The Reasons Behind Long-Term Endemicity of Brucellosis in Low and Middle-Income Countries: Challenges and Future Perspectives.

Brucellosis is a neglected worldwide zoonotic disease with more than 500,000 new human cases each year. Direct contact with infected animals and consumption of undercooked animal origin foods are the main routes of brucellosis transmission to humans. Although long endeavor has been applied to control and eliminate brucellosis from animal and human populations in developing countries especially in low- and middle-income countries (LMICs), the disease is still endemic in these regions. Many common or unique factors including raw milk consumption, unhygienic slaughter of livestock, extensive husbandry, budgetary limitations, misdiagnosis, and other conditions play a role in long-term endemicity of brucellosis in these locations. It has been shown that One Health is the only practical approach to control brucellosis; however, applying such methods is challenging in low-resource areas. In such conditions, brucellosis is continuously maintained in animals and repeatedly spread to human populations. In this article, factors playing a critical role in brucellosis endemicity, and the real conditions challenging the application of One Health approach in control of brucellosis are highlighted.

Strengthening the One Health Approach in the Eastern Mediterranean Region.

One Health aims to use a multidisciplinary approach to combat health threats at animal, human, and environmental health interfaces. Among its broad focus areas are issues related to food safety, the control of zoonoses, laboratory services, neglected tropical diseases, environmental health, biosafety and biosecurity, and combatting antimicrobial resistance. A roundtable session was conducted on November 18, 2021, as part of the Eastern Mediterranean Public Health Network's (EMPHNET) seventh regional conference to highlight what role Global Health Development (GHD)|EMPHNET can play to strengthen the One Health approach. This viewpoint summarizes the findings of the roundtable discussion to highlight the experts' viewpoints on strengthening the One Health approach, including the extent of zoonotic diseases and the dynamics of pathogens and emerging diseases; the occurrence of antimicrobial-resistant pathogens as a silent pandemic; issues surrounding the globalization of trade and food safety; the importance of integrated solutions as a new norm; issues around the institutionalization and governance toward effective operationalization of the One Health approach in the region; and how the One Health approach can be operationalized at global, regional, and local levels. The panel concluded that One Health is an integrated unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems, and provided recommendations to strengthen the One Health approach. It also discussed how GHD|EMPHNET can play its role in transferring the concept of One Health from theory to practice via a solid operationalization road map guide at the Eastern Mediterranean region level. The five broad priority areas of this operational guide include (1) establishing and strengthening a governance architecture, legal framework, and policy and advocacy structure for One Health operationalization in the region; (2) fostering coordination, communication, and collaboration for One Health actions across the region and beyond; (3) building the workforce capacity for effective One Health operationalization in the region; (4) supporting regional platforms for timely, effective, and efficient data sharing and exchange on all One Health-related issues; and (5) supporting risk communication, behavior change communication, and community engagement efforts in the region.

Health System Resilience in the Eastern Mediterranean Region: Perspective on the Recent Lessons Learned.

BACKGROUND: Public health has a pivotal role in strengthening resilience at individual, community, and system levels as well as building healthy communities. During crises, resilient health systems can effectively adapt in response to evolving situations and reduce vulnerability across and beyond the systems. To engage national, regional, and international public health entities and experts in a discussion of challenges hindering achievement of health system resilience (HSR) in the Eastern Mediterranean Region, the Eastern Mediterranean Public Health Network (EMPHNET) held its seventh regional conference in Amman, Jordan, between November 15 and 18, 2021, under the theme "Towards Resilient Health Systems in the Eastern Mediterranean: Breaking Barriers." This viewpoint paper portrays the roundtable discussion of experts on the core themes of that conference. OBJECTIVE: Our aim was to provide insights on lessons learned from the past and explore new opportunities to attain more resilient health systems to break current barriers. METHODS: The roundtable brought together a panel of public health experts representing Field Epidemiology Training Programs (FETPs), Centers for Disease Control and Prevention in Atlanta, World Health Organization, EMPHNET, universities or academia, and research institutions at regional and global levels. To set the ground, the session began with four 10-12-minute presentations introducing the concept of HSR and its link to workforce development with an overall reflection on the matter and lessons learned through collective experiences. The presentations were followed by an open question and answer session to allow for an interactive debate among panel members and the roundtable audience. RESULTS: The panel discussed challenges faced by health systems and lessons learned in times of the new public health threats to move toward more resilient health systems, overcome current barriers, and explore new opportunities to enhance the HSR. They presented field experiences in building resilient health systems and the role of FETPs with an example from Yemen FETP. Furthermore, they debated the lessons learned from COVID-19 response and how it can reshape our thinking and strategies for approaching HSR. Finally, the panel discussed how health systems can effectively adapt and prosper in the face of challenges and barriers to recover from extreme disruptions while maintaining the core functions of the health systems. CONCLUSIONS: Considering the current situation in the region, there is a need to strengthen both pandemic preparedness and health systems, through investing in essential public health functions including those required for all-hazards emergency risk management. Institutionalized mechanisms for whole-of-society engagement, strengthening primary health care approaches for health security and universal health coverage, as well as promoting enabling environments for research, innovation, and learning should be ensured. Investing in building epidemiological capacity through continuous support to FETPs to work toward strengthening surveillance systems and participating in regional and global efforts in early response to outbreaks is crucial.

