Health Organization Eastern Mediterranean Region Research Articles

Bacterial Meningitis Surveillance in the Eastern Mediterranean Region, 2005-2010: Successes and Challenges of a Regional Network

To describe epidemiology of bacterial meningitis in the World Health Organization Eastern Mediterranean Region countries and assist in introduction of new bacterial vaccines. A laboratory-based sentinel surveillance was established in 2004, and up to 10 countries joined the network until 2010. Personnel at participating hospitals and national public health laboratories received training in surveillance and laboratory methods and used standard clinical and laboratory-confirmed case definitions. Over 22,000 suspected cases of meningitis were reported among children ≤5 years old and >6600 among children >5 years old. In children ≤5 years old, 921 of 13,125 probable cases (7.0%) were culture-confirmed. The most commonly isolated pathogens were S pneumoniae (27% of confirmed cases), N meningitidis (22%), and H influenzae (10%). Among culture-confirmed case-patients with known outcome, case-fatality rate was 7.0% and 12.2% among children ≤5 years old and those >5 years old, respectively. Declining numbers of Haemophilus influenzae type b meningitis cases within 2 years post-Haemophilus influenzae type b conjugate vaccine introduction were observed in Pakistan. Bacterial meningitis continues to cause significant morbidity and mortality in the Eastern Mediterranean Region. Surveillance networks for bacterial meningitis ensure that all sites are using standardized methodologies. Surveillance data are useful to monitor impact of various interventions including vaccines, but maintaining data quality requires consistent reporting and regular technical support.

Health policy reviews in the JRSM

Health systems throughout the world face many challenges. These challenges include the rising prevalence of chronic diseases such as diabetes; a rise in unhealthy behaviours and risk factors for poor health outcomes, such as physical inactivity, calorie-rich diets and obesity; increasing difficulty in maintaining expenditure on health services and funding new, high-cost treatments; maintaining the population's access to healthcare while at the same time curtailing this growth in healthcare spending; and determining the most appropriate balance between primary care and specialist services.1 Other key areas include making the most effective use of new technology, and addressing issues of patient safety and quality of care.2 Added to these challenges, in many countries and in Europe in particular, is the impact that financial austerity is now having on health services.3 In countries such as Spain and Greece, we are now seeing major cutbacks in health and social care services. Elsewhere in the world, expectations of prosperity and political reforms go hand in hand with a desire for better public services. In many Arab countries, for example, we are now seeing public expectations of increased political freedoms and greater economic prosperity, as well as a desire for improved access to health, education and social care services. In low-income countries, such as much of sub-Saharan Africa, poverty, weak health systems, neglected tropical diseases and a rising burden of chronic diseases, all contribute to poor health outcomes and high rates of premature mortality. A new series of health policy reviews in the JRSM will report on these issues and how health systems are aiming to address key health policy challenges. Traditionally, research and debate in these areas has been very nation-specific, with relatively few attempts to carry out cross-national studies. However, if many of the challenges faced by healthcare systems are similar, then it is likely that countries can draw upon each other's experiences in developing methods of dealing with these challenges. The first review in this series discusses the role of non-medical community health workers in improving access to care.4 The use of such workers is seen as one way of improving access to health services in a cost-effective manner. Another review will discuss the state of health research and development in the World Health Organization Eastern Mediterranean Region. This is a region that is currently going through considerable political change and where – because of the strategic importance of the region – the results of these changes will have an impact on many other countries. Future articles will discuss the feasibility of defining ‘ambulatory care sensitive conditions’ that can act as markers of high-quality delivery of primary care services, and initiatives to limit the harms caused by excessive alcohol consumption. Although some of the early articles will focus on the challenges facing England's National Health Service, in future articles, the range of topics and also of countries and regions covered will increase. The aim will be to cover important areas of health policy and provide evidence that clinicians, managers and policy-makers can use in helping them to meet the many challenges that the health systems they work in are currently facing. Articles will generally have authors from at least two different countries to ensure that their lessons are widely applicable and not overly focused on one particular country. Ideas for articles for the series and potential authors are welcome and can be sent to either the Editor of the JRSM or to Azeem Majeed at Imperial College.

