Tag: 2019

  • Emotional Labour – Organisational Behaviour

    Emotional Labour – Organisational Behaviour

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    Abstract:

    Putting on a good show, keeping face, professionalism in customer treatment can all be examples of emotional labour. When in the workplace dealing with others whether they be colleagues or customers we tend to give a positive emotional response despite the negativity of the other person (customer complaint) or our own current mood state (sadness, irritability) known as emotional dissonance. In this paper we will explore the phenomenon of emotional labour and its effect on workers productivity and social relations. The general outcome being that the strain of that dissonance creates mental health problems in the workplace.

    Introduction:

    Emotional labour can be seen as the affect of the current mood of a worker whilst engaging in interactions with others – putting on a good face for example despite feeling emotionally uncomfortable. (1. Robins/Judge 2013) These emotions can be driven by organisational expectations of an employees behaviour towards customers, clients and co-workers in support of the business goals to profit. For example in the service industry, customer complaints should be handled with a polite professional smiling attitude so that the customer perceives that their complaints are receiving serious attention. Despite the fact the service provider (customer relations officer) maybe be in a personal bad mood, have life problems or employment concerns – all this is swept aside to provide the company’s public positive image to the customer. For the employee engaged in such activities the strain of appearing positive and enthusiastic may cause both physical and emotional strain often leading to further deterioration in mood after work and in between assignments. You could argue that a good deal of the time we are in fact faking our emotions (feelings) in front of and towards others to support social conventions for example being polite. If a customer’s complaint is unreasonable, they are showing anger, accusing the company or misleading them and selling shoddy products – the company service support worker must maintain control over their own emotions despite feeling that the customer is wrong and the complaint is unwarranted or even ridiculous they still have to maintain the company driven reaction to the customer with calm professionalism. (2. Myler – Case Studies 2018) Some companies make being happy at work almost mandatory – where staff entertain, create an atmosphere or encourage excitement over the product and its associated feelings of happiness. For example, theme park staff forced to smile all day – try it yourself – it is very stressful to keep a happy demeanor in the face of disgruntled visitors waiting hours in a queue for a five minute ride or the phone shop worker being asked to entertain the queue of waiting customers with hi-fives and silly games. (3. Grandey et.al. 2010) Many customers in fact reporting discomfort at being targeted for unwanted attention and interaction). Therefore there is a difference between felt emotions (what I am actually thinking and feeling) than with displayed emotions (what is expected of me). After an interaction the employee can feel both exhausted by the forced situation and emotionally angry at faking their feelings for the benefit of others. Many people who suffer from depression report that faking happiness is the biggest strain of the day.

    Culture and Emotional Labour

    Culture may impact on how someone sees emotional labour as the expectations of others in the light of social comparison. (4. Matsumoto etal. 2009) For example many American service jobs, such as retail staff, service providers and customer interaction workers all feel that a positive upbeat smiling enthusiastic person is a definite requirement for the companies image management. The monocor – have a nice day – often rings false in the ears of those who understand this is not a genuine sentiment but a practiced social grace. In other cultures such as Japan or Asia in general – forced politeness or deference to not displaying emotions may in fact cause particular strain on everyday life where displaced emotion can be seen in acts of violence and sexual deviance. The French tend to not display openness in dealing with customers but in fact a non-smiling or even impolite attitudes towards their clients. This can cause companies dealing in global markets problems with staff in having to adapt and understand policy in line with the cultural underlying expectations of behaviour.

    Mental Health

    Many psychologists, counsellors and others such as nurses encounter patients (clients) who maybe presenting mental health problems such as anxiety (worry about future events) or depression (living with the past) that report difficulties in the work place in faking their emotions towards both colleagues and customers – that they feel the strain of the day at home later through irritability, sexual indifference a lack of appetite and sleep. Keeping up appearances at work therefore effects the very quality of our lives both in and out of the work place. (5. Myler Case Studies 2018) Dealing with difficult people whether customers or colleagues leaves us feeling exhausted physically and mentally. In therapy the psychologist maybe searching for psycho-dynamic reasons for the negative feelings from past patterns of behaviour and often miss the power of the here and now effect of faking your feelings at work simply due to enforced company policies that require us to present an image of well- being and happiness that actually is not there. Treatment therefore should focus on workplace stress rather than personal history.

    Role Play & Emotional Labour:

    Of course we are schooled from an early age in how to act given certain social situations, for example being happy at a birthday party ( don’t spoil it for everyone) to look sad at the funeral (even when we did not even like the deceased). We have learned behavior for situational displays of affect. Have you ever been told off – criticised – looked at the person with a smile on your face – and they say, “what are you smiling at?” they think you are not taking them seriously enough, acknowledging their concerns – the truth maybe that we think their remarks are unwarranted and silly – however our learned correct response is to – look serious and be intently listening – while all the time inside feeling what an idiot this person is! In other words we are often asked to fake it – for the sake of the other persons feelings – this is often seen as high empathy when in fact it is more often just a learned reaction to a situational event. Emotional intelligence is seen a as a panacea for management effectiveness but maybe little more than learned responses to situations, rather than a genuine cognitive response to some event. In other words emotional intelligence maybe more pop psychology than a fact. Measurement for emotional understanding may reflect no more about the learned response to given situations we have come to understand through cultural, generational and traditional customs of our community or group behaviour. Psychometric tests for emotional intelligence may in fact be invalid and not robust enough to provide any useful measure of a persons feelings towards others but in fact reflect that learned behaviour – what should be the response not what I actually feel inside.

    Attributions Theory – Misunderstanding Others:

    Attribution theory ( 6. Heider – 1958) suggests that we attend to what we see more than what we know. In other words – we do in fact judge a book by its cover. So if we are busy faking our emotions so must everyone else? So how do we know that the mood being displayed to us is genuine or faked. We pride ourselves on being able to know others feeling by their facial expressions, there seemingly genuineness and authentic sounding responses. In fact much of the time we maybe reacting to the faked emotion rather than the real one. We are often surprised to hear someone committed suicide – we may say – they always seemed so positive and happy looking – but that is exactly what a mis-attribution is – the lack of skills to identify a real emotion from a faked one – we are actually quite good at emotional labour at work and so do we really know what anyone is actually feeling, as opposed to what they are displaying to us. So the helpful shop assistant may in fact be bored rigid at having to seem enthusiastic about a product she has already spoken about ten times that day already.

