Communicable Disease Control Programs in the Eastern Mediterranean Region of the World Health Organization

B. Sadrizadeh MD

Unit of Integrated Control of Diseases, World Health Organization, Regional Office for the Eastern Mediterranean, Alexandria, Egypt

The Eastern Mediterranean Region (EMR) of WHO consists of 23 Member States, from Pakistan in the East to Morocco in the West.¹ According to the organizational structure, the WHO Eastern Mediterranean Regional Office (EMRO) consists of seven divisions. The Division of Integrated Control of Disease (DCD) is responsible for communicable disease control in the Region. The Division (DCD) in turn consists of eight units as follows:

? Sexually Transmitted Disease including AIDS (ASD)

? Control of Diarrhoeal and Respiratory diseases (CDR)

? Control of Communicable Diseases (CDS)

? Control of Tropical Diseases (CTD)

? Eradication/Elimination of polio and other diseases (EED)

? Malaria Control (MAL)

? Vaccine Preventable Diseases and Immunization (VPI)

? Control of Tuberculosis (TUB)

Each unit is staffed by a regional advisor and a secretary. Depending on the number of the projects and the workload, some of these units are entitled to supplementary staff.

Communicable Disease Control Programs:

The following is a brief summary of communicable disease control programs in the region with special reference to the Islamic Republic of Iran.

1. Eradication/elimination of specific communicable diseases

1.1. Dracunculiasis eradication

The member states of the EMR can be divided into the following groups according to the status of dracunculiasis eradication:²

? Countries with local transmission of dracunculiasis and active eradication programs (e.g., Sudan and Yemen).

? Countries with previous a history of dracunculiasis transmission and without certification of present status (e.g., Afghanistan, Djibouti, Libya, Morocco, Saudi Arabia, Somalia).

? Countries certified by the International Commission for the Certification of dracunculiasis Eradication as free from local transmission (e.g., Bahrain, Cyprus, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Syrian Arab Republic, Tunisia, United Arab Emirates).

Sudan continues to be the leading country in the world with 43,596 cases of dracunculiasis reported from 5,744 endemic villages by the end of 1997, compared with 118,578 cases reported from 5,466 villages in 1996. The decline in the number of cases is mainly due to under reporting from highly endemic and difficult to access areas in southern Sudan. However, in accessible areas in the northern states, the incidence was reduced due to eradication activities of the National Guinea Worm Eradication Program.

Most cases (79%) in the northern states have been contained. The situation in Yemen is improving with only 7 cases reported during 1997 and "zero" cases identified during the first quarter of 1998.

There were no reported cases of either local or imported dracunculiasis by other regional countries during 1997.

In Afghanistan and Somalia evaluation will resume after reconstruction of health infrastructures and the establishment of efficient surveillance systems in these countries.

In 1997, the World Health Assembly adopted a resolution reiterating its request that dracunculiasis be eradicated as soon as possible. The eradication strategy is based on interruption of transmission in endemic foci of infection, establishment of efficient surveillance systems and certification of the eradication of dracunculiasis.³

Dracunculiasis endemic foci in Iran at the beginning of the century were located in the areas stretching from Bushehr, Bandar Lengeh, Bandar Abbas on the coastal area encircled by Jahrom to the north and returning back to Bushehr. The number of cases was significantly reduced with time. Most cases from Bastak and Bandar Abbas were eradicated before 1971. Some cases were later reported in six villages, southwest Lar, but they declined gradually and by 1973, or about that time, the prevalence of infection dropped to zero.

The International Certification Team on eradication of dracunculiasis visited the I.R. Iran in November-December 1996 and concluded that the disease has been eradicated from the country. The International Commission for the Certification of Dracunculiasis Eradication presented its recommendations in its second meeting, which was held in Geneva on January 23-24, 1997 and WHO officially certified the I.R. Iran as "being free of dracunculiasis transmission".⁴

1.2. Leprosy Elimination

The magnitude of leprosy as a public health problem has been significantly reduced in the majority of member states. The total number of registered cases in the region was 12,514 by the end of 1997 with the regional prevalence of leprosy as 0.287 per 10,000 population.³

The available data indicates that there is a significant difference between countries in the region regarding the number of registered cases. More than 32% of the total number of registered cases have been recorded in one country of the region, namely Sudan. In addition, Egypt, Pakistan and Yemen collectively registered 43.5% of cases. Other countries, have either not recorded any cases, or registered only a few cases of leprosy.

