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Innovative Approaches to Improve Public Health Practice in the Eastern Mediterranean Region: Findings From the Sixth Eastern Mediterranean Public Health Network Regional Conference

Public health professionals in the Eastern Mediterranean region (EMR) have limited access to continuing education, including workshops and conferences in public health. Held under the theme Innovative Approaches: Adapting to the Current EMR Context, the Eastern Mediterranean Public Health Network (EMPHNET) organized and conducted the Sixth EMPHNET Regional Conference from March 26 to 29, 2018. This paper summarizes the key activities including workshops, roundtable discussions, oral and poster presentations, keynote speeches, and side meetings. Before the opening, 5 preconference workshops were held: “Field Epidemiology Training Program (FETP) Accreditation,” “Innovative Public Health Surveillance,” “Human and Animal Brucellosis,” “Rapid Response Teams,” and “Polio Transition and Routine Immunization.” The conference hosted 6 roundtable discussions: “Consolidation of the FETP Network,” “One Health to Achieve Global Health Security,” “Polio Eradication Efforts and Transition Planning for Measles Elimination,” “Mobile Data Collection and Other Innovative Tools to Enhance Decision Making,” “Confronting Candida auris: An Emerging Multidrug-resistant Global Pathogen,” and “Functioning and Sustainable Country Public Health Emergency Response Operation Framework.” One of the conference’s key objectives was to provide a space for FETP residents, graduates, and public health professionals to showcase achievements. A total of 421 abstracts were submitted and after professional review, 34.9% (147/421) were accepted (111 for oral presentations and 36 for poster presentations) and published by Iproceeding. The conference met the primary objectives of showcasing the public health accomplishments and contributions of the EMR, encouraging the exchange of ideas and coordination among stakeholders, and engaging cross-sectoral workforce in producing recommendations for approaching regional and global health concerns. Moreover, the conference presented a unique opportunity for FETPs and other public health professionals from the Mediterranean region to present their significant scientific work and also facilitated networking among professionals. EMPHNET strives to continue to present similar exchange opportunities for public health professionals in the region.

The Eastern Mediterranean Public Health Network (EMPHNET) is launching its Sixth Regional Conference with the goal of addressing a variety of innovative approaches to public health. Conference sessions will focus on how these approaches can be adapted to the current Eastern Mediterranean Region (EMR) contest and challenges.
Taking place in Amman, Jordan, EMPHNET's Sixth Regional Conference presents field epidemiologists and public health professionals from across the region and around the world with opportunities to share their experiences in dealing with critical issues at the forefront of public health. The conference also presents an important platform for maximizing skills among field epidemiologists and public health professionals working to better serve their countries.
Held between March 26 and March 29, 2018 at the Landmark Hotel, the conference's three-day program will include sessions that will provide valuable opportunities for knowledge exchange regarding issues that jeopardize the health status of the region's populations. It will also offer a platform to showcase the scientifically grounded work of Field Epidemiology Training Program (FETP) residents and graduates, as well as other public health professionals who have chosen to share their achievements, research findings and field investigations with a wide participation base.
More specifically, the conference objectives are to; • Create an opportunity for public health professionals from the region to present their accomplishments to a wide range of audience.
• Bring together public health officials, experts and scientists to examine and discuss innovative approaches attempted to strengthen public health in the EMR.
• Engage members of the public health community in a dialogue that focuses on reducing the impact of public health problems in the region.
• Encourage the exchange of innovative ideas, approaches and solutions in counteracting public health challenges and problems.

Theme
The central theme of the Sixth EMPHNET Regional Conference is Innovative Approaches: Adapting to the Current EMR Context. Within this theme, the conference sessions will provide a platform to present how innovative approaches can be adapted to improve public health practice in countries throughout the Eastern Mediterranean Region (EMR).
In line with EMPHNET's mandate to secure "better health for people in the EMR", the conference will focus on adopting innovative strategies in response to public health issues and problems challenging countries in the region. Such challenges include the high burden of NCDs, communicable disease outbreaks, emerging and re-emerging infections, weak surveillance systems, public health threats in mass gatherings, risks to biosecurity and public health emergencies. Hence, exploring new ideas and approaches to address public health challenges typical to the EMR is essential when considering the unprecedented political unrest and the enduring instability that left millions of people in the EMR at risk of disease exposure or suffering due to lack of health access.

The Conference Agenda
Prior to the official conference launch there will be a day of pre-conference workshops taking place on March 26, 2018. The conference will be officially launched on March 26, and its sessions will run until March 29, 2018. The conference agenda will include keynote official and scientific addresses, panel discussions, mini-symposiums, as well as oral and poster presentations highlighting the work of FETP residents, roundtable, graduates, and public health professionals, roundtable meetings, and a day of pre-conference workshops.
The pre-conference workshops will be facilitated by experts within their respective fields, while the roundtable sessions will host a wide range of expert panelists who will raise critical and controversial questions that trigger audience discussions and experience sharing. These sessions will tackle issues related to the high burden of NCDs, communicable disease outbreaks, emerging and re-emerging infections, weak surveillance systems, public health threats in mass gatherings, risks to biosecurity and public health emergencies, while pre-conference workshops will highlight public health concepts relevant to the EMR.
On a lighter note, the conference will also offer many social activities to encourage further networking amongst participants within a less formal setting.
The oral and poster presentations of abstracts reflect the work of FETP graduates and residents as well as public health professionals. The abstracts presented at the conference will cover a wide range of topics including cancer, child health, hepatitis and HIV, mental health, non-communicable diseases (NCDs), outbreak investigations for respiratory diseases, outbreak investigations for vaccine preventable diseases, surveillance systems, zoonotic and vector-borne diseases and other pressing topics.
Presenters include teams of public health experts and FETP graduates and residents from different countries across the EMR including Afghanistan, Bangladesh, Egypt, Iraq, Jordan, Lebanon, Morocco, Pakistan, Palestine, Saudi Arabia, Sudan, Tunisia, Yemen and other countries.

Excellencies, Distinguished Delegates, Ladies and Gentlemen
It gives me great pleasure to extend to you all a very warm welcome on behalf of the EMPHNET Board of Directors as representing the Field Epidemiology Training programs (FETPs) of the Eastern Mediterranean Region (EMR) to EMPHNET 6th Regional conference. This conference would not have possibly taken place in this beautiful city of Amman, without the tireless efforts of my colleagues in EMPHNET, FETP country directors, the Jordan Ministry of Health and the Jordan Public Health Association. I extend my sincere thanks and appreciation to all.
I believe, this conference will provide us with an opportune time to renew our commitments towards improving the health status of our people with efforts joined with delegates from member countries across our region.
Population health status in the EMR is partly influenced by events and circumstances that challenge the region's national health system. The high burden of non-communicable diseases, the spread of communicable diseases, the presence of emerging and re-emerging infections and the growing threats to biosecurity are issues that challenge public health in the EMR. Furthermore, the long lasting presence of political conflict, humanitarian crises, natural disasters and emergencies interfere with the provision and quality of healthcare services in most countries of our region, thus compromising population health outcomes and increasing the risk of disease outbreaks.
In time of increasing public health needs and diminishing resources, the ability to respond tp public health challenges in the EMR is essential. It requires enhanced public health capacity, which must be supported through collaboration and innovation among countries. As per the theme of this year of the conference which is "Innovative Approaches towards Adapting to the current Eastern Mediterranean Region Context" this conference is an important platform for presenting how innovative approaches can be adapted to improve public health practices in countries throughout the region No matter how much we can do by ourselves on the national level, whether it be research or development, it is never enough. In a spirit of true cooperation, we must join in an action-oriented effort to attack and solve the problems that beset health development in our region and beyond. If on the national level we can, and must, pursue health development as a multi-dimensional concept, encompassing the economic, social, institutional and physical elements of development, in a wider sense, it would be relatively easy to effect the necessary adjustments for a truly effective cooperation on the regional basis. This is fully consonant with our official position taken and the full support of the concept of international health development adjustment at this conference.

RECOGNITION LETTERS
Dear Colleagues, It gives me great pleasure to extend to you a very warm welcome on behalf of EMPHNET and to express how grateful we are to Her Royal Highness Princess Muna Al-Hussein for her esteemed patronage of our Sixth EMPHNET Regional Conference and to the Jordan Ministry of Health for hosting this event here in our beloved capital Amman.
For this conference we received 421 abstracts, out of which 111 were accepted for oral presentation and 36 for poster presentation. Accepted abstracts were developed by FETP residents and graduates and public health professionals from Pakistan, Iraq, Egypt, Yemen, Morocco, Jordan, Saudi Arabia, Lebanon, Afghanistan, Bangladesh, Palestine, Tunisia, Oman and other countries beyond the EMR.
The agenda for the Conference, which is being held under the theme "Innovative Approaches: Adapting to the Current Context in the EMR", covers a wide range of topics. All these topics are related to the development of innovative strategies . They highlight how such strategies may be adapted to respond to public health issues that pose challenges for countries in the region.
Sessions will focus on the high burden of non-communicable diseases, communicable disease outbreaks, emerging and re-emerging infections, weak surveillance systems, public health threats in mass gatherings, risks to biosecurity and public health emergencies. Hence, exploring new ideas and approaches to address public health challenges specific to our region is essential. We are aware that regardless of what we do on the national level, be it research or response, more can be done through collaboration. In a spirit of true cooperation, we in this region are proud of nurturing all past and present civilizations. Therefore, we must join in an action-oriented effort to respond to those challenges that delay development; especially when considering the unprecedented political unrest and instability that left millions of our people at risk of disease exposure or suffering.
I would like to emphasize that this three-day event presents a great opportunity for you to reach a large number of participants from the public health community, and to exchange information and ideas, draw attention to new methodologies, and receive recognition.
In conclusion, you carry with you best wishes from EMPHNET for both a productive and successful Conference, and a pleasant stay amongst us.

Dr. Mohannad Al Nsour Executive Director, EMPHNET
Purpose To describe the pattern, drug sensitivity and treatment outcome of DR-TB.
Methodology Data on DR-TB cases from 2014 to 2016 was obtained from National Tuberculosis Control Program (NTCP). The NTCP modified WHO case definitions for treatment outcome was used where treat-ment success defined as completing treatment according to program protocol with at least five consecutive negative smears from samples collected at least 30 days apart in the final 12 months of treatment.

Results
Out of 32,528 TB patients diagnosed during 2014 -2016, 115 (4/1000) were DR-TB. The highest number was reported from Aden (40%) and lowest from Taiz 12%; 59% among males; and 67% among most productive years (24-45 years). Furthermore, 97% was among previously treated TB patients and 3% was positive for HIV. MDR-TB confirmed in 68% and Rifampicin Resistance (RR-TB) in 31%. The treatment success rate was 70% and death rates was 15%. Detection and enrollment rates were 27% and 80%. Title Evaluation of Drug-Resistant Tuberculosis Surveillance System Before and After Implementing "Genexpert" in Morocco, 2007Morocco, -2016 Background Drug-resistant tuberculosis (DR-TB) is a serious problem in the fight against tuberculosis worldwide. WHO has been actively encouraging countries to establish continuous DR-TB surveillance systems based on routine drug susceptibility testing (DST). In Morocco, a DR-TB surveillance system was implemented to monitor and to control epidemiology of Multidrug-resistance TB (MDR-TB). "Genexpert" for Rifampicin resistance detection was introduced in 2012, to scale up of national surveillance system.

Purpose
Our study aims to evaluate DR-TB surveillance system before and after implementing "Genexpert. " Methodology This is a retrospective de-scriptive study with a quantitative approach, to assess the data quality, sensitivity (ability to detect MDR-TB cases compared to cases estimated from national MDR-TB survey) and the PPV of the surveillance system, using data reported from 2007 to 2016 and laboratory results for "Genexpert" and Conventional DST, as gold standard, to validate the data collected.
Results 1063 DR-TB cases confirmed reported from 2007 to 2016, among them 92% were MDR-TB. The missing data for the variables assessed represented 11%. It was important for DST results (32%) and treatment outcomes (34%). The sensitivity of DR-TB surveillance system was low (17% on average) before introducing "Genexpert" (2012) and reached to 70% since 2015. In 2016, the sensitivity was 100% for detection of MDR-TB among patients previously treated for TB and 29% among new TB patients. The PPV of DR-TB surveillance system was 34% before introducing "Genexpert" (2012) and reached to 99% in 2016.

Conclusions
The current DR-TB surveillance system based on active case detection was satisfactory for data quality, sensitivity, and PPV. This is related to introduction of "Genexpert" since 2012. It's recommended to strength MDR-TB detection among new TB cases using "Genexpert" and to maintain MDR-TB detection among patients previously treated for TB to improve the sensitivity of the DR-TB surveillance system in order to establish continuous DR-TB surveillance system.

40
Background Eight million people are infected and 3 million die due to TB every year. Pakistan ranks 5th amongst 22 High burden countries with TB and 4th among 27 DR-TB high burden countries and accounting for about 81% of all estimated TB cases worldwide. Pakistan contributes about 65% of TB burden in Eastern Mediterranean Region. In Balochistan patients are filtered from chest and medicine OPDs of tertiary care hospitals and from Basic Management Units (BMU) of districts, sputum of eligible DR-TB patient is sent by transportation mechanism. Diagnosis of DR-TB requires Gene-Xpert testing, available at 04 Programmatic Management Drug Testing (PMDT) sites.
Purpose An evaluation of MDR-TB surveillance system was conducted to identify strengths and weaknesses of surveillance system and make recommendations for improvements. Purpose Assess the performance of MDR-TB Surveillance and provide recommendations.

Methodology
We use the Center of Diseases Control (CDC) updated guideline for evaluating public health surveillance systems.
In-depth interviews were conducted with six NTCP and 12 central and regional MDR-TB Centers' managers/staff. We used 5-Likert scale to assess performance by attributes (e.g. usefulness, simplicity, flexibility) according to the following scoring system: Poor (<60%), average (60-80%), and good (>80). NTCP-modified WHO case definitions for treatment outcome was used where treatment success defined as completing treatment according to protocol with at least five consecutive negative smears from samples collected at least 30 days apart in the final 12 months of treatment.
Results MDR-TB Surveillance System achieved good performance in usefulness, acceptability and data quality compared to average score in flexibility and simplicity; and poor score in stability. Detection rate was 25% in 2014 and increased to 32% in 2016 compared to the target of 40%. Enrollment decreased from 92% in 2014 to 69% in 2016 compared to 100% target. Treatment success reached 70% in 2016.
Conclusions MDR-TB surveillance system was found to be useful, but more efforts is needed to improve stability through ensuring constant power supply for the labora- Adapting WHO shorter regimen and inpatients management when needed will help to improve treatment success.

Anti-Microbial Resistance
Abstract Background Urinary tract infections (UTIs) remain a growing public health concern as it may lead to treatment failure and increasing morbidity and mortality. To optimize empirical antibiotic prescription, it is important for clinicians to have a working knowledge regarding UTIs etiological pathogens and its susceptibility patterns.
Purpose Determine the prevalence of UTIs, describe their responsible pathogens, and their antimicrobial resistance.
Methodology 2015 data on patients attended the Microbiology Department in National Centre for Public Health laboratories (NCPHL) for urine cultures was obtained. UTIs defined as =100,000 CFU/ mL of an uropathogen in midstream urine culture. The causative pathogen was identified, and antibiotic resistance carried out by disc-diffusion method.
Conclusions Findings highlight the doubling of UTIs prevalence and growing antibiotics resistance e.g. for Nalidixic acid from 54% to 70% since 2002. Results should guide antibiotic prescribing and developing strategies for controlling resistance. It also underlines the need to establish Antimicrobial Stewardship Program to reduce selection pressure and minimize resistance.

ORAL ABSTRACT PRESENTATIONS
Background Field Epidemiology Training Programs, TEPHINET, and the CDC EIS Program concentrate almost exclusively on nonintervention epidemiology. Fields of health services research that concentrate on interventions such as randomized controlled trials or operations research are seldom taught. We believe this is a mistake; unless interventions are performed, health and healthcare are not improved. We analyzed the oral presentations of the 2015 EIS Conference (2015 EISC) and the 2015 TEPHINET Conference (2015 TEPHINETC) to determine how frequently interventions were performed.
Purpose To determine the frequency that authors perform interventions.
Methodology Three reviewers read ab-stracts. Two reviewers read the 2015 EISC and two the 2015 TEPHINETC. Abstracts were judged to have had an intervention or not and, if so, whether the principal intention was to present an intervention ("primary intervention") or, if the intervention followed a noninterventional epidemiology investigation, a "secondary intervention. " Abstracts were then graded by whether the presenters called for an intervention to be done or not ("intervention needed"). Discrepancy in scoring was resolved by discussion.
Results Neither set of abstracts contained the words "randomized controlled trial, " "operations research" or "operational research. " The 2015  . PHEP-BFE is a three-month in-service training program that focuses on detection of and response to diseases and events of public health concern. In July 2017; first training course was conducted for first cohort and graduation was in October 2017.
Purpose We aimed to raise the epidemiological capacity of sanitarians due to their valuable contribution in detection of and response to public health threats and evaluate program effectiveness.

ORAL ABSTRACT PRESENTATIONS
Background Public health surveillance provides crucial information for monitoring the health of the public, identifying public health problems, and triggering action to prevent further illness. Health professionals' knowledge and awareness of the disease surveillance is essential for effective reporting diseases to health departments.
Purpose This study aimed to identify the knowledge and attitudes of Jordanian physicians towards public health surveillance.
Methodology A cross-sectional study was conducted among resident doctors who were working in four main ministry of health (MOH) hospitals and two teaching hospitals in Jordan in September 2017. Residents from all specialties were visited by the research-er and invited to participate in this study. A self-administered paper-based questionnaire was used to collect the data. The questionnaire collected information about socio-demographic and practice-related characteristics of physicians and included items to assess their knowledge of surveillance and reporting practices. Background The Ministry of Health in Lebanon is in the process of migrating surveillance reporting from a cumbersome paper-based system to a web-based electronic platform (DHIS-2).

Results
Purpose The aim of the project is to have real-time information flows in order to timely detect alerts and outbreaks in order to take quickest action.
Methodology DHIS-2 tool was initially piloted in Lebanon in 2014 for school-based surveillance. In May 2017, the tool was extended progressively for other surveillance programs collecting aggregate data from hospitals, medical centers, dispensaries and laboratories. As part of the roll-out process, the online application was developed: cus-tomized aggregated-based datasets, organization units, accounts users and generic dashboards. 80 training sessions targeting 1290 users were conducted throughout the country. Those trained included 35 district and province health officers, 150 focal persons working in all public and private hospitals, 140 focal persons in laboratories and 800 in medical centers and dispensaries. To assess improvements in surveillance reporting, we compare completeness and timeliness for reporting for the period before and after the implementation of DHIS2. Challenges and lessons learned during the rollout process are documented.

