Molecular epidemiology and evolution of A(H1N1) pdm09 and H3N2 viruses in Jordan, 2011-2013.

Understanding the genetic evolution of A(H1N1)pdm09 and H3N2 viruses can help better select strains to be included in the annual influenza vaccine. There is little information on their evolution in Jordan so this study investigated the genetic and antigenic variability of A(H1N1)pdm09 and H3N2 viruses in Jordan by performing phylogenetic and genetic analyses of the HA and NA genes of A(H1N1)pdm09 and H3N2 viruses between 2011 and 2013. The full HA and NA genes of 16 H1N1-positive samples obtained in our study and 21 published HA sequences and 20 published NA sequences from Jordanian viruses that were available on online gene databases were analysed. For H3N2, we generated 20 HA and 19 NA sequences and included 19 published HA and NA sequences each in the analysis. Jordanian H1N1 viruses had mutations that are characteristic of antigenic group 6 while H3N2 virus mutations belonged to group 3. No markers of resistance to oseltamivir were detected. The individual mutations are described in detail.

Molecular epidemiology and evolution of A[H1N1] pdm09 and H3N2 viruses in Jordan, 2011-2013

Understanding the genetic evolution of A [H1N1]pdm09 and H3N2 viruses can help better select strains to be included in the annual influenza vaccine. There is little information on their evolution in Jordan so this study investigated the genetic and antigenic variability of A[H1N1]pdm09 and H3N2 viruses in Jordan by performing phylogenetic and genetic analyses of the HA and NA genes of A[H1N1]pdm09 and H3N2 viruses between 2011 and 2013. The full HA and NA genes of 16 H1N1-positive samples obtained in our study and 21 published HA sequences and 20 published NA sequences from Jordanian viruses that were available on online gene databases were analysed. For H3N2, we generated 20 HA and 19 NA sequences and included 19 published HA and NA sequences each in the analysis. Jordanian H1N1 viruses had mutations that are characteristic of antigenic group 6 while H3N2 virus mutations belonged to group 3. No markers of resistance to oseltamivir were detected. The individual mutations are described in detail

La compréhension de l'évolution génétique des virus A[H1N1]pdm09 et H3N2 permet de mieux sélectionner les souches devant être ajoutées au vaccin antigrippal annuel. Peu de renseignements sont disponibles sur les mutations des virus saisonniers de la grippe A[H1N1]pdm09 et H3N2 en Jordanie. Afin de remédier à ce problème et d'étudier les variations génétiques et antigéniques des virus A[H1N1]pdm09 et H3N2, nous avons procédé à des analyses génétiques et phylogénétiques des gènes de l'hémagglutinine [HA] et de la neuraminidase [NA] de ces virus, sur la période 2011-2013 en Jordanie. L'analyse a porté sur les séquences complètes des gènes de l'HA et de la NA de 16 échantillons positifs au virus H1N1 prélevés dans le cadre de cette étude, ainsi que sur 21 séquences publiées de l'HA et 20 séquences publiées de la NA, issues de virus jordaniens disponibles sur les bases de données de gènes en ligne. Pour le virus H3N2, nous avons généré 20 séquences de l'HA et 19 de la NA, et avons également inclus dans l'analyse 19 séquences publiées de l'HA et 19 de la NA. Les virus H1N1 jordaniens présentaient des mutations caractéristiques du groupe antigénique 6, tandis que les virus H3N2 appartenaient au groupe 3. Aucun marqueur de résistance à l'oseltamivir n'a été détecté. Les mutations individuelles sont décrites en detail

Risk factors for neonatal intensive care unit admission in Amman, Jordan.

A better understanding of risk factors for neonatal intensive care unit (NICU) admission can inform interventions to improve neonatal survival. This study aimed to describe a population of newborns admitted to a NICU in Amman, Jordan, and compare them with newborns discharged to home. Newborns born within 96 hours at Al-Bashir Hospital were enrolled from February 2010 to June 2011. Demographic and clinical data were collected for mothers and newborns. Of 5466 enrolled neonates, 373 (6.8%) were admitted to the NICU. The median gestational age of NICU infants was 36 weeks, median birth weight was 2.2 kg and 49.5% were delivered by non-elective caesarean section. Lower gestational age, lower birth weight, delivery by caesarean section and birth in the month of May were statistically significant risk factors for NICU admission. Risk factors for NICU admission were consistent with other populations worldwide; however, median gestational age and birth weight were higher than in developed countries.

