Annual report of the Regional Director 2018

Introduction Strengthening health systems for universal health coverage Promoting health across the life course

Noncommunicable diseases Communicable diseases WHO Health Emergency Programme

Implementing WHO management reforms Annexes Previous reports

Download the full report

Communicable diseases

Breakdown of health and other systems due to conflicts, massive population displacement, environmental disasters and climate changes have resulted in the reemergence of communicable diseases as important threats, with many devastating epidemics. WHO’s strategic emphasis on expanding universal health coverage and strengthening primary health care is an opportunity to improve the prevention and control of communicable diseases, with a focus on strengthening systems, including surveillance, laboratory services and service delivery, leading to better integration of services at various levels of health care.

Wild poliovirus transmission continued in the two endemic countries, Afghanistan and Pakistan, with a total of 33 cases reported in 2018 (21 in Afghanistan and 12 in Pakistan). Patterns of both human cases and environmental positives indicate continued circulation of the virus in known reservoir areas in both countries. Access to all populations (affected by insecurity and bans on immunization in Afghanistan), the quality of immunization campaigns in reservoir areas, population movements and the safety of frontline workers remain the key challenges. Growing hesitancy to vaccinate, often related to the spread of misinformation over traditional and social media, has further complicated efforts to reach every child with polio vaccine. Afghanistan and Pakistan continue to implement robust national emergency action plans (NEAPs), and emergency operations centres remain vital mechanisms at national and subnational levels to coordinate eradication efforts and monitor the implementation of NEAPs. A strong mechanism of cross-border coordination between the two countries has been established.

The onset of the last polio case in the world due to wild poliovirus type 2 (WPV2) was in 1999, and onset of the most recent case due to wild poliovirus type 3 was in November 2012. The eradication of WPV2 was certified in September 2015 by the Global Commission for the Certification of Poliomyelitis Eradication (GCC).

The circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak in Syrian Arab Republic which began in 2017 and paralyzed 74 children was officially closed in 2018. Concurrent outbreaks of cVDPV2 and circulating vaccine-derived poliovirus type 3 (cVDPV3) emerged in Somalia in 2018. There were 12 paralytic cases due to circulating vaccine-derived poliovirus (cVDPV) in 2018 (five due to cVDPV2, six due to cVDPV3, and one due to coinfection with cVDPV2 and cVDPV3).

The detection of cVDPVs in Somalia reflects a significant population immunity gap, primarily due to the large number of inaccessible children in areas controlled by non-state armed groups. A comprehensive response plan is being implemented in coordination with other Horn of Africa countries, and the key lessons learnt from this ongoing response are being collected by regional teams to improve preparedness and response to any possible cVDPV outbreaks in other high-risk countries in the Region.

The twentieth meeting of the Emergency Committee under the International Health Regulations (2005) regarding the international spread of poliovirus, held on 19 February 2019, voiced concern over the increase in wild poliovirus type 1 (WPV1) cases globally in 2018. The Committee unanimously agreed that the risk of international spread of poliovirus remained a Public Health Emergency of International Concern, recommending the extension of Temporary Recommendations for a further three months. Afghanistan and Pakistan fall under states infected with WPV1, with potential risk of international spread, while Somalia falls under states infected with cVDPV2 and cVDPV3 with risk of international spread.

Despite the tremendous progress globally and in the Region, as long as wild poliovirus (WPV) is circulating anywhere, risks remain. Three countries in the Region are at very high risk, namely Somalia, Syrian Arab Republic and Yemen, and three are at high risk, namely Iraq, Libya and Sudan. All are experiencing varying degrees of complex emergency and have access or security constraints that hamper efforts to maintain high population immunity and sensitive surveillance. WHO is providing technical and logistic support to these countries to implement supplementary immunization and surveillance activities. However, the global supply shortage of inactivated polio vaccine (IPV), first identified in 2016, continued in 2018, posing additional challenges to some countries with respect to covering all birth cohorts with at least one dose of IPV.

Surveillance performance indicators in countries of the Region have generally been maintained at or above certification standards in 2018. The acute flaccid paralysis (AFP) surveillance system reported nearly 23 000 cases in 2018 and all Member States but two met the key standard surveillance indicators for non-polio AFP rates (2 per 100 000 children under 15 years of age) and percentage of AFP cases with adequate specimens (80%). A network of 12 WHO-accredited laboratories supports this system. Environmental surveillance efforts continued to expand in 2018, with established and growing systems functioning in Afghanistan, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Pakistan, Somalia, Sudan and Syrian Arab Republic. Arrangements are in place for expansion to Iraq in 2019. Environmental surveillance functions as a vital early-warning detector for VDPVs, which remain a risk, particularly in conflict-affected countries where a significant number of children are inaccessible to immunization services.

