Rapid response teams in the Eastern Mediterranean Region: Results from the baseline survey of country-level capacities, operations and outbreak response capabilities.

The aim of this study is to assess WHO/Eastern Mediterranean region (WHO/EMR) countries capacities, operations and outbreak response capabilities. Cross-sectional study was conducted targeting 22 WHO/EMR countries from May to June 2021. The survey covers 8 domains related to 15 milstones and key performance indicators (KPIs) for RRT. Responses were received from 14 countries. RRTs are adequately organised in 9 countries (64.3%). The mean retention rate of RRT members was 85.5% ± 22.6. Eight countries (57.1%) reported having standard operating procedures, but only three countries (21.4%) reported an established mechanism of operational fund allocation. In the last 6 months, 10,462 (81.9%) alerts were verified during the first 24 h. Outbreak response was completed by the submission of final RRT response reports in 75% of analysed outbreaks. Risk Communication and Community Engagement (RCCE) activities were part of the interventional response in 59.5% of recent outbreaks. Four countries (28.6%) reported an adequate system to assess RRTs operations. The baseline data highlights four areas to focus on: developing and maintaining the multidisciplinary nature of RRTs through training, adequate financing and timely release of funds, capacity and system building for implementing interventions, for instance, RCCE, and establishing national monitoring and evaluation systems for outbreak response.

Factors associated with hospitalization for seasonal influenza in Morocco.

Background: Morocco is actively working towards expanding its influenza vaccine policy to cover high-risk groups, as recommended by the World Health Organization (WHO). Aims: We assessed the risk factors for influenza-associated hospitalization for severe acute respiratory infections (SARI) that occurred during the last 5 seasons. Methods: We conducted a retrospective, analytical study among patients recruited in the ambulatory and hospital sites of the influenza sentinel surveillance system in Morocco between 2014 and 2019. Using multiple logistic regression, we compared the characteristics of influenza-positive patients with SARI to those with influenza-like illness (ILI) to identify factors associated with severe disease. Results: We included 1323 positive influenza patients with either SARI (41.7%) or ILI diagnosis (58.3%). A(H1N1)pdm09, A(H3N2) and influenza B, respectively, contributed 49.2%, 29.5% and 20.6% of the cases. The main risk factors considered in the bivariate analysis were found in the multivariate analysis to be significantly associated with influenza-related hospitalization (SARI): age < 2 years (aOR = 7.08, P < 0.001); age ≥ 65 years (aOR = 3.59, P < 0.001); diabetes (aOR = 1.98, P = 0.017); obesity (aOR = 2.94, P = 0.034); asthma or chronic respiratory disease (aOR = 4.99, P < 0.001); chronic renal failure (aOR = 4.74, P = 0.005); pregnancy (aOR = 7.49, P < 0.001); and the A(H1N1)pdm09 subtype (aOR = 1.82, P < 0.001). Conclusion: This study provides epidemiological evidence for the expected benefit of an influenza vaccination strategy for high-risk groups as recommended by the WHO.

Influenza activity in the Eastern Mediterranean Region (EMR) in 2020-2021 amidst the COVID-19 pandemic.

INTRODUCTION: A global reduction in influenza virus activity during the COVID-19 pandemic has been observed, including in the Eastern Mediterranean Region (EMR). However, these changes have not been thoroughly evaluated scientifically in the EMR. OBJECTIVE: We aim to present data on seasonal influenza activity during the pre-pandemic period (2016-2019) and compare it to the pandemic period (2020-2021) in EM countries. METHODS: Epidemiological and virological influenza surveillance data were retrieved from both WHO FluNet and EMFLU networks. Four pre-pandemic analytical periods were used in the comparative analysis. We compiled and calculated weekly aggregated epidemiological data on the number of enrolled patients, number of tested specimens and number of positive influenza specimens. RESULTS: 19 out of the 22 countries of the EMR have functioning sentinel influenza surveillance systems, and these countries report the influenza data to WHO through FluNet and EMFLU. The number of enrolled patients and tested specimens increased gradually from 51 384 and 50 672, respectively, in 2016-2017 analytical period to 194 049 enrolled patients and 124 697 tested specimens in 2019-2020. A decrease has been witnessed in both enrolled patients and tested specimens in 2020-2021 'pandemic period' (166 576 and 44 764, respectively). By comparing influenza activity of analytical period 2020-2021 with that of 2016-2019 analytical periods, we found that there has been a decrease in influenza positivity rate in the EMR by 89%. CONCLUSION: The implementation of non-pharmaceutical interventions to control the COVID-19 pandemic may have also impacted the spread of influenza viruses. The low circulation of influenza viruses during 2020-2021 and the associated potential immunity gap may result in increased transmission and severity of post-pandemic influenza seasons. This necessitates high vigilance to continuous data and virus sharing to monitor circulating viruses in a timely fashion to reduce the intensity and severity of future influenza epidemics.