    In Summery:

    Emotional labour is a situation where the employee expresses the companies desired response to a given situation. Emotional dissonance are our feeling of confusion between our internal feelings and the face we put upon the situation given company policy towards others. Felt emotions therefore being what we actually feel as opposed to displayed emotion being the faked response to another person. Finally emotional intelligence being no more than learned responses to events as we behave given the situation we find ourselves in. The consequences of faked emotions can be strain leading to emotional exhaustion that has both physical and emotional outcomes for mental health and general well-being. Judging others may in fact lead to mis-attributions where we think the faked emotion is in fact the real feelings of the other party.

    To be honest, open and authentic would be real intimacy in our relationships but carries the high risk of rejection and misunderstandings.

    References:

    1. Robins S.P. Judge T.A. 2013 – Organizational Behavior 15Ed Pearson Publishing

    2. Myler S.F. 2018 – Myler Case Studies 2018/19 Unpublished

    3. Grandey A. et.al. 2010 – Work in the Global Services Economy – Journal of Service Management.

    4. Matsumoto D. 2009 – Culture & Emotional Expression – New York, Taylor & Francis publishing.

    5. Myler S. F. 2019 – Myler Case Studies 2019 Unpublished

    6. Heider F 1958 – Attribution Theory – Oxford Dictionary of Psychology 2001

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    Source by Stephen F. Myler

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  • Shop Smart & Save Money 2019

    Shop Smart & Save Money 2019

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    In this eCommerce era, it has become possible to find the best deals using a smartphone or a laptop, and get it shipped to your doorstep. It also became possible to score deals in stores, online and through apps.

    There are 3 ways to shop smart and save money in 2019, before buying, while buying and after purchase.

    1-How to save money before buying an item?

    When I find a product I want or need, the first step is to decide whether to purchase it online or in store. Then what store or online platform offers the best quality to price ratio. I also look at some elements that I believe to be very important before making any purchase:

    -Shipping Policy: It’s important to know if a price tag online comes with free shipping or if the customer is responsible for this cost.

    -Return Policy: It’s also important to find out if a seller or a shopping platform offers free returns or not. With a free return policy in place, the seller will pay for the return shipping cost if the customer doesn’t like the item received.

    -Location: Where is the item you are purchasing being shipped from? The items origin location will determine how long it should take for your item to arrive. However there are a lot of online sellers that use the drop shipping method. When the consumer purchases, the seller (who doesn’t have the item on hand) then has the manufacturer or a 3rd party entity ship the item to the customer. These items are usually being shipped from overseas from countries like China, which will take a lot longer for the for the item to arrive. If you are OK waiting that long for shipping it makes no sense to go through a drop shipper, you could pay less by going directly to Alibabba or ALiexpress websites.

    Following are some ways I use to score some good deals

    Disclaimer: This post contains affiliate links to products. We may receive a commission for purchases made through these links.

    Shop & Save Money

    -Goodwill Outlet Store

    Goodwill Outlet is a good example of a store that I never visited before 2018. Now I can go there and buy as many items as I want for very cheap, and if I’m lucky enough that day, I can find some brand name items, to keep or resell online. I can pay up to $1.49 for a pound of clothes (prices vary depending upon location). The Goodwill outlet in my opinion is not only for someone who resells online. I encourage you to visit the Goodwill outlet store in your area, it’s an experience that you will enjoy if you like finding deals, and it’s for a good cause. If you decide to go after reading this article or if you have been there, please share with us your experience in the comments area for everyone to learn from

    -eBay Auctions

    eBay is another platform where you are most likely to score a deal. It’s in my list of smart ways to shop online in 2019 for 3 reasons:

    1. Huge inventory with a possibility to make an offer, which gives you some control over the price to are willing to pay for an item. If the seller accepts you have a deal.

    2. HUGE number of auctions you can win for cheap if you know what you are doing. I usually score a great deal quickly by bidding on auctions that are ending soon with no bidders. I found out that winning auctions is a great way to save money and shop smart.

    3. Rare finds in all categories

    eBay has been around for a while and has a strong brand that offers a good buyer protection policy and has trust from around the world.The eBay platform is another smart way to shop, and also get rid of unwanted items around the house. I sell on eBay and keep a Top Rated seller status with a 100% customer feedback, just by keeping my prices low, accepting reasonable offers, and trying to give the best customer service possible. You can still get a good feedback even if the item isn’t brand new, as long as you are honest and mention any scratches or blemishes in the description. You can find my store on eBay here. I will appreciate it if you check it out.

    -Poshmark

    I love the poshmark app because It’s easy to use, and it’s a great way to find some good deals in the clothing category. As a posher, you can make offers on items you like and use the power of negotiation to your advantage to ask poshers to lower their prices. You can also follow the sellers you like and join parties based on brands or item categories you’re interested in.The Poshmark App made it to my list of smart ways to shop in 2019 because it allows it’s members to be buyers and sellers at the same time. It’s a great way to clean up your closet and get rid of the clothes you don’t use anymore.If you don’t have a Poshmark account, you can receive a free $5 bonus when you sign up with my code SARADRETAIL.

    Disclaimer: If you use my code to sign up to poshmark for free, you will receive a $5 credit and I will receive a $5 credit after you make your first purchase. Please leave me a comment below to follow your closet, you can check out my closet here.

    -ThredUP:

    ThredUP is another website that makes buying brand name preowned clothing and accessories affordable.Their customer service is great, their shipping is quick, and their prices are some of the best in the market. Every purchase I make in the thredUP website is a deal. Check it out here if you are looking for some high ticket items for a really good price. Some of the brands available on thredUP: GUCCI, BURBERRY, GIORGIO ARMANI, MAX MARA, J.CREW, THEORY, COACH, VINCE, MICHAEL KORS…

    2-HOW TO SAVE MONEY WHILE BUYING AN ITEM?

    There are a couple of different ways to save money while buying products. When you are buying online, depending upon your platform (ie. eBay, amazon, poshmark, craigslist, letgo, offerup, etc.) you may have the power of negotiating your price. Haggling over price is still used in many cultures all over the world, but ultimatley as a buyer we haggle to get the best price we can. Many platforms now have a way to haggle through “Best offer” or “Make an Offer” options. Of course the seller ultimately gets to decide to accept, counter or decline the offer. As long as you offer a reasonable price and don’t low ball in most cases you can expect to pay a lower price than originally was being asked.

