Health emergencies
These arise from all hazards – natural (geological, hydrometeorological), biological/outbreaks, societal (especially conflict and civil strife) and technological. Moreover, the Region hosts the largest number of people in need of humanitarian assistance globally, is the source of the largest number of forcibly displaced persons, and hosts the largest number of forcibly displaced people.
Of the 131.7 million people in need of aid globally in 2018, 70.2 million (53.3%) lived in the Region. The Region also faced increased population movement due to forced displacement and migration. At the end of 2018, 70.8 million people were forcibly displaced worldwide – including refugees and internally displaced persons. Of these, 32.1 million (45.3%) originated from the Region, while 25.4 million continued to reside in the Region.
Nine out of 22 countries in the Region continued to respond to emergencies in 2018 (Grade 3, as per WHO’s grading: Somalia, Syrian Arab Republic and Yemen; Grade 2: Iraq, Libya, Palestine and Sudan; Grade 1: Afghanistan and Pakistan). Saudi Arabia has been at Grade 2 for Middle East respiratory syndrome coronavirus (MERS-CoV) since 2012. An additional seven countries in the Region were directly or indirectly affected by emergencies: Djibouti, Egypt, Jordan, Kuwait, Lebanon, Oman and United Arab Emirates.
Attacks on health care continued relentlessly in a number of countries, making it the most dangerous region for health workers among all WHO regions. WHO’s Surveillance System on Attacks on Health Care documented 725 attacks in the Region during 2018, resulting in 137 deaths. At country level, steps were taken to prevent and mitigate such attacks, by increasing awareness of the right to health, as well as various physical measures to limit the impact of attacks on health infrastructure.
Ensuring country preparedness
WHO convened its seventh regional meeting of stakeholders under the International Health Regulations (IHR) (2005) in December 2018, bringing together diverse national sectors and technical partners. The meeting gathered more than 100 participants to discuss the current situation in implementation of core capacities and the way forward for the Region. WHO also developed guidance on the terms of reference and functions of the IHR multisectoral committee and the linkages such a committee should have with the other coordination structures in a country.
In accordance with Article 54 of the IHR (2005), States Parties within the Eastern Mediterranean Region continued to produce annual reports to WHO on The Eastern Mediterranean Region is highly prone to emergencies. Annual report of the Regional Director 2018 79 the achievement of IHR-related core capacities. The annual reporting tool was modified to improve its alignment with the joint external evaluation (JEE) tool following a consultative process with IHR national focal points. The revised annual reporting tool was introduced to States Parties in March 2018.
JEE is a voluntary collaborative process to assess a country’s capacity under the IHR (2005) to prevent, detect and rapidly respond to public health threats. As of December 2018, 17 countries in the Region had conducted JEE and 15 JEE reports had been produced. The overall mean JEE score across the 19 technical areas in the Region was 3, meaning “developed capacity”, and on average most of the attributes for these technical areas were available; however, work is still needed to meet the remaining attributes and ensure the sustainability of all capacities.
A national action plan for health security is an essential next step in the process of monitoring and evaluation of IHR core capacities in countries. In using the JEE to develop its action plan, each country is able to highlight gaps and needs for current and prospective donors and partners in an effort to fill gaps with resources. Implementing a national action plan for health security enables countries to address gaps through structured actions supported by stakeholders at the national, regional and global level. The plans guide Member States in building capacity to be better prepared and operationally ready to manage public health risks and events, and therefore to better protect populations. In 2018, 12 countries of the Region completed their national action plans for health security and three were planning to finalize their plans; a further three countries are planning to finalize their action plans in 2019 (Morocco, Tunisia and United Arab Emirates). Implementation of the action plans requires dedicated resources and will be a priority for WHO support in 2019.
Mapping of hazards and development of national all-hazards public health preparedness and response plans were supported in Egypt, Iraq, Jordan, Libya, Morocco, Pakistan, Somalia and Tunisia. A regional profile for potential hazards as well as hazard-specific contingency plans were developed to facilitate and streamline the support provided to countries responding to public health emergencies.
Several activities were conducted for building IHR (2005) requirements at points of entry into Member States, including the development of all-hazards public health emergency preparedness and response plans enhancing cross-border collaboration, and providing advice on exit and entry screening in the context of public health emergencies.
In 2018, WHO provided training in conducting national simulation exercises for all countries in the Region. As an initial and key part of national exercises, participants were instructed on how to design and implement table-top exercises to test plans and procedures outlining their IHR capacities. The WHO simulation exercise manual has been translated into French and is being translated into Arabic. WHO supported external review of national responses to acute public health events, particularly the systems in place and capacities in surveillance, laboratories, coordination, risk communications and case management. After-action reviews were conducted for the Islamic Republic of Iran (earthquake), Morocco (brucellosis) and Pakistan (dengue), with similar activities planned for Oman (dengue). Simulation exercises were conducted in Iraq, Jordan, Palestine, Pakistan and Tunisia, to test national responses to acute public health events. A regional simulation exercise was also conducted for potential importation of Ebola virus disease; the exercise tested several elements of regional capacity to scale up preparedness and operational readiness in countries.
