaria to HIV/AIDS education, communities throughout our Region are involved in the mobilization of resources and the planning of activities, in particular health promotion through mass media, for creating awareness of TB, HIV/AIDS , and other communicable diseases and their consequences. The role of the community has been indispensable in controlling rabies in animals and preventing human exposure to rabies. Water and sanitation education and management, and health education in schools through peer counselling are carried out with the assistance of community organizations. Many initiatives in the Region have succeeded in involving the community in local development. Healthy cities and villages programmes and primary health care systems in which volunteers play an important role in health care delivery are all illustrations of how community participation can be effective. Nongovernmental organizations are a clear example of how of community participation can be organized.
Va c c i n e p r e v e n ta b l e d i s e a s e s a n d immunization Routine immunization Routine immunization is the most cost-effective health intervention. The Expanded Programme on Immunization (EPI) has a proven track record in communicable disease control. Since 1990 EPI coverage has improved and the incidence of the target diseases has rapidly decreased. However, average regional EPI coverage has stagnated at around 80% in the past several years because of slow progress in six countries. Therefore, supplementary immunization targeting high-risk areas and surveillance are incorporated into routine immunization programmes for disesaes targeted for elimination or eradication (Table 3).
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Response of the people Ta b l e 3 . R e p o r t e d i m m u n i z a t i o n c ov e r a g e o f c h i l d r e n i n t h e i r f i r s t y e a r a n d p r e g n a n t wo m e n i n t h e e a s t e r n mediterr anean region, 2000 Immunization coverage (%) Children under 1 year Country/area BCG Afghanistan Bahrain Cyprus* Djibouti Egypt Iran, Islamic Republic of Iraq Jordan Kuwait Lebanon* Libyan Arab Jamahiriya Morocco Oman Pakistan Palestine Qatar Saudi Arabia Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates Yemen, Republic of UNRWA** Regional average
DPT3
OPV3
Measles
Pregnant women TT2+ HBV3
45 – – 34 96 99 79 – – – 99 97 98 94 94 100 92 39 66 100 95 98 78 100 90
30 97 98 46 96 100 85 94 98 94 95 92 100 74 95 88 94 18 65 97 97 94 72 99 80
32 97 98 46 96 100 86 93 98 94 95 92 100 72 95 88 94 18 65 97 97 94 72 99 97
35 99 86 50 96 100 93 92 99 81 95 90 100 75 94 94 92 26 61 94 96 94 68 99 79
– 97 89 – 96 99 67 91 100 86 95 33 100 – 97 90 93 – – 93 94 92 14 99 80
19 72 – 15 71 46 23 23 ... – 42 90 44 51 24 – ... 16 35 48 86 – 30 ... 51
* Based on previous survey results ** United Nations Relief and Works Agency for Palestine Refugees in the Near East – Not included in national EPI ... Coverage % not calculated due to incomplete reports
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A majority of the countries have shown considerable improvement in routine immunization coverage in recent years. Seventeen countries have achieved national DPT3/OPV3 coverage of 90% or more. Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen account for 47% of the total population of the Region, where routine immunization is lagging. The weakness of EPI programmes in these countries can be attributed to poor accessibility to immunization services (particularly in conflict areas and mobile populations), lack of public awareness and poor quality of immunizations due to inadequate attention to cold chain requirements. Fortunately, these six countries are eligible for support from the Global Alliance Vaccine Initiative (GAVI) and four of them (Afghanistan, Pakistan, Somalia, Yemen) received support in 2001.
Measles elimination In 1997 the Regional Committee for the Eastern Mediterranean adopted the target of measles elimination by 2010. Countries are divided into two groups according to their poliomyelitis eradication status and epidemiological context. Group one consists of 15 countries aiming at measles elimination. These countries have achieved more than 80% immunization coverage and have adopted a two-dose routine vaccination strategy. Some of these countries conducted catch-up campaigns and have successfully reduced the measles incidence to a low level that suggests interruption of indigenous transmission of the virus. Group two consists of eight countries whose aim is measles control. In some of these countries, nationwide measles immunization campaigns were conducted. However, measles immunization coverage rates are still less than 80% in six countries. For example, Afghanistan and Somalia have less than 40% measles coverage.
Neonatal tetanus in Egypt As a result of successful implementation of the high-risk approach, the incidence of neonatal tetanus in Egypt fell from 3275 in 1990 to 321 in 2000. A total of 118 campaigns were conducted from 1994 to 2000. Active surveillance was introduced in highrisk districts. The disease is now confined to three districts only.
Neonatal tetanus elimination The regional target is to achieve neonatal tetanus elimination by 2005, defined as an incidence of neonatal tetanus of less than 1 case per 1000
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Response of the people live births in each administrative district of a country. 15 countries have already achieved this target, and the focus is on the remaining eight countries: Afghanistan, Djibouti, Egypt, Iraq, Pakistan, Somalia, Sudan and Yemen, which have finalized national elimination action plans, and obtained the necessary resources to move forward. Strategies include a high-risk approach with supplementary immunization of at least 90% of all women of child-bearing age with three properly spaced doses of tetanus toxoid, and routine vaccination for pregnant women. Egypt and Iraq have successfully implemented the high-risk approach and are expected to achieve the target soon. The other six countries are currently implementing the high-risk approach. For example, in Yemen, 27 districts were selected to vaccinate 617 000 women of child-bearing age in 2000. In Sudan, 177 345 women of child-bearing age were vaccinated in 16 districts covering four States. Further efforts are needed in these six countries since their routine vaccination coverage with tetanus toxoid is still low: Afghanistan 20%, Djibouti 15%, Somalia 16%, Sudan 35% and Yemen 30%.
