World Health Organization - Jordan

BACKGROUND: Limited information is available in Iraq regarding the causes of under-five mortality. The vital registration system is deficient in its coverage, particularly from rural areas where access to health services is limited and most deaths occur at home, i.e. outside the health system, and hence the cause of death goes unreported. Knowledge of patterns and trends in causes of under-five mortality is essential for decision-makers in assessing programmatic needs, prioritizing interventions, and monitoring progress. The aim of this study was to identify causes of under-five children deaths using a simplified verbal autopsy questionnaire.The objective was to define the leading symptoms and cause of death among Iraqi children from all regions of Iraq during 1994-1999. METHODS: To determine the cause structure of child deaths, a simplified verbal autopsy questionnaire was used in interviews conducted in the Iraqi Child & Maternal Mortality Survey (ICMMS) 1999 national sample. All the mothers/caregivers of the deceased children were asked open-ended questions about the symptoms within the two weeks preceding death; they could mention more than one symptom. RESULTS: The leading cause of death among under-five children was found to be childhood illnesses in 81.2%, followed by sudden death in 8.9% and accidents in 3.3%. Among under-five children dying of illnesses, cough and difficulty in breathing were the main symptoms preceding death in 34.0%, followed by diarrhea in 24.4%. Among neonates the leading cause was cough/and or difficulty in breathing in 42.3%, followed by sudden death in 11.9%, congenital abnormalities in 10.3% and prematurity in 10.2%. Diarrhea was the leading cause of death among infants in 49.8%, followed by cough and/or difficulty in breathing in 26.6%. Among children 12-59 months diarrhea was the leading cause of death in 43.4%, followed by accidents, injuries, and poisoning in 19.3%, then cough/difficulty in breathing in 14.8%. CONCLUSION: In Iraq Under-five child mortality is one of the highest in the Middle East region; deaths during the neonatal period accounted for more than half of under-five children deaths highlighting an urgent need to introduce health interventions to improve essential neonatal care. Priority needs to be given to the prevention, early and effective treatment of neonatal conditions, diarrheal diseases, acute respiratory infections, and accidents. This study points to the need for further standardized assessments of under-5 mortality in Iraq.

Exposure to air pollution can cause detrimental health and be an economic burden. With newly developed equipment, monitoring of different air pollutants, identifying the sources, types of air pollutants and their corresponding concentrations, and applying mitigation intervention techniques became a crucial step in public health protection. Countries in the Eastern Mediterranean Region (EMR) are highly exposed to dust storms, have high levels of particulate matter (PM) concentrations, and have a unique climatic as well as topographic and socio-economic structure. This is the first study conducted to systemically and qualitatively assess the health impacts of air pollution in the EMR, identify susceptible populations, and ascertain research and knowledge gaps in the literature to better inform decisions by policy makers. We screened relevant papers and reports published between 2000 and 2014 in research databases. A total of 36 published studies met the inclusion criteria. A variety of indoor and outdoor exposures associated with various acute and chronic respiratory health outcomes were included. Respiratory health outcomes ranged in severity, from allergies and general respiratory complaints to lung cancer and mortality. Several adverse health outcomes were positively associated with various indoor/outdoor air pollutants throughout the EMR. However, epidemiological literature concerning the EMR is limited to a few studies in a few countries. More research is needed to elucidate the health outcomes of air pollution. Standardized reliable assessments on the national level for various air pollutants in different regions should be implemented and made publically available for researchers to utilize in their research. Moreover, advancing and utilizing more sound epidemiological designs and studies on the effect of air pollution on the respiratory health outcomes is needed to portray the actual situation in the region.

