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WHO EMR 53rd Session

Ministers of health from the Eastern Mediterranean Region gathered in Isfahan, Iran, from 9-12 September for the 53rd Session of the WHO Regional Committee for the Eastern Mediterranean. Reporting from Isfahan, Callan Emery provides an overview of this important annual meeting.

Under tight security health ministers, their representatives and advisers from the Middle East, the Levant, North Africa, Pakistan and Afghanistan as well as observers from UNCEF, UNDP, UNHCR, various other UN bodies, the League of Arab States and numerous other regional organisations gathered at the historical Abbasi Hotel in Iran’s cultural capital, Isfahan, to participate in the 53rd Session of the WHO Regional Committee for the Eastern Mediterranean.

They came together at this important annual meeting to formally discuss the state of public health in the region, check progress made in the past year, look at challenges that lie ahead and adopt resolutions to chart the way forward. High on the agenda were issues such as regional preparedness for avian influenza, health conditions in Lebanon and the Occupied Palestinian Territories, growing alcohol consumption in the region and the election of a new regional director for the World Health Organisation (WHO) Eastern Mediterranean Regional Office (EMR).

Four days were set aside to work through the comprehensive agenda. At times discussions were studious and sedate such as that on the issue of avian influenza, at other times it was heated and vociferous as in the talks on the critically poor state of health in the Occupied Palestinian Territories. On the final day member states adopted a number of resolutions to provide guidance and clarify responsibilities for the year ahead.

Overview

Following is a summary overview of the event’s proceedings. Inaugurating the meeting, Dr Bervis Davoodi, the Vice President of Iran, welcomed delegates of member states and called for greater unity and equity in healthcare across the region.

He urged members to take advantage of new scientific methods to facilitate delivery of health care to the less advantaged and pointed out that Developing Countries needed to be supported in the development of new technology which would help bridge the gap between rich and poor.

Dr Davoodi also emphasised the importance of developing a well-trained and dedicated public health workforce which would promote efficiency of the health systems and help control emerging infectious diseases such as malaria, HIV/AIDS and TB, and eradicate entrenched chronic diseases in the region. In his opening remarks Dr Hussein Gezairy, the Regional Director for WHO Eastern Mediterranean Region denounced Israel’s violation of international laws with the targeting of civilians and the use of cluster bombs in the war on Lebanon.

He stressed the importance of investing in emergency preparedness, remarking that each of the past several years the region had experienced a largescale emergency – the earthquake in Iran, the earthquake in Pakistan, the war on Lebanon.

He also noted that member states needed to focus on vaccination safety, saying that the region had to gain self sufficiency of vaccine production, especially with some countries such as Egypt and the Iran having the potential for producing vaccines. Dr Anders Nordström, WHO Acting Director - General, emphasised the relevance and importance of the WHO and its role in providing technical support, assessing health trends, setting norms and standards, articulating policy options or providing leadership.

Dr Kamran Lankarani, Minister of Health and Medical Education for Iran, welcomed delegates to his country and said that without paying attention to the social effects of poverty and unemployment and without considering social justice, development could not take place. He acknowledged the important contribution by the WHO in supporting key national health programmes

HIV/AIDS

The WHO EMR Secretariat pointed out that due to inadequate HIV/AIDS surveillance in the region it is not possible to provide an accurate epidemiological profile for HIV/AIDS in the region. “Only a few countries collect and report this information to the Regional Office.”

However, it is estimated that by the end of 2004 the total number of people living with HIV in the region had reached 750,000, and that there were an estimated 67,000 new infections in 2005. Most reported AIDS cases (up to June 2005) were due to heterosexual transmission (52%) and sharing of needles among injecting drug users (7%).

“Injecting drug use in the region is of major concern. Several countries have reported rising numbers of drug users in addition to increased shifting from non-injecting to injecting modes of drug consumption.” The WHO reported that besides the established epidemic among drug users in Iran, an epidemic has been emerging in Pakistan in recent years. A study in Lahore and Karachi in 2005 showed HIV prevalences of 0.5% and 23% respectively.

