Table of Contents

Table of Contents ...... 1 Introduction ...... 3 Research Conducted ...... 4 Using Mobile Technology and Enhanced Counselling to Improve Family Planning Among Syrian Refugees and Host Communities in Lebanon and (2019-2022)...... 4 Evaluating the Impact of Enhanced Laboratory-Based Surveillance of Animal and Human Brucellosis in Jordan (May 2019 - October 2020) ...... 5 The Epidemiology of Invasive Meningococcal Disease: multicenter, hospital-based surveillance of Meningococcal meningitis in (June 2018 - May 2020) ...... 6 Enhancing brucellosis surveillance in Pakistan ...... 7 Eid-al-Adha Survey of Animals in Kabul City for Hard Ticks as Suspected Cases of CCHF (August 2019) ...... 9 Real-Time Surveillance for Infectious Diseases and Other Health Conditions During Iraq Al- Arba’een Mass Gathering (October 2018) ...... 10 The Effect of Increased Self-Efficacy and Knowledge on Improved Sexual and Reproductive Health Service Use among Adolescent Girls and Young Women Refugees - The SEEK Trial (2018 - 2021). 12 Establishing a harmonized Reproductive Health Registry (hRHR) in Jordan to Improve Maternal and Child Health (2017-2021) ...... 14 Family and Community Medicine Team (FCMT) Implementation in Jordan (2019) ...... 15 Strengthening Brucellosis Surveillance, Diagnostics, and Control in Iraq...... 16 Improving Diagnosis and Safe Handling of Anthrax in Jordan ...... 17 The Epidemiology of Invasive Meningococcal Disease: multi-center, hospital-based surveillance of Meningococcal meningitis in Iraq...... 18 Evaluating the Impact of Enhanced Laboratory-Based Surveillance of Animal and Human Brucellosis in Jordan ...... 19 Evaluation of Polio Village Volunteers (PVV) Training (April 2019) ...... 20 Retention Survey and Utilization of Long-Lasting Insecticide Nets (LLINs) in Ibb, Taiz and Lahj [December 2018 to January 2019] ...... 21 Reaching Full Immunization Goal through Applying Appreciative Inquiry Model in Selected Districts in Iraq (2018-2019)...... 23 Real-Time Surveillance for Infectious Diseases and Other Health Conditions During Iraq Al- Arba’een Mass Gathering (November 2016) ...... 24 Community Engagement to Increase Vaccine Demand in Afghanistan, 2016 – 2020 ...... 26 Jordan’s Maternal Mortality Surveillance Response (JMMSR) System (2016 – 2021): ...... 27

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Neonatal Death and Stillbirth Audits Among Syrians from Zaatari and Azraq Refugee Camps, Jordan, April 2016 – Present ...... 29 Strengthening Management Systems for scaling up Integrated School Health (ISH) in government schools and Makani informal education centers in Syrian refugee camps in Jordan 2016/17...... 29 Estimating Population Immunity to Poliovirus in Jordan’s High-Risk Areas, 2016 ...... 30 Burden of Influenza Virus Infection among Hospitalized Infants and the Potential of Prevention through Influenza Vaccination, 2015/17 ...... 31 Vaccination Coverage Survey in Baghdad Resafa, Iraq.2016 ...... 32 The Epidemiology of Middle East respiratory syndrome corona-virus study in Jordan, 2016 ...... 32 Strengthening Brucellosis Surveillance, Diagnosis and Control in Jordan, 2016...... 33 Strengthening Brucellosis Surveillance, Diagnosis and Control in Iraq, 2016 (Research proposal submitted)...... 34 Sero-Epidemiologic Investigation of MERS-CoV in Survivors, Contacts for Jordan’s 2015 Cases: ... 35 Preventing Emerging and Re-emerging Infections Mini-grant Projects, 2015 ...... 36 Middle East respiratory syndrome corona-virus Follow-up Study in Jordan, 2015 ...... 36 Outbreak Investigation of Hepatitis B and C Among Syrian Hemodialysis Patients from Zaatari and Azraq Refugee Camps in Jordan, 2015 ...... 36 Knowledge, Attitudes and Practices towards Family Planning and Reproductive Health in Selected Districts in Jordan, 2015...... 37 Mass Gathering Project in Iraq, 2014 ...... 38 Acute Respiratory Infections among Returning Hajj Pilgrims in Jordan, 2014 ...... 39 Service Availability and Readiness in the North of Jordan, 2014 ...... 39 Obesity and Related Factors among Jordanian Women of Reproductive Age Based on Three DHS Surveys (2002, 2009 and 2012), 2014 ...... 40 Jordan Valley Assessment of Syrian Refugees, 2014 ...... 40 School Health Assessment Survey, 2014 ...... 41 Post-Polio Vaccination Campaign Evaluation, 2014 ...... 42 Mental Health Assessment of Syrian Refugees, 2013 ...... 42 Stillbirth during infection with Middle East respiratory syndrome corona-virus (MERS-CoV), 2013 ...... 42 Non-Communicable Diseases Risk Factors Survey in and Jarash Governorates, 2011...... 43 Supplement on Mass Gatherings, 2011 ...... 43 Projecting the prevalence of major non-communicable diseases / risk factors for the Jordanian youth population for the years, 2011 ...... 44 Assessment of Health Competent School Initiative, 2010 ...... 44 Other Activities and Partners ...... 46

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Introduction

Academic institutions advance science through research. Other non-academic institutions who are engaged in field activities face operational challenges and address their problems to optimize their operations and maximize program impact. Similarly, institutions funding public health programs, both governmental and non-governmental, need to show more accountability in the utilization of funds and the return on investment of such funds on the lives of the people.

The Eastern Mediterranean Public Health Network (EMPHNET) receives financial support from governmental, United Nations and other donor institutions to support countries of the Eastern Mediterranean Region (EMR) in public health workforce development, epidemiological studies of communicable and non-communicable diseases (NCDs), evaluation of program impact, development and monitoring of surveillance programs, rapid assessment of the health care and needs of internally displaced people (IDPs) and refugee populations, and assessment of sexual violence against women and children of IDPs, refugees and other vulnerable populations. Additionally, EMPHNET has research collaboration with academic and non-academic institutions in areas of communicable and non- communicable diseases.

Currently, countries in the EMR are going through different types of unrests that forces people to move either internally or across borders to seek safety. Such movements expose millions of people to starvation and diseases and may cause destruction of health services infrastructure. In addition, COVID-19 has posed new challenges at the global level, to which our region is no exception. The international community commits immense funds for humanitarian relief. However, and to be able to assist displaced populations, agencies need rapid health and nutritional assessment, delivery of health care services and continuous monitoring of the situation and relief program impact. Professional expatriates often face security risks; hence, they collaborate with EMPHNET to provide technical assistance to host countries and international humanitarian and public health agencies that provide relief services to the displaced and refugee populations.

Due to the increasing demand of a large number of agencies on EMPHNET, the increasing needs of technical capacities of public health programs supported and/or implemented by humanitarian and developmental organizations, non-governmental (NGOs) and governmental organizations, and the increasing research collaboration with academic and non-academic institutions, EMPHNET is continuously improving the quality of technical assistance offered to partners, program operations and impact of public health programs serving the populations in the region.

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of vulnerable segments of the local Research Conducted population and Syrian refugees. EMPHNET currently supports several assessments, applied research and There is a need to develop novel and low- laboratory studies, and has completed cost solutions to promote the utilization and many studies and research projects over improve the quality of existing Family the past nine years. This document Planning services. One of these solutions provides brief description of the ongoing is the use of Digital technologies, which and successfully completed research have the potential to reach out to women projects. The projects are arranged in (and their spouses) seeking Family reverse chronological order, from newest/ Planning services and to overcome the most recent to the oldest: need for information about the availability and points of delivery of Family Planning Using Mobile Technology and services . Enhanced Counselling to Improve Family Planning Among Syrian GHD|EMPHNET in collaboration with IDRC, and based on a partnership and Refugees and Host Communities in interdisciplinary collaborative between Lebanon and Jordan (2019-2022) institutions based in Lebanon (American

University of Beirut) and Jordan (Jordan Family Planning is an important expression University of Science and Technology) is of the basic human rights to freely choose implementing the use of mobile technology to become a parent and to determine the and enhanced counselling to improve number or spacing of children. In Jordan and Lebanon, access to maternal health care and Family Planning services is particularly difficult in rural areas and among unregistered refugees who are not eligible to receive coverage for the services subsidized by the UNHCR. The unmet need for Family Planning in Lebanon and Jordan is a major barrier to the development and empowerment

