Prioritizing zoonotic diseases utilizing the One Health approach: Jordan's experience

Background

Zoonotic diseases constitute a threat to humans and animals. The Middle East Region is a hotspot for such a threat; given its geographic location under migratory birds' flight paths, mass gatherings, political conflicts, and refugee crises. Thus, prioritizing zoonotic diseases of national significance is critical for preventing and controlling such threats and optimizing limited resources. Using a multi-sectoral One Health (OH) approach, this study aimed at prioritizing zoonotic diseases of national significance to Jordan and identifying future recommendations and action plans.

Methods

Zoonotic diseases of national significance to Jordan were initially identified (n = 27 diseases). In December 2019, national staff from governmental and non-state sectors were invited to develop ranking criteria, including questions and answers choices, and to weigh each criterion. Then, the national staff were asked to assess zoonotic diseases' priority using the developed criteria and provide recommendations and action plans to strengthen multi-sectoral collaboration.

Results

Seven zoonotic diseases were identified as being of great significance. Rabies was ranked as the number one priority disease, followed by middle east respiratory syndrome, avian influenza, brucellosis, leishmaniasis, rickettsiosis, and salmonellosis. The highest weighted criteria used to rank diseases were disease severity, outbreaks profile, and potential human-to-human transmission. Establishing a one-health platform, surveillance, laboratory, preparedness planning, outbreak response, and workforce were suggested as recommendations for approaching the priority diseases. Respondents identified data sharing, coordination, event-based surveillance, and effective communication channels as vital areas to enhance prevention and control strategies, conduct joint outbreak investigations, and improve multi-sectoral collaboration.

Conclusions

This study represents the first attempt to prioritize zoonotic diseases of national significance in Jordan using the OH approach and a semi-qualitative, transparent, and comparative method. Study results can be used as a decision-making guide for policymakers and stakeholders and a cornerstone for combating zoonotic disease threats.

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This is the first regional report to prioritize zoonotic diseases using the One Health (OH) approach.

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A list of country relevant zoonotic diseases was identified, prioritized, and approved using the OH Zoonotic Disease Prioritization (OHZDP) tool.

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Relevant surveillance systems in Jordan should adopt a standardized data sharing mechanism and an event-based method for zoonotic events.

A global analysis of the regional variation in the symptoms of acute respiratory infection during childhood: Epidemics and their association with environmental vulnerability

Using Demographic and Health Surveys from 48 low-income and middle-income countries (N = 432,860), we investigated whether or not the presence of symptoms of acute respiratory infection (ARI) are contingent on environmental vulnerabilities such as the region, the level of ambient air pollution, community orphanhood status, and household poverty among young children under five. In addition, we also examined whether such an effect may be a consequence of socioeconomic development and/or lifestyle. Using multilevel logistic regression models, environmental vulnerability was found to be significantly associated with the likelihood of childhood ARI symptoms and this association seemed to be related to the level of ambient air pollution. Our findings suggest that important roles are played by both geographic region and ambient air pollution, and that these factors may disproportionately shape a child's risk of ARI symptoms in a global context.

Preventing Emerging and Re-emerging Infections in the Eastern Mediterranean Region: Gaps, Challenges, and Priorities

BACKGROUND

The Eastern Mediterranean Public Health Network, supported by the Biosecurity Engagement Program, contributed significantly to strengthening the preparedness and response to the emerging and re-emerging infections in the region.

OBJECTIVE

This study aimed to determine the gaps, challenges, and priorities for preventing the emerging and re-emerging infections, with a focus on biosafety and biosecurity in four countries of the region, namely, Egypt, Iraq, Jordan, and Morocco.

METHODS

A total of two different methods were used to determine the gaps and priorities for preventing the emerging and re-emerging infections. The first method was a rapid assessment for the preparedness and response to the emerging and re-emerging infections in four countries of the region, with a focus on biosafety and biosecurity. The second method was a face-to-face round table meeting of the participating teams for two days, where the teams from all countries presented their countries' profiles, findings, priorities, and gaps based on the countries' assessments.

RESULTS

The assessment and meeting resulted in several priorities and recommendations for each of the countries in the areas of legislation and coordination, biosafety and biosecurity, surveillance and human resources, case management and response, infection control and prevention, and risk communication and laboratory capacity.

CONCLUSIONS

Many recommendations were relatively consistent throughout, including improving communication or building collaborations to improve the overall health of the country.