Important progress was achieved in enhancing hospital preparedness. Activities were conducted to assess hospital preparedness, develop preparedness plans and train the hospital workforce in Bahrain, Libya and Sudan. Online training packages have been developed for hospital preparedness and management of all hazards, to be rolled out in countries using a blended approach of online and face-to-face training. Good progress was also made in advancing One Health activities in the Region; new approaches were used including a national bridging workshop on veterinary services and after-action reviews in Morocco. A regional plan was developed (based on JEE results) to enhance the One Health approach in countries, including an online training package.
The Khartoum Declaration on Sudan and Bordering Countries: Cross-Border Health Security was signed by Chad, Egypt, Ethiopia, Libya, South Sudan and Sudan in November 2018, to commit to strengthening preparedness and response to public health threats and events across borders in an effort to further the implementation of the IHR and pursue global health security.
The second global meeting on migrant health gathered migrant health focal points from WHO offices and representatives of stakeholder institutions to agree on a number of recommendations for promoting refugee and migrant health. The outcomes of the two-day meeting were aligned with the WHO global action plan for promoting the health of refugees and migrants. A regional action plan is being developed to promote the health of refugees and migrants and ensure their inclusion in national public health preparedness and response plans.
Managing infectious disease outbreaks
In 2018, 19 major outbreaks of 10 different emerging and epidemic-prone diseases occurred or continued in 12 of the 22 countries in the Region, resulting in 435 625 cases of illness and 844 deaths. Outbreaks included: chickenpox (varicella) in Pakistan; chikungunya in Sudan; cholera in Somalia and Yemen; Crimean-Congo haemorrhagic fever in Afghanistan, Iraq and Pakistan; dengue 82 The work of WHO in the Eastern Mediterranean Region fever in Oman, Pakistan, Sudan and Yemen; diphtheria in Yemen; extensively drug-resistant typhoid fever in Pakistan; MERS-CoV in Kuwait, Oman, Saudi Arabia and United Arab Emirates; travelassociated Legionnaires’ disease in United Arab Emirates; and West Nile fever in Tunisia. WHO collaborated with the countries concerned to investigate and respond to these outbreaks and minimize their impact.
In Yemen, WHO collaborated with the Ministry of Public Health and Population (MoPHP) to strengthen early warning disease surveillance and case management, deploy oral cholera vaccines and improve access to safe water and sanitation. WHO, the MoPHP and partners launched Yemen’s first oral cholera vaccination campaign in May 2018, aiming to control the world’s largest cholera outbreak. The campaign was launched as part of a broader ongoing integrated response plan for cholera that included surveillance and case detection, community engagement and awareness, enhancing laboratory testing capacity, improving water and sanitation, and training and deploying rapid response teams. In March 2018, WHO, in coordination with the Ministry of Public Health and Population and the United Nations Children’s Fund (UNICEF), conducted a large-scale vaccination campaign to control the spread of diphtheria. The campaign targeted around 1 million children aged 6 weeks to 15 years in 39 priority districts from 11 governorates. In Sudan, WHO supported the improvement of early detection, laboratory diagnosis, case management and access to safe water and sanitation, thus reducing cases of acute watery diarrhoea and related deaths. Sudan’s Federal Ministry of Health, supported by WHO and partners, also contained an outbreak of chikungunya with integrated vector control management, risk communication and improved surveillance. Pakistan experienced a large outbreak of extensively drug-resistant typhoid fever, and WHO supported the country’s response with technical support for a field investigation and the development of a national action plan.
Regional Emergency Operations Centre
In 2018, the regional Emergency Operations Centre (EOC) continued to coordinate the organizational response to graded emergencies through real-time information sharing and collective decision-making. Additionally, the EOC hosted a number of global and regional simulation and table-top exercises for potential disease outbreaks and health emergencies, including influenza and Ebola virus disease.
In one of these, seven countries from the Region participated in a simulation exercise for a global pandemic in December 2018, coordinated by the WHO Global EOC and the EOC Network, a global network of health emergency operations centres. Egypt, Jordan, Lebanon, Oman, Saudi Arabia, Tunisia and United Arab Emirates were among more than 40 countries worldwide participating in the three-day simulation, which was the first global pandemic response training exercise.