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family planning among Syrian refugees and true burden and major risk factors of host communities in Lebanon and Jordan. brucellosis in humans and animals in three selected governorates. It also aims at Year one of this project was the formative providing a description of the geographic phase, in which the listed activities were distribution of the circulating Brucella sub- planned and implemented. Project types that can be derived from animal and activities started with the kick-off human clinical samples using non-culture- meeting/workshop, then establishing based methods. In addition, the following Project’s Advisory Committees, conducting research areas will be conducted: 1) online project meetings, conducting field Determine the main risk factors enhancing visits to 6 PHCs and meeting local human and animal infections and mapping stakeholders, con ducting 15 Focus the most endemic areas in Jordan; 2) Group Discussions (Formative research Evaluate the usefulness of current with clients), ending with conducting 17 diagnostic assays for human and animal Individual Interviews (Formative research brucellosis. This may include rose Bengal with health professionals). The formative test (RBT), serum agglutination test (SAT), phase informed the co-design of the Enzyme immunoassays (ELISA) IgG and intervention for the remaining period of this IgM, PCR, microbial culture and research project. fluorescence polarization assays (FPA); 3) Assess or evaluate the antibiotic resistance Evaluating the Impact of Enhanced (AMR) profile and genotypes for the Laboratory-Based Surveillance of Brucella isolates recovered from blood Animal and Human Brucellosis in clots of brucellosis cases collected throughout the project; 4) Evaluate the role Jordan (May 2019 - October 2020) of Rev-1 vaccine strain in causing

infections to humans and/or abortion in Brucellosis is a disease of high animals; and 5) Molecular characterization consequence causing significant morbidity of animal and human Brucella strains in animals and humans ;qualifying Brucella circulating in Jordan using whole genome spp. as a potential biothreat. Brucellosis is sequencing (WGS) and MLVA. the most commonly reported zoonotic

disease worldwide and is highly prevalent More than thirteen one-day training in the Middle East, including Jordan. This workshops were rolled out targeting 151 study aims to establish active surveillance clinicians, 47 laboratory technicians, and and confirmatory testing in the human and 24 veterinary and laboratory professionals animal sectors of Jordan. The general from targeted sites in the three objectives of this study are to determine the governorates covered in the project. In

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addition, several technical training on data up to 70-80%. Thirteen serogroups of collection tool (Kobo), Rose Bengal Test meningococci have been identified by (RBT), serum agglutination test (SAT), immunologic specificity of capsular Enzyme-Linked Immunosorbent Assay polysaccharides. The most important (ELISA), fluorescence polarization assays serogroups associated with disease in (FPA), and real-time PCR have been humans are A, B, C, Y and W-135). conducted. Meningococcal antigens are found in blood and cerebrospinal fluid of patients with During May 2019 to October 2020, 556 active disease. Under this project, GHD human cases have been enrolled: 138 in aims to determine the mean annual East , 288 in , and 130 in incidence of cerebrospinal fluid (CSF) Karak. 63% of these cases were males, positive cases for Neisseria meningitides, while 37% were females. On the other and to identify the commonly circulating hand, 199 farms were investigated: 63 in serogroups of N. meningitides in Iraqi East Amman, 93 in Mafraq, and 43 in population. Accordingly, 18 hospitals were Karak. More than 2,219 (including blood selected as study sites (twelve hospitals in and milk) biological samples were collected Baghdad and six hospitals in from animals, most of which were sheeps three governorates (Karbala, Karkouk, and goats. Mysan)) according to geographical areas, known number of populations of the The Epidemiology of Invasive catchment area, and provide high standard Meningococcal Disease: health care. multicenter, hospital-based GHD trained 24 physicians and surveillance of Meningococcal laboratorians on meningitis case detection meningitis in Iraq and definition; using the investigation form (June 2018 - May 2020) to collect the data, specimen collection and

transportation. Also, Molecular (PCR) Neisseria meningitidis (meningococci) Detection and Subtyping of N. meningitidis meningitis occurs in epidemic waves in the from Clinical Specimens training was world and is pathogenic for humans. It has conducted and trained five laboratorians polysaccharide capsules, and it is usually from CPHL/MOH. colonizing the upper respiratory tract where

it can spread to cause meningitis. Five to A total of 2,314 patients with suspected thirty percent of normal population may meningitis were admitted to 18 designated harbor meningococci in the nasopharynx hospitals in four Iraqi governorates during and in epidemics, the carrier rate might go the study period 1st of June 2018 - 30th of

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May 2020. Their age ranged between 3 As livestock are the only source of human days and 91 years, with a median of two infection, reducing prevalence of years. Of all cases, 58.9% were males, brucellosis in livestock is usually where 41.1% of cases were females. The accompanied by a reduction in human male to female ratio was 1:1.4. Overall, 370 cases. Therefore, the identification of cases (16.0%) had confirmed bacterial various Brucella species and their biovars meningitis. Of those, 215 (58.1%) were and their reservoirs is important. Such caused by N. meningitidis, 154 (41.6%) information is critical for designing a control were caused by S. pneumonia, and 1 program for the choice of vaccine and (0.03%) case was caused by Haemophilus selection of host species for targeting influenzae type b (Hib) as confirmed by RT- control efforts. PCR. Almost two-thirds of patients with N. Meningitidis (63.2%) and S. Pneumoniae The overall objective of the study was to (61%) were males. understand the epidemiology of brucellosis in peri urban dairy farms in ICT to fill the Enhancing brucellosis surveillance gaps in the existing knowledge and provide in Pakistan data support for any future control strategies. Brucellosis is identified by the Government of Pakistan as a priority zoonotic disease.

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A total of 220 herd from Tarlai and Sohan Two outbreaks were reported in small were investigated from June 2018- Jun ruminants (goats and sheep). Both herds 2019, The Epi Info software was used for were found negative for brucellosis. data entry and analysis. However, of the 04 outbreaks reported in large animals, 03 were confirmed to be Pooled milk samples were collected from brucellosis. dairy farms. These samples were screened by milk ring test (MRT) and positives It is recommended that a one health samples were confirmed for brucellosis by approach should be followed to investigate ELISA for pooled milk. On initial screening the risk of brucellosis to farmers, workers by MRT, 43 (19.55%) herds were positive and general public that can lead to for brucellosis. However, only 28 of these appropriate mitigation strategy in livestock. herds were confirmed to have brucellosis As animals are the only source of infection by ELISA, with an overall herd brucellosis in humans, a control strategy prevalence of 12.73% using vaccination and local epidemiology of disease should be considered. As DNA was extracted from positive milk brucellosis is a chronic disease in most samples (38 from 28 positive herds) using human cases, the socioeconomic impact of Qiagen DNAeasy kit. Realtime PCR was this infection among farming communities used for identification of Brucella. B. should be determined. This will also help in abortus has been identified in 07 samples making a justified case for control of so far. brucellosis in livestock.

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Eid-al-Adha Survey of Animals in accompanied by high mortality, were Kabul City for Hard Ticks as probably the result of exposure to infected Suspected Cases of CCHF animal’s blood and tissues especially during Eid-ul-Adha feast (WHO, 2018). (August 2019) Also, according to FAO and WHO, in the

last two years (2017 – 2018), CCHF cases Crimean-Congo hemorrhagic fever or increased beyond expectations and there (CCHF) is a zoonotic viral disease that has have been more than 267 confirmed cases high case fatality rate (CFR) in humans. of CCHF just form the beginning up to the Ticks are the main reservoirs of CCHF end of August 2018 in 23 out of 34 virus, but animals including cattle, sheep, . goat, camel, small mammals, and birds

(especially ostrich) play a major role in the EMPHNET, in close collaboration with the maintenance and spread of the viral agent Faculty of Veterinary Sciences of Kabul to the ticks and humans. University (FVS-KU), Kabul Municipality,

and the Animal Health Directorate of the CCHF is endemic in Afghanistan. On Ministry of Agriculture & Livestock (MAIL), average, about 50 cases have occurred successfully conducted a survey of annually in Afghanistan and many randomly selected animals in Kabul City outbreaks has been documented in the streets and markets before Eid-al-Adha country. In recent years, especially after (August 6 – 9, 2019). The survey was April 2017, CCHF cases in humans carried outby 150 students and staff dramatically increased. Recent outbreaks members of the Faculty of Veterinary of CCHF in Afghanistan, which were

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Science of Kabul University. During this The number of visitors to Karbala during survey, around 4,000 animals were the Arba’een gathering reaches millions of randomly selected and surveyed for the people from Iraq and other countries. presence of ticks. In total, over 1,500 Although the walk of this huge population samples of ticks were collected for further takes place over several days before the morphological and lab investigations. event and via different routes, such huge gathering is enough to overwhelm any This survey is considered as an important health system in the world and the step in the implementation of projects presence of massive crowd at all times focusing on zoonotic diseases in around the day of Arba’een is an issue of Afghanistan as part of the one health concern to public health security. Mass approach. gatherings of such sizes, which take place within a relatively limited space and time Real-Time Surveillance for period, are usually associated with Infectious Diseases and Other concerns over disease outbreaks and other Health Conditions During Iraq Al- health-related conditions such as food poisoning, health conditions due to Arba’een Mass Gathering seasonal changes (hot or cold weather, (October 2018) including heat exhaustion/heat strokes),

wounds and accidental injuries, as well as The World Health Organization (WHO) concerns related to non-communicable defines mass gathering as an event where the number of people attending is sufficient to strain the planning and response resources of the community, state or nation hosting the event. Each year, millions of visitors walk to Karbala in Iraq to observe Al-Arba’een. Arba’een is considered as one of the largest annual mass gatherings in the world. It falls on the 20th day of the month of Safar (a lunar month in the Islamic Calendar). Similar to other Islamic events, the occurrence of Arba’een varies from year to year by drifting approximately 11 days earlier each year. The date of the last Arba’een was October 30, 2018.