Emergency stock for meningitis epidemics The Regional Office participates actively in the International Coordinating Group to control epidemic meningitis. This includes mobilization and resource allocation to ensure the availability of the global emergency stock of meningococcal vaccine, oily chloramphenicol and auto-disable syringes. The activities of the Regional Office and the International Coordinating Group were instrumental in controlling the meningitis epidemic in Sudan in 1999–2000.
Hepatitis B Eighteen countries have fully integrated hepatitis B vaccination for children under 1 year of age into their national immunization programmes. These 18 countries account for 57% of the total infant population of the Region. Fourteen countries even reported coverage rates of 90% or more. Of the remaining five countries (Afghanistan, Djibouti, Pakistan, Somalia and Sudan), Pakistan has started vaccination on a small scale. Pakistan and Yemen have both received GAVI support for the introduction of hepatitis B vaccination.
Haemophilus influenzae type b (Hib) With respect to immunization against Haemophilus influenzae type b (Hib) disease, only four countries (Bahrain, Cyprus, Kuwait and Qatar) have introduced the vaccine into their routine immunization programmes. In order to encourage the remaining countries to introduce this vaccine, the Regional Office implemented activities demonstrating the costeffectiveness as well as documenting the impact of using the Hib conjugate
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vaccine. During 2000, technical assistance using the rapid assessment tool, to Egypt, Islamic Republic of Iran, Oman and Yemen resulted in the decision of the Ministries of Health in Oman and Yemen to introduce the Hib conjugate vaccine into their routine EPI. In addition, technical and financial support was provided to Tunisia in order to assess the disease burden. Next on the horizon for countries in the Region is the pneumococcal conjugate vaccine, through the local EPI.
Community participation in Jordan The Jordanian Anti-Tuberculosis Association (JATA) is a strong supporter of tuperculosis patients in the countr y. JATA , in collaboration with the national tuberculosis programme, provides financial support to all tuberculosis patients: each patient receives the equivalent of US$ 30 every month during the treatment period. This has contributed to the national tuberculosis programme’s high treatment success rate.
Tuberculosis The global targets for tuberculosis control are to detect 70% of existing cases and successfully treat 85% of them by 2005. Directly observed treatment, short-course (DOTS) is the most cost-effective strategy for tuberculosis control, and has been implemented in the Region since 1995. Expansion of DOTS to achieve nationwide coverage (DOTS ALL OVER) in the Region has shown significant progress. By 2000, 18 countries had achieved DOTS ALL OVER. Among the remaining five countries, Sudan and Yemen are achieving high DOTS coverage, 81% and 97% respectively, and are expected to achieve DOTS ALL OVER in 2002. Somalia has achieved 70% DOTS coverage despite continuous complex emergencies, with a treatment success rate of 85%. Afghanistan is lagging in DOTS expansion due to the long-standing complex emergency situation there. Pakistan also lags in DOTS expansion due to delays in initiating activities and the extremely high burden of tuberculosis. Innovative approaches through operational research are being made throughout the Region. A private–public mix approach is being tried in several countries. For example, Egypt has started receiving tuberculosis notifications from the private health sector, prison health services, universities and the Health Insurance Organization. Collaboration with medical schools
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Response of the people has started at the regional level with the aim of including DOTS in medical education.
Political commitment in the Syrian Arab Republic Anti-tuberculosis drugs used to be widely sold in private pharmacies in the Syrian Arab Repulic, sometimes even without prescription. After long dialogue with the private sector, the Minister of Health decided in 1998 to ban the sale of anti-tuberculosis drugs in private pharmacies. Antituberculosis drugs are now under the full control of the national tuberculosis programme.
The Region still faces challenges in tuberculosis control. First, the regional case detection rate is low at 30%, although the treatment success rate is around 80%. Second, the comprehensiveness of the DOTS approach calls for the involvement of all health care providers. Key health care providers, particularly the private health sector, are not fully involved in DOTS. In many countries, even the government health sector other than ministries of health, is not fully involved in DOTS activities. Third, DOTS is lagging in the countries with the highest tuberculosis burden, particularly Pakistan and Afghanistan. These two countries account for 43% and 12% of the regional burden, respectively, and both have only 15% DOTS coverage (Figure 7).
100% 50–99% 10–49% 1–10% 0%
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F i g u r e 7. D OT S c ov e r a g e ( a s o f e n d 2 0 0 1 )
Malaria The Roll Back Malaria (RBM) programme was launched in the Region in 1999. The global target of RBM is to reduce the malaria burden by 50% by 2010. Countries in the Region can be classified into four groups, according to the gravity of the malaria challenges they face. These groups are: Countries that have achieved interruption of malaria transmission (group 1) Countries where malaria is firmly under control, which are targeting eradication (group 2) Countries with moderate endemicity and relatively well established control programmes (group 3) Countries with severe malaria problems and or threatened by epidemics and complex situations (group 4) There are nine countries in group 1, representing 7% of the population in the Region, that have achieved interruption of malaria transmission. The aims for this group are to ensure early detection and prompt treatment of all malaria cases, and prevent re-establishment of malaria transmission. All the countries in group 1 have been successful in maintaining their malaria-free status, except Lebanon in 1998–1999 and Libyan Arab Jamahiriya in 1999–2000. Countries in group 2 are aiming at elimination of malaria transmission through a strong time-limited intervention to prevent reintroduction of malaria in malaria-free areas. By 2000, the United Arab Emirates had succeeded in interrupting malaria transmission and Morocco is on its way to eliminating malaria with no cases reported in 2001. Egypt, Oman and the Syrian Arab Republic have developed strategic plans to eliminate malaria in the near future.