    Another way to save money online is through coupons, ecoupons, and promo codes. You may be thinking did I just read coupons, aren’t those the things my mom cuts out of the Sunday paper. Well they aren’t just for in store purchases any more. Everything is online now-a-days and that includes discount coupons. There are websites that offer online discounts and printable coupons for almost any item, any store and any retailer at the click of button. These discount codes can be entered at checkout to get anywhere from 10-70% off your total purchase. Plus on many platforms if you bundle (purchase more than 1 item from the same seller) your purchase you can save even more.

    Coupons have been used at grocery retailers for over a hundred years. With technology retailers are now able to offer their customers direct mail and email coupons, they can put coupons on their website and customers can even save them on their phone. There are coupons available for any item, any discount and any retailer. Its just a matter of finding the best coupon to use for your purchase.

    Here you can check out Coupons.com for some good deals.

    Shop Smart In 2019

    3-How to Save money after purchase?

    3-How to Save money after purchase?

    You may be wondering what I mean by saving money after you have made a purchase. It doesn’t make sense that you can save money after you have already purchased an item. Well in actuality I mean cash back rewards. Cash back rewards allow you to earn cash back on any item you have purchased, in turn allowing you to save off the purchase of that product.

    We are in the age of apps. We have become glued to our phones, never letting them out of our site, using them to not only make phone calls but browse the internet, purchase products, watch tv, read a book, etc. Apps have become a normal part of our phones anatomy. And there are some apps which allow you to make cash back by doing your normal everyday shopping. These apps include Ibotta, Shopkick, Receipt Hog, FetchRewards, etc. The basic premise of these apps is once you make a purchase you upload your receipt and based upon the items purchased and total spent, you will receive a point value. The points equal a dollar amount and once you reach a certain points total you get that dollar amount either through paypal or through gift cards, etc. Each app has its own unique additions such as getting points just to walk into a store, or scanning certain products. Its nice to know that you can get rewarded for doing normal everyday things such as shopping.

    These are the apps I use. If you sign up under me you will get starting bonus:

    Ibotta: gyrrrvo

    Shopkick: SAVE219356 – get 250 kicks for signing up

    Fetch Rewards: YF8AD – get 3000 points for signing up

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    Source by Sarah Labdar

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  • WHO and European Investment Bank strengthen efforts to combat COVID-19 and build resilient health systems to face future pandemics

    • WHO and the European Investment Bank enhance cooperation to support countries in addressing the health impact of COVID-19
    • The first phase will address urgent needs and strengthen primary health care in ten African countries
    • Enhanced WHO-EIB partnership will scale up financing to assure the chain of essential supplies, including personal protective equipment, diagnostics and clinical management
    • New initiative will accelerate investment in health preparedness and primary health care with a focus on health work force, infrastructure, and water, sanitation and hygiene
    • The initiative involves measures to address the growing threat of antimicrobial resistance

    The World Health Organization and the European Investment Bank will boost cooperation to strengthen public health, supply of essential equipment, training and hygiene investment in countries most vulnerable to the COVID-19 pandemic.

    The new partnership between the United Nations health agency and the world’s largest international public bank, announced at WHO headquarters in Geneva earlier today, will help increase resilience to reduce the health and social impact of future health emergencies. 

    “Combining the public health experience of the World Health Organization and the financial expertise of the European Investment Bank will contribute to a more effective response to COVID-19 and other pressing health challenges,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

    “WHO looks forward to strengthening cooperation with the EIB to improve access to essential supplies including medical equipment and training, and deliver better water, sanitation and hygiene where most needed. New initiatives to improve primary health care in Africa and support the EU Malaria Fund hint at the potential impact of our new partnership,” Dr Tedros concluded.

    “The world is facing unprecedented health, social and economic shocks from COVID-19. The European Investment Bank is pleased to join forces with the World Health Organization as a key part of Team Europe’s efforts to address the global impact of the COVID-19 pandemic. The EU Bank’s new partnership with the WHO will help communities most at risk by scaling up local medical and public health efforts and better protect people around the world from future pandemics. This new cooperation will enable us to combat malaria, address anti-microbial resistance and enhance public health in Africa more effectively,” said Werner Hoyer, President of the European Investment Bank.

    Improving local public health efforts to tackle coronavirus

    The WHO and the EIB will increase cooperation to help governments in low- and middle-income countries to finance and secure access to essential medical supplies and protective equipment through central procurement.

    Building resilient health systems in vulnerable countries across Africa

    The WHO and the EIB will reinforce cooperation to support immediate COVID-19 needs and jointly develop targeted financing to enhance health investment and build resilient health systems and primary health care to address public health emergencies as well as accelerate progress towards Universal Health Coverage.

    The partnership will benefit from the EIB’s planned 1.4 billion EUR response to address the health, social and economic impact of COVID-19 in Africa.

    This will address immediate needs in the health sector and provide both technical assistance and support for medium-term investment in specialist health infrastructure.

    The collaboration envisages rapid identification and fast-track approval of financing for health care, medical equipment and supplies. 

    The first phase of the collaboration will see public health investment in ten African countries. 

    Long-term collaboration to overcome market failures in global health

    The agreement signed today establishes a close collaboration to overcome market failure and stimulate investments in global health, accelerating progress towards Universal Health Coverage. Increased cooperation between the WHO and the EIB will strengthen the resilience of national public health systems and enhance preparedness of vulnerable countries against future pandemics, thanks to investments in primary care infrastructure, health workers and improved water, sanitation and hygiene. 

    Future cooperation will strengthen the EIB’s 5.2 billion EUR global response to COVID-19 outside the European Union.

    Scaling up investment to tackle antimicrobial resistance

    The two organisations will also cooperate in an initiative to address investment barriers hindering development of new antimicrobial treatment and related diagnostics. Antimicrobial resistance is amongst the most significant global health threats.

    The WHO and the EIB are working on a new financing initiative to support development of novel antimicrobials and address the estimated 1 billion EUR needed to provide medium-term solutions to antimicrobial resistance. Other crucial partners have been invited to join this discussion. 

    Improving the effectiveness of malaria treatment

    Under the new agreement the EIB and WHO will support development of the EU Malaria Fund, a new 250 million EUR public-private initiative intended to address market failures holding back more effective malaria treatment. 