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diseases such as exacerbation of ischemic effective to enable the country to gain a heart disease symptoms and other chronic better understanding of the public health health conditions. In case of a disease threats during the event, enhance outbreak, mass gathering can pose a preparedness/ rapid response capabilities, serious challenge to global public health and enable evidence-based decision because of the potential for the spread of making to strengthen the public health diseases both during and after the event as system. a result of crowd density and population movement. Thus, on one side, MGs can With its unique experience in the past stretch health systems beyond their Arba’een events, EMPHNET worked with capacity. On the other hand, these events the survey teams and provided round-the- can also present opportunities for long clock (24/7) support during the MG event lasting positive legacy in the form of that took place from October 8th to strengthened public health systems, November 3rd, 2018. EMPHNET closely enhanced medical and hospital services, worked with Iraq Ministry of Health (MOH), improved living environment, and the Field Epidemiology Training Program increased public health awareness. (FETP) and other institutions in Iraq to build the capacity of and provide technical Building the capacity in the conduction of support to 300 data collectors in 152 health real-time surveillance of infectious facilities en-route to Karbala across eleven diseases and other health conditions is one (11) governorates (a significant expansion such opportunity where EMPHNET’s of the surveillance activity from 60 data technical capacity and background collectors in 20 health facilities across 2 experience in previous MGs in Iraq and its governorates in the year 2016). EMPHNET overall technical expertise can be very provided technical support in conducting

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real-time surveillance of infectious Ministry of Health and other partners diseases and health conditions during the involved in the event for the years to come. mentioned MG event. An enhanced and effective real-time surveillance system The Effect of Increased Self-Efficacy (powered by mobile technology and linked and Knowledge on Improved Sexual to a server where real-time data from all 11 and Reproductive Health Service governorates were aggregated) enabled Use among Adolescent Girls and MOH to trigger early response and Young Women Refugees - The appropriate measures to address health SEEK Trial (2018 - 2021) security issues and reduce the chances of any mishaps during the event. On the other Conducted simultaneously in Jordan, hand, activities during the pilot project were Lebanon, and Turkey and led and funded specifically designed to strengthen the by WHO Geneva, this multi-country capacities in real-time data collection and community-based randomized trial will be the effective utilization of the influx of data. the first in the Middle East to examine the These measures will ensure informed impact of psychosocial SRH infused follow-up on outbreak investigations and intervention to improve the use of SRH present opportunities for long lasting services during humanitarian crisis. positive legacy in the form of strengthened Evidence gained through this research public health system and, hence, a effort will enhance the gained life skill reduction in the global threats. By the end approaches to enrich the Minimum Initial of the MG event, an overwhelming number Service Package (MISP) for SRH in of infectious, chronic, and injury cases humanitarian crisis settings among (more than 338,000) were recorded in 152 adolescent girls and young women. It will health facilities in the mentioned 11 also result in a smooth translation and governorates. Majority of these cases were cultural adaptation of the intervention Iraqi and Irani nationals followed by other package among the targeted populations. nationalities (Bahrain, Kuwait, Pakistan,

Lebanon, India, Oman, , The SEEK Trial project aims at the effect of , Afghanistan, and other countries). increased self-efficacy and knowledge Since literature on Arba’een MG in Iraq is (using an innovative psychosocial scarce as opposed to other religious and package) on improved sexual and non-religious mass gatherings around the reproductive health service use among world, findings from this pilot project will adolescent girls and young women contribute to the literature body and will be refugees. This comes in parallel to other essential to inform decision making by the efforts to reduce maternal/child morbidity

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and mortality, decrease the level of sexual orientation. The MISP is a sphere sexually transmitted infections, prevent and standard and is integrated in the global manage the consequences of sexual health cluster guidance. It offers universal violence. The successful implementation of minimum standard of life saving SRH a comprehensive SRH services integrated interventions. The use of selected SRH into the primary health care will services from the MISP, particularly family expressively improve equitable access of planning, will serve as the primary outcome upgraded health services and better-quality of this research. This project aims to of life, not only to Syrian refugees but also improve and adapt a low-intensity multi- to all residents of Jordan. component psychosocial intervention, infused with SRH knowledge, with an The SEEK Trial stresses on the importance emphasis on self-efficacy empowerment of integrating the MISP into primary health regarding the use of particular SRH care. MISP is a set of SRH intervention services defined within the MISP. priorities that need to be implemented at the onset of emergency. It necessitates Currently the research team focuses on the access to comprehensive and inclusive, first two formative phases of the larger high- quality SRH care for all persons, community-based randomized trial aimed irrespective of age, gender, ethnicity and to test the feasibility and effectiveness of

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the herein proposed intervention package: education, communication skills Phase 1) the development of the proposed acquisition, problem management, self- package, guided by local priorities and efficacy and decision making. It is perspectives; and Phase 2) local rationalized that this intervention package translation and cultural adaptation of the will improve the use of SRH services. In package for use in the context of Jordan, other words, it will enhance the outcomes Lebanon and Turkey. The research of SRH services amongst Syrian women methodology is informed by the UK Medical refugees. This includes preventing Research Council framework for the unplanned pregnancies, averting sexually development of complex interventions, transmitted infections, and declining the which recognizes iterations of a) level of complications from abortion, Intervention Development; b) Feasibility pregnancy and childbirth. and Piloting; c) Evaluation; and d) Implementation, and assist in predicting as Establishing a harmonized well as identifying problems pertaining to Reproductive Health Registry acceptability, compliance, delivery of the (hRHR) in Jordan to Improve intervention, recruitment and retention Maternal and Child Health before the large definitive scale trail is (2017-2021) conducted. This is an implementation research project, The psychosocial-SRH infused inter- where EMPHNET collaborates with the vention package is believed to have a Ministry of Health (MoH) in Jordan to positive impact on individuals’ emotional improve the health of women of regulation, SRH education, psycho- reproductive age by introducing a

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sustainable intervention that will influence that needs to be addressed by decision the access and use of reproductive health makers and stakeholders. data to support program planning, policy development and decision making at all The second year includes the levels of the health system. Creating implementation phase, which will be harmonized Reproductive Health Registry through developing a web-based (hRHR) for women, will allow personalized application by the Electronic Health care information throughout pregnancy and Solutions Company (EHS-Hakeem) to childbirth to be easily accessed during allow all sectors to be part of the antenatal visits, labor, delivery, and harmonization process and ensure one postnatal visits, thereby improving care patient record across all sectors. The provision. The hRHR will be implemented Project team will conduct training in Al initially and then workshops for residents of the Jordan Field it is intended by MOH to be rolled out to Epidemiology Training Program (FETP) include all . and focal points from Central MOH as well as Mafraq Health Directorate, hospitals and The hRHR is a three-year project, funded MCHs with the aim to establish a core by the International Development technical team that can maintain and Research Centre- Canada (IDRC). The administer the new system. project involves three phases: Preparatory phase, Implementation phase and Finally, an evaluation will be conducted to Documentation phase. The preparatory assess the impact of the implemented phase was accomplished by establishing electronic hRHR system. A comparison of different committees including the the situation before and after the Technical Steering Committee and SRH implementation, to analyze the success- and ICT Subcommittees. A situation fulness of the introduced electronic hRHR, analysis was conducted during the first will be conducted at each quarter of data year of the project. The overall aim of the entry during the Documentation phase situation assessment was to understand (third year) of the project. the current situation of data registration system, SRH data flow in all health centres Family and Community Medicine providing MCH services, and to explore Team (FCMT) Implementation in factors associated with low and non- Jordan (2019) registry issues. Results of the preparatory phase identified several components The Family and Community Medicine regarding SRH health information system Team (FCMT) is an innovative approach

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that aims to improve access to quality EMPHNET mapped and identified gaps in Primary Health Care (PHC) services and the existing information and education and reduce out-of-pocket expenditure on health communication materials to better respond for the vulnerable populations including to the needs and expectations of patients in refugees. FCMT is new health care model vulnerable and marginalized populations, that focuses on outreach, prevention, and mapped and identified gaps in the existing health education and promotion. It is a guidelines and protocols on PHC, and partnership between physicians at the developed recommendations for updating PHC, family practitioner, and community and re-designing existing old materials and health service providers such as guidelines. Moreover, EMPHENT Community Health Committee staff, developed training packages for all Community-Based Organizations, and stakeholders and workers in FCMT primary Community Health Volunteers who visit health and trained 30 trainers, 100 health households, screen for chronic diseases, professionals, and 200 community workers provide health education and health in and Mafraq governorates. promotion materials and refer patients to EMPHNET team had collected the the PHC, when needed, for further care. necessary pre and post data to evaluate the impact of the developed training The aim of this project is to map and materials on the trainees’ knowledge and identify gaps in the existing information and attitudes. education and communication materials to better respond to burden of NCDS and the Strengthening Brucellosis needs and expectations of patients in Surveillance, Diagnostics, and vulnerable and marginalized populations. Control in Iraq To reach this aim, EMPHNET has conducted a full desk review of available The project addresses the high incidence information and education and of brucellosis in Iraq and will strengthen the communication materials including surveillance system in Iraq. In 2014, brochures, pamphlets, posters, and others molecular detection techniques were at the MoH and its health facilities at introduced at Iraq Central Public Health different levels; village primary, and Laboratory (CPHL) to determine the comprehensive health centers (CHC). Brucella species causing human disease burden. Under this project, GHD EMPHNET has supported UNICEF- Jordan collaborates with the Ministry of Health and provided technical expertise to (MOH) and the Ministry of Agriculture implement the FCMT. The project started (MOA) to strengthen surveillance and on 15th of January 2019. Specifically,

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Operating Procedures (SOPs) and materials.

