Field Epidemiology Research in the Mediterranean Region

Due to the emergence of the SARS-CoV-2 B.1.1.7 (Alpha) variant in the UK in 2020 and its risk of increased transmission, the Ministry of Health in Tunisia implemented a sequencing surveillance strategy for SARS-CoV-2. The aim of this study was to analyze SARS-CoV-2 genomic surveillance data in Tunisia (January 2021–February 2022) and to assess the implementation of the sequencing strategy for SARS-CoV-2 in accordance with national recommendations and the guidance for SARS-CoV-2 genomic surveillance for public health goals. A descriptive study of all sequenced RT-PCR samples sequenced (January 2021–February2022). An internal audit was also done to assess the compliance against standards covering national recommendations and the Guidance for SARS-CoV-2 genomic surveillance for public health goals. A total of 12 simple or composite requirements related to the following areas were included in the audit standards: sampling (one requirements); data collection/analysis (six requirements); partnership (one requirement); and ethical considerations (one requirement). A total of 4819 samples were sent to laboratories and 4278 samples were sequenced. A total of 3648 samples were classified. Positive variants of concern (VOC) samples were 80.92%, differentiated as follows: Alpha, 40.24%; Beta, 0.24%; Gamma, 0.03%; Delta, 45.26%; and Omicron, 14.19%. Three principal phases of VOCs per ISO-week were shown: Alpha 3/2021–25/2021; Delta 26/2021–2/2022; and Omicron 3/2022–6/2022. Levels of compliance were identified; from a total of 12 requirements, 7 were considered as “not met”, 4 as “partially met”, and 1 as “fully met” but including not totally achieved objectives. In conclusion, the internal audit of the national SARS-CoV-2 sequencing strategy revealed an overall “not met” level of compliance. The results offered a trigger to collaborate with all stakeholders to develop a surveillance strategy for early detection and response to outbreaks caused by VOCs. Full article

The burden of tuberculosis (TB) in Jordan is largely unknown due to the paucity of high-quality data, under-reporting, and a lack of good quality vital registration system. This study aimed to assess the characteristics of TB patients in Jordan, determine the TB notification rate and assess the trend of TB notification in Jordan between 2016 and 2020. Methods: This study analyzed the TB Surveillance data in Jordan for the period 2016–2020. The obtained data included information on age, gender, nationality, marital status, date of symptoms onset and date of diagnosis, and site of TB. Results: During the period 2016–2020, a total of 1711 patients (989 women and 722 men) were diagnosed with and treated for tuberculosis. The mean (SD) age of patients was 30.1 (17.2) years. Almost half of them (48.4%) were Jordanians. The majority of non-Jordanian patients were from Syria, Philippines, and Bangladesh. Two thirds of patients (66.0%) had pulmonary TB and 34.0% had extra-pulmonary TB. Almost half (50.7%) of the patients were diagnosed within one month of the symptoms’ onset. The average annual TB notification rate during 2016–2020 was 3.32 per 100,000 pop (4.08 per 100,000 women and 2.64 per 100,000 men). The average annual standardized notification rate was 4.13 per 100,000 pop (4.52 per 100,000 women and 3.52 per 100,000 men). The overall age-standardized notification rate increased from 3.88 per 100,000 pop in 2016 to 4.58 per 100,000 pop in 2019 and declined to 2.46 per 100,000 pop in 2020. The trend in TB notification differed significantly according to gender. While the notification increased in the last three years among women, it decreased significantly among men. Conclusions: While TB notification increased in the last three years among women, it decreased significantly among men. There is a need to ensure that the national TB plans set clear targets for reducing the burden of TB. Full article

Lebanon has been one of the most affected countries by the Syrian humanitarian crisis. The national communicable disease surveillance was enhanced to detect outbreaks among Syrians. In this study, we aim to describe the findings of the communicable disease surveillance among Syrians in Lebanon, compare it to residents’ data, and describe the implemented surveillance activities between 2013 and 2019. During the study period, data on communicable diseases was mainly collected through the routine national surveillance system and an enhanced syndromic surveillance system. Predefined case definitions and standard operating procedures were in place. Data collection included both case-based and disease-specific reporting forms. Descriptive data and incidence rates were generated. Information was disseminated through weekly reports. Activities were conducted in close collaboration with different partners. The most commonly reported diseases were: viral hepatitis A, cutaneous leishmaniasis, mumps, and measles. Hepatitis A incidence increased in 2013 and 2014 among Syrians as well as residents. For leishmaniasis, the incidence increased only among Syrians in 2013 and decreased after that. An outbreak of mumps was reported among Syrians between 2014 and 2016, with a peak in 2015 concomitant with a national outbreak. Outbreaks of measles were reported among Syrians and residents in 2013, 2018, and 2019. The infrastructure of the well-implemented surveillance system in Lebanon has been utilized to monitor the health status of Syrians in Lebanon, early detect communicable diseases among this population, and guide needed preventive and control measures. This highlights the importance of having a flexible surveillance system that can be adapted to emergencies and the importance of sharing results with involved partners. Full article