Middle East respiratory syndrome coronavirus not detected in children hospitalized with acute respiratory illness in Amman, Jordan, March 2010 to September 2012.

Hospitalized children < 2 years of age in Amman, Jordan, admitted for fever and/or respiratory symptoms, were tested for Middle East respiratory syndrome coronavirus (MERS-CoV): MERS-CoV by real-time RT-PCR (rRT-PCR). This was a prospective year-round viral surveillance study in children <2 years of age admitted with acute respiratory symptoms and/or fever from March 2010 to September 2012 and enrolled from a government-run hospital, Al-Bashir in Amman, Jordan. Clinical and demographic data, including antibiotic use, were collected. Combined nasal/throat swabs were collected, aliquoted, and frozen at -80°C. Specimen aliquots were shipped to Vanderbilt University and the Centers for Disease Control and Prevention (CDC), and tested by rRT-PCR for MERS-CoV. Of the 2433 subjects enrolled from 16 March 2010 to 10 September 2012, 2427 subjects had viral testing and clinical data. Of 1898 specimens prospectively tested for other viruses between 16 March 2010 and 18 March 2012, 474 samples did not have other common respiratory viruses detected. These samples were tested at CDC for MERS-CoV and all were negative by rRT-PCR for MERS-CoV. Of the remaining 531 samples, collected from 19 March 2012 to 10 September 2012 and tested at Vanderbilt, none were positive for MERS-CoV. Our negative findings from a large sample of young Jordanian children hospitalized with fever and/or respiratory symptoms suggest that MERS-CoV was not widely circulating in Amman, Jordan, during the 30-month period of prospective, active surveillance occurring before and after the first documented MERS-CoV outbreak in the Middle East region.

Intrauterine transmission of H1N1 disease: a theory that needs evidence!

Three pandemics of influenza in the 20th century have been described. Unfortunately, a little is known about the effect of those pandemics on newborn infants. We are reporting our experience with newborns born to mothers proved to have H1N1 illness perinatally, who presented with sepsis-like illness at birth or shortly after, and were treated as having H1N1 disease. This study will report on the clinical features, outcome and discuss diagnosis and treatment challenges and also the possibility of intrauterine H1N1 transmission. Our cases had good neonatal outcome, H1N1 intrauterine transmission still a possibility that needs further research efforts.

Mass psychogenic illness following tetanus-diphtheria toxoid vaccination in Jordan.

In September 1998, more than 800 young people in Jordan believed they had suffered from the side-effects of tetanus-diphtheria toxoid vaccine administered at school; 122 of them were admitted to hospital. For the vast majority, their symptoms did not result from the vaccine but arose from mass psychogenic illness. The role played by the media, the children's parents, and the medical profession in the escalation of this mass reaction appeared, at first sight, to be unusual and even unique to the circumstances in Jordan at the time. A review of the literature showed, however, that this mass reaction was similar in many ways to previous outbreaks, even though the underlying causes varied. There are about 200 published accounts of mass responses to situations involving suspected poisoning or other events. Because such mass reactions are relatively rare and the triggers so diverse, individuals faced with responding to them are unlikely to have prior experience in how to handle them and are unlikely to take bold steps to prevent their escalation. Indeed they may be unaware that such events have been recorded before. The lessons learned from this incident in Jordan may help other immunization programme managers to handle crisis situations elsewhere.

Nosocomial infections in the intensive care units at a university hospital in a developing country: comparison with National Nosocomial Infections Surveillance intensive care unit rates.

OBJECTIVE: As a measure of the quality of care provided to patients in the intensive care unit, comparison of nosocomial infection rates with those of the National Nosocomial Infection surveillance was completed during a 3-year observation period. DESIGN: The study design was a prospective study during 3 years between 1993 and 1995. During that period, patients at the medical/surgical and neurosurgical intensive care units and the high-risk nursery were surveyed for nosocomial infections. Device use, bloodstream infection, urinary tract infection, and ventilator-associated pneumonia nosocomial infection rates were calculated and compared with the National Nosocomial Infection Surveillance published rates for the same period. SETTING: The study setting was the medical/surgical intensive care unit, the neurosurgical intensive care unit, and the high-risk nursery at the Jordan University Hospital. RESULTS: Overall infection rates were 17.2 per 100 patients in the medical/surgical intensive care unit, 14.2 to 18.5 per 100 patients in the neurosurgical intensive care unit, and 13.4 to 73.5 per 100 patients in the high-risk nursery. When compared with the weight of the infants, these rates were 61.9 to 94 per 100 in infants weighing <1500 g, 26 to 30.8 per 100 patients in infants weighing >1500 g to 2500 g, and 11.7 to 14.4 per 100 in infants weighing >2500 g. Whereas device use was moderate, bloodstream infection and ventilator-associated pneumonia rates were >90th percentile for National Nosocomial Infection Surveillance in the high-risk nursery, and urinary tract infection was >90th percentile in the medical/surgical and neurosurgical intensive care units. Nosocomial infections at the intensive care units in developing countries need further investigation and control.