OBJECTIVES: To summarize the existing knowledge of the impact of climate change on health from previous research in the Eastern Mediterranean region (EMR) and identify knowledge and research gaps. METHODS: Different databases were searched for relevant studies published in the region between 2000 and 2014. The review was limited to studies reporting the impacts of climate change on health or studying associations between meteorological parameters and well-defined human health outcomes. RESULTS: This systematic review of 78 studies identified many knowledge and research gaps. Research linking climate change and health is scarce in the most vulnerable countries of the region. There is limited information regarding how changes in temperature, precipitation and other weather variables might affect the geographic range and incidence of mortality and morbidity from various diseases. Available research has many limitations and shortcomings that arise from inappropriate study designs, poor assessment of exposure and outcomes, questionable sources of data, lack of standardized methods, poor adjustment of confounders, limited geographical area studies, small sample sizes, poor statistical modeling and not testing for possible interactions between exposures. CONCLUSIONS: Research and information on the effect of climate change on health are limited. Longitudinal studies over extended periods of time that investigate the link between climate change and health are needed. There is a need for studies to be expanded to include more countries in the region and to include other environmental, social and economic factors that might affect the spread of the disease.

Background. Waterpipe nicotine dependence and its association with depressive symptoms and dual usage among adolescents are currently not examined in the literature. Adolescents are a vulnerable population that is susceptible to depression and initiation of tobacco use. We aim, in this novel study, to assess the association between depressive symptoms and waterpipe nicotine dependence among adolescents in Jordan, evaluate the association between waterpipe smoking status (waterpipe smoker vs. dual user) and waterpipe nicotine dependence, and assess the internal validity of the Waterpipe Nicotine Dependence Scale (WNDS). Method. A cross-sectional study among adolescents of grade 9th to 12th in Jordan was conducted through multistage cluster random sampling. The self-reported Arabic Youth Tobacco Use Composite Measure Questionnaire (YTUCM) was used to collect the surveys that include demographic information, smoking status, and the WNDS to assess waterpipe nicotine dependence and depressive symptoms. Multiple linear regression and the t-test were used to analyze the data. Findings. One thousand three hundred and three surveys were collected, of which 1082 were included in the study (443 males and 639 females). 64.9% of the sample were nontobacco users, while 20.1% were waterpipe- (WTP-) only smokers, 11.4% were dual users, and 3.7% were cigarettes-only users. After adjusting for weights, 66.6% were nonsmokers, 19.2% were WTP-only smokers, 10.2% were dual users, and 3.9% were cigarettes-only smokers. Using multiple linear regression, depressive symptoms were significantly associated with WTP nicotine dependence (β 0.618), upon adjusting for confounders. Furthermore, dual users were associated with higher WTP nicotine dependence (β 12.034) compared to WTP-only smokers after adjusting for confounders. Cronbach’s alpha for the WNDS was 0.955. Conclusions. Our study shows that there is a statistically significant association between depressive symptoms and WTP nicotine dependence and higher dependence among dual users compared to WTP-only smokers. The WNDS can be a useful tool to assess WTP nicotine dependence with high internal consistency. However, a longitudinal study is needed to further understand the association and temporality between the depressive symptoms and WTP nicotine dependence. Additionally, research is needed to shorten the WNDS while maintaining high internal consistency and assess the external validity of the WNDS and the short- and long-term consequences of dual usage.

There is limited research on indoor air quality in the Middle East. In this study, concentrations and size distributions of indoor particles were measured in eight Jordanian dwellings during the winter and summer. Supplemental measurements of selected gaseous pollutants were also conducted. Indoor cooking, heating via the combustion of natural gas and kerosene, and tobacco/shisha smoking were associated with significant increases in the concentrations of ultrafine, fine, and coarse particles. Particle number (PN) and particle mass (PM) size distributions varied with the different indoor emission sources and among the eight dwellings. Natural gas cooking and natural gas or kerosene heaters were associated with PN concentrations on the order of 100,000 to 400,000 cm−3 and PM2.5 concentrations often in the range of 10 to 150 µg/m3. Tobacco and shisha (waterpipe or hookah) smoking, the latter of which is common in Jordan, were found to be strong emitters of indoor ultrafine and fine particles in the dwellings. Non-combustion cooking activities emitted comparably less PN and PM2.5. Indoor cooking and combustion processes were also found to increase concentrations of carbon monoxide, nitrogen dioxide, and volatile organic compounds. In general, concentrations of indoor particles were lower during the summer compared to the winter. In the absence of indoor activities, indoor PN and PM2.5 concentrations were generally below 10,000 cm−3 and 30 µg/m3, respectively. Collectively, the results suggest that Jordanian indoor environments can be heavily polluted when compared to the surrounding outdoor atmosphere primarily due to the ubiquity of indoor combustion associated with cooking, heating, and smoking.