Results
For laboratory-based surveillance, completeness of reporting increased from 70.8% in May to 89.6% in October. Timeli-ness has improved from 25% to 74%. For medical centers an improvement of 8.1% in the reporting and 9.4% in the timeliness is recorded before and after training sessions. For zero reporting, completeness remains the same (88%) and timeliness has improved from 74% to 87%. There was also increase in the reporting of communicable diseases. Implementation challenges included limited access to internet (29%) and limited workforce (21%).
Conclusions Implementation of DHIS2 resulted improvement in timeliness and completeness for aggregated data reporting. Continued onsite support, monitoring and system enhancement included internet connectivity are needed to enhance the performance of DHIS2. Background Population displacement and damage to infrastructure in Syria has contributed to an increase in water borne infectious diseases including enteric fever. The collection, presentation and analysis of data collected in real time is therefore vital for early identification of outbreaks. EWARN and EWARS are used in Syria for the reporting of communicable diseases however this is not always available to facilities in real time. As such, the prompt availability of diagnostics and treatment may be lacking. This is vital for enteric fever where morbidity and mortality without appropriate treatment is high.

ORAL ABSTRACT PRESENTATIONS
Purpose In this study, we examine the utility of a data visualization tool to track cases of enteric fever in three facilities supported by the Syrian American Medical Society (SAMS.) Methodology All cases of enteric fever between March 2017 and July 2017 were tracked in near real time and presented using data visualization software, namely Tableau. Tableau is a visualization software generally used within the business sector, but its ability to visually express data has far reaching potential in the realm of public health. Sites in Daraa, Quneitra and Rural Damascus were included. Close communication with data personnel in SAMS' country offices and health workers working in the facilities was maintained.

Results
In March 2017, there were 21 cases of enteric fever across the three governorates and in July 2017, this had increased to 784 cases. Close liaison with the teams on the ground identified that facilities were see-ing a significant increase in cases and that there was a shortage of appropriate antibiotics to treat patients. It was also apparent that there was a shortage of microbiology facilities which could isolate the causative organisms (Salmonella typhi or paratyphi) and therefore limited ability to identify the susceptibility of the organisms resulting in empiric therapy where available. Using data visualization in real time can allow for preparedness and responsiveness to outbreaks of communicable diseases during the conflict.
Conclusions Visualization should be integrated into online and offline data collection tools in order to create an early warning system on each device used in the field. Purpose To evaluate the perception of active HESN users on its performance as a surveillance system, identify its weaknesses and suggest practical recommendations for improvement.

Innovative Tools in Surveillance
Methodology A complete list of 11324 HESN users was identified. Active user was defined as a user with minimum use of one single time for either immunization or investigation purposes and has a valid email contact. Out of 1535 active users, 700 participants were selected randomly, and a cross sectional study conducted. A pre-designed electronic questionnaire was sent via emails to all the participants. The response rate was (87%), of which the completed forms were 493 (81%). Purpose Determine the rate and causes of cesarean deliveries in north of Jordan.

Results
Methodology A prospective hospital-based longitudinal study was conducted. Women were enrolled in the study after delivery. All women who gave birth (dead or alive) at 20 weeks of gestation or more in four selected hospitals were eligible for inclusion. Necessary data for mothers were gathered through face-to-face interview using a semi-structured questionnaire and by abstraction of data from medical records. Information on causes of CS were confirmed by physicians. Background UNRWA introduced family planning services in 1994 as an integral part of its expanded maternal and child health care program. The main objective of UNR-WA's family planning program is to promote the health of mothers, children and subsequently their families.

Results
Purpose The ultimate objective of this follow-up study was to assess the current situation regarding contraceptive practices among the target population after five years from the 2010 follow-up study and to identify future program needs leading to the development of action-oriented activities.
Methodology A cross-sectional survey was conducted by trained nurses from June -December 2015. Participants were Palestine refugee mothers who attended well-baby clinics with their youngest child (aged 2 months through 5 years) at all UN-RWA health centers. A sample size of 10478 participants was calculated based on contraceptive use prevalence in 2010, using Epi Info sample size calculation. Mothers were interviewed and retrospective data from health records was used as supplement.
All participants provided verbal informed consent. The study protocol approved and cleared by UNRWA health department ethical committee. A multiple logistic regression was performed to test if maternal age and parity predicted contraceptive use. Chisquare was used to analyze the relationship between previous contraceptive use and birth interval, birth weight, and gestational age.
Results Data was obtained from 9860 mothers, with a mean age of 29.8 years. Of them, 59.3% were using modern contraceptives at the time of the survey, 17.7% were using traditional methods, and 23.0% were not using any contraceptive method. The most common modern contraceptive was intrauterine device (37.4%), and UNRWA was the main provider for 82.6% of women currently using modern contraceptives. The most common reasons for not using contraceptives were child wish (21.7%), pregnancy (18.6%) and husband opposition (19.7%).
Using women with <3 pregnancies as the reference category, women with 3-6 pregnancies are significantly more likely to use contraceptives (p<0.001; a OR=1.58, CI (1.43 -1.73)), as are women with >6 pregnancies (p<0.001; a OR=1.6, CI (1.28 -1.99)). Women with at least 1 male child are significantly more likely to use contraceptives (p<0.001; a OR=1.39, CI (1.24 -1.56)). Maternal age over 35 was not a significant predictor for modern contraceptive use. Chi-square used to test the association of modern contraceptive use prior to pregnancy with birth weight, the result showed statistically significant 23.88 (p<0.001)] while gestational age was not a significant in the child born of that pregnancy.
Conclusions It is encouraging that mothers seeking modern contraceptives rely on UN-RWA to provide family planning services. We found that mothers with higher parity are more likely to use modern contraceptives, which comply with UNRWA recommendations. As expected, modern contraceptives lead to better birth spacing. However, mothers above 35 years of age are not more likely to use modern contraceptives. These mothers may be at higher risk for negative maternal and infant health outcomes. UN-RWA family planning services could focus more on counseling this group of mothers. Purpose We investigated the association between HIV status and contraceptive use.

Maternal and Child Health
Methodology We conducted a cross-sectional comparative study in which we systematically sampled 500 HIV-positive and 500 HIV-negative women of reproductive age group at the Anti-retroviral and General outpatient clinics of the State Specialist Hospital, Akure. We collected data using interviewer-administered questionnaire. We calculated proportions, odds ratio (OR) and 95% confidence intervals (CI). We conducted multiple logistic regression with level of significance of 5%. Background Reproductive health rights (RHR) were declared as fundamental human rights since Cairo's (1994) and Beijing's (1995) conferences. The acknowledgement of the importance of these rights was a momentous point for reproductive health. In the Palestinian context, RHR are severely affected by the combination of constraints of the political system and the cultural context. RHR remain one of the least prioritized matters making them extremely unmentionable.

Results
Purpose To underpin the multiple political-demographic and cultural factors/conditions that influence Palestinian women RHR.
Methodology This research relied on an empirical qualitative study. Semi-structured interviews were done through Skype. A purposive sample of ten Palestinian women living in Bethlehem Area in the West Bank was selected. These interviews formed the basis of the analysis.

Results
Findings were considered under five emergent themes: knowledge, information and education; services and resources; Palestinian context and norms; conflict and occupation; violence against women. These intersecting themes shaped women's knowledge and perceptions of RHR. They highlighted the underpinning factors that influence the existing opportunities and challenges for Palestinian wom-en to access to RHR, and health seeking behaviors and overall wellbeing.
Conclusions This research emphasizes the great importance of this topic to the field of public health in general and specifically women's health. This research is rare in its kind in the Palestinian context. In insuring universal access to RHR in Palestine, it is recommended that governments should demonstrate commitment to prioritizing RHR initiatives. Creating economic opportunities and socio-cultural empowerment for women in Palestine would build women's resilience. Further researches regarding RHR should be conducted in other areas of Palestine.

ORAL ABSTRACT PRESENTATIONS
Background Preterm is a major determinant of infant mortality and morbidity. It is generally recognized that the etiology of preterm is multifactorial. In Iraq the preterm birth rate in 2010 is generally 6, 5% and deaths due to preterm birth 9%.
Purpose To determine the risk factors of preterm new-borns in Al Zahra Hospital. Background Preterm birth (PTB) is a delivery that occurs before 37 weeks of gestation. It is the leading cause of newborn deaths in Morocco and worldwide.

Methodology
Purpose The aims of our study were to identify the main risk factors of PTB and to propose measures to prevent and improve its management in our context.

Methodology
We conducted case-control study in intensive care unit of neonatal medical service in Rabat university hospital considered as the inter-regional hospital. We included 87 preterm births before 37 gestations weeks and 174 term-controls. Data about the women's obstetrical and gynecological history, pregnancy complications and behavior during pregnancy was obtained using a structured questionnaire and medical records. The data was analyzed using SPSS version 20. The logistic regression was employed to identify risk factors of preterm birth. Conclusions Neonatal mortality in the Al Hoceima hospital remains high and is mainly related to the course of pregnancy and childbirth as well as the characteristics of the newborn at birth. To this end, pregnancy monitoring, confinement in a supervised environment and integrated management of the mother-to-newborn couple are the key measures to reduce this real health problem. . Multinomial logistic regression analyses were conducted before and after adjustment for confounding using STATA IC14 using the least unfavorable response as the referent category.

Maternal and Child Health
Results Pregnant women were more likely to sleep both shorter and longer than 7-9 hrs (RRR = 1.22-1.45), and they were also more likely to struggle to get to sleep within 30 min on a regular basis (RRR = 1.07-1.28). Al-though pregnant women reported more frequent sleep disturbance than non-pregnant women (RRR = 1.35-3.72), they did not report coughing/snoring more frequently (RRR = 0.89-1.20). Likewise, despite reporting poorer sleep quality than non-pregnant women (RRR = 1.60-2.21), pregnant women were less likely to report using sleep medication on a regular basis (RRR = 0.44-0.55). Finally, pregnant women were more likely to report difficulty staying awake during the day than non-pregnant (RRR = 1.28-1.77).

Conclusions
The findings of the present study confirm that pregnant women sleep differently to non-pregnant women, although these differences may partly reflect the lower use of medication by pregnant women. Background In Iraq, the long-standing war and civil unrest had negatively affected food security, water quality, sanitation and environmental conditions that contributed to decline in the nutritional and health status of children.

ORAL ABSTRACT PRESENTATIONS
Purpose The objective of this study is to assess the trend of different types of malnutrition among <5years children in Iraq, 2002-2016.

Methodology
We used data from four Multiple Indicator Cluster Surveys (MICS 2, 3, 4 and 5). Three WHO malnutrition indicators were assessed: stunted growth (z-score of height for age = -2.01), underweight (z-score of weight for age =-2.01) and wast-ing (z-score of weight for height = -2.01).

ORAL ABSTRACT PRESENTATIONS
Background The Kingdom of Saudi Arabia (KSA) has made tremendous improvements in its health system in a short period of time due to extensive investments from oil revenues. In 2015, the Saudi Ministry of Health (MOH) housed 250,000 personnel, including 31,516 physicians and 75,978 nurses, and operated 249 hospitals with 34,000 beds .It is responsible for 60% of healthcare services, with the remaining 40% managed by a number of semi-public organizations and the private sector .The MOH is in charge of health promotion, disease prevention, and treatment. Health care services are provided for free throughout the country. In recent years and with improvements in infrastructure and health services, an increasing burden of non-communicable diseases is emerging. We recently reported high rates of diabetes mellitus.
Purpose Diabetes mellitus is a major burden in the Kingdom of Saudi Arabia (KSA). We estimated the direct cost of diabetes in KSA and the future cost accounting for currently undiagnosed and borderline diabetics. Methods: We used a bottom-up approach to determine the direct cost of diabetes mellitus in KSA at the population level using Saudi Ministry of Health (MOH) cost data for medications, health visits, laboratories, and hospitals.
Methodology KSA MOH, developed a database of available published and unpublished data sources to generate the burden of disease for KSA. Key inputs into this database included systematic reviews of the lit-erature, analysis of household survey data, antenatal clinic surveillance, reportable disease notifications, disease registries, hospital admissions data, outpatient visit data, population-based cancer registries, active screening data, and other administrative data. Moreover, the MOH provided detailed data on the prices of medications, laboratory testing, medical procedures, and clinic and hospital visits and stays. We assumed that the MOH cost estimates apply to the population served by the private sector and other governmental health agencies such as the armed forces or the National Guard. Blood samples were collected at local health clinics and analyzed in a central lab at the King Fahd Medical City in Riyadh. COBAS IN-TEGRA400 plus was used to measure blood levels of HbA1c, or glycated hemoglobin. A Roche Hitachi COBAS 8000 system was used to measure cholesterol. Respondents were considered to be diabetic if they met any of the following criteria: 1) measured HbA1c equals or exceeds 6.5% (48.5 mmol/ mol), or 2) measured HbA1c does not equal or exceed 6.5% (48.5 mmol/mol), but the respondent reported taking medications for diabetes. Respondents were considered to be have borderline diabetes (glucose intolerant) if: 1) they did not report taking drugs for diabetes, and 2) their measured HbA1c blood level was greater than 5.7% (35.3 mmol/mol) and less than 6.5% (48.5 mmol/ mol). Women were asked if they were diagnosed with diabetes during pregnancy. Respondents were considered hypercholesterolemic if they met any of the following criteria: (1) measured cholesterol equal to or exceeding 6.2 mmol/L or measured cho-lesterol not exceeding 6.2 mmol/L, but the respondent reported taking medications for hypercholesterolemia. Results Overall, 1,095,776 (8.5%) Saudis reported being diagnosed with diabetes. However, a total of 1,745,532 (13.4%) Saudis aged 15 years or older had diabetes. This total group is the sum of measured diabetes (1,193,075, 68.4%) and those who were currently on diabetes medication with controlled levels of HbA1c (552,457, 31.6%). Among those that our survey identified as diabetic from blood tests, 43.6% were undiagnosed. Moreover, 15.2% of Saudis, or 979,953, had borderline diabetes. the total cost of diabetes in KSA. The cost currently is at 17 billion Riyals. If those who are undiagnosed joined the treatment pool, the cost would increase to 27 billion Riyals. If those with glucose intolerance (pre-diabetes) progressed at the current observed rate, the total cost would be 43 billion Riyals.

Conclusions
Our study calls for immediate action to reduce the burden of diabetes and non-communicable diseases (NCD). A national plan to prevent and control the rising burden of chronic diseases should be developed and implemented. We previously reported that Saudis do not seek preventive care. Hence, it is crucial that the programs involve community engagement and early screening. Campaigns to educate the public about the disease should be a priority. The campaigns should include information on the risk factors for diabetes and gestational diabetes. the total cost of diabetes in KSA. The cost currently is at 17 billion Riyals.

ORAL ABSTRACT PRESENTATIONS
Background In low-and middle-income countries, cytology-based programs are very difficult to implement, and where they are implemented, the screening coverage is low. Routine screening of cervical cytology has been implemented in Tunisia in order to decrease cervical cancer incidence and mortality. Understanding the factors associated with cervical cancer screening among target populations is important to improve the screening participation rate. In Tunisia, few studies have examined cancer screening among women in relation to socio demographic and socioeconomic status.
Purpose To estimate the coverage of women by cervical cancer testing and to assess the relation with sociodemographic and socioeconomic determinants.
Methodology A cross-sectional survey was conducted in 2014 and face-to-face interview questionnaires were completed by a sample of 1494 women aged 18 years and older.

Results
Only 36.6% (95% CI [34.3%-39.2%]) of 1494 women aged =18 years had received a previous cervical screening test. This rate increased significantly (p<10-3) with age from 13.9% for those aged less than 30 years to 29.1% for those aged between 30 and 40 years, to 47.9% for women aged 40-50 years old and 49.3% for those aged more than 50 years. In multivariate, we found previous cervical cancer screening was significantly associated with household income, occupation, level of education, tobacco use, medical pre-vious history and familial history of cancer, at risk sexual behavior and history of sexual transmitted diseases.

Conclusions
The coverage of women population with cervical cancer screening was found to be very poor. Analyses of cancer screening rates by measures of income, educational level, and other factors may help to implement a comprehensive, integrated approach across different health programs. Given the importance of knowledge in encouraging women to participate in screening is key to reducing cervical cancer burden in Tunisia. A health promotion intervention should be developed and implemented in project counties focusing on improving their knowledge. Purpose This study was conducted to describe the epidemiological characteristics, estimate incidence and identify mechanism of fatal domestic injuries (FDI), Iraq, 2010-2015.

Methodology
We conducted this cross-sectional study on all fatalities due to injuries reported from all the coroner offices in Iraq for the period of 2010-2015 as part of Iraqi Injury Surveillance System. The surveillance form included detailed data on the demographics, injury circumstances and injury mechanisms. National and governorates population data were obtained from Ministry of Planning.
Results Total number of FDI during 2010-2015 was 17,211 with an average annual incidence of 11/100,000Population (P). FDI represented 24.5% of total fatal injuries. The incidence of FDI decreased from 11.6/100,000P in 2010 to 10.2/100,000P in 2015. Female to male ratio was 1.1:1 and 38.8% occurred at the age group 20-39 years. The highest incidence 27.5/100,000P was recorded at the age group =70 years. About 71.5% were unintentional with average annual incidence 7.7 /100,000P and the remaining were intentional with average annual incidence of 1.6/100,000P. About Background Mobile use while driving is a major cause of road traffic injuries.
Purpose To determine the rate of mobile use while driving among King Saud University students, their perception of the risks and its contribution to collisions.
Methodology A cross-sectional study was conducted in May 2014 targeting 986 male students of King Saud University. A questionnaire was used to obtain data on possessing a driving license, years of driving, driving hours, and collision or near collision in the six months preceding the study. Eight statements were used to assess the behavior and perceptions related to the use of mobile phones while driving.
Data were analyzed using the chi-square statistic, odds ratio (OR) and the 95% confidence interval (95%CI).

Results
Half the participants (45.3%) have a driving experience of 4 -6 years and 18.3% of them did not have a driving license. Collision in the preceding six months was reported by 44.6% of participants and 37.9% of them attributed their occurrence to mobile phones. Variable proportions reported always texting (53.3%) or talking in handheld (66.2%) or hand-free (26.1%) phones while driving. A significantly higher risk of collision was observed among participants who reported always talking on mobile phones while driving as hand-held (OR=1.435) and hand-free (OR=1.469) as well as sending or receiving text messages (OR=1.885). The risk increased significantly from 2.052 among participants who reported driving daily for 1 -2 hours to 3.165 among those who reported driving for more than 6 hours.   Background Globally, about 600 million fall ill and 420,000 die every year after eating contaminated food. On June 12, 2017, Iraq CDC informed about a food poisoning outbreak among internally displaced persons (IDPs) in Al-Khazir camp, Northern Iraq after consuming "Iftar" (Ramadan breakfast) provided by an NGO. "Iftar" was composed of rice, white bean broth, chicken, yogurt, date and bread.