A study in Iran was also noted where “6% of prostitutes in a city in western Iran were HIV positive and all of these were injecting drug users.”

The WHO said that this highlights the way HIV transmission bridges the gap between injecting drug users and the general population. The growing prevalence of HIV-positive injecting drug users in Afghanistan and Libya was also highlighted.

The Regional Office noted that the assessment of highrisk sexual behaviour in the region is lacking, but pointed out that, based on police reports and news media, prostitution and high-risk sexual behaviour among homosexuals exists in almost every country in the region.

Studies in the region pointed to the low rate of condom use during commercial sexual encounters.



Member states were told that the “cultural, social and religious values that promote protective behaviour, such as sexual abstinence before marriage, and abstinence from alcohol and other drugs are reducing vulnerability to HIV.

However, the silence surrounding sexuality and sexual behaviour limits the possibility for information and education of youth and for setting up preventative interventions for people at risk.

The stigma and discrimination towards vulnerable high-risk populations forces these populations underground and makes epidemiological surveillance and effective interventions extremely difficult if not impossible.”

The Regional Committee noted that there has been some progress in the past year with access to antiretroviral treatment (ART), however, it admitted that as of June 2005 only 5% of those in need in the region are receiving ART.

Obstacles included the cost, lack of health system infrastructure and skilled personnel, and stigma and discrimination. To confront future challenges the Regional Committee said it would focus on: strengthening surveillance and operational research; developing healthcare infrastructure and technical capacity building to provide a continuum of prevention, treatment and care; and promoting HIV prevention interventions for injecting drug users.

Polio

The committee remarked that since adopting in 1988 a resolution with the goal of eradicating poliomyelitis in the region, the number of countries endemic for polio had declined from 22 in 1988 to just two by the end of 2005.



It was noted that due to unfounded concerns over the polio vaccine in Nigeria, immunisation was halted in that country between mid 2003 and mid 2004. Nigeria became the source for the spread of polio to many countries in Africa, including Sudan from where it spread to Somalia and Yemen, which had largescale epidemics last year.

The committee welcomed the fact that Egypt has finally been declared polio free after years of endemicity. Countries which remain at risk include Afghanistan, Pakistan, Sudan, Yemen and Somalia where there are ongoing immunisation campaigns.

The regional committee stressed that high routine immunisation coverage is crucial for maintaining polio-free status after successful eradication and added that “it is crucial to maintain certification standard surveillance in all countries of the region until global certification is achieved.”

Tobacco

In the area of tobacco control the committee pointed out that the focus is currently on two issues: the implementation of the WHO Framework Convention on Tobacco Control; and addressing the increasing use of shisha in the region.

MDGs

Regarding Millennium Development Goals (MDGs) relating to maternal and child health, the regional committee noted that it was unlikely that, at the current rate of progress, these MDGs will be fulfilled, especially in countries where the levels of maternal and child death are still unacceptably high.

The regional committee said: “While low-cost effective interventions are available and can prevent around two-thirds of underfive deaths and 80% of maternal deaths, still today 1.5 million children under five years and 53,000 mothers are dying every year in the Eastern Mediterranean Region.

Furthermore, neonatal mortality is increasingly appearing as a significant component of under-five mortality in many countries.”

The Regional Office’s interventions to assist member states in achieving the MDGs are focused mainly on two areas: making pregnancy safer and the integrated management of child health. Member states were warned that “strong commitment, intensive efforts and effective national policies and strategies are now urgently required in order to translate vision into action.

Such efforts and plans should target the strengthening of health systems, expansion in the coverage of effective integrated interventions, and recognition of the essential role of individuals, families and communities in promoting the health of children and their mothers.”

Emergency preparedness

The Regional Committee looked at progress made since adopting a resolution in 2005 to improve emergency preparedness in the region. WHO EMR pointed out that “at present, a formalised network of such experts does not exist within the region.

Moreover, very few schools and institutions of public health are training professionals with the necessary disaster response skills.” In an effort to create a regional network of disaster response experts WHO EMR has begun work to create a roster of experts who have experience in emergency settings.

