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Najwa Khuri-Bulos MD,CIC,FIDSA Professor of Infectious Disease Jordan University Hospital Consultant to the National Center for Security and Crisis Management Amman, Jordan

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Page 1: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Najwa Khuri-Bulos MD,CIC,FIDSAProfessor of Infectious DiseaseJordan University HospitalConsultant to the National Center for Security and Crisis ManagementAmman, Jordan

Page 2: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Country background

Page 3: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 4: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

6 million peopleChildren < 18 about 35% of the populationHigh literacy rate >90% Male and female literacy almost equalFour medical schoolsPublic sector accounts for more than 75% of medical careMedical care for children up to six years of age is for free in government hospitalsFree vaccination covering all basic plus vaccines

Page 5: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Health care provided by

◦ Government hospitals and clinics◦ University Hospitals and clinics◦ Private hospitals and clinics◦ Armed forces hospitals and clinics◦ UNRWA clinics◦ NGO (very minor role)

Page 6: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

However, Jordan is in the center of many upheavals and regional conflicts and Host to many migrants

Page 7: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Wor

ld P

opul

atio

n in

bill

ions

(

)

Day

s to

Circ

umna

viga

te (

)

th

e G

lobe

Year1850

0

400

350

300

250

200

150

100

50

2000

0

1900 1950

1

2

3

4

5

6

Speed of Global Travel in Relation toWorld Population Growth

Page 8: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Total population 325,512,000Total population 325,512,000

Page 9: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Low income Low middle income High middle income High income

Mauritania Algeria Lebanon Bahrain

Somalia Egypt Libya Kuwait

Sudan PNA Oman Qatar

Yemen Iraq Saudi Arabia UAE

The comorros Jordan

Djiboti Morocco

Syria

Tunis

Page 10: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Infant Mortality Rate (2004)

0

20

40

60

80

100

120

UAEBah

rain

Kuwai

tOm

anSy

riaLi

bya

Qatar

Saud

i Ara

bia

Tuni

sia

Pales

tine

Jord

anEg

ypt

Leba

non

Alger

iaM

oroc

coCom

oros

Suda

nM

aurit

ania

Yemen

Dijbou

tiIr

aqSo

mal

ia

Country

Infant mortality rateInfant mortality rate

Unicef State of the world children 2006Unicef State of the world children 2006

Page 11: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Neonatal mortality rate in the Arab States 2000

01020304050607080

OPTMaurita

n ia IraqSomaliaD jiboutiYemen

ComorosSudan

EgyptMorocco

A lgeriaLebanon

JordanTunisi a

Saud i Arab iaBahrain

L ibyan Arab Jamah iriy

Syr ian Arab Repub li Kuwait

OmanQ ata r

Un ite d Arab Em irates

Unicef State of the world children 2006Unicef State of the world children 2006

Page 12: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 13: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 14: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 15: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Country Capacity in

◦ Surveillance◦ Detection◦ Diagnosis◦ Containment of infectious disease in

humans, animals and food (plant sources)

Page 16: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Event detection

The MOH surveillance system.. How good is it??

Page 17: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Surveillance System in Jordan

Data collection process for infectious diseases and diarrhoea is built on weekly and monthly basis in addition to any disease or event of potential public health concern ( … new type of influenza ). 

‐Passive surveillance ( Routine data collection)

‐Active surveillance (In outbreaks & some events)

This is also applied to AFP zero reporting by active weekly surveillance

Page 18: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Jordanian reporting system

Communicable Diseases Directorate

MOH Peripheral Health Directorate

UNRWA ! military Medical Services !

Health centers Public Hospitals Private sectors Health centers

Primary Heath care administration

MOH

Working well

independently Working

Partially involved

NGO’s

Not involved

Page 19: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Health DirectoratesHealth Directorates

Public & Private Hospitals Public Health Centers

DCD

Peripheral level Health centres and Hospitals

Intermediate level Health DirectoratesAnd Reporting Sites

Central levelCommunicable  Diseases Directorate 

Surveillance  Tasks

Detect  TreatReport

Analyse at healthcentres levelInvestigateReportRespondFeedback

Analyse at directorate  levelInvestigateConfirmRespondPlan and FundFeedback

Page 20: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Local Health Directorates

Local Health Directorates

Local Health Directorates

Local Health Directorates

Communicable Diseases Directorate

Pub.HC

Pub.HC

Pub.HospPub.