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Response of the people For countries in group 3 the objective is to decrease the malaria burden so that it is no longer a public health problem. By 2000, three of the four countries with low/moderate endemicity (Islamic Republic of Iran, Iraq and Saudi Arabia), had significantly reduced the number of cases occurring. In 1991, in the wake of the Gulf War, a major malaria epidemic occurred in Iraq affecting 100 000 people. With the assistance of WHO, Iraq was able to contain this epidemic through intensive indoor residual spraying as the main intervention. Thereafter, malaria cases reached 98 705 in 1995. By 2000, the annual number of cases was reduced to 3212, despite many obstacles including economic deterioration and international sanctions. Pakistan has been facing problems in decreasing the malaria burden. It is anticipated that in 2002 Pakistan will strengthen the capacity of the malaria programme, particularly in high burden provinces. Group 4 comprises only four countries, but accounts for 95% of the malaria burden in the Region. The main strategic approaches include: early detection and adequate management of cases; intermittent presumptive antimalarial treatment for pregnant women; prediction, early detection and prompt control of epidemics; use of insecticide-treated mosquito nets and other integrated vector control measures. In 2000, Sudan, with WHO support, launched the malaria-free initiative in Khartoum and Gezira States with the aim of stopping transmission. In Yemen, two intensive antimalaria programmes were successfully implemented in Socotra Island resulting in a decline in school absenteeism and morbidity from malaria infections. RBM will continue to play a leading role in formulating strategy, setting standards and engaging in political and financial advocacy. The malaria situation in the Region has a noticeable impact on neighbouring regions, such as the African and European Regions, and vice versa. This calls for a greater consideration of malaria problems from a wider perspective and organization of joint activities.
Epidemic preparedness in Iraq In 1995, Iraq had an epidemic of malaria, affecting 98 705 people. The Ministry of Health, in collaboration with WHO, took large-scale control measures, including indoor residual spraying. Even under the extremely difficult economic conditions, the epidemic preparedness measures worked effectively. The malaria incidence was reduced to 3212 cases in 2000.
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H I V / A I D S a n d s e x u a l ly transmitted diseases Since the beginning of the AIDS epidemic, 20 years ago, the Regional Office has been at the forefront of HIV prevention and control in the Region, working very closely with all Member States. As a result, the Region has experienced an increase in political and religious awareness of the problem as well as in commitment to end it. National capacity in AIDS has grown steadily, and great achievements have been made in setting and maintaining safe blood transfusion strategies, in health education interventions, and in mobilization of civil society and, to a lesser extent, non-health sectors. STD syndromic care approaches have been successfully adopted in a number of countries. However, even with this early response, there has been no tangible success in halting the unfolding HIV epidemic in the Region. There is a pressing need to recognize the new threats from HIV in this Region and to renew the commitment for action. AIDS remains a major public health problem and warrants a more effective public health response. The changing scale and nature of the epidemic in the Region calls for immediate and decisive action in order to foster a health sector response that measures up to the present challenges and those still ahead. The Regional Office took up this challenge in 2001 and assisted countries in developing a strategic vision for the improvement of the health sector response, to be implemented up to 2005. This strategic plan outlines those priorities central to increasing the national health system capacity for better preparedness and management of the epidemic. It tries to tackle issues related to the insufficient political and social support for HIV/AIDS/STD programmes, poorly designed decentralization, integration and referral, as well as lack of reliable and sufficient information about HIV/AIDS. The plan also tries to address the issues of limited funding, and access to and coverage of prevention and care services.
AIDS telephone hotline in Egypt The AIDS hotline and counselling service was launched in 1996. The objective of the project is to provide accurate information about HIV/AIDS to the general public, including young people, and to provide confidential and anonymous HIV/AIDS counselling services. The numbers of calls to the hotline surpassed all expectations; around 1000 calls take place per month. Most of the callers are young people, between 15 and 25 years of age. The hotline has given users the opportunity to discuss sensitive issues which are rarely addressed in public forums.
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Response of the people
E m e rg i n g i n f e c t i o n s a n d e p i d e m i c - p ro n e diseases Meningococcal disease The Regional Office supports the various task forces for epidemic management in the Region. WHO is represented in the task force for epidemic meningitis control in Sudan and the task forces for outbreak response in Afghanistan and Somalia. WHO and its partners respond immediately to outbreaks by providing expert advice to the governments in disease confirmation, field investigation and implementation of control measures to contain the spread of the disease, advising on case management, disseminating health education messages, providing supplies for epidemic control and putting in place measures to protect high-risk groups. Meningitis vaccine, oily chloramphenicol for management, auto-disable syringes and incineration boxes are provided by the Regional Office and the international coordinating group. In order to contain the epidemic of meningococcal meningitis that occurred in Sudan in 1999–2000, 15 million doses of meningococcal meningitis AC vaccine were used in 1999 and 3.6 million doses in 2000 for mass vaccination of those aged 2–29 years. This strategy of mass vaccination coverage in areas of high population density resulted in preventing the occurrence of another epidemic in Sudan in 2001, despite its occurrence in several neighbouring countries. A regional surveillance system was introduced to monitor the situation monthly in all the countries. Laboratory capacity has been strengthened in recent years, particularly in those countries more prone to epidemics. There is a regional contingency plan to ensure rapid response to epidemics occurring in the Region, and the Regional Office has a stockpile of 40 000 doses of oily chloramphenicol and 1.6 million doses of the vaccine available for rapid shipment to any part in the Region, with a proper cold chain established.