In 2018, the regional polio eradication programme continued to support national preparedness and response planning. All polio-free countries of the Region, except Yemen, have conducted polio outbreak simulation exercises. The regional team has started a process to update the methodology used for polio outbreak simulation exercises, in light of the lessons learned and best practices in other regions and programmes.

Four countries in the Region (Afghanistan, Pakistan, Somalia and Sudan) are among the 16 countries that have been identified globally as a priority for post-eradication transition planning. An additional four countries (Iraq, Libya, Syrian Arab Republic and Yemen) are considered regional priorities for assessing what polio functions will be integrated into other existing initiatives and what functions may be prioritized or phased out. In 2018, transition plans for Somalia and Sudan were drafted and consultation meetings held. The timeline for implementation of transition planning in the Region has been affected by the outbreak of cVDPV in Somalia and continued transmission of WPV1 in Afghanistan and Pakistan. Iraq, Syrian Arab Republic and Yemen are expected to begin work on transition plans in 2019.

The absolute priority for 2019 is to stop wild poliovirus transmission in Afghanistan and Pakistan by supporting implementation of national emergency action plans through technical, financial and logistical support. Another key focus will be stopping the current cVDPV outbreaks in Somalia and raising immunization levels to prevent subsequent outbreaks. Enhancing preparedness and response capacity in all countries will continue, with a strong focus on improving surveillance systems to ensure early detection and effective response to any introduction of poliovirus, and supporting countries in laboratory containment of poliovirus and preparation for certification of polio eradication.

By the end of 2018, the number of people living with HIV (PLHIV) in the Region had reached 400 000, with 41 000 new HIV infections occurring during the year. The number of deaths among PLHIV reached 15 000, up 84% on 2010.

Member States continued efforts to scale up HIV diagnosis and treatment. The number of PLHIV receiving antiretroviral therapy (ART) increased to 82 000. Despite this, overall coverage of ART in the Region remains at 21%, due largely to limited coverage of HIV testing services, inefficient case detection, late diagnosis, poor linkage to treatment services and attrition from treatment after initiation of ART. In line with the Vision 2023 strategic priority to expand universal health coverage, 2018 saw a focus on increasing HIV diagnosis and treatment coverage. The Islamic Republic of Iran was supported to initiate plans to integrate HIV services into harm reduction services for people who inject drugs and primary health care, and Pakistan for national consultations on HIV self-testing and decentralizing HIV care.

An estimated 21 million people are chronically infected with viral hepatitis B and 15 million infected with viral hepatitis C in the Region. Egypt and Pakistan account for over 80% of the hepatitis C burden. Regional coverage of hepatitis B vaccine birth dose immunization was 33% in 2018. Egypt is leading in the global effort to eliminate hepatitis C, driven by a presidential initiative to test 45–52 million people and refer those who test positive to treatment. During 2018, Pakistan was supported to assess its hepatitis diagnosis capacity and linkages to treatment, programme monitoring and strategic data collection and utilization, and the integration of HIV, tuberculosis and hepatitis services for key populations. In addition, a consultation with hepatitis and pharmaceutical regulatory focal points from ministries of health and civil society representatives considered ways to achieve affordable prices for hepatitis B/C medicines and diagnostics.

An estimated 771 000 people developed tuberculosis (TB) in the Region in 2017 – 8% of the global TB burden – and 536 185 TB cases were notified, representing a treatment coverage rate of 68%. Five countries (Afghanistan, Morocco, Pakistan, Somalia and Sudan) carry 91% of the regional TB burden. Drug-resistant TB continues to be a public health crisis globally and in the Region; in 2017 about 21 000 multidrug-resistant TB (MDR-TB) cases were estimated among the notified cases in the Region, but only 4353 of them (21%) were put on treatment. Treatment success rates of 92% and 62% were achieved among drug-sensitive and drug-resistant TB cases, respectively – the highest rates of any world region.

The first-ever UN General Assembly high-level meeting on TB was held on 26 September 2018. As part of preparations for the meeting, six high-burden countries (Afghanistan, Djibouti, Morocco, Pakistan, Somalia and Sudan) participated in a regional consultation.

