Influenza vaccination situation in Middle-East and North Africa countries: Report of the 7th MENA Influenza Stakeholders Network (MENA-ISN)

ContentslistsavailableatScienceDirect

Journal

of

Infection

and

Public

Health

j o u r n al ho me p ag e :h t t p : / / w w w . e l s e v i e r . c o m / l oc a t e / j i p h

Influenza

vaccination

situation

in

Middle-East

and

North

Africa

countries:

Report

of

the

7th

MENA

Influenza

Stakeholders

Network

(MENA-ISN)

Salah

Al

Awaidi

_,

_Suleiman

_Abusrewil

_,

_Muslim

_AbuHasan

_,

_Meral

_Akcay

_,

Fatma

N.B.

Aksakal

_,

_Uzma

_Bashir

_,

_Omar

_Elahmer

_,

_Abdoulreza

_Esteghamati

_,

Milad

Gahwagi

_,

_Yusuf

_K.

_Mirza

_,

_Cindy

_Grasso

_,

_George

_Kassianos

_,

_Moulud

_Khris

_,

Masoud

Mardani

_,

_Helena

_Maltezou

_,

_Jalal

_Nourlil

_,

_Hicham

_Oumzil

_,

_Ab

_Osterhaus

_,

Valentina

Picot

_,

_Tamer

_Pehlivan

_,

_Mitra

_{Saadatian-Elahi}

_{, ˙Ilham}

_Tali

_,

_Hesham

_Tarraf

_,

Baris

Ugur

_,

_Hassan

_Zaraket

_,

_7th

_MENA-ISN

_study

_group

_List

_of

_authors

_is

_in

alphabetical

order

,

b_{MedicalschoolTripoliuniversity,Tripoli,Libya} c_{MinistryofHealth,SaudiArabia}

d_{SanofiPasteur,Turkey}

e_{DepartmentofPublicHealth,GaziUniversityMedicalFaculty,Ankara,Turkey} f_{Nationalinstituteofhealth,Islamabad,Pakistan}

g_{NationalCentreforDiseaseControl,Tripoli,Libya} h_{IranUniversityofMedicalsciences,Tehran,Iran} i_{SanofiPasteur,Libya}

j_{Aghakhanuniversity,Karachi,Pakistan} k_{FondationMérieux,Lyon,France}

l_{TheRoyalCollegeofGeneralPractitioners,London,UnitedKingdom} m_{SanofiPasteur,Morocco}

n_{ShahidBehestUniversityofMedicalSciences,Tehran,Iran} o_{HellenicCentrefordiseasecontrolandprevention,Athens,Greece} p_{InstitutPasteurduMaroc,Casablanca,Morocco}

q_{MinistryofHealth,Raba,Morocco} r_{Erasmus,RIZTihoHannover,TheNetherlands} s_{EdouardHerriotHospital,Lyon,France} t_{FacultyofMedicine,CairoUniversity,Egypt} u_{AmericanUniversityofBeirut,Lebanon}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received13February2018 Receivedinrevisedform2July2018 Accepted5July2018

Keywords: Influenza

Vaccinationcoverage Surveillance

MiddleEastandNorthAfrica

a

b

s

t

r

a

c

t

Background:TheMiddleEastandNorthAfrica(MENA)regionfacesadualchallengewithregardto

influenzainfectionduetoseverezoonoticinfluenzaoutbreaksepisodesandthecirculationofNorthern

Hemispherehumaninfluenzavirusesamongpilgrims.

Methods:TheMENAInfluenzaStakeholderNetwork(MENA-ISN)wasset-upwiththeaimofincreasing

seasonalinfluenzavaccinationcoverageby(i)enhancingevidence-basedexchanges,and(ii)increasing

awarenessonthesafetyandbenefitsofseasonalvaccination.Duringthe7thMENA-ISNmeeting,

rep-resentativesfrom8countriespresentedtheirinfluenzasurveillance,vaccinationcoverageandactions

achievedandprovidedalistofcountryobjectivesfortheupcoming3years.

Results:MENA-ISNcountriessharethegoaltoreduceinfluenzarelatedmorbidityandmortality.

Par-ticipantsadmittedthatlackofknowledgeaboutinfluenza,itsconsequencesintermsofmorbidity,

mortalityandeconomyarethemajorbarriertoattaininghigherinfluenzavaccinationcoverageintheir

countries.Thecostofthevaccineisanotherkeybarrierthatcouldcontributetolowvaccinationcoverage.