Innovative epidemic management systems Even under difficult situations, epidemics can be managed effectively. The Early Warning and Rapid Response Network (EWARN) in the southern part of Sudan facilitated the detection of and response to outbreaks of malaria, relapsing fever and meningococcal meningitis in 1999 and 2000. In Pakistan, the Disease Early Warning System (DEWS) has been instrumental in controlling 134 outbreaks since 1998.
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Each year Saudi Arabia issues a health bulletin with vaccination requirements for the Hajj in order to prevent outbreaks of meningococcal meningitis and this has largely led to containment of outbreaks since 1987. Following the 1987–1988 epidemic, vaccination of high-risk groups against meningococcal disease is being implemented by several countries (e.g. Egypt, Islamic Republic of Iran, Lebanon, Saudi Arabia and Syrian Arab Republic). These groups include children at 2 years of age or school entry, military recruits, travellers to high-risk areas and household contacts of meningococcal meningitis cases. However, no study has yet been done to elucidate the impact of such a measure.
Malaria in Morocco Morocco is on the road to eliminating malaria, a strategy having been initiated in 1997. The Ministry of Health, in collaboration with other ministries (Agriculture, Interior, Civil Engineering) and travel agencies, has strengthened malaria control activities, such as surveillance and vector control. Malaria incidence fell from 781 cases in 1990 to zero local cases in 2001.
Cholera/epidemic diarrhoea Prevention of cholera is very difficult in some countries (Afganistan, Djibouti, Somalia and Sudan) therefore, the main efforts have been directed towards mitigating the outbreaks and lowering the case fatality rate through proper epidemic preparedness, epidemic management and establishment of cholera task forces. Proper case management, through establishing cholera treatment centres, and making oral rehydration solutions and intravenous fluids widely available, has largely contributed to lowering the CFR, from more than 10% to around 3% in the 3 years since the introduction of the containment measures in Afganistan and Somalia. The work of the task forces has also focused on chlorination of wells, provision of safe water supply and public health education.
Viral hepatitis A, C and E No specific measures have been taken for the prevention of HAV and HEV infection in the Region as these measures would be mainly focused on environmental sanitation, safe water supply and personal hygiene. The HAV vaccine has not been introduced on a wide scale in the Region as it is relatively expensive and the epidemiological situation is not considered to require it. Several specific measures have been taken for the prevention of HCV, most of which related to blood safety and safe injection practice and were taken either separately or as part of an infection control programme.
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Response of the people
Viral haemorrhagic fevers The main strategies to control outbreaks of VHF are early detection and proper diagnosis, protection of health care workers dealing with cases, isolation of cases and proper case management, vector control, vaccination when available, and health education of contacts and the community at large. The Regional Office plays a critical role in increasing the awareness of VHF among health workers. Guidelines have been developed on how to prevent and treat cases, and links provided with international laboratories for rapid confirmation. Vector control measures are initiated in countries where needed. In recent years case management has improved, lowered the CFR and prevented nosocomial outbreaks, which were the main issues facing the countries. Nosocomial outbreaks of CCHF were prevented in Afghanistan, Iraq and Pakistan in 2000 and 2001. The control of Rift Valley fever relates to many sectors, such as public health, veterinary, laboratory and environment. Collaboration and coordination of activities and sharing information on disease transmission between all the concerned ministries and agencies is crucial to maximize use of available resources and to avoid duplication of efforts. At the same time, cross-border collaboration between concerned countries is important to ensure coordination of surveillance, prevention and control activities and exchange of all available information on occurrence of the disease among humans and animals. When Rift Valley fever affected Saudi Arabia and Yemen in 2000, such intersectoral and cross-border collaboration took place effectively, and the epidemic was contained without delays.
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Zoonoses Brucellosis The main efforts in the countries have been directed towards improving diagnosis of human brucellosis and identifying the epidemiological situation through seroepidemiological surveys. The results of such studies conducted in Egypt, Jordan, Lebanon, Oman, Saudi Arabia and Sudan showed that brucellosis is a public health problem in those countries. Links with the veterinary sector have been crucial in controlling the animal population.
Brucellosis in Palestine Intersectoral collaboration between the Ministry of Health and Ministry of Agriculture, and partnership with the Government of Greece, UNDP and WHO, significantly reduced the number of human brucellosis cases in Palestine, from 29 per 100 000 in 1990 to 10 per 100 000 in 2000. The brucellosis control programme is in its final stage of accomplishment.
Rabies The dog population is the most dangerous reservoir of rabies infection. Control measures, such as removal of stray dogs, strychnine poisoning and canine population control through shooting, have not been efficient in the majority of countries. However, mass vaccination of dogs has led to a sustainable reduction of rabies transmission among dogs in some countries, like Morocco and Tunisia. Mass vaccination of dogs was successfully implemented in Bahrain, Kuwait, Morocco, Qatar, Saudi Arabia and Tunisia, however, in other countries the vaccination coverage of dogs is low. Unfortunately, the number of stray dogs is increasing and the measures to control them have dissolved in most of the urban areas, particularly the growing slum areas. Most countries have now switched to using the human diploid cell vaccines. The annual number of imported doses of vaccines is around 500 000. The human rabies vaccine, of neural tissue origin, is produced locally in Egypt, Pakistan, S u d a n a n d Tu n i s i a . H u m a n immunoglobulin is used in some countries but the majority of the countries continue to use the equine immunglobulin.
