WHO Eastern Mediterranean Region (EMR) 2012-2013

The core activities of cooperative agreements and technical assistance between WHO/EMRO and CDC are:

• To enhance the quality, sensitivity and effectiveness of surveillance system for influenza and severe acute respiratory infections (SARI) as well as sustaining and further enhancing the laboratory capacities of National Influenza Centers for timely detection of novel influenza virus;
• To develop the capacities of the countries to use routinely collected surveillance data to improve their understanding on influenza epidemiology so as to better inform the national health authorities on appropriate preventive and control strategies for influenza; and
• To support the development of appropriate public-health policies that will promote introduction and increased use of seasonal influenza vaccines in at-risk population groups in the region.

Meg McCarron, MPH
Health Scientist
Extramural Program
Influenza Division, NCIRD
U.S. Centers for Disease Control and Prevention
Email: mmccarron@cdc.gov

Christopher Zimmerman, MD
Medical Epidemiologist
International Epidemiology and Research Team
Influenza Division, NCIRD
U.S. Centers for Disease Control and Prevention
Email: czimmerman@cdc.gov

Mark Thompson, PhD
Health Scientist
International Epidemiology and Research Team
Influenza Division, NCIRD
U.S. Centers for Disease Control and Prevention
Email: mthompson2@cdc.gov

A map of the WHO Eastern Mediterranean Region (EMR) shows all 23 EMR member states/countries. The member countries, outlined with gray borders, include Afghanistan, Bahrain, Djibouti, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Occupied Palestinian Territory, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen.

Countries with shading indicate that the Influenza Division provides project funding and technical assistance through cooperative agreements. Tunisia is shaded yellow to indicate a Capacity Building Cooperative Agreement. Afghanistan, Egypt, Morocco, and Pakistan are shaded dark green to indicate Sustainability Cooperative Agreements. Morocco is also shaded with blue dots to indicate a Vaccine Policy Cooperative Agreement.

CDC Field Staff, indicated by a yellow dot, are located in Cairo, Egypt.

The Global Disease Detection [GDD] Site, indicated by the red “X”, is located in Cairo, Egypt. The Naval Medical Research Unit No. 3 (NAMRU-3), indicated by a pink diamond, is also located in Cairo.

WHO National Influenza Centers (NICs), indicated by a purple dot, are located in the following cities: Amman, Baghdad, Beirut, Cairo [2], Damascus, Doha, Islamabad, Kabul, Khartoum, Manama, Muscat, Rabat, Shaab, Tehran and Tunis.

The WHO Regional Office for the Eastern Mediterranean (EMRO), indicated by a blue star, is located in Cairo, Egypt.

• Developed concrete road maps for establishing sentinel surveillance system for SARI/ILI in Djibouti, Lebanon, South Sudan and Yemen.
• The Regional Office made visible progress in designating the Central Public Health Laboratories in Libya and Yemen to become National Influenza Centres (NIC).
• Five countries in the region have acquired the skills and knowledge for estimating the disease burden associated with influenza in general populations using SARI sentinel surveillance data.
• The Regional Office is regularly publishing a weekly epidemiological monitor to inform the Member States of the influenza situation in the Region, as well as of other public health emergencies of potential concern in the region.
• Eight out of the sixteen NICs in the region are regularly sharing seasonal influenza viral isolates to the Global Influenza Surveillance and Response System (GISRS); eleven out of these sixteen NICs are also participating in the WHO External Quality Assessment Project (EQAP) with notable proficiency test results.

US CDC Direct Support

This current five year project (2011–2016) on strengthening surveillance and response to seasonal and pandemic influenza by the Regional Offices of the World Health Organization is built on a previous cooperative agreement (2006–2010) between the Regional Office of the Eastern Mediterranean (EMRO) of WHO and the U.S. Centers for Disease Control and Prevention (CDC) on a project titled Strengthening Surveillance and Response to Avian and Pandemic Influenza in the Eastern Mediterranean Region that was launched in October 2006.