The regional strategies for the elimination of leprosy are oriented towards the reduction of leprosy prevalence in endemic countries to less than 1 per 10,000 in all endemic foci by the year 2,000. The main emphasis being placed on:

? Promotion of passive case detection,

? Creation of community awareness and reduction of stigmas,

? Wide distribution and availability of drugs for MDT

? Strengthening of managerial and technical capabilities of national programs,

? Integration of leprosy surveillance and control activities within existing public health infrastructures,

? Support of special intensive operations to detect leprosy in pockets of infection or in difficult to access areas and among specific groups of population,

? Improvement of supervision and monitoring of elimination activities.

Several WHO initiatives have been introduced in order to strengthen the surveillance and control of leprosy. In particular, some national programs received WHO support through Special Action Projects for the Elimination of Leprosy (SAPEL) for the organization of special surveys among high-risk groups and difficult-to-reach areas. Leprosy elimination campaigns (LEC) have been introduced in areas with large numbers of backlog cases and where MDT has not been applied properly.

The National Leprosy Control Program in the I.R. Iran has made significant progress in the elimination of leprosy as a public health problem. Although the country prevalence is less than 1 per 10,000, the prevalence in some provinces is higher than target values and further action should be taken in order to reduce the leprosy prevalence in all endemic foci.

Leprosy surveillance and control activities in the I.R. Iran are integrated within the existing health delivery system. During the past five years since 1992, more than 7,900 leprosy patients have been registered and treated with MDT. In 1997 only 69 new cases were identified in 18 provinces, mostly in Tehran, East Azerbijan, Hormozgan, Gilan and Kordestan. The case detection rate was 0.1 per 100,000 population. The total number of registered cases by the end of 1997 was 754 and the prevalence rate was reduced to 0.12 per 10,000 compared to 0.4 per 10,000 population in 1994.

WHO supported inter-country cooperation between the I.R. Iran and neighboring countries. Leprosy specialists from Iran served as WHO consultants in Afghanistan and other countries. Border meetings between Afghanistan, Pakistan and Iran were organized by WHO in 1997 in order to coordinate leprosy elimination activities.^5,6,7

1.3. Polio Eradication

The four principal strategies for polio eradication include:

? Routine immunization coverage in the form of National Immunization Days (NIDS) with oral polio vaccine,

? Surveillance and investigation of acute flaccid paralysis (AFP) cases and,

? Mopping-up in areas or among populations where poliovirus transmission persists.

In the EMR, surveillance for acute flaccid paralysis is currently established in 20 member states and is being initiated in the remaining three (i.e., Somalia, Yemen and United Arab Emirates).

In the I.R. Iran, NIDs have been carried out successfully since 1994. Immunization with 30 PV doses is almost 100%. The target is to sustain high routine coverage. Mopping up immunization was conducted in border areas to coincide with NIDs in neighboring countries (in the west in coordination with Turkey, Syria and Iraq and in the east simultaneously with Pakistan and Afghanistan).

13 cases of polio were reported in 1997. Only 2 laboratory confirmed cases were reported in 1998 (up to May). AFP surveillance has achieved the required level of sensitivity (rate of non-polio AFP per 100,000 population ?15 is 1.5).^8,9

1.4 Neonatal Tetanus Elimination

In 1989 the World Health Assembly committed WHO member states to achieving the elimination of neonatal tetanus defined as less than one case for every 1,000 live births in each administrative district throughout the world. The global target has not been met on time, and has been deferred to the year 2000.

The recommended strategies include tetanus toxoid immunization, clean deliveries with effective neonatal tetanus surveillance and the 'high-risk area' approach to accelerate progress towards elimination.

Neonatal tetanus elimination has been achieved in 15 of the 23 member states of the EMR.

In accordance with the definition of elimination, NT elimination has been achieved in the I.R. Iran with only 21 cases reported in 1997. Efforts should be made to maintain elimination status. The aim should be to administer 5 doses of TT before the age of 15. In this respect school booster programs are of importance. There is a need to strengthen NT surveillance. This would include active surveillance and community based surveillance.^8,9

1.5 Measles Elimination

The global measles vaccine coverage remains around 80% since 1990. Measles continues to be a major childhood killer, with an estimated 40 million cases and 1 million deaths occurring each year.