Purpose
The objective was to describe the outbreak, identify the causative agent and recommend preventive measures.
Methodology A team of FETP residents dispatched to investigate the outbreak. The case patient was defined as any person in the camp who ate "Iftar" and developed nausea/vomiting or diarrhea or abdominal pain. A retrospective cohort study was initiated.

Results
The total number of IDPs in the camp was 6,425; 1,470 (22.9%) were in sections C, D and E who got "Iftar" and all were directly interviewed. The mean age of patients was 19 (±15years), and the female: male ratio was 1.1:1. The attack rate was 91%. The most frequent symptoms were nausea and vomiting (86.6%), abdominal pain (68.4%) and diarrhea (59%). The range of incubation period was 15 minutes-16 hours; 62.2% had symptoms after three hours. About 72% of patients treated in the nearby PHCs and 28% transferred to the ER. None of the patients was hospitalized or died. The implicated food items were: rice (RR=1.4; 95%CI: 1.2-1.6) and chicken (RR=1.2; 95%CI: 1.1-1.3). Laboratory results of examined leftover food samples revealed Staphylococcus aureus growth. All meals were prepared by one restaurant, not kept in refrigerators and served after 10 hrs. For legal causes, the team was not allowed to assess the restaurant or examine the workers.

Conclusions
The large number of ordered meals from a single restaurant led to suboptimal food preparation and storage. We recommended rigorous implementation of food handing instructions and health education of the food handlers.

Outbreak Investigation/FWBD (Foodborne)
Abstract Background On 12 October 2017, three cases of unexplained abdominal pain including one death after eating fresh unknown plant were reported to epidemiology and surveillance unit at directorate health affairs.
Purpose Investigation was done to confirm the outbreak, identify the risk factors, and provide control measures.
Methodology Outbreak investigation team defined a case as abdominal pain, diarrhea and vomiting. Active case finding was done and 3 cases were detected. One case died, and a questionnaire was filled for the two alive cases by surveillance team. One stool sample was collected for microbiological testing. The team collected water sample from occupation place for microbiological testing. The team collected samples from the unknown mushroom.

Results
The dead case consumed the mushroom 1 pm and the case deteriorated rapidly and died at 4.30 pm with acute hepatic and renal failure. Symptoms emerged in one case at 7 pm and active case finding was done for the third case which was hospitalized at 10 pm. Two alive cases had moderate symptoms. No more cases were detected. Age range was 43-55. The 3 cases were male workers in a resort. All sick cases consumed mushroom. The symptoms revealed were 100% vomiting, 100% diarrhea, 100% dyspnea, 33.3% malaise, 100% abdominal pain and 66.67% bitter tongue. Results of water and stool samples were negative microbiologically. The mushroom type was called the death cap (Amanita phalloides).

Conclusions
The outbreak was associated with consuming fresh collected death cap mushroom which is hepatotoxic. Control measures were taken to remove all implanted mushroom in the grass of resort and making announcement that there is a poisonous mushroom implanted in the grass. Follow up done for more cases.
Background On 14 September 2017, one hundred and one residents in the town of Hatem in Irbid (Jordan) were admitted to local healthcare center and a city hospital in Irbid with symptoms of diarrhea, vomiting, fever, and abdominal pain after eating a meal from a nearby restaurant.
Purpose Identify the cause and mode of transmission and to implement control measures.
Methodology The food poisoning outbreak was described by time, person, and place. A case was defined as any person with two or more of the following symptoms: diarrhea, vomiting, fever, and abdominal pain, who had been in the town of Hatem (Irbid) in the period 14-19 September 2017. We conducted a cohort study and collected data on demographics, water sources, and food sources. We conducted environmental survey for water sources and for food in local restaurants for fecal contamination, and tested water, food, and stool samples for microorganisms.

Results
Among 8,000 residents, we identified 101 food poisoning cases. Outbreak was during 14-19 September 2017 with peak (73 cases) on 17 September 2017. Attack rate was the highest among residents aged 10-19 years (47 cases) and residents aged 5-9 years (33 cases). Females were more affected than males (58% vs. 42%). The food poisoning outbreak was associat-ed with taking 'Hommos" meal and 'Falafel' from a local restaurant. The stool samples of patients and the restaurant owner were positive for Shigella sonnei and Escherechia col. The ground 'Hommos' samples taken from the local restaurant were positive for Shigella sonnei.

Conclusions
The food poisoning outbreak in the town of Hatem in Irbid (Jordan) was associated with eating 'Hommos" meal and 'Falafel' from a local restaurant contaminated with Shigella sonnei. We recommend periodic inspection and active monitoring of water and food, as well as of the caterers, across the county to reduce the likelihood of such outbreaks.

Outbreak Investigation/FWBD (Foodborne)
Abstract Background Foodborne diseases outbreaks are common worldwide and an important public health issue. According to WHO, approximatively 600 million of foodborne illness and 400 thousand related deaths per year. In Morocco, an average of 1500 cases is notified annually. On June 18, 2017, the public health service was alerted about 43 suspected students in a training Institute in Rabat admitted in emergency for collective foodborne disease following an uptake of meal a day before.
Purpose We investigated this outbreak to confirm the outbreak, to identify the source of contamination and to recommend control measures.

Methodology
We conducted a case control study. We selected cases and controls in the ratio of 1:1. We defined a case as anyone who attended the meal served on 17 June 2017 at the Institute's restaurant and presented in the two days after diarrhea and one of the following signs: nausea, vomiting, abdominal pain, fever, and dizziness. A control was defined as anyone who had consumed the same meal and had not presented any digestive signs. We conducted bivariate and multivariable analysis. Stools of ill students were collected, and food specimen was collected for bacterial testing.

Results
Among 100 students interviewed, we identified 50 cases. Among cases, males were predominant (86%), the median age was 21 years. 47 sought medical care. The episode was short with an estimated average incubation period of 9 hours. The epidemic curve oriented towards a common source of contamination. Among food items, Briwates were strongly associated with the illness with an odd ratio of 14.23 (5.04-40.04). Laboratory testing of Briwates found EColi O157 and Staphylococcus Aureus.
Conclusions This was an outbreak associated with the consumption of Briwates contaminated by two germs, which was the source of this episode. We recommended to strengthen hygiene measures and safe food handling, to raise awareness and educate the staff.

Title Cholera Outbreak Investigation in Baghdad Al-Rusafa August-November 2017
Background Iraq is a cholera-endemic country with outbreaks occurring every 3-4 years. Since 29th, August 2017, Iraq CDC received reports on confirmed cholera patients in Baghdad/ Resafa (Eastern Baghdad with a population of 4.8 million). Up to Nov 29th the total number of confirmed cholera patients was 257.
Purpose To determine the epidemiological characteristics of the patients and identify potential risk factors.
Methodology A team of FETP residents dispatched to investigate the outbreak and developed a form to compile demographic and epidemiological data from all the patients' investigation forms that were filled at the treating hospitals. Then a case-control study conducted using the accessible cholera patients and neighbors' controls. The cholera case was defined as any patient with acute watery diarrhea, and isolation of Vibrio cholera O1 or O139 from a stool sample.

Conclusions
Methodology A case control study was conducted, with a case definition as any pilgrims who ate lunch meal at the Fajr Al Eman Hotel on Wednesday 30th August 2017 and experienced abdominal pain, diarrhea, vomiting and fever. The ratio of cases to control was 2:1. A standardized questionnaire was used to collect information on symptoms, onset of illness, and food history.

Results
In this study we identified 30 (15 males and 15 females) cases and 60 controls. The most commonly reported symptoms were abdominal pain (100%), diarrhea (24%), vomiting (3%) and fever (17%). The epidemiological curve shows that the onset of the first cases was at 3:00 AM on Thursday 31/08/2017 then the cases started to increase gradually until 9:00 PM on the same day; the peak was at 3:00 PM. The incubation period was 6-32 hours with a mean of 22 hours. The analysis showed a statistically significant association with eat-ing lamb meat and tomato stew (P = 0.03 for and P = 0.04, respectively). The association with the other two kinds of food; rice and Kubah were not statistically significant.
All laboratory results were negative. Background Diarrheal diseases are the second leading cause of death among children <5, 1 in 9 children die from diarrhea infection worldwide. The majority (88%) of these deaths are associated with unsafe water, inappropriate sanitation and lack of hygiene. Vibrio Cholerae bacterium can cause extremely virulent diarrhea. On October 2016 an outbreak of watery diarrhea occurred among a family in Al-Nasser St. Sawan area, Shuaub district, Sana'a capital city, Yemen.

Conclusions
Purpose An outbreak investigation was done to confirm the outbreak, to identify the source, risk factors and recommend control measures.
Methodology A descriptive and analytical studies were conducted. Active search of cases and control was performed. WHO case definition of cholera during epidemic was adopted. Stool samples were taken and sent to the public health central lab. for confirmation. The data was entered and analyzed by Epi Info 7.2 and Excel sheet were performed. Chi square and odds ratio were calculated.
Conclusions Cholera outbreak was confirmed. Most cases were children up to ten years old. There was association between drinking water, eating raw vegetables and cholera infection. Boiling or chlorination of water and hand washing were recommended to control the outbreak Background On January 14, 2017, a suspected watery diarrhea outbreak was reported in Heran area, Dhamar district, Dhamar Governorate by electronic disease early warning system (eDEWS) coordinator. A team from FETP had investigated the outbreak.
Purpose To confirm the outbreak, find out the source, and recommend control measures.
Methodology Unmatched case control study was conducted with ratio of 1: 2 respectively. A case was defined as a person with acute watery diarrhea, with or without vomiting in Heran area. A control was defined as a person from the same house or neighborhood of a case who does not has diarrhea or vomiting. Data were collected from cases and control using semi-structured questionnaire including basic demographic information, potential food and water exposures, and hygienic practices. Seven stool samples were taken only from patients for laboratory confirmation of cholera by culture. Water and sewage samples were also taken. We performed bivariate analysis using Epi-Info version 7.2.
Results A total of 12 cases and 24 control that met the case definition were recruited. About 83% of cases were clustered in one house, 40% of cases aged 7 -14 years, and 58% were females. The overall attack rate in Haran area was 0.1% and the case fatality among cases was 8.3%. The only significant risk factor identified was poor sanitation [OR= 5.9, 95% CI:1.1-32.9]. Vibrio cholera 01 serotype ogawa was isolated from all stool samples but all water samples were found to be negative.

ORAL ABSTRACT PRESENTATIONS
Background On 4th August 2015, electronic media reported unusual occurrence of acute watery diarrhea (AWD) cases and one death in Chashma village at Ibrahim Hyderi, District Malir, Karachi. On same day, District health authority deputed 3 members team to identify the source, risk factors and recommend preventive measures.
Purpose To estimate the extent and magnitude of the outbreak, to assess risk factors associated with the outbreak, to institute control measures, and to formulate recommendations for future prevention.
Methodology A matched case control study was conducted. Case was defined as "any person living at Chashma village, who has 3 or more watery stools in last 24 hours from 2nd to-10 August 2015". Review of hospital records and active case finding was done. Age and sex matched controls (1:1) were taken to analyze risk factors. Environmental assessment was done. Six water samples and rectal swabs were collected to isolate the causative agent.
Results A total of 189 diarrhea cases were identified out of which (56%) were female. Mean age was 32 years (rang: 4-64 years). Along-with diarrhea (100%), the abdominal pain (56%), Vomiting (54%), nausea (11%), blood in stool (6%), and fever (2%)were the predominant symptoms. Case fatality was 3.2 with Attack rate 1.4%. Drinking water from storage tank (OR: 12.8, p-value <0.05, CI=1.5-14) found strongly associated with the illness. Sanitary assessment revealed that usage of contaminated drinking water from storage tank resulted outbreak. The water samples were unfit for drinking due to presence of coliform bacteria. Vibrio cholera O1 El Tor Bio type isolated from 4 of 6 stool samples.
Conclusions Contaminated storage tank water was possible source of outbreak. Immediately evacuate and contain the water tank. Poor personal hygiene and sanitation may be aggravating factors. Health education regarding hygienic practices and use of safe drinking water were imparted. Chlorinated tablets distributed. Washing and bathing was prohibited at drinking water source. Sustained health education and provision of purified water were recommended.

Outbreak Investigation/FWBD (Waterborne)
Abstract Purpose On 1st July 2017 a team was deputed to confirm outbreak, evaluate risk factors and recommend control measures.
Methodology A case was defined as "sudden onset of 3 or more episodes of loose stools per day with or without vomiting in a resident of UC Khirzan District Khuzdar from 28th June to 4th July 2017". Active case find-ing was done in affected village and records of Rural Health Center were reviewed. A case control study was conducted. Age and sex matched controls were enrolled in a ratio of 1:1. Water sources and toilet facilities were assessed. Three water samples from water stream and household wells were taken and sent to NIH Islamabad.
Results A total of 105 cases were identified with an overall attack rate of 1.08%. No deaths were recorded. Mean age was 27 years (range = 1 to 70 years). Males were more affected n=54 (51%). Most affected age group was 0-4 years (n=29, 27.6%) with attack rate 0.3%. Dehydration (n=95, 94%), nausea (n=80, 76.1%) and vomiting (n=70, 66.6%) were most fre- Background Globally, diarrheal disease is the second leading cause of death among children under five. Account for one per nine deaths of children. About 88% of diarrhea death cases associated with unsafe water, inappropriate sanitation and lack of hygiene. In Yemen, it is the second cause of mortality and morbidity in children. On 19 August 2016, an increase number of diarrheal patients was reported in Wild-Rabiae district, Albaida governorate notified by local surveillance coordinator. A team from FETP was sent for investigation.
Purpose To confirm the outbreak, find out the source, and recommend control measures.
Methodology A descriptive cross-sectional study was performed. Data were collected using modified CDC cases definition. Samples (drinking waters, and powder milk) were collected, and sent to the National Central Public Health laboratories for testing. Data were entered into Excel and analyzed using EPI-info program.
Results A total of 53 residents met the case definition; 85% of them were in the neighborhood, and 15% were in the refugee building. All cases were children less than 15 years old. Age group of 1 -< 3 years was most affected (38%). About 60% of cases were male. The overall attack rate was 9.5% (13% in the refugee building and 9% in the neighborhood). The overall cases fatality rate was 7.5%. Drinking water in neighborhood and powder milk in refugee building were contaminated by coliform and E. coli. Purpose To investigate the outbreak and take necessary control measures.

Conclusions
Methodology A case was defined as 'any person of any age and gender belonged to the reported village of district Shangla, with 3 or more episodes of loose stools per day with or without vomiting from 12-20 September 2016' . Descriptive study was carried out by visiting the affected village to identify cases, areas and risk factors.
District Health Information System reports were reviewed for any reported cases from that area during previous months. Admitted cases and other cases found during active search were interviewed. Samples from different water sources were taken and sent to laboratory for analysis.

Results
Three hundred and thirty-six cases were identified from hospital record and during active case finding in the affected village among population of 2800 (attack rate; 12%). Age range of cases was 5-65 years with mean age of 26 years. 32% (n=109) cases were females while 68% (n=227) were males. Male to female ratio of cases was 2.1:1. 27% (n=92) cases belonged to 20-29 years age group while 24% (n=81) from 30-39 years age group. It was found that 71% (n=237) cases were using spring water (attack rate; 8.5/100,000 population) and remaining 29% (n=99) were using other water sources (attack rate; 3.3/100,000 population Purpose To assess the cause of death, evaluate the magnitude of outbreak, and to recommend control measures.
Methodology A descriptive study conducted. Active case finding done and data collected using pretested questionnaire. Health facility records checked and verbal autopsies carried-out. "A case was defined as any person with fever, throat pain and Greyish white membrane on Tonsils or nasal mucosa or Pharynx or larynx with or without any of the following symptoms including: neck swelling, difficulty in swallowing residing in Union council Tarai from 20th August to10th September 2016". Data was analyzed while using MS Excel and Epi Info.
Conclusions Outbreak was most probably due to very low routine immunization coverage and poor health seeking behaviors con- Purpose A team of FELTP fellows was deputed to assess the magnitude, evaluate risk factors and recommend control measures.

Methodology
The investigation was carried out in the military training center in Karachi. A case-control study was conducted. A case was defined as "sudden onset of jaundice with or without fever, nausea, vomiting, loss of appetite, malaise, diarrhea and abdominal pain plus presence of Hep-atitis E IgM on ELISA in a resident of military training center from 9th March to 12th May 2017". Cases were identified by reviewing hospital records and active case finding. Age-matched controls were selected from the same center. Water samples were tested for presence of coliforms. Frequencies were ascertained, attack rates calculated, and odds ratios were determined at 95% confidence interval and p value of less than 0.05.
Results A total of 79 cases were identified (49 through active case finding). All cases were male with mean age of 22 years (range18-45 years). Overall attack rate was 9% with most affected age group of 18-22 years (attack rate of 12%). Out of 79 cases 62 consumed tap water (OR: 2.28, 95%CI:1.14-4.58). Consumption of filtered water from coolers and hand washing was Background Most studies of risk factors for HPV infection have focused on overall HPV positivity and have not examined determinants for high-risk and low-risk HPV types separately.
Purpose To evaluate the prevalence and type distribution of high-risk and low-risk HPV infection and to describe the risk factors associated with different profiles in Tunisia.

Methodology
We studied risk determinants for genital HPV infection in a randomly sample of women aged 18 years and older with normal cervical cytology in Tunisia during 2014. All women had a personal interview, a Pap smear, and cervical swabs for HPV DNA detection using a PCR technique. Information on sociodemographic, reproductive, lifestyle characteristics, and health-seeking behaviors was collected. were the main risk factors for the oncogenic HPV types. A statistically increase risk was found in women whose partners had multiple sex partners. Furthermore, a previous sexual infection was associated with the high-risk HPV types. HR-HPV infection risk was observed in women aged less than 30 years, who were smokers, divorced/separated and having a high educational level. In contrast, the most important determinants for nononcogenic HPV infection were contraceptive variables related to the physical protection of the cervix and low standard of living.

Conclusions
The results indicate that different risk profiles exist for infections with different HPV groups with high-risk types being the most common types detected. HR-HPV positivity was associated with social determinants, behavioral and sexual characteristics. These results should assist in designing strategies for control of cervical cancer targeting at risk population. Background An innovative strategy; to identify the vaccine preventable disease cases from the community by the frontline polio workers during door to door OPV campaign, was adopted in district Shikarpur, Sindh. During polio field work training front line workers were also briefed about sign and symptoms of vaccine preventable diseases to identify and report their cases. On January 17, 2017 (1st day of OPV campaign) front line polio teams reported three measles cases including one death from a remote rural village. A team was deployed to confirm and determine the extent of the outbreak and implement preventive and control measures.
Purpose To confirm and determine the ex-tent of the outbreak.
Methodology A case was defined as a child (= 15 years of age) residing in district Shiparpur, with: a generalized rash for three or more days, fever at or above 101°F, and one or more of the associated symptoms, including cough, or coryza, or conjunctivitis from 1st January to March 6, 2017. Active case finding was done from the community and health facilities. Blood samples from fourteen willing cases were collected and sent to NIH Islamabad for Laboratory diagnosis.