Epidemiological and genetic characterization of pH1N1 and H3N2 influenza viruses circulated in MENA region during 2009-2017

BACKGROUND

Influenza surveillance is necessary for detection of emerging variants of epidemiologic and clinical significance. This study describes the epidemiology of influenza types A and B, and molecular characteristics of surface glycoproteins (hemagglutinin [HA] and neuraminidase [NA]) of influenza A subtypes: pH1N1 and H3N2 circulated in Arabian Gulf, Levant and North Africa regions during 2009-2017.

METHODS

Analysis of phylogenetics and evolution of HA and NA genes was done using full HA and NA sequences (n = 1229) downloaded from Influenza Research Database (IRD).

RESULTS

In total, 130,354 influenza positive cases were reported to WHO during study period. Of these, 50.8% were pH1N1 positive, 15.9% were H3N2 positives and 17.2% were influenza B positive. With few exceptions, all three regions were showing the typical seasonal influenza peak similar to that reported in Northern hemisphere (December-March). However, influenza activity started earlier (October) in both Gulf and North Africa while commenced later during November in Levant countries. The molecular analysis of the HA genes (influenza A subtypes) revealed similar mutations to those reported worldwide. Generally, amino acid substitutions were most frequently found in head domain in H1N1 pandemic viruses, while localized mainly in the stem region in H3N2 viruses. Expectedly, seasons with high pH1N1 influenza activity was associated with a relatively higher number of substitutions in the head domain of the HA in pH1N1 subtype. Furthermore, nucleotide variations were lower at the antigenic sites of pH1N1 viruses compared to H3N2 viruses, which experienced higher variability at the antigenic sites, reflecting the increased immunological pressure because of longer circulation and continuous vaccine changes. Analysis of NA gene of pH1N1 viruses revealed sporadic detections of oseltamivir-resistance mutation, H275Y, in 4% of reported sequences, however, none of NAI resistance mutations were found in the NA of H3N2 viruses.

CONCLUSIONS

Molecular characterization of H1N1 and H3N2 viruses over 9 years revealed significant differences with regard to position and function of characterized substitutions. While pH1N1 virus substitutions were mainly found in HA head domain, H3N2 virus substitutions were mostly found in HA stem domain. Additionally, more fixed substitutions were encountered in H3N2 virus compared to larger number of non-fixed substitutions in pH1N1.

Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and 2015: findings from the Global Burden of Disease 2015 study

OBJECTIVES

We used data from the Global Burden of Disease 2015 study (GBD) to calculate the burden of lower respiratory infections (LRIs) in the 22 countries of the Eastern Mediterranean Region (EMR) from 1990 to 2015.

METHODS

We conducted a systematic analysis of mortality and morbidity data for LRI and its specific etiologic factors, including pneumococcus, Haemophilus influenzae type b, Respiratory syncytial virus, and influenza virus. We used modeling methods to estimate incidence, deaths, and disability-adjusted life-years (DALYs). We calculated burden attributable to known risk factors for LRI.

RESULTS

In 2015, LRIs were the fourth-leading cause of DALYs, causing 11,098,243 (95% UI 9,857,095-12,396,566) DALYs and 191,114 (95% UI 170,934-210,705) deaths. The LRI DALY rates were higher than global estimates in 2015. The highest and lowest age-standardized rates of DALYs were observed in Somalia and Lebanon, respectively. Undernutrition in childhood and ambient particulate matter air pollution in the elderly were the main risk factors.

CONCLUSIONS

Our findings call for public health strategies to reduce the level of risk factors in each age group, especially vulnerable child and elderly populations.

Emerging and Reemerging Diseases in the World Health Organization (WHO) Eastern Mediterranean Region-Progress, Challenges, and WHO Initiatives

The Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) continues to be a hotspot for emerging and reemerging infectious diseases and the need to prevent, detect, and respond to any infectious diseases that pose a threat to global health security remains a priority. Many risk factors contribute in the emergence and rapid spread of epidemic diseases in the Region including acute and protracted humanitarian emergencies, resulting in fragile health systems, increased population mobility, rapid urbanization, climate change, weak surveillance and limited laboratory diagnostic capacity, and increased human-animal interaction. In EMR, several infectious disease outbreaks were detected, investigated, and rapidly contained over the past 5 years including: yellow fever in Sudan, Middle East respiratory syndrome in Bahrain, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen, cholera in Iraq, avian influenza A (H5N1) infection in Egypt, and dengue fever in Yemen, Sudan, and Pakistan. Dengue fever remains an important public health concern, with at least eight countries in the region being endemic for the disease. The emergence of MERS-CoV in the region in 2012 and its continued transmission currently poses one of the greatest threats. In response to the growing frequency, duration, and scale of disease outbreaks, WHO has worked closely with member states in the areas of improving public health preparedness, surveillance systems, outbreak response, and addressing critical knowledge gaps. A Regional network for experts and technical institutions has been established to facilitate support for international outbreak response. Major challenges are faced as a result of protracted humanitarian crises in the region. Funding gaps, lack of integrated approaches, weak surveillance systems, and absence of comprehensive response plans are other areas of concern. Accelerated efforts are needed by Regional countries, with the continuous support of WHO, to build and maintain a resilient public health system for detection and response to all acute public health events.

