PROBLEM: Before 2003 there was substantial underreporting of deaths in Jordan. The death notification form did not comply with World Health Organization (WHO) guidelines and information on the cause of death was often missing, incomplete or inaccurate. APPROACH: A new mortality surveillance system to determine the causes of death was implemented in 2003 and a unit for coding causes of death was established at the ministry of health. LOCAL SETTING: Jordan is a middle-income country with a population of 6.4 million people. Approximately 20 000 deaths were registered per year between 2005 and 2011. RELEVANT CHANGES: In 2001, the ministry of health organized the first meeting on Jordan’s mortality system, which yielded a five-point plan to improve mortality statistics. Using the recommendations produced from this meeting, in 2003 the ministry of health initiated a mortality statistics improvement project in collaboration with international partners. Jordan has continued to improve its mortality reporting system, with annual reporting since 2004. Reports are based on more than 70% of reported deaths. The quality of cause-of-death information has improved, with only about 6% of deaths allocated to symptoms and ill-defined conditions – a substantial decrease from the percentage before 2001 (40%). Mortality information is now submitted to WHO following international standards. LESSONS LEARNT: After 10 years of mortality surveillance in Jordan, the reporting has improved and the information has been used by various health programmes throughout Jordan.

OBJECTIVE: We evaluated an alternative administration route, reduced schedule priming series, and increased intervals between booster doses for anthrax vaccine adsorbed (AVA). AVA's originally licensed schedule was 6 subcutaneous (SQ) priming injections administered at months (m) 0, 0.5, 1, 6, 12 and 18 with annual boosters; a simpler schedule is desired. METHODS: Through a multicenter randomized, double blind, non-inferiority Phase IV human clinical trial, the originally licensed schedule was compared to four alternative and two placebo schedules. 8-SQ group participants received 6 SQ injections with m30 and m42 "annual" boosters; participants in the 8-IM group received intramuscular (IM) injections according to the same schedule. Reduced schedule groups (7-IM, 5-IM, 4-IM) received IM injections at m0, m1, m6; at least one of the m0.5, m12, m18, m30 vaccine doses were replaced with saline. All reduced schedule groups received a m42 booster. Post-injection blood draws were taken two to four weeks following injection. Non-inferiority of the alternative schedules was compared to the 8-SQ group at m2, m7, and m43. Reactogenicity outcomes were proportions of injection site and systemic adverse events (AEs). RESULTS: The 8-IM group's m2 response was non-inferior to the 8-SQ group for the three primary endpoints of anti-protective antigen IgG geometric mean concentration (GMC), geometric mean titer, and proportion of responders with a 4-fold rise in titer. At m7 anti-PA IgG GMCs for the three reduced dosage groups were non-inferior to the 8-SQ group GMCs. At m43, 8-IM, 5-IM, and 4-IM group GMCs were superior to the 8-SQ group. Solicited injection site AEs occurred at lower proportions in the IM group compared to SQ. Route of administration did not influence the occurrence of systemic AEs. A 3 dose IM priming schedule with doses administered at m0, m1, and m6 elicited long term immunological responses and robust immunological memory that was efficiently stimulated by a single booster vaccination at 42 months. CONCLUSIONS: A priming series of 3 intramuscular doses administered at m0, m1, and m6 with a triennial booster was non-inferior to more complex schedules for achieving antibody response.

Swine origin 2009 H1N1 influenza virus has spread globally to cause the first influenza pandemic of the 21(st) century. Serological studies can improve our understanding of the extent of human infection and risk factors associated with transmission of this pandemic virus. The "gold standard" for serodiagnosis of human influenza infection is the detection of seroconversion between acute and convalescent stage samples. However, timing of seroepidemiologic investigations often precludes collection of truly acute phase sera, requiring development of serologic criteria for evaluating convalescent phase sera that optimize detection of true positives and true negatives. To guide seroepidemiologic investigations into the spread of the novel 2009 pandemic H1N1 virus, we characterized serum antibody responses to 2009 H1N1 virus in 87 individuals with confirmed viral infection and 227 non-exposed U.S. individuals using microneutralization (MN) and hemagglutination-inhibition (HI) assays. Sensitivity and specificity were determined for each assay alone, and in combination, for detection of 2009 H1N1-specific antibodies in convalescent sera. Although the HI assay was more specific for detecting antibody to 2009 H1N1, the MN was more sensitive, particularly for detecting low titer seroconversions. A combination of titers (MN ≥40 and HI ≥20) provided highest sensitivity (90%) and specificity (96%) for individuals aged < 60 years and 92% specificity for adults aged ≥60 years for detection of serologically confirmed 2009 H1N1 infections in U.S. populations during the first pandemic waves. These studies provide an approach to optimize timely serologic investigations for future pandemics or outbreaks of novel influenza viruses among humans.