410 Promoting public–private mix for TB-DOTS: a multicountry study from the WHO Eastern Mediterranean Region

This study was carried out to document the implementation status of public-private mix (PPM) in 6 member countries of the World Health Organization Eastern Mediterranean Region, with a particular focus on advocacy, communication and social mobilization (ACSM) specific to PPM. Interviews and focus group discussions were held with staff of national tuberculosis control programmes and partners. Four PPM models were being practised. For all models, ACSM specific to PPM was at the elementary stage. Participants perceived that promoting private partners was difficult, specific policy guidelines were deficient and human resources and capacity for both initiatives were lacking across the region. Building ACSM capacity is required along with the development of guidelines and the implementation of country-specific communication plans to carry out local-level advocacy, strategic communication and effective social mobilization to maximize the benefits of PPM.

Measles Control and Elimination in Somalia: The Good, the Bad, and the Ugly

Despite enormous challenges, Somalia has been successfully implementing accelerated measles control activities since 2005. Through innovative strategies and with the support of local and international partners, the country has shown potentials of implementing measles mortality reduction activities in complex emergencies. Measles incidence has been reduced by >80% after the measles catch-up campaigns of 2005-2007, and national reported measles routine immunization coverage with first dose measles containing vaccine has reached 59% for the first time in 2009. However, the near collapse of the health care system and the ongoing insecurity continue to hamper the implementation of recommended measles control and elimination strategies in some parts of the country, making these achievements fragile. Somalia exemplifies the challenges in meeting measles elimination goals in the World Health Organization Eastern Mediterranean region. As the region is entering its 2010 measles elimination goals, it appears necessary to establish realistic and flexible interim goals for measles control in Somalia that will take into consideration the specificities of the country. Maintaining flexibility in conducting field operations, securing financial resources, multiplying opportunities for measles vaccination, and improving disease monitoring systems will remain vital to sustain and improve current achievements.

Assessment and management of latent tuberculosis infection in a refugee population in the Northern Territory

To assess the prevalence of latent tuberculosis infection (LTBI) in recently arrived refugees in the Northern Territory and to obtain comprehensive data for rates of treatment acceptance and completion for this condition. Prospective data collection and follow-up of all 471 newly arrived refugees seen at the Centre for Disease Control, NT refugee health clinic from February 2006 to January 2009. Rates of LTBI determined by tuberculin skin testing; subsequent assessment and treatment compared with local protocols. 458 of 465 eligible refugees were adequately assessed for LTBI, of whom 146 (31.9%) were diagnosed with LTBI. Older age, male sex and World Health Organization Eastern Mediterranean region of birth were associated with increased prevalences of LTBI. Of the refugees diagnosed with LTBI, 10 failed to attend for follow-up and 15 were not offered treatment. Isoniazid therapy was accepted by 93 of 121 refugees (76.9%), and 41 of these (44.1%) completed treatment. The most common reasons for discontinuation of therapy were medication-related side effects (most often gastrointestinal) and loss to follow-up. Increasing age was associated with failure to complete treatment. Outcomes of assessment and treatment for LTBI in newly arrived refugees in the NT are comparable to those for other target groups screened in developed countries. Loss to follow-up caused significant attrition in numbers, but complete data were obtained for a large proportion of eligible refugees. Most refugees who are offered treatment for LTBI accept, but less than half complete treatment.

Implementation of integrated vector management for disease vector control in the Eastern Mediterranean: where are we and where are we going?

Integrated vector management (IVM) is an acknowledged strategy of choice for the prevention and control of vector-borne diseases. The paper describes and documents the progress countries of the World Health Organization (WHO) Eastern Mediterranean Region have made in endorsing and translating the strategy into action at the national level. These include increased political commitment; strengthened intersectoral coordination and partnership; strengthened capacity in entomology and vector control; and scaling up of vector control interventions through universal access. These efforts, however, are compromised by inappropriate institutional arrangements in some countries; weak national capacities to address management of pesticides; , development and spread of vector resistance to insecticides, including to pyrethroids; and the expansion of emerging and re-emerging vector-borne diseases. With WHO leadership and support from partners, countries continue to address these challenges head-on.