In the EMR, the target of 90% morbidity and 95% mortality reductions for measles has been met in most of the member states and is being actively pursued in the remaining countries. However, outbreaks/epidemics of measles continue to be reported from most member countries. This is mainly due to the fact that, even with such high coverage rates, at risk groups still exist. These at risk children have not received the vaccine or have failed to sero-convert. However, due to high coverage rates the accumulation of susceptable individuals has reduced (dependant on vaccine coverage and efficacy) this in turn is slowly, resulting in the elongation of the inter-epidemic period (now standing at between four to eight years).

Realizing this situation and the fact that measles elimination could be achieved using the currently available vaccine, the Regional Committee in its 44th session, held in Tehran, the I.R. Iran, October 4-7, 1997, adopted a resolution for measles elimination from member states by the year 2010.

Measles is still common in the I.R. Iran where outbreaks still occur. A total of 3,901 cases were reported in 1997. In view of the Regional Committee's resolution to eliminate measles from EMR member states by the year 2010, the I.R. Iran is planning to upgrade measles control activities. Full implementation of measles elimination strategies in the I.R. Iran will start after interruption of wild poliovirus transmission.^8,9

2. Control of Other Communicable Diseases

2.1 Vaccine Preventable Diseases Control and Immunization

In 1974, when the Expanded Program on Immunization was launched by WHO, less than 5% of the world's children were immunized against the initial six-target diseases diphtheria, tetanus, whooping cough, polio, measles and tuberculosis. During recent years, global immunization coverage has remained stable with an average coverage of 87% for BCG, 82% for OPV3, 80% for DPT3 and 79% for measles among children under one year of age and 48% for TT2+ among pregnant women in 1997. In 1993 the World Bank initiative for "EPI Plus" was introduced which incorporated vaccines against hepatitis B and yellow fever together with supplementation of vitamin A and iodine. Currently hepatitis B coverage is accelerating with more than 90 countries having introduced immunization into their routine programs.

Since 1996 the average regional coverage in the EMR of the WHO initiative has improved for all EPI antigens. Based on the reports received from member states for 1997, the regional average coverage rates were 90% for BCG, 82% for OPV3/DPT3 and measles for children in their first year of life.

An effective immunization program has been established and maintained in the I.R. Iran. High immunization coverage rates were achieved during the early 1990's and have been sustained. For 1997, the reported coverage rates among children under one year of age was 91% for BCG, 100% for OPV3/DPT3 and 96% for measles. In addition, 13 vaccine was introduced in the program in 1994 with a coverage rate of 93% in 1997. The coverage of pregnant women with two or more doses of tetanus toxoid (TT2+) was 59% for 1997.^8,9

2.2 Control of Acute Respiratory Infections (ARI) and Diarrhoeal Diseases (CDD)

In the past decade, major progress has been made to reduce childhood mortality and morbidity through control of diarrhoeal diseases and acute respiratory infections. The childhood mortality rates in developing countries fell by an average of 35%.

In spite of this progress, major challenges remain, progress has been uneven across the world's geographic regions, and the mortality rates are still unacceptably high. Every year about 12 million children die before reaching their fifth birthday. Over 70% of these deaths, the vast majority, occur in the developing world. They are due to acute respiratory infections, diarrhoeal diseases, malaria, measles and malnutrition, often in combination. In keeping with the convention on the rights of the child, every child has the right to access medical care for the most prevalent causes of illness and death as well as the measures to prevent them.

Therefore WHO, jointly with UNICEF developed the strategy of Integrated Management of Childhood Illness (IMCI) which started in 1992.

This process involves three phases.

1. Introduction phase: Countries conduct orientation meetings, train key decision makers in IMCI, identify a management structure in preparation for IMCI, planning and early implementation, and to promote government commitment to move forward with the IMCI strategy.

2. Early implementation phase: Countries gain experience while implementing IMCI in a limited geographic area. They develop their national strategy and then, adapt the IMCI guidelines to their national context, build management and training capacity in a limited number of districts, start implementing and monitoring IMCI in first-level facilities, and review their experience before planning for expansion.

3. Expansion phase: Countries increase the range of IMCI intervention, and increase their coverage. An important challenge during the expansion phase is maintaining quality while expanding coverage.