Field Epidemiology and Public Health Research Priorities in the Eastern Mediterranean Region: Delphi Technique.

Research is essential for evidence-based decision making. This study aimed to identify research priorities in the areas of field epidemiology and public health in the Eastern Mediterranean Region (EMR) from the perspectives of public health professionals. A Delphi technique, using online survey, was employed to reach 168 public health professionals who have experience in the EMR countries. The study took place between November 2019 and January 2020. Consensus on the research priorities was reached after two-round online questionnaires. A list of top 10 field epidemiology and public health research priorities in the EMR was developed. Of those priorities, four fell under health in emergency, war and armed conflict, two under communicable diseases, two under immunization, one under digital health, and one under sexual, reproductive, and adolescent health. Availability, adequacy, and quality of health services in crisis settings were scored as a top priority (mean = 4.4, rank 1), followed by use of technology to improve the collection, documentation, and analysis of health data (mean = 4.28, rank 2), and capacity of countries in the region to respond to emergencies (mean = 4.25, rank 3). This study was conducted prior to COVID-19 pandemic and, thus, it did not capture COVID-19 research as a priority area. Nevertheless, identified priorities under communicable diseases including outbreak investigation of infectious diseases, epidemics and challenges related to communicable diseases in the EMR were still notable. In conclusion, the field epidemiology and public health research priorities identified in this study through a systematic inclusive process could be useful to make informed decisions and gear the research efforts to improve the health of people in the EMR.

Midwives and women's perspectives on family planning in Jordan: human rights, gender equity, decision-making and power dynamics.

OBJECTIVES: This study explored midwives' and Jordanian and Syrian women's perceptions towards family planning (FP) counseling and the process of FP decision making mechanism to provide evidence for expanding the access and improving the quality and utilization of FP services in Jordan. METHODS: Explorative qualitative study that purposively recruited 24 women for 4 focus group discussions (FDGs) and 17 midwives for in-depth interviews from two governorates in Jordan. The transcribed narratives were subjected to deductive content analysis. RESULTS: Two themes were extracted from the narratives: The power dynamics in FP decision-making process and the barriers and motivators of FP decision making. The first theme was built on the perceived influence of gender equity and social pressures and gender-based violence on FP decision making. The second theme was constructed on the respondents' beliefs about reproductive health including FP as a human right and their perceptions of the obstacles and facilitators of FP Decision Making. Overall, husbands have an influential role, and perhaps the final say, in deciding whether to use FP services or not as well as the type of method to use. However, wives must initiate the family planning conversation with her husband and do so in a way that will be pleasing to the husband. Whether the husband agrees with the wife's idea to use family planning and gives her permission and funds for use, depends largely on her presentation of the idea, her husband's education level, and his personality. CONCLUSIONS: This study revealed several relevant issues that play a role in Jordanian and Syrian women's decision to seek FP services. While cultural and social norms related to family planning and decision making continue to exert pressure on women, women have a deep interest in continuing to broaden their knowledge about family planning services. Engaging men and incorporating digital technology in family planning counselling has the potential to improve shared FP decision-making process among Jordanian couples and overcome some of the barriers.

Perceptions Toward the Use of Digital Technology for Enhancing Family Planning Services: Focus Group Discussion With Beneficiaries and Key Informative Interview With Midwives.