∗ Correspondingauthorat:FondationMérieux,17rueBourgelat,69002Lyon,France. E-mailaddress:valentina.picot@fondation-merieux.org(V.Picot).

https://doi.org/10.1016/j.jiph.2018.07.003

1876-0341/©2018TheAuthors.PublishedbyElsevierLimitedonbehalfofKingSaudBinAbdulazizUniversityforHealthSciences.Thisisanopenaccessarticleunderthe CCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Participantsdrewalistofstrategicinterventionstobridgegapsintheknowledgeofinfluenzaburdenin

thisregion.

Conclusions:Participatingcountriesconcludedthatdespiteanincreaseinvaccineuptakeobserved

dur-ingthelastfewyears,influenzavaccinationcoverageremainsrelativelylow.Priorityareasshouldbe

identifiedandactionplanstailoredtoeachcountrysituationset-uptoinvestigatethebestwaytomove

forward.

©2018 TheAuthors.PublishedbyElsevierLimitedonbehalfofKingSaudBinAbdulazizUniversityfor

HealthSciences.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.

org/licenses/by-nc-nd/4.0/).

Introduction

Worldwide, influenza affects 10–20% of the population and causesmore than 1 million deaths annually [1]. This vaccine-preventable infectious disease belongs tothe listof the World HealthOrganization(WHO)recommendedvaccines,yetthe vac-cineuptakeisingenerallowinbothdevelopedand developing countries[2].ThefindingoftheWHOFlu-Netdatabaseshowedthat dynamicofinfluenzaepidemicsinthelargemajorityoftheMiddle EastandNorthAfrica(MENA)countrieswasinlinewiththe North-ernHemisphere,withthelargestpeakobservedbetweenJanuary andMarch[3].AnnualvaccinationcampaignsintheMENAregion targetprimarily specifichigh-risk groups i.e. pregnantwomen; individuals>6monthswithunderlyingchronicdiseases,elderly, residentsoflong-termcarefacilities,childrenaged6–59months andhealthcareproviders.

TheMENAregionfacesadualchallengewithregardtoinfluenza infection.First,theregiontackledseverezoonoticinfluenza out-breaks episodes with lethal cases during the last years [4–8]. Second,theNorthernHemispherehumaninfluenzaviruses circu-lateintheregionandarethemostfrequentlydetectedrespiratory virusesamongpilgrims[9],increasingtheriskforfurtherspreadof thedisease.Inaddition,thereisariskofhumaninfectionfrom Mid-dleEastrespiratory syndromecoronavirus (MERS-CoV).Indeed, since2012,outbreaksofMERS-CoVandveryfewsporadic travel-relatedcaseswererecordedinSaudiArabia[10]andreturningHaji

[11],respectively.Althoughepidemiologicalanalysisdoesnot sup-porthumantohumantransmission,overcrowding,massgathering andtravelincreasethefearaboutpotentialMERS-CoVinternational dissemination.

Itisverywellknownthatdiabeticshaveasignificantlyincreased riskof flu-relatedhospitalization and death[12].With approx-imately 37 million adults aged 20–79living with diabetes,the MENAregionhasthehighestglobalprevalenceofdiabetesinthe adultpopulation[13].Thispointemphasizesonthecommitment toincreaseinfluenzavaccinationcoverageinthisregion.

Thefewavailablepublishedliteraturesoninfluenzavaccination coverageinMENAreportlowcoverageinthisregion[1,14–16]. AlignedwiththeobjectiveoftheWHOGlobalInfluenzaVaccine ActionPlantoincreaseinfluenzaawareness,theMiddleEastand NorthAfricaInfluenzaStakeholderNetwork(MENA-ISN)hasbeen initiatedin2014.MENA-ISNisanetworkofregionalexpertswith theglobalmissiontoincreaseseasonalinfluenzavaccination cover-ageby(i)enhancingevidence-basedexchangeswithnationaland internationalactors,and(ii)increasingawarenessonthesafetyand benefitsofseasonalvaccination.

MENA-ISNsupporttheWHOinitiative inbuildinglaboratory capacityandsurveillanceintheregionandurgethegovernments togivehighprioritytotheestablishmentandcontinuedsupportfor influenzasurveillancesystems;identifytheneedsofcountriesfor establishingorimprovingexistingsurveillancenetworks; dissem-inatesurveillanceanddiseaseburdendatathroughpublications anddevelopactionstoincreasevaccinationcoverageratesinhealth careprofessionals(HCPs),pregnantwomen,peopleatrisk,elderly andchildren.