In the I.R. Iran, the childhood illness included in the IMCI genetic guidelines are present:

? Diarrheal diseases and acute respiratory infections are considered still to be important problems (17% and 10% of mortality rates in 5 year olds and under according to 1993 CDD Health House Survey and the latest vital horoscope statistics)

? Nutritional component (16% of girls under 5 years showed moderate malnutrition, and moderate anemia was observed in about one fifth of young children)

? Irrational use of drugs remains at high levels (53% of diarrhea cases are given antidiarrheal drugs)

? Only about half the children with acute diarrhea increased fluid and food intake.

Therefore, it was conducted that the IMCI strategy proposed by WHO and UNICEF was applicable in I.R. Iran. The Ministry of Health and Medical Education expressed interest and commitment in introducing the IMCI in the country as a major strategy for further reduction of morbidity and mortality among young children through improved child health care in the overall context of the PHC system.

WHO and UNICEF will provide joint technical and financial support for IMCI introduction and implementation.^8,9

2.3 Tuberculosis Control

TB kills more youth and adults than any other infectious disease in the world today. It is a bigger killer than malaria and AIDS combined and kills more women than all the combined causes of maternal mortality. It kills 2 to 3 million people each year. In 1993, WHO took an unprecedented step and declared TB a global emergency. It is estimated that between now and 2020, nearly one billion people will be newly infected. Two hundred million people will get sick, and 70 million will die from TB, if controls are not strengthened.

The WHO TB control strategy is DOTS (Directly Observed Treatment, short-course). DOTS combines five elements: Political commitment, microscopy services, direct observation of treatment (DOTS), drug supplies and monitoring systems. DOTS is the most effective strategy available for controlling TB, and can produce cure rates of up to 95% even in the poorest countries. DOTS prevents new infections and the threat of multi-drug resistant (MDR) TB. The World Bank considers DOTS one of the most cost-effective health strategies available.

In the EMR, TB continues to be a serious public health problem. The incidence and mortality of TB has increased in some countries in the region. In 1998, the estimated incidence and mortality reached a level of 750,000 and 300,000, respectively. If this trend continues, during the next ten years (1998-2007), 9 million TB cases and 4 million TB deaths will occur in the region.¹

The Regional Office, in the face of such a serious TB epidemic, has taken the lead for the improvement of TB control and has made marked progress. Firstly, the regional TB control strategy was formulated. This strategy aims to achieve nation-wide implementation of the DOTS strategy (or DOTS all over) in all countries by the year 2000 and TB elimination in the countries with low incidence by the year 2010. This is the first challenge in the field of TB control at the regional level in the world. In accordance with the strategy, several activities have been carried out throughout the region. These include human resource development, review of TB control programs, strengthening of TB laboratory capacities and advocacy of the strategy.

TB is intermediately prevalent in Iran. The estimated incidence of smear positive cases and all forms of TB are 25 and 55 per 100,000 populations, respectively. These rates mean that 15,200 cases of smear positive TB and 33,400 cases of all forms of TB are occurring each year in I.R. Iran.

In 1991 the Ministry of Health and Medical Education initiated a national TB control program in line with the DOTS strategy. It includes 1) integration of sputum microscopy laboratory in all laboratories at the district level, 2) revision of case definitions and the provision of recording and reporting forms, and 3) intensive training at all levels for all categories of health personnel. At present, the four elements of the DOTS strategy, have been successfully introduced in Iran.

To ensure the successful expansion of the DOTS strategy, the following issues are important:

? Publication of national guidelines on technical and operational policies.

? Strengthening collaboration between the concerned organization and institutes for the publication of national guidelines, for quality control of smear microscopy, and implementation of the guidelines, particularly at the provincial level.

? Continue the on-going anti-TB drug resistance survey according to WHO guidelines.

? Establish demonstration sites for collaboration with the private sector for the implementation of the DOTS strategy and analyze the results. This may include the control of anti-TB drugs in private pharmacies.

? Establish a mechanism to study treatment outcomes among mobile populations as one of the priorities for operational research.

2.4 Control of Emerging Diseases

Emerging infectious diseases, according to WHO definitions, are those "diseases whose incidence in human has increased during the last two decades and which threatens to increase in the near future."

Emerging infectious diseases have already threatened the downward trend in morbidity and mortality from communicable disease, which has been one of the great achievements of this century. Many of the emerging diseases have shown a clear epidemic potential and pose a threat to the health of millions of people. To date several of them have no treatment, cure or vaccine.