BACKGROUND: Modern family planning (FP) methods allow married couples to discuss and determine the number of children and years of spacing between them. Despite many significant improvements in FP services in Jordan, there are still many issues related to the uptake of FP services for both host communities and Syrian refugees, due to limitations in the health care system based on public health facilities. Digital technologies can provide opportunities to address the challenges faced in the health system, thus offering the potential to improve both coverage and quality of FP services and practices. OBJECTIVE: The aim of this study was to explore the perceptions of Jordanian women, Syrian refugees, and midwives in Jordan toward the use of digital health technology to support and enhance access to FP services. METHODS: We employed a qualitative study based on semistructured, face-to face key informative interviews with 17 midwives (providers) and focus group discussions with 32 married women of reproductive age (clients). Both midwives and clients were recruited from 9 health centers in 2 major governorates in Jordan (Irbid and Mafraq), where 17 in-depth interviews were conducted with midwives and 4 focus groups were conducted with the women. Each focus group included 4 Syrian refugees and 4 Jordanian women. The transcribed narratives were analyzed using inductive thematic analysis. RESULTS: Three major themes were derived from the narratives analysis, which covered the pros of using digital technology, concerns about digital technology use, and the ideal app or website characteristics. Ten subthemes emerged from these 3 main themes. Overall, midwives and women (Syrian refugees and host communities) agreed that digital technology can be feasible, cost-effective, well accepted, and potentially beneficial in increasing woman's awareness and knowledge regarding the FP methods and their side effect. Furthermore, digital technology can assist in enabling women's empowerment, which will allow them to make better decisions regarding FP use. No harmful risks or consequences were perceived to be associated with using digital technology. However, several concerns regarding digital technology use were related to eHealth literacy and the accuracy of the information provided. Midwives were mainly concerned about the patients who would rely mostly on the technology and choose to avoid consulting a health care professional. CONCLUSIONS: As perceived by midwives and women, incorporating digital technology in FP services can be feasible, cost-effective, well accepted, and potentially beneficial in increasing woman's awareness regarding the FP methods and their side effect. It may also empower the women to play an active role in the shared (with their husband and family) decision-making process. Therefore, digital technologies are recommended to address the challenges faced in health system and to improve both the coverage and the quality of FP services and practices.

Real-Time Surveillance of Infectious Diseases, Injuries, and Chronic Conditions During the 2018 Iraq Arba'een Mass Gathering.

The Arba'een pilgrimage in Iraq is now the largest annual gathering in a single place worldwide. To monitor and address the health needs of pilgrims in field clinics near the pilgrimage route, a syndromic surveillance system was designed and implemented by Global Health Development/Eastern Mediterranean Public Health Network in collaboration with Iraq Ministry of Health. This study aimed to analyze the effectiveness of the surveillance system and the data it gathered in evaluating the burden of common acute and infectious conditions, chronic conditions, and trauma and injuries during the Arba'een pilgrimage in 2018. Data were collected at 152 field clinics located across 11 governorates in Iraq at strategic points along the Arba'een pilgrimage route from all governorates to Karbala between October 8 and November 3, 2018. A team of 24 surveillance supervisors trained, oversaw, and provided technical support for 304 data collectors. The data collectors recorded data from 338,399 patients (42.5% female and 57.5% male) in the span of 26 days. The vast majority of patients were from Iraq (n = 294,260, 87.6%) and Iran (n = 34,691, 10.3%). Of the 338,399 patients whose data were recorded by the surveillance system, 246,469 (72.8%) reported acute and infectious conditions, 202,032 (59.70%) reported chronic conditions, and 6,737 (2.0%) reported traumas and injuries. Many patients reported several conditions in multiple categories. The most prevalent acute condition treated was influenza-like illness, identified through patients exhibiting a combination of fever and cough symptoms. Findings from this study will help inform future planning efforts so healthcare workers can be better prepared for treating such cases at mass gatherings. With the latest challenges posed by the COVID-19 pandemic, preparations for a possible future outbreak of the novel coronavirus are also discussed. The information from this study serves as a foundation to inform and optimize future planning of wide-scale surveillance efforts and address challenges in health service delivery and health security.

An overview of the sexual and reproductive health status and service delivery among Syrian refugees in Jordan, nine years since the crisis: a systematic literature review.