The data collection and samples testing started on April 2019. Fifteen human samples were collected and tested positive by Rose Bengal. Of these, fourteen laboratory capacity of brucellosis in four were negative by PCR and one sample new districts in Iraq. Brucella melitensis was positive (B. abortus). and Brucella suis were developed experimentally as biological weapons by Improving Diagnosis and Safe state-sponsored programs. It is essential Handling of Anthrax in Jordan that health and veterinary authorities are skilled in detecting, preventing and Currently, suspected cases of human responding to Brucella outbreaks and the Anthrax in Jordan are rarely sent for threat of bacteria being weaponized. laboratory testing as the diagnostic

capacity is not existent.Suspected cases of GHD trained 45 technicians on brucellosis animal Anthrax are only tested by non- technical knowledge and skills, 26 rapid and non-characterizing culture test. clinicians on Brucellosis case definition, Through this project, EMPHNET aims at diagnosis and control, 16 veterinary and strengthening the diagnostic capabilities for laboratory professionals, 8 technicians on Anthrax that could be a threat to humans Brucella diagnosis and detection using and animals or used as bioweapons while ELISA Technique, 8 on Epi Info system on also increasing biosecurity and biosafety Brucellosis, and 17 of high-risk workers on public awareness on preventing the spread of Brucellosis. In addition to the capacity building activities, GHD developed a follow up mechanism with Iraqi focal point to ensure proper implementation of the circulated Standard

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awareness for Jordanian laboratory staff. polysaccharides. The most important Under this project, a laboratory serogroups associated with disease in assessment was performed, specialized humans are A, B, C, Y and W-135). and general laboratory supplies were Meningococcal antigens are found in blood provided, biosafety/biosecurity training was and cerebrospinal fluid of patients with conducted, and the disease diagnostics active disease. Under this project, GHD tools for Anthrax were upgraded. aims to determine the mean annual incidence of cerebrospinal fluid (CSF) positive cases for Neisseria meningitides, The Epidemiology of Invasive and to identify the commonly circulating Meningococcal Disease: multi- serogroups of N. meningitides in Iraqi center, hospital-based surveillance population. Accordingly, 18 hospitals were selected as study sites (twelve hospitals in of Meningococcal meningitis in Iraq Baghdad governorate and six hospitals in

three governorates (Karbala, Karkouk, Neisseria meningitidis (meningococci) Mysan)) according to geographical areas, meningitis occurs in epidemic waves in the known number of populations of the world and is pathogenic for humans. It has catchment area, and provision of high polysaccharide capsules and it is usually standard health care. colonizing the upper respiratory tract where GHD trained 24 physicians and it can spread to cause meningitis. Five to laboratorians on meningitis case detection thirty percent of normal population may and definition; using the investigation form harbor meningococci in the nasopharynx to collect the data, specimen collection and and in epidemics, the carrier rate might go transportation. Also, Molecular (PCR) up to 70-80%. Thirteen serogroups of Detection and Subtyping of N. meningitidis meningococci have been identified by from Clinical Specimens training was immunologic specificity of capsular

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conducted whereby five laboratorians from the most commonly reported zoonotic CPHL/MOH received training. disease worldwide and is highly prevalent in the Middle East, including Jordan. This A total of 1242 specimens were collected study aims to establish active surveillance from admitted patient to all selected and confirmatory testing in the human and hospital from selected governorates for animal sectors of Jordan. The general one-year period from June 2018 – May objectives of this study are to determine the 2019. Out of which, 59.9% of patients were true burden and major risk factors of males and 40.1 % were females. As well, brucellosis in humans and animals in three 1188/1244 (95.5%) samples either from selected governorates and to describe the CSF or blood serum were tested in the geographic distribution of the circulating public health center. Brucella sub-types that can be derived from animal and human clinical samples using Evaluating the Impact of Enhanced non-culture-based methods. In addition, Laboratory-Based Surveillance of the following research areas will be Animal and Human Brucellosis in conducted: 1) Determine the main risk factors enhancing human and animal Jordan infections and mapping the most endemic

areas in Jordan; 2) Evaluate the usefulness Brucellosis is considered a disease of high of current diagnostic assays for human and consequence causing significant animal animal brucellosis. This may include Rose and human morbidity qualifying Brucella Bengal test (RBT), serum agglutination test spp. as a potential bio-threat. Brucellosis is (SAT), Enzyme immunoassays (ELISA)

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IgG and IgM, PCR, microbial culture and further weakened the Acute Flaccid fluorescence polarization assays (FPA); 3) Paralysis (AFP) surveillance system. Assess or evaluate the antibiotic resistance Furthermore, Yemen is threatened by the (AMR) profile and genotypes for the possible importation of poliovirus from the Brucella isolates recovered from blood remaining endemic countries and the clots of brucellosis cases collected spread of circulating vaccine-derived throughout the project; 4) Evaluate the role poliovirus from neighboring countries in the of Rev-1 vaccine strain in causing Horn of Africa. infections to humans and/or abortion in EMPHNET supports Yemen Ministry of animals; and 5) Molecular characterization Public Health and Population to strengthen of animal and human Brucella strains the AFP surveillance capacities through circulating in Jordan using whole genome training 350 Polio Village Volunteers sequencing (WGS) and MLVA. (PVVs) and 51 District Surveillance Officers (DSOs) from 51 high risk districts. Evaluation of Polio Village As part of this capacity building efforts, an Volunteers (PVV) Training evaluation was conducted to find out (April 2019) whether the training has achieved its objectives and to capture the lessons Yemen, declared by World Health learned to improve the outcome of future Organization as polio-free in 2009, remains trainings. at high risk of reinfection with poliovirus. This evaluation employed the worldwide The recent conflict that led to decreasing standard for evaluating the effectiveness of access to social and healthcare services, training (Kirkpatrick Four Level Model) that including vaccination for children, has measures reaction, learning, behavior and

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results or impact. Out of the targeted 51 of the 28 million total population of the districts, 17 districts (33%) were randomly country. The damage to health facilities selected where 108 trained PVVs and 17 and breakdown of basic infrastructure has DSOs were included together with the increased the vulnerability to Governorate Surveillance Coordinators communicable diseases in general and (GSCs) from the randomly selected seven Malaria in particular. Malaria is endemic in governorates and the National AFP Yemen and because of the current Surveillance team members. A mix of situation, the registered cases of malaria qualitative and quantitative data collection and other mosquito-transmitted diereses, techniques was used to exploit as dengue fever, were increased in the triangulation and identify the convergence past five years. and divergence. In order to respond to this threat, Long- In general, the finding showed that the Lasting Insecticides Nets (LLINs) were overall objectives of the PVVs training were distributed in priority Governorates in met and the training has shown a positive Yemen as a preventive measure for impact on AFP surveillance. Furthermore, controlling malaria and other mosquitoes the trainees’ behavior was found to be transmitted diseases. positively changed and the trainees are utilizing their skills in their work effectively During 2017, Yemen’s Malaria National and efficiently. Most significantly, the Control Program (MNCP), supported by the evaluation showed that training has International Organization for Migration contributed to improved surveillance for (IOM), managed to secure 400,200 LLINs AFP cases in Yemen. to cover neediest populations in 13 districts in three ; Taiz, Ibb Retention Survey and Utilization of and Lahj. The 399,700 LLINs were Long-Lasting Insecticide Nets successfully distributed to 809,079 HHs in (LLINs) in Ibb, Taiz and Lahj the selected districts of the three Governorates mainly targeting under-five Governorates [December 2018 to children, pregnant women and elderlies. January 2019] The distribution included internally

displaced persons (IDPs), hard-to-reach Considered one of the most emergency- populations and communities at risk. affected countries in the world, Yemen’s

conflict has exacerbated the already fragile Accordingly, GHD/EMPHNET conducted a situation and threatened the health and survey aiming at assessing the level of survival of more than 20 million people out retention of bed LLINs in high-risk areas in

Research Involvement and Engagement 21

Yemen. For such purpose, five districts Two training workshops were held in namely; Almadareba in Lahj Governorate, Sana’a and Aden to acquire the needed Gabal Habashi and Almaafer in Taiz skills for data collectors to fill out the Governorate and Almakhader and questionnaire properly. As well, a capacity Alssabra in Ibb Governorate were selected building program was held to provide to conduct the assigned assessment. A participants with important knowledge sample of 210 HHs were targeted in 30 about Malaria and other diseases random villages (clusters) in each district transmitted by mosquitoes and role of (30 by 7 technique). A detailed LLINs in its prevention. Additionally, questionnaire was developed, tested and participants were equipped with knowledge approved as the assessment tool. The about sample size and its distribution on statistical data analysis was performed by different villages. SPSS 24 and the main important indicators were determined in line with the survey’s The statistical analysis of the collected data objectives. gave in-depth insights about the HHs characteristics, LLINs distribution including The overall goal of the retention survey was utilization and reserve and health issues to provide evidence for strengthening the training. These insights can be used as a MNCP thus improving district level capacity guideline for future more effective in Malaria control and managing related interventions. local public health threats during emergencies. Specific objectives included identifying gaps in LLINs distribution at household level; measuring the proportion of populations at risk with at least one LLIN that has been optimally used; assessing the retention and distribution of LLINs as effective and efficient practices to control Malaria; identifying the gaps in utilization of the distributed bed nets; and recommend actions for improving bed net retention. This survey was not intended to measure durability elements of LLINs including survivorship, fabric integrity and insecticidal activity (bio-efficacy).