The current project draws on existing partnerships and collaborative arrangements in the Eastern Mediterranean Region of WHO between WHO/EMRO, the U.S. Centers for Disease Control and Prevention (CDC), Food and Agriculture Organization (FAO), UNICEF, IOM, GDDRP, U.S. Naval Medical Research Unit No. 3 (NAMRU-3) and WHO Headquarters on strengthening, consolidating and sustaining regional preparedness for human pandemic influenza.

The unit of Pandemic and Epidemic Diseases (PED) under the Division of Communicable Disease of WHO/EMRO is the lead technical unit responsible for implementation of this current cooperative agreement.

The overarching objective of this current cooperative agreement is to improve the epidemic and pandemic preparedness for influenza in the Eastern Mediterranean Region of WHO through implementation of three major projects. These include (i) enhancing the quality, sensitivity and effectiveness of surveillance system for influenza and severe acute respiratory infections (SARI) as well as sustaining and further enhancing the laboratory capacities of National Influenza Centers for timely detection of novel influenza virus; (ii) developing the capacities of the countries to use routinely collected surveillance data to improve their understanding on influenza epidemiology so as to better inform the national health authorities on appropriate preventive and control strategies for influenza; and (iii) supporting the development of appropriate public-health policies that will promote introduction and increased use of seasonal influenza vaccines in at-risk population groups in the region.

The Regional Office has continued to provide technical and operational support to the countries in the Region for enhancing the quality, sensitivity and effectiveness of surveillance systems for influenza and severe acute respiratory infections (SARI) in the Eastern Mediterranean Region.

As a result of this ongoing support, 14 out of 23 countries in the Region are currently implementing sentinel surveillance systems for severe acute respiratory infection (SARI) and influenza-like illness (ILI).

In addition, 12 out of 23 countries in the Region are currently participating in the virological surveillance for seasonal influenza as part of the Global Influenza Surveillance and Response System (GISRS).

Surveillance Activities

• Conducted technical missions to Yemen, South Sudan and Djibouti during October–November 2012, to assist in planning sentinel surveillance systems for influenza and SARI in collaboration with the respective national Ministries of Health. The objective of the mission was to assess the readiness and training needs of the country for establishing sentinel surveillance system for influenza and SARI. Following these missions, a concrete road map was elaborated which would be followed up for implementation in the coming project period of September 30, 2013 to September 29, 2014.
• Conducted a sub-regional workshop in collaboration with the Ministry of Health, Jordan, in Amman, Jordan, November 11–15, 2012 to design an appropriate surveillance system for influenza in refugees and displaced population settings. Countries hosting large number of internally displaced populations attended this workshop. As an outcome of this workshop, draft guidance on establishing appropriate surveillance system for influenza in refugees and displaced population was developed with the focus on early detecting any suspected cluster of influenza or any other acute respiratory infections of potential public health concern in these settings.
• Organized the second meeting of the Eastern Mediterranean Region Acute Respiratory Infection Surveillance (EMARIS) network in partnership with GDDRP of NAMRU-3. This meeting was held in Sharm El-Sheikh, Cairo, Egypt on December 12–13, 2012. The theme of this year’s EMARIS network meeting was “Data for Action” which led to endorsing a resolution in the meeting by the participating countries on strengthening data collection for surveillance of influenza and SARI and using the surveillance data to generate evidence for informed public health decisions for prevention and control of influenza in the countries.
• Conducted a technical mission in Lebanon from December 3–12, 2012 in order to assess the sentinel sites proposed by the Ministry of Public Health (MOPH) for establishing surveillance for ILI and SARI. The mission led to detailing a road map for establishing a SARI surveillance system in the country which will be followed up for implementation during the project period of September 30, 2013 to September 29, 2014.