“A number of profiles have been identified which include expertise in epidemiology, environmental health, public health, primary health care, hospital management, health information management, communications, logistics, administration, maternal and child health, and mental health.

Candidates meeting defined criteria will be placed on a roster and mobilised in the event of a major emergency.”

Appropriate training courses are conducted annually and a “pre-deployment” training course is being developed which will address the practical and operational aspects of emergency response for those professionals providing humanitarian assistance in an affected area.

The Regional Committee noted that there is a clear need to establish a regional emergency solidarity fund (RESF) to ensure the availability of funds to initiate emergency operations, as in the past appeals for health funding for emergencies has been poor.

“The fund is not intended to replace existing appeal mechanisms or the need for humanitarian partners to fund lifesaving health interventions in crisis situations. The RESF comprises 1% of regular budget country allocations per biennium. To date, only 10 out of 22 countries in the region have agreed to this deduction from their country allocation.”

Another aspect of emergency preparedness planning was the establishment of a regional hub and various national hubs to ensure the availability of emergency supplies. In this regard WHO EMRO said a feasibility study on establishing a regional disaster management centre in Pakistan is under way.

Primary Health

A number of member states reported progress in improving primary heath care. Afghanistan has focused on strengthening its district health system and developing the essential package of care, ambulatory care and referral.

In Iran, four provinces piloted a number of interventions to increase the effectiveness and efficiency of health care delivery and methods of financing, such as the diagnosis-related grouping technique in selected provinces and hospital autonomy.

Iran has also embarked on designing a model for involving the community in managing public sector health services.

Yemen has started designing a process for integration of all vertical programmes in selected districts and an essential package of services has been drafted. Lebanon has developed five axes to strengthen primary healthcare.

The five axes highlight development of infrastructure, especially health centres, continuity of care, intersectoral collaboration, community participation and quality of primary health care. Egypt, said it had reviewed its family health model in respect to its operational, logistic and technological aspects as well as accessibility, community participation, decentralisation and financing.

Egypt and Oman have implemented accreditation of primary healthcare facilities in selected governorates and wilayat respectively. And Iran said it is formulating a licensing and accreditation system in the public and private sector.

Several countries reported having embarked on e-care as an important and innovative approach to increase access, quality and efficiency in certain primary health care settings, especially for remote health care coverage.

Global diseases

Tuberculosis
The global targets for tuberculosis control, set for the end of 2005, were to:

- Achieve 100% population coverage with the WHO-recommended strategy of directly observed treatment, short-course (DOTS);

- Detect at least 70% of smear positive pulmonary tuberculosis cases; and

- Successfully treat at least 85% of them.

Only five countries of the region – Jordan, Lebanon, Morocco, Oman and Tunisia – achieved the global targets on time.

WHO EMRO said: “Countries that have not yet achieved the global targets for tuberculosis control need to drastically improve tuberculosis control by adopting the new Stop TB Strategy in order to achieve the targets by 2008. The strategy is built on the DOTS strategy, and includes components to: pursue high quality DOTS activities; address HIV/TB, multidrug-resistant tuberculosis and complex emergencies; contribute to health system strengthening; engage all care providers; empower communities; and promote research.”

Measles
The regional goal is to eliminate measles by 2010. The regional strategy for measles elimination includes:

- High routine measles vaccination coverage (>90% in all districts) among children aged one year

- One-time, nationwide mass immunisation campaign or catch-up campaign targeting all children

- Second opportunity for measles immunisation either through periodic follow-up campaigns every 3-5 years targeting all children born since the last campaign or achieving >95% routine coverage with a second dose of measles vaccine

- Case-based surveillance for measles with laboratory confirmation of disease

- Optimal case management of children with acute disease.

WHO EMRO says overall, 17 countries have implemented the full strategy for measles elimination including nationwide catch-up campaigns.

Five countries that have not conducted campaigns, but have plans to do so in the next two years.

“Since 1999, more than 111 million children have been vaccinated in catch-up campaigns.