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On another note, it is highly recommended targeted areas through ensuring their to build on this survey results to plan for a completion of all routine vaccines based on field research regarding the durability of the the governmentally approved routine LLINs. This proposed research would vaccination schedule. enable more decision-making tools in regard to survivorship, attrition, physical The ideology and approach of AI was integrity and bio-efficacy of the distributed piloted by GHD/EMPHNET in two districts nets towards more effective utilization in in Iraq to improve immunization coverage the future. and successfully reached the 100% coverage targets in the selected areas. In order to confirm the accuracy of the Reaching Full Immunization Goal reached goal, a field verification survey through Applying Appreciative took place in the targeted areas of the two Inquiry Model in Selected Districts targeted districts before declaring the in Iraq (2018-2019) selected areas as AI success story. A random sample of 10% of the targeted Appreciative Inquiry (AI) for immunization children in the selected areas was taken is a community engagement strategy representing 240 children equally pioneered in Nepal and proved to be distributed between Al Hurr and Al effective in increasing vaccination Mahaweel Districts all under the age of 15 coverage. It aims at mobilizing local months. Female infants represented communities and building ownerships 48.75% of the surveyed children. towards improving health indicators of priority programs. The approach is A team of health workers were trained to designed to motivate and empower local perform the field work including data communities to be actively engaged in collection accompanied by volunteers from taking lead and ownership to achieve the communities who were trained as well. challenging goals. Consequently, To ensure independence of staff and avoid communities become catalysts and any possible conflict of interest, selected empowered for arising dedication towards health workers for Al Mahawwel the selected health programs. intervention areas worked in Al Hurr intervention areas and vice versa. Considering that GHD’s vision is directed towards better health for people in the House to house visits were conducted and Eastern Mediterranean Region, this 60 households were visited during the field initiative was undertaken to contribute to survey. Systematic random sampling improving health among Iraqi infants of the method was used selecting the fifth house

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in the targeted areas subject to availability of a child under the age of one. All collected The World Health Organization (WHO) forms were sent by data collectors to the defines mass gathering as an event where central Expanded Program on the number of people attending is sufficient Immunization (EPI) in Baghdad. to strain the planning and response resources of the community, state or nation In conclusion, the AI succeeded in reaching hosting the event. Each year, millions of all targeted children and most importantly Shia visitors walk to Karbala in Iraq to the engagement of local communities. observe Al-Arba’een. Arba’een is considered as one of the largest annual mass gatherings in the world. Similar to other Islamic events, the occurrence of Arba’een varies from year to year by drifting approximately 11 days earlier each year. The date of the Arba’een in the year 2016 was November 21.

The number of visitors to Karbala during the Arba’een gathering of December 2, 2015 reportedly exceeded 22 million individuals from Iraq and other countries. Although the walk of this huge population takes place over several days before the event and via different routes, such huge gathering is enough to overwhelm any Ensured enrolment of whole system and health system in the world and the stakeholders in full immunization initiative presence of massive crowd at all times in the district was a great achievement with around the day of Arba’een is an issue of clear understanding and know how developed about full immunization program and defaulters tracking.

Real-Time Surveillance for Infectious Diseases and Other Health Conditions During Iraq Al- Arba’een Mass Gathering (November 2016)

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concern to public health security. Mass better understanding of the public health gatherings of such sizes, which take place threats during the event, enhance within a relatively limited space and time preparedness/ rapid response capabilities, period, are usually associated with and enable evidence-based decision concerns over disease outbreaks and other making to strengthen the public health health-related conditions such as food system. poisoning, health conditions due to seasonal changes (hot or cold weather, With its unique experience in the past including heat exhaustion/ heat strokes), Arba’een events, EMPHNET worked with wounds and accidental injuries, as well as and provided round-the-clock (24/7) concerns related to non-communicable support during the MG event that took diseases such as exacerbation of ischemic place from November 12 to 21, 2016. heart disease symptoms and other chronic EMPHNET closely worked with Iraq health conditions. In case of a disease Ministry of Health (MOH), the Field outbreak, mass gathering can pose a Epidemiology Training Program (FETP) serious challenge to global public health and other institutions in Iraq to build the because of the potential for the spread of capacity of and provide technical support to diseases both during and after the event as selected number of health outlets en-route a result of crowd density and population to Karbala in two movement. Thus, on one side, MGs can (Karbala and Najaf) in conducting real-time stretch health systems beyond their surveillance of infectious diseases and capacity while, on the other hand, these health conditions during the MG event. An events can also present opportunities for enhanced and effective real-time long lasting positive legacy in the form of surveillance system (powered by mobile strengthened public health systems, technology and linked to a server where enhanced medical and hospital services, real-time data from both governorates were improved living environment, and aggregated) enabled MOH to trigger early increased public health awareness. response and appropriate measures to address health security issues and reduce Building the capacity in the conduction of the chances of any mishaps during the real-time surveillance of infectious event. On the other hand, activities done diseases and other health conditions is one during the pilot project were specifically such opportunity where EMPHNET’s designed to strengthen the capacities in technical capacity and background real-time data collection and the utilization experience in previous MGs in Iraq and its of the influx of data in an effective way. overall technical expertise can be very These measures will ensure informed effective to enable the country to gain a follow-up on outbreak investigations and

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present opportunities for long lasting positive legacy in the form of strengthened In Afghanistan, despite progress in routine public health system and, hence, a immunization and availability of services, reduction in the global threats. By the end national penta3 coverage is 59.7% and of the MG event, an overwhelming number 75% of disease outbreaks are measles of infectious, chronic, and injury cases outbreaks (EPI Coverage Survey, 2013 (more than 41,000) were records in 20 and Disease Early Warning System, 2014). health facilities in the mentioned two Lack of awareness regarding the benefits governorates. Majority of these cases were of vaccines and negative perceptions Iraqi and Irani nationals followed by other regarding vaccine safety remain key nationalities (Bahrain, Kuwait, Oman, challenges to increasing vaccine Lebanon, Saudi Arabia, Pakistan, acceptance throughout Afghanistan. The Afghanistan, India, and other countries). 2013 National EPI Coverage survey found Since literature on Arba’een MG in Iraq is that the top five reasons for not vaccinating scarce as opposed to other religious and children are related to vaccine acceptance non-religious mass gatherings around the and confidence, including “lack of world, findings from this pilot project also awareness of the need” “no faith in contributed to the literature body and will immunization”, and “fear of side effects”. remain essential to inform decision making Afghanistan has the highest rates of by the Ministry of Health and other partners missed children due to refusals and low involved in the event for the years to come. community perceptions about polio and the vaccine. These findings indicate that Community Engagement to activities that address vaccine concerns Increase Vaccine Demand in and complacency are critical in Afghanistan Afghanistan, 2016 – 2020 to increase vaccine acceptance, ensure

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sustained public trust in the immunization collaboration with the Ministry of Public program, and allow for coverage levels Health in Afghanistan implemented a case- necessary to reach control or elimination control study in a cluster randomized goals. Currently, the Expanded Program on design and evaluated the effect of holistic Immunizations (EPI) in Afghanistan is community-based interventions aimed at focused on the issues of vaccine supply increasing acceptance and demand for and little is done for demand generation. immunizations in Afghanistan. The goal of Efforts to educate and engage parents, this project was to capture information on households, and communities overall knowledge, attitude and practices (KAP) regarding the benefits of vaccines are and demand related to Virus-preventable needed. diseases (VPDs) at randomly selected Current strategies used to raise awareness communities in 5 southern and eastern include printed materials, i.e. brochures, provinces of Afghanistan and provide pamphlets, banners, billboards and information that is specific to the evaluation messages communicated through media of this intervention in Afghanistan and outlet i.e. TV channels, radio stations and contribute to the knowledge within this health education through health facilities. context. These messages are often ineffective because approximately 75% of the Jordan’s Maternal Mortality Afghanistan population live in rural areas, Surveillance Response (JMMSR) the majority do not have access to TVs and System (2016 – 2021): radios, are illiterate and can’t read printed messages, and refuse printed materials Under this project, EMPHNET with the with pictures particularly those designed support of Abt Associates Inc. with female photos. There is a need to use USAID/Jordan Health Service Delivery innovative and culturally appropriate Activity, provides technical assistance in interventions that generate demand for planning and implementing of the JMMSR routine immunization. Because at least System. The primary goal of this project is 60% of the Afghanistan population has to eliminate preventable maternal mortality access to mobile phones (according to by obtaining and using information on each Ministry of Communication and IT), this maternal death to guide public health could be an effective communication actions and monitor their impact. strategy for raising awareness around routine immunizations and polio SIAs. The JMMSR system consists of the following five steps: 1) Notification of all To address the above-mentioned issues, Women of Reproductive Age (WRA) EMPHNET in close coordination and

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suspected death cases; 2) Identification of EMPHNET is working to collect accurate all suspected cases that happened during data on all maternal deaths; analyze and pregnancy, childbirth, and puerperium; 3) interpret the collected data; use the data to Maternal death review conducted for the make evidence-based recommendations investigation of causes and contributing for action to decrease maternal mortality; factors at both health facility and household disseminate findings and levels; 4) Analysis of the causes and recommendations to civil society, health contributing factors surrounding each personnel, and decision-makers and maternal death case; and, 5) Response policy-makers to increase awareness and dissemination of results. about the magnitude, social effects, and preventability of maternal mortality; ensure The project expands on ongoing efforts to actions take place by monitoring the provide information that can be used to implementation of recommendations; develop programs and interventions for inform programmers on the effectiveness reducing maternal morbidity and mortality of interventions and their impact on and improving access to and quality of care maternal mortality; allocate resources more that women receive during pregnancy, effectively and efficiently by identifying delivery, and the puerperium. It also aims specific needs; enhance accountability for to provide information that will lead to maternal health; improve maternal specific recommendations and actions and mortality statistics and move towards improve the evaluation of their complete civil registration/ vital statistics effectiveness. records; and to guide and prioritize research related to maternal mortality.