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Response of the people
With evidence of rabies among wild and domestic animals, notification of animal bites in humans was made mandatory in Oman within 24 hours of the person reporting to any health facility. During the period from 1992 to 1997 as many as 25 000 doses of anti-rabies vaccine (human diploid cell vaccine) were used in Oman in addition to human rabies immunoglobulin. The cost of both biological preparations was about US$ 125 000. The total cost of health care, cost of diagnostic support services, salary of personnel involved in the care services and cost of other incidentals was calculated as US$ 250 000. During this period only three human deaths occurred due to rabies. The example of Oman demonstrates the high cost paid by national programmes for prevention of human rabies.
Leishmaniasis For anthroponotic cutaneous leishmaniasis the main strategy is vector control, along with early detection and treatment of cases. Unfortunately, most countries have not succeeded in controlling this type of leishmaniasis through an integrated vector control approach. For zoonotic cutaneous leishmaniasis, Jordan, Syrian Arab Republic and Tunisia have been successful in their rodent control strategies. Measures are being taken to improve the capacity in diagnosis using the direct agglutination test (DAT). The use of insecticide-impregnated bednets along with better case management has led to a decrease in mortality in the most affected countries, such as Sudan, compared with the situation 5 years ago. An integrated approach to control of visceral leishmaniasis in full cooperation with the malaria control and HIV control programmes is being developed in Sudan.
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Pa r a s i t i c a n d t r o p i c a l d i s e a s e s Schistosomiasis The most critical approach in the control of schistosomiasis is that of single dose treatment with praziquantel, particularly at sentinel sites of schoolchildren. Access to safe water and sanitation and improved hygiene are other main preventive measures. Sustainable control efforts in several formerly heavy burden countries have resulted in a significant reduction in morbidity and mortality. In Egypt, for example, from 1988 the Ministry of Health and Population made praziquantel available free of charge to all patients diagnosed with schistosomiasis. Since 1997, more than 22 million doses of praziquantel have been dispensed through mass chemotherapy campaigns in selected governorates. As a result, the prevalence of S. haematobium in Upper Egypt decreased from 5.7% in 1995 to 2.9% in 1999, and the prevalence of S. mansoni in Lower Egypt decreased from 14.5% in 1995 to 3.3% in 1999. In Morocco, the annual incidence was reduced from 6.8% in 1990 to 0.8% in 1999. In Saudi Arabia, the overall prevalence of schistosomiasis fell from 11% in 1983 to less than 1% since 1990. In the Syrian Arab Republic, the number of schistosomiasis cases decreased from 194 in 1995 to 4 cases in 1999. Unfortunately, this success in schistosomiasis control has not been seen in Somalia, Sudan and Yemen where the situation has in fact deteriorated. Accordingly, there is a plan to rehabilitate the programmes in these three countries.
Integrated interventions for schistosomiasis control Schistosomiasis interventions include passive and active case-finding, treatment, health education, vector control and provision of safe water supplies to human settlements. Integrated interventions have been instrumental in significantly reducing the incidence in many countries, such as Egypt, Morocco, Saudi Arabia and Syrian Arab Republic, and stopping transmission in the Islamic Republic of Iran, Jordan, Oman and Tunisia.
Lymphatic filariasis The target to eliminate lymphatic filariasis from the Region is 2010. The basic strategy for elimination is community-wide treatment of the population in endemic areas (prevalence of infection above 1%) using single dose combination of two drugs (DEC and albendazole) for 4–6 years. Egypt was one of the first countries to adopt the lymphatic filariasis elimination strategy. Mass drug administration campaigns began in 2000, after a preparatory phase of capacity-building and social mobilization. In 2000, 2 million people received treatment with 96% compliance, and the
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Response of the people following year 2.1 million received a second-year dose with a compliance rate of 98%. Yemen will launch its mass treatment campaign in 2002.
Partnership in Egypt The national tuberculosis programme established a national tuberculosis board representing all partners. Pilot projects with general practitioners and private laboratories started in 2000. Good collaboration has been established with the Health Insurance Organization, prison health services and universities. Egypt is one of the few countries in the world that receives case notifications from the private health sector as well as from the Health Insurance Organization, prison health services and universities.
Dracunculiasis Eradication of dracunculiasis requires maintaining surveillance to identify cases and villages where dracunculiasis is endemic, rapidly implementing control measures, and a peaceful and stable environment. In 1997, Pakistan received a dracunculiasis eradication certification. Yemen is also on the road to eradication. However, Sudan is the only country in the Region with endemic foci. The main constraint is the insecurity of the highly endemic areas of the southern part of the country. Efforts are mounting for sustained national commitment with multisectoral governmental support, ensured access to people living in endemic areas in the southern states of Sudan, and international partners to assist in providing human and financial resources.
Leprosy The target is to eliminate leprosy as a public health problem at sub-national level by 2005. The number of registered leprosy cases has significantly decreased during the past few years from 14 209 cases in 1995 to 8924 in 2000. Accordingly, the regional prevalence of leprosy per 10 000 population decreased from 0.33 in 1995 to 0.2 in 2000. All the countries have achieved the elimination target of prevalence less than 1 case per 10 000 population at the national level. Coverage with multidrug therapy (MDT) increased from 93.7% in 1995 to 99.2% in 2000. A total of more than 65 000 leprosy patients have completed MDT treatment since its introduction in 1983. The compliance to MDT treatment has improved due to availability of free MDT drugs in blister packs and better organization of defaulter tracing activities.