Implementing the Health Early Warning System based on syndromic and event-based surveillance at the 2019 Hajj.

BACKGROUND: During the 2019 Hajj, the Ministry of Health in Saudi Arabia implemented for the first time a health early warning system for rapid detection and response to health threats. AIMS: This study aimed to describe the early warning findings at the Hajj to highlight the pattern of health risks and the potential benefits of the disease surveillance system. METHODS: Using syndromic surveillance and event-based surveillance data, the health early warning system generated automated alarms for public health events, triggered alerts for rapid epidemiological investigations and facilitated the monitoring of health events. RESULTS: During the deployment period (4 July-31 August 2019), a total of 121 automated alarms were generated, of which 2 events (heat-related illnesses and injuries/trauma) were confirmed by the response teams. CONCLUSION: The surveillance system potentially improved the timeliness and situational awareness for health events, including non-infectious threats. In the context of the current COVID-19 pandemic, a health early warning system could enhance case detection and facilitate monitoring of the disease geographical spread and the effectiveness of control measures.

Pandemic influenza preparedness (PIP) framework: Progress challenges in improving influenza preparedness response capacities in the Eastern Mediterranean Region, 2014-2017.

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014-2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons.

MERS-CoV infection among healthcare workers and risk factors for death: Retrospective analysis of all laboratory-confirmed cases reported to WHO from 2012 to 2 June 2018.

BACKGROUND: Approximately half of the reported laboratory-confirmed infections of Middle East respiratory syndrome coronavirus (MERS-CoV) have occurred in healthcare settings, and healthcare workers constitute over one third of all secondary infections. This study aimed to describe secondary cases of MERS-CoV infection among healthcare workers and to identify risk factors for death. METHODS: A retrospective analysis was conducted on epidemiological data of laboratory-confirmed MERS-CoV cases reported to the World Health Organization from September 2012 to 2 June 2018. We compared all secondary cases among healthcare workers with secondary cases among non-healthcare workers. Multivariable logistic regression identified risk factors for death. RESULTS: Of the 2223 laboratory-confirmed MERS-CoV cases reported to WHO, 415 were healthcare workers and 1783 were non-healthcare workers. Compared with non-healthcare workers cases, healthcare workers cases were younger (P < 0.001), more likely to be female (P < 0.001), non-nationals (P < 0.001) and asymptomatic (P < 0.001), and have fewer comorbidities (P < 0.001) and higher rates of survival (P < 0.001). Year of infection (2013-2018) and having no comorbidities were independent protective factors against death among secondary healthcare workers cases. CONCLUSION: Being able to protect healthcare workers from high threat respiratory pathogens, such as MERS-CoV is important for being able to reduce secondary transmission of MERS-CoV in healthcare-associated outbreaks. By extension, reducing infection in healthcare workers improves continuity of care for all patients within healthcare facilities.

Epidemiology of severe cases of influenza and other acute respiratory infections in the Eastern Mediterranean Region, July 2016 to June 2018.

BACKGROUND: Influenza surveillance systems in the Eastern Mediterranean Region have been strengthened in the past few years and 16 of the 19 countries in the Region with functional influenza surveillance systems report their influenza data to the EMFLU Network. This study aimed to investigate the epidemiology of circulating influenza viruses, causing SARI, and reported to the EMFLU during July 2016 to June 2018. METHODS: Data included in this study were collected by 15 countries of the Region from 110 SARI sentinel surveillance sites over two influenza seasons. RESULTS: A total of 40,917 cases of SARI were included in the study. Most cases [20,551 (50.2%)] were less than 5years of age. Influenza virus was detected in 3995 patients, 2849 (11.8%) were influenza A and 1146 (4.8%) were influenza B. Influenza A(H1N1)pdm09 was the predominant circulating subtype with 1666 cases (58.5%). Other than influenza, respiratory syncytial virus was the most common respiratory infection circulating, with 277 cases (35.9%). CONCLUSION: Influenza viruses cause a high number of severe respiratory infections in EMR. It is crucial for the countries to continue improving their influenza surveillance capacity in order detect any unusual influenza activity or new strain that may cause a pandemic.