Results
Twenty cases were identified with one death (CFR 5%), 55% (n = 11) were females. Mean age was 43 months (range: 11 to 108 months). Eight (40%) cases were identified by front line polio workers from remote areas. Eight cases were from two families. Fourteen (70%) cases were un-immunized and 6 (30%) partially immunized against measles. NIH Lab declared thirteen (93%) cases positive out of fourteen. Background On March 3, 2017, cases with fever and skin rash were reported in Khywan, Huth district, Amran by electronic disease early warning system (eDEWS) coordinator. A team from Y-FETP was sent to investigate the problem.

Conclusions
Purpose To confirm the existence of outbreak and recommend control measures.

Methodology
We conducted active house to house-case search. Suspected case was any person with fever and skin rash at any age in Khywan area, Huth district, Amran governorate, from 5 February to 5 March 2017. Data analysis was performed by Epi Info version 7.2.
Results 32 cases met the standard case definition, the index case was reported in 5 Feb. 2017, the outbreak continued till 5 March with the peak of cases in 3 March 2017 (6 cases). The percentage of females was 53%. The highest percent was among the age group 1-< 5 years with the attack rate 21/1000 of population. The percent of non-vaccinated cases was 97%. Reasons for non -vaccination were: lack of outreach vaccination services (39%), absence of vaccine in the nearby health center (39%), and vaccination refusal (22%). All cases had fever and skin rash, 97% of cases had cough and conjunctivitis. About 13% of cases were admitted in Huth hospital due to pneumoniae as a complication of measles. Purpose To confirm the outbreak, assess its magnitude, identify risk factors and to implement prevention and control activities to stop spread of the outbreak.

Conclusions
Methodology A case was defined as "Rash with fever and cough, coryza or conjunctivitis in a child younger than 14 years of age, resident of Bara, during 3rd February to 15th March, 2017. " Active search of cases done. Data was collected using a pretested structured questionnaire and analyzed using Epi Info version 7.1. Descriptive analysis was done followed by age & sex matched case control study. Case fatality rate, attack rate, vaccine efficacy, and secondary infectivity rates were calculated. Conclusions This study in a post-conflict repatriated population showed relationship of low socioeconomic status, low vaccination coverage, distance from health facility and overcrowding with the disease. Awareness sessions and mop-up vaccination in the area contributed in controlling the outbreak.

Results
Background On 10th November 2017, District Surveillance Coordinator Shaheed Benazir-Abad notified eight suspected measles cases to Disease Surveillance Unit Hyderabad. Teams of Fellows constituted and deputed to the village to investigate the reported cases.
Purpose To verify, assess the magnitude, to evaluate risk factors and formulate recommendations for future control.
Methodology A descriptive study was carried out. Active case finding carried out; hospital records checked. Case was defined, a person resident of Jogi para Village Mehmood Jamali having fever with maculopapular rash and one of the following clini-cal features; cough, coryza and conjunctivitis from 1st November 2017 to 13th December 2017. Verbal autopsy was carried out with parents of deceased children. Data were analyzed using Epi Info 7.1.
Conclusions Measles outbreak was most probably due to very low routine immunization coverage. Outbreak was timely contained with active surveillance and initiation of Mop up vaccination. Cases were mobilized and admitted in hospitals therefore, no more deaths reported. There is need of strong supervision and monitoring of routine immunization activities in the district. Health education sessions should be arranged in the community on importance of immunization with active involvement of local stakeholders. Purpose The objectives of the investigation were to assess the magnitude, evaluate risk factors, and suggest control measures.

Outbreak Investigation/VPD
Methodology A review of the reported cases was conducted. Active case finding was undertaken to identify more cases in the village. A case was defined as sudden onset of fever, maculopapular rash, and any of cough, coryza, conjunctivitis in a resident of village Manzoor Sawand, from 10th November to 10th December 2016. Data was collected using a structured questionnaire. Vaccination coverage survey was done by using 30 x 7 cluster sampling technique. Six blood samples were sent to NIH for lab confirmation.
Results A total of 15 cases including 2 deaths (CFR13.3%) were identified; 12 through active case finding. Mean age was 24 Months (range 9-54 months). Overall attack rate was 1/1000 and the most affected age group was 12-48 months n=13 (AR 3.8/1000). Apart from fever and rash cough (100%), coryza (80%) and conjuctivitis (60%) were the most prominent symptoms. A total of 210 children were assessed for vaccination status. Attack rate in unvaccinated children was 2.1% and in vaccinated children was 4.3%; vaccine efficacy was 51%. Reasons for non-vaccination was unawareness (n=12; 80%) followed by vaccinator did not visit (n=7; 46.6%). Ice-lined-refrigerator (ILR) was found to be non-functional at the EPI Centre. All blood samples were positive for measles.

Conclusions
The most probable cause of the outbreak was low immunization status. Awareness sessions were conducted. Vaccinator was assigned to conduct outreach activities. A total of 713 eligible children were vaccinated against measles and Vitamin A was administered. On our recommendations ILR was made functional.
Background AFP Surveillance is a key strategy of Global Polio Eradication. In Iraq, it started in 1995. WHO established some performance indicators that should be used to assess the quality of AFP surveillance.
Purpose The objective of this study is to identify the trends of different performance indicators of AFP in Iraq, 2007 -2016.

Methodology
We reviewed AFP surveillance data in the IFA (Information for Action) software for 2007-2016. The data were compiled from almost all public health outlets in Iraq and compiled at the National AFP surveillance office. Six WHO indicators were reviewed: Non-polio AFP rate <15 years of age (Target >2/100,000), Reported AFP cases investigated <48 hours of report (Target >80%), Reported AFP cases with 2 specimens collected <14 days since onset (Stool adequacy) (Target >80%), Specimens arriving at national laboratory <3 days of being sent (Target >90%), Specimens arriving at laboratory in good condition (Target >80%) and Stool specimens from which non-polio enterovirus was isolated (NPEV%) (Target >10%).
Results A total of 4,915 cases were reported; 35% aged <2 years, 60% were male, 60% had fever at onset of paralysis and 38% had asymmetrical Paralysis. Only 1.3% received no OPV vaccine, 77% received >3 doses. At sixty days' examination 24% had residual paralysis. Seven cases were vac-cine-derived, 156 cases were Sabin-like polioviruses and no vaccine-associated polio case. Two wild polio cases reported in 2014. Guillain-Barre syndrome accounted for 51% of cases. Specimens arriving at the national laboratory <3 days was not achieved during the whole period. NPEV% achieved the target except in 2013 (7.3%). All other indicators achieved the target throughout the whole period.
Conclusions While most indicators achieved the standard, additional efforts are still needed to address the timeliness of adequate stool specimens' arrival to the laboratory. We are currently working on similar analysis at governorates and districts levels.

Title Antibiotics Prescribed Among Patients with Severe Acute Respiratory Illness in Bangladesh
Background Proper use of antibiotics helps to minimize the recovery time of patients with severe acute respiratory illness (SARI). Although Bangladesh faces increasing concerns with antimicrobial resistance, there is no national guideline covering preferred antibiotics for SARI cases. Hospital Based Influenza Surveillance (HBIS) identifies SARI patients caused by different microorganism including influenza and other bacterial organisms.
Purpose We analyzed HBIS data to observe the antibiotic prescription pattern for SARI patients.

Methodology
We analyzed HBIS data from May 2013 to December 2016 from 12 sentinel hospitals regarding length of hospital stay, chronic illness, different classes and generations of antibiotics prescribed to SARI patients. We used proportion test with 95% confidence interval to compare use of different classes of antibiotics.
Conclusions Newer generation cephalosporin was most frequently prescribed, which raises the concern of developing antimicrobial resistance. As patients given macrolides had a shorter hospital stay may be recommended for SARI patients. However, development of a national guideline for management of SARI patients including appropriate use of antibiotic is recommended.
Background Severe acute respiratory illness (SARI) is recognized as a leading cause of morbidity and mortality. SARI tends to be rapidly progressive illness caused by pathogens like influenza, which have pandemic potential. Egypt established SARI sentinel surveillance sites since 2007 in eight representative sites.
Purpose Describe epidemiology of SARI, identify influenza positivity and circulating influenza subtypes among SARI patients.

Methodology
Patients who met standard WHO-SARI case definition (fever =38c + cough without any other cause in the last 10 days in a hospitalized patient) from 2009 to mid-2017, were enrolled. Epidemiological data were collected using standardized investigation form. Nasopharyngeal/ oropharyngeal swabs, for all patients, were tested for influenza viruses by reverse transcription polymerase chain reaction (RT-PCR). Data were extracted and analyzed by MS excel 2013.
Background Sentinel surveillance for severe acute respiratory infections (SARI) is an important tool to monitor influenza circulation and burden of other respiratory pathogens. In Yemen, two sites established at Sana'a and Aden city. Pharyngeal samples are tested for influenza and noninfluenza by the Real-Time-PCR assay in NAMRU 3.
Purpose Describe severity of SARI as indicated by admission to intensive care unit (ICU) and fatality as well as associated influenza and non-influenza viruses among patients in the two sites to provide recommendations for improving SARI surveillance.
Methodology Data from 2012-2016 of SARI patients who admitted in the two sites based on WHO case definition was obtained from Ministry of Health, It analyzed by Epi info 7 and P value < 0.05 was the cut point for significance.
Conclusions Our findings showed that children < 2 years are more affected by SARI. Both influenza and non-influenza viruses lead to mortality and necessitate prompt diagnosis and treatment. Expanding SARI surveillance to involve more hospitals at different governorate is recommended to give more comprehensive picture regarding SARI.
Background Influenza infection represents a substantial public health problem resulting in global burden of mortality and morbidity. Influenza thresholds indicate level of disease activity that would signal the start or end of a season and provide an alert to an unusually severe or atypical season so, adjust preventive and control measures.
Purpose To establish baseline and threshold values for 2016/17 season.
Methodology Using Acute Respiratory Illness (ARI) surveillance data from 2013 to 2017, two parameters were assessed to monitor influenza activity: percentage of ARI samples positive for influenza and composite parameter (percentage of samples tested positive *ARI rate). Three threshold levels (baseline, alert and epidemic) were established by calculation of average of each week in all preceding seasons, 40% Upper Confidence Limit (UCL) and 90% UCL of each week respectively, then a four-week running average used to smooth the curve. Each parameter was compared against corresponding threshold and transmission intensity was categorized as low, moderate and high. can assess not only seasonal influenza but also potential pandemic influenza, contributing to the country's pandemic prepared-Background Pakistan is among the high endemic countries for TB and ranked 5th in the high TB burden countries with estimated 4th highest prevalence of multidrug resistance (MDR) TB. TB patients in Pakistan are facing different socio-economic and cultural constraints. TB patients are stigmatized and have been affected negatively due to poor knowledge about the disease dynamics, wrong socio-cultural myths and misapprehensions in general public.

Purpose
The study conducted by active TB patients to explore and evaluate different constraints that TB patients are facing in Mardan, Pakistan.
Methodology A cross sectional study was conducted in district Mardan during March to June 2015. From 350 selected patients 210 were enrolled in study after informed consents. Data were collected though structured questionnaire and statistically analyzed by Epi-info/SPSS.

Results
Overcrowding (p = 0.001, CI, 95%), unawareness of disease (86%), low educational status (p < 0.002, CI 95%), poverty and access to healthcare facilities were directly related to poor compliance. Attitude of family members, colleagues, society and even healthcare staff (p = 0.002, CI 95%) were also found significant. Age groups, marital status and treatment duration were found to be highly significant (p < 0.002). 85% patients were unaware with the risk factors and precautions during the treatment. 42% patients were unemployed, 58% employed less than 200 USD/month (p = 0.001, CI 95%). 59% patients complained worst behavior of their colleagues (p = 0.001) and 41.7% complained worst behavior of healthcare staff (p = 0.003. CI 95%).
Conclusions TB patients were found stigmatized due to poor economic conditions and bad attitude of family, colleagues and healthcare staff. Unemployment, malnutrition and overcrowding were among the worst constraints. Sensitization of medical staff and doctors to diagnose the disease in time and behave properly with patients is recommended. Dedicated patients and family education sessions must be conducted.
Background MERS-CoV emerged as a zoonotic disease in Saudi Arabia with 1437 cases as of July 2016.
Purpose This study aimed at describing the epidemiology of MERS-CoV infection, clinical aspects of the disease and the determinants of survival.
Methodology Medical records were reviewed between April 2014 and December 2015 to identify admission and discharge with MERS-CoV. Patient's characteristics, epidemiologic and clinical data and laboratory results were extract-ed and described. Logistic regression analyses were used to model the determinants of the survival of these patients. Significance of the results were judged at the 5% level.
Results 249 laboratory confirmed cases were admitted mostly in August (20.48%) and September (14.86%) of the year 2015. These cases were non-healthcare workers (85.14%), Saudi (58.63%), males (57.03%) with a mean age of 46.71±17.92 years. A third (39.36%) reported contact with suspected or confirmed cases, developed the disease after 6.2 days and Purpose A team of Saudi field epidemiology training program was responsible to investigate the outbreak, to determine causes and to prevent recurrence.
Methodology List of cases were obtained from hospital administration. Information was collected by interviewing infection control team, outbreak team at hospital, local MERS-CoV coordinator and by observing most relevant sections at hospital.

Results
A total of 13 cases of MERS CoV infection were reported at Domat Al-Jandal hospital. Of these 13 cases, 8 cases were health care workers (3 physicians and 5 nurses), 3 cases were contacts cases of the index case. Most of cases acquired infection by person to person transmission at male medical ward and intensive care unit, only 3 contacts cases may get infect-ed when they brought the primary case to hospital. Attack rate among physicians was 12% and among nurses was 9.8%. We found that late diagnosis, improper isolation of patients and non-compliance on infection control protocols are the leading causes of spread of the infection.

Conclusions
Sorting and examining patients carefully at triage and emergency before admission to hospital, adhering to infection control protocols, applying effective isolation measures are a must in the way to stop or prevent any MERS-CoV infection at hospitals.
Background Hajj is one of the largest human mass gatherings. Due to crowding, there is the potential for respiratory infections to spread among attendees. Health education and vaccination for respiratory infections are the main preventive measures taken for Saudi Arabian pilgrims prior to hajj.
Purpose To describe knowledge gained from preventive programs in Qatif district in Saudi Arabia's eastern province. This information can improve the health educational programs for Saudi pilgrims.

Methodology
We randomly sampled pilgrims from 39 troops distributed across Qatif district. Questionnaires assessed pilgrim's awareness towards respiratory in-fections during hajj and to identify the factors influencing pilgrim's awareness about MERS-CoV in Saudi Arabia. Data analyses were completed using Epi Info 7.
For preventive measures, 91% of pilgrims identified face masks, 86% identified frequent hand washing and 85% identified social distancing as effective. MERS-CoV was identified a serious disease by 76%, and 30% said MERS-CoV was treatable. For transmission of MERS-CoV, 75 % identified airborne transmission and 60% identified consuming infected camel. Only 55% of pilgrims correctly responded that MERS-CoV is still circulating in the kingdom.
Conclusions Pilgrim knowledge about causes, symptoms, and preventive measures for respiratory infections were acceptable, but knowledge towards respiratory illness treatment and MERS-CoV were poor. We recommend national health education programs target these areas in the future.

Title Food-borne Illness Surveillance and Etiology of Diarrhea in Bangladesh
Background In Bangladesh, yearly 30 million people are affected by foodborne illnesses caused by Rotavirus, Vibrio cholerae, Escherichsia coli, Shigella and Salmonella. Since 2013, the country has been conducting active foodborne illness surveillance (FBIS) in ten sentinel sites to collect epidemiological data and stool samples of acute watery diarrhea (AWD) cases.
Purpose To describe the microbiological findings of stool samples and their relation with epidemiological data of FBIS.
Methodology We described AWD cases reported in FBIS from 2014 to 2015 by age, causative organisms and analyzed cholera cases by behavioral risk factors and geographic area. FBIS defined AWD cases as >3 episodes of loose stools or <3 loose stools causing dehydration or at least a single episode of bloody loose stool in 24 hours among >2 months of age, and watery stools that changed from usual pattern and frequency among <2 months of age. To find statistical association, we performed z-test for two proportions.
Conclusions As the majority of stool cultures could not identify causative organisms, we recommend increasing the microbiological identification capacity of FBIS. We also recommend conducting studies to identify true association of cholera with taking food from roadside vendors and drinking well-water.
Background In 2004, Pakistan escalated from 'low-prevalence' to 'concentrated' phase of HIV epidemic. Despite global decline in HIV incidence since 1997, rate of HIV infections in Pakistan is persistently rising since 1990. Available literature focuses on key populations or localized outbreaks and is limited by short study duration and regional applicability of results.
Purpose We studied HIV seroconversion trends over a period of 8 years in a geographically diverse population and evaluated associated risk factors.
Methodology A desk review of HIV surveillance data from 2010 to 2017 was carried out at Armed Forces Institute of Pathology. A case was defined as any adult enrolled in Pakistan Army as civilian employee, initially screened for HIV but later seroconverted on ELISA and western blot. Case-control study was conducted on cases diagnosed in 2017. Age and sex matched controls were identified from same population sub-group. Structured telephonic interviews were conducted, and statistical analysis done at 5% margin of error.
Results From 2010-2017, 109 cases of HIV were notified from 75,000 HIV negative civilian workers. Annual case count remained <12 till 2016 when it rose to 24. Upward trend continued in 2017 with 34 cases reported to date (183% increase from baseline). Acquisition of HIV was significantly associated with commercial sex activities (OR=5.71; 95%CI: 1.25-395). No statistically significant association was found for blood transfusion, surgical/dental procedure, barber shops visits, piercing or substance abuse.
Conclusions HIV seroconversion rates among Pakistan Army civilian employees have increased significantly in past 2 years. Unlike HIV outbreaks previously reported from Pakistan, sexual route has been recognized as the predominant mode of transmission. Consequently, sex education sessions were conducted in all formations and a section on prevention of STIs was included in Pak Army health pamphlet. Similar focus is mandated on prevention of sexual transmission of HIV at national level as well for all vulnerable populations.

Surveillance System
Abstract Background Dengue is a significant public health problem affecting 50% population worldwide. Every year 50-100 million cases of DF while 250000-500000 cases of DHF are reported worldwide. Mortality rate of DHF/ DSS is 5-10%.

Purpose
The study was conducted to evaluate the system in terms of its core functions, system attributes and challenges faced in order to make recommendations for improvement.
Methodology This evaluation was conducted during November 2017 at Islamabad District. A desk review of literature, departmental reports and documents was conducted. Quantitative and qualitative system attributes were assessed using Updated CDC Guidelines for Evaluating Public Health Surveillance Systems, 2001. Stakeholders were identified and interviewed. A semi structured questionnaire was used to collect data.