Based on campaign results, surveillance data and routine EPI coverage, there has been a 54% reduction in measles mortality since 1999.

“Despite the considerable progress, measles remains a leading cause of death among children less than 5 years of age in the region.

Most of these deaths occur in countries that have not implemented the full strategy, including Pakistan, Somalia, south Sudan and Yemen,” says WHO EMR. “Of the 17 countries that have implemented the full elimination strategy, Iraq, Lebanon, Saudi Arabia and Syria continue to experience measles outbreaks.” No countries in the region have achieved elimination.

Leprosy

All countries in the region have achieved the global target of less than one per 10,000 and the prevalence continues to decline.

The Regional Office said: “The main challenge is to sustain control activities and achievements. Because of the chronic nature of leprosy, long-term commitment is needed. In this regard, integration of leprosy control within the existing primary healthcare system is an important challenge.”

Maternal and neonatal tetanus

The global target for the elimination of maternal and neonatal tetanus, set for 2005, was to reduce the incidence of maternal and neonatal tetanus to less than one case per 1,000 live births in all districts of a country.

Fifteen countries of the region had already achieved the Global Target by 2004. The remaining seven countries of the region that have not yet achieved the elimination target are: Afghanistan, Egypt, Iraq, Pakistan, Somalia, Sudan and Yemen. Of them, Egypt is close to elimination.

These seven countries are among the 57 countries worldwide that have not eliminated maternal and neonatal tetanus.

Alcohol consumption

The status of alcohol consumption in the region is not clear and although it is not considered an imminent threat to health in the region it appears, from recent data, consumption is growing among groups of young people.

For this reason WHO EMR believes a regional policy should be developed for the region. “Awareness should be raised among member states of the potential for public health problems arising from alcohol consumption and the need to develop integrated strategies at national level to address the prevention and treatment of substance abuse including 44 alcohol, and to respect and make best use of the religious and cultural legacy of the region in controlling public health problems of alcohol.”

Avian flu

Member states were warned that the threat of a pandemic of avian flu remains a serious problem in the Eastern Mediterranean Region.

The Regional Office estimates that in the event of pandemic influenza (attack rate of 35%), more than 180 million people in the region would fall ill, 96-168 million would require medical care, 6.4-28.1 million would need hospitalisation and 150,000- 750,000 would die.

To date the H5N1 virus has been reported in wild and migratory birds in the Islamic Republic of Iran and Kuwait, and among domestic poultry in Afghanistan, Djibouti, Egypt, Iraq, Jordan, Palestine and Sudan. Influenza A (H5N1) has also been reported in humans in Iraq (3 cases), Egypt (14 cases), Jordan (one imported case from Egypt) and Djibouti (one case).

Egypt said migratory birds had arrived in the country earlier than expected this year.

Between 31 August and 5 September authorities reported nine positive foci of H5N1 virus in poultry in five different Governorates: Sohaj, Cairo, Ismailiya, Dimyat and Giza. Member states welcomed the International Health Regulations (2005), which are scheduled to come into force in June next year.

The IHR (2005) aims to prevent and protect against the international spread of disease and provides roles and responsibilities for member states, in particular to develop and maintain core surveillance and response systems to detect, assess and report public health events to WHO.

WHO, in turn, is to collaborate with member states to evaluate their public health capacities, facilitate technical cooperation, logistical support and the mobilisation of financial resources for building capacity in surveillance and response. The secretariat stressed the need for speed and transparency when reporting outbreaks of H5N1 in countries across the region.

“All countries are encouraged to demonstrate full transparency and prompt sharing of information and appropriate outbreak communication related to avian and pandemic influenza.” The avian flu preparedness strategy emphasises the role of public awareness in reducing morbidity and mortality during pandemic influenza and in avoiding unnecessary panic.

The Regional Committee said it would prepare educational and culturally appropriate communication material to support interventions at the animal-human interface, especially for protection of identified risk groups such as cullers, healthcare and laboratory workers.