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ra hh e ep p ee oo pp le RC eo su po ng se e o off t t le
ra hh e ep p ee oo pp le RC eo su po ng se e o off t t le
“There are no incurable diseases—only the lack of desire” (Ibn Sina, 980–1037 AD) The people of the Eastern Mediterranean express their courage using innovative steps to move beyond the ordinary responses. All countries of the Region apply control measures through different degrees of integration within the primary health care system. In recent years disease-specific control programmes have applied high quality intervention strategies, expanded their service coverage and made comprehensive links with partners. This has resulted in successes in several areas ranging from eradication or elimination of specific diseases to initiation of pilot activities that the community can then build on. Each success story is inspiring and educational, and gives credibility to health systems, which invites more success. All together are instrumental in understanding important areas for effective communicable disease control.
Success stories in 10 major areas of communicable disease control Action-oriented political commitment Strong technical and managerial leadership Well-functioning organizational structure Effective partnership within the health sector Effective intersectoral collaboration Focused operational research activities Active participation of the community Early preparedness and rapid response Effective advocacy activities
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Close link with global initiatives
Political commitment
A mass treatment campaign for lymphatic filariasis takes place in 2 weeks, treating 2.5 million people living in 178 villages in Egypt Filariasis is an ancient disease, and has a long history in Egypt dating back to antiquity. Egypt was one of the first endemic countries to commit itself to eliminating lymphatic filariasis as a public health problem. In 1997 the Ministry of Health and Population took the lead in developing an elimination plan in concert with many sectors outside of health. The plan was funded by the Ministry and international partners starting in 1999. The Ministry translated its commitment into key activities. Decision-makers, such as governors, and religious and community leaders of the target areas, were brought together. 1200 nurses and 1200 doctors were trained in endemic areas. Extensive social mobilization activities took place to inform communities about the importance of mass treatment campaigns. In the first campaign in 2000, a compliance rate of 96% was achieved. The following year the compliance rate increased to 98%. Egypt aims to eliminate lymphatic filariasis by 2004, much earlier than the regional target of 2010.
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ra hh e ep p ee oo pp le RC eo su po ng se e o off t t le
Leadership
Iraq achieves DOTS ALL OVER despite difficult economic conditions
Economic difficulties seriously affected the tuberculosis situation and control activities in Iraq. Incidence more than doubled in 5 years: from 13 527 cases in 1991 to 29 196 in 1996. At the same time, the national tuberculosis programme was short of funds, drugs and laboratory supplies. The national tuberculosis programme manager took the risk of challenging the extremely difficult situation. He led his team at central and provincial levels in preparing for DOTS pilot activities: training of health personnel, field visits to the pilot area and development of DOTS guidelines. In April 1998, with support from an international partner and WHO, a DOTS pilot activity started. The pilot activity was a success, achieving more than 85% cure rate. The programme expanded its DOTS activities when a sufficient quantity of drugs was made available in 1999. In October 2000, the programme achieved DOTS ALL OVER in Iraq.
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Organizational structure
Pakistan is the first among the 19 endemic countries in the world to achieve eradication of dracunculiasis (guinea-worm disease)
Pakistan received its dracunculiasis eradication certificate in 1997. This was a significant achievement because, of the 19 countries that jointly began the global eradication campaign in the early 1980s, only five achieved eradication by 2000. The key factor behind the eradication was the well functioning organizational structure of the programme at national, provincial, district and community levels, which enabled comprehensive strategies to be translated into action in the field. Activities included strict implementation of a containment policy, application of larvicide, provision of safe water supplies to endemic villages and introduction of a cash reward system for reporting of cases. This reward system for case reporting was widely advocated through radio and newspapers and by health workers using megaphones in the high-risk areas, and proved very effective. Rumour registers were kept in the endemic areas. No cases have been reported since 1997.
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ra hh e ep p ee oo pp le RC eo su po ng se e o off t t le
Pa rt n e r s h i p w i t h i n t h e h e a l t h sector
Effective partnership in Somalia makes DOTS successful: 88% treatment success rate despite the complex emergency situation
Tuberculosis control in Somalia, despite operating in a situation of complex emergency with a seriously damaged health system, is fully functioning. WHO has coordinated an effective network of nongovernmental organizations (NGOs) and local health authorities. In 1993, all NGOs working in Somalia adopted DOTS as the tuberculosis control strategy and they are implementing DOTS strictly, providing daily supervised treatment for 6 months to each patient, and submitting regular reports to WHO. WHO provides them with tuberculosis drugs and laboratory supplies for proper management. An advocacy video was made to disseminate their success story globally.
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Intersector al collabor ation
Collaboration with partners in the Republic of Yemen reduces incidence of malaria in Socotra Island by 90% in 1 year Socotra Island is situated in the Indian Ocean off the southern coast of Yemen and is known as an island affected by malaria. Until 1999 there was no malaria control programme in place and no measures were being taken to control the disease there. In mid 2000, the national and local authorities, with 3000 advice from WHO, developed a sectorwide collaboration with the health, 2500 agriculture and environment sectors 2000 and initiated an innovative pilot project to eliminate malaria from the island by 1500 2005. All partners are working together 1000 on the project. Within 1 year, the incidence of malaria fell to one-tenth, 500 from 2595 cases (August 1999–July 0 2000) to 265 cases (August 2000–July August 1999–July 2000 August 2000–July 2001 2001). The pilot project in Socotra Island is setting a standard for other Fi g u r e 8 . L a b o r a to ry c o n f i r m e d malaria control activities, and indicates malaria cases in socotr a island that dramatic reductions in malaria before and 1 year after the project for malaria incidence can be achieved and that eradication started in August/September 2000 elimination is possible in certain situations (Figure 8).