Children and adolescents account for a small proportion of confirmed COVID-19 cases, with mild and self-limiting clinical manifestations. The distribution and determinants of COVID-19 among this group in Sudan are unclear. This study used national COVID-19 surveillance data to study the epidemiology of COVID-19 among children and adolescents in Sudan during 2020–2021. A cross-sectional study was performed to estimate the reported incidence of children and adolescents with COVID-19; the clinical features; and the mortality among those who tested positive for COVID-19. A total of 3150 suspected cases of COVID-19 infection fulfilled the study criteria. The majority of cases were above 10 years of age, 52% (1635) were males, and 56% (1765) were asymptomatic. The reported incidence rates of COVID-19 among children and adolescents in Sudan was 1.3 per 10,000 in 2021. Fever, cough, and headache were the most frequent symptoms reported among the suspected cases. The case fatality rate was 0.2%. Binary logistic regression revealed that loss of smell was the most significantly associated symptom with a positive test. We recommend further study to identify risk factors. Additionally, we recommend including these age groups in the vaccination strategy in Sudan. Full article

This is the first evaluation of the Yemen Field Epidemiology Training Program (Y-FETP) to assess if it met its objectives. We collected data using mixed methods including desk review, a focus group discussion with the Y-FETP staff, in-depth interviews with 21 program stakeholders, and an online survey for the program’s graduates. We transcribed/analyzed qualitative data using explanatory quotations and survey data using descriptive methods. The desk review indicated that Y-FETP covers 18 (82%) out of 22 governorates and conducted >171 outbreak investigations, 138 surveillance system analyses/evaluations, 53 planned studies, published >50 articles and had >155 accepted conference abstracts. Qualitative findings showed Y-FETP helped save lives and reduced morbidity/mortality using building capacities in outbreak response; provided evidence-based data for decision-making; and increased awareness about public health issues. An online survey showed that Y-FETP helped 60 to 80% of graduates conduct outbreak investigations, surveillance analysis/evaluation, manage surveillance systems/projects, engage in public health communication (reports/presentation), and use basic statistical methods. However, the evaluation revealed that Y-FETP is primarily funded by donors; thus, it is not sustainable. Other challenges include low graduate retention and limited training in policy development and management. Y-FETP achieved its main objectives of increasing the number of epidemiologists in the workforce, making a positive impact on public health outcomes. Full article

In Lebanon, the nationwide vaccination against COVID-19 was launched in February 2021 using the Pfizer-BioNTech vaccine and prioritizing elderly people, persons with comorbidities, and healthcare workers. Our study aims to estimate the post-introduction vaccine effectiveness (VE) of the Pfizer-BioNTech vaccine in preventing COVID-19 hospitalizations among elderly people ≥75 years old in Lebanon. A case–control study design was used. Case patients were Lebanese, ≥75 years old, and hospitalized with positive PCR results during April–May 2021, and randomly selected from the database of the Epidemiological Surveillance Unit at the Ministry of Public Health (MOPH). Each case patient was matched by age and locality to two controls. The controls were hospitalized, non-COVID-19 patients, randomly selected from the MOPH hospital admission database. VE was calculated for fully (2 doses ≥14 days) and partially vaccinated (≥14 days of the first or within 14 days of the second dose) participants using multivariate logistic regression. A total of 345 case patients and 814 controls were recruited. Half were females, with a mean age of 83 years. A total of 14 case patients (5%) and 143 controls (22%) were fully vaccinated. A bivariate analysis showed a significant association with gender, month of confirmation/hospital admission, general health, chronic medical conditions, main income source, and living arrangement. After adjusting for a month of hospital admission and gender, the multivariate analysis yielded a VE of 82% (95% CI = 69–90%) against COVID-19-associated hospitalizations for those fully vaccinated and 53% (95% CI = 23–71%) for those partially vaccinated. Our study shows that the Pfizer-BioNTech vaccine is effective in reducing the risk for COVID-19-associated hospitalizations of Lebanese elderly people (≥75 years old). Additional studies are warranted to explore VE in reducing hospitalizations for younger age groups, as well as reducing COVID-19 infections. Full article

