Presentation for NIH

1. Emerging and re-emerging
viral diseases in the
WHO Eastern Mediterranean
Region
Dr Gabriele Riedner (WHO)
Endemic and Emerging Viral Diseases of Priority in MENA:
A Scientific Workshop to Promote Research Collaboration
26th - 29th May 2014
Doha, Qatar

2. 2 |
OutlineOutline
Emerging infectious diseases in the region:
– Background and overview
– Polio
– Avian influenza
– Dengue Haemorrhagic Fever
– MERS-CoV

3. 3 |
BackgroundBackground
 In the past 20 years, the incidence of emerging infectious
diseases has increased globally
 A large proportion (over 60%) of these new infections are
caused by novel viruses
 Many of these new pathogens are zoonotic in origin;
(HIV; Ebola; Crimean-Congo HF; Rift Valley Fever, A/H5N1, A/H1N1;
A/H7/N9; SARS-CoV, MERS-CoV etc.)
 This trend has also been observed in the WHO Eastern
Mediterranean Region

4. 4 |
Emerging & re-emerging diseases
reported in the WHO EMR: 1994- 2014
P H1N1 2009
Polio
Plague
Anthrax
A(H5N1)
MERS-CoV
CCHF
Dengue
Ebola
Rift Valley fever
Yellow Fever
Al Khurma

5. 5 |
Polio

6. 6 |
Polio‐Paralyzed Children, 2013International Spread of Polio, 2013
Syria re‐infected
Horn of Africa re‐infected
Cameroon re‐infected
, Palestine, Egypt Israel
(isolation from sewage)

7. 7 |
Poliovirus type 1 affected districts
past 6 months: 21 Nov 2013 – 20 May 2014
Poliovirus type 1 affected districts
past 6 months: 21 Nov 2013 – 20 May 2014

8. 8 |
Declaration of public health emergency
of international concern
Declaration of public health emergency
of international concern
 On 5 May 2014, the DG of the WHO declared the international
spread of wild poliovirus (WPV) a public health emergency of
international concern (PHEIC).
 Temporary Recommendations are made under the IHR (2005) to
reduce the international spread of polio to those states that
– are currently still exporting Wild Poliovirus (Pakistan, Syria,
Cameroon)
– are infected with Wild Poliovirus but not currently exporting
(Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel,
Nigeria, Somalia)

9. 9 |
Avian influenza (H5N1)

10. 10 |
Number of confirmed H5N1 cases by
country and month of onset (as of 15 May 2014)
Number of confirmed H5N1 cases by
country and month of onset (as of 15 May 2014)
Iraq
Last case
Egypt

11. 11 |
Dengue

12. 12 |
1
Current Dengue Situation in EMRCurrent Dengue Situation in EMR
Kingdom of Saudi Arabia, Yemen, and Pakistan:
– Repeated outbreaks in the last two decades in urban settings;
– Becoming a leading cause of hospitalization/death (children and
young adults);
– Fatal hemorrhagic cases have been reported; and
– Little or no evidence that the disease is spreading to rural areas
Sudan, Djibouti and Somalia:
– Small outbreaks of the disease are becoming more frequent;
– Multiple virus serotypes are co-circulating; and
– Disease is gradually expanding geographically within the country

13. 13 |
Dengue outbreaks in the EMR

14. 14 |
MERS CoV
as of 17 May 2014

15. 15 |

16. 16 |
Epidemic CurvesEpidemic Curves
Confirmed cases by outcome
Many cases were not reported with a symptom onset (onset estimated) or were asymptomatic (n=129)

17. 17 |
Characteristics of primary cases over timeCharacteristics of primary cases over time
Symptom onset date
2012 to 28 Feb
2014
1 March to 17 May
2014
Total number of primary cases 70 34
Median age in years (range) 58.5 (2-83) 55.5 (13-90)
% of male cases 78.6% (55/70) 87.9% (29/33)
% of cases with one or more underlying
condition reported
79.4% (50/63) 96.3% (26/27)
% of cases classified as fatal 53.6% (37/69) 38.2% (13/34)
% Severe 94.2% (65/69) 73.5% (25/34)

18. 18 |
TransmissionTransmission
Zoonotic transmission from camels to humans
– Exposures to camels resulting in infection are unknown;
Human-to-human transmission in the community:
– Very little human-to-human transmission is occurring among family
members in household settings
Nosocomial transmission
– Nosocomial transmission is occurring in health care workers and
patients; health care setting outbreaks
– Transmission via contact and/or fomite?

19. 19 |
Thank you!

20. 20 |
Geographic distribution of serologic evidence for
MERS-CoV or MERS like CoV in camels
Geographic distribution of serologic evidence for
MERS-CoV or MERS like CoV in camels
Source: Reusken, Messadi et al. 2014 EID 20, 8 – Jul 2014.

21. 21 |
Pakistan, 2013 & 2014*
> 500,000 children unreached with OPV
82% of Cases in FATA and KP
*As of May
92% of Cases in FATA and KP
20142013
• North & South
Waziristan - Ban on
Vaccination since
June 2012
• Peshawar & Karachi -
Attacks on health
workers since July
2012
• 2013: 93 polio cases
(58 in 2012)
• 2014: 66 cases to date
(13 at the same date in
2013)

22. 22 |
Middle East Polio Outbreak
Polio, AFP cases & SIAs (campaigns) in Syria,
April 2013 – March 2014
Syria:
36 WPV cases
(35 in 2013, 1 in 2014)
Iraq:
2 WPV cases in 2014
2nd case onset on 7 April