The exercise provided a hands-on opportunity to determine the capacity of WHO and countries to respond to a potential outbreak of influenza with pandemic potential, allowing the identification of gaps that need to be addressed. The exercise occurred on the centenary of the 1918 influenza pandemic, which is estimated to have infected one third of the global population and resulted in the deaths of millions of people.
WHO helped Member States enhance their capacity for prevention, surveillance, preparedness and response for seasonal and pandemic influenza. In Tunisia, experts and health ministry staff from five countries convened to strengthen national pandemic influenza preparedness plans, focusing on improving influenza surveillance, risk assessments, preparedness and response, and determining the severity of outbreaks. Advanced training on pandemic influenza severity assessment was conducted with the aim of strengthening the capacity of 14 countries to determine influenza baselines and threshold values. As a result, five countries in the Region completed the calculation of influenza baseline and threshold values in 2018. Influenza experts from 13 countries received advanced training on influenza detection and characterization in order to enhance and standardize the detection and confirmation of seasonal and pandemic influenza viruses.
In Somalia, WHO trained health surveillance officers from 11 regions across the country on the electronic Early Warning Alert and Response Network (EWARN), an upgraded version of the system which improves timely detection and information sharing for various high-threat pathogens. Likewise, during the yearly Hajj pilgrimage in Saudi Arabia, surveillance was a priority activity. WHO and the Ministry of Health of Saudi Arabia successfully piloted a Disease Early Warning System (DEWS), as well as implementing a range of preparedness and readiness measures as required under the IHR (2005) for mass gathering events. Due in part to these concerted efforts, the Hajj was once again free from any public health event of potential concern (as it has been since the emergence of MERS in 2012). Furthermore, in 2018 WHO helped establish a pool of MERS experts in the Region who can be deployed rapidly during any outbreak of the disease.
To improve the speed and quality of emergency response, 130 members of multidisciplinary Ebola and MERS rapid response teams received additional training in five countries. The trainings improved knowledge and skills on how to conduct rapid risk assessments, outbreak investigations and epidemiological data analysis, and how to implement initial public health measures to contain an outbreak. The trained national rapid response teams were actively deployed and responded to several emergencies, including outbreaks in Afghanistan, Libya, Somalia, Syrian Arab Republic and Yemen.
In 2019, WHO will finalize the regional strategic framework for the prevention and control of emerging and epidemic-prone diseases, and provide technical assistance to Member States to roll out its implementation. The framework covers all priority areas within infectious hazards management, from prevention and surveillance to preparedness and response. Some of the priorities for WHO in 2019, as detailed in the framework, include continuing to strengthen existing epidemiological and virological surveillance systems for various high-threat emerging and re-emerging diseases. In countries facing complex emergencies, WHO will regularly train the health workforce and improve electronic platforms for real-time data collection and automated analysis to support outbreak investigation, intervention and containment.
Countries will receive support for their core laboratory diagnostic capacity to detect high-threat pathogens, as required under the IHR (2005), and be supported to increase rapid response capacity by enhancing operational skills and competencies to conduct timely field investigations and response activities. WHO will also support research efforts to improve understanding where there are gaps in knowledge about etiology, transmission, risk factors, disease burden and patient outcomes associated with high-threat pathogens.
Responding to humanitarian health emergencies
WHO continues to strengthen its management of emergencies through application of the Incident Management System (IMS) – an international best practice that has been adopted by many public health agencies worldwide. Increasingly consistent application of the IMS has assisted the Organization in becoming more predictable and effective in its response to emergencies, including in the Eastern Mediterranean Region. WHO has also improved its management of protracted emergencies through application of the humanitarian–development nexus, which brings humanitarian and development partners together for joint analysis, joint planning and the identification of collective outcomes.
The regional Emergency Operations Centre (EOC) continued to coordinate the organizational response for graded emergencies, and also hosted a number of global and regional simulation and table-top exercises in 2018 for potential disease outbreaks and health emergencies.
WHO’s operations and logistics hub at the International Humanitarian City in Dubai continued to ensure the safe, reliable, timely and uninterrupted delivery of medicines and other health supplies to ensure the protection of people from the impact of health emergencies. Nearly 75% of all WHO health supplies procured globally in 2018 were delivered to countries in the Eastern Mediterranean Region: overall, WHO delivered more than 1462 metric tonnes of health supplies for more than 4.5 million beneficiaries in 22 countries across three WHO regions from its logistics hub in Dubai.
To help Yemeni children suffering from medical complications due to malnutrition, WHO established 25 therapeutic feeding centres in 2018 (bringing the total number of functional centres to 54 in 19 governorates), delivered 450 severe acute malnutrition kits to the feeding centres, trained 621 health workers on case management of severe acute malnutrition, and provided medicines and fuel to keep health centres functioning. In total in the period 2017–2018, WHO treated 14 697 children, increasing the cure rate from 75% (2017) to 87% (2018).