The 7th MENA-ISN meeting was organized by Foundation Mérieuxon9–10September,2017inRiga,Latvia.Atotalof25 par-ticipantsfrom8countries(Egypt,Iran,Lebanon,Libya,Morocco, Oman,PakistanandSaudiArabia)attendedthemeeting.In addi-tiontoMENA-ISNcountryrepresentatives,expertsfromtheWHO globalinfluenzaprogram,thecollegeofGeneralPractitioners(UK), theHannoverVeterinaryUniversity(Germany),andHellenic Cen-trefordiseasepreventionandcontrol(Greece)werealsopresent.

Eachcountryrepresentative summarizedtheircurrent situa-tionofinfluenzasurveillance,influenzavaccinationcoverageand actionsachieved,andprovidedalistofcountryobjectivesforthe upcoming3years.Apaneldiscussionontheseconddayallowed theparticipantstodiscusshowtostrengthenthenetworkandits visibilityandhowtoreinforcebetweencountryresearchand pub-lications.Herein,wereportasummaryofthecountrysituationand actionstomoveforward.

Countrysituation:actionsachievedandfutureobjectives

Egypt

VaccinationcoverageinEgyptremainslow[17].However,the ministryofhealth(MoH)makesalleffortstomonitorinfluenzaand makepublicrecommendationstothebenefitofinfluenza vaccina-tionparticularlyinhighriskgroupsorinfaceofepidemics.

Egyptisoneofthecountriesthathaveexperiencedalarge epi-zooticofhighlypathogenicavianinfluenzainpoultrycausedbythe influenzaA(H5N1)virus[18].Anintegratednationalplanforavian andpandemicinfluenzawasdevelopedinresponsetotherapid spreadofavianinfluenzainthiscountry.Nationalinfluenza cen-tersequippedwithtestssuchasvirusisolation,PolymeraseChain Reaction(PCR),serologyandsequencingexistandarecurrently functioning.Thesurveillance ofSevere AcuteRespiratory Infec-tion(SARI)isenhancedandthereisalsoasignificantincreasein theavailable numberof influenza vaccines doses.Furthermore, severalsocial mobilizationand advocacy campaigns have been recentlyconducted.Progressachievedsofarandthemainmid-and long-termobjectivesofthecountryaredetailedinTables1and2

respectively. Iran

Influenzasurveillancesystemhasbeenset-upin2004.The anal-ysisofInfluenzaA/H1N1pdm09andA/H3N2virusescollectedin Iranduringthe2014–2015providedevidenceofco-circulationof severalinfluenzaAvirusstrains[19].Ofthe200Influenza typ-ingstudiesspecimens,80wereinfluenzaA-positive,including44 A/H1N1pdm09and36A/H3N2,while18wereinfluenzaB-positive

[19].AnalysisoftheA/H3N2virusesshowedageneticdriftfrom thevaccinestrainA/Texas/50/2012with5mutations[19].

SerologicalstudyamongpoultryworkersfromFarsprovinceof IranshowedthatexposuretoavianH9N2viruseshadoccurredin thispopulation[7].Influenzasurveillancesystemhasbeen estab-lished since 2004 and an increased number of publications of

Table1

ProgressachievedinMENA-ISNcountries.

Country Surveillance Vaccination Socialmobilization Advocacyandpolicy

Egypt FunctionalNIC

GoodepidemiologicaldataonSARI andILI

SupportfromthePartnership contributionfunds

Increasedfrom800000to1 400000in2017

MedicalSocietiesmeetings,TV programs,Media,Posters

SeveralPressconferencesincluding MoHandpolicymakers

Iran Hospital-based,Lab-basedand sentinelsurveillancesince2004 Lebanon 1650specimenanalysedsince

2008

28%vaccinationamongILI casesin2016-17fluseason Libya Availabilityofadatabaseforflu

vaccinationtargetgroup

Growthinvaccinedoses availablefrom200,000in2012 to1,100,00in2016

EducationalmaterialsforHCPs, schools,etc.

FlucampaigninNov20162017-2018 fluseasonalpreparation

Oman Surveillancedata

(ARI/SARI/virological)widely disseminatedinnon-MOHand privatesectorinstitutions

Extendvaccinationtoother highrisksi.e.paediatric& diabetes

Assessfluvaccinehesitancy

Communityawareness Mobilizationamongpopulation throughprivatesectors

Pakistan Sentinelbasedinfluenza surveillancenetworkinplaceand supportedbyNICatNIHIslamabad

Increasepublicawareness throughpressandmediaahead ofthefluseason

FirstincountrymeetingofLocal InfluenzaStakeholderNetwork plannedinOctober2017Three symposiain3majorcitiesofPakistan SaudiArabia StartedinJan2017in5regional

labs;6regions(hospitalandPHC)

HCWs,Pregnantwomen, ChronicPatients,Young Children,Elderly,Pilgrims

Awarenesslevelraisedin publicandHCPs

Vaccinationchannelsimproved

MoHisfundingvaccinationinits facilitiesplusaddingFluvaccineunder healthinsurancerequirement NIC:NationalInfluenzaCentre;MoH:MinistryofHealth;NIH:NationalInstituteforHealth;PHC:PublicHealthCentres;HCP:HealthCareProviders.

influenzainpeer-reviewedjournalsareamongthemostkeyactions achieved.

