Development and piloting of One Health curriculum in Jordan.

Background: In Jordan, several steps have been done to implement One Health (OH) approach. To increase the awareness for OH concept and approach among health professionals, there was an apparent need to develop an OH curriculum or package to orientate human, animal, and environmental health officials and professionals. Aim: The aim of this study was to describe the development and piloting of a OH curriculum for human, animal, and environmental officials and professionals in Jordan. Methods: OH curriculum was developed and consisted of four chapters/sections, each of which contained series of power point presentations that covered subject thoroughly and met the learning objectives for each section. Four day workshops on OH curriculum were done for four cohorts of participants from different OH partners. Each section started and ended with a quick knowledge assessment consisting of multiple choice questions (MCQs) (pre- and post-chapter). Comparison of the pre- and post-chapter knowledge assessment scores/results were used to assess gain of knowledge after each section of OH curriculum was completed. The scores of correct answers were compared within the different cohorts using Pearson's chi-square test with p-values ≤0.05 considered significant. Results: Of the total attendance, pre- and post- training quizzes were scored for 102 participants (816 quizzes). Pre-training scores for the different cohorts ranged from 29% to 36%, while post-training scores for the different cohorts ranged from 80% to 87%. Post-training correct answers scores were significantly higher than those were for pre-training scores for the different cohorts (p < 0.05). Percentage of knowledge gain ranged from 41% to 62% for the first section, 34% to 47% for the second section, 41% to 55% for the second section, and 48% to 60% for the fourth section. Average percentage of knowledge gain for the first, second, third, and fourth cohorts were 51%, 53%, 47%, and 47%, respectively, and was 50% for all cohorts. Conclusion: The developed OH curriculum improved different OH partners and officials understanding of the OH concept and approach.

Lessons from the field: Supporting infection prevention and control and antimicrobial stewardship in Amman, Jordan.

BACKGROUND: To reduce antimicrobial resistance (AMR), appropriate antimicrobial prescribing is critical. In conjunction with Infection Prevention & Control (IPC) programs, Antimicrobial Stewardship Programs (ASP) have been shown to improve prescribing practices and patient outcomes. Low- and middle-income countries (LMIC) face challenges related to inadequate ASP policies and guidelines at both the national and healthcare facility (HCF) levels. METHODS: To address this challenge, the World Health Organization (WHO) created a policy guidance and practical toolkit for implementation of ASPs in LMIC. We utilized this document to support a situational analysis and two-day ASP-focused workshop. In follow-up, we invited these attendees, additional HCF and hospital directors to attend a workshop focused on the benefits of supporting these programs. RESULTS: Over the course of a total three days, we recruited hospital directors, ASP team members, and IPC officers from fifteen different healthcare facilities in Jordan. We describe the courses and coordination, feedback from participants, and lessons learned for future implementation. CONCLUSIONS: Future efforts will include more time for panel-type discussion. which will assist in further delineating enablers and barriers. Also planned is a total three-day workshop; with the first two days being with ASP/IPC teams, and the final third day being with hospital directors and leadership. The WHO policy guidance and toolkit are useful tools to address overuse of antimicrobial agents. Strong leadership support is needed for successful implementation of ASP and IPC. Discussions on quality/safety, as well as cost analyses, are important to generate interest of stakeholders.

A model for public-private partnership during the COVID-19 pandemic: Lessons from Biolab and public laboratories working in the Hashemite Kingdom of Jordan.

INTRODUCTION: The global COVID-19 pandemic overwhelmed national public health and laboratory capacity in Jordan and globally. In response, Biolab, a private laboratory group with 27 branches across Jordan, assisted with testing. Biolab was equipped to quickly increase molecular testing capacity without compromising quality or turnaround time, allowing them to contribute to national COVID-19 surveillance efforts. METHODS: Biolab expanded testing in Jordan by operationalizing automated testing platforms at various locations, including 16 branches, 2 drive-through and 2 walk-through centres, and entry points for airports and marine passenger arrivals. Genomic and molecular testing were implemented to track variants. Information technology platforms were introduced for sample management, registration, and commercial sample payments. Data were directly provided to the Ministry of Health through these platforms to support public health decision-making and responses. Biolab prioritized staff well-being by providing mental, financial, and physical health support during the pandemic. RESULTS: Biolab processed more than two million samples, with a turnaround time of ~1.5 h. Results were transmitted directly to key stakeholders in near real time. Biolab conducted variant evaluations on >1.4 million samples using molecular variant testing and >1000 samples using whole genome sequencing. Biolab prioritized staff well-being, improving staff satisfaction from 74% to 91%, a remarkable achievement when many laboratory systems experienced staff burnout and dissatisfaction. CONCLUSION: The collaboration between public and private laboratories during COVID-19 established a model for future joint efforts to prevent outbreaks from becoming pandemics. Biolab's focus on efficiency, quality, and staff well-being enabled consistent, high-quality performance. The introduction of innovative information technology platforms ensured swift information dissemination. Biolab plans to continue investing in these platforms and expand pathogen testing, creating a top-tier testing infrastructure in Jordan with a demonstrated ability to cooperate with the government for public benefit.

