Immunization of Children under 2 Years Old in the Coastal Hadhramaut Governorate, Yemen, during Public Health Emergencies: A Trend Analysis of 2013-2020.

Although immunization is one of the most successful and cost-effective interventions that prevents millions of infant and child deaths yearly, it has failed to achieve its intended goals in some low-income countries. Yemen is currently experiencing the most extreme humanitarian crisis globally, which has affected health and worsened its economy and political governance instability. There are few reports on Yemeni vaccination statuses. The present study aimed to investigate the effect of the public health emergency crises on childhood immunization in Yemen. A retrospective descriptive study was conducted in the Coastal Hadhramaut Governorate, Yemen. Secondary data from governorate annual reports for 2013-2020 were extracted. The assessment of the annual immunization coverage rate according to each vaccine was tabulated. The analysis revealed that the 2013-2019 vaccination coverage in Coastal Hadhramaut demonstrated an increasing trend. However, vaccination coverage decreased for all vaccines in 2015-2016 and 2020. Although all three doses of the pentavalent vaccine demonstrated >85% coverage in all years, the coverage of the first and second doses decreased in 2016, and the coverage of all doses decreased in 2020 during the COVID-19 pandemic. Public health emergencies negatively affected routine immunization coverage in Yemen. The trend correlated with the humanitarian crisis and other research findings in Yemen. The national response to public health threats during emergency crises must involve strengthening the program for monitoring and evaluating vaccine-preventable diseases.

Responding to COVID-19 pandemic at the local level: lessons from Yemen.

Background: The health authorities in Hadhramaut Valley and Desert responded to the COVID-19 pandemic differently from other areas in Yemen. Aims: To document the response of the local authority and Ministry of Health in Hadhramaut to COVID-19. Methods: The local authority in Syoun (Hadhramaut Valley) convened a meeting of all key players from the health and related sectors in February 2020 where a decision was made to establish a committee to evaluate the health situation and assess the needs. Based on the results of these assessments, a plan was designed to respond to the pandemic. We reviewed available documents on the COVID-19 response in Hadhramaut, interviewed the main stakeholders, and conducted site visits to the COVID-19 response centres. Results: There was evidence of the crucial role played by the local authority in response to COVID-19. They established 3 well-equipped isolation centres with a total of 142 beds, a stock of 2250 oxygen cylinders, 2 new polymerase chain reaction units, a simplified referral system, and an effective patient follow-up and oxygen home therapy strategy. Conclusion: Political commitment at the local level is crucial to bridge the gap between policy and implementation, especially during infectious disease outbreaks. It is important to train public health leaders on how to effectively assess local health needs and develop effective and efficient response strategy. Lessons from this study in Hadhramaut provide evidence on how local authorities can coordinate response to emerging health needs and update their strategies.

Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems.

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.

Malnutrition among hospitalized children 12-59 months of age in Abyan and Lahj Governorates / Yemen.

BACKGROUND: The analysis of acute malnutrition in 2018 for the Integrated Phase Classification of Food Security in Yemen shows that high malnutrition rates are present in Abyan governorate (23%) and Lahj governorate (21%). This analysis was community based addressed all children and mostly due to problems related to food intake. The role of diseases was not yet addressed in Yemen. The aim of this study is to assess acute and chronic malnutrition among hospitalized children at 12-59 months of age in Lahj and Abyan governorates in Yemen. METHODOLOGY: A cross-sectional, multi-center study is designed. The assessment of the nutritional status was measured by standardized anthropometry of 951 sick children at 12-59 months of age. RESULTS: The prevalence of Global acute malnutrition (GAM) among the sick children seeking care in health facilities in Lahj and Abyan is 21%. More specifically; the prevalence of moderate acute malnutrition (MAM) is 15.1% while the prevalence of severe acute malnutrition (SAM) is 6.2%. The prevalence of acute malnutrition (wasting) among the studied sick children in lahj is 23.4% while in Abyan is 19.3%. The prevalence of MAM in Lahj is 17.7% and the prevalence of SAM is 5.7%. The prevalence of acute malnutrition (wasting) in Abyan is 12.6% while the prevalence of SAM in Abyan is 6.7%. The prevalence of acute malnutrition among male children (25.2%) is significantly higher than among female children (17.5%). The prevalence of the chronic malnutrition (Stunting) in the studied sick children is 41.3%; the prevalence of stunting in Lahj is 41% while in Abyan is 41.7%. CONCLUSIONS: High acute and chronic malnutrition rates were identified among sick children seeking care in health facilities in lahj and Abyan, and higher than the SPHERE indicators of malnutrition. Boys are more exposed than girls to acute and chronic malnutrition.