Progressachievedandcountryobjectivesfortheupcoming3 yearsarelistedinTables1and2respectively.

Lebanon

Influenza surveillance has continued through the 2016–17 influenzaseason,duringwhichnasopharyngealswabsfrom518 Influenza-LikeIllness(ILI)caseswereanalyzed.Theresultsshowed circulation of both influenza B Yamagata and Victoria lineage viruses in addition to influenza A/H3N2 and A/H1N1pmd09, emphasizing the importance of introducing the quadrivalents influenzavaccine.Amongthestudypopulation,only28%were vac-cinated(unpublisheddata).

Analysisoffluvaccinationuptakeovertimeshowedrelatively highvaccinationcoverage(40%–60%)until2011withapeakduring the2009pandemicanddecreasedsubsequentlytoreach28%in 2016–17(unpublisheddata).However,thesefiguresmostlyreflect thevaccinationcoverageofthepopulationservedbyonemajor hospitalinBeirut.Itwasnotedthatfurtherstudiestoincludemore representativepopulationfromthroughoutthecountryareneeded toaccuratelyreflectthevaccinationcoverageinthecountry.Based onvaccinedosedistribution,vaccinationcoverageinLebanonis estimatedat6%.

Increasedfluvaccinecoverageandincreasedlaboratory capac-itytoisolateanddetectinfluenzaarethemainsuccessesthathave beensofarachieved.Althoughvaccineuptakeisimproving,thereis stillalongwaytoreachoptimalvaccinationcoverageinhigh-risk individuals.Thesearchforadvocacycontinuesandincludes rep-resentativesfromacademic,publicandthegovernment.Themain achievementsandobjectivesarelistedinTables1and2 respec-tively.

Libya

The number of available doses of influenza vaccine has increasedbymorethan 5foldssince2012.Also, goodprogress hasbeenachievedinsurveillance,socialmobilizationand advo-cacy. Progress achieved and the main objectives are listed in

Tables1and2respectively.

Morocco

Influenza is one of the MoH priorities in Morocco. Sentinel surveillanceexistssince1995.However,influenzaburdenisnot wellunderstood.Currently,378healthcentersinalldistrictsand 80privatephysiciansin9citiesareinvolvedintheILIsurveillance system.Overall,8regionallaboratoriesareinchargeofdetection andidentificationofinfluenzastrainsbyReverseTranscriptasePCR (RT-PCR.)TheNationalInstituteofHygiene(Rabat)andthe Pas-teurinstitute(Casablanca)havethecapacitytoperformRT-PCR, sequencing,virusisolation,andantiviralsusceptibilityscreening. Oftheoverall178samplesanalyzedinCasablancaduringthe 2016-17influenza season95.5% belongedtotype A(H3N2)and4.54% wereVictoriaBlineage.

ThemainobjectivesfortheupcomingyearsarelistedinTable2.

Oman

SARIsurveillancehasbeenlaunchedatsentinelsitessince2008 andtheCentralPublicHealthLaboratoryisrecognizedbytheWHO asNationalInfluenzaCenter(NIC)sinceMarch2009.In2017,648 patientswereenrolledinSARIsurveillance.Thehighestnumbers of SARIcaseswere recordedamong children0–2years old fol-lowedbythose2–4yearsofage.Theoverallmortalityratedue toinfluenzawas9.3%butnodeathwasreportedamongpregnant women.InfluenzastrainsA(H1N1)pdm09,A(H3N2),andBviruses weredetectedduringthisseason.

InfluenzavaccineisrecommendedforHCPsworkingin criti-calandnon-criticalunits,administrativeagentsandeducational institutionstaff.

Pre-vaccinationawarenessemailssenttoHCPstoinformthem about the availability of the vaccine and the beginning of the vaccinationcampaignatthehospital.Inaddition,theawareness campaignincludespresentations,person-personcommunication, pamphlet, banner, etc. Vaccinators visit the wards to offer the vaccine.Electronicandmanualrecordsaremaintainedatthe insti-tutional,governorateandnationallevel.