Diabetes mellitus (DM) is one of tuberculosis’ (TB) ending barriers. TB patients with DM are at a higher risk than non-diabetes patients to develop complication, relapse and die. In Yemen, information on TB–DM comorbidity is lacking. This study aimed to determine the prevalence and associated factors of diabetes among TB patients at the National Tuberculosis Center (NTC) in Sana’a. A facility-based cross-sectional study was conducted. All TB patients aged >15 years who attended the NTC from July to November 2021 were screened for DM. Socio-demographic and behavioral information were collected through face-to-face interviews using questionnaires. A total of 331 TB patients were enrolled, 53% were males, 58% aged <40 years, and 74% were newly diagnosed with TB. Overall, DM prevalence was 18%. Higher rates of DM were found among TB patients that were male (OR = 3.0; 95% CI; 1.4–6.7), ≥50 years of age (OR = 10.8; 95% CI; 4.3–27.3), and those with a family history of diabetes (OR = 3.4; 95% CI; 1.6–6.9). Almost one fifth of TB patients had DM. The early detection of DM through immediate screening after a TB diagnosis and periodically during the course of treatment is crucial for TB patients’ optimal care. Dual diagnostics for reducing the dual burden of TB–DM comorbidity is recommended. Full article

The extent of the SARS-CoV-2 circulation and the COVID-19 epidemic in Tunisia three months after virus circulation was unknown. The aim of this study was to determine the extent of SARS-CoV-2 infection among household contacts of confirmed COVID-19 cases living in Hot spot areas of Great Tunis, Tunisia by estimating the seroprevalence of antibodies anti SARS-CoV-2 and to identify factors associated to seroprevalence at the first stage of the pandemic in order to guide decision making and to constitute a baseline for further longitudinal analysis of protective immunity to SARS-CoV-2. The National Observatory of New and Emerging Diseases (ONMNE), Ministry of Health Tunisia (MoH), with the support of the Office of the World Health Organization Representative in Tunisia and the WHO Regional Office for the Eastern Mediterranean (EMRO)), conducted a household cross-sectional survey on April 2020 in Great Tunis (Tunis, Ariana, Manouba and Ben Arous). The study was based on the WHO seroepidemiological investigation protocol for SARS-CoV-2 infection. SARS-CoV-2 specific antibodies (IgG and IgM) were qualitatively detected using a lateral immunoassay that detect SARS-CoV-2 nucleocapsid protein and administered by the interviewers. The included subjects were confirmed COVID-19 cases and their households contacts resided in hot spot areas (cumulative incidence rate ≥ 10 cases/100,000 inhabitants) of Great Tunis. Results: In total, 1165 subjects were enrolled: 116 confirmed COVID-19 cases (43 active cases and 73 convalescents cases) and 1049 household contacts resided in 291 households. The median age of participants was 39.0 with 31 years’ interquartile range (Min = 8 months; Max = 96 years). The sex ratio (M/F) was 0.98. Twenty-nine per cent of participants resided in Tunis. The global crude seroprevalence among household contacts was 2.5% (26/1049); 95% CI 1.6–3.6%, 4.8%; 95% CI 2.3–8.7% in Ariana governorate and 0.3%; 95% CI 0.01%–1.8% in Manouba governorate. In multivariate analysis, the associated factors independently related to seroprevalence were age ≥25 years (aOR = 5.1; 95% CI 1.2–22.0), history of travel outside Tunisia since January 2020 (aOR = 4.6; 95% CI 1.7–12.9), symptomatic illness in the previous four months (aOR = 3.5; 95% CI 1.4–9.0) and governorate of residence (p = 0.02). The low seroprevalence estimated among household contacts in Great Tunis reflect the effect of public health measures early taken (national lockdown, borders closed, remote work), the respect of non-pharmaceutical interventions and the efficacy of COVID-19 contact-tracing and case management at the first stage of the pandemic in Tunisia. Full article