    Strengthening EIB support for healthcare, life science and COVID-19 investment

    In recent years the European Investment Bank has provided more than 2 billion EUR annually for health care and life science investment.

    In the context of the COVID-19 pandemic, the EIB is currently assessing over 20 projects in the field of vaccine development, diagnostic and treatment, leading to potential investments in the 700 million EUR range. The EIB will also take part in the EU’s rolling pledging effort for the coronavirus global response that is taking place on May 4th.

    Background information

    The European Investment Bank (EIB) is the long-term lending institution of the European Union owned by its Member States. It makes long-term finance available for sound investment in order to contribute towards EU policy goals.

    The World Health Organization provides global leadership in public health within the United Nations system. Founded in 1948, WHO works with 194 Member States, across six regions and from more than 150 offices, to promote health, keep the world safe and serve the vulnerable. Our goal for 2019-2023 is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and wellbeing. For updates on COVID-19 and public health advice to protect yourself from coronavirus, visit www.who.int and follow WHO on Twitter, Facebook, Instagram, LinkedIn, TikTok, Pinterest, Snapchat, YouTube

    WHO’s information site on the COVID-19 pandemic

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  • Massive proportion of world’s population are living with herpes infection

    Massive proportion of world’s population are living with herpes infection

    Virus causing genital herpes may put millions of people at greater risk of infection with HIV

    About half a billion people worldwide are living with genital herpes, and several billion have an oral herpes infection, new estimates show.

    Authored by staff at the University of Bristol, World Health Organization (WHO), and Weill Cornell Medical College-Qatar, and published in the Bulletin of the World Health Organization,
    the new study estimates the global infection prevalence and incidence of herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) in 2016. 

    “Herpes infection affects millions of people across the globe and can have far-reaching health effects. We need more investment and commitment to develop better treatment and prevention tools for this infection.” says Dr Sami Gottlieb, Medical
    Officer at WHO and an author of the study.

    Prevalence and incidence

    An estimated 491.5 million people were living with HSV-2 infection in 2016, equivalent to 13.2% of the world’s population aged 15 to 49 years. HSV-2 is almost exclusively sexually transmitted, causing infection in the genital or anal area (genital
    herpes).

    An estimated 3.7 billion people had HSV-1 infection during the same year – around 66.6% of the world’s population aged 0 to 49. HSV-1 is mainly transmitted by oral to oral contact to cause infection in or around the mouth (oral herpes). However,
    HSV-1 can also be transmitted to the genital area through oral-genital contact – during oral sex – to cause genital herpes. Most HSV-1 infections were oral; however, between 122 million to 192 million people were estimated to have genital
    HSV-1 infection, depending on the assumptions used in the estimation model.

    Because herpes is a lifelong infection, estimated prevalence increased with age; HSV-2 prevalence was also higher among women and in the WHO African Region.

    Health and social impacts

    Most people living with herpes, caused by either HSV-1 or 2, are unaware they have the infection.

    When symptoms do occur however, oral herpes infection can lead to painful sores around the mouth (“cold sores”). Genital herpes infection can cause recurring, often painful, genital sores, often referred to as genital ulcer disease. 

    WHO and partners published a study in March 2020 estimating that around 5% of the world’s population (187 million people) suffered from at least one episode of herpes-related genital ulcer disease in 2016 (1). Most of these episodes were due to
    HSV-2, which can recur frequently over many years.

    Recurrent symptoms of genital herpes can lead to stigma and psychological distress, and can have an important impact on quality of life and sexual relationships. However, in time, most people with herpes adjust to living with the infection.

    “Genital herpes is a substantial health concern worldwide – beyond the potential pain and discomfort suffered by people living with the infection, the associated social consequences can have a profound effect on sexual and reproductive health”
    says Dr Ian Askew, Director of the Department of Sexual and Reproductive Health and Research at WHO. 

    Herpes and HIV

    A strong association exists between HSV-2 infection and HIV infection. In 2019, WHO commissioned a modeling study to estimate how much HSV-2 infection might contribute to HIV incidence. The study estimated that almost 30% of new sexually acquired HIV
    infections in 2016 worldwide were likely attributable to HSV-2 infection (2). 

    Evidence shows that people with HSV-2 infection are at least three times more likely to become infected with HIV, if exposed. HSV-2 leads to inflammation and small breaks in the genital and anal skin that can make it easier for HIV to cause infection.
    In addition, people with both HIV and HSV-2 infection are more likely to spread HIV to others.

    Women have higher biologic susceptibility to both HSV-2 and HIV. Women living in the WHO Africa Region have the highest HSV-2 prevalence and exposure to HIV – putting them at greatest risk of HIV infection, with negative implications for their health
    and well-being. 

    For people living with HIV (or who are living with other conditions that compromise their immune systems) as well as HSV-2, the symptoms of herpes can be more severe and more frequent. 

    Neonatal herpes

    Neonatal herpes can occur when an infant is exposed to HSV in the genital tract during delivery. This is a rare condition, occurring in an estimated 10 out of every 100,000 births globally, but can lead to lasting neurologic disability or death. The risk
    for neonatal herpes is greatest when a mother acquires HSV infection for the first time in late pregnancy. Women who have genital herpes before they become pregnant are at very low risk of transmitting HSV to their infants.

    No cure – better treatment and prevention needed

    There is no cure for herpes. At present, antiviral medications, such as acyclovir, famciclovir, and valacyclovir, can help to reduce the severity and frequency of symptoms but cannot cure the infection.

    As well as increasing awareness about HSV infection and its symptoms, improved access to antiviral medications and heightened HIV prevention efforts for those with genital HSV symptoms are needed globally. 

    In addition, development of better treatment and prevention interventions is needed, particularly HSV vaccines. WHO and partners are working to accelerate research to develop new strategies for prevention and control of HSV infections. Such research includes
    the development of HSV vaccines and topical microbicides. Several candidate vaccines and microbicides are currently being studied.

    “A vaccine against HSV infection would not only help to promote and protect the health and well-being of millions of people, particularly women, worldwide – it could also potentially have an impact on slowing the spread of HIV, if developed
    and provided alongside other HIV prevention strategies” says Dr Meg Doherty, Director of the WHO Department of Global HIV, Hepatitis, and STI Programmes.