Risk as catalyst for positive change: lessons learnt from public health readiness for cholera in Jordan.

This case study highlights how a looming health crisis was leveraged as drivers for positive change for the health sector, in line with the health security agenda. In Jordan, several authorities are mandated by law to manage health emergencies. Following the declaration of outbreaks of cholera in Iraq, Lebanon and Syria, health authorities in Jordan called for a series of emergency meetings during September 2022 to discuss implications around travel and trade as well as shared waters. WHO was part of the consultations and provided guidance on the application of the International Health Regulations 2005. As the risk for cholera importation persisted, the Ministry of Health assumed its leadership role for the overall health sector response while the Jordanian Center for Disease Control assumed a coordinating function. Roles and responsibilities were enshrined in the National Cholera Preparedness and Response Plan. In consideration of the vulnerability of refugee camps and settlements towards Cholera, the existing Jordan humanitarian coordination platforms such as the Health Sector Working Group were used to share information and to coordinate activities. A whole-of-government risk assessment during December 2022 was complemented by a field visit at Zaatari refugee camp. This helped assess the risk and readiness for a cholera outbreak in Jordan and informed priority activities, such as the establishment of a national risk communication and community engagement working group as well as training on case management.

Participatory Mathematical Modeling Approach for Policymaking during the First Year of the COVID-19 Crisis, Jordan.

We engaged in a participatory modeling approach with health sector stakeholders in Jordan to support government decision-making regarding implementing public health measures to mitigate COVID-19 disease burden. We considered the effect of 4 physical distancing strategies on reducing COVID-19 transmission and mortality in Jordan during March 2020-January 2021: no physical distancing; intermittent physical distancing where all but essential services are closed once a week; intermittent physical distancing where all but essential services are closed twice a week; and a permanent physical distancing intervention. Modeling showed that the fourth strategy would be most effective in reducing cases and deaths; however, this approach was only marginally beneficial to reducing COVID-19 disease compared with an intermittently enforced physical distancing intervention. Scenario-based model influenced policy-making and the evolution of the pandemic in Jordan confirmed the forecasting provided by the modeling exercise and helped confirm the effectiveness of the policy adopted by the government of Jordan.

Implementation of one health approach in Jordan: Joint risk assessment of rabies and avian influenza utilizing the tripartite operational tool.

Background Health challenges at the human-animal-environment interface vary and include zoonotic and food-borne diseases as well as antimicrobial resistance. These are serious threats to animal and public health, and account for the majority of emerging and re-emerging conditions or infectious diseases. Reducing zoonotic disease threats requires an understanding of where and why risks exist. To support countries in building multi-sectoral mechanisms to jointly assess the risks at the human-animal-environment interface, a new operational tool is available to complement the existing tripartite guide to addressing zoonotic diseases in countries. The aim of this study is to conduct joint risk assessment (JRA) of rabies and avian influenza in Jordan utilizing the tripartite Joint Risk Assessment Operational Tool (JRA OT). Methods Representatives of sectors that are involved in zoonotic diseases outbreak investigation, control, surveillance and risk assessment, were trained on JRA OT. The operational tool of tripartite guide to addressing zoonotic diseases in countries that was developed by WHO (World Health Organization), FAO (Food and Agriculture Organization of the United Nations) and WOAH (World Organization for Animal Health) was utilized to conduct risk assessment for rabies and H5N1 avian influenza in Jordan. Results The risk assessment outcome for rabies were as follows: Likelihood is high; impact is moderate with moderate level of uncertainty. The impact of the disease is moderate because the virus transmitted only by animal bite in Jordan. The level of uncertainty is moderate due to existence of some gaps in data available from the ministries regarding the surveillance and collection areas of wild animals with feral dogs. The risk assessment outcome for H5N1 AI indicated a low likelihood estimate with moderate uncertainty level. The impact estimate for H5N1 AI in Jordan is moderate with a low level of uncertainty. Conclusions The tripartite JRA OT provides a helpful and easy to follow guide to bring together expertise and information from all relevant sectors to jointly assess risks from zoonotic diseases and contributes to the understanding and management of shared threats at the human-animal-environment interface.

Implementation of One Health approach in Jordan: Review and mapping of ministerial mechanisms of zoonotic disease reporting and control, and inter-sectoral collaboration.