HospPub.HC

Pub.Hosp

Pub.HC

Pub.Hosp

With

in 3

day

s max

Mon

day

Tue

sday

By Phone followed bye written reporting

Electronically dialup

Feed

bac

k W

eekl

y M

onth

ly r

epor

tData Flow Chart

Page 21: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 22: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

(2007)  44 diseases

Page 23: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 24: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 25: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Number of Diarrhoea cases in Balqa During Week 52

120

108

90 9759

115

115

7211

411

611

196 11

8 138

143 18

417

2 219

230

214

201

209

185 23

618

824

2 264

222 233

238

217

200 213

206 24

018

5 200

183 22

0 255

190

196

196

192

166 18

9 210

189

156

156

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Week

Cas

es

2004 Upper threshold Lower threshold 2003

Previous year

Upper Threshold 90th PercentileLower threshold

10th Percentile

# cases in respective week

Page 26: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

"Occurrence of Diarrhoea cases In Week 52 In Jordan For the year 2006 Compared to the 90th & 10th percentiles During the last 5 years 2001 - 2005

1408

1091 16

2914

7713

71 1539 18

1516

6515

87 1913

1874

1968

1744 19

9320

4019

8819

2719

79 2512

2610 28

5434

69 3684 3869 4054

3912

3676

3600

3627

3385

3332

2956

3058

2820 2999

3003

3109

2993

2786

2721 2884

2747

2065

2772

2550

2598

2517

2643

2580

2481

2127

1480

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Week

Cas

es

2006 Upper threshold Lower threshold 2005

Week 71815 case

Threshold 1325

490 case in excess

Page 27: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

A good network of well trained people

Efficient communication system

Rapid response (small country)

Page 28: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Weak involvement of Private sector

Staff turn over

Weakness of coordination with other sectors

Little communication of results outside of the MOH in real time

Page 29: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Response during the H1N1Pandemic

Page 30: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

The committee is composed of IHR focal pointAcademics from all University hospitalsPrivate sector (medical associations)MOH staff including the Jordan CDC and the National lab and major hospitalsReport directly to the Minister of HealthRecommended adoption of case definition, lab needs and therapeutic guidelinesChairman is the undersecretary of health

Page 31: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Capacity building in

◦ Surveillance◦ Detection◦ Diagnosis◦ Containment of infectious disease in

humans, animals and food (plant sources)

Page 32: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

For H1N1 preparedness for H5N1 was a great helpNational laboratory and university hospitals were well equipped to perform the tests including PCR testingManagement plan in place but was modified taking into account the epidemiology of H1N1H5N1 included coordination with Ministry of AgricultureHowever the actual coordination mechanism remain based on personal connection and needs further evaluation and improvement

Page 33: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 34: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 35: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity
Page 36: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Surveillance for influenza was successful due to knowledge from other countries which tested for influenza on routine basis.Had we had an outbreak of respiratory illness would we have been equipped to test for the disease??In the absence of a good diagnostic facility with sustainable supplies, viral and unusual bacterial pathogens will not be detectedIn this case there has to be a good reliable reference lab to use on a short notice and at will

Page 37: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Capacity building in

◦ Surveillance◦ Detection◦ Diagnosis◦ Containment of infectious disease in

humans, animals and food (plant sources)

Page 38: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

No viral isolation capability◦ No level 3 or level 4 facility to study the virus

further and determine aspects of drift or shift at the molecular level◦ No scientific input which also triggers retention of

the young and the brightest

◦ Major problem is retention of well trained personnel even if they initially join the public sector

Difficulty in obtaining the necessary kits to perform the tests

Page 39: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Coordination ◦ Multiple players but little exchange of information

among the different experts◦ Need for mapping the resources, human expertise,

equipment, supplies◦ Sharing supplies and expertise among the different

sectors and within the region ◦ Risk communication to the public ◦ Use of electronic media especially to teach medical

experts (websites)

Page 40: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

No clear line of commandCommittees are not sufficient since they do not have the authority to act.?? Task force to support the functionNCSCM , the national center for security and crisis management recently created in Jordan

Page 41: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Capacity building in

◦ Surveillance◦ Detection◦ Diagnosis◦ Long term Containment and mitigation in

humans, animals and food (plant sources)if applicable

Page 42: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Vaccination

This for now is almost totally dependent on other suppliers for all vaccines outside of the region including H1N1

This makes all plans to effectively control this outbreak in time highly difficult to implement

Page 43: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Jordan like many developing countries has been improving health services and laboratory know how and surveillance for infectious diseases however

Surveillance has to be tested to assure quality and sensitivitySurveillance for animal health needs to be coordinated with human health and upgradedA level 3 or 4 facility to upgrade bio security, bio safety

?? Implementation support unit equivalent to bring up the country capacity in line for IHR and BWC utilizing article X ??

Page 44: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

The need exists in Jordan and the region for a vaccine making capability with transfer of technology to be built up for the coming few yearsRegional CDC ??

Jordan is ideally suited for being a focal point for some of these activities

Page 45: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Which one to tackle

next???

Page 46: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

The Jordan University Hospital, Amman, Jordan

Page 47: The National Center for Security and Crisis ManagementhttpAssets)/0DD3C25AE… · `NCSCM , the national center for security and crisis management recently created in Jordan `Capacity

Thank you


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