Strengthening of preparedness measures for epidemics received special attention in 1997. This was because almost all of the emerging diseases have high epidemic potential and are difficult to contain in advanced stages.

Emerging diseases continued to make news in 1997, keeping the issue in the public eye. The first occurrence of infection in humans by an avian type influenza virus, resulting in a high fatality rate was seen. This event raised the threat of a new influenza pandemic. An outbreak of Rift Valley fever occurred in southern Somalia and northern Kenya causing relatively high mortality. These events made it clear that the fight against communicable diseases is not, as thought by some, yet in its final stages.

Infectious diseases are still a major public health problem in I.R. Iran although more attention is being directed towards non-communicable diseases.

The current surveillance system, particularly that of communicable disease, is relatively functional. However, it needs strengthening regarding the following points:

? Revision of the list of reportable diseases being an exercise of prioritization in line with recommended criteria.

? More active role at the intermediate and peripheral levels in analysis and interpretation of data.

? A closer monitoring of timeliness and completeness of reporting.

? A pragmatic move towards involving the private sector in disease surveillance.

? A more sustainable and informative method of feed-back such as an epidemiological bulletins.

2.5 Control of Tropical Diseases of Regional Specificity

2.5.1 Control of Schistosomiasis

Urinary schistosomiasis caused by S. haematobium occurs in 10 countries of the EMR, including the I.R. Iran. Intestinal schistosomiasis caused by S. mansoni is found in Egypt, Libya, Oman, Saudi Arabia, Sudan and Yemen.^10,11,12

Urinary schistosomiasis was prevalent in several foci in the Province of Khuzestan in the late 1950s. In 1959 a WHO-assisted Schistosomiasis Control Project was established in order to study the epidemiology and the magnitude of the disease. The only species of parasite found in human population was S. haematebium and the intermediate host was B. truncatus. It was estimated that about 40-50 thousand people were infected with schistosomiasis at that time.

The adopted control strategies included provision of diagnostic facilities in the endemic foci, chemotherapy, elimination of snail habitats through the use of molluscicides and environmental modifications and the provision of health education. As a result, the incidence of schistosomiasis has been gradually decreased in the endemic areas and reached 0.653% in 1980, 0.021% in 1988 and 0.042% in 1989. In 1990, 37 cases were registered in all endemic foci. Only 14 cases of urinary schistosomiasis were recorded in Khuzestan province in 1996.

The objective of the Ministry of Health and Medical Education is to eliminate local transmission in the next few years.

The presently adopted elimination strategies include screening of the total population in endemic areas three times a year, treatment of all positive cases with praziquantel and follow up of cases with microscopic examination of urine. Snail population control with regular checks on control measures are carried out with the use of bayluscide in water bodies and the provision of health education. Other activities include improvement of sanitation, supply of fresh water, building bridges to minimize human contact with water, and the building of lavatories.

It is hoped that the elimination of schistosomiasis in the I.R. Iran can be achieved in the near future.

2.5.2 Control of Leishmaniasis

The principal forms of leishmaniasis in the EMR are zoonotic and antroponotic visceral and cutaneous leishmaniasis. VL in most of foci is a zoonosis caused by L. infantum with canines as the animal reservoir. The distribution is scattered and most cases occur in rural areas. Some countries have reported endemic foci with a significant number of cases. VL caused by L. donovani is endemic in some parts of Sudan, sometimes in epidemic proportions.

Zoonotic and antroponotic cutaneous leishmaniasis are registered in most countries of the region.¹³

Leishmaniasis is an important public health problem in the I.R. Iran. Zoonotic cutaneous leishmaniasis is widely distributed in the northeast and the central parts of the country, including the Provinces of Isfahan, Khuzestan, Bushehr, Khorasan, Fars, Mashihr Golestan, Shiraz and Bam. Antroponotic cutaneous leishmaniasis is prevalent in Bam, Tehran and some other cities. In recent years the incidence of both types has increased and new foci of transmission have been identified in the southern slopes of the Zagros Mountains. The annual number of registered cases for both forms in 1996 was 16,000 and 2,000 cases, respectively.

Zoonotic visceral leishmaniasis is widespread in the northwest and in the south of the country with a total of 3,031 cases reported during 1989-93.