Trends of Hematopoietic Stem Cell Transplantation in the Eastern Mediterranean Region, 1984-2007

Hematopoietic stem cell transplantation (HSCT) activity was surveyed in the 9 countries in the World Health Organization Eastern Mediterranean region that reported transplantation activity. Between the years of 1984 and 2007, 7933 transplantations were performed. The number of HSCTs per year has continued to increase, with a plateau in allogeneic HSCT (allo-HSCT) between 2005 and 2007. Overall, a greater proportion of transplantations were allo-HSCT (n = 5761, 77%) compared with autologous HSCT (ASCT) (n = 2172, 23%). Of 5761 allo-HSCT, acute leukemia constituted the main indication (n = 2124, 37%). There was a significant proportion of allo-HSCT for bone marrow failures (n = 1001, 17%) and hemoglobinopathies (n = 885, 15%). The rate of unrelated donor transplantations remained low, with only 2 matched unrelated donor allo-HSCTs reported. One hundred umbilical cord blood transplantations were reported (0.017% of allo-HSCT). Peripheral blood stem cells were the main source of graft in allo-HSCT, and peripheral blood stem cells increasingly constitute the main source of hematopoietic stem cells overall. Reduced-intensity conditioning was utilized in 5.7% of allografts over the surveyed period. ASCT numbers continue to increase. There has been a shift in the indication for ASCT from acute leukemia to lymphoproliferative disorders (45%), followed by myeloma (26%). The survey reflects transplantation activity according to the unique health settings of this region. Notable differences in transplantation practices as reported to the European Group for Blood and Marrow Transplantation over recent years are highlighted.

Screening for breast cancer in the Eastern Mediterranean Region

1Associate Director Research, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada (Correspondence to A.B. Miller: ab.miller@sympatico.ca). Breast cancer is the most important cancer in women in the World Health Organization (WHO) Eastern Mediterranean Region (EMR), being the number one cancer in 16 of the 22 countries. In many technically advanced countries mammography screening, generally from the age of 50 years, is the most common breast cancer control strategy performed. The WHO has recommended a step-wise approach to introducing screening, beginning with the promotion of early diagnosis through public and professional education, to pilot studies of organized programmes, followed by national programmes as resources permit [1,2]. This approach has been incorporated in the Cancer Control Strategy of the EMR Office of WHO. In summary, the planning steps include:

Leishmaniasis in the World Health Organization Eastern Mediterranean Region

Leishmaniasis represents a major public health problem in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO). Cutaneous and visceral leishmaniasis are mainly seen in 14 of the 22 countries of the region. In several of these countries outbreaks have an apparent tendency to occur at around 10-year intervals. In 2008, some 100 000 new cases of cutaneous leishmaniasis were reported. Foci of zoonotic cutaneous leishmaniasis, caused by Leishmania major, occur in Afghanistan, Egypt, Iran, Iraq, Jordan, Libya, Morocco, Palestine, Pakistan, Saudi Arabia, Sudan, Syria, Tunisia and Yemen. Anthroponotic cutaneous leishmaniasis, caused by L. tropica, occurs in Afghanistan, Iran, Iraq, Morocco, Pakistan, Saudi Arabia, Syria and Yemen. Anthroponotic visceral leishmaniasis, caused by L. donovani, occurs mainly in Sudan and Somalia. Zoonotic visceral leishmaniasis, caused by L. infantum, occurs in most countries of the region. In order to address the problem of leishmaniasis in the EMR, WHO is supporting ministries of health through a strategic plan focusing on (a) training programme managers and health workers on diagnosis and case management; (b) establishing a harmonized regional surveillance system; (c) creating a regional network of experts; (d) promoting political commitment of national governments.

Status of hematopoietic stem cell transplantation in the WHO Eastern Mediterranean Region (EMRO)

Several centers are now performing allogeneic hematopoietic stem cell transplantation (HSCT) in the World Health Organization Eastern Mediterranean Region (EMRO) but the availability is still limited due to high cost and the need for multi-disciplinary team and an advanced laboratory support. Special issues including compatible donor availability, potential for alternate donor programs, differences in pattern of disease, pre-HSCT general status particularly for patients with BM failure, high sero-positivity for CMV, Hepatitis B and C infection and specific observations about GVHD with its relation to genetically homogeneous community are discussed. A total of 17 HSCT programs (performing five or more HSCTs annually) exist in nine countries of the EM region. Only six programs are currently reporting to EBMT or IBMTR. A total of 7617 HSCTs including 5701 allogeneic HSCTs have been performed. Due to low HSCT team density (1.5583 teams/10 million inhabitants versus 14.4333 in Europe) and very low HSCT team distribution (0.2729 teams/10,000 sq km area versus <1 to 6 teams in Europe) only 70.8% of total population has access to such a program in EM region. GNI/capita had no clear association with low HSCT activity; however improvement in infrastructure and establishment of EM regional HSCT registry need prioritization.