    Related publications

    WHO guidelines for the treatment of Genital Herpes Simplex Virus

    WHO preferred product characteristics for herpes simplex virus vaccines

     

    ———————-

    (1) Looker KJ, Johnston C, Welton NJ, et al. The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study. BMJ Glob Health. 2020;5(3):e001875. doi: 10.1136/bmjgh-2019- 001875.

    (2) Looker KJ, Welton NJ, Sabin KM, et al.Global and regional estimates of the contribution of herpes simplex virus type 2 infection to HIV incidence: a population attributable fraction analysis using published epidemiological data. Lancet Infect Dis.2020;20(2):240-249. doi: 10.1016/S1473-3099(19)30470-0.

    Massive proportion of world’s population are living with herpes infection
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  • Indonesia firmly committed to eliminating lymphatic filariasis as a public health problem

    Indonesia firmly committed to eliminating lymphatic filariasis as a public health problem

    Indonesia recently completed the last of its annual large-scale treatment for lymphatic filariasis (also known as elephantiasis or Penyakit Kaki Gajah) in Malaka District located in its southernmost province, East Nusa Tenggara. Unprecedented
    progress by the National Lymphatic Filariasis Elimination Programme has strongly placed the country on the path to achieving the elimination of lymphatic filariasis as a public health problem.

    “We reached an estimated number of 40.7 million people living in the 118 high-risk districts during this month-long treatment campaign in October 2019” said Dr Anung Sugihantono, who recently retired as Director General of Diseases
    Prevention and Control, Ministry of Health Indonesia. “
    Single doses of diethylcarbamazine citrate and albendazole facilitated by WHO were delivered to all eligible populations.”

    In 2010, an estimated 125 million Indonesians were still at risk of the disease and required treatment.

    But things changed considerably in 2015 when Indonesia mounted an annual national campaign to resolutely address transmission of the disease and to tackle the morbidity and disability associated with it. The results were apparent as early as 2017, with
    remarkable progress.

    In Indonesia, LF is considered a significant public health concern. In 2009, risk mapping identified a population of 124.5 million people needing treatment for LF. The country initiated a national level LF elimination campaign in 2015, addressing both
    disease prevention and management. 

    “In 2017 and in just two years we managed to achieve 100% geographical coverage of all people requiring treatment” said Dr Sugihantono. “It meant achieving more than 78% epidemiological coverage – much higher than the generally recommended 65% to stop transmission.”

    Transmission of lymphatic filariasis can be stopped through large-scale treatment (or mass drug administration – MDA) of entire at- risk communities with recommended medicines once a year. These medicines kill the microfilariae in an infected patient’s
    blood preventing mosquitoes to transmit1 the disease to others. Through mass treatment, the aim is to reduce the reservoir of microfilariae in the blood to a level insufficient to maintain transmission by the mosquito vector.

    This strategy to interrupt transmission is the corner-stone of the World Health Organization’s (WHO) Global Program to Eliminate Lymphatic Filariasis (GPELF). Indonesia has been using the GPELF’s strategy since 2002 using a district or city
    as its implementation unit.

    In 2005, it listed the elimination of LF as a national priority for controlling infectious diseases and the medicines it has been using in large-scale treatment programmes are diethylcarbamazine citrate (DEC) and albendazole2 which are
    largely distributed by volunteer community health workers3.

    “Community health volunteers are themselves members of the community and know how to reach people effectively to improve compliance” said Dr. Stefanus Bria Seran, the Regent of Malaka District, one of LF endemic district in Indonesia. “Besides ensuring every single person ingests the medicine given to them, these community workers help in disseminating information well before a large-scale treatment campaign and also assist in reporting activities related to each treatment campaign”. 

    Indonesia’s efforts to eliminate lymphatic filariasis began in the 1970s but faced numerous challenges including programme coordination in the many inhabited islands, conducting information, education and awareness programmes, lack of capacity and
    insufficient medicines.

    Furthermore, the situation in Indonesia is unusual than in many other countries endemic for lymphatic filariasis as the country is endemic for all three species of thread-like filarial worms – Brugia malayi, Brugia timori, and Wuchereria bancrofti –
    that cause the disease. Most of the infections in Indonesia, however, are caused by B. malayi.

    In the past, some of the factors that prevented access to the medicines (DEC and albendazole) were social stigmatization linked to the disease, the vast geography of the territory and challenges in reaching remote populations.

    With an estimated population of 242 million, Indonesia is the world’s largest island nation and consists of approximately 17,000 islands, of which 5,000–6,000 are inhabited. It is the fourth most populated nation behind China, India, and the United
    States.

    Indonesia is endemic for many other neglected tropical diseases and an estimated 110 million Indonesians are believed to suffer from at least one neglected tropical disease (NTD), including lymphatic filariasis and soil-transmitted helminth infections.
    Leptospirosis (not classified as NTD) is also widespread.

    Indonesia is the only country of WHO’s South East Asia Region with endemic schistosomiasis. Like many other countries of the Region, it also faces recurrent threats of dengue outbreaks.

    Global progress

    The world has made significant progress towards the elimination of lymphatic filariasis as a public health problem.

    Sixteen countries4 and one territory are now acknowledged by WHO to have achieved elimination of lymphatic filariasis as a public health problem.  

    Seven additional countries have successfully implemented recommended strategies, stopped large-scale treatment and are under surveillance to demonstrate that elimination has been achieved.

    The disease

    Lymphatic filariasis is caused by infection with parasitic worms living in the lymphatic system. The larval stages of the parasite (microfilaria) circulate in the blood and are transmitted from person to person by mosquitoes.

    Infection involves asymptomatic, acute, and chronic conditions. Most infections are asymptomatic, showing no external signs while contributing to transmission of the parasite. Although asymptomatic, these infections still cause damage to the lymphatic
    system and the kidneys and alter the body’s immune system.

    When lymphatic filariasis develops into chronic conditions it leads to lymphoedema (tissue swelling) or elephantiasis (skin/tissue thickening) of limbs and hydrocele (scrotal swelling). Involvement of breasts and genital organs are common.

    Manifestation of the disease after infection takes time and can result in an altered lymphatic system, causing abnormal enlargement of body parts, and leading to severe disability and social stigmatization of those affected.