Support was provided to several countries in the Region (Afghanistan, Jordan, Lebanon, Pakistan, Syrian Arab Republic and Yemen) to update their national strategic plans and guidelines for TB, childhood TB and latent TB infection. Pakistan was supported to begin implementing the FIND. TREAT. ALL #ENDTB initiative to reach the targets of the Political Declaration of the UN General Assembly high-level meeting on TB. The initiative is a joint undertaking between WHO, the Stop TB Partnership, and The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to enhance the capacity of the 13 highest TB burden countries.

Progress has been made in improving the detection and management of MDR-TB cases through implementation of a new molecular test for rifampicin resistance, GeneXpert, in all countries of the Region; more than half of retreated cases were tested in 2017. TB programme review and rGLC support missions for drug-resistant TB were conducted in nine countries (Afghanistan, Djibouti, Jordan, Lebanon, Morocco, Pakistan, Somalia, Sudan and Tunisia). Furthermore, annual meetings of the regional Green Light Committee (rGLC) and laboratory task force were held to review and accelerate programme management of drug-resistant TB.

Along with the missing third of TB cases, high dependency on external financing is a major challenge in the Region. Currently, 43% of the budget for regional TB programmes comes from international sources and 21% from domestic sources, leaving a funding gap of 36%. In addition, the destruction of health systems, huge population movements and poor security have severely impacted TB control programmes in countries experiencing complex emergencies.

WHO continues to support Member States to develop national strategies and plans incorporating the commitments made under the Political Declaration, and to promote a multisectoral approach to accelerate efforts to reach the targets set for 2022 and end TB by 2030. To find the missing TB cases, WHO is promoting the adoption of a roadmap to harness the full potential of private providers. Countries are being supported to transition towards the new drug-resistant TB policy, scale up latent TB infection treatment and roll out a new roadmap towards ending TB in children and adolescents.

Progress in reducing the malaria burden is stalling, with an increase in estimated cases since 2016. In 2018, the Region reported more than 5 million presumed and confirmed cases, of which nearly 2.2 million were confirmed. The Islamic Republic of Iran and Saudi Arabia are aiming to eliminate malaria: local cases in the Islamic Republic of Iran declined to 20 in 2018, while in Saudi Arabia the number remained below 100 between 2010 and 2015, but has risen in recent years to reach 194 in 2018. The other endemic countries (Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen) are at the burden reduction stage. The number of malaria cases reached an alarming level in Djibouti due to population movement from neighbouring countries, the presence of invasive An. Stephensi and an inefficient control programme.

In 2018, countries continued to be supported to increase access to preventive, diagnostic and treatment services to reach targets for universal health coverage. Coverage has increased in recent years, but is still below target. There were reports of stock-outs of medicines and diagnostics, and delays in distributing vector control interventions in Djibouti, Sudan and Yemen. Political unrest and instability in some countries has set back malaria control and allowed the emergence or re-emergence of other vector-borne diseases. Outbreaks of dengue and chikungunya have occurred in malaria-endemic countries and put increased strain on already-weak resources. Malaria control interventions were supported in countries affected by insecurity and humanitarian emergencies, including Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen, and therapeutic efficacy studies for antimalarial medications continued to be supported in endemic countries of the Region.

A regional plan of action to implement the Global vector control response 2017–2030 was developed through broad consultation. Vector control needs assessments and the development of integrated vector management and insecticide resistance management strategies were supported in priority countries. Vector control interventions and surveillance, including insecticide resistance monitoring, were supported in countries affected by outbreaks of vector-borne diseases, including Afghanistan, Djibouti, Oman, Pakistan, Somalia, Sudan and Yemen.

Table 1. Parasitologically-confirmed cases in countries with no or sporadic transmission and countries with low malaria endemicity

Table 2. Reported malaria cases in countries with high malaria burden

The fight against neglected tropical diseases continued in 2018. The seventeenth meeting of the Regional Programme Review Group on elimination of neglected tropical diseases under preventive chemotherapy programmes was held in December 2018, covering five diseases: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. The meeting was attended by representatives from 11 countries of the Region and partners, including UNRWA, The END Fund, the Mectizan Donation Program, Sightsavers and GlaxoSmithKline plc. Collaboration strengthened with the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN), a five-year project launched by the WHO Regional Office for Africa in 2016 to provide countries with technical and fundraising support to help them accelerate control and elimination of the five neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs) with the greatest burden on the continent: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. Five countries of the Eastern Mediterranean Region (Djibouti, Egypt, Somalia, Sudan and Yemen) participated in an ESPEN meeting in Kigali, Rwanda, in July 2018, and resources were secured from ESPEN to support three countries for mass drug administration campaigns.