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O p e r a t i o n a l r e s e a rc h
Small Grants Scheme supports countries in finding innovative approaches to controlling communicable diseases Operational research is a priority at the Regional Office for the Eastern Mediterranean. The Small Grants Scheme (SGS) was created in 1992 to support operational research projects in specific target diseases in the Region. Since then SGS has expanded its support to include other communicable diseases and the annual funds have been increased from US$ 150 000 to US$ 300 000. SGS has been instrumental in promoting innovative operational research. A good example is the development of the direct agglutination test (DAT) to diagnose visceral leishmaniasis. DAT was invented in Sudan in the mid 1980s; with SGS support, DAT was modified and improved and is now the most reliable test for diagnosis of visceral leishmaniasis. The test can be applied in any field conditions and is rapid, cheap and highly sensitive (98%). DAT is now widely used in other countries affected with visceral leishmaniasis, including Islamic Republic of Iran, Morocco, Sudan, Syrian Arab Republic and Tunisia.
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C o m m u n i t y p a rt i c i p a t i o n
Measles elimination proves possible in the Republic of Yemen through community mobilization
Routine immunization coverage increased in Yemen from 46% in 1997 to 72% in 2000. Communities throughout Yemen participated in a nationwide measles immunization campaign in 2001. During this campaign 2 194 921 children (9 months to 5 years of age) received the measles vaccine regardless of their previous immunization status. A high level of planning, organization and supervision, as well as a strong and multivaried social mobilization campaign resulted in 94% coverage, showing the importance of all involved. Measles surveillance was also improved recently and was integrated with the acute flaccid paralysis surveillance system.
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Preparedness and response
The first epidemic of Rift Valley fever outside Africa, in Saudi Arabia and the Republic of Yemen, is successfully contained
Rift Valley fever has long been known as a disease associated only with the African continent. In September 2000, the first reported epidemic outside the African continent occurred simultaneously in Saudi Arabia and Yemen. This historic epidemic was contained smoothly through emergency preparedness and rapid response. WHO, in collaboration with NAMRU-3 Egypt, dispatched a mission immediately the epidemic was first reported. The national authorities worked very closely with the mission and provided all the support necessary throughout the relevant sectors, such as health and agriculture. Moreover, the two countries worked together effectively through cross-border collaboration, coordinating activities on surveillance, prevention and control, and sharing available information on disease occurrence among humans and animals.
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Ad vo c a c y Mass media campaigns prove a highly useful tool for advocacy and social mobilization on AIDS throughout the Region HIV is a disease that is closely related to human behaviour and tightly linked to cultural and religious factors. Because of its special nature, it is not always as apparent as other communicable diseases. These characteristics made raising awareness an important strategy for its prevention. The activities that take place in the Region around the 1st of December each year to celebrate World AIDS Day are good examples of advocacy and awareness-raising. They usually make use of multiple channels and methodologies, involve several community sectors and target various population groups in different countries. These activities form suitable opportunities to confirm national commitment and to show visible aspects of community mobilization and involvement against AIDS. Common country-level advocacy activities include printed materials, official events and intense media coverage. On World AIDS Day 2000, the activities involved NGOs in Lebanon, targeted youth and young people in Egypt, the Syrian Arab Republic and Tunisia, and addressed the general public in Jordan, Oman, Pakistan and Sudan. The Regional Office gives a lot of attention to advocacy and public information regarding HIV/AIDS. For this reason it established a specialized centre for this purpose, the AIDS Information Exchange Centre or AIEC, which is the only one of its kind in the Region. The AIEC disseminates HIV/AIDS information and supports advocacy and education activities in the countries. It also carries out an information exchange process by exchanging country publications and materials between Member States, as well as by posting them on its web page. The web page users can also send in questions, and replies are returned by e-mail.
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Link with global initiatives Links with GAVI facilitate activities in childhood immunization in four out of six eligible countries GAVI (Global Alliance for Vaccines and Immunization) is a global initiative to assist countries to provide childhood immunizations. The six countries in the Region that are lagging behind in immunization coverage are eligible for GAVI support. These countries (Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen) have prepared, with assistance from WHO, the documentation needed for completing GAVI applications. GAVI has already approved its support for immunization coverage in Afghanistan, Pakistan, Sudan and Yemen. In addition, Pakistan and Yemen also got approval for GAVI support for the introduction of hepatitis B and, hib and hepatitis B vaccine respectively.
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Futur e for the people
The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the full cooperation of individuals and States. (WHO Constitution)(UNICEF/WHO, 2001) The people are showing their courage by taking responsibility and accountability for applying communicable disease control measures in effective and equitable ways. Dracunculiasis has been eradicated in all but one country. Leprosy has been eliminated as a public health problem. Neonatal tetanus has been eliminated in 15 countries. Malaria has been eliminated in 10 countries. DOTS ALL OVER is available in 20 out of 23 countries in the Region, and is succeeding even in complex emergency situations. The first incidence of Rift Valley fever outside Africa was successfully contained. Heads of State have openly addressed the HIV/AIDS problem for the first time in public. However, past achievements, and failures, in disease control must not be an obstacle to continual improvement in the perceptual, political and financial will needed for sustaining the health and well-being of the people today and tomorrow. Conventional, disease-specific activities should be SCALED UP, since currently these activities are not universally available. Diseasespecific control activities need to be carried out with the same intensity as surveillance, epidemic management and infection control activities. These general activities need to be STRENGTHENED and should be linked with other disease-specific activities. All too often though, dialogue,
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planning and management of different activities are separate. A SYNERGY of all activities is needed.