     


    1Lymphatic filariasis is transmitted by different types of mosquitoes – e.g the Culex mosquito which widespread across urban and semi-urban areas; Anopheles, mainly found in rural areas; and, Aedes, mainly
    in endemic islands in the Pacific.

    2In 2017, WHO recommended an alternative three drug treatment to accelerate the global elimination of lymphatic filariasis. The treatment, known as IDA, involves a combination of ivermectin, diethylcarbamazine citrate and albendazole.
    It is recommended annually in settings where its use is expected to have the greatest impact.

    3Community health workers, also called ‘cadres’, are volunteers who form part of the communities they serve and work with local
    communities to educate families. Their contribution in promoting health has been significant in the country.

    4Cambodia, The Cook Islands, Egypt, Kiribati, Maldives, Marshall Islands, Niue, Palau, Sri Lanka, Thailand, Togo, Tonga, Vanuatu, Viet Nam, Wallis and Futuna, and Yemen

    Indonesia firmly committed to eliminating lymphatic filariasis as a public health problem
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  • INFOSAN Quarterly Summary, 2020 #1

    Food safety incidents

    During the first quarter of 2020, the INFOSAN Secretariat was involved in 38 food safety incidents involving 109 WHO Member States and 9 territories of WHO Member States. There were 25 incidents involving a biological hazard (Salmonella spp. [8], Listeria monocytogenes [5], Norovirus [3] Shiga-toxin producing Escherichia coli [2], Clostridium botulinum [2] Bacillus cereus [2], Cronobacter spp. [1], Shigella sonnei [1], unspecified biological hazard [1]), 6 involving an undeclared allergen (milk [3], peanut (1), egg [1], gluten [1]), 5 involving a physical hazard (undetermined foreign matter [2], glass [1], metal [1], plastic [1]), one involving a chemical/toxin hazard (histamine), and one linked to an unspecified hazard.

    The food categories that were most commonly involved in the 38 incidents during the first quarter of 2020 involved fish and other seafood (8), herbs and spices (4), legumes and pulses (4), milk and dairy products (3), nuts and oilseeds (3), snacks, desserts and other foods (3), cereals and cereal-based products (2), composite food (2), fruit and fruit products (2), meat and meat products (2), vegetables and vegetable products (2), products of special nutritional use (1), and food for infants and small children (1). One incident involved an unknown food source.

    During such international food safety incidents, the INFOSAN Secretariat relies on the swift action of national INFOSAN Emergency Contact Points to respond to requests for information. Rapid sharing of information through INFOSAN enables members to implement appropriate risk management measures to prevent illness in their respective countries.

    Geographic scope

    The outlined incidents involved Member States from all WHO regions: Europe (39), followed by the Americas (24), Africa (24), the Western Pacific (18), the Eastern Mediterranean (8) and South-East Asia (6).

    Recall in several countries of frozen spring roll sheets from Singapore due to the presence of an undeclared allergen

    In February 2020, the INFOSAN Secretariat was notified by the European Rapid Alert System for Food and Feed (RASFF) and INFOSAN colleagues in Australia of a recall in Australia and several European countries of frozen spring roll sheets due to the detection of an undeclared allergen (milk), imported from Singapore. In collaboration with RASFF, the INFOSAN Secretariat was informed that the implicated frozen spring roll sheets were distributed internationally to 46 Member States from four WHO regions and 4 territories in Europe and the Western Pacific. Moreover, through engagement with the INFOSAN Emergency Contact Point (ECP) in Singapore, the INFOSAN Secretariat also received details of further distribution of implicated products to additional WHO Member States from all WHO regions, taking the total number of Member States involved to 65. It was also reported that the products involved had been redistributed by some countries to Europe, the Americas and Africa. Consequently, several countries recalled the implicated products to relabel them and investigated the issue to identify illnesses related to the consumption of the implicated frozen spring roll sheets. No illnesses were reported to the INFOSAN Secretariat.

    This incident has highlighted undeclared allergens as an important category of hazards that can result in a largescale international response to implement risk management measures and prevent illness. In addition, it exemplified efficient communication among INFOSAN members and the Secretariat.

    Outbreak of Listeriosis in the United States of America linked to enoki mushrooms imported from the Republic of Korea

    In March 2020, the INFOSAN Secretariat was made aware by the United States (US) Centers for Disease Control and Prevention (CDC) of an outbreak of Listeriosis in the US linked to the consumption of enoki mushrooms, imported from the Republic of Korea. In total, 36 cases including 4 deaths have been reported in the US. Following investigations in Canada, carried out in collaboration with the US, the INFOSAN Secretariat was informed of 6 cases of Listeriosis between 2017 and 2019 in Canada potentially related by whole genome sequencing (WGS) to the ongoing outbreak in the USA. In addition, food isolates (from enoki mushrooms from the Republic of Korea) genetically associated with the cluster of cases have been collected in 2019 by authorities in Canada. The WGS information pertaining to the cases and food isolates were shared on the INFOSAN Community Website to assist the identification of cases in other countries.

    The INFOSAN Secretariat engaged the INFOSAN Emergency Contact Point (ECP) in the Republic of Korea to seek details on any further international distribution of the implicated enoki mushrooms. Investigations are ongoing. 

    News & activities

    Food Sector and the COVID-19 outbreak

    On 31 December 2019, WHO was alerted to several cases of pneumonia of unknown origin in the city of Wuhan, Hubei Province, China. The virus, a previously unknown coronavirus has been named SARS-CoV-2 and is the cause of the COVID-19 disease.

    The WHO Epidemic Information Network (EPI-WIN) aims to share information tailored to specific sectors, including food and agriculture. The INFOSAN Secretariat has recently developed a guidance document for food businesses with regards to COVID-19 and food safety which is now available online. The guidance has also been disseminated through EPI-WIN and presented during two webinars.

    Call for applicants: INFOSAN Train-the-Trainer Workshop

    In February, the INFOSAN Secretariat issued a call for applications for the INFOSAN Train-the-Trainer workshop. With the constant growth of the network, and the increased need for training that this entails, the INFOSAN Secretariat, in collaboration with the Canadian Food Inspection Agency (CFIA), has announced this workshop which aims to increase the human resources available to train INFOSAN members on a range of INFOSAN-related topics, online or in-person. As a result, it is expected that the understanding of the roles and responsibilities of INFOSAN members will be improved, resulting in greater participation that will enhance speed and efficiency during the response to food safety emergencies at the global level. The INFOSAN Secretariat, together with CFIA, look forward to hosting this important workshop later this year.