Trachoma elimination is progressing in the Region following the regional action plan developed in collaboration with the Eastern Mediterranean Region Alliance for Trachoma Control. In 2018, elimination of trachoma as a public health problem was validated in the Islamic Republic of Iran; Iraq was supported in preparing a draft dossier for validation; and Yemen launched its first mass drug administration campaign for trachoma, targeting 395 139 people in Al Hudaydah governorate. Technical support was also provided to Yemen to prepare a dossier for validation of lymphatic filariasis elimination, which was reviewed by the dossier review group, and a regional consultation was held to support Sudan and Yemen to develop multi-year plans for onchocerciasis elimination. A deworming campaign was supported in Afghanistan that saw 9 million school children receive albendazole, while Yemen, with support from WHO and partners, conducted an integrated largescale treatment campaign covering 86 districts in 14 governorates that targeted 4 871 924 people for schistosomiasis and soil-transmitted helminthiases, and 627 190 people for onchocerciasis.

Capacity-building activities were carried out for national staff from Jordan, Saudi Arabia and Yemen on snail control and from Djibouti on mycetoma case management. Additionally, 15 participants from countries of the Region were selected to enroll in an online neglected tropical skin diseases course. The DHIS2 platform was used for 2016 and 2017 leprosy data collection in endemic countries. Active case finding of leprosy was implemented in five priority countries and a field visit made to Sudan to review a special project there. Increased active case-finding activities in Somalia resulted in the detection of 2610 new cases in 2018, up 66% on the previous year and 311% on the year before that.

With 82% of countries in the Eastern Mediterranean Region endemic for both forms of leishmaniasis, control remains challenging, especially in conflict-affected environments. The Region bears about 70% of the global burden of cutaneous leishmaniasis and 20% of visceral leishmaniasis. In 2017, 141 904 new cutaneous leishmaniasis cases and 5245 visceral leishmaniasis cases were reported. Surveillance was strengthened and data quality enhanced in 2018. Six high-priority countries reported detailed country-level data directly through DHIS2 and nine low-burden/ non-endemic countries reported through standardized templates for 2016–2018. To ensure access to treatment for at-risk people in Syrian Arab Republic, WHO delivered around 170 000 vials of meglumine antimoniate and 63 000 bed nets to the country’s north-eastern governorates and 15 000 vials of meglumine antimoniate and related supplies to the Mentor Initiative, a nongovernmental organization that operates in the north-east. Increased attention was given to visceral leishmaniasis, which is potentially fatal, with countries supported to update treatment guidelines and secure donations for first-line recommended medicines. Training workshops for paediatricians, medical staff and programme managers in Morocco and Tunisia on the use of AmBisome and recommended surveillance practices were carried out. The regional situation was reviewed and interregional collaboration strengthened at a meeting on leishmaniasis among neighbouring endemic countries in the WHO African, European and Eastern Mediterranean regions, held in Amman, Jordan, in September 2018. A joint WHO Regional Office/headquarters review mission was conducted in response to the increase in reported cutaneous leishmaniasis cases in Iraq.

During 2018, emphasis continued to be placed on achieving universal vaccination coverage. Analysis of subnational immunization data and providing timely feedback to countries continued in order to ensure high coverage and equity. The development of coverage improvement plans and microplans for low coverage districts was supported, and Gavi-eligible countries were supported to develop and submit applications for resource mobilization to Gavi. The regional network for measles/rubella case-based surveillance and the regional surveillance network for bacterial meningitis, bacterial pneumonia and rotavirus gastroenteritis were also supported.

Different strategies were used in emergency situations to suit each local situation. In 2018, 98 health facilities resumed routine immunization in north-west Syrian Arab Republic, achieving over 90% coverage. Routine immunization antigens were provided to all newly accessible areas under government control. Regular availability of vaccines was secured for the entire country through exceptional support from Gavi, while WHO provided technical support and operational costs.