The Regional Committee said it would also assist in disseminating information by providing a 24-hour on-call system for reporting of potential pandemic influenza signals. Among a number of capacity-building measures the Regional Committee said it would develop and implement a set of training modules and activities in rapid detection, response and containment of pandemic influenza.

The Regional Committee will use a “training of trainers” approach to provide training to national staff. They also plan to further strengthen mechanisms for collection and transportation of clinical specimens for rapid testing.

The secretariat pointed out several challenges that lay ahead. “One of the challenges that could impede the preparedness of countries is lack of adequate resources, including the financial resources needed to implement preparedness plans and to support affected countries.

Moreover, there is only one regional reference laboratory for influenza, and further capacity is needed in epidemiology and laboratory surveillance.

“Most countries of the region also lack adequate infection control practices in their health facilities.”

It also pointed out that several important guidelines and documents needed to be translated into Arabic.

The secretariat warned that it “is expected that there will be a visible shortage of antiviral medicines, as their accessibility is already limited. Likewise, accessibility of new influenza vaccines is extremely limited.”

Among a range of recommendations the secretariat proposed that: countries should promote community participation and empower nongovernmental agencies, scientific societies, academic institutions and the like by involving them in the preparation and implementation of national preparedness plans; countries should give serious attention to the role of risk communication to the public to increase awareness and promote appropriate interventions.

These recommendations were adopted in a resolution on avian influenza on the final day of the summit in which member states also requested the regional director to “support development of the Eastern Mediterranean Regional Network for Outbreak Alert and Response to ensure prompt response to and containment of outbreaks of avian influenza and human pandemic influenza.

Lebanon

The Lebanese Ministry of health presented an update on the state of health in Lebanon and a national strategy for early recovery of the health sector following the five-week Israeli war on Lebanon.



The war had a devastating impact on health in Lebanon with the high number of injured and disabled people generating additional pressure on the already overwhelmed health services; the considerable damage to health facilities and functional disruption mainly of primary healthcare clinics and centres, as well as key hospitals; the disruption of basic public health functions; and the damage to infrastructure – roads, bridges, etc – impeding access to healthcare facilities.

The MoH has embarked on two different but complementary approaches to meet the challenges of restoring the healthcare system – the “National Early Recovery Strategy” and “Action Plan for the Health Sector in Lebanon”.

“The first approach should be the implementation of urgently needed interventions that will allow the restoration of essential public health functions, basic healthcare services, and mechanisms of referral to specialised care.

“The second approach would be the development and implementation of a Master Plan for Reconstruction of the Health Sector in Lebanon.

The Master Plan will form the fundamental agenda and roadmap for the long term reconstruction of Lebanon’s health system,” said the Lebanese MoH.

Occupied Palestinian Territories

The report to the Regional Committee on the health conditions in the occupied Palestinian territories (oPt) stated that the oPt is “facing a three-layered humanitarian crisis: vulnerability resulting from the conflict during the last five years, the financial crisis of the Ministry of Health since March 2006, and the recent escalation of the security and humanitarian situation, especially in the Gaza Strip”.

The report outlined the health consequences of the financial crisis which affected a broad spectrum of services from the supply of essential medication (many of which were already out of stock) to solid waste disposal.

The report noted that “the system had not yet collapsed and health services and programmes were still running, even in the Gaza Strip”. However, it warned that “lack of sustainable funding may result in disruption of essential public health functions and of a substantial part of the delivery of basic health services”.

The report stated that WHO action in the occupied Palestinian territory has three objectives: to reduce the vulnerability of Palestinian society through a package of public health interventions within the framework of the Consolidated Appeal Process; to ensure that the funding crisis of the Ministry of Health is being properly addressed (on a humanitarian basis to cover the salary and non-salary basic requirements needed to run the essential services and programmes); to provide immediate life-saving assistance to the population of the Gaza Strip.

Regional Director re-elected

In a secret ballot during a private meeting of the committee Dr Hussein Gazairy was nominated for re-election by the Executive Board as Regional Director for the Eastern Mediterranean for another term in office beginning 1 October 2007.

The 54th Session

The 54th Session of the WHO EMR Committee will take place in Sudan next year.