Regardingpregnantwomen,influenzavaccinationisintegrated into the antenatal program and administered during antenatal visits.Pre-vaccinationcounsellingisalsoprovided.Furthermore,

Table2

ActionplanfortheupcomingthreeyearsinMENA-ISNcountries.

Country Surveillance Vaccination Socialmobilization Advocacyandpolicy

Egypt Improvesurveillanceanddisease burdendata

Improvecoveragerates particularlyinhigh-riskgroups& HCPs

InfluenzaAdvisoryBoardto includeMedicalSocietiesdealing withhighriskgroups,EMROand MoH

InclusionofvaccinationinNational guidelinesandvaccination programs

Iran Reestablishmentofsentinelsites CommunicationwithWHO countryofficefornominationofa focalpointinIPWImeetings DevelopingILIreportingguideline andinvolvementofphysiciansin privatesector

Expansionofprivatesectorand involvementofmedicalassociation inreportingILI

DataSharingwithprivatesector, enhancementinformaticsystemto increaseawareness

Encourageinsurancecoverageand reimbursementforfluvaccine Increasevaccineavailabilityin publicandprivatesectors Increaseawarenessonvaccination andrighttimingforhighrisk groupsthroughrelatedmedical associations

Periodicmessagesonfluandflu vaccinatingbysocialmediaand SMSPromotionofvaccinationon Fluvaccinationday

Awarenesscampaignfor pharmacistonrighttimingofflu vaccination

Developingpromotionalmaterial onfluandvaccination

Annualinternationalpaediatric congressinMay

Pamphletandbrochuresonflu vaccination

AnnualNationalInfluenza symposium

Lebanon ContinueSARI&sentinel surveillanceAnalysedataand reportonBstrain

Continuouscommunication throughonlinebulletin

Increasevaccinecoveragein generalpopulationandchildren QIVintroductionandexpansionin childrenandelderly

Newtargetgroup

Extendedfluvaccinationseason

Initiateactionplanwithfluvaccine companies

Workshopontargetgroups Focusonpharmaciestoincrease easeofaccesstovaccine Communicationon recommendationsforspecific high-riskgroups

Partnershipwithsocieties Initiateandimplementtailored actionplanpertargetgroup Advisoryboardforlocalinsight& recommendationfromHCPs CommunicationaboutBstrainand needforQIV

Libya Improveinfluenzasurveillance (sentinelandlab-based)

Increasecoverage Publichealth,HCPsandmedia campaigns

GuidelineforHCPsPostersand pamphlets

Fightmisconception Morocco Strengthsurveillanceofinfluenza

andSARI

StrengthVirologicaldiagnostic Capacities

Produceevidence-basedstudies Increasecoverageamongpregnant, HCPsandthosewithchronic diseases

Improvecommunicationfor generalpublic(TVspots,flayers, media)

EducationaleffortsamongHCPs

Conferences,pressrelease Involvescientificsocieties (Paediatrics,obstetrics,Cardiology) andNGOs

Oman MOHnationalnewslettertobe usedtowidelycirculatethe surveillancedata Maintainsurveillance

Nationaladvisorycommitteeson immunizationtoapprovevaccine introduction

Involvetheprivatesectorasitis usedby40%ofthepopulation Increasecommunitydemand

InvolveNationalImmunization TechnicalAdvisoryGroups Meetingwiththenationalmedical societies

Pakistan Investigateusefulnessofcurrent surveillancedata&howtouseit foridentifyinghighriskgroups ContinueSentinellab-based SurveillanceforseasonalInfluenza viruses

Maintainmolecularcapacityfor detection&diagnosisofseasonal andpotentialnovelstrains Prospectivetargetedsurveillance atpointofentry

Includeotherrespiratory pathogensinILI/SARIsurveillance

Provide/increaseofficial recommendationsforinfluenza vaccination

Set-upcampaignsduringflu seasonthroughmaterialsprovided byregionalteam

Useavailabledatatosupport maternaleducationforchildhood vaccination

Identifykeysocialfactorstobe targetedforeffectivemessages

IncludeofInfluenzaAssociated SARIinNationalPrioritydisease list

Supportpostvaccinationimpact evaluationforotherkeypathogens Performinfluenzasburdenstudies Increaseawarenessamong physiciansandHCPsaboutthe influenza

SaudiArabia Enhancelabperformanceand WHOcertifiedlabforstrain recommendation

Set-uptooltomonitorvaccine coverageamongtargetgroups

LinkHajjpermissiontovaccination certificate

Trackvaccinecoveragedigitally Reach30%coveragein3years

RaiseeducationallevelofHCPsto reachmorethan85%coverage amongHCPs

Launchamegapublicawareness campaignConductaseriesof educationalmeetingsforHCPs LaunchvaccinationinPharmacies QIV:QuadrivalentInfluenzaVaccine.

influenzaadvocacycampaignsprovideawarenesstothefamilyand pregnantwoman.