Results
Staff was trained in data collection and data entry. NS1 (Non-structural pro-tein1) and dengue-specific IgM antibody test were available at all tertiary care hospitals to confirm diagnosis. Case definition was simple and strictly followed. Data flow was easy. System is less flexible but able to integrate with other systems. Quality of data was poor as 80% of filled forms were incomplete in demographic and clinical profile. Acceptability was good due to sense of ownership and good coordination among all stakeholders. Sensitivity was 27.6% and predictive value positive was 81.5%. Representativeness was poor, covering only tertiary care hospitals. Timeliness was excellent with daily reporting and case response within 24 hours. The system is useful as it provides dengue fever data base for planning and management purpose. System is stable, secure and available when required.

Conclusions
The evaluation shows the performance of dengue surveillance system was good overall. System is not representative but has ability to detect and respond to outbreaks within time. Expansion of the coverage to include all public and private healthcare facilities is needed. Regular data collection trainings are recommended. Feedback mechanism is necessary to ensure data quality.
Background Globally, an estimated 212 million cases of malaria were reported in 2015. In Pakistan, health facility-based confirmed cases were reported to be 0.2 million. Total reported deaths were 34 as compared to estimated 740 deaths. Malaria information system (MIS) detected 0.084 million confirmed cases of malaria in 2016, in province Balochistan.
Purpose An evaluation of Malaria Surveillance System in Balochistan was conducted to identify strengths and weaknesses and make recommendations for improvement.
Methodology A desk review of literature, office records and reports were conducted in Provincial Malaria directorate Quetta from March to May 2017. Evaluation was conducted for the year 2016. Assessment of qualitative and quantitative system attributes was done using the framework of updated CDC guidelines for evaluating public health surveillance systems, 2001. A semi-structured questionnaire was used for interviews. Stakeholders were identified and engaged.

Results
Case definition was simple, and system was easy to operate but inflexible in accommodating additional information like outbreaks. Data quality was assessed as poor, because on random evaluation 30% forms were found completed. Timeliness was also poor as report took 2 months to reach Malaria directorate from district level. system had good acceptability, stability and representativeness. sensitivity of the system was excellent 100% whereas PPV was 12.8%.

Conclusions New approach of Malaria
Control Program should be vector control rather than malaria control because coastal areas of Balochistan are at high risk for Dengue, Chikungunya, Zika and Yellow fever as these have common vector for spread. A software is strongly recommended for reporting of malaria cases which will improve the timeliness of reporting. During transmission season active case finding and taking blood samples from affected people would be highly effective in picking cases at right time for better management. All the staff working for malaria control and prevention should be trained for other vector borne diseases as well. Purpose To enhance early detection and rapid response to potential public health threats and to improve the performance of the EBS team.
Methodology At the end of June 2017, the reporting form, database and the stan-dard Operating Procedures (SOP's) of EBS were updated. EBS team received training for the system updates. Data from April to September was investigated for the source of information, signal filtration, verification, and timeliness of response. For the events that are routinely reported by IBS, early detection was checked for both systems. The results were compared three months before and after the training.
Conclusions Increase EBS capacity for early detection of potential public health threats. Marked improvement of EBS team performance. Raise community awareness, expand the sources of information and shift to electronic database are highly recommended.
Background Adverse drug reactions (ADRs) are a major cause of drug related morbidity and mortality. Globally, about 5% of all hospital admissions are due to an ADR and 10%-20% of inpatients have at least one ADR during their hospitalization. Pharmacovigilance is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other drug-related problem(s).
Purpose To evaluate the knowledge, practice and attitudes (KAP) toward ADRs reporting and pharmacovigilance among hospital pharmacists in Mansoura, Egypt, 2016.
Methodology A cross-sectional study was conducted among random sample of hospi-tal pharmacists in Mansoura, who were invited to attend a workshop on Pharmacovigilance. A structured pilot tested questionnaire was developed based on the previous literature. The questionnaire was distributed to the attending pharmacists before and after the workshop. Collected data was analyzed using SPSS v.16.0.

Results
Of the total 200 invited pharmacists, 95% attended and agreed to participate in the study. The majority were females (87%), with mean age 30.6±4.2 years. Before the workshop, the average percentage of correct answers on the knowledge items was 55% indicating a fair to poor score which had been enhanced after the workshop (90%). The majority of pharmacists had pos-itive attitude toward Pharmacovigilance and agreed that ADRs reporting should be mandatory, prompt and online but without legal penalties on the reporter. According to their practice, the most reported ADRs were severe serious reaction (22.5%), unexpected reaction (21.5%) and unlabeled reaction (17.5%). Besides, the most barriers to ADRs reporting were uncertainty whether the reaction is actually due to ADR (25%), already well-Known ADR (15.5%) and forgetfulness (14.5%).

Title Evaluation of National Electronic Disease Surveillance System (NEDSS) Regarding Typhoid Fever in Sharkia governorate, Egypt, 2016
Background Typhoid fever is a systemic infection caused by Salmonella Typhi. It is still common in the developing world, where it affects about 21.5 million people each year, 222 000 typhoid-related deaths occur annually worldwide. It can be prevented and can usually be treated with antibiotics. Cases are reported through National Electronic Disease Surveillance System (NEDSS) from all healthcare facilities to department of Epidemiology and Surveillance.
Purpose To identify strengths and weaknesses of surveillance system of reported typhoid cases for improvement and disease control.

Methodology
The evaluation was conducted using CDC guidelines for evaluating pub-lic health surveillance. NEDSS data regarding Typhoid from 1st January 2016 to 31 December 2016 were extracted on an excel sheet for calculating completeness and timeliness. A structured questionnaire was used to assess the following attributes: Usefulness, Simplicity, Acceptability, and Stability. The assessment was implemented on four levels: central, Health directorate, Health district, Fever hospital levels. Sharkia governorate had been selected which was the highest governorate in reporting typhoid cases. Data were analyzed using Microsoft Excel.
Results According to surveillance officers in all levels which interviewed (n=10), the mean of system usefulness, simplicity, acceptability and stability was 92.5%, 98.8%, 94%, and 85.5%, respectively. The mean completeness of some variables (Outcome, occupation, national ID, address, final diagnosis) was 75.9%. It takes 2 minutes for case / day for data entry and 27minutes/ month for data analysis. Median time between electronic Insertion to Reporting and admission to Notification date was 1 day for both, IQR (3-1) and (2-1) respectively. Positive predictive value was 50%. Satisfaction of surveillance team was 100%.

Conclusions
The system is simple, flexible, stable, acceptable and useful for the surveillance team which is satisfied with their job, the timeline of reporting is considered acceptable in between different levels and Lack of laboratory confirmation of cases (use tube agglutination test only).
Background Hemophilia is an inherited bleeding disorder caused by a deficiency of either factor VIII (hemophilia A) or IX (hemophilia B). Treatment with intravenous replacement of these factors and blood carries the risk of transfusion transmitted viral infections.
Purpose We performed this study to estimate the prevalence and seroconversion rates and identify risk groups of hepatitis C (HCV), hepatitis B (HBV) and human immunodeficiency virus (HIV) infections among hemophilia patients in Baghdad City, Iraq, 2016.
Methodology We conducted this cross-sectional study by reviewing records of all hemophilia patients resided in Baghdad in 2016 and registered and received treatment in the four hemophilia centers in Baghdad. All hemophilia patients are annually screened for anti-HCV antibody, HBsAg and HIV antibodies. Positive samples are sent for confirmation at the Central Public Health Laboratory and the results are reported in the patients' records. Conclusions Despite screening of blood and blood factors, HBV and HCV infections still occurring in hemophilia patients. Closer monitoring of transfused blood and ensue vaccination of all hemophilia patients for HBV are recommended.

Title The Epidemiological Profile of Viral Hepatitis B and C in Morocco Between 2013 and 2016
Background Hepatitis B and C virus infections (HBV/HCV) are a global health problem. Morocco is considered as a middle endemic country. HBV/HCV surveillance system was implemented in Directorate of Epidemiology by the Ministry of Health as an ongoing process of case investigation, data collection, analysis and also dissemination of data to public health professionals.
Purpose The aim of this study was to analyze the epidemiological profile of HBV/ HCV infections during a four-year period.

Methodology This was a descriptive and retrospective study of HBV/HCV cases registered from 2013 to 2016 by 22 referral centers for viral hepatitis in Morocco.
Registration of new cases was reported monthly via a reporting form using WHO case definitions. Socio-demographic characteristics, diagnostic circumstances, modes of transmission, clinical and biological data of suspected or confirmed cases were collected.
Results A total of 1160 HBV/HCV cases were registered (95% HCV vs 5% HBV). Male/female ratio was 0.52 and 48% were married. Free Medical regimen was available in public health services for 90% of patients. HCV cases came mostly from two northern regions: Rabat (24%) and Casablanca (21%). Regarding diagnostic circumstances, cases were identified during screening (25%), systematic blood check (21%), cytolyse (18%) or during blood ex-ams before surgery (13%). Infections were frequently transmitted during dental care (58%), followed by transfusion-transmitted infections in 8% of cases and sexually transmitted in 4% of cases. In 80% of cases, HCV were active. The presence of detectable HCV RNA sequences, 54% were Genotypes 1 and 43% were genotype 2.
Conclusions This analysis is from the data of surveillance system recently implemented. It allowed us to have an idea about the epidemiological profile of HCV/HBV in Morocco. However, these results point out the necessity to reinforce the surveillance system by involvement of more different regions in order to report more cases, and also the computerization of notification process. Purpose The objective is to evaluate the MSS and to identify its strengths and its potential gaps for its improvement. Purpose The Purpose of this evaluation was to identify strengths and weaknesses of the system to formulate recommendation.

Methodology
Methodology CDC's updated guidelines for evaluating public health surveillance system 2011 were followed. Descriptive study was conducted in May 2015. Major stakeholders were identified and interviewed through Semi-structured questionnaire. Qualitative & quantitative assessment of AFP surveillance system attributes were done. Sensitivity and PPV was calculated using previous years estimates for FATA.

Results
System was found simple, stable and flexible. Representativeness was found average as not covering private sector. Sensitivity was 100% while predictive value positive was 48%. Cases with adequate stools were 81% (n=128). Completeness and timeliness of reports were 87% (n=26). Case investigations within 48 hours of re-port was 99% (n=156). Stool specimens collected within 14 days of paralysis onset were 81% (n=128). AFP cases with 60 days follow-up were 36% (n=58). Lack of ownership and accountability, poor data management and analysis, inadequate logistics and feedback were identified as major weaknesses.
Conclusions Health care provider's knowledge regarding AFP was found inadequate and needs regular capacity building. There was lack of government ownership and this system needs official ownership at all levels in order to bring improvements. Human resources and logistics provision needs to be ensured. Regular surveillance data analysis and feedback to health workers is recommended. Background Communicable diseases (CDs) surveillance is vital for early detection of outbreak and reduce CDs burden. Surveillance officers at the grassroots up to the highest level should be adequately equipped with field epidemiology competencies. In Iraq, district surveillance officers (DSOs) are responsible for compiling, analysis of CDs data from Primary Healthcare Centers (PHCs) in their district and forwarded to the provincial level.

Surveillance System/VPD
Purpose to assess background characteristics, qualifications and competencies of DSOs in Iraq.

Methodology
In this cross-sectional study, we involved all DSOs (136) in Iraq. We developed a structured questionnaire through a meeting involved central and provincial officers and academia. The questionnaire gathered data on demographics, service characteristics, status of competencies in basic epidemiology, biostatistics, surveillance, outbreak investigation, rapid response to health incidence, laboratory models, developing scientific report and basic computers skills. Questionnaires were sent and received from DSOs via e-mails.

Results
The response rate was 85.3%. About half of DSOs was responsible for <10 PHCs, while only 13.8% were responsible for 20-29 centers. Also, about 55% were responsible for 1-2 hospitals and only 10% were responsible for 3-4 hospitals. Males constituted 78.4%. The highest academic degree of 63.4% was a two years Diploma after high school. The proportion of previous training of the DSOs was: basic surveillance 69.8%, outbreak investigation 34.5%, basic epidemiology 26.7%, rapid response to health incidents 21.6%, laboratory models 19.8%, biostatistics 13.8% and scientific reporting 8.6%. DSOs who didn't attend any training activity were 15.6%. Cholera and food poisoning were the most frequently reported incident and outbreak investigated (53.8%, 43.8%, respectively). Microsoft word was the most frequently reported computer skill (48.3%). Polio-Free Jordan, 2012-2016 Background As part of polio eradication strategy, World Health Organization (WHO) has established a global Acute Flaccid Paralysis (AFP) surveillance. In Jordan, AFP surveillance has succeeded to achieve the polio-free certification. However, there is a substantial risk of polio importation from neighboring countries including Syria and Iraq.

Title Evaluation of Acute Flaccid Paralysis Surveillance System in
Purpose This study aimed to evaluate the AFP surveillance in Jordan to ensure that the system operates effectively in order to maintain the polio free status.
Methodology This retrospective study was based on secondary analysis of data routinely collected between 2012 and 2016 by the Jordan's Expanded Program on Immuniza-tion (EPI). All AFP cases reported to the EPI during this period were included. The WHO minimum performance indicators were used to evaluate the quality of AFP surveillance. Data were analyzed using the data management system for AFP surveillance data and excel 2010.

Results
Cumulatively, 328 AFP cases had been reported during the study period. Almost half (51.3%) of cases aged between one and five years and 55.8% were males. All cases had been discarded. The most common cause of AFP was Guillain-Barre Syndrome (35.1%). Annualized non-polio AFP rate increased from 1.4/100,000 population under 15 years in 2012 to 4.3 in 2016. National and subnational sensitivity was not met in 2012 and 2013. Adequacy of stool specimens and timeliness of specimens arriving and processing in the laboratory were constantly above the WHO minimum target. Timeliness of investigation met the expected target but with a decreasing trend. The proportions of stool specimens where non-polio enterovirus (NPEV) was isolated were below the WHO minimum target except in 2016.
Conclusions AFP surveillance system in Jordan is performing well, however additional efforts are needed to strengthen the subnational sensitivity. Moreover, laboratories are required to increase the NPEV isolation rate. Providing feedback to the reporters is recommended to maintain the reporting and investigation above the target.
Background Pakistan is among three countries in the world with ongoing wild poliovirus transmission. Pakistan established an AFP Surveillance system in 1995 and in 2000 further technical strengthening was provided to system at all levels by WHO. Sindh reported 8 confirmed cases of poliomyelitis in 2016 and 3 cases were from Larkana Division. An adjacent division, Sukkur, is a big reservoir for poliovirus and an intersection between three provinces.
Purpose The evaluation was conducted to identify the gaps in the surveillance system and suggest recommendations for improvement.
Methodology A descriptive study was conducted during November-December 2016. The study setting was Sukkur Division. Quantitative and qualitative attributes of the system were assessed using Updated CDC Guidelines for Evaluating Public Health Surveillance Systems, 2001. A desk review of literature, departmental reports and records was undertaken. Major stakeholders were identified and interviewed using a semi-structured questionnaire. Sensitivity and PPV were calculated by using WHO estimates of Sindh Province for previous year.
Results Case definition used was simple and gathered all essential information. System demonstrated its flexibility by incorporating information on other diseases like measles and neonatal-tetanus (NNT). The System captured all cases from 3 districts of the Sukkur Division. Data quality is good with 90% of the reports being completely and correctly filled and timeliness of data sharing was excellent with 85% reports reaching the provincial level weekly. Representativeness is average as system has limited coverage of private sector. System sensitivity is 100%, whereas PVP is 0.087%. System functions showing good stability without any disruption.
Conclusions Polio is marked for eradication hence the system is fulfilling its objectives. We recommend coverage of the system to be extended to private sector and report sharing at directorate level. Regular capacity building of the staff is recommended for maintaining the quality and timeliness.
Background Globally 5-10% of adults and 20-30% of the children are affected by influenza annually. Annual epidemics results in 3-5 million cases and 500,000 deaths. Influenza is a common illness in Pakistan however absence of a robust surveillance system makes assessment of burden of disease an issue.
Purpose The study was conducted to identify key strengths and weaknesses of the system and to make recommendations based on findings.
Methodology An evaluative descriptive study was conducted from April to July 2017. The Lab-based Influenza Surveillance System was conducted at the national level. As-sessment of qualitative and quantitative system attributes was done utilizing the CDC's Updated Guidelines for Evaluating Public Health Surveillance Systems, 2001. Desk review of literature, departmental documents and reports were also conducted. The stakeholders were identified and interviewed using a semi-structured questionnaire.

Results
The system was found to be simple and easy to operate but less flexible to integrate with other diseases. Data quality was good as 80% of observed forms were completely filled. Timeliness was good as the data takes 24-48 hours from sample collection to report submission to the central level. Acceptability is good as private and public-sector hospitals and labs are in-volved. Sensitivity calculated was 62% and Predictive Value Positive (PVP) was 37.2%. The representativeness of Lab based influenza surveillance system is poor as it is a sentinel surveillance with specific reporting sites strategically placed. Data from all sentinel sites is analyzed at national reference lab where it is summarized to use for planning and management purposes.

Conclusions
The system is meeting its objectives. Sustainability and stability of the system needs to be improved by allocation of public funds. Extension of the coverage of the system will result in improved representativeness. Regular capacity building of the staff at reporting site will ensure continued quality of reporting.
Background Hepatitis B virus (HBV) can be detected by different serological and molecular biological methods. Nationally, high laboratory cost and lack of availability of Enzyme linked immunosorbent assay (ELISA) technique in peripheral health facilities raise the need for evidence-based decision on the use of HBs Ag rapid test in detection of HBV infection.
Purpose to evaluate the validity of ACON-HBs Ag rapid diagnostic tests in detection of hepatitis B virus infection in sentinel sites at Salahaldin Province. Background Immunization is one of the successful and cost-effective health interventions that averts >2.5 million child deaths annually. WHO and UNICEF estimates of immunization coverage in Iraq in 2015 revealed 58% for DTP3 and 57% for measles. High-quality immunization session practices (ISPs) can ensure safer, more effective vaccination and higher coverage rates.
Purpose The objective of this study was to assess the impact of training of primary healthcare centers (PHCs) vaccinators on quality of ISPs in PHCs in Wasit province.
Methodology An interventional study was conducted on ten (18%) PHCs in Wasit province where two PHCs were randomly selected from each health district. ISPs were first assessed by direct on-job observation of immunization sessions through a single visit for each PHC using modified WHO immunization session checklists and findings were grouped into seven domains: vaccine and diluent management, cold chain management, session's equipment, registration, communication, vaccine preparation and administration and waste management. Then, the vaccinators in these PHCs were enrolled in a one-day training using WHO module "Managing an Immunization Session" as a training material. A second assessment was made one month later using the same method. Mean differences in the domains' scores were calculated.
Results A significant improvement was clear in three domains: vaccine and diluent management (P=0.005), cold chain management (P=0.01) and vaccine preparation and administration (P=0.003). Eight PHCs (80%) showed improved, whereas the remaining two (trained vaccinators were moved away soon after training in one, while the other was conducting a badly managed campaign with influenza vaccine) showed some decline.
Conclusions Training of PHCs' vaccinators was effective in improving ISPs. We recommend using this training module for other PHCs to improve utilization of immunization services. The impact on vaccination coverage may be assessed one year later.
Background Annually, vaccines prevent more than 2.5 million child deaths globally. WHO and UNICEF estimates of immunization coverage in Iraq in 2016 revealed 63% for DTP3 and 66% for MCV1. Wasit is among governorates with a large number of under-immunized children, opening the door for many future outbreaks. Immunization session practices (ISPs), when maintained of high-quality, can ensure safer and more effective vaccination as well as higher coverage rates.
Purpose The objective of this study was to assess ISPs in Primary Healthcare Centers (PHCs) in Wasit province.
Methodology We conducted this cross-sectional study on 24(44%) PHCs in Wasit prov-ince, selected by simple random sampling. Based on WHO and the national guidelines, checklists were developed to assess 58 ISPs that were grouped into seven domains: vaccine and diluent management, cold chain management, session's equipment, communication with clients and caregivers, vaccine preparation and administration, card review and registration and waste management. The score (out of 100%) was calculated for each domain in all selected PHCs, then the average for all domains was calculated in each PHC. The assessment was made by direct on-job observation of immunization sessions, through a single visit conducted to each PHC.

