Trend of Cutaneous Leishmaniasis in Jordan From 2010 to 2016: Retrospective Study.

BACKGROUND: Cutaneous leishmaniasis (CL) is endemic in the Middle East, with countries such as Syria reporting high incidence rates. OBJECTIVE: This study aimed to assess the trends in the incidence of cutaneous leishmaniasis (CL) in Jordan from 2010 to 2016. METHODS: This retrospective study included all cases of CL that had been reported to the Leishmaniasis Surveillance System in the Department of Communicable Diseases at the Jordan Ministry of Health during the period from 2010 to 2016. A total of 1243 cases were reported and met the case definition. RESULTS: A total of 1243 cases (60.65% [754/1243] males and 39.34% [489/1243] females) were diagnosed during the study period. Of this sample, 233 patients (19.13%) were aged <5 years old, 451 (37.03%) were aged between 5-14 years old, 190 (15.60%) were aged between 15-24 years old, and 344 (28.24%) were aged ≥25 years old. Of those, 646 (51.97%) were Jordanians and 559 (44.97%) were Syrians. The average annual incidence rate of 1.70 per 100,000 people between 2010 and 2013 increased to 3.00 per 100,000 people in the years 2014 to 2016. There was no difference in incidence rates between Jordanians and Syrian refugees between 2010 and 2012. After 2012, the incidence rate increased significantly among Syrian refugees from 1.20 per 100,000 people in 2012 to 11.80 per 100,000 people in 2016. On the contrary, the incidence rate did not change significantly among Jordanians. CONCLUSIONS: The incidence rate of leishmaniasis in Jordan has increased in the last three years because of the influx of Syrian refugees into Jordan. A massive effort toward reservoir and vector control, along with actively pursuing diagnosis in endemic foci, will be helpful. Proper and studious reporting of cases is also a necessity for the eradication of this disease.

Evaluation of the Acute Flaccid Paralysis Surveillance System in Polio-Free Jordan, 2012-2016: Retrospective Secondary Analysis.

BACKGROUND: As part of the polio-eradication strategy, the World Health Organization (WHO) has established a global acute flaccid paralysis (AFP) surveillance system. AFP surveillance has successfully helped Jordan achieve polio-free certification. However, there is a substantial risk of polio importation from neighboring countries including Syria and Iraq. OBJECTIVE: This study aimed to evaluate the AFP surveillance in Jordan and identify areas that need improvement. METHODS: This retrospective study is a secondary analysis of data that were routinely collected between 2012 and 2016 by Jordan's Expanded Program on Immunization. The WHO's minimum performance indicators were used to evaluate the AFP surveillance. RESULTS: Cumulatively, 328 AFP cases had been reported. Almost half (n=168, 51.3%) of the patients were aged 1-5 years, and 55.8% (n=183) were male. All cases were discarded (classified as a nonpolio case). The most common cause of AFP was Guillain-Barre Syndrome (n=115, 35.1%). The annualized nonpolio AFP rate increased from 1.4/100,000 children below 15 years of age in 2012 to 4.3 in 2016. National and subnational sensitivities were not met in 2012 and 2013. Adequacy of stool specimens and timeliness of specimens arriving at and processed in the laboratory were constantly above the minimum target. Timeliness of the investigation met the expected target but with a decreasing trend. The nonpolio enterovirus isolation rate was below the target, except in 2016. CONCLUSIONS: The AFP surveillance system in Jordan is performing well; however, additional efforts are needed to strengthen the subnational sensitivity. The cold chain from sample collection to laboratory testing has to be maintained to ensure the reliability of stool specimens required for isolation of the nonpolio enterovirus.

Knowledge, Awareness, and Compliance of Disease Surveillance and Notification Among Jordanian Physicians in Residency Programs.