The misuse of antibiotics is a worldwide public health concern. Behavioral Intervention programs that aim to reduce patients’ own request for antibiotics during their visit to primary care clinics is an attractive strategy to combat this problem. We tested the effectiveness of a behavioral modification method known as the Tailoring Antimicrobial resistance Programs (TAP) in reducing the request for antibiotics by patients visiting primary care clinics for mild upper respiratory tract infections (URTIs). A stratified cluster randomized design with two groups pre-post, comparing intervention with the control, was conducted in six health centers. TAP was implemented for eight weeks. Request for antibiotics was assessed before (period 1) and after introducing TAP (period 2). The percentage of patients or their escorts who requested antibiotics in period 1 was 59.7% in the control group and 60.2% in the intervention group. The percentage of patients who requested antibiotics did not significantly change between period 1 and 2 in the control group, who continued to receive the standard of care. The above percentage significantly decreased in the intervention group from 60.2% to 38.5% (p < 0.05). We conclude that behavioral change programs including TAP are a viable alternative strategy to address antibiotic misuse in Jordan.

The Eastern Mediterranean Region of the WHO is the poorest region in the world in water resources as a Region and per capita. This paper summarizes existing practices and constraints regarding wastewater treatment and reuse in the Region and describes the health impact of inappropriate practices. Appropriate treatment for agricultural use from the health point of view, and the health regulations and guidelines for wastewater reuse in the Region are outlined. The work of the WHO Regional Office to assist countries face the challenges of water scarcity and wastewater reuse are described. Finally, key suggestions that could enhance the use of reclaimed wastewater while at the same time safeguarding human health are presented.

Air quality is intimately linked to human activities, climate, atmosphere and ecosystems. Many of the anthropogenic contributors to air pollution are also sources of greenhouse gases including CO2 and other short-lived climate pollutants, such as Ozone and black carbon, which greatly contribute to the climate change phenomenon and its adverse effects on human health. Unfortunately, fragile and dry ecosystems prevailing in most of our countries in the Eastern Mediterranean Region may be implicated for exacerbation of this air pollution and climate change dilemma even more severely.

Reclaimed wastewater must be considered as an important component of the water budget in Jordan where water resources are rather limited. It has been estimated that wastewater effluents will amount to about 50% of the water deficit that is anticipated by the year 2000. This constitutes about 23% of the total renewable groundwater resource capacity. Quality characteristics of wastewater effluents from different treatment plants and other sources are presented. Review of institutional and legal aspects of water reuse is recommended toward encouraging treated effluent reuse. Outlines for a new reuse strategy have been suggested to ensure that wastewater reuse projects are operationally sustainable and environmentally sound.

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

Influenza causes significant morbidity and mortality worldwide. Owing to its ability to rapidly evolve and spread, the influenza virus is of global public health importance. Information on the burden, seasonality and risk factors of influenza in countries of the World Health Organization Eastern Mediterranean Region is emerging because of collaborative efforts between countries, WHO and its partners over the past 10years. The fourth meeting of the Eastern Mediterranean Acute Respiratory Infection Surveillance network was held in Amman, Jordan on 11-14 December 2017. The meeting reviewed the progress and achievements reported by the countries in the areas of surveillance of and response to seasonal, zoonotic and pandemic influenza. The first scientific conference on acute respiratory infection in the Eastern Mediterranean Region was held at the same time and 38 abstracts from young researchers across the Region were presented on epidemiological and virological surveillance, outbreak detection and response, influenza at the animal-human interface, use and efficacy of new vaccines to control respiratory diseases and pandemic influenza threats. The meeting identified a number of challenges and ways to improve the quality of the surveillance system for influenza, sustain the system so as to address pandemic threats and use the data generated from the surveillance system to inform decision-making, policies and practices to reduce the burden of influenza-associated illnesses in the Region.