In 2018, the rapidly evolving situation in the Syrian Arab Republic required WHO to intervene in many geographic locations. In eastern Ghouta, more than 4200 people were referred to public hospitals and over 55 000 children were vaccinated against polio and other childhood diseases; community workers and mobile teams also provided basic psychological interventions to almost 34 000 people. In the southwest of the country, WHO distributed over 70 tonnes of medicines and supplies to health care facilities and supported nongovernmental organizations that provided more than 97 000 primary health care consultations through fixed clinics and mobile teams. In November 2018, an interagency and Syrian Arab Red Crescent convoy managed to reach people in Rukban for the first time in over 9 months; WHO delivered over 3 tonnes of medicines and medical supplies (enough for 31 601 treatments) to the camp and assessed the health situation and health needs. From its cross-border hub in Gaziantep, Turkey, WHO supported the operating costs of 38 primary and secondary health care facilities, 185 mobile teams and 54 mobile clinics and ambulances in northwest Syria. The Gaziantep hub delivered 497 tonnes of medical supplies to the areas where health needs were greatest and supported 1.8 million primary health care consultations and the treatment of more than 88 800 trauma patients. The hub also supported partners through the provision of technical expertise and training. In the autumn of 2018, the Gaziantep hub delivered its largest ever cross-border shipment of emergency medicines and supplies to northwest Syria: 104 tonnes of supplies were delivered to 180 health care facilities. In 2018, WHO delivered over 245 tonnes of medical equipment and supplies (enough to address the health needs of more than 200 000 people) to northeast Syria through the Al-Yarubiyah border crossing in Iraq. WHO also supported an international nongovernmental organization that provided primary health care and emergency referral services to over 10 000 people in ArRaqqa city in 2018.
Violence in southern Tripoli, Libya, in September 2018 left hundreds of injured people in need of urgent, life-saving medical care. Attacks on health care were also reported from the country. To support the response efforts of the Ministry of Health, WHO deployed 10 mobile emergency trauma teams to areas where fighting was ongoing. WHO also delivered trauma medicines for 200 critical cases. Medicines for the treatment of chronic diseases were delivered to health facilities in areas hosting people displaced as a result of the violence.
In August 2018, WHO and Iraqi health authorities responded to an outbreak of gastrointestinal illnesses in Basra as a result of unsafe water supplies. WHO and the Ministry of Health responded by providing medicines and medical supplies, ensuring free treatment to all patients, training and deploying health staff, conducting community awareness campaigns, and scaling up water quality monitoring in affected areas.
To support people affected by drought in Afghanistan, WHO supported rapid response implementation of the basic package of health services for areas at greatest threat. WHO also sent medicines and medical supplies to health facilities in prioritized drought-affected areas. In 2018, more than 1.24 million health consultations were provided, 18 mobile health teams were deployed to provide essential lifesaving services to drought- and conflict-displaced populations, and 32 hard-to-reach districts were provided with essential health services.
In 2018, WHO’s work in the area of emergencies was funded at 80%, through the support of a number of key donors. These included the United States Agency for International Development (USAID), United States Department of State, European Commission’s Civil Protection and Humanitarian Aid Operations department (ECHO), Germany, United Nations Office for the Coordination of Humanitarian Affairs (OCHA), Japan, Republic of Korea, United Nations Central Emergency Response Fund (CERF), Department For International Development (DFID) United Kingdom, Norway, Qatar, Kuwait, World Bank, Saudi Arabia, United Arab Emirates, Oman, China, Italy, Algeria, Slovakia, Sweden and Lithuania. However, although some countries received substantial support from donors in 2018, other countries are facing forgotten emergencies, where health needs remain significantly underfunded, including Somalia, Sudan and refugee-hosting countries.
Partnerships remain vital for work in response to emergencies, with an emphasis on collective action and inter-sectoral coordination, especially with the nutrition and water and sanitation sectors. WHO has three main operational partnerships worldwide, all of which are active in the Region: the Global Health Cluster (GHC), the Global Outbreak Alert and Response Network (GOARN) and emergency medical teams (EMTs).
The GHC is the most operational partner in humanitarian crises, with 29 clusters active at country and regional levels, operating out of eight national and 42 sub-national sites, and aiming to serve 57.1 million people in need of health services. GOARN represents a network of public health institutions that deploys technical experts in response to outbreaks and public health events worldwide. WHO’s Regional Office for the Eastern Mediterranean hosts 12 GOARN partners and during 2018 deployed experts from the network to an outbreak of dengue fever in Pakistan. EMTs are self-sufficient teams that can augment clinical services during emergencies. National EMTs are expanding throughout the Region, with some Member States also developing EMTs that may eventually deploy internationally to provide additional support when national capacities elsewhere are overwhelmed.