Integr ated approach in communicable disease control Our integrated approach is a practical vision that is comprehensive in its communicable disease control activities in order to reduce significantly the disease burden. Integrated disease control is the merging of resources, services and interventions. An integrated approach involves all the various levels, as well as different sectors, to improve health outcome. This approach is applicable even if the diseases are dissimilar, since there are common aspects of disease control, such as surveillance systems; training and continuing education; drug distribution and monitoring of drug resistance systems; diagnosis, treatment and patient-referral systems; and infection control systems.
Scaling-up disease-specific control activities Routine immunization should achieve higher coverage rates, close to 100%. DOTS made available to all populations in the Region, and it must be of high quality. RBM strategies should reach all areas where malaria is present. All disease-specific programmes should attain their global and regional targets on time. Scaling-up requires stronger political commitment, stronger control programmes capable of conducting the activities in a timely and efficient manner, and better use of available human and other resources at country level. It may also involve coordinating and attaining support from the international community . Scaling-up needs to be financially feasible. Global initiatives, such as GAVI, Global Fund for AIDS, Stop TB and Roll Back Malaria are critical partnerships that countries should make good use of in order to achieve reductions in specific
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Futur e for the pe eo p l e e diseases. An Inter-Agency Coordination Committee on Communicable Disease Control would be a possible mechanism for broadening support for all communicable disease activities. Scaling-up does not mean creating more or bigger programmes, but consists rather of re-grouping existing communicable disease programmes so that they are more streamlined and comprehensive. Pooling of resources to achieve a broad spectrum of objectives will be possible for certain groups of diseases, such as vector-borne diseases (e.g. malaria, leishmaniasis, filariasis, Rift Valley fever), EPI targeted diseases, tuberculosis and HIV/AIDS, and tuberculosis and leprosy.
Strengthening general control activities Several activities in communicable disease control cut across diseasespecific control programmes. Strengthening involves facilitating the expansion of such activities according to local priorities, the epidemiological context and existing control activities. These general cross-cutting activities should be compatible with the organizational structure of disease control within ministries of health. The five cross-cutting activities and their key responsibilities are illustrated in table 4. All these activities are conducted in collaboration and coordination with the disease-specific units.
Synergy of the managerial process
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The Scaleing-up of disease-specific programmes and strengthening of cross-cutting activities should be carried out efficiently, through a synergy
Ta b l e 4 . S t r e n g t h e n i n g g e n e r a l a c t i v i t i e s General Crosscutting Activities Key Responsibilities
Surveillance forecasting and epidemic management
Establish integrated communicable disease surveillance to monitor the epidemiological situation and control activities Coordinate and facilitate management of epidemics/ outbreaks with disease-specific programmes. Introduce comprehensive measures on infection control, particularly at health care setting Coordinate and facilitate containment of antimicrobial resistance with disease specific programmes and other programmes such as laboratory, and essential drug programmes. Coordinate and conduct structured training on principles on communicable disease control and epidemiology. Facilitate operational research activities to address key issues in communicable disease control through expansion of the Small Grants Scheme. Coordinate and conduct advocacy activities for communicable disease control at large, and for specific diseases.
Infection control and containment of antimicrobial resistance
Capacity building Operational research
Advicacy
of the managerial process: planning, budgeting, implementing, monitoring and evaluation. It is essential to coordinate all activities in communicable disease control under one leadership that provides objective guidance and assumes accountability. Under the leadership, all disease-specific programmes and general control activities will develop, in a concerted and agreed upon manner, one communicable disease control Plan for every fiscal year. In time, this Plan will be translated into a mid-term (3-5 years) strategic plan. Synergy should also take place in the implementation of activities as much as possible. Synergy should also be extended to link with other activities in the Ministry of Health (intrasectoral collaboration) and other sectors
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Futur e for the pe eo p l e e
(intersectoral collaboration). The people's commitment, response and courage reflect a collective vision of the integrated approach: scale up and strengthen through synergy. A future free from the scourge of communicable diseases can be our reality but will depend on all of our actions. The people of the Eastern Mediterranean Region - all 478 million - must continue to move forward, in a spirit of unity without leaving a single community or individual behind.
Str eamlined DCD Structur e General activities Surveillance forecasting and eqidemic management Capacity-building
DCD
Research Advocacy Infection control and containmen of antimicrobial resistance
Disease-specific activities Coordinator Coordinator
EID Emerging and eqidemic diseases
VPI
PZD Parasitic and zoonotic diseases
ASD
RBM
STB
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©World Health Organization 2002 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. Designed and printed by DAT Ltd. Document WHO-EM/DCD/001/E/G/02.02/2000
DCD DCD staff staff Dr. Hallaj, Zuhair Director Dr. Atta, Hoda Dr. Baghdadi, Samiha Dr. Bassili, Amal Dr. Ben Ismail, Riad Dr. Gaafar, Taky Dr. Keiko, Enaba Dr. Mohsseni, Ezz El-Din Dr. Mnzava, Abraham Dr. Neouimine, Nikolai Dr. Sabatinelli, Guido Dr. Seita, Akihiro Dr. Tawilah, Jihane Dr. Teleb, Nadia Dr. Ziady, Hany
E Ed diit to or riia al l C Co om mm miit tt te ee e Dr. Atta, Hoda Ms. Best, Peige Dr. Hallaj, Zuhair Mrs. Ibrhim, Samar Mrs. Nicholson, Jane Dr. Seita, Akihiro
Photographs: DCD and WHO photo libraries Printed by: DAT Ltd.
For more information contact Division of Communicable Diseases 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 2535 Fax.: 670 2492/4 E-mail: dcd@emro.who.int Web Site: www.emro.who.int