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Neonatal Death and Stillbirth Audits project are: to understand the number of Among Syrians from Zaatari and stillbirths and neonatal by obtaining Azraq Refugee Camps, Jordan, information over the time; and, to collect information from review of each stillbirth April 2016 – Present and neonatal death individually,

investigating causes and contributing In line with UNHCR’s global Strategy for factors and using the information to guide Public Health (2014 – 2018) and with the health system and provide action to support of the Gates Foundation, UNHCR prevent similar deaths in the future . started a special project to improve

neonatal care focusing on low-cost interventions in Jordan, Kenya and South Strengthening Management Sudan. UNHCR Jordan approached Systems for scaling up Integrated EMPHNET to assist in conducting the School Health (ISH) in government neonatal mortality audits in the two refugee schools and Makani informal camps. Thus, in close coordination with education centers in Syrian refugee UNHCR, EMPHNET has been regularly camps in Jordan 2016/17. conducting neonatal death audits among Syrian refugees to systematically capture The Integrated School Health (ISH) information on the number and causes of project, implemented by EMPHNET and all neonatal deaths and the potential supported by UNICEF, aims to strengthen avoidable factors linked to deaths. These the delivery of school health services in audits were conducted in a no-blame, Syrian refugee camps to simultaneously interdisciplinary environment to improve improve the health and educational the care provided to all mothers and outcomes of Syrian refugee children and babies. The Main objective behind this youth. The ISH project delivers capacity research is to investigate possible causes building, coordination, information of death/ and factors affecting the coverage management, performance-based pay and and quality of babies’ care with an aim to monitoring and evaluation to organize key improve neonatal care in refugee camps stakeholders towards the establishment of and to prioritize action to save lives of a comprehensive, inclusive and integrated babies. school health program. This project included a research component which Since July 2018, stillbirth audits among closely looked at vaccinations, physical, refugees of the two camps were also vision, hearing and dental examinations included in the mentioned surveillance among more than 8,000 school-going system. Thus, the overall aims of the

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Syrian children and youth in around 30 vaccinations were received (e.g. outpatient schools in three camps. clinic, private clinic, home), source of information on vaccinations, and reasons Estimating Population Immunity to for non-vaccination. Additionally, Poliovirus in Jordan’s High-Risk approximately 2-ml of blood will be Areas, 2016 collected by venipuncture from each subject. This serosurvey is part of a collaborative project with CDC that aims to inform the The expected outputs are 1) National and polio outbreak preparedness plan and governorate level estimates of immunity routine immunizations program in Jordan. levels to poliovirus types 1, 2 and 3 among The primary objective of the serosurvey is children less than five years of age residing to estimate population immunity to in the high risk areas of Jordan; 2) poliovirus from sera obtained from children estimates of immunity levels among under five years of age in high risk areas in Syrians compared to Jordanians in high Jordan to inform the Ministry’s Expanded risk areas; 3) estimates of the contribution Program on Immunizations policy and of demographic factors to immunity levels; implementation. Questionnaires will be and 4) estimates of the burden of disease administered to collect information on of chronic hepatitis B and immunity levels demographic factors, place of birth of the to diphtheria, tetanus, measles, and rubella child, vaccination status of the child for all viruses. The results will be used by Jordan vaccine preventable diseases, place where MOH to guide program planning and implementation.

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Burden of Influenza Virus Infection clinical diagnosis and management of among Hospitalized Infants and the influenza and RSV infections in hospital Potential of Prevention through settings.

Influenza Vaccination, 2015/17 The study will enroll around 300-500

hospitalized infants per year over two This prospective cohort study is supported years. Respiratory specimens will be by Abt Associates which aims to provide collected for all enrolled hospitalized important information that is lacking on the infants in order to test for influenza virus burden of severe disease associated with infection and potentially other viruses using influenza virus infection among infants molecular diagnostics. Acute sera and younger than one year in low- and middle- convalescent sera will be examined using income countries, including the clinical serologic assays to examine changes in presentation and course of illness in influenza antibodies associated with infants, influenza-associated hospital- influenza virus infection and biomarkers of ization, its related outcomes, and the disease severity. Information on hospital potential value of influenza vaccine treatment and interventions will be effectiveness and antiviral treatment. This abstracted daily from medical records. assessment will examine hospitalizations Additionally, around 100-200 non-ill infants due to both respiratory and non-respiratory acute medical illnesses using both molecular and serologic diagnostic assays. The expected output is to estimate the burden of severe influenza that is potentially vaccine-preventable through indirect protection of infants aged 0-5 months old and through direct vaccination of infants aged 6-11 months old. Secondary objectives include: 1) describing the local use of and potential preventive value of interventions in settings where influenza vaccines and/or antiviral agents are available; 2) addressing the primary objectives as they apply to other respiratory pathogens specially, respiratory syncytial virus (RSV) infection among hospitalized infants; and 3) examining the

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will be enrolled during weeks when local Pentavalent vaccines and one dose of influenza virus circulation is confirmed. measles vaccine. The study found that Respiratory specimens will be collected for around 41% of children had completed the molecular diagnostic testing in order to vaccine schedule within the date. Fully examine possible shedding of influenza vaccinated children were 75%. Only 2.2% virus, RSV, or other viruses among infants were never vaccinated. Card retention rate that are not acutely ill. Descriptive and was 94%. Immunization coverage for medical information will be collected from a pentavalent 1 (access) was 93%, parent interview. pentavalent 2 was 77%, and measles was76%. Forty-two percent of all children Vaccination Coverage Survey in surveyed received valid doses of Rota Baghdad Resafa, Iraq.2016 vaccine. Dropout rate was 17%, while it was around 25%in rural districts. Parents’ Baghdad Resafa is the eastern side of neglect ion, mother busy, vaccine not Baghdad, with around 4.6 million available were the main causes of “never inhabitants and a lot of slums areas. The vaccinated” and incomplete vaccination by two cases of poliomyelitis reported in 2014 different antigen. The study concluded that were from this area. Meanwhile, it is the fully immunized children are still below most affected area by Mumps outbreak in national target besides the high dropout 2016. The purpose of this study was to particularly in rural districts. The access is estimate immunization coverage for all good in all districts while utilization is low in antigens among children aged 12-23 districts with slums. Public communication months, in Baghdad Resafa Directorate of strategies and raising capacity of health Health, 2016, and characterize it by workers were recommended to address districts; and, to identify the causes of reasons of un-vaccination. “never” or “delayed vaccination”. The survey methodology involved 600 children The Epidemiology of Middle East selected randomly using the proportionate respiratory syndrome corona-virus cluster (120 clusters) survey. Twenty study in Jordan, 2016 teams (each of two) participated in the data collection using the standard WHO In coordination with EMPHNET and the questionnaire. Data were compiled using Jordan Ministry of Health, CDC staff have tablets and timely reviewed and analyzed. been invited to assist in defining the The study defined a “fully immunized child” epidemiology and transmission of MERS- as a child who received one dose of BCG, CoV among surviving 2015 cases and their three doses of oral polio vaccine and contacts. The aim of this study is to identify

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any genetic changes in the genomic PCR as a reference laboratory testing in sequences of the virus obtained from the Central Public Health Laboratory patient samples and direct further sero- (CPHL) in Amman, establish human epidemiologic investigation on the specimen collection, management and transmissibility and pathogenicity of new transport system, work on human data MERS-CoV strains. management and reporting, and describe the epidemiology of human brucellosis in Strengthening Brucellosis Jordan. Surveillance, Diagnosis and Control in Jordan, 2016 Additionally, EMPHNET will conduct refresher veterinarian training on diagnosis In this project, EMPHNET aims to improve and testing for brucellosis in sheep and the surveillance system and the diagnostic goats, establish serology confirmatory test capacity in human and veterinary (ELISA test), establish PCR as a reference laboratories in Jordan. This collaborative laboratory testing in the Central project will work in the areas of detecting Veterinarian Laboratory (CVL) in Amman, both human and animal brucellosis establish animal specimen collection, detection. Hence, EMPHNET will conduct management and transport system, work clinician refresher training on diagnosis and on animal data management and reporting, testing for brucellosis, establish serology and describe the epidemiology of sheep confirmatory test (ELISA test), establish and goat brucellosis in Jordan. Further, the

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project will aim at integrating animal and confirmation utilizing any additional human data in order to target vaccination diagnostics. The recommended treatment campaigns and assessing cost- course of brucellosis is six weeks with at effectiveness of vaccination of animals. least two antibiotics, so accurately identifying confirmed cases is critical for Strengthening Brucellosis treatment of the individual and for targeted Surveillance, Diagnosis and Control public health interventions. in Iraq, 2016 (Research proposal In the brucellosis Iraq project EMPHNET submitted). collaborates with the Iraq Ministry of Health

to work with two districts in Iraq where There are over 6000 cases of human disease surveillance has shown a high brucellosis reported by the Government of incidence of brucellosis. Within these Iraq per year. The Iraq Ministry of Health districts, the project will add additional has requested CDC assistance with confirmatory ELISA testing for persons with implementing a rational brucellosis a positive initial agglutination test; diagnostic testing strategy, improving the supplement the current surveillance surveillance of human brucellosis, systems with updated surveillance forms investigating risk factors and modes of and investigative tools to document and transmission, and creating an evidence investigate cases; support epidemiologists base to inform brucellosis control action in the investigation of outbreaks of plans. Currently, the majority of human brucellosis; establish molecular methods in brucellosis cases are diagnosed with a the Central Public Health laboratory to simple agglutination test without

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further characterize Brucella by species; epidemiologic investigation for survivors and foster partnerships with the Ministry of and contacts of the Middle East Agriculture through meetings and data Respiratory Syndrome Coronavirus sharing to target control interventions, (MERS-CoV). The investigation was done primarily vaccination of animals. The Iraq for the cases identified in 2015, and was Ministry of Health (MOH) will provide active performed in hospitals in Amman and leadership of the project and the outcome between April 2 and 7, 2016. will inform the MOH on how to expand this surveillance and testing strategy to the rest The first known cases of MERS-CoV in of the country. Consequently, this Jordan occurred in Zarqa between March approach can be used as a model for other and April of 2012. New cases and clusters countries in the region. of the MERS-CoV infections continue to occur within the Arabian Peninsula and Sero-Epidemiologic Investigation of have been exported to other countries MERS-CoV in Survivors, Contacts around the world. Little is known regarding for Jordan’s 2015 Cases: the duration of antibody responses following MERS-CoV exposure and In collaboration with the Centers for infection. Moreover, for the first time, a Disease Control and Prevention (CDC) and large-scale deletion in the MERS the Jordanian Ministry of Health, coronavirus has been identified. Notably, EMPHNET conducted a sero- all MERS cases in Jordan of 2015 were