Sixteen NICs are currently functional in the Region, owing to the technical and financial support provided to the countries through the cooperative agreement. Eight out of the sixteen NICs are regularly sharing seasonal influenza viral isolates to the GISRS; eleven out of these sixteen NICs are also participating in the WHO EQAP with notable proficiency test results.

Laboratory Activities

• Conducted a technical mission in Lebanon from December 3–12, 2012 to discuss ways to revitalize the functions of the National Influenza Centre currently hosted at the Rafik Hariri University Hospital (RHUH) and assess the existing capacity of laboratory to support virological surveillance for ILI and SARI, particularly for isolation and detection of influenza virus by molecular techniques. The mission team members also conducted a short training session on influenza specimen collection, storage, shipment and diagnosis of influenza virus infection using PCR techniques.
• Provided technical support to Iraq, Jordan, Palestine and Tunisia in view of unexpectedly high and severe transmission of influenza in these countries during the last winter (December–February 2013). Laboratory tests performed in the NICs of these countries confirmed that the transmission was caused by influenza A(H1N1) pdm2009. Support was extended to these countries in order to share the influenza viral isolates with a WHO Collaborating Centre for characterization and to understand the changing virulence, if any.
• Conducted a technical mission for assessment of influenza laboratory and specimen collecting sites in Libya, in collaboration with Ministry of Health (MOH) from March 3–7, 2013. The mission assessed the competence and existing capacity of the Public Health Laboratory in Libya to conduct virological surveillance for seasonal influenza and be designated as a National Influenza Centre (NIC).
• Provided logistics and operational support to seven NICs in the Region in terms of providing laboratory reagents, primers, collection kits, etc. to further improve their capacities for isolation and sequencing of seasonal influenza virus including any novel influenza virus.

The national preparedness plan for human pandemic influenza continues to be reviewed and updated in all the 23 countries in the Region following the experiences gained and lessons learned during the pandemic (H1N1) 2009.Technical support was provided in the areas of assessment and risk management during the current period.

Preparedness Activities

• Participated in a technical mission, upon an invitation from the Kingdom of Saudi Arabia, from October 23–31, 2012 to observe and review the public health preparedness measures for influenza and other respiratory viruses undertaken by the Kingdom for the Hajj 1433/2012. The technical mission advised the Ministry of Health of Kingdom of Saudi Arabia on implementing appropriate surveillance strategies and public health measures for prevention and control of influenza and other respiratory infections amongst the Hajj pilgrims and also identified a number of important issues for consideration of the Kingdom for maintaining an effective surveillance and response system for influenza and other respiratory infections in the Kingdom.
• Organized a regional consultation on risk communication for pandemic influenza in Hammamet, Tunisia from October 18–20, 2012. Forty-six participants representing Ministries of Health, crisis management centres, academic institutions and WHO staff from country offices, regional office and WHO Headquarters attended this consultation. The objective of this consultation was to improve the effectiveness of risk communicating before, during and after pandemic influenza through a systematic and structured application of appropriate communication strategies and health messages targeted for different audiences.
• Conducted a meeting on Influenza at the human-animal interface in Cairo, Egypt from March 19–21, 2013. The main objective of this consultative meeting was to develop a strategic framework for risk assessment for influenza and other viral zoonotic diseases at the human-animal interface and to identify the areas of collaboration between the animal and human health sector for prevention, detection and response to influenza caused by any novel virus. The meeting was attended by a total of 30 participants representing the Ministries of Health and Ministries of Agriculture and Animal Resources from Egypt, Iran, Jordan, Pakistan and Sudan; and experts from FAO, OIE, NAMRU-3, CDC and WHO. Following the consultative meeting, an agreement was reached for strengthening collaborations between the human and animal sectors and strengthening joint surveillance and response activities at the human-animal interface to provide early warning for emergence of novel influenza and other respiratory viruses of pandemic zoonosis in the Eastern Mediterranean Region.
• Organized a sub-regional workshop on improving public health preparedness for epidemic influenza in Amman, Jordan on August 20–22, 2013. The objective of the meeting was to improve the preparedness for seasonal outbreaks of influenza in the Eastern Mediterranean Region drawing on lessons from the severe and high transmission of influenza in some countries of the region as observed during the last winter (2012–2013). The Head of Disease Surveillance Departments and the Head of Public Health Laboratories of Iraq, Jordan, Libya, Morocco, Palestine, Tunisia and Yemen attended this meeting along with representatives from NAMRU-3, WHO Collaborating Centre for Reference and Research on Influenza, Division of Virology, National Institute for Medical Research, Mill Hill, London, UK as well as staff members from WHO/HQ, WHO/EURO.