Health professionals' knowledge and awareness of the disease surveillance is essential for reporting diseases to health departments. This study aimed to assess the knowledge and attitudes of Jordanian physicians toward public health surveillance of communicable disease. A cross-sectional study was conducted among resident doctors who were working in 4 main Ministry of Health hospitals and 2 teaching hospitals in Jordan in September 2017. A self-administered paper-based questionnaire was used to collect the data. The questionnaire collected information about sociodemographic and practice-related characteristics of physicians and included items to assess their knowledge of surveillance and reporting practices. This study included 223 physicians (152 males and 71 females). About 60.1% of the residents were graduates from medical schools in Jordan and the remaining (39.9%) were graduates from medical schools in other countries. Approximately two thirds of residents (62.3%) were doing their residency in Ministry of Health hospitals and the rest (37.7%) in 2 teaching hospitals. Only 44.8% of physicians had defined surveillance correctly. Only 27.4% of physicians had been educated or trained on surveillance. About 39.5% of physicians had filled at least one report form during their practice. The main reasons for not reporting mandatory diseases were high workload (49.8%) and being not trained on reporting diseases (46.6%). A relatively high percentage of physicians have insufficient knowledge of surveillance and reporting of notifiable communicable diseases. Training of physicians on surveillance and diseases notification is highly needed. The practice of disease notification should be enforced in Jordanian hospitals.

Innovative Approaches to Improve Public Health Practice in the Eastern Mediterranean Region: Findings From the Sixth Eastern Mediterranean Public Health Network Regional Conference.

Public health professionals in the Eastern Mediterranean region (EMR) have limited access to continuing education, including workshops and conferences in public health. Held under the theme Innovative Approaches: Adapting to the Current EMR Context, the Eastern Mediterranean Public Health Network (EMPHNET) organized and conducted the Sixth EMPHNET Regional Conference from March 26 to 29, 2018. This paper summarizes the key activities including workshops, roundtable discussions, oral and poster presentations, keynote speeches, and side meetings. Before the opening, 5 preconference workshops were held: "Field Epidemiology Training Program (FETP) Accreditation," "Innovative Public Health Surveillance," "Human and Animal Brucellosis," "Rapid Response Teams," and "Polio Transition and Routine Immunization." The conference hosted 6 roundtable discussions: "Consolidation of the FETP Network," "One Health to Achieve Global Health Security," "Polio Eradication Efforts and Transition Planning for Measles Elimination," "Mobile Data Collection and Other Innovative Tools to Enhance Decision Making," "Confronting Candida auris: An Emerging Multidrug-resistant Global Pathogen," and "Functioning and Sustainable Country Public Health Emergency Response Operation Framework." One of the conference's key objectives was to provide a space for FETP residents, graduates, and public health professionals to showcase achievements. A total of 421 abstracts were submitted and after professional review, 34.9% (147/421) were accepted (111 for oral presentations and 36 for poster presentations) and published by Iproceeding. The conference met the primary objectives of showcasing the public health accomplishments and contributions of the EMR, encouraging the exchange of ideas and coordination among stakeholders, and engaging cross-sectoral workforce in producing recommendations for approaching regional and global health concerns. Moreover, the conference presented a unique opportunity for FETPs and other public health professionals from the Mediterranean region to present their significant scientific work and also facilitated networking among professionals. EMPHNET strives to continue to present similar exchange opportunities for public health professionals in the region.

Multihospital Outbreak of a Middle East Respiratory Syndrome Coronavirus Deletion Variant, Jordan: A Molecular, Serologic, and Epidemiologic Investigation.

BACKGROUND: An outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in Jordan in 2015 involved a variant virus that acquired distinctive deletions in the accessory open reading frames. We conducted a molecular and seroepidemiologic investigation to describe the deletion variant's transmission patterns and epidemiology. METHODS: We reviewed epidemiologic and medical chart data and analyzed viral genome sequences from respiratory specimens of MERS-CoV cases. In early 2016, sera and standardized interviews were obtained from MERS-CoV cases and their contacts. Sera were evaluated by nucleocapsid and spike protein enzyme immunoassays and microneutralization. RESULTS: Among 16 cases, 11 (69%) had health care exposure and 5 (31%) were relatives of a known case; 13 (81%) were symptomatic, and 7 (44%) died. Genome sequencing of MERS-CoV from 13 cases revealed 3 transmissible deletions associated with clinical illness during the outbreak. Deletion variant sequences were epidemiologically clustered and linked to a common transmission chain. Interviews and sera were collected from 2 surviving cases, 23 household contacts, and 278 health care contacts; 1 (50%) case, 2 (9%) household contacts, and 3 (1%) health care contacts tested seropositive. CONCLUSIONS: The MERS-CoV deletion variants retained human-to-human transmissibility and caused clinical illness in infected persons despite accumulated mutations. Serology suggested limited transmission beyond that detected during the initial outbreak investigation.