Leishmaniasis is a notifiable disease, reported to the Ministry of Health and Medical Education.

During 1995-97. WHO supported the national activities in the control of leishmaniasis through the provision of supplies and equipment for production of antigen for direct agglutination test (DAT) in diagnosis of VL, provision of diagnostic equipment, fellowships for training, and support of national workshops.

Development of preventive methods against leishmaniasis is an important activity of the national program and scientific groups in I.R. Iran. In 1983 staff at the Institute of Public Health Research initiated a leishmanization program in a hyperendemic area north of Isfahan and later on among newly recruited soldiers and members of the Revolutionary Guard during the war between the I.R. Iran and Iraq for the prevention and control of zoonotic cutaneous leishmaniasis. More than two million people underwent leishmanization and it proved successful in reducing the incidence of the disease by between one-sixth and one-eighth of its original level. The success of the leishmanization campaign confirms the efficiency of this method for the prevention in high-risk groups of the population against CL.

Killed L. major vaccine was produced at the Razi Vaccine and Serum Institute according to good manufacturing practices. Phase 1-11-111 of clinical trials of a single injection of killed L. major vaccine plus BCG as adjuvant were successfully completed. Phase 1-11 were completed with two and three injections, and phase 111 trials started with two injections in 1997. The trials have been initiated in the foci of zoonotic cutaneous leishmaniasis in Isfahan and in foci of antroponotic cutaneous leishmaniasis in Bam. In Sudan in foci of VL limited phase 1-11 trials have been completed and phase 111 trials are in progress. The trials of L. major killed vaccine have been supported by UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases (TDR).¹³

2.5.3 Malaria Control

Malaria is recognized as one of the major health problems in the world. According to the WHO, based on estimates for 1996, malaria kills 1.5 to 2.7 million people annually, in other words, it is one of the top killers among the infectious diseases, along with lower respiratory infections (3.9 million), tuberculosis (3 million), diarrheal diseases (2.5 million) and AIDS (1.5 million).

Among the eco-epidemiological type, the most important is Afrotropical malaria which prevails in sub-Saharan Africa and the South of the Arabian Peninsula. About 90% of malaria problems in the world are associated with this type of malaria.

In the EMR this type occupies only its southern flank. Yet this area is responsible for about 85% of the total malaria load in the region which is estimated at 14 million cases annually. The situation is particularly serious in this part of the region, since about 95% of cases are caused by P. falciparum. In most of the areas, this type of malaria is refractory to the usual control measures.¹⁴

Still serious, but more amenable to control is malaria of the oriental type that occurs in Pakistan, Oman, parts of Afghanistan, I.R. Iran and United Arab Emirates. The rest of the region used to be occupied by malaria of the palaearclic type. To date, many of the areas of this part of the region have been freed from malaria, and P. falciparum has almost been eradicated.

I.R. Iran sits at the junction of two types of malaria: Oriental in Sistan-Baluchistan, eastern part of Hormozgan and the tropical part of Kerman, and palaearctic in the rest of the country. Consequently, the malaria risk is more serious in the former area where P. falciparum is widespread and often resistant to chloroquine and where malaria vectors are more effective than elsewhere in the country. In the palacatctic areas there are only a few foci of transmission of P. falciparum in the south, and most of the locally contracted malaria is due to P. vivax.

The number of officially recorded cases in I.R. Iran in 1997 was 38,684; down from 56,363 found positive in 1996. About 20-25% of these cases were due to P. falciparum. This relatively low figure is the result of malaria control, which has been carried out at a national level since the late 1930s.

Despite these successes, most of the formerly endemic areas of I.R. Iran are still susceptible.

The strategy of malaria control in I.R. Iran is currently being revised. The following objectives of the program are being formulated, with particular attention being payed to regional requirements:

? To maintain a malaria-free status in areas where it has been already achieved (most of the Iranian territory). Efforts to achieve this goal include surveillance, detection of imported cases, monitoring of the epidemic risk, early recognition of transmission from the imported cases and timely anti-epidemic measures, including indoor residual spraying and larviciding

? To limit morbidity of malaria in areas where there is a transmission of P. vivax only, so that malaria ceases to be a serious health problem (most areas of the south of the country). Steps taken to achive this goal include full detection of cases and their epidemiological, classification, monitoring of the status of transmission in rural areas, routine vector control including indoor residual spraying and anti-epidemic measure when warranted. Signs of transmission of P. falciparum in these areas should be considered as an emergency, and measures taken to interrupt transmission should be promptly applied.