Themainprogressachievedandfutureobjectivesaredetailed inTables1and2respectively.

Pakistan

Currently,influenza isnot consideredasa health priorityin Pakistan.Thereisadistinctseasonalitywithpeakactivitylevels observedinmostregionsduringthewinterseason.Availabledata indicatesthat thereis a sizeableburdenof influenza.However, influenzarelatedmorbidityandmortalityestimatesarenotwell known.

In 2017, influenza epidemics started on Oct 1st and ended onMarch31stwitha peakinDecember.Influenzavirusstrains belonged to (i) influenza A/H3N2 (A/Hong

Kong/4801/2014-like, HA Genetic Group: 3C.2a1), (ii) influenza A/H1N1pdm09 (A/Michigan/45/2015 Sep, HA Genetic Group: 6B.1), and (iii) InfluenzaBbothYamagata(Y3)andVictoria(V1A).

Thekeyachievementsincludetheimplementationofsentinel influenzasurveillancenetworksand thereinforcementof social mobilizationandadvocacy(Table1).Countryspecificvaccination prioritiesmustbedeterminedforpolicyrecommendations.The mainobjectivesarelistedinTable2.

SaudiArabia

Historically,vaccinationcoveragehasbeenthan2%SaudiArabia buthigherratesareseenamongHCPs,pregnantwomen,elderly, Hajiandpatientswithchronicdiseases.Influenzasurveillance sys-temhasbeenrecentlyset-upinhospitalsandpublichealthcentres

insixregions.Inordertoincreasevaccinationcoverage,a3-phase strategicproject(3P)hasbeenlaunchedin2014withtheaimof reaching30%vaccinationcoverageamongat-riskpopulationin5 yearsscope.Severalpublicawarenesscampaignshavealsobeen conductedandtheMoHisfundingfluvaccination.

Themainachievementsandfuture objectivesare detailedin

Tables1and2respectively.

Paneldiscussion

Thepanel discussionfocused onexploringways to increase influenzavaccinationcoverageintheparticipatingcountriesand involvingtheMoHinthenetwork.

Lackofknowledgeaboutinfluenza,itsconsequencesintermsof morbidity,mortalityandeconomyisthemajorbarriertoattaining higherinfluenzavaccinationcoverageintheMENA-ISNcountries. Asstressedbytheparticipatingcountries,underawarenessabout influenzacoulditselfberelatedtocommunicationgaps.Tailored communicationmessagestothecommunitytopromoteinfluenza vaccinationandtoincreaseawarenessoninfluenzainfectionhave beenputinplacein severalcountries. Thisincludesadvertising panelsinthestreets,laypublicactivitiesinshoppingmallsand air-ports,bulkmessages,socialmediacampaigns,etc.,butmoreneeds tobedone.

Besideslackofknowledge,otherfactorssuchasmisbeliefsand personalexperiencescouldleadtolowvaccineuptake. Participat-ingcountriesconcludedthatabetterunderstandingofthefactors underlyinghesitancyandacceptabilityoftheinfluenzavaccineis neededtodeviseevidence-basedcommunicationcampaignsaimed atincreasingvaccinationcoverage.TheadaptationofWHO-SAGE availabletoolsiseachcountryhasbeensuggestedasan appropri-atemeanstodeterminetheunderlyingdeterminantsofvaccine hesitancyineachcountry.Thecostofthevaccineisanotherkey barrierthatcouldcontributetolowvaccinationcoverage. Coun-tryrepresentatives concludedthat depending onthe economic situation,countriesshouldprimarilyfocusonincreasing vaccina-tioncoverageamongknownhigh-riskgroups(diabetics,pregnant women,peoplewithunderlyingchronicdiseases,etc.).Some coun-triesbelievedthatevenwithinthehigh-riskgroups,aprioritylist shouldbedrawnaccordingtoinfluenzaburdenineachgroupand eachcountry.

Fromcountrypresentations,itwasevidencedthattheuseof privatehealthcarefacilitiesismoreusualthanthepublicfacilities. Nevertheless,alackofcommunicationbetweenthesetwosectors wasnoted.StrategiccommunicationbyMENA-ISNandtheuseof uniformtermsofreferencesforlocalstakeholderscouldhelpin enhancingtheinvolvementofMoHandtheprivatesectorthereby improvingthesituationforvaccineimplementation.