Background: Mapping across relevant sectors builds an understanding of a successful multi-sectoral One Health approach. This requires a review and understanding of existing national infrastructure, capacity, resources, and existing mechanisms for collaboration across sectors for addressing zoonotic diseases. The objective of this study is to review and map the existing structures of ministry of health and ministry of agriculture in relation to zoonotic diseases reporting and control, and inter-sectoral collaboration in Jordan. Methods: Jordanian ministerial infrastructures, mechanisms, legislation, responsibilities, programs, and activities related to zoonotic disease detection and reporting were reviewed. Publicly available information of national government agencies drawn from annual reports, official websites, program guidelines, advisories, minutes of meetings, and inter-ministerial communications were also reviewed. In addition, personal interviews with official, subject matter experts, and technical representatives of ministries of health and agriculture were conducted to gather, clarify, and verify data. Results: Although the current infrastructure of both Ministries is organized and well established, several gaps and challenges were identified. The regulations to judge and manage zoonotic disease notification and reporting need to be revised to become thorough and systematic between the two ministries. In addition, inter-ministerial zoonotic diseases reporting and notification between the two ministries is inconsistent, which may prevent reporting zoonotic disease in timely manner. The current reporting and surveillance system is closer to an indicator- based surveillance system which limits the ability to investigate and report new emerging zoonotic diseases. The capability to diagnose zoonotic diseases is not always present, and diagnostic tests used to confirm zoonotic diseases are not readily available or done for all diseases. Conclusions: Development of information sharing agreement between ministries, regulations and band y laws that organize and manage zoonotic disease notification and reporting in Jordan is needed. It is essential to review and modify the current reporting and surveillance systems at the two ministries to allow reporting new emerging zoonotic diseases. Capacity building in terms of zoonotic disease diagnosis remains vital for a One Health approach implementation in Jordan.

Infection prevention and control risk factors in health workers infected with SARS-CoV-2 in Jordan: A case control study.

BACKGROUND: Despite under-reporting, health workers (HWs) accounted for 2 to 30% of the reported COVID-19 cases worldwide. In line with data from other countries, Jordan recorded multiple case surges among HWs. METHODS: Based on the standardized WHO UNITY case-control study protocol on assessing risk factors for SARS-CoV-2 infection in HWs, HWs with confirmed COVID-19 were recruited as cases from eight hospitals in Jordan. HWs exposed to COVID-19 patients in the same setting but without infection were recruited as controls. The study lasted approximately two months (from early January to early March 2021). Regression models were used to analyse exposure risk factors for SARS-CoV-2 infection in HWs; conditional logistic regressions were utilized to estimate odds ratios (ORs) adjusted for the confounding variables. RESULTS: A total of 358 (102 cases and 256 controls) participants were included in the analysis. The multivariate analysis showed that being exposed to COVID-19 patients within 1 metre for more than 15 minutes increased three-fold the odds of infection (OR 2.92, 95% CI 1.25-6.86). Following IPC standard precautions when in contact with patients was a significant protective factor. The multivariate analysis showed that suboptimal adherence to hand hygiene increased the odds of infection by three times (OR 3.18; 95% CI 1.25-8.08). CONCLUSION: Study findings confirmed the role of hand hygiene as one of the most cost-effective measures to combat the spreading of viral infections. Future studies based on the same protocol will enable additional interpretations and confirmation of the Jordan experience.

A three-phase population based sero-epidemiological study: Assessing the trend in prevalence of SARS-CoV-2 during COVID-19 pandemic in Jordan.

The evolution of the COVID-19 pandemic in Jordan during the first 10 months of the epidemic was peculiar and can be easily categorized in three different phases: a first period featuring a very low number of reported cases, a second period with exponential growth from August with up to 8000 cases on the 18th November 2020, and a third phase with steady and progressive decline of the epidemiological curve. With the aim of better determine the entity of the population exposed to SARS-CoV-2, the Jordan Ministry of Health with the support of the WHO launched three rounds of the nationwide sero-prevalence survey. Using population proportionate to size (PPS) methodology, around 5000 individuals were selected from all Jordan governorates. Blood samples were collected from all participants and ELISA assays for total IgM, IgG antibodies to COVID-19 were used for testing at the National Public Health Laboratory. Results revealed that seroprevalence dramatically increased over time, with only a tiny fraction of seropositive individuals in August (0.3%), to increase up to more than 20-fold in October (7.0%) and to reach one-third of the overall population exposed by the end of 2020 (34.2%). While non age-specific trends were detected in infection rates across different age categories, in all three rounds of the seroprevalence study two out of three positive participants did not report any sign and/or symptom compatible with COVID-19. The serial cross-sectional surveys experience in Jordan allowed to gain additional insights of the epidemic over time in combination with context-specific aspects like adherence to public health and social measures (PHSM). On the other hand, such findings would be helpful for planning of public health mitigation measures like vaccinations and tailored restriction policies.

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.