    Developing the new INFOSAN Community Website

    The INFOSAN Community Website (ICW) continues to be an effective tool for the network to disseminate information during food safety emergencies. Over the past year, through the INFOSAN member survey, the Secretariat has gained a better understanding of how members use the ICW and how it can be improved to enhance information sharing. The information collected, together with the experience of members of the Secretariat, has provided numerous innovative ideas to guide the development of the new ICW. The Secretariat is pleased to announce that the competitive process to select the vendor that will develop the new INFOSAN Community Website has concluded and the work on the creation of the new ICW has begun. 

    Voice of an active network member

    voice-5-2020

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  • WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa

    WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa

    Severe disruptions to insecticide-treated net campaigns and in access to antimalarial medicines could lead to a doubling in the number of malaria deaths in sub-Saharan Africa this year compared to 2018, according to a new modelling analysis released by
    WHO and partners ahead of World Malaria Day (25 April).

    WHO urges countries to move fast and distribute malaria prevention and treatment tools at this stage of the COVID-19 outbreak in sub-Saharan Africa, and to do their utmost to safely maintain these essential malaria control services.

    The analysis considers nine scenarios for potential disruptions in access to core malaria control tools during the pandemic in 41 countries, and the resulting increases that may be seen in cases and deaths. 

    Under the worst-case scenario, in which all insecticide-treated net (ITN) campaigns are suspended and there is a 75% reduction in access to effective antimalarial medicines, the estimated tally of malaria deaths in sub-Saharan Africa in 2020 would reach
    769 000, twice the number of deaths reported in the region in 2018. This would represent a return to malaria mortality levels last seen 20 years ago.

    According to the World malaria report 2019, sub-Saharan Africa accounted for approximately 93% of all malaria cases and 94% of deaths in 2018. More than two-thirds of deaths were among children under the age of five.

    A window of opportunity

    To date, the number of reported cases of COVID-19 in sub-Saharan Africa has represented only a small proportion of the global total, though cases are increasing every week. This means that countries across the region have a critical window of opportunity
    to minimize disruptions in malaria prevention and treatment and save lives at this stage of the COVID-19 outbreak.

    Mass vector control campaigns should be accelerated, while ensuring that they are deployed in ways that protect health workers and communities against potential COVID-19 transmission. WHO and partners commend the leaders of Benin, the Democratic Republic of the Congo, Sierra Leone and Chad
    for initiating ITN campaigns during the pandemic. Other countries are adapting their net distribution strategies to ensure households receive the nets as quickly and safely as possible.

    Preventive therapies for pregnant women and children must be maintained. The provision of prompt diagnostic testing and effective antimalarial medicines are also essential to prevent a mild case of malaria from progressing to severe illness and death.

    WHO and partners have developed guidance to ensure that those suffering from malaria can safely receive the care they need within the package of essential health services to be delivered in COVID-19 settings. Tailoring malaria interventions in COVID-19 response includes guidance on the prevention of infection through vector control and chemoprevention, testing, treatment of cases, clinical services, supply chain and laboratory activities.

    Note to the editor

    The modelling analysis was conducted by WHO in close collaboration with partners, including PATH, the Malaria Atlas Project and the Bill & Melinda Gates Foundation. 

    The analysis is subject to uncertainties. It does not consider, for example, the effects of an interruption in indoor residual spraying or seasonal malaria chemoprevention (except in Burkina Faso); a suspension of these core malaria prevention tools would
    also lead to considerable loss of life.

    In addition, there is limited understanding of the spread of COVID-19, its epidemiology and interactions with malaria. The model will be updated as such data become available, and countries will be provided with relevant information to tailor their responses
    accordingly.

    WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa
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  • Hard fought gains in immunization coverage at risk without critical health services, warns WHO

    Hard fought gains in immunization coverage at risk without critical health services, warns WHO

    Shutting down immunization services in the COVID-19 pandemic risks triggering a resurgence of diseases that can be prevented with safe and effective vaccines, warns WHO in the lead-up to World Immunization Week (24-30 April). 

    When immunization services are disrupted, even for brief periods during emergencies, the risk of vaccine-preventable disease outbreaks, such as measles and polio, increase. Last year’s deadly measles outbreak in the Democratic Republic of the
    Congo, which took more than 6000 lives in a country already facing its largest Ebola outbreak, highlights the importance of maintaining essential health services, such as immunization in times of emergency. Further disease outbreaks will also overwhelm
    health systems already battling the impacts of COVID-19.

    “Disease outbreaks must not remain a threat when we have safe and effective vaccines to protect us,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “While the world strives to develop a new vaccine for COVID-19 at record speed,
    we must not risk losing the fight to protect everyone, everywhere against vaccine-preventable diseases. These diseases will come roaring back if we do not vaccinate.”

    WHO is working with partners all over the world to accelerate research and development of a safe and effective vaccine and ensure equitable access for the billions of people who will need it.

    But even with an expedited process, development of a vaccine for COVID-19 will take time. Precautionary measures are essential now to help keep us safe from disease, including diseases for which vaccines already protect children and adults.

    Too many people are still excluded from the benefits of vaccines

    Prior to the COVID-19 pandemic, the world had made immense progress in ensuring that children are vaccinated. In 2018, 86 percent of children under the age of five globally were vaccinated with three doses of diphtheria, tetanus and pertussis (DTP3) and
    one dose of the measles vaccine, up from 72 percent in 2000 and 20 percent in 1980. The number of children paralyzed by polio has been reduced by 99.9 percent worldwide. 

    Yet, global vaccination coverage is still far from the 95 per cent coverage needed to fully protect communities against outbreaks of this vaccine-preventable disease. 

    In 2018 nearly 20 million children worldwide – more than 1 in 10 – missed out on lifesaving vaccines, such as measles, diphtheria and tetanus. Roughly, 13 million of the children have never received any vaccines, putting them and their communities
    at risk of disease and death. The majority of these children live in countries with already fragile health systems, further limiting their access to essential health services when they fall sick.

    Measles continues to remain an ever-present threat, especially if vaccination rates drops. Current projections indicate that the number of reported measles cases for 2019 will be at least 800 000. In 2020 there are increasing concerns about another
    resurgence, especially if vaccination rates fall due to delay or suspension of scheduled immunization activities as a result of COVID-19. 