A Review of Asymptomatic and Subclinical Middle East Respiratory Syndrome Coronavirus Infections.

The epidemiology of Middle East respiratory syndrome coronavirus (MERS-CoV) since 2012 has been largely characterized by recurrent zoonotic spillover from dromedary camels followed by limited human-to-human transmission, predominantly in health-care settings. The full extent of infection of MERS-CoV is not clear, nor is the extent and/or role of asymptomatic infections in transmission. We conducted a review of molecular and serological investigations through PubMed and EMBASE from September 2012 to November 15, 2018, to measure subclinical or asymptomatic MERS-CoV infection within and outside of health-care settings. We performed retrospective analysis of laboratory-confirmed MERS-CoV infections reported to the World Health Organization to November 27, 2018, to summarize what is known about asymptomatic infections identified through national surveillance systems. We identified 23 studies reporting evidence of MERS-CoV infection outside of health-care settings, mainly of camel workers, with seroprevalence ranges of 0%-67% depending on the study location. We identified 20 studies in health-care settings of health-care worker (HCW) and family contacts, of which 11 documented molecular evidence of MERS-CoV infection among asymptomatic contacts. Since 2012, 298 laboratory-confirmed cases were reported as asymptomatic to the World Health Organization, 164 of whom were HCWs. The potential to transmit MERS-CoV to others has been demonstrated in viral-shedding studies of asymptomatic MERS infections. Our results highlight the possibility for onward transmission of MERS-CoV from asymptomatic individuals. Screening of HCW contacts of patients with confirmed MERS-CoV is currently recommended, but systematic screening of non-HCW contacts outside of health-care facilities should be encouraged.

Worldwide Reduction in MERS Cases and Deaths since 2016.

Since 2012, Middle East respiratory syndrome (MERS) coronavirus has infected 2,442 persons worldwide. Case-based data analysis suggests that since 2016, as many as 1,465 cases and 293-520 deaths might have been averted. Efforts to reduce the global MERS threat are working, but countries must maintain vigilance to prevent further infections.

Qatar experience on One Health approach for middle-east respiratory syndrome coronavirus, 2012-2017: A viewpoint.

The emergence of the Middle East Respiratory Syndrome Corona Virus (MERS-CoV) in the Middle East in 2012 was associated with an overwhelming uncertainty about its epidemiological and clinical characteristics. Once dromedary camels (Camelus dromedarius) was found to be the natural reservoir of the virus, the public health systems across the Arabian Peninsula encountered an unprecedented pressure to control its transmission. This view point describes how the One Health approach was used in Qatar to manage the MERS-CoV outbreak during the period 2012-2017. One Health focuses on the association between the human, animals and environment sectors for total health and wellbeing of these three sectors. To manage the MERS outbreak in Qatar through a One Health approach, the Qatar National Outbreak Control Taskforce (OCT) was reactivated in November 2012. The animal health sector was invited to join the OCT. Later on, technical expertise was requested from the WHO, FAO, CDC, EMC, and PHE. Subsequently, a comprehensive One Health roadmap was delivered through leadership and coordination; surveillance and investigation; epidemiological studies and increase of local diagnostic capacity. The joint OCT, once trained had easy access to allocated resources and high risk areas to provide more evidence on the potential source of the virus and to investigate all reported cases within 24-48 h. Lack of sufficient technical guidance on veterinary surveillance and poor risk perception among the vulnerable population constituted major obstacles to maintain systematic One Health performance.

Reported Direct and Indirect Contact with Dromedary Camels among Laboratory-Confirmed MERS-CoV Cases.