Despite emergencies in several countries, regional diphtheriatetanus-pertussis (DTP3) immunization coverage increased in 2018 to 82%, with 14 countries achieving and maintaining 90% coverage nationally for DTP3- containing vaccine, while coverage with the first dose of measles-containing vaccine (MCV1) exceeded 95% in 12 countries. Moreover, neonatal tetanus elimination was certified in Djibouti in 2018. However, an estimated 2.9 million children missed at least one dose of DPT3 immunization in 2018, with more than 90% of them in six countries: Afghanistan, Iraq, Pakistan, Somalia, Syrian Arab Republic and Yemen. An outbreak of diphtheria in Yemen, first reported in October 2017, led to over 3000 cases, including 178 deaths. In response, technical support was provided in 2017/2018 for case management, vaccination campaigns and resource mobilization, including exceptional support from Gavi to procure diphtheria and tetanus vaccines for older age groups.

DTP3 coverage reached 82% in 2018, but 2.9 million children still missed at least one dose

Nine countries reported a very low incidence of endemic measles virus transmission (less than 2 cases per million population), with five (Bahrain, Egypt, Jordan, Oman and Palestine) reporting no endemic transmission; these countries are now seeking verification of elimination. The regional commission for verification of measles and rubella elimination is fully functioning, and a workshop was held in June 2018 to train countries close to achieving elimination on the documentation required for verification. All countries in the Region except Djibouti and Somalia are implementing national measles and rubella case-based laboratory surveillance.

In 2018, more than 50 million children received measles-containing vaccines in Afghanistan, Libya and Pakistan through vaccination campaigns, achieving over 90% coverage. WHO worked closely with all partners to support these campaigns, providing technical support in all phases of planning and implementation. To help control the high endemicity of measles in Somalia, support was provided to develop a fiveyear strategic plan for measles control, prepare Gavi applications for follow-up supplementary immunization activities, introduce a second dose of measles vaccine, and develop an immunization data quality improvement plan. Djibouti was supported for training on immunization, data quality assessment, developing an improvement plan and implementing a measles vaccination campaign.

New vaccines were successfully introduced, including rotavirus vaccine in Afghanistan, inactivated polio vaccine in Egypt (the remaining country to do so in the Region), and human papilloma virus vaccine in United Arab Emirates, and approval was granted for Gavi support to introduce typhoid vaccine in Pakistan.

A regional strategic plan for vaccine-preventable diseases and immunization is being developed, aligned with GPW 13. The new strategic plan will encompass the role of immunization in promoting health, achieving universal vaccination coverage and equity, and ensuring no one is left behind, and the provision of immunization during health emergencies.

Public health laboratories make a cross-cutting technical contribution to the surveillance of, and response to, communicable diseases and emerging pathogens, including drug-resistant pathogens. Halfway through its lifespan, implementation of the regional strategic framework for strengthening health laboratory services 2016–2020 remains essential to improve the quality and safety of health laboratory services and meet country obligations under the International Health Regulations (2005). While there has been progress, work remains to be done.

To date, eight countries in the Region have endorsed a national laboratory policy and two are drafting policies. Renewed momentum is needed to strengthen the leadership and governance of national laboratory systems by establishing national laboratory working groups, policies and strategies in more countries. Health laboratory services must remain a priority nationally, with adequate resource planning and budgeting for operations, otherwise resource constraints and competing priorities will jeopardise implementation of the strategic framework and the recommendations of joint external evaluations.

Producing quality results is at the core of every laboratory’s work, and a valuable tool to assess and improve laboratory diagnostic performance is external quality assessment (EQA). In 2018, 35 laboratories in 20 countries participated in the regional EQA programme for microbiology, coordinated by laboratories in the Islamic Republic of Iran and Oman. The programme has been running since 2005, and is currently being evaluated. In addition, Jordan and Pakistan were supported to evaluate their national EQA programmes. To work towards establishing sustainable, sufficient and competent human resources for laboratory service delivery, WHO and partners are developing a global laboratory leadership programme, with the Regional Office leading the development of a pilot module for Pakistan.

In 2018, WHO continued to support countries to implement the regional strategic framework for blood safety and availability (2016–2025) to improve access to affordable and quality-assured blood and blood products at all times, including during humanitarian emergencies. Work focused on strengthening the organization and governance of national blood systems for effective management of blood and blood products, establishing mechanisms for plasma fractionation, improving blood donor management and meeting the increased demand for blood transfusion during emergencies.

Demand for blood and blood products continues to increase in countries affected by humanitarian emergencies. Five countries (Afghanistan, Libya, Somalia, Syrian Arab Republic and Yemen) were supported to integrate blood transfusion services into their national emergency preparedness and response efforts, and to address the safety and availability of blood transfusion during humanitarian emergencies.