Conclusionsandrecommendations

Asreflectedbyindividualcountrypresentations,allMENA-ISN countriessharethegoaltoreduceinfluenzarelatedmorbidityand mortality.Vaccinationcoveragehasslightlyincreasedinall par-ticipatingcountries,yetmoreworkshouldbedonetoreachthe optimalvaccinationcoverage.Themainchallengestoincrease vac-cinecoveragewere: underawareness aboutinfluenza,financial andpoliticalissues,andlimitedcollaborationbetweenprivateand publichealthsectors.

Countryrepresentativesagreedontheneedtodesignstudies aimedataccuratelyestimatingvaccinationcoverageamong dif-ferent populationsand risk groupsand assessing theimpactof vaccinationonhospitalization,mortalityandherdimmunity.This canbepresentedtotheMoHtodevelopevidence-basedpolicies orpolicyupdates. Thedatacanbealsocommunicatedwiththe

publictoincreasetheirawarenessandwillingnessforinfluenza vaccination.

Pharmaciescanplayafundamentalroleastheyareeasily acces-sible, but policies in some countries prevent pharmacies from administrating vaccines. In parallel, region specific information about vaccine efficacy, economic impacts of influenza (absen-teeism,hospitalization,etc.)shouldbeprovidedinordertoprovide moreconfidenceaboutinfluenzavaccine.IncentivesforGeneral Practitioners(GPs)couldalsobeusefulinMENA-ISNcountriesand shouldbeconsidered[17].

Participating countriesrecommended the following steps to moveforward

• Developactionplanstailoredtoeachcountrysituationby focus-ing on four main areas: (i) epidemiological and virological surveillance;(ii)vaccination;(iii)communication/awarenessand (iv)advocacy

• Expandtheinfluenzastakeholdernetworktoinvolve decision-makersincludingMoH,GPs,patients,industry,etc.

• Reinforcelocalinfluenzanetworkandadvisorygroups

• Set-upresearchagendatogeneratecountryandregion-specific data

• Identifypriorityareastoinvestigatethebestwaytomove for-ward

• Promoteandincreasecollaborativeresearchamongthe MENA-ISNcountries

• Encouragepublicationandsharingofexistingdata

• Set-upa publicMENA-ISNwebsite toincreaseitsvisibilityat nationalandinternationallevels

• Improve/reinforcethelinkbetweenMENA-ISNandWHO-EMRO PandemicInfluenzaPreparednessFramework.

Fundingsource

ThemeetingwasmadepossiblethankstoFondationMérieux andunrestrictedgrantsfromSanofiPasteur.

Conflictofinterest

MG,IT,KM,MA,BU,and TPareemployeeofSanofi Pasteur. Othersauthorsdonothaveanyconflictofinteresttodeclare.

References

[1]deLatailladeC,AuvergneS,DelannoyI.2005and2006seasonalinfluenza vaccinationcoverageratesin10 countriesinAfrica,Asia Pacific,Europe, LatinAmericaandtheMiddleEast.JPublicHealthPolicy2009;30(1):83–101,

http://dx.doi.org/10.1057/jphp.2008.40.

[2]Palache A, Oriol-Mathieu V, Abelin A, Music T. Influenza vaccine supply task force (IFPMA IVS). Seasonal influenza vaccine dose distri-bution in 157 countries (2004–2011). Vaccine 2014;32(48):6369–76,

http://dx.doi.org/10.1016/j.vaccine.2014.07.012.

[3]CainiS,El-GuercheSéblainC,CiblakMA,PagetJ.Epidemiologyofseasonal influenzaintheMiddleEastandNorthAfricaregions,2010–2016: circulat-inginfluenzaAandBvirusesandspatialtimingofepidemics.InfluenzaOther RespirViruses2018;12(May(3)):344–52,http://dx.doi.org/10.1111/irv.12544. [4]Hagag IT, Mansour SM, Zhang Z, Ali AA, Ismaiel el-BM, Salama AA, et al. Pathogenicity of highly pathogenic avian influenza virus H5N1 in naturally infected poultry in Egypt. PLoS One 2015;10(5):e0120061,

http://dx.doi.org/10.1371/journal.pone.0120061.

[5]WHO/GIP, datain HQasof 27September2017. Cumulative numberof confirmed human cases for avian influenza A(H5N1) reported to WHO, 2003-2017;http://www.who.int/influenza/humananimalinterface/201709 27tableH5N1.pdf?ua=1.[Accessed5December2017].