Index medicus for the Eastern Mediterranean region

The study provides the rationale, history and current status of the Index Medicus for the World Health Organization Eastern Mediterranean Region. The Index is unique in combining the geographic coverage of peer-reviewed health and biomedical journals (408 titles) from the 22 countries of the Region. Compiling and publishing the Index coupled with a document delivery service is an integral part of the WHO Regional Office's knowledge management and sharing programme. In this paper, bibliometric indicators are presented to demonstrate the distribution of journals, articles, languages, subjects and authors as well as availability in printed and electronic formats. Two countries in the Region (Egypt and Pakistan) contribute over 50% of the articles in the Index. About 90% of the articles are published in English. Epidemiology articles represent 8% of the entire Index. 15% of the journals in the Index are also indexed in MEDLINE, while 7% are indexed in EMBASE. Future developments of the Index will include covering more journals and adding other types of health and biomedical literature, including reports, theses, books and current research. The challenges and lessons learnt are discussed.

Basic development needs approach in the Eastern Mediterranean Region: from theory to practice

Poverty and health are mutually reinforcing and deprivation in one area produces negative effects in the other. Unfortunately at the beginning of the 21st century, the number of people living in absolute poverty continues to rise with grim health consequences. Many studies have clearly established that health is related to and influenced by a complex of environmental, social and economic factors ultimately related to each other. Therefore, actions undertaken outside of the health sector are likely to have effects much greater than those obtained through the health sector alone. Thus, the countries of the World Health Organization Eastern Mediterranean Region have adopted basic development needs to address all the determinants of health collectively through community empowerment in order to transform social lifestyles and enhance human development. This article presents the contribution made by basic development needs in empowering local communities and vulnerable groups to acquire their essential needs through the efficient use of available resources. The assessment surveys of the ongoing programme conducted periodically in different countries have demonstrated significant reduction in poverty levels and improvement in quality of life indices pertaining to a wide range of fields, including health, nutrition and other social sectors.

Water-conscious development and the prevention of water misuse and wastage in the Eastern Mediterranean Region

Many countries of the World Health Organization Eastern Mediterranean Region suffer from severe water shortage, primarily as a result of population growth. The problem will undoubtedly worsen in the future with possibly drastic consequences. This paper outlines the current situation in the Region and the possible impact of water scarcity on health and the environment. Water conservation in agricultural, commercial and domestic areas is discussed from the perspective of water-conscious development and possible strategies are proposed.

Partnership of the community in support of health for all

Health for all is a people-based approach to health which considers the community as its focus. Community partnership is an important principle of health for all. This paper describes the many aspects of community partnership and gives examples of community partnerships initiatives in the World Health Organization Eastern Mediterranean Region, such as the basic development needs approach. The main agenda of community partnership for health for all is discussed and some opportunities conducive to community partnership in the Region are outlined.

Maternal mortality surveillance and maternal death reviews in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on maternal mortality surveillance systems and death review activities in the Region. Data were collected by questionnaire completed by ministry of health personnel. The findings show that 13 countries require official reporting of deaths of women of reproductive age. Most of the countries conduct maternal death reviews although only 8 have surveillance systems. Other areas investigated were the sources of information on maternal deaths, types of data collected, how the data are analysed and how such data are used. There is a need to strengthen information systems on maternal mortality in the Region in order to guide decision-makers in the planning and evaluation of maternal health programmes.

Family planning services and programmes in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on the family planning services and programmes in the Region. Data were collected using a questionnaire which explored the following areas: the presence of population or family planning policies and family planning activities, the family planning services available, promotional and educational activities on family planning, quality assurance, family planning data collection, analysis and dissemination, and the use of such information. The results indicate that 13 of the countries have national policies on population and family planning but even in those that do not, family planning services are widely available. The scope of the services provided varied. There is still a need to implement or strengthen family planning programmes in the Region, a need which is recognized by the countries themselves.

A view of the World Health Organization Eastern Mediterranean Region.

A view of the World Health Organization Eastern Mediterranean Region.