BACKGROUND: The Syrian refugee crisis has led to massive displacement into neighboring countries including Jordan. This crisis has caused a significant strain on the sexual and reproductive health (SRH) services to the host communities and Syrian refugees. The Minimum Initial Service Package (MISP) is a standard package of services that should be implemented at the onset of an emergency. Due to their importance in protracted humanitarian crisis, this systematic review aimed to assess the utilization of SRH and MISP after 9 years of the crisis. METHODS: We searched PubMed, Medline/Ovid and Scopus for both quantitative and qualitative studies from 1 January 2011 to 30 November 2019. Our search included both free text key words and Medical Subject Headings (MeSH) for various forms and acronmym of the following terms: (Sexual and) Reproductive Health, Sexual/Gender-based/Family/Intimate partner violence, Minimum Initial Service Package, MISP, Women, Girls, Adolescents, Syrian, Refugee, Jordan, Humanitarian crisis, War, (armed) conflict, and Disaster. Boolean operators and star truncation (*) were used as needed. We further conducted an in-depth review of the available grey literature published during the same timeframe. Using a narrative synthesis approach, two authors independently extracted and analyzed data from published papers. After removal of duplicates, screening, and assessing for eligibility of 161 initially identified citations, 19 papers were selected for review. RESULTS: Findings from this review indicated a number of barriers to access, utilization, and implementation of SRH services, including lack of reliable information on sexual and gender-based violence (SGBV), aggravation of early marriages by crisis setting, gaps in the knowledge and use of family planning services, inadequate STIs and HIV coverage, and some issues around the provision of maternal health services. CONCLUSION: The findings from this review are suggestive of a number of barriers pertaining to access, utilization, and implementation of SRH services. This is especially true for transitioning from MISP to comprehensive SRH services, and particularly for refugees outside camps. Following are needed to address identified barriers: improved inter-agency coordination, better inclusion/engagement of local initiatives and civil societies in SRH services delivery, improved quality of SRH services, adequate and regular training of healthcare providers, and increased awareness of Syrian women and adolescent girls. Also, more implementing research is required to identify ways to transition SRH provision from the MISP to comprehensive care for the Syrian refugee population in Jordan.

Real-Time Surveillance of Infectious Diseases and Other Health Conditions During Iraq's Arbaeenia Mass Gathering: Cross-Sectional Study.

BACKGROUND: The most common religious mass gatherings in the Middle East are the Hajj at Mecca in Saudi Arabia, which occurs annually, and the Arbaeenia in Karbala. The importance of developing public health surveillance systems for mass gatherings has been previously emphasized in other reports. OBJECTIVE: This study aimed to describe the common illnesses and health conditions affecting people during the Arbaeenia mass gathering in Iraq in 2016. METHODS: A total of 60 data collectors took part in the field data collection over a period of 11 days, from November 12, 2016 to November 22, 2016. Data were collected from 20 health outlets along the major route from Najaf to Karbala (10 health facilities in each governorate). Two digital forms, the Health Facility Survey and the Case Survey, were used for data collection. RESULTS: A total of 41,689 patients (33.3% female and 66.7% male) visited the 20 health care facilities over a period of 11 days from November 12, 2016 to November 22, 2016. More than three quarters of patients (77.5%; n=32,309) were between 20-59 years of age, more than half of patients were mainly from Iraq (56.5%; n=23,554), and about 38.9% (n=16,217) were from Iran. Patients in this study visited these health care facilities and presented with one or more conditions. Of a total 41,689 patients, 58.5% (n=24,398) had acute or infectious conditions and symptoms, 33.1% (n=13,799) had chronic conditions, 23.9% (n=9974) had traumas or injuries, 28.2% (n=11,762) had joint pain related to walking long distances, and 0.3% (n=133) had chronic dermatologic conditions. CONCLUSIONS: The Arbaeenia mass gathering in 2016 exerted a high burden on the Iraqi health care system. Therefore, efforts must be made both before and during the event to ensure preparedness, proper management, and control of different conditions.

Afghanistan's national strategy for improving quality in health care.

QUALITY PROBLEM OR ISSUE: When the Ministry of Public Health (MoPH) of the Islamic Republic of Afghanistan began reconstructing the health system in 2003, it faced serious challenges. Decades of war had severely damaged the health infrastructure and the country's ability to deliver health services. INITIAL ASSESSMENT: A national health resources assessment in 2002 revealed huge structural and resource disparities fundamental to improving health care. For example, only 9% of the population was able to access basic health services, and about 40% of health facilities had no female health providers, severely constraining access of women to health care. Multiple donor programs and the MoPH had some success in improving quality, but questions about sustainability, as well as fragmentation and poor coordination, existed. PLAN OF ACTION: In 2009, MoPH resolved to align and accelerate quality improvement efforts as well as build structural and skill capacity. IMPLEMENTATION: The MoPH established a new quality unit within the ministry and undertook a year-long consultative process that drew on international evidence and inputs from all levels of the health system to developed a National Strategy for Improving Quality in Health Care consisting of a strategy implementation framework and a five-year operational plan. LESSONS LEARNED: Even in resource-restrained countries, under the most adverse circumstances, quality of health care can be improved at the front-lines and a consensual and coherent national quality strategy developed and implemented.