[6]Kayali G, Webby RJ, Samhouri D, Mafi AR, Bassili A. Influenza research in the Eastern Mediterranean Region: the current state and the way forward. Influenza Other Respir Viruses 2013;7(6):914–21,

http://dx.doi.org/10.1111/irv.12136.

[7]Heidari A, Mancin M, Nili H, Pourghanbari GH, Lankarani KB, Leardini S, et al. Serological evidence of H9N2 avian influenza virus exposure

among poultry workersfrom Fars province of Iran. Virol J 2016;13:16,

http://dx.doi.org/10.1186/s12985-016-0472-z.

[8]BarbourEK,SagherianVK,SagherianNK,DankarSK,JaberLS,UsayranNN, etal.AvianinfluenzaoutbreakinpoultryintheLebanonandtransmissionto neighbouringfarmersandswine.VetItal2006;42(2):77–85.

[9]RefaeyS,AminMM,RoguskiK,Azziz-BaumgartnerE,UyekiTM,LabibM,etal. Cross-sectionalsurveyandsurveillanceforinfluenzavirusesandMERS-CoV amongEgyptianpilgrimsreturningfromHajjduring2012–2015.Influenza OtherRespirViruses2017;11(1):57–60,http://dx.doi.org/10.1111/irv.12429. [10]AlyM,ElrobhM,AlzayerM,AljuhaniS,BalkhyH.OccurrenceoftheMiddle

EastRespiratorySyndromeCoronavirus(MERS-CoV)acrosstheGulf Corpora-tionCouncilcountries:fouryearsupdate.PLoSOne2017;12(10):e0183850,

http://dx.doi.org/10.1371/journal.pone.0183850.

[11]WorldHealthOrganisation,MiddleEastrespiratorysyndromecoronavirus (MERS-CoV)summaryandliteratureupdate–asof11June2014.http://www. who.int/csr/disease/coronavirusinfections/MERSCoVsummaryupdate 20140611.pdf(AccessedonNovember7th2017).

[12]Goeijenbier M, van Sloten TT, Slobbe L, Mathieu C, van Gen-deren P, Beyer WEP, et al. Benefits of flu vaccination for persons with diabetes mellitus: a review. Vaccine 2017;35(38):5095–101,

http://dx.doi.org/10.1016/j.vaccine.2017.07.095.

[13]Sherif S,Sumpio BE. Economicdevelopmentand diabetes prevalence in MENA countries: Egypt and Saudi Arabiacomparison. World J Diabetes 2015;6(2):304–11,http://dx.doi.org/10.4239/wjd.v6.i2.304.

[14]Lafond KE, Nair H, Rasooly MH, Valente F, Booy R, Rahman M, et al. Global roleand burden ofinfluenza inpediatric respiratory hospitaliza-tions, 1982–2012:a systematicanalysis.PLoS Med 2016;13(3):e1001977,

http://dx.doi.org/10.1371/journal.pmed.1001977.

[15]CiblakMA,GripPlatformu.InfluenzavaccinationinTurkey:prevalenceofrisk groups,currentvaccinationstatus,factorsinfluencingvaccineuptakeandsteps takentoincreasevaccinationrate.Vaccine2013;31(3):518–23.

[16]AbdullahBrooksW,TerebuhP,BridgesC,KlimovA,GoswamiD,SharmeenAT, etal.InfluenzaAandBinfectioninchildreninurbanslum,Bangladesh.Emerg InfectDis2007;13(10):1507–8,http://dx.doi.org/10.3201/eid1310.070368. [17]Palache A,Oriol-Mathieu V, FinoM,Xydia-CharmantaM.Influenza

Vac-cine Supply task force (IFPMA IVS). Seasonal influenza vaccine dose distribution in 195 countries (2004–2013): little progress in esti-mated global vaccination coverage. Vaccine 2015;33(42):5598–605,

http://dx.doi.org/10.1016/j.vaccine.2015.08.082.

[18]Younan M, Poh MK, Elassal E, Davis T, Rivailler P, Balish AL, et al. Microevolution ofhighlypathogenicavianinfluenzaA(H5N1)viruses iso-latedfromhumans,Egypt,2007–2011.EmergInfectDis2013;19(1):43–50,

http://dx.doi.org/10.3201/eid1901.121080.

[19]MoasserE,BehzadianF,MoattariA,FotouhiF,RahimiA,ZaraketH,etal. Molec-ularcharacterizationandphylogeneticanalysisofhumaninfluenzaAviruses isolatedinIranduringthe2014–2015season.ArchVirol2017;162(7):1975–84,