In the World Health Organization Eastern Mediterranean Region (EMR), over 100 million people fall ill every year from foodborne diseases, of whom an estimated 37 000 die annually (disproportionally children). A number of studies have identified a clear relationship between occupational exposure to pesticides and a number of noncommunicable diseases (NCDs). For example, respiratory symptoms were reported in 65.9% of farmers exposed to pesticides in Pakistan; lymphoproliferative disorders following exposure to pesticides in Egypt; and hepatocellular carcinoma in Yemen with 73.7% of farmers having a history of chemical contact with insecticides or fertilizers. However, a challenging task regarding the burden of foodborne disease is the attribution to chemicals in food as a source for NCDs, since this requires long-term epidemiological and exposure monitoring data.

The purpose of this study was to propose an approach to predict the distribution of chemicals in food in developing countries to assess consumer risk and access to the international market with a limited number of laboratory analyses. The first step consists of identifying the GEMS/Food Contaminants database and the chemical/food combination relevant for a particular country. The identification of critical chemical/food combination should be used to prioritize the analysis to be performed in a total diet study (TDS). The second step consists of modelling a distribution model based on the mean concentration generated from TDS associated with the variability observed in a larger dataset consisting of individual food contamination data from the GEMS food database. The simulated distributions may provide information regarding how to establish food safety standards and to assess the potential for accessing international market in the context of a value chain. This method is illustrated by case studies from the recent Regional TDS (RTDS) conducted in Sub Saharan Africa. We concluded that further work is needed to gain experience and to fully validate this approach. However, organized data sharing and developing harmonized methods for data analysis are key roles for international organizations, such as FAO, WHO, and WTO. Finally, it is important to remember that such a data-driven approach still requires significant investments in terms of human resources and analytical capacity.

Influenza causes significant morbidity and mortality worldwide. Owing to its ability to rapidly evolve and spread, the influenza virus is of global public health importance. Information on the burden, seasonality and risk factors of influenza in countries of the World Health Organization Eastern Mediterranean Region is emerging because of collaborative efforts between countries, WHO and its partners over the past 10 years. The fourth meeting of the Eastern Mediterranean Acute Respiratory Infection Surveillance network was held in Amman, Jordan on 11–14 December 2017. The meeting reviewed the progress and achievements reported by the countries in the areas of surveillance of and response to seasonal, zoonotic and pandemic influenza. The first scientific conference on acute respiratory infection in the Eastern Mediterranean Region was held at the same time and 38 abstracts from young researchers across the Region were presented on epidemiological and virological surveillance, outbreak detection and response, influenza at the animal-human interface, use and efficacy of new vaccines to control respiratory diseases and pandemic influenza threats. The meeting identified a number of challenges and ways to improve the quality of the surveillance system for influenza, sustain the system so as to address pandemic threats and use the data generated from the surveillance system to inform decision-making, policies and practices to reduce the burden of influenza-associated illnesses in the Region.

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

The authors would like to correct the published article [...]