? To contain or interrupt the transmission of P. falciparum in areas where it still persists, especially in parts of Sistan-Baluchistan, Hormozgan and Kerman. Measures will include treatment of cases, prevention of severe malaria, individual protection with insecticide-impregnated materials, limited vector control measures wherever deemed cost-effective and sustainable.

2.6 Control of Sexually Transmitted Diseases (including AIDS)

The AIDS epidemic started later in the EMR than in other regions of the world, due mainly to high religious and moral values in this region. The epidemic is still at a low level in the region, as demonstrated by low prevalence levels among vulnerable groups tested in 1997. It has also been shown that it is spreading at a slower pace. The prevalence rates in these groups varied from country to country.

More than 26,000 HIV infections were reported by mid 1998 but owing to under recognition, under-reporting and reporting delays, the actual number of cases is estimated to be over 200,000.

The first case of AIDS was reported in I.R. Iran in 1987. Since then, 194 cases have been reported up to the end of 1997. Of them, 177 (91%) where male and 17 (9%) female. 14 cases were under 15 year old, 170 cases 15-49 years old, 9 cases above 49 years old and one unknown. Most of the earlier cases were due to contaminated blood and blood products but subsequently, cases due to heterosexual transmission started predominating and more recently cases among injecting drug users in prisons and outside have increased. According to tests performed in 1997, the HIV infection rate was 1.17% among prisoners and 1.75% among injecting drug users.¹

2.7 Zoonoses

All major zoonoses with public health significance are prevalent in the EMR. Some of them like brucellosis, rabies, zoonotic leishmanioses, cyclic echinococcosis, salmonellosis have widespread distribution. Some others, like Rift Valley fever, screw worm disease, Crimean-Congo hemorrhagic fever have been recorded in the form of outbreaks in some countries and are considered emerging diseases.¹³

The epidemiological data on these diseases are frequently incomplete. This is partly explained by the lack of proper laboratory facilities in some remote areas as well as by poor cooperation and exchange of information between veterinary and health services. However, even with these shortcomings, more than 45,000 cases of human brucellosis, about 900 animal cases of rabies and 150 cases of human deaths due to rabies, and more than 55,000 cases of zoonotic cutaneous leishmaniasis on average are reported annually by the member states.^13,15,16

Priority areas in the control of zoonotic diseases in countries of the region depend on the epidemiological pattern of these diseases and on the availability and structure of health care and veterinary services. It is interrelated with farming practices, habits of the people, trade of animal and animal products.

The Ministry of Health and Medical Education in cooperation with veterinary organizations associated to the Ministry of Jihad-e-Sazandegi established an efficient surveillance system on zoonoses in the I.R. Iran. The main objectives of the zoonoses control program is the reduction of prevalence and the prevention of outbreaks of zoonotic infections.

Brucellosis is one of the most common zoonoses in the country, particularly in the western and north-western provinces where animal husbandry is most developed. In the majority of cases brucellosis is caused by B. melitensis, sheep and goats being the main reservoir. The main source of human infection is fresh milk, cheese and other animal products. The reported number of human cases dropped from 90,478 in 1988 to 25,219 in 1997 mainly due to increased animal immunization and an intensive health education campaign.

According to the information from the Pasteur Institute of Iran, which is recognized as a WHO Collaborating Center for Reference and Research on Rabies, rabies diagnostic and post-exposure treatment centers have been established in 25 provinces. During 1996, a total number of 51,378 peoples received post-exposure treatment with Vero cell rabies vaccine. Among them, 12,135 individuals were additionally treated with human rabies immunoglobulin.

The situation in the country regarding echinococcosis still needs further clarification. In 1992, 770 human cases were reported from central southern and western provinces. During 1993-94 only 30 surgical cases of echinococcosis were reported.