Familial Mediterranean fever in children: the expanded clinical profile.

The clinical picture of familial Mediterranean fever (FMF) has been appreciably expanded in the last 10 years. Over 8 years, we studied the expanded clinical profile of FMF in 476 children. Of these, 81% had abdominal pain, 41% chest pain, 42% arthritis, 12% severe myalgia, 12% skin manifestations, 4% scrotal swelling, 3% recurrent episodic fever, and one child (0.2%) developed recurrent hyperbilirubinaemia. Two (0.4%) children developed renal complications which were reversed by colchicine; however of 19 probands, 36 family members suffered from chronic renal failure. Our study indicates a familial predisposition to nephropathy in certain families with FMF. This study is the first to report the expanded clinical profile of FMF in a large group of Arab children, giving an opportunity to compare the findings with those in children with FMF in other ethnic groups, and to help in the study of genotype-phenotype correlation.

Epidemiology of needlestick and sharp injuries at a university hospital in a developing country: a 3-year prospective study at the Jordan University Hospital, 1993 through 1995.

OBJECTIVE: To study the epidemiology of needlestick and sharp injuries in a university hospital in a developing country, Jordan. METHODS: A prospective study was undertaken of all needlestick and sharp injuries among workers at the Jordan University Hospital between 1993 and 1995. Health care workers were asked to report in person to the infection-control team to verify the incident and to respond to a questionnaire. Blood was obtained from patients and health care workers immediately and from the health care workers 6 months later for hepatitis B virus, hepatitis C virus, and HIV testing. RESULTS: During the 3-year period, 248 health care workers had needlestick and sharp injuries. Of these, 34.6% were staff nurses, 19%, environmental workers, 15.7%, interns, 11.7%, residents, 8.5%, practical nurses, and 6% were technicians. The incidence density was highest for the interns followed by staff nurses and environmental workers. Of incidents, 22.6% occurred during blood drawing, 11.3% during placing intravenous lines, 8.5% during administration of medication, 11% during recapping the needle, 10.5% during needle disposal, 12.5% during garbage collection, and 5% were caused by a neglected needle. Only 117 patients were identified; 36 of 62 of these had positive results for hepatitis B surface antigen, and 8 of 13 for hepatitis C virus. CONCLUSION: Needlestick and sharp injuries occur frequently in developing countries. Safer disposal facilities and routine hepatitis B vaccine should be adopted.

Measles in Jordan: a prototype of the problems with measles in developing countries.

Until recently measles was a very severe illness of infancy and early childhood in Jordan. Incidence rates were estimated to be as high as 500 to 1000/100,000 and case fatality rates were as high as 10%. Since 1981 mandatory and routine vaccination was introduced by the Ministry of Health. Because infants accounted for the most severe cases and almost all mortality, measles vaccine was given at 9 months of age. No booster doses were recommended. Since 1981 there has been a steady shift in the age distribution of cases toward the older age group. In recent years children > 5 years of age accounted for > 60% of cases. Commensurate with that the mortality rate has decreased to almost nil in recent years. There is also evidence of a marked decrease of inpatient admission of measles cases to one of the largest hospitals, the Jordan University Hospital. Despite high immunization rates in excess of 88%, however, outbreaks of measles continue to occur. To evaluate the impact of measles vaccination on outbreaks, a study in one village in 1987 showed that there was almost no protective efficacy in children > 5 years of age (relative risk 0.80 and confidence interval 0.06 to 0.67 vs. relative risk 0.73 and confidence interval 0.54 to 1.15). Although the current measles immunization strategy has decreased the mortality and morbidity rates, we propose that the continuing occurrence of outbreaks necessitates the addition of a booster dose after 15 months of age.(ABSTRACT TRUNCATED AT 250 WORDS)

Foodhandler-associated Salmonella outbreak in a university hospital despite routine surveillance cultures of kitchen employees.