Background: Population-based serosurveillance is a cornerstone to furthering our understanding of the COVID-19 pandemic at the community levels. In Jordan, four waves (phases) of seroprevalence epidemiological investigations were conducted using representative population-based national samples. This study aims to estimate the population-based seropositivity, herd immunity, and vaccination coverage at the fourth wave. Methods: Multistage sampling technique was implemented to recruit a nationally representative sample for the fourth wave of the seroprevalence investigation (June to August 2021). Electronically collected data utilized a questionnaire on background demographics, chronic diseases, and COVID-19 vaccination history. Also, blood samples were collected to detect the presence of total Anti-SARS-CoV-2 IgM and IgG using Wantai/ELISA assays. Prevalence estimates were presented using percentage and 95% Confidence Intervals (C.I.). Results: There were 8821 participants included in this study, with a mean age of 31.3 years, and 61.7% were females. COVID-19 national seroprevalence and vaccination coverage estimates were 74.1% (95% C.I.: 73.1-74.9%) and 38.4% (95% C.I.: 37.1-39.6%), respectively. Among children, seroprevalence estimates were similar to unvaccinated adults. Among COVID-19 adults, 57.2% were vaccinated. Among vaccinated participants, 91.5% were seropositive, while among unvaccinated, 63.2% were seropositive. By age group, seroprevalence ranged between 53.0% and 86.9%. Seroprevalence estimates were significantly different by gender, vaccination status and dose, and residence. Conclusion: The reported interplay between seropositivity and vaccination coverage estimate seems insufficient to provide herd immunity levels to combat new variants of SARS-CoV-2. Children and healthcare workers seem to be an epidemiologically influential group in spreading COVID-19. As the globe is still grappling with SARS-CoV-2 infection, national seroepidemiological evidence from Jordan calls for more focus on vaccination coverage, especially among epidemiologically vulnerable groups, to optimize herd immunity.

The Impact of the SARS-CoV-2 Pandemic on Mental Health in Vulnerable Population Settings: The Case of Jordan

This randomised controlled trial compared a 10-session chatbot intervention with 5 weekly brief support calls (STARS) to enhanced usual care (EUC) in distressed young adults in Jordan (N = 344). Primary outcome was change in anxiety and depression severity assessed at baseline by the Hopkins Symptom Checklist (HSCL), 1-week posttreatment, and 3 months after treatment (primary outcome timepoint), as well as secondary outcome measures of psychological distress, personally identified problems, functional impairment, wellbeing and perceived agency. At the 3-month assessment, relative to EUC participants enrolled in STARS reported greater reductions of anxiety (effect size, 0.70) and depression (size, 0.61), as well as greater reductions in psychological distress, personally identified problems, functional impairment and greater improvement in wellbeing and sense of agency. Similar levels of efficacy were retained even for those with more severe symptom levels. This guided chatbot offers a scalable psychological intervention that can be implemented to increase access to evidence-based mental health care. Trial Registration: The trial was prospectively registered on ISRCTN on 02/11/2022 ( https://doi.org/10.1186/ISRCTN19217696 ).

Purpose: The Eastern Mediterranean Region (EMR) countries suffer from exposure to high levels of ambient air pollutants due to dust storms and have unique climatic as well as topographic and socio-economic conditions which lead to adverse health effects on humans. The purpose of the review was to evaluate the quantity and quality of published articles on air pollution and health-based studies in 22 EMR countries to determine if they can be applied to adopting air quality standards. Methods: We designed a review based on a broad search of the literature in the Scopus, PubMed, and web of science (WOS) databases published from January 1, 2000, to January 2, 2022, using combinations of the following relevant terms: air pollution, health, and EMR countries. The generic eligibility criteria for this review were based on the population, exposure, comparator, outcome, and study design (PECOS) statement. Results: The search results showed that following the PRISMA approach, of 2947 identified articles, 353 studies were included in this review. The analysis of the types of studies showed that about 70% of the studies conducted in EMR countries were Health Burden Estimation studies (31%), Ecological and time trend ecological studies (23%), and cross-sectional studies (16%). Also, researchers from Iran participated in the most published relevant studies in the region 255 (~ 63%) and just 10 published documents met all the PECOS criteria. Conclusion: The lack of sufficient studies which can meet the PECOS appraising criteria and the lack of professionals in this field are some of the issues that make it impossible to use as potential documents in the WHO future studies and adopt air quality standards. Supplementary Information: The online version contains supplementary material available at 10.1007/s40201-023-00862-1.