2.8 Other Communicable Diseases of Regional Importance

2.8.1 Acute Meningitis

The most reliable figures concerning the annual incidence of bacterial meningitis in our region ranges from between 5 to 15 cases per 100,000 population. The annual endemic incidence rate of meningococcal meningitis in most countries of the region range from between 1 and 5 per 100,000 population. The fatality rate is usually around 10-15% even with specific treatment.¹

WHO/EMRO activities for the control of meningococcal diseases concentrates on strengthening notational capacity and preparedness to deal properly with acute meningitis. Recently these activities included a) revision and regional adaptation of the WHO practical guidelines on control of meningococcal disease and development of a training manual on identification and control of meningococcal meningitis, b) assisting member states in developing plans of action for the early detection and appropriate management of meningococcal epidemics, and c) assisting member states to strengthen their laboratory capabilities in the diagnosis and typing of meningococcal groups and strains with the aim of developing lab-based surveillance of the disease. At the same time, EMRO is an active participant in the Meningitis International Cooperation Group (ICG) which plays a major role in the control of global vaccine production and distribution.

The meningitis situation in the I.R. Iran does not differ much from the general situation in the region. No epidemic of meningococcal meningitis has occurred in the country in the past decade. Control activities are in line with WHO strategic approach.

2.8.2. Cholera

Cholera remains a priority health problem in our region. Available figures, although lacking accuracy, show that the different types of the disease have either high or intermediate endemicity in all countries of the region. Hepatitis B is by far the most important form of viral hepatitis in the region, and its chromic infection plays a major etiological role in chronic liver disease in most member states. Hepatitis C is of particular importance.¹

Hepatitis A is highly endemic particularly in areas with substandard hygienic conditions. All five types of viral hepatitis are found in the I.R. Iran. The reported incidence of acute viral hepatitis is approximately 26/100,000 population. This rate has been decreasing over the past few years, which may be attributed to the establishment of safe medical practice and blood safety, increased immunization coverage with hepatitis B vaccine and improved sanitation.

2.8.4. Influenza

Influenza epidemics occur annually in the region. Their effects are far more impressive than usually mentioned or currently calculated. The continuous evolution of the influenza virus carries the threat of a pandemic spread of new variants with serious, to catastrophic, results. To guard against unpreparedness to such developments, WHO developed a global surveillance and monitoring system consisting of a network that involves some 110 collaborating laboratories in 82 countries.¹

The I.R. Iran participates in the global influenza network through its collaborating laboratory and through reporting yearly influenza epidemic activity within the country to WHO. However, there is still room for further improvement of influenza surveillance and for laboratory investigations.

References

1 The work of WHO in the Eastern Mediterranean Region. Report of the Regional Director. WHO/EMRO, 1997.

2 Dracunculiasis-Global Surveillance summary, 1997; Weekly epidemiological Record, No 18, 1998; 73: 129-36.

3 International Commission for the Certification of Dracunculiasis Eradication, Third Meeting Report and Recommendations, WHO/FIL/DRA/98.193.

4 Eradication of Dracunculiasis in the Islamic Republic of Iran, Country Report, November 1996; WHO/CTD/96.13.

5 Progress towards leprosy elimination. Weekly Epidemiological Record, No 21, 1998; 73, 153-60.

6 Trends in leprosy detection. weekly epidemiological records, No 23, 1998; 73: 169-76.

7 Report on the Intercountry Border Meeting on Leprosy, Karachi, Pakistan, 22-24 September 1997; WHO-EM/ LEP/57/E/L.

8 Integrated Management of Childhood Illness: A WHO/UNICEF Initiative. Scientific Journal of WHO; Suppl No 1, volume 75, 1997; Bulletin of WHO.

9 The World Health Report 1996. Fighting disease Fostering development, WHO 1996; 56-8.

10 Savioli L, et al: Control of Schistosomiasis?A global picture. Parasitol Today 1997; 13:444-8.

11 The control of schistosomiasis. Second report of WHO Expert Committee, Geneva, 1993; (WHO Technical Report Series, No 830).

12 Report on the Regional Workshop on comprehensive Approaches for Schistosomiasis Control, EMRO, Alexandria, Egypt, 6-10 June 1993; WHO-EM/PDP/29-E/L.

13 Regional workshop on the diagnosis, prevention and control of major zoonoses, Tunis, Tunisia, 5-8 June 1995, WHO-EM/VPH/22/E-L.

14 Implementation of the global malaria control strategy. WHO TRS, 1993; No 839.

15 World Survey of Rabies No 31 for the Year 1995, WHO/EMC/ZOO/97.1.

16 World Survey of Rabies No 32 for the Year 1996, WHO/EMC/ZDI/98.4.

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