Jordan Field Epidemiology Training Program: Critical Role in National and Regional Capacity Building.

Field Epidemiology Training Programs (FETPs) are 2-year training programs in applied epidemiology, established with the purpose of increasing a country's capacity within the public health workforce to detect and respond to health threats and develop internal expertise in field epidemiology. The Jordan Ministry of Health, in partnership with the US Centers for Disease Control and Prevention, started the Jordan FETP (J-FETP) in 1998. Since then, it has achieved a high standard of success and has been established as a model for FETPs in the Eastern Mediterranean Region. Here we describe the J-FETP, its role in building the epidemiologic capacity of Jordan's public health workforce, and its activities and achievements, which have grown the program to be self-sustaining within the Jordan Ministry of Health. Since its inception, the program's residents and graduates have assisted the country to improve its surveillance systems, including revising the mortality surveillance policy, implementing the use of electronic data reporting, investigating outbreaks at national and regional levels, contributing to noncommunicable disease research and surveillance, and responding to regional emergencies and disasters. J-FETP's structure and systems of support from the Jordan Ministry of Health and local, regional, and international partners have contributed to the success and sustainability of the J-FETP. The J-FETP has contributed significantly to improvements in surveillance systems, control of infectious diseases, outbreak investigations, and availability of reliable morbidity and mortality data in Jordan. Moreover, the program has supported public health and epidemiology in the Eastern Mediterranean Region. Best practices of the J-FETP can be applied to FETPs throughout the world.

Knowledge, attitude, and behaviors of health professionals towards smoking cessation in primary healthcare settings.

This study aimed to assess the behaviors of multiple health professionals in primary healthcare settings in Jordan towards smoking cessation counseling and to determine the barriers to effective smoking cessation behaviors. A survey of 456 health professionals in primary healthcare settings was conducted. A self-administrated questionnaire was used to collect the data. About half of health professionals reported that they usually ask patients about smoking status and advise them to stop smoking (51.4% and 50.5%, respectively). Only 23.7% reported assessing the willingness of the patients to quit smoking and 17.9% reported discussing counseling options with smokers. Considerably fewer percentages of health professionals reported preparing their patients for withdrawal symptoms (6.0%), discussing pharmacotherapies (3.8%), and prescribing nicotine patches (6.4%). Key barriers to smoking cessation counseling, as reported by health professionals, included: insufficient resources and organizational support, limited coverage of cessation interventions, and lack of motivation to quit. Smoking cessation counseling was not routinely implemented by Jordanian health professionals. Barriers to effective delivery of smoking cessation counseling need to be integrated within relevant strategies aiming at enhancing the frequency and quality of health professionals' engagement in smoking cessation.

Inclusion of MERS-spike protein ELISA in algorithm to determine serologic evidence of MERS-CoV infection.

The Centers for Disease Control and Prevention (CDC) algorithm for detecting presence of serum antibodies against Middle East Respiratory Syndrome coronavirus (MERS-CoV) in subjects with potential infections with the virus has included screening by indirect ELISA against recombinant nucleocapsid (N) protein and confirmation by immunofluorescent staining of infected monolayers and/or microneutralization titration. Other international groups include indirect ELISA assays using the spike (S) protein, as part of their serological determinations. In the current study, we describe development and validation of an indirect MERS-CoV S ELISA to be used as part of our serological determination for evidence of previous exposure to the virus.

Blood Pressure of Jordanian Workers Chronically Exposed to Noise in Industrial Plants.

BACKGROUND: Occupational studies investigating the association between blood pressure and noise exposure are almost lacking in the Eastern Mediterranean Region countries. OBJECTIVE: To determine the association between occupational exposure to high level of noise and blood pressure among a group of workers in Jordan. METHODS: All workers who had been exposing to noise for at least 3 years in 3 plants in Madaba governorate in Jordan were included in this cross-sectional study. A structured questionnaire was used to collect data. The occupational noise level was measured with a portable calibrated sound meter. RESULTS: We studied 191 male workers, of whom 145 (75.9%) were exposed to a noise level higher than the permissible limit of 85 dBA. The mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the prevalence of hypertension were significantly higher among those exposed to higher noise level. In multivariate analysis, workers exposed to high level of noise had a significantly higher odds of hypertension compared to those exposed to noise level lower than the permissible limit (OR 4.7, 95% CI 1.6 to 13.8). The odds of hypertension increased by 17% (95% CI 10% to 30%) for each dB increase in noise intensity. CONCLUSION: Exposure to high level of noise is associated with elevated blood pressure.