    Outbreaks of polio, diphtheria and yellow fever are also of high concern, especially in the countries least able to respond quickly and decisively to address an emerging outbreak, as seen in previous emergencies such as the polio outbreak in Syria in
    2013. 

    Maintaining immunization services during COVID-19

    As the response to COVID-19 continues, countries must act now protect immunization services, in order to further minimize disease outbreaks and loss of life. This includes, facilitating urgent catch up programmes in places where
    services have been disrupted, ensuring strong supply chains, disease surveillance and trained health workers. Caregivers should also make sure they continue to vaccinate their children in line with national policies.

    New WHO guidelines on immunization and COVID-19 recommend that governments temporarily pause preventive immunization
    campaigns where there is no active outbreak of a vaccine-preventable disease. But it urges countries prioritize the continuation of routine immunization of children in essential service delivery, as well as adult vaccinations such as influenza
    for groups most at risk. If immunization services must be suspended, urgent catch-up vaccinations should be rescheduled as soon as possible, prioritizing those most at risk.

    Hard fought gains in immunization coverage at risk without critical health services, warns WHO
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  • A meeting on digital innovations, TB and implementation research organised by WHO and the European Respiratory Society

    A meeting on digital innovations, TB and implementation research organised by WHO and the European Respiratory Society

    Group of people posing after a meeting on TB, in Geneva

    WHO’s Global Tuberculosis Programme (WHO/GTB) and the European Respiratory Society convened a technical meeting on digital innovations, TB and implementation research, in Geneva on 7 February 2020. This meeting brought together funders,
    partners, representatives of national TB programmes, civil society and scientists to discuss the challenges and opportunities when evaluating, integrating and scaling up digital technologies under programmatic settings.  Specifically, this meeting
    sought to receive input on the elements of a toolkit on implementation research that is currently being developed by WHO/GTB and the Special Programme for Research and Training in Tropical Diseases (TDR) to support evidence-informed use of
    digital technologies under programmatic settings. Th etoolkit will be launched in mid-2020. Considering that several countries are updating their national TB strategic plans and preparing funding proposals for submission to the Global Fund, this meeting
    also sought to create mutual understanding on the importance of resourcing implementation science to bridge the divide between research and practice.

    This present meeting, is the latest in a series of efforts by WHO/GTB to facilitate the meaningful use of digital technologies for TB prevention and care. It
    was preceded by a one-day workshop on 6 February held at the same venue for partner agencies of the ASCENT project. ASCENT is a UNITAID-funded project that started in 2019 with the aim of increasing demand and adoption of affordable digital technologies for TB medication adherence. The project is led by KNCV in partnership with Aurum Institute for Health
    Research, PATH and the London School of Hygiene and Tropical Medicine. Activities are running in Ethiopia, the Philippines, South Africa, Ukraine and Tanzania UR. This was the first in a series of annual meetings that will be coordinated by the WHO/GTB
    to assess progress in implementation of country activities and results from the interventions.

    A meeting on digital innovations, TB and implementation research organised by WHO and the European Respiratory Society
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  • Strengthening accountability to end TB

    WHO today released a Checklist to enable Member States and their partners to assess the status of work at the national level to strengthen accountability to End TB, principally: national commitments made, actions taken on those commitments, monitoring & reporting approaches, and the nature of any high-level review mechanisms. The Checklist has been developed in response to requests from Member States, regions, civil society and partners as a tool to support the adaptation and implementation of the WHO Multisectoral Accountability Framework (MAF-TB) released in 2019. It responds also to the UN General Assembly request to WHO to ensure implementation of the Framework.

    There are four components of the MAF-TB that form a cycle for strengthening accountability: Commitments, Actions, Monitoring and Reporting, and Review, that were released during the World Health Assembly in May, 2019. In the political declaration of the first UN high-level meeting on TB, world leaders called for WHO to finalize the framework and ensure its implementation in 2019.

    After its publication in May, 2019, WHO began work with pathfinding country counterparts who were seeking to move ahead on key elements including, among others: formal adoption of country-specific targets for 2022 for increased TB case detection and treatment in line with the global targets in the political declaration; updating or development of new national TB strategic plans based on 2022 and 2030 targets and other new commitments; coordination platforms across sectors and stakeholders; formalizing engagement with civil society across End TB efforts;  producing robust performance reports; and, using those reports to inform high-level review bodies that will assess and drive faster progress.  Based on the MAF-TB document, relevant country experiences, and specific requests from countries and partners, WHO developed the MAF-TB Checklist. The Checklist is especially relevant for high TB burden countries, but has content relevant to all countries.  The appropriateness of different approaches may vary, according to national constitutional, legal and/or regulatory frameworks or other relevant factors.

    The MAF-TB Checklist has three annexes on:

    1. engagement across government ministries and bodies;
    2. engagement of civil society and affected communities; and,
    3. adoption  and implementation of WHO TB guidance.

    In releasing this MAF-TB Checklist today, Dr Tereza Kasaeva, Director of the WHO Global TB Programme noted,  “At this enormously difficult time, all countries and partners are focused on the COVID-19 pandemic.  Lessons learnt from ongoing TB programmes are helping the response. Likewise, TB efforts will benefit from learning underway on collaboration, innovation and accountability in confronting the virus.”

    WHO will be helping Ministries of Health and partners to use the Checklist, hold related consultations and move forward with more effective collaboration and review mechanisms.  The WHO Civil Society Task Force on TB also will support countries and civil society partners, using the Checklist. Progress in strengthening accountability will be assessed in the 2020 Report of the UN Secretary-General on progress since the 2018 TB UN high-level meeting, as well as in the WHO Global TB Report 2020.

    The WHO TB Civil Society Task Force, National TB  Programme Managers and other country officials, WHO staff at all levels, consultants working with WHO and The Global Fund, and staff of partner agencies, contributed content to, and/or provided feedback on, the MAF-TB Checklist during its development.   Access the Checklist and 3 annexes.  

    An online form of the checklist will be available shortly here, along with additional information.  

    Translations of the Checklist and annexes, as soon as available in Arabic, Chinese, French, Russian and Spanish, will be posted at the above link as well.   Kindly contact gtbprogramme@who.int if you have questions regarding the MAF-TB Checklist or to request versions in MS Word format if needed.

     

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