Dromedary camels (Camelus dromedarius) are now known to be the vertebrate animal reservoir that intermittently transmits the Middle East respiratory syndrome coronavirus (MERS-CoV) to humans. Yet, details as to the specific mechanism(s) of zoonotic transmission from dromedaries to humans remain unclear. The aim of this study was to describe direct and indirect contact with dromedaries among all cases, and then separately for primary, non-primary, and unclassified cases of laboratory-confirmed MERS-CoV reported to the World Health Organization (WHO) between 1 January 2015 and 13 April 2018. We present any reported dromedary contact: direct, indirect, and type of indirect contact. Of all 1125 laboratory-confirmed MERS-CoV cases reported to WHO during the time period, there were 348 (30.9%) primary cases, 455 (40.4%) non-primary cases, and 322 (28.6%) unclassified cases. Among primary cases, 191 (54.9%) reported contact with dromedaries: 164 (47.1%) reported direct contact, 155 (44.5%) reported indirect contact. Five (1.1%) non-primary cases also reported contact with dromedaries. Overall, unpasteurized milk was the most frequent type of dromedary product consumed. Among cases for whom exposure was systematically collected and reported to WHO, contact with dromedaries or dromedary products has played an important role in zoonotic transmission.

Influenza-associated severe acute respiratory infections in 2 sentinel sites in Lebanon-September 2015 to August 2016.

BACKGROUND: Given the sparse information on the burden of influenza in Lebanon, the Ministry of Public Health established a sentinel surveillance for severe acute respiratory infections (SARI) to identify the attribution of influenza to reported cases. We aim to highlight the proportion of influenza-associated SARI from September 1st, 2015 to August 31st, 2016 in 2 Lebanese hospitals. METHODS: The study was conducted in 2 sentinel sites located in Beirut suburbs and southern province of Lebanon. WHO's 2011 standardized SARI case definition was used. Data from September 1, 2015 to August 31, 2016 were reviewed, and all-cause hospital admission numbers were obtained. Nasopharyngeal swabs were collected and tested by RT-PCR. Descriptive and bivariate analyses were conducted using STATA 13. RESULTS: The 2 sentinel sites reported 746 SARI cases during the studied time frame: 467 from the southern province site and 279 from the Beirut suburbs site. SARI reports peaked between January and March 2016. All, except 4, cases were sampled, and a co-dominance of influenza B (43%) and influenza A (H1N1) (41%) was evident. A high proportion of cases was reported in children <2 years 274 (37%). The proportional contribution of influenza-associated SARI to all-cause hospital admissions was high in children <2 years in the south (4.5% [95% CI: 3.1-6.5]) and in children <5 years in Beirut (0.7% [95% CI: 0.6-0.8]). CONCLUSION: This is the first study to highlight the proportion of influenza-associated SARI in 2 hospitals in Lebanon. The findings will be beneficial for supporting respiratory prevention and immunization program policies.

Emerging and Reemerging Diseases in the World Health Organization (WHO) Eastern Mediterranean Region-Progress, Challenges, and WHO Initiatives.

The Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) continues to be a hotspot for emerging and reemerging infectious diseases and the need to prevent, detect, and respond to any infectious diseases that pose a threat to global health security remains a priority. Many risk factors contribute in the emergence and rapid spread of epidemic diseases in the Region including acute and protracted humanitarian emergencies, resulting in fragile health systems, increased population mobility, rapid urbanization, climate change, weak surveillance and limited laboratory diagnostic capacity, and increased human-animal interaction. In EMR, several infectious disease outbreaks were detected, investigated, and rapidly contained over the past 5 years including: yellow fever in Sudan, Middle East respiratory syndrome in Bahrain, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen, cholera in Iraq, avian influenza A (H5N1) infection in Egypt, and dengue fever in Yemen, Sudan, and Pakistan. Dengue fever remains an important public health concern, with at least eight countries in the region being endemic for the disease. The emergence of MERS-CoV in the region in 2012 and its continued transmission currently poses one of the greatest threats. In response to the growing frequency, duration, and scale of disease outbreaks, WHO has worked closely with member states in the areas of improving public health preparedness, surveillance systems, outbreak response, and addressing critical knowledge gaps. A Regional network for experts and technical institutions has been established to facilitate support for international outbreak response. Major challenges are faced as a result of protracted humanitarian crises in the region. Funding gaps, lack of integrated approaches, weak surveillance systems, and absence of comprehensive response plans are other areas of concern. Accelerated efforts are needed by Regional countries, with the continuous support of WHO, to build and maintain a resilient public health system for detection and response to all acute public health events.