Results
PHCs were ranging in their ISPs: 52-78%; with a mean of 67% (± 8%). The high-est scores were for the following domains: session's equipment (88%), waste management (82%) and card review and registration (81%). The least achieving domains were: communication with clients and caregivers (36%) and cold chain management (38%). Vaccine preparation and administration was scoring 69%, whereas the score for vaccine and diluent management was only 50%.
Conclusions ISPs practiced in PHCs in Wasit province were far from the standard. National Expanded Program on Immunization should work on raising the capacity of vaccinators, particularly their communication skills with the clients and caregivers and the management of vaccines and cold chain. Background In Lebanon, MMR was introduced at 12 months and 4-5 years in 1996. In 2014, the 2nd MMR dose was shifted to 18 months with 79% coverage; a six-fold increase in mumps national incidence was observed in December.

Vaccine Preventable Diseases
Purpose This study aims to determine mumps vaccine effectiveness (VE) among Lebanese population to guide immunization policies.

Methodology Clinical and confirmed mumps cases reported to Epidemiological Surveillance Program between 2014W46
and 2015W11 were eligible if Lebanese and aged 1.5 to 19 years-old. They were matched 1:1 on age and locality to randomly selected controls using phonebook of the same area. Information was collected by structured phone interviews. Mumps vaccination status was based on documented valid dates for MMR doses. Data were entered using Epidata 3 and analyzed using Stata13. VE [(1-OR) x100] of one and two doses and ORs (95%CI) for acquiring mumps were estimated using conditional logistic regression.
Conclusions Two-doses of MMR vaccine were estimated as 88% effective against mumps, similar to results found in the literature. Suboptimal MMR2 coverage can explain this outbreak. Efforts should focus on achieving high MMR coverage and raising population's awareness about preserving documentation of vaccination.
Background Meningitis remains a serious public health problem worldwide. Morocco has implemented a national program against this disease since 1989, but it still causes high morbidity and mortality, with an average rate of lethality of 10%.
Purpose Our study aims to describe the epidemiology profile of meningitis in the prefecture of Temara from 2011 to 2016.
Methodology We conducted a descriptive study of all cases of meningitis reported to the Provincial Epidemiology Unit (CPE) of the province of Temara in Morocco between 2011 and 2016. We collected data from the database of the CPE at the prefectural delegation of health. Data analysis was done using the Epi-info software.
Results During our study period, we recorded 140 meningitis cases. Trend shows a maximum of cases in 2012 (34.0%), because we tested an application of instant declaration via internet which was abandoned. Cases were males in 59.0% and most were in urban areas (80.0%). The mean age was 40.5 years and the most affected age group was 5 to 15 years (28.5%). Most cases of meningitis (51.4%) were presumptively attributed to bacterial pathogens without final determination of causative organisms, and a third of cases were viral meningitis (30.0%). Only 9.0% of cases were culture-confirmed. The mains pathogens were Nesseria meningitidis (5 cases = 38.5%) followed by pneumo-coccus (4 cases, 30.7%) and Heamophilus influenza (1 case, 7.6%). Among patients with known outcome (n=36), case-fatality rate was 33.3%. Investigations around cases were carried out. should be available to increase the confirmation rate. We also need to strengthen the involvement of the private sector which is very weak in notification. Background Measles are one of the leading causes of vaccine-preventable death among young children in the worldwide. In Morocco, vaccination against measles has been introduced into the National Immunization Program (NIP) since 1987, as a single dose at nine months old. A second dose has been introduced since 2003 as part of the elimination strategy.

Vaccine Preventable Diseases
Purpose The purpose of our work was to evaluate the vaccine effectiveness of measles vaccination after the first and the second dose among children aged between 12 and 60 months, from 2010 to 2016 in Morocco.

Methodology
We conducted a test negative design using data from the measles surveillance system. Only children aged 12-60 months with laboratory result recorded was included. The vaccine status (unvaccinated, vaccinated one dose, vaccinated two doses) was defined among cases: children who had confirmed infection (presence of IgM specific antibodies for measles) and controls: children who had negative lab result (absence of IgM specific antibodies for measles). Vaccine effectiveness (VE) was estimated using the formula VE = [1-odds ratio (vaccinated/ unvaccinated)] × 100.

Results
In total 897 children were included from January 2010 to December 2016. The mean age was 36 months. The male female sex ratio was 0.8:1. According to the vaccination status, 785 were vaccinated, 79% of them have received one dose and 21% have received two doses. Lab result was positive for 186 (21%) of 897 patients. VE was 87% (CI 95%: 82%-93%) after one dose and 97% (CI 95%: 93%-99%) after two doses.

Conclusions
The field assessment of vaccination effectiveness confirms that measles vaccine is an effective way to prevent measles especially with two doses. The NIP should be reinforced by more vaccination campaign to cover all children who have not received the second dose.
Background On April 14, 2017, two measles cases were reported by local health practitioner from Farash Town. A team of FELTP fellows were deputed to investigate the outbreak.
Purpose On the request of district health authorities an outbreak investigation was conducted to assess magnitude, identify risk factors and recommend control measures.
Methodology Outbreak investigation was carried out from April 18 to May 05, 2017. Active case finding was conducted through a house-to-house survey. A case was defined as "onset of maculopapular rash with fever and presence of any of the sign/symptoms like coryza, conjunctivitis and cough in a resident of Farash Town from March 25, 2017 to April 30, 2017". Community-based age and sex-matched controls were selected. Vaccine coverage survey was conducted in a cluster of 245 houses. Frequencies were calculated, attack rates computed, and vaccine efficacy was determined. Blood samples of 03 suspected cases were sent to Public Health Laboratories at NIH Islamabad for confirmation.

Title Potential Impact and Cost-Effectiveness of Rotavirus Vaccination in Afghanistan
Background Despite progress made in child survival in the past 20 years, 5.9 million children under five years died in 2015, with 9% of these deaths due to diarrhea. Rotavirus is responsible for more than a third of diarrhea deaths. In 2013, rotavirus was estimated to cause 215,000 deaths among children under five years, including 89,000 in Asia. As of April 2017, 92 countries worldwide have introduced rotavirus vaccination in their national immunization program. Afghanistan has applied for Gavi support to introduce rotavirus vaccination nationally.
Purpose This study estimates the potential impact and cost-effectiveness of a national rotavirus immunization program in Afghanistan.
Methodology This study examined the use of Rotarix® (RV1) administered using a twodose schedule at 6 and 10 weeks of age. We used the ProVac Initiative's UNIVAC model (version 1.2.09) to evaluate the impact and cost-effectiveness of a rotavirus vaccine program compared with no vaccine over ten birth cohorts from 2017 to 2026 with a 3% annual discount rate. All monetary units are adjusted to 2017 US$.

Results
Rotavirus vaccination in Afghanistan has the potential to avert more than one million cases; 660,000 outpatient visits; approximately 50,000 hospital admissions; 650,000 DALYs; and 12,000 deaths, over 10 years. Not accounting for any Gavi subsi-dy, rotavirus vaccination can avert DALYs at US$82/DALY from the government perspective and US$80/DALY from the societal perspective. With Gavi support, DALYs can be averted at US$29/DALY and US$31/DALY from the societal and government perspective, respectively. The average yearly cost of a rotavirus vaccination program would represent 2.8% of the total immunization budget expected in 2017 and 0.1% of total health expenditure.

Conclusions
The introduction of rotavirus vaccination would be highly cost-effective in Afghanistan, and even more so with a Gavi subsidy.
Background District Health Officer Gwadar reported chikungunya cases to Provincial Disease Surveillance and Response Unit Quetta and requested for an epidemiological field investigation.
Purpose A team sent to confirm, investigate and suggest control measures on 17th March 2017.
Methodology A case was defined as a resident of District Gwadar with history of fever with joints pain within last 03 months (January -March 2017). Active case finding was done from 18th to 24th March 2017. Public and private health facilities were visited to review their records. water storage and sanitation practices for vector identification were assessed.
Conclusions Lack of proper sanitation and storage techniques in combination of warmer temperature of this coastal district are most probable causes of outbreak. Awareness sessions among community, district administration and healthcare providers regarding chikungunya, its prevention and control were conducted along with vector control on immediate basis through fogging of reservoirs and internal residual spray (IRS). Surveillance system established for regular reporting.
Title An Outbreak Investigation of Chikungunya Fever -District Tharparkar, Pakistan, August 2017 Background On 8th August 2017 print media reported 49 cases of fever with severe joint pains from different villages of District Tharparkar. On the same day a team of FELTP fellows was deputed to investigate the situation.
Purpose The objectives of the investigation were to determine the extent of outbreak, evaluate the risk factors and suggest recommendation for control. Methodology A descriptive followed by age and sex-matched case-control study was conducted in District Tharparkar in August 2017. Review of reported cases and active case finding was conducted. A case was defined as acute onset of fever (102°F) and severe arthralgia or arthritis not explained by other medical conditions, in a resident of District Tharparkar from 13 July to 27 August 2017. " A structured questionnaire was used to collect the information. Blood samples were sent to National Institute of Health for confirmation RT-PCR. An entomological survey was conducted in the affected area. Frequencies were calculated, attack rates computed, and multivariate analysis undertaken at 95% confidence interval and a 5% margin of error.
Results A total of 204 cases were identified, 155 through active case search. Mean age was 25.5 years (range 01 month -80 years) with a female preponderance (n=112; attack rate (AR) 54%). The overall AR was 26.7/1000, with 20-29 years being the most severely Conclusions Presence of uncovered water containers in the house were potential breeding sites for the vector and was the most probable cause of the outbreak. Indoor residual spray followed by fogging and community awareness were conducted.
Background About 50 to 100 million people get infected with Dengue every year. Since 2003, Pakistan has seen multiple outbreaks with biggest one in 2011 in Lahore involving 22,000 cases. From August 6 to September 16, 2017, 112 Dengue fever cases were reported to a hospital in town X of District Peshawar.
Purpose A case-control study was conducted to assess the magnitude of the disease, evaluate risk factors and recommend control measures.
Methodology A desk review of available records and active case finding was conducted. A case was defined as "fever of >38 0C for 2 to 10 days with minimum two of the following; headache, rash, retro-orbital pain, myalgia and bleeding in a resident of town X from July 24 to September 21, 2017 and a positive NS-1 test". Age and sex-matched controls were identified from the same locality. A structured questionnaire was used to collect information about cases and controls. Frequencies were calculated, attack rates computed, and odd ratios determined at 95% confidence interval with p value <0.05.

Results
A total of 140 cases were identified (28 cases through active case finding) with mean age of 28.9 years (range 8-55 years). Male to female ratio was 8:1 with an overall attack rate of 9.3%. The most affected age group was 21-30 Conclusions Presence of open water containers inside the house served as breeding grounds for the vector and were the most probable cause of the outbreak. Regular use of repellents was shown to be protective. Local breeding sites were destroyed, and residents were educated Background Dengue is the most rapidly spreading mosquito-borne viral disease in the world. It is one of the important public health emergencies of international concern as per International Health Regulations (IHR). In Punjab the disease suddenly saw an upsurge towards August 2011 especially in Lahore and adjoining areas of Punjab. By 2011, total of 20864 cases of Dengue had been reported in the province, including 17256 in Lahore alone. A large number of these cases i.e. 21292 in Punjab including 17232 in Lahore only were cured while a total of 352 deaths including 279 in Lahore were reported. Apart from Lahore, maximum number of cases have been reported from Faisalabad (783), followed by Rawalpindi (410), Pakpattan (233) and Sheikhupu-ra (225).
Purpose To identify epidemiological determinants responsible for causation of Dengue for preventing future outbreaks in the study area particularly and in Punjab in general.
Methodology A case control study was conducted in December 2013 to identify the epidemiological determinants for spread of Dengue Fever. Cases were those confirmed with IgM/IgG positive (n=147) living in Data Ganjbaksh town Lahore and controls (n=300) were selected from the same area who were suspected cases with laboratory negative results. A standardized questionnaire was developed to collect data. A line list of cases was developed, and data was analyzed using Epi Info® version 7.0 Results Variables found significant in the bivariate analysis were included in a logistic regression analysis. The presence of indoor stagnant water (OR = 3.7), indoor larvae (OR = 3.1), not using repellent (OR = 2.7), and older age (OR = 1.2) were independent determinants of dengue infection (P < 0.01 for all).
Conclusions Health education campaigns for improved water storage practices. Indoor residual sprays in urban and peri-urban high-risk areas 1 month before the transmission period. Community based environmental management was recommended.
Background Dengue fever is an acute arboviral disease transmitted to humans by bite of mosquito genus Aedes. On September 13, 2015, private hospital reported cluster of 19 suspected dengue cases from district Malir. In response to this, we initiated an epidemiological and entomological investigation.
Purpose To know magnitude, risk factors, Contain and suggest recommendations.
Methodology Descriptive followed by case-control study was carried-out Age-and sex-matched controls were taken with a ratio of 1:2. World Health Organization standard case definition was used to identify suspected and confirmed cases. Active case finding done in health facilities and in com-munity from September 14 to November 10, 2015.Data were analyzed using EpiInfo® version 7.0. Bivariate analysis done on 95% Confidence interval with 5% margin of error. Blood was collected for confirmation. Entomological surveillance was carried out.
Conclusions Stagnant of fresh water in and around domestic premises and not using of repellents in homes and larvicides were most probable causes of this outbreak. Failure to implement mosquito preventive control measures may have contributed to this outbreak. Establishment of isolation wards, Mass awareness, distribution of bed nets, spraying mosquito insecticide and fogging contributed to control outbreak.
Title Outbreak Investigation of Dengue Fever in Water Scarce District Tharparkar of Pakistan, 2016.
Background On 8th December 2016, 43 cases of dengue fever were reported from Tharparkar to Director General Health Office. The very next day FELTP fellows were assigned to investigate the outbreak.
Purpose Objectives were to assess the magnitude, evaluate the risk factors and recommend control measures.
Methodology Review of hospital records and active case finding was done. A descriptive followed by a case control study was conducted in December 2016. A case was defined as acute fever more than 102°F lasting >3 days, plus a positive NS-1 test in a resident of Tharparkar during September to December 2016. During entomological survey objects containing water were sampled and investigated for presence of larvae or pupa. The collected vectors were examined for species identification.
Methodology A case was defined as a resident of Tehsil Spinwam with one or more papular, nodular or ulcerative lesions on the skin after history of sand fly bite from February 2016 to April 2016.Hospital records were reviewed, patients and health staff were interviewed, and suspected sites visited. A case control study was conducted with one control for each case.

Conclusions
The area is bordering with Afghanistan and index case had a travel history from Afghanistan four months before appearance of his lesion. He left it untreated allowing the parasite to be transmitted to the indigenous sandflies and subsequently resulted in an outbreak. Based on results existing surveillance system for Leishmaniasis was strengthened, indoor residual spray and fumigation for vector control carried out, bed nets and insect repellants provision were ensured. Injection Glucontine was arranged. Regular awareness sessions were recommended. During the 04-month follow up period 32 cases were reported who had sand fly-bite histories of longer than 05 months.

Background On 7 August 2017, District
Health office received information about 2 deaths due to high grade fever at Usta Mohammad. 7 similar cases were also reported from same village.
Purpose Descriptive followed by Case Control study was conducted to investigate outbreak and to assess risk factors Methodology Descriptive followed by Case Control study was conducted to investigate outbreak and to assess risk factors. Case was defined "any person resident of Usta Mohammad, regardless of age and sex, having fever with chills with August 7th August to 26th September 2017. Review of hospital records and active case finding was done through house to house survey. Matched for Age and sex controls were taken from locality with a ratio of 1:2 and interviewed. Blood samples were taken for microscopy and rapid diagnostic tests. Data were analyzed using EpiInfo® version 7.0.
Conclusions Stagnant Pond water was major mosquito breeding site and probable cause of outbreak. Mass awareness, Residual sprays, pond treatment by larvicidal, provision of bed nets and prophylaxis with chloroquine were able to control the outbreak. Background On May 26th 2014, new malaria cases were reported from Aswan in upper Egypt to the ministry of health and population (MOHP) through the national surveillance system(NEDSS), with no history of travel to a malaria-endemic country. MOHP interfered with a rapid response team(RRT) to investigate and contain any suspected outbreak. Efforts were concentrated on active-case finding, laboratory testing, entomological surveillance, proper treatment of patients and health education Purpose To investigate and contain any suspected outbreak. Methodology Field investigation in the affected village and its surrounding 15 villages. started on May 28th,2014 after confirmation of the first case. The RRT used a standardized case definition and distributed it to all hospitals and health unites in Aswan. Cases were diagnosed clinically, and laboratory confirmed. Active case finding was done. Investigation continued till June 19th till no additional cases were reported. Results A total of 319 suspected cases at Edfu Fever Hospital; about 14,696 samples examined during active case-finding; where 4 samples proved positive and were transferred to Edfu Fever Hospital to receive proper treatment. A total of 22 cases were confirmed for malaria, all were caused by P. vivax. The median age of patients was 19 (range 6-90 years), with male: female ratio 1:1. No complications or deaths were reported. All cases were discharged after full recovery and after performing 4 blood films all of which are negative for plasmodia. Background CCHF cases from Balochistan and Afghanistan are referred to isolation ward in Quetta. CCHF is endemic to Balochistan but still there is no established surveillance system in province and no tick bite reporting system. The main objective was to determine the means of transmission and the epidemiologic characteristics of disease.