OBJECTIVE: To describe an outbreak of salmonella food poisoning that probably was due to contamination of mashed potatoes by a foodhandler, which occurred despite a policy for routine surveillance stool cultures of kitchen employees. DESIGN: A case control study of 223 individuals who ate the lunch meal on September 23, 1989, at the Jordan University Hospital (JUH) cafeteria. SETTING: Tertiary care university hospital in Amman, the capital of Jordan. PATIENTS: Individuals who developed loose stool or vomiting 6 to 72 hours after eating the lunch meal of September 23, 1989, at the JUH cafeteria. RESULTS: Of 619 individuals, 183 fit the case definition (attack rate, 19.6%); 150 were employees, 26 were inpatients, and seven were visitors. Twelve other employees became sick 4 to 6 days later and probably were infected secondarily. The incubation period ranged from 16 to 72 hours in 183 instances. Symptoms included diarrhea (88%), fever (71%), abdominal pain (74%), dehydration (34%), and bloody stool (5%). Eighty-four were hospitalized. Cultures of eight food items were negative, but stool culture on 90 of 180 patients and 11 of 61 kitchen employees yielded Salmonella enteritidis group D. A cohort study of 223 individuals revealed a food-specific attack rate of 72% for the steak and potato meal and 18% for the rice and meat meal (RR, 4; CI95, 2.62 to 6.24; P < 0.01). Stratified analysis of the steak and potato meal revealed that the potatoes were implicated most strongly (RR, 1.93; CI95, 1.42 to 2.64; P < 0.01). Cultures were obtained from all kitchen employees, and 11 of 61 grew Salmonella enteritidis group D. One asymptomatic, culture-positive employee prepared the mashed potatoes on September 23. All of these employees had negative stool cultures 3 months earlier. CONCLUSION: This outbreak probably was caused by massive contamination of mashed potatoes by the contaminated hands of the foodhandler. Routine stool culture of foodhandlers is not cost-effective and should not be used as a substitute for health education and proper hygienic practices.

Treatment of childhood brucellosis: results of a prospective trial on 113 children.

Treatment of childhood brucellosis is controversial and is currently dependent on inclusion of aminoglycoside antibiotics which are both costly and potentially toxic. Hence an alternate mode of therapy preferably dependent exclusively on oral agents is desirable because this decreases medical cost. In this study we prospectively treated 113 children with a combination of two oral agents, trimethoprim-sulfamethoxazole (10 to 12 mg/kg trimethoprim, 50 to 60 mg/kg sulfamethoxazole and rifampin 15 to 20 mg/kg in two divided doses for 6 weeks. The treatment was well-tolerated and all patients responded by defervescence of fever and resolution of all symptoms within 1 to 3 weeks. Relapse after 6 months occurred in four children all of whom responded to repeat therapy by the same agents. We conclude that the combination of trimethoprim-sulfamethoxazole and rifampin is both cost-effective and safe for the treatment of childhood brucellosis.

The changing epidemiology of diphtheria in Jordan.

Outbreaks of diphtheria used to occur regularly in Jordan, the last such outbreak being in 1977-78. Since that time, a massive immunization programme targeted at pre-school-age children has been markedly successful. Hence, when an outbreak of diphtheria occurred in 1982-83, it was unexpected. Of the 35 patients who were treated at the Jordan University Hospital, two died and the remaining 33 recovered uneventfully. Contrary to our findings in previous diphtheria epidemics in Jordan, this outbreak largely involved adolescents and young adults.

The paralytic poliomyelitis epidemic of 1978 in Jordan: epidemiological implications.

Poliomyelitis is endemic in Jordan, but until 1978 there were no epidemics. In that year, 66 children were admitted to the Jordan University Hospital with a paralytic illness, compared with 13 in 1979 and 11 in 1980. The epidemic reached a peak in the summer and fall of 1978. While 54% of the patients had not received any vaccine, 19% had received 3 doses of oral poliovaccine; 82% of the cases were in children less than 2 years of age, and all belonged to the lower socioeconomic group. There were 28 deaths with complications of the disease.Poliovirus was isolated from 10 out of 14 rectal swab samples examined (9 with poliovirus 1, 1 with poliovirus 2), and from 4 out of 13 throat specimens from the same patients. It is concluded that as a result of improving living standards in Jordan and neighbouring countries, more epidemics may occur unless immunization efforts against poliomyelitis are intensified.