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identified as having this deletion. It is for In April 2012, the Jordan Ministry of Health this reason that the sero-epidemiologic investigated an outbreak of lower investigation was conducted. respiratory illnesses at a hospital in Jordan; two fatal cases were retrospectively Preventing Emerging and Re- confirmed by real-time reverse emerging Infections Mini-grant transcription polymerase chain reaction Projects, 2015 (rRT-PCR) to be the first detected cases of Middle East respiratory syndrome (MERS- EMPHNET offered mini grants for CoV). Epidemiologic and clinical competitive proposals with the purpose of characteristics of selected potential cases implementing projects related to regional were assessed through serum blood priority challenges to address country gaps specimens, medical record reviews, and related to infectious diseases. Hence, joint interviews with surviving outbreak animal and human health teams from members, household contacts, and Eastern Mediterranean countries partnered healthcare personnel. Cases of MERS- to develop proposals with the ultimate goal CoV infection were identified using three of improving management best practices CDC serologic tests for detection of anti– and sustainable disease control MERS-CoV antibodies. methodologies for evolving pathogens. From these proposals, EMPHNET funded In 2015, EMPHNET in collaboration with four projects related to enhancing biosafety MOH and CDC measured longitudinal and biosecurity by developing reference antibody responses to Middle East materials and conducting training of Respiratory Syndrome coronavirus trainers for MOH personnel in Egypt; (MERS-CoV) from the 2012 outbreak. The developing biorisk management guidelines aim of this study was to better understand for Jordan; developing rapid response the persistence of these antibodies over teams’ guidelines in Jordan; and time. establishing an integrative zoonotic epidemiological surveillance system to Outbreak Investigation of Hepatitis address human health risks in Morocco by B and C Among Syrian employing West Nile Fever and Rift Valley Hemodialysis Patients from Zaatari Fever as a model. and Azraq Refugee Camps in Jordan, 2015 Middle East respiratory syndrome corona-virus Follow-up Study in In March 2015, representatives of Jordan Jordan, 2015 Ministry of Health (MOH) and Office of High

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Commissioner for Refugees (UNHCR) field level programming with key target reported to MOH a temporal cluster of groups in selected geographic sites. cases of hepatitis B (HBV) and hepatitis C (HCV) that occurred on around 24 March To be able to achieve set targets and 2015. The incidence of these cases among assess the impact of various community- Syrian hemodialysis patients in Zaatari and based interventions, JCAP is planning to Azraq refugee camps suggested the carry out pretest and posttest surveys in possibility of an outbreak of hepatitis due to designated intervention and control sites contaminated hemodialysis machines. following a quasi-experimental design. Objectives of the investigation were to Population-based Survey will focus on characterize the extent of the outbreak, measuring knowledge attitudes and determine the most likely source(s) of the practices of currently married women of outbreak or method of transmission, and reproductive age. Hence, EMPHNET make recommendations to assist MOH in conducted a study and provided results of taking appropriate action to control the the pretest phase (bassline) survey that outbreak and protect hemodialysis covered 16 districts in the three regions of patients. Jordan (central, north and south). In addition to Jordanian women, Syrian Knowledge, Attitudes and Practices women from the central and north regions towards Family Planning and were included in the study. Eight of the 16 Reproductive Health in Selected districts served as intervention sites and the other eight as controls. Fielding of the Districts in Jordan, 2015 study including data entry was carried out

by the Center for Research Studies at The Jordan Communication, Advocacy, Jordan University. EMPHNET performed and Policy (J-CAP) Project is a 5-year data cleaning, analysis and report writing USAID-funded activity that aims at for the subject baseline survey. increasing demand for and use of modern

family planning (FP) methods; increasing The main objectives of the survey were 1) capacity of government, civil society, and To provide reliable estimates of knowledge, other partners for social behavioral change, attitude and practice parameters related to policy, and advocacy; and improving the family planning and reproductive health for enabling environment for FP programs. married women of reproductive age (15-49 Whereas the J-CAP project will conduct living in JCAP implementation and non- major communication campaigns at implementation (control) sites in Jordan. National level, it will also employ a phased The information generated by the baseline approach to conducting community-based can be used by program managers to

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improve programming decisions 2) To Naturally, public health concerns arise analyze the comparability of demographic within such conditions, whereby such and other key characteristics of the married concerns include: the occurrence of women of reproductive age respondents in injuries, communicable diseases, non- intervention and control sites to document communicable diseases, exhaustion and their equivalencies at baseline; 3) To heat related illnesses, alongside other provide a methodologically and statistically public health related issues, such sound basis and valid findings as the circumstances impose challenges to public foundation for measuring changes in key health systems. knowledge, attitude and practice variables across time. Findings from this baseline EMPHNET in collaboration with the Iraq study will be employed in a planned end Ministry of Health has implemented a line impact assessment study of the JCAP project that aimed 1) To identify and Activity, measuring ‘discrepancy in the implement strategies that can strengthen differences’ at start and completion. efforts geared towards decreasing morbidity and deaths during mass Mass Gathering Project in Iraq, 2014 gatherings 2) To strengthen Iraq's MOH public health system by enhancing the Mass Gathering is an annual religious research skills of Iraqi's MOH graduates, occasion where eight million individuals residents and FETP residents 3) To from Iraq and other countries visit Karbala. strengthen surveillance at the mass The event draws large crowds within a gathering event in order to identify relatively limited space and time period. strengths and weaknesses, assess gaps,

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and make necessary evidence based Hajj is one of the largest annual mass recommendations 4) To tackle main health gatherings in the world, with millions of problems during the gathering and provide pilgrims from over hundred countries recommendations for decision-makers. traveling each year to Mecca, Kingdom of Saudi Arabia (KSA). The emergence of As part of this project, EMPHNET Middle East Respiratory Syndrome supported eight operational research coronavirus (MERS-CoV) in 2012 projects on 1) Knowledge, attitude, and prompted additional travel guidance and practice of food handlers on food safety surveillance recommendations for Hajj, and personal hygiene, during Arbaeenia given that the majority of cases have mass gathering 2) Assessment of mobile occurred in KSA, including those in the clinics during Arbaeenia mass gathering at same region and time period as the 2014 Baghdad-Alkarkh 3) Satisfaction with Hajj, which began on 2 October 2014. Post- health services provided at mobile clinics Hajj surveillance for MERS-CoV was a during Arbaeenia mass gathering at priority for Jordan, which has reported Baghdad 4) Temporary health care cases of MERS-CoV and shares its services for mass gatherings at Karbala 5) southern border with KSA. In October Disease burden on health facilities in 2014, Jordan established targeted governorates South of Karbala during the surveillance of acute respiratory illnesses Arbaeenia mass gathering 6) Injuries in Hajj pilgrims returning to Jordan. reported from selected health facilities Subsequently, EMPHNET with Jordan during Arbaeenia mass gathering at Babel MOH and other partners characterized this Governorate 7) Communicable disease surveillance initiative, which included syndromic surveillance among attendees testing for MERS-CoV and other of mobile clinics during mass gathering of pathogens known to cause acute Imam Al Husain's Arbaeenia at Wassit respiratory illnesses. Governorate 8) Non-communicable disease emergencies during Arbaeenia Service Availability and Readiness mass gathering at Karbala, Najaf and in the North of Jordan, 2014 Babel hospitals. This survey utilized a short adapted version Acute Respiratory Infections among of the WHO service availability and Returning Hajj Pilgrims in Jordan, readiness assessment (SARA) tool. The 2014 target facilities are MOH operated comprehensive healthcare centers (CHCs) and hospitals in the four northern

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governorates of Ajloun, Irbid, Jarash, predicting factors associated with obesity Mafraq, in addition to in among Jordanian women. the central region. General service readiness was measured in five main Both individual and household member domains of basic amenities, basic data sets for each survey were used to get equipment, standard infection prevention, data for ever-married and unmarried diagnostic capacity and essential women respectively. The Body Mass Index medicines. Service-specific availability and (BMI) of each woman was calculated as readiness was measured for only maternal her weight in kilograms divided by the and child health services (antenatal care, square of her height in meters. Binary vaccination and childcare), non- obesity variable identifying obese women communicable chronic diseases (diabetes, with BMI of 30 kg/m2 and above was used cardio-vascular and chronic pulmonary throughout for descriptive, bivariate and diseases), mental health and services for multivariate analyses. Two sets of analysis patients with special needs. Service- were performed, one for all women and the specific availability and readiness refer to other for ever- married women only. Each the ability of health facilities to offer a set of analysis covers the three individual specific service, and the capacity to provide DHS surveys. For multivariate analysis, in that service measured through addition to three models of standard logistic consideration of tracer items that include regression for individual surveys a fourth trained staff, guidelines, equipment, model using multi-level fixed effect model diagnostic capacity, and medicines. was used for the pooled data. Independent variables included: age, education, place of Obesity and Related Factors among residence, wealth quintiles and marital Jordanian Women of Reproductive status. For the ever-married sample, Age Based on Three DHS Surveys additional variables related to parity, use of contraceptive method, smoking and (2002, 2009 and 2012), 2014 working status were used.