Vector Borne Diseases
Purpose Describe the Epidemiology of CCHF and analyze the situation of health facility.
Methodology A descriptive study was carried out in the CCHF isolation ward in Quetta from March-August 2017. Using standardized case definition, all patients admitted in Isolation ward with clinical evidence of CCHF were included in the study. After taking informed consent, data was collected on demographic factors, history of animal contact, tick bite history, co morbidity, laboratory results and treatment outcome. Means and percentages were calculated.

Results
During the study period, 51 suspected CCHF patients were admitted in Isolation ward, 38 (74.5%) males were affected. Mean age of the cases was 30 years (range 02-75years). Most affected 16 (31%) age group was 21-30 years.48 (94%) cases had history of animal contact and 44 (86%) with tick bite. Majority of cases 42 (82%) were reported from May -August. 30 patients in study were tested by PCR, 16 (53.3%) were positive, out of which 5 (31%) expired. It is only isolation ward in whole province with 02 doctors, 02 nurses & 01 paramedics. Proper Personal protective equipment was not available. No Laboratory was available for immediate investigations.
Conclusions Given the overall results important risk factors for CCHF are history of tick bite, high-risk occupations and having contact with livestock. Public health measures should focus on preventing tick bites, increasing awareness of CCHF signs and symptoms, adopting hospital infection control practices, timely investigation & treatment to reduce mortality. Government should set up isolation units in all Major hospitals with proper surveillance system in Province.
Background Avian influenza H9N2 is highly endemic in commercial and backyard poultry in Pakistan. Its widespread circulation and high mutation rates provide a possibility of novel reassorted viruses hence posing a serious public health threat.
Purpose This study was aimed to isolate and evaluate the AI H9N2 viruses circulating in poultry as well as aquatic birds in Pakistan between 2014 and 2017.
Methodology Specimens were collected from morbid or dead birds suspected for AI H9N2 on the basis of clinical signs or post-mortem lesions brought to five poultry diagnostic laboratories in Punjab. The sam-ples were subjected for virus isolation. The isolates then were confirmed for H and N type using PCR. Six isolates were subjected to phylogenetic analysis of Haemagglutinin gene. The results were compared with isolate reported previously from Pakistan and other regional countries for homology.
Results 129,622 samples from 7481 poultry flocks were processed, 5.3% (399/7481) were positive for AIV H9N2. Sequence analysis showed that it had homology of 84-93% with different regional strains. Changes were seen at 24 different sites and at cleavage site at K148R and I151R in comparison to previous Pakistani isolates. Six possible glycosylation sites were observed. Neigh-bor joining phylogenetic tree confirmed its 93.4% homology with the isolate of Iran.
The isolates were the same clade as other regional isolates and have common ancestors. Background Non-typhoid salmonella infections are one of the leading food borne infections worldwide. Similarly, ever increasing antimicrobial resistance has become a major problem to animal as well as human health worldwide. Poultry being the single largest animal protein source in Pakistan is one of the major suspects for both these public health concerns.

Conclusions The prevailing H9N2 viruses in
Purpose This study was aimed to determine the prevalence of Salmonella Enteritidis and Salmonella Typhimurium in commercial poultry flocks of Punjab and to evaluate their antimicrobial susceptibility patterns.
Methodology Specimens were collected from morbid or dead birds suspected for salmonella infection on the basis of clinical signs or post-mortem lesions brought to five poultry diagnostic laboratories in Punjab between 2014 and 2017. The samples were then processed for bacterial isolation and molecular confirmation through PCR. The isolates were then subjected to antibiotic sensitivity test using disc diffusion method. The susceptibility was determined using CLSI guidelines for antimicrobial susceptibility testing. The frequencies and percentages were calculated using Epi info.
Conclusions Salmonella isolates were found more sensitive to Ciprofloxacin, followed by Gentamicin, Enrofloxacin and Amoxicillin while the isolates were least sensitive to Doxycycline.
Background Brucellosis is a bacterial disease caused by genus brucella. Bovine brucellosis affects cattle, sheep & goats, camels, equines, dogs and may also infects other animals. The disease in animals is characterized by abortion in last trimester and reproductive failure. All ages of cattle are susceptible, and infection can last for many years. Infected males develop epididymitis, orchitis and testicular abscesses. In humans, brucellosis can be caused by B. abortus, B. melitensis, B.suis (biovars 1-4) and rarely B. canis. The major losses caused by brucellosis are; decreased milk production, weight loss, calf mortality, infertility and lameness.
Purpose To identify the animals infected with brucellosis in selected districts and to develop disease control and mitigation measures of brucellosis.

Methodology
The present study was aimed to determine the prevalence of brucellosis in cattle with reproductive disorders, randomly selected cattle, cross breed cattle and small ruminants (sheep and goat) in eight districts of Sindh by Milk Ring Test (MRT), Rose Bengal Plate Test (RBPT) and Indirect ELISA.
Results A total of 4559 animals with reproductive disorders (4225 female and 334 male) were screened. The prevalence was found 25.16% in female cattle while 27.84% in male cattle. A total of 6390 randomly selected animals (6248 female and 142 male) were screened. The prevalence was found to be 10.57% in female cattle while 21.12% in male cattle. The 1002 samples were screened from cross breed cattle, the prevalence was 25.54%. A total of 1639 samples were screened from sheep and goat. The prevalence was found to be 14.46%.

Conclusions It was concluded from the present study that brucellosis is endemic in
Sindh, therefore the prevention of brucellosis with vaccination is best policy for the control of the disease.

Zoonotic Diseases
Abstract Background Brucellosis is endemic in Pakistan and poses a great challenge owing to nonspecific clinical manifestations. On 7th January 2017 three workers of cattle dairy farm at Renala Khurd reported to have intermittent fever.
Purpose A team was sent on 8th January 2017 to estimate magnitude of outbreak, evaluate risk factors and recommend control measures.
Methodology A case was defined as "prolonged intermittent fever, profuse night sweats and headache in a worker of cattle dairy farm at Renala Khurd from 7th to 21st January 2017. " Cases and controls were matched by age and locality (1:4). Epidemiological information was recorded on a questionnaire. Serological testing was conducted using Rose Bengal plate test & iELI-SA. Frequencies were calculated, odd ratios determined at 95% confidence interval with p value less than 0.05.

Conclusions
The most probable cause of this outbreak was consumption of unprocessed contaminated milk and contact with secretions/excretions of infected animals. Monthly screening of workers, for a period of six months was recommended. Human cases were referred for medical treatment and Department of Health was notified.
Background Brucellosis is prevalent in livestock causing huge economic losses due to loss of production. On January 4, 2017, six abortions at third trimester of gestation were reported from a cattle dairy farm at Renalakhurd, District Okara.
Purpose An Outbreak investigation was initiated to assess the magnitude, identify risk factors and recommend control measures.
Methodology A case-control study was conducted. A case was defined as "adult cow in the affected dairy farm aborting at third trimester, without fever, from 18th December 2016 to 7th January 2017". Agematched controls were selected from the same farm (1:4). Semen doses used for insemination, were tested by molecular and culturing technique. Serological testing was done through RBPT and i-ELISA. Frequencies were calculated, odd ratios determined calculated at 95% confidence interval with p value less than 0.05.

Results
A total of 49 pregnant cows were identified and 16 of them had aborted at 3rd trimester. The age ranged from 5-7 year (median=5 year). For the 16 cases attack rate was 33% for aborting cows, 24% for close contact cows. The aborting cows were more likely to have brucellosis (OR: 35; 95%CI: 7-175; p=0.00) as compared to non-aborting cows and close contact cows were more likely to have brucellosis (OR: 5; 95%CI: 1.4-16; p=0.017) as compared to cows from other sheds. A total of 18.4% (23/125) farm cattle were found infected with brucellosis on serological testing. Brucellae were not detected in semen doses. Index case was a newly added (2 month before) exotic cow that was not screened by RBPT neither quarantined.
Conclusions Infected exotic cow was the most probable cause of the outbreak. Healthy animals got infection by licking aborted fetus or vaginal secretions of aborting cow. Vaccination of eligible calves using strain19, culling of confirmed cases, isolation of pregnant cows, screening & quarantine of newly purchased animals was recommended.

Zoonotic Diseases
Abstract Background Anthrax is endemic and human infection has been identified in 15 of 64 districts of Bangladesh. Outbreak are associated with exposure to infected animals during droughts, floods or soil disturbances. On September 6, 2017 the civil surgeon of Rajbari District, reported six people with anthrax like lesions with exposure to one sick cow.
Purpose We investigated to determine cause of outbreak, describe the epidemiological and clinical features of cases, and to control the outbreak.

Methodology
We selected cutaneous anthrax cases among the people presented with painless skin lesion including papular, vesicular and depressed black eschar living in Kalukhali, Rajbarj from 27th August to 09th September 2017. Human cases exposure with sick cow identified by contract tracing. We interviewed the suspected cases for clinical symptoms and types of exposure. We collected skin swabs from 5 humans and meat from the slaughtered sick cow and tested these samples by RT-PCR.

Results
We found 11 cases from community by contract tracing and 6 cases from medical record. Most (71%) cases were male; median age of cases was 30 years. Among the cases, five females cleaned meat, nine males butchered the animal, and three males carried the meat. Most (59%) cutaneous lesions were found on hands. The cattle became sick after eating of "Kolmi shak" (water spinach) from a nearby flooded area. Cutaneous symptoms developed in 1 to 9 days (median 5 days). Bacillus anthacis was positive by PCR in one cattle meat sample and one human swab sample.
Conclusions This was the first reported anthrax outbreak in the Rajbari district. To control this outbreak, all the cattle in the village were vaccinated and an awareness program to avoid slaughtering of sick cattle was conducted. To prevent future outbreaks, anthrax vaccination of ruminants should be conducted yearly, and priority should be given in the flood affected district. Methodology This is a retrospective descriptive study, using data reported from 2007 to 2016. MDR-TB cases were defined as confirmed based on rapid diagnostic test "Xpert MTB/RIF" and Conventional DST results. The description focused on the analysis of temporo-spatial distribution, the individual characteristics and classification of the MDR-TB cases. Analysis was done using Epi-Info 7. Conclusions Trend towards increased of MDR-TB cases was observed. MDR-TB affected young men, aged 15-45 years, resident in urban area and who have previously received anti-TB treatment. It is recommended to improve treatment outcomes for sensible tuberculosis patients, specially to fight against TB treatment failure; to maintain the efforts for MDR-TB detection among patients previously received anti-TB treatment and to strength MDR-TB detection among new TB patients.

Results
Background Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial and community pathogen. It has a high impact not only on patient morbidity and mortality but also on hospitalization costs.
Purpose This study was carried out to determine the frequency of Methicillin-resistant Staphylococcus aureus (MRSA) in a tertiary care hospital.
Methodology This descriptive study was carried out in the Department of Microbiology, Abbas Institute of Medical Sciences Muzaffarabad from December 2015 to November 2017. Various clinical specimens of both indoor and outdoor patients were received in the laboratory of the hospital. All specimens were inoculated on appropriate media. Staph aureus was identified on the basis of colony morphology, Gram staining, catalase test, coagulase test and DNase test. All confirmed S. aureus isolates were screened for methicillin resistance using cefoxitin (Fox) disc. To check methicillin resistance, bacterial lawn was prepared on Mueller-Hinton agar and Fox disk was placed on it, followed by incubation at 37 °C for 18 to 24 hours. Antibiotic sensitivity was interpreted as per the CLSI guidelines (CLSI 2015). and interviews were held using semi structured questionnaire. Background For the successful Anti-tubercular treatment the relapse rate is an important indicator for the success of any treatment regimen, but it has not been normally measured. So a study was planned to examine the predictors of relapse among a cohort of sputum smear-positive pulmonary tuberculosis (PTB) patients who had successfully completed treatment of tuberculosis and the frequency of drug resistance among them.

Results
Purpose To determine the frequency of drug resistance among the patients and determine factors associated with relapse among anti-tubercular treatment completed pulmonary TB patients under DOTS program.
Methodology After taking the informed written consent 200 relapsed patients were enrolled and are suspected to have relapse of pulmonary tuberculosis. From each patient two sputum specimens were collected for Ziehel Neelsen (ZN) smear microscopy and L-J culture. Those found positive on culture were subjected for drug susceptibility testing by standard drug proportion method on L-J medium .A semi-structured questionnaire was used to collect the information regarding the factors for relapse. Data was analyzed by using the SPSS.

Results
A total of 200 patients were enrolled in the study. The major factors for the relapse were found to be previous addiction history (50%) and non-adherence to the pre-vious treatment (52.5%). Around 167(83.5%) cases had not submitted the sputum at the end of previous treatment for which they were considered to be cured of TB. Among the Co-morbidities the diabetes is found to be very prominent as most the diabetic patients 45(22.5%) had relapse of TB. Regarding drug resistance the isoniazid and rifampicin resistance were 36% and 28% respectively.
Conclusions Important factors associated with the relapse of TB are addiction and non-adherence to the previous treatment so steps needs to be taken to stop the development of Drug resistance.

POSTER ABSTRACT PRESENTATIONS
Background WHO estimates that, worldwide, almost four million stillbirths occur each year (7,8). Many of the conditions linked to stillbirth could be prevented or treated. No available data in Jordan about rates and common causes of stillbirth.
Purpose This study was conducted to determine stillbirth rate in Jordan and determine its main causes.

Methodology
The study is based on secondary data analysis from the national study of perinatal mortality which was conducted between 2011 and 2012 in Jordan. Extensive data were collected on each woman included in the study and her newborn through interview and by abstraction relevant data from medical records. The stillbirth rate was calculated as the number of stillbirths per 1,000 live births plus fetal deaths (stillbirths). The causes of stillbirths were ascertained using the NICE classification system.

Results
A total of 21,928 women gave birth to 22,591 births (22,330 live births and 261 Stillbirths) at 20 weeks of gestation or later in the 18 selected hospitals during the period 1st March 2011 and 30th April 2012. The rates of stillbirths were 11.6/1,000 total births for a gestational period of =20 weeks. According to the WHO and UNICEF's international reporting criteria, the corrected stillbirth rate was 8.2 per 1,000 total births. According to NICE classification, the main causes of stillbirths were maternal diseases (19.5%), un-explained immaturity (18.8%), congenital anomalies (17.6%), unexplained antepartum stillbirths (17.6%), obstetric complications (8.4%), placental abruption (5.7%) and multiple births (5%). It was judged that 34.5% of all fetal deaths were preventable and 30.3% were possibly preventable with optimal care.

Conclusions
The rate of stillbirth in Jordan is comparable to that in other neighboring countries. However, many of the conditions that were shown to be linked to stillbirth in this study could be prevented or treated.
Evidence-based and cost-effective interventions needed to be implemented to decrease the burden of stillbirth. Purpose To investigate Neonatal Tetanus cases to evaluate and determine risk factors for mortality from Neonatal Tetanus and to make recommendation for future strategies.

Maternal and Child Health
Methodology Case-control study was conducted in District Naseerabad. Matched for Age and sex, controls were taken from community with a ratio of 1:2 and interviewed. Case was defined "any neonate resident of Naseerabad with a normal ability to suck and cry during the first 2 days of life; and who between 3-28 days of age cannot suck normally and becomes stiff or has convulsions during 2016-2017. " Hospital record and NNT surveillance data, case investigation form reviewed. Verbal autopsy and inspection of delivery scenes were conducted. Questionnaire was developed for data collection. Epi info version 7 was used for data compilation and analysis.
Results A total of 82 cases were identified. Mean age of cases was 8.6 days with range from 4-22 days. Male female ratio was 1.5:1. Overall Mortality was 18 (22%). 79 (96%) deliveries were conducted at homes by untrained traditional birth attendant with zero TT shots. Survived had significantly greater mean bodyweight, later onset of disease, hospitalized early and received TIG while generalized rigidity, fever, fits, cyanosis, undercurrent infections and respiratory arrest were significantly more common in fatal group. Delivery scenes were unclean on inspection. Significant statistical associations were found between umbilical cord cutting with unsterilized scissor (OR 12.9; CI 1.4 -13; p value <0.05) and NNT. Umbilical cord tied with unsterilized thread (P = 0.002), ash used to cover umbilical cord (P: 0.004), no hand washing during delivery by TBAs (P: 0.006), illiteracy (P: 0.0002), low socioeconomic status (P: 0.003), and nonuse of antenatal care services played aggravating role.

Conclusions
Poor TT immunization and umbilical cord cutting with unsterilized scissor were probable cause. Lack of awareness regarding antenatal care and poor hygienic deliveries were main risk factors. Enhancing antenatal care, improvement in TT vaccination coverage and awareness in community regarding TT vaccination were recommended.

POSTER ABSTRACT PRESENTATIONS
Background According to World Health Organization (WHO) around two million Afghans (almost 7% of the total population) suffer from mental disorders. Mental health (MH) became a part of Basic Package of Health Services (BPHS) in 2005 and integrated as community-based MH services to Primary healthcare (PHC) level. Due to this initiative, the availability and accessibility of MH services have significantly increased, however the quality of services is still not up the mark.
Purpose Explore the factors affecting quality of MH services at PHC level in Kabul, Afghanistan.
Methodology This qualitative exploratory study was conducted from July to September 2016 at five PHC clinics in Kabul. A purposive sampling technique was used. In-depth interviews (IDIs) were conducted with patients' attendants and clinics' staff. Key informants' interviews (KIIs) were conducted with MH senior management staff of MoPH and implementing NGOs. Desk review was also done. The data were triangulated and manually analyzed by using thematic approach.

Results
The findings of study draw a connection between the main influences on the quality of MH in Kabul-specifically financial constraints, security problems, weak stewardship, corruption, poor management and limited public health capacity of the MH department. Moreover, shortage and low quality of supplies, turnover of staff, high workload, lack of work plan, low salaries and no benefits for clinic staff were perceived to be the major barriers. Above all, fragile monitoring and evaluation system, weak coordination, low public awareness, and lack of community support were found to be the major factors undermining the quality of MH service at PHC clinics a in the country.

Conclusions Study findings highlighted
various factors affecting quality of MH in PHC clinics which need to be considered by healthcare providers, health system managers, and policy makers for improving quality of MH services at PHC clinics in Afghanistan. Methodology A cross-sectional study was conducted between Nov. -Jan. 2017 among sample of IDPs aged > 40 years selected randomly (multistage, systematic cluster sampling method). Thirty clusters were selected in the first stage and ten households from each cluster were selected randomly in the second stage. The selected IDPs were interviewed; a questionnaire including socio-demographic data and potential risk factors of D.M was filled. Associations between D.M and different risk factors were evaluated using the chi-square test. To assess the strength of association the odds ratio and 95% confidence interval of odds ratio was calculated.