Significant progress was made in tackling antimicrobial resistance (AMR) in the Region in 2018. Development of national AMR action plans continues to be a key priority. By the end of 2018, nine countries (Afghanistan, Egypt, Islamic Republic of Iran, Jordan, Libya, Oman, Pakistan, Saudi Arabia and Sudan) had officially endorsed and submitted their plans to the WHO online platform, while five countries (Bahrain, Iraq, Morocco, Qatar and Tunisia) had completed their plans pending endorsement by ministers of health. Planning involves the human health, animal health, livestock, agriculture, environment and food production sectors.

WHO’s global action plan on AMR is being implemented in the Region with a focus on generating surveillance data: 14 countries from the Region are enrolled in the global antimicrobial resistance surveillance system (GLASS) platform, with 12 reporting AMR data for the 2018 data call. To complement human AMR surveillance, the Tricycle Project was launched in 2018 to develop a global harmonized protocol on integrated AMR surveillance of extended-spectrum B-lactamase (ESBL) Escherichia coli in humans, animals and the environment. The Project reflects tripartite collaboration between WHO, the Food and Agriculture Organization of the United Nations (FAO) and the World Organisation for Animal Health (OIE). Four countries in the Region (Egypt, Jordan, Morocco and Sudan) are being supported to implement the Project, while Pakistan began implementation in 2018. National antimicrobial consumption data from the Islamic Republic of Iran, Jordan and Sudan was included in the first WHO report on surveillance of antibiotic consumption, released at the end of 2018.

With support from the Korea International Collaboration Agency (KOICA), Jordan established a multidisciplinary national AMR committee and national coordinating centre, assigned a national AMR reference laboratory, selected eight sentinel AMR surveillance sites and developed a national AMR surveillance plan. Support was provided to build the capacity of the eight AMR sentinel hospitals, create and train AMR surveillance teams, and train hospital laboratories on standardizing operating procedures for pathogen identification, antimicrobial susceptibility testing and quality control. WHONET software was installed at the national coordinating centre and surveillance sites for data collection and reporting. A point prevalence survey to measure the prevalence of antimicrobial use among hospitalized patients was conducted in the eight surveillance sites, and data analysis is in progress.

Laboratory capacities to support AMR detection in countries were mapped and national reference laboratories for microbiology and AMR surveillance assessed in Jordan, Pakistan, Sudan and Tunisia; action is being taken to raise workforce competency to international standards. Technical support was provided to set up internal laboratory quality control systems for three countries (Iraq, Jordan and Sudan). Furthermore, the status of infection prevention and control programmes was assessed in 14 countries.

Studies were piloted in Egypt and Sudan using tailored behaviour-change interventions for the containment of AMR. Efforts focused on changing antibiotic prescription practices in primary health care facilities in Sudan, and on improving prescription practices for surgical prophylaxis in Egypt. Qualitative research studies were conducted to identify target behaviours, followed by capacity-building and the implementation of interventions. Currently, both countries are evaluating the impact.

The Video for Change initiative was launched in Egypt, Jordan and Sudan to encourage young people to use technology to promote behaviour change to combat AMR. Over 100 medical, pharmacy and veterinary students attended a health communication training course. World Antibiotic Awareness Week was celebrated on 12–16 November 2018 under the theme “Safeguarding Antibiotics – Handle with Care”. The campaign included five days of tailored messaging around each of the objectives of the global action plan on AMR and a joint press conference between WHO and FAO regional offices on the importance of a One Health approach to AMR.

The WHO European and Eastern Mediterranean regions have started to map and document areas of collaboration to define potential areas for future collaboration and identify synergies. Collaboration in 2018 included an interregional workshop on preparing to transition towards domestic financing in TB, HIV and malaria programmes, an interregional consultation meeting on leishmaniasis among neighbouring endemic countries in the Eastern Mediterranean, African and European regions, and a meeting on laboratory strengthening. The two regions also collaborated in documenting and estimating the TB burden in selected regions of north-east Syrian Arab Republic and securing TB medicines to treat detected cases; immunization activities were coordinated with the WHO Project Office in Gaziantep, Turkey.

Collaboration also included experience exchange between national HIV/ AIDS and sexually transmitted disease programme staff from Pakistan and Ukraine, and collaboration on laboratory regulatory frameworks, workforce and EQA, among other areas. Lessons were learnt from the European Region in establishing an AMR surveillance network, and its tailored AMR behaviour-change programme was adapted to the Eastern Mediterranean Region.