The main objective of this study is to analyze the trends of obesity among Jordan Valley Assessment of Syrian Jordanian women of reproductive age over Refugees, 2014 a 10-year period from 2002 to 2012 based on three Demographic Health Surveys A rapid assessment with a purposive carried out during this period. Furthermore, sample was conducted. The sample the study aims at analyzing the possible consisted of well-known 24 locations (sites) of Syrian refugees living in temporary

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shelters (tents), distributed over 13 areas School Health Assessment Survey, located in three districts of the Central and 2014 Northern JV. The UN Office for the Coordination of Humanitarian Affairs This survey was intended to assess (OCHA)’s standard tool/ World Health effectiveness of certain interventions, Organization for Initial Rapid Assessment mainly the Health School National (IRA) was used to conduct this study. The Accreditation and Think First Programs as tool was adapted for Jordan; many judged by practices of students at these questions were added to the questionnaire public schools. A total of 2103 respondents in coordination with UNHCR, after which it participated in the study. In addition to was translated into and validated. drawing a sample of schools implementing The data collected were related to health these programs, another set of schools and its related needs, namely water, was selected to serve as a comparison sanitation, hygiene, shelter, food, essential group. Variables were collected to cover non-food items, education and access to meal intake, food consumption, oral and governmental services. Data were hand hygiene, availability of drinking water, collected through the use of key informant’s bullying, smoking, practices during playing, interviews (both community and official), physical assault and violence and physical group discussions, observations and injuries. EMPHNET involvement was facility visits. limited to data analysis and report writing.

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shared by Jordan Office of World Health Organization.

Mental Health Assessment of Syrian Refugees, 2013

Between June to July 2013, the Eastern Mediterranean Public Health Network, in collaboration with the Ministry of , the World Health Organization and the International Medical Corps, conducted a mental health assessment survey for Syrian refugees in Jordan. This survey aimed to present findings of a survey undertaken to assess the mental health and psychosocial (MHPSS) problems, services, and needs of displaced Syrians in Jordan. The assessment was based on Post-Polio Vaccination Campaign quantitative and qualitative tools adapted Evaluation, 2014 from the WHO-UNHCR Toolkit for The objective of this study was to evaluate Assessing MHPSS Needs and Resources quality of the campaign conducted between in Humanitarian Settings. The study was 2-6 March 2014, through estimation of OPV conducted in Amman, Irbid, Mafraq and vaccination coverage in Zaatari camp. Ramtha. EMPHNET was responsible for Hence, a random cluster survey was the design, data collection, data entry, data conducted. Management of the camp analysis, and report writing of the study. divided the camp into twelve districts. Findings were based on data collected Population of each district in the camp were from 1811 families, providing information obtained from UNHCR. Ultimately, thirty on 7964 individuals. Information on family clusters were randomly selected from members was reported by the heads of twelve districts of the camp. The number of households who were interviewed in this clusters in each district was proportionate study. to the size of population of each district.

From each cluster, thirty families who had Stillbirth during infection with at least one child under five years of age were interviewed using a questionnaire, Middle East respiratory syndrome corona-virus (MERS-CoV), 2013

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their behavioral risk factors in Ajloun and In May 2013, EMPHNET joined Jarash governorates, with particular epidemiologists from the Centers for emphasis on hypertension, diabetes, and Disease Control and Prevention (CDC) and obesity. The prevalence of major the Jordan Ministry of Health to conduct a modifiable NCD risk factors (tobacco use, retrospective investigation of an April 2012 physical inactivity, and unhealthy diet) was outbreak of respiratory illness, using newly also estimated in these two governorates. developed serologic tests for detection of The study findings aimed at encouraging MERS-CoV antibodies. In this investigation use of data in planning and implementing a study, serum specimens were collected scalable NCD project, and in promoting the and epidemiologic data were obtained from use of data among public health planners potentially exposed groups, including and policy makers. outbreak survivors and household A sample size of 1800 households was contacts, through medical chart reviews randomly selected using a three-stage and interviews. stratified cluster sampling design. Three strata were used, two for Ajloun and one for Interviews focused on a range of topics, Jarash. Data for the study was collected including the history of illness, detailed using an instrument which was developed contact history (with surviving outbreak based on the WHO NCD stepwise group members, the household members instrument BRFSS instrument and tailored of outbreak group members, visiting to address study needs and objectives. travelers, and animals, travel history, and Data was collected during the first two occupation. As a result of this investigation weeks of October 2011. Ten teams of study; novel serologic tests allowed for the trained data collectors participated in data detection of otherwise unrecognized cases collection through face-to-face interviews of MERS-CoV infection among contacts in and assessment of physical a Jordanian hospital-associated respiratory measurements. Data analysis was done illness outbreak in April 2012, resulting in a using complex sample analysis. total of 9 test-positive cases. Supplement on Mass Gatherings, Non-Communicable Diseases Risk 2011 Factors Survey in Ajloun and Jarash Governorates, 2011 EMPHNET and the Centers for Disease Control and Prevention (CDC) developed The study aimed at establishing baseline and conducted 2 workshops on Public prevalence estimates of major NCDs and Health Surveillance during Mass

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Gatherings for field epidemiology training Committee. This study was planned with programs and ministry of health focal the intention of promoting the use of points from 10 countries. In addition, each information and data among health service team country was awarded a mini grant in planners and policymakers in Jordan. The order to implement field project in its study aimed at generating and providing country. Mass Gathering Supplement of projections for the prevalence of major non- Eastern Mediterranean Health Journal communicable diseases (NCDs) and risk (EMHJ) was published as a result of this factors among Jordanian youth aged 18-34 collaborative project. This supplement years using data from the 2007 Stepwise describes major mass gatherings in the surveillance survey and applying it to the MENA region, and the public health nationally adopted population projections implications of these events, and provides data developed by the Higher Population. recommendations for public health officials of the host country. The main potential Assessment of Health Competent public health concerns associated with School Initiative, 2010 mass gatherings include infectious diseases (e.g. respiratory disease, gastro- EMPHNET in collaboration with The intestinal tract disease, foodborne Jordan Health Communication disease), injuries, traffic accidents, heat- Partnership, a program under the auspices related illnesses, insect stings, non- of the Johns Hopkins Bloomberg School of communicable diseases and terrorism. Public Health’s Center for Communication Programs, conducted the survey assessing the effectiveness of the Health Competent Projecting the prevalence of major School Initiative. The survey was a school- non-communicable diseases / risk based, cross-sectional survey targeting factors for the Jordanian youth youth aged 13 to 15 years. The sampling population for the years, 2011 frame for this survey at national level

consisted of all Health Competent Schools In 2012, The Higher Population Council including 8th through 10th grades. This (HPC) collaborated with EMPHNET in study employed a one-stage clustered estimating projections for the prevalence of design whereby the population is major NCDs and their related risk factors partitioned into strata (defined by region: for the Jordanian youth population (18-34) North, Middle, South) and primary for the years 2007-2050. The technical sampling units (PSUs) - e.g., schools - are support provided by EMPHNET was sampled independently within each stratum enhanced by involving the Technical Team using systematic equal probability of the National Population Projection sampling.

44 Research Involvement and Engagement

Research Involvement and Engagement 45

Other Activities and Partners In addition, EMPHNET participates, in partnership with WHO, NGOs and others, in refugee needs assessment, design of intervention services and evaluation of its impact, capacity building for the host country for the refugees and IDPs, as shown in the examples below:

Partners: Jordan Ministry of Health, FETPs of Iraq and Yemen . A training on Applied Epidemiology Methods and Epi Info 7 was conducted in July 2016 for participants from Iraq and Yemen FETPs. The training was applied in nature with focus on research projects of the participants.

Partners: Jordan Ministry of Health . Rotavirus and infection control training provided for health workers in Zaatari Camp, 2015

Partners: Jordan Ministry of Health, UNHCR . Health Facility Assessment of Hospitals and Community Health Centers in the Northern Governorates of Jordan, December 2014

Partners: World Health Organization . Post-Polio Campaign Evaluation in Zaatari and Azraq refugee camps, August 2014

Partners: World Health Organization, Jordan Ministry of Health . Assessment of Mental Health Psychosocial Support Needs of Displaced Syrians in Jordan, October 2013

Partners: World Health Organization, International Medical Corps, Jordan Ministry of Health . Needs Assessment of Syrian Refugees in the Jordan Valley, January 2014

Partners: UNHCR . Public Health in Emergencies Training, October 2013-January 2014

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The Eastern Mediterranean Public Health Network - EMPHNET

The Eastern Mediterranean Public Health Network is a regional network that focuses on strengthening Public Health Systems in the Eastern Mediterranean Region (EMR). EMPHNET works in partnership with Ministries of Health (MOH), non-government organizations, international agencies, private sector, and other public health institutions in the region and globally to promote public health and applied epidemiology.

GHD and EMPHNET: Working together for better health

Global Health Development (GHD) is a regional initiative created to support countries in the Eastern Mediterranean Region (EMR) and to strengthen their health systems to respond to public health challenges and threats. GHD was initiated to advance the work of the Eastern Mediterranean Public Health Network (EMPHNET) by building coordinating mechanisms with Ministries of Health, International Organizations and other institutions to improve population health outcomes. As an implementing arm to EMPHNET, GHD aligns its strategies with national policies and directions. Serving as a collaborative platform, GHD/EMPHNET is dedicated to serve the region by supporting national efforts to promote public health policies, strategic planning, sustainable financing, resource mobilization, public health programs, and other related services.

GHD/EMPHNET  42 Abdallah Ben Abbas Street, Shmeisani, Amman, Jordan

  Tel: +962-6-5519962 Fax: +962-6-5519963 www.globalhealthdev.org Research Involvement and Engagement 47