Results
The total number of interviewed participants was 300. Of those, 68 were con-firmed as cases of D.M (prevalence 24%). Of confirmed cases, 24 (33%) were newly detected. Male: female ratio was 1: Background The prevalence of Non-Communicable Diseases is increasing throughout the world. Drugs and lifestyle changes to control Hypertension and diabetes and associated conditions can only be effective through adherence to the overall prescribed regimen. Reduced adherence not only results in poor health outcomes, but it also has a significant impact on healthcare costs.
Purpose To measure prevalence and identify the demographic, social and personal factors affecting adherence in a sample of diabetic and hypertensive patients, Baghdad, Iraq, 2016.
Methodology A cross-sectional study was conducted on a sample of 584 male and female adults with HTN and/or DM. Two ques-tionnaires were filled by direct interview. The first questionnaire for socio-demographic information and the second was the Morisky Medication Adherence Scale (MMAS-8). A score < 6 was considered poor, 6 -< 8 was considered moderate and 8 was considered good adherence. Dates of first symptoms, first consultation, diagnosis and of access to treatment were used to define different delays.

Results
Among the 132 women, 81% were diagnosed at advanced stage FIGO (IIB, III and IV). The median of "Total delay" and "patient delay" were respectively 35 and 15.5 weeks. High risk for a long "Total delay" more than 6 months was observed for women with children (ORa= 6.8, CI 1.0-46.0), having vaginal discharge (ORa=4.1, CI 1.02-16.1) and for who the diagnostic of cancer was serious (ORa=4.3, CI 1.3 -14.0). However, women had lower risk to have a "Total delay" more than 6 months when they had a family history of cancer (ORa=0.2, CI 0.05-0.60) and when they had used transport to consultation place (ORa=0.3, CI 0.08-0.82). Background The burden of NCDs is disproportionately carried by prisoners. Chief Justice of Pakistan ordered for the improvement of health status of prisoners in Punjab prisons. Subsequently this study was planned, to highlight areas for action.

Conclusions
Purpose To assess the prevalence of potential risk factors of NCDs among prison population in Punjab, Pakistan.
Methodology A descriptive cross-sectional study was undertaken. A total of 301 male adult prisoners were enrolled through proportionate random sampling from 29 prisons of Punjab. Anthropometric measurements taken and information on age, education, type of prisoner, recreational/work activities, and smoking gathered by trained medical staff. Prison diet menu reviewed. Fractions of basic dietary ingredients and per day caloric value of diet worked out.

Results
Mean age of participants was 40 years. Overall prevalence of obesity/overweight was 51% and Central obesity/overweight was 44%. Recreational facilities were not available in any prison. Convicted prisoners (CT) have been deputed for moderate physical labor. Under trial (UT) and condemned prisoners (CP) remained sedentary almost all the time. Prevalence of overweight/obesity among CP, UT and CT was 59%, 54% and 43%, respectively. Overweight/obesity depicted increasing trend with age. Being educated was significant-ly associated with obesity (OR 2.86; 95% CI 1.58-5.17, P < .05) and physical inactivity with central obesity (OR 1.6; 95% CI 1.03 -2.69, P < .05). Active and passive smoking among prisoners was 44% and 78% respectively. Daily caloric intake was 2955 (recommended; 2150 for sedentary and 2350 for moderate physical work). Daily added salt, fiber and fat intake was 7gms, 5 -6gms and 60gms respectively (recommended: added salt; < 5gms, fiber; 30gms and fat; <30gms).
Conclusions Prison population has shown high prevalence of multiple preventable risk factors of NCDs. We recommended revision of prison diet menu, arrangements for recreational activities and initiation of smoking cessation programs. Background End-stage renal failure (ESRF) become a major public health problem and it is highly prevalent globally. More than 1.4 million patients receiving renal replacement therapy (RRT) globally, with an annual incident rate reaching 8%. In Yemen 7000 new patients every year, the estimated annual incidence of ESRF in Sana'a region is 385 per million population.

Non-communicable Diseases
Purpose Identify the risk factors of ESRF in Sa'adah governorate of Yemen and provide recommendations to prevent and control ESRF.

Methodology A hospital-based case control study of ESRF patients attending Aljomhory
Hemodialysis center in Sa'adah. We interviewed 349 persons, 86 of them were cases attending Aljomhory Hemodialysis center for regular hemodialysis and 263 were control who are healthy persons, the case definition of ESRF is GFR (< 15 mL/min/1.73 m²) or very high albuminuria (>300 mg/24 h). Analysis was performed using Epi Info, OR was calculated.
Conclusions Hypertension, recurrent urinary tract infection, urolithiasis, and family history of ESRF were risk factors for ESRF in Sa'adah, north of Yemen. Follow up for those factors well help to prevent and control ESRF. Background Staphylococcal food poisoning is one of the most common food-borne disease worldwide. The incidence of food poisoning is underestimated, in Belgrade several individual cases are registered each month. On October 3, 2017, the Institute of Public Health of Belgrade received the information of potential outbreak-20 cases of gastroenteritis in one school in Belgrade.

Outbreak Investigation/FWBD
Purpose To investigate the potential outbreak and to identify the etiologic agent and the source of the infection with intention to recommend the control measures.
Methodology A retrospective cohort study was used. Study population was 2,276 children from 21 schools in Belgrade. The standardized epidemiological questionnaire for data collection was used. A case was defined as a consumer of macaroni with Bolognese sauce prepared in one catering company and served at lunch time (11:30-14:00h) in 21 schools at 2nd October 2017 vomiting AND/ OR diarrhea AND/OR stomach cramps developed within 8 hours.

Results
In total 176 cases from 21 schools in Belgrade were identified with a median age of 7.8 years (range:6-12). The onset of illness for all cases was the 2nd October 2017. Macaroni with Bolognese sauce was associated with illness (RR=114.5, 95% CI:15.5 to 785.1). First and second graders in schools were at greatest risk of food poisoning comparing with older students (RR=76.2, 95% CI:10.7 to 543.3; RR=33.2, 95% CI:4.6 to 242.2). Two samples of food (macaroni with Bolognese sauce on 2nd October and cabbage salad on 3rd October) were collected in two schools.
In the throat/nose swabs of five food handlers, staphylococcus aureus was detected. Purpose A FELTP fellow was assigned were to confirm, investigate outbreak identify and risk factor and suggest control measures on 28th December 2016.

Conclusions
Methodology A case was defined as any person resident of village Kakshai District Zhob with high grade fever, maculopapular rash and having any of following; conjunctivitis, coryza or cough, from December 13, 2016 to January 11, 2017. Descriptive study was conducted through active case finding, deaths were verified by verbal autopsy and vaccination status was assessed. Blood samples collected and sent to National Institute of Health.

Conclusions
Most probable cause of outbreak was no routine immunization and poor nutritional status of children of village. Misconceptions and unawareness found regarding RI in affected Village. We recommended Immediate Mass vaccination of whole village and a total 250 children were vaccinated. Awareness sessions conducted among community regarding importance of RI, Health/Personal Hygiene. Surveillance for measles and other VPD diseases needs improvement to prevent future outbreaks. Purpose To estimate the magnitude, evaluate risk factors and formulate control measures.

Methodology
The investigation was carried out from 26th September to 10th October 2017. Review of reported cases and active case finding was carried out and verbal autopsies were conducted for deceased children. A case was defined as sudden onset of fever with maculopapular rash and one of the following clinical features; cough, coryza and conjunctivitis in a resident of Village Jogi Sabbri from 22nd August to 10th October 2017. Vaccination coverage survey was done using 30 x 7 cluster-sampling strategy. Blood samples were sent to NIH Islamabad for Lab confirmation.

Conclusions
The most probable cause of the outbreak was low immunization status. Door to door vaccination campaign was initiated in the village and Vitamin A was also administered.
Background Measles is readily spread to susceptible individuals, a leading cause of morbidity and mortality in the developing countries including Pakistan. During week, 20 of May-2017 total 17 measles patients reported, eight cases from UC Anjani and seven cases from UC Kadda Orakzai Agency.
Purpose The objective of a field investigation to identify gaps and provide recommendations for measles outbreak response and immunization program improvement.

Methodology
The study conducted from 25th May to 8th June 2017.A case of measles was defined as "A person of any age resident of UC Anjani and UC Kadda, with rash, fever and at least one of the following cough, co-ryza and conjunctivitis presenting between 1st May to 8th June-2107. Epidemiological, clinical and risk factors were recorded and analyzed by using Epi Info.

Results
There were 51 cases and Zero deaths identified of measles during outbreak investigation. The symptoms were fever, rash, coryza and conjunctivitis in 51(100%) and pneumonia in 41(80%) of the 51 cases. About 22 (45%) cases were males and 28(55 %) were females. The mean age of cases was 56 months, while most of the cases 26 (51%) of 51cases were in the age group of 6-10 years. All of the 51(100%) respondent parents were illiterate. The vaccination status of all 51 (100%) cases were zero doses. The index case was on May 1, 2017 and cases in-creased from 5th May 2017.The EPI survey in UC Anjani were 40% RI coverage. The EPI survey in UC Kadda were 80% RI coverage. Majority 41(80.39 %) of 51respondents were unaware about RI, whereas 29 (56.36%) of 51 respondents stated that the vaccinator did not visit their areas. The Vaccine Efficacy were 28%.

Conclusions
This outbreak was a result of vaccination coverage gap. Functionalization of EPI centre, vaccinations of all children and mass education was strongly recommended. Outreach activity must be carried out regularly to reach scattered population. Surveillance for vaccine preventable diseases should be strengthened to prevent outbreaks. Background Epidemic meningitis in African meningitis belt remains an important public health problem. Sudan as one of 26 countries of the belt remain suffering of the diseases. Studying meningococcal carriage and human-to-human transmission is a key because Neisseria meningitides (Nm) hosted only by humans. Transmission of the meningococcal occurs usually through close contact or by air-borne large respiratory droplets from asymptomatic human carriers. Identifying the sero-types and the risk factors are essential to implement suitable control measures such as new vaccine introduction.

Outbreak Investigation/VPD
Purpose To study the frequency of coloniza-tion of Neisseria meningitides as well as the distribution of the different N. meningitides serotypes isolated from in healthy children from 1-15 years in Khartoum State 2016.
Methodology This is a cross-sectional community-based study in Khartoum State, Sudan. A total 824 of pharyngeal swabs were taken from children 1-15 years old using multi stage cluster sampling technique and processed using conventional PCR in order to identify Nm type and subtypes.

Results
The overall prevalence of Nm was 18.1%( 149 out of 824). In under 5 years children, the prevalence was 18.2% (25/137). The prevalence was 23.5% in children 5-15 years (124 out of 528). The dominant identified sero-groups was type C. Age group 5-15 years, living in crowdedness environment and passive smoking were in great risk to be a carrier positive.

Conclusions
The dominant sero-type was C with no detection of Nm type A which was predominant in Sudan, which is most probably due to the effect of conjugate A meningitis vaccine introduction. Risk factors associated with high risk acquisition rate of Nm carriage included age group 5-15, crowdedness and passive smoking. Therefore, it is recommended to introduce a new meningitis conjugate vaccine including sero-type C.

Respiratory Diseases
Abstract Background Hepatitis C viral infection is endemic in Egypt. Egyptian demographic health survey conducted in 2015 concluded that 4.4% of the populations have been infected. In 2001, the Ministry of Health and Population (MOHP) began developing the National Electronic Disease Surveillance System (NEDSS), an Egyptian communicable disease reporting system. In 2006, the webbased system was established and started in all Governorates in 2012. Acute viral hepatitis infection is one from the reportable diseases on the system.
Purpose Detect gaps of the system and give recommendations.
Methodology Reported cases of acute viral hepatitis were extracted from the NEDSS for year 2016. Hepatitis C cases were classified according to the criteria of surveillance case definition of the national surveillance guidelines into suspected, probable and confirmed. CDC guidelines were used to evaluate the system attributes. A structured questionnaire was designed to interview 22 participants randomly selected to evaluate the system on four levels: Epidemiology and surveillance general administration at the Ministry of Health (central level), Health directorate level, Health district level and Fever hospital level (peripheral levels).

Results
The total number of reported hepatitis C cases in Cairo in 2016 was 676 (527(78%) confirmed cases, 1 probable case and 148(22%) suspected cases). The system was simple (85.4%), flexible (85%), stable (77%), and acceptable (67%). Twelve variables were used for evaluating data completeness with mean 74.6%. Timeliness was not well expressed. The system had low representativeness and fairly sensitive but with 78% Predictive Value Positive. Results Based on records, the number of reported tuberculosis cases was 3797 over the five years. Its average incidence was higher in Meknes than the national rate with respectively 99 cases compared to 85cases/100 000 populations.88.5% of cases live in urban areas in poor and overcrowding conditions. The median age is 32 year showing male predominance with a sex ratio male/ female at 1.4. Primary pulmonary TB was predominant in 51% of cases. The TB detection methods were in passive screening in 54% of cases and in contact tracing in 1% of cases.

Conclusions
Confirmed tuberculosis cases represent 41% of reported cases. The treatment completion rate is 84.2%. The estimated case fatality rate is 3.6%. Treatment failure is 0.7% and the rate of lost to follow up is 7.1%. Tuberculosis VIH co-infection varied from 0.1% to 0.4%. Results Reporting mechanism of system was simple with use of standardized case definition. The system was flexible to accommodate other related health events and was acceptable to all stakeholders. The reports were 100% complete and 83% reports were received within stipulated time limits, but the system was lacking feedback mechanism to the grass root level. The system was stable as it was dependent on public funds. The representativeness was not good because it had no involvement of private sector. Sensitivity of the system was 0.07% while predictive value positive (PVP) was12.69%.

Conclusions
Conclusions Sensitivity and representativeness of the system needs to be improved by increasing coverage of the system and involvement of private sector. A mechanism is required to be established for sharing feedback to all levels of the systems.
Title Evaluation of Blood Transfusion Services in Public and Private Blood Bank Centers, Sana'a Capital, Yemen, 2016 Background Evaluating Blood Transfusion Services (BTS) is the corner stone to ensure its proper delivery and avoiding related problems such as transfusion-transmitted infections (TTIs).
Purpose To evaluate BTS at the main blood banks of the Sana'a Capital.

Methodology
The four main blood banks (BBs) in Sana'a Capital at the National Blood Transfusion and Research Centre (NBTRC), National Central Public Health Laboratories (NCPHL), University of Science and Technology Hospital (USTH) and Kuwait University Hospital (KUH) were evaluated according to World Health Organization safe BTS standards. Qualitative and quantitative data were collected through in-depth interviews with BBs officers using semi-structured questionnaires covering seven components: activities, quality assurance system (QAS), training, donation, grouping and compatibility testing, components, and screening for TTIs. An overall BTS score was calculated where < 60% was unsatisfactory, 60-79.9% satisfactory, = 80% highly satisfactory.

Results
Although the four BBs are performing collection, screening, grouping and cross matching, none is performing therapeutic transfusion. While 75% of the BBs have received training in biosafety and half in Standard Operating Procedures (SOPs), no QAS in place at any. The four BBs depended on 71% of their transfusions on replacement family donors. Although all BBs reported using SOPs for compatibility testing, half do not perform Reverse Grouping and half do not keep patient/donor samples for the required minimum five days. All BB reported screening blood for HIV, Hepatitis B, and Hepatitis C using ELISA. The overall BTS score shows that only NBTRC achieved highly satisfactory and USTH achieved satisfactory scores. Methodology Case was defined "as onset of fever, and two or more of following signs/ symptoms; headache, retro-orbital pain, joint/bone pain, myalgia and petechial rash, in a resident of Gwadar city, from 1st November 2016 to 21st February 2017'' . Descriptive study was carried out to identify cases, affected areas and risk factors through active case finding. Hospital records were also reviewed. Blood samples were sent to NIH for laboratory confirmation.

Results
Total 203 cases (overall AR=1.24%) were identified during active case finding and from records of only health facility in Gwadar city. Males were more affected (n= 126, 62%). Mean age was 28 years (range:6 to 60 years) and most affected age group was 25-29 years (n=41, 20%, AR=3.1%). Nausea/ vomiting (95.1%) and myalgia (90.6%) were most frequent symptoms. All the cases had no travel history during last one month. Among 185 samples, 151 (81.6%) were dengue positive. First case reported on 1st November and peak was achieved on 12th November, but after on 21st February 2017 no case was reported. Four stagnant water pools with Larvae were identified.
Conclusions Presence of stagnant water pools in and around houses being breeding places for Aedes aegypti mosquitos was most probable cause of outbreak. Elimination of mosquito breeding sites, larvicidal activities and advocacy on use of protective measures against mosquito bites were recommended. Thermal fogging in densely populated localities and Indoor Residual Spraying (IRS) were carried out in 250 households. Sensitization and awareness on dengue control were conducted among community, schools, projects and key players(n=1225) in outbreak area.
Background Anthrax is caused by Bacillus Anthracis, classified as A-priority Pathogen for biodefense with a high case fatality rate. On August 25, 2016, unusual deaths of a female and cattle in village Umarai, Bajaur were reported to health department.
Purpose An outbreak investigation team was constituted to assess the magnitude, identify risk factors and to implement appropriate control measures.
Methodology A case was defined as "Any person of village Umarai suffering from acute illness revealing a painless skin lesion developing over 2 to 6 days into eschar with surrounding edema and any of the symptoms: fever, malaise, myalgia, edema, lymph-adenopathy or epidemiological evidence relating it to anthrax from 12th to 29th August 2016". Data was collected on a pre-tested structured questionnaire. Descriptive statistics were computed; attack rates and odds ratios determined at 95% confidence interval and p value < 0.05. Age and sex matched controls were selected from the same area with 1:3.

Results
Total 12 cases were identified with male to female ratio of 11:1. Case Fatality Rate was 8.3 %(n=1). Mean age was 38.5 Years (Range: 16-65 Years). Fifty eight percent (n=8) cases were farmers. All the cases were involved in slaughtering of animals. All cases had Myalgia, Malaise and lymphadenopathy while 92% (n=11) cases had eschar and headache. Significant statistical association was found with having contact with open wounds/cuts (OR 23.8, 95% CI 3.82-148.45, p value <0.05) low socioeconomic status (OR 8.8,95% CI 1.68-46.70, p value <0.05). Laboratory results were found negative for Bacillus Anthracis probably due to prior antibiotics use.

Conclusions
The outbreak investigation revealed strong association of Anthrax with low socioeconomic status and contact with open wounds and cuts. Community awareness regarding proper handling and disposal of infected animals and development of a coordinated strategy to establish surveillance system for zoonotic diseases by Health and Livestock departments were suggested.

Vector Borne Diseases
Abstract the total suspected cases. Death occurred in one case with case fatality rate 11% (1/9). All confirmed cases were housewives with one infant. The most affected age group was between 35 and 65 years. All confirmed cases had bird exposure; 3 cases had exposed to diseased bird, 1 exposed to dead bird, 5 ex-posed to birds during slaughtering. The way we work in public health is, we make the best recommendations and decisions based on the best available data Tom Frieden