WHO EMRO conducted a number of training activities to improve surveillance and response capacities of the countries in the areas of pandemic and seasonal influenza.

• Conducted a sub-regional training workshop on early recognition, detection and response to respiratory outbreaks in Cairo, Egypt from October 14–17, 2012. A total of 22 participants from Djibouti, Jordan, Lebanon, Oman, Morocco, Palestine, Somalia and South Sudan attended this sub-regional training workshop.
• Conducted a training course on data management for surveillance of influenza and SARI in Cairo, Egypt from April 21–25, 2013. The purpose of the course was to orient the participants to understand the basic concepts of epidemiological data analysis, the application and hands-on practice of data management techniques in analysis of influenza and SARI surveillance data. A total of 23 participants from Afghanistan, Iraq, Jordan, Lebanon, Morocco, Oman, Pakistan, Palestine, Somalia, Tunisia and Yemen attended this course.
• Conducted a sub-regional training workshop, on estimating the burden associated with influenza in general population using sentinel surveillance data, in Sharm El-Sheikh, Egypt from December 9–11, 2012. The workshop was attended by five participants from Egypt and Morocco, four participants from Jordan and Pakistan and two participants from Oman. It was facilitated by WHO Temporary Advisers who were drawn from the Field Epidemiology and Laboratory Training Programme of Pakistan, MRC Centre for Outbreak Analysis and Modeling, Imperial College, UK and the Centre for Population Health Sciences, the University of Edinburgh in UK. During the workshop, the participants were trained on calculating the disease burden estimation for influenza using the WHO manual and the electronic tools adapted by the Regional Office. Using the acquired knowledge and skills in the workshop, the participants from the attending countries calculated a national level disease burden estimation for influenza in the general population using its own SARI surveillance data.

The Regional Office, along with the GDDRP and NAMRU-3, is extending technical support to the national health authorities of all the 23 countries in the Region to strengthen the Eastern Mediterranean Region Influenza Surveillance Network (EMRISN) to improve both epidemiological and virological surveillance for SARI and ILI in the region. The Regional Office is encouraging the participating countries in the network to enhance the quality, sensitivity and effectiveness of surveillance system for SARI and ILI and to use routinely collected surveillance data to improve their understanding on influenza epidemiology so as to better inform the national health authorities on appropriate preventive and control strategies for influenza.

Sk. Md. Mamunur Rahman Malik, MBBS, Dip (Health Economics), MSc, MPhil
Regional Adviser, ad interim
Pandemic and Epidemic Disease
Department of Communicable Disease Prevention and Control
WHO Regional Office for the Eastern Mediterranean
Cairo, Egypt
Email: malikm@emro.who.int

L. Martin Opoka, MBBS, PG. Diploma, MSc
Technical Officer
Pandemic and Epidemic Disease
Department of Communicable Disease Prevention and Control
WHO Regional Office for the Eastern Mediterranean
Cairo, Egypt
Email: opokal@emro.who.int

Ali R. Mafi, MD, MPH
Medical Officer
Pandemic and Epidemic Disease
Department of Communicable Disease Prevention and Control
WHO Regional Office for the Eastern Mediterranean
Cairo, Egypt
Email: mafia@emro.who.int