Combined target site (kdr) mutations play a primary role in highly pyrethroid resistant phenotypes of Aedes aegypti from Saudi Arabia

Background

Pyrethroid resistance is a threat to effective vector control of Aedes aegypti, the vector of dengue, Zika and other arboviruses, but there are many major knowledge gaps on the mechanisms of resistance. In Jeddah and Makkah, the principal dengue-endemic areas of Saudi Arabia, pyrethroids are used widely for Ae. aegypti control but information about resistance remains sparse, and the underlying genetic basis is unknown. Findings from an ongoing study in this internationally significant area are reported here.

Methods

Aedes aegypti collected from each city were raised to adults and assayed for resistance to permethrin, deltamethrin (with and without the synergist piperonyl butoxide, PBO), fenitrothion, and bendiocarb. Two fragments of the voltage-gated sodium channel (Vgsc), encompassing four previously identified mutation sites, were sequenced and subsequently genotyped to determine associations with resistance. Expression of five candidate genes (CYP9J10, CYP9J28, CYP9J32, CYP9M6, ABCB4) previously associated with pyrethroid resistance was compared between assay survivors and controls.

Results

Jeddah and Makkah populations exhibited resistance to multiple insecticides and a similarly high prevalence of resistance to deltamethrin compared to a resistant Cayman strain, with a significant influence of age and exposure duration on survival. PBO pre-exposure increased pyrethroid mortality significantly in the Jeddah, but not the Makkah strain. Three potentially interacting Vgsc mutations were detected: V1016G and S989P were in perfect linkage disequilibrium in each strain and strongly predicted survival, especially in the Makkah strain, but were in negative linkage disequilibrium with 1534C, though some females with the Vgsc triple mutation were detected. The candidate gene CYP9J28 was significantly over-expressed in Jeddah compared to two susceptible reference strains, but none of the candidate genes was consistently up-regulated to a significant level in the Makkah strain.

Conclusions

Despite their proximity, Makkah and Jeddah exhibit significant differences in pyrethroid resistance phenotypes, with some evidence to suggest a different balance of mechanisms, for example with more impact associated with CYP450s in the Jeddah strain, and the dual kdr mutations 989P and 1016G in the more resistant Makkah strain. The results overall demonstrate a major role for paired target site mutations in pyrethroid resistance and highlight their utility for diagnostic monitoring.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-017-2096-6) contains supplementary material, which is available to authorized users.

Evaluation of the timeliness and completeness of communicable disease reporting: Surveillance in The Cuban Hospital, Qatar

Public health surveillance systems should be evaluated periodically, and should involve an assessment of system attributes. Objective: Evaluate hospital-based surveillance of communicable diseases using the elements of timeliness and data quality. Method: Descriptive study was conducted of communicable diseases reported at The Cuban Hospital, Qatar during January 2012 to December 2013. The completeness of notifications were assessed for contact number, address, place of work, and date of symptom onset. Time between the symptoms onset and physician notification, time between physician and Supreme Council of Health notification and time between physician notification and lab confirmation were calculated for each case. Analysis: Percentage of cases with documented essential information and 95% confidence interval (CI) were determined. Mean and standard deviation (SD) of time were calculated. Results: 1065 patients were reported, 75% were male, 80% non-qataries and 91.5% were group 1 (high priority) diseases. Symptom onset date was documented in 91.5% (95% CI, 89.8; 93.2) of cases; contact number in 84.7% (82.5;86.8), with lower frequencies for address (68.1%, 65.3;70.9) and place of work (60.5%, 57.5;63.4). Diagnostic time for tuberculosis was 61.7 days (SD 93.0), acute hepatitis 18.5 days (SD 17.6), typhoid fever 17.0 days (SD 11.6 days), other diseases of sexual transmission 300.2 days, chronic hepatitis 165 days and AIDS 154.5 days. The time of notification to the Supreme Council of Health for group 1 diseases was 1.2 days (SD 1.4). Conclusion: Our results show that the quality of essential data and timeliness is not sufficient to meet the needs of the health system. Additional studies should focus on the evaluation of time delay for diagnosis of high priority diseases.