Acute respiratory infections among returning Hajj pilgrims-Jordan, 2014.

BACKGROUND: The emergence of Middle East Respiratory Syndrome coronavirus (MERS-CoV) has prompted enhanced surveillance for respiratory infections among pilgrims returning from the Hajj, one of the largest annual mass gatherings in the world. OBJECTIVES: To describe the epidemiology and etiologies of respiratory illnesses among pilgrims returning to Jordan after the 2014 Hajj. STUDY DESIGN: Surveillance for respiratory illness among pilgrims returning to Jordan after the 2014 Hajj was conducted at sentinel health care facilities using epidemiologic surveys and molecular diagnostic testing of upper respiratory specimens for multiple respiratory pathogens, including MERS-CoV. RESULTS: Among the 125 subjects, 58% tested positive for at least one virus; 47% tested positive for rhino/enterovirus. No cases of MERS-CoV were detected. CONCLUSIONS: The majority of pilgrims returning to Jordan from the 2014 Hajj with respiratory illness were determined to have a viral etiology, but none were due to MERS-CoV. A greater understanding of the epidemiology of acute respiratory infections among returning travelers to other countries after Hajj should help optimize surveillance systems and inform public health response practices.

Persistence of Antibodies against Middle East Respiratory Syndrome Coronavirus.

To determine how long antibodies against Middle East respiratory syndrome coronavirus persist, we measured long-term antibody responses among persons serologically positive or indeterminate after a 2012 outbreak in Jordan. Antibodies, including neutralizing antibodies, were detectable in 6 (86%) of 7 persons for at least 34 months after the outbreak.

Hospital-associated outbreak of Middle East respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description.

BACKGROUND: In April 2012, the Jordan Ministry of Health investigated an outbreak of lower respiratory illnesses at a hospital in Jordan; 2 fatal cases were retrospectively confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) to be the first detected cases of Middle East respiratory syndrome (MERS-CoV). METHODS: Epidemiologic and clinical characteristics of selected potential cases were assessed through serum blood specimens, medical record reviews, and interviews with surviving outbreak members, household contacts, and healthcare personnel. Cases of MERS-CoV infection were identified using 3 US Centers for Disease Control and Prevention serologic tests for detection of anti-MERS-CoV antibodies. RESULTS: Specimens and interviews were obtained from 124 subjects. Seven previously unconfirmed individuals tested positive for anti-MERS-CoV antibodies by at least 2 of 3 serologic tests, in addition to 2 fatal cases identified by rRT-PCR. The case-fatality rate among the 9 total cases was 22%. Six subjects were healthcare workers at the outbreak hospital, yielding an attack rate of 10% among potentially exposed outbreak hospital personnel. There was no evidence of MERS-CoV transmission at 2 transfer hospitals having acceptable infection control practices. CONCLUSIONS: Novel serologic tests allowed for the detection of otherwise unrecognized cases of MERS-CoV infection among contacts in a Jordanian hospital-associated respiratory illness outbreak in April 2012, resulting in a total of 9 test-positive cases. Serologic results suggest that further spread of this outbreak to transfer hospitals did not occur. Most subjects had no major, underlying medical conditions; none were on hemodialysis. Our observed case-fatality rate was lower than has been reported from outbreaks elsewhere.

Stillbirth during infection with Middle East respiratory syndrome coronavirus.

We conducted an epidemiologic investigation among survivors of an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Jordan. A second-trimester stillbirth occurred during the course of an acute respiratory illness that was attributed to MERS-CoV on the basis of exposure history and positive results of MERS-CoV serologic testing. This is the first occurrence of stillbirth during an infection with MERS-CoV and may have bearing upon the surveillance and management of pregnant women in settings of unexplained respiratory illness potentially due to MERS-CoV. Future prospective investigations of MERS-CoV should ascertain pregnancy status and obtain further pregnancy-related data, including biological specimens for confirmatory testing.