Vaccine hesitancy from parents and healthcare providers perspectives in Hadhramout Governorate, Yemen: a mixed-method study protocol.

INTRODUCTION: Although immunisation prevents the death of millions of infants and children each year, the vaccination coverage of routine childhood vaccination does not reach its target. The reasons for low vaccination uptake can be related to both demand and supply side determinants. The prevalence of vaccine hesitancy is increasing globally. However, data on vaccine hesitancy in low-income Arabic countries are scarce. To investigate this issue in Yemen, an Arabic low-income country, we aim to examine the link between vaccine hesitancy and the immunisation status of children living in Costal Hadhramout, Yemen, from the perspective of their parents and healthcare providers. METHODS AND ANALYSIS: We will use a mixed-method research design. The study will be conducted in Costal Hadhramout in three phases. Phase 1 will involve a situational analysis using secondary data from records of the national expanded immunisation programme in Costal Hadhramout to examine the trend for previous years. Phase 2 will be a quantitative study aimed at assessing the prevalence of vaccination status of children aged <2 years and the determinants of parental vaccine hesitancy perception through a validated questionnaire. Lastly, phase 3 will be a qualitative study that explores vaccine hesitancy in Yemen using in-depth interviews and focus group discussions with parents and healthcare providers, respectively. ETHICS AND DISSEMINATION: The study has been approved by the Research Committee of the Faculty of Medicine, University Kebangsaan Malaysia. The findings will be disseminated via publication in peer-reviewed academic journals, academic conferences and public presentations.

SARS-CoV-2 seroprevalence in Aden, Yemen: a population-based study.

BACKGROUND: In Yemen, initial surveillance of coronavirus disease 2019 (COVID-19) focused primarily on patients with symptoms or severe disease. The full spectrum of the disease remains unclear. To the best of the authors' knowledge, this is the first seroprevalence study performed in Yemen. METHODS: This cross-sectional investigation included 2001 participants from all age groups from four districts in Aden, southern Yemen. A multi-stage sampling method was used. Data were collected using a well-structured questionnaire, and blood samples were taken. Healgen COVID-19 IgG/IgM Rapid Diagnostic Test (RDT) Cassettes were used in all participants. All positive RDTs and 14% of negative RDTs underwent enzyme-linked immunosorbent assay (ELISA) testing (WANTAI SARS-CoV-2 Ab ELISA Kit) for confirmation. RESULTS: In total, 549 of 2001 participants were RDT positive and confirmed by ELISA, giving a prevalence of COVID-19 of 27.4%. The prevalence of immunoglobulin G was 25%. The prevalence of asymptomatic COVID-19 in the entire study group was 7.9%. The highest prevalence was observed in Al-Mansurah district (33.4%). Regarding sociodemographic factors, the prevalence of COVID-19 was significantly higher among females, housewives and subjects with a history of contact with a COVID-19 patient: 32%, 31% and 39%, respectively. CONCLUSION: This study found high prevalence of COVID-19 in the study population. Household transmission was common.

Excess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Aden governorate, Yemen.

BACKGROUND: The burden of COVID-19 in low-income and conflict-affected countries remains unclear, largely reflecting low testing rates. In parts of Yemen, reports indicated a peak in hospital admissions and burials during May-June 2020. To estimate excess mortality during the epidemic period, we quantified activity across all identifiable cemeteries within Aden governorate (population approximately 1 million) by analysing very high-resolution satellite imagery and compared estimates to Civil Registry office records. METHODS: After identifying active cemeteries through remote and ground information, we applied geospatial analysis techniques to manually identify new grave plots and measure changes in burial surface area over a period from July 2016 to September 2020. After imputing missing grave counts using surface area data, we used alternative approaches, including simple interpolation and a generalised additive mixed growth model, to predict both actual and counterfactual (no epidemic) burial rates by cemetery and across the governorate during the most likely period of COVID-19 excess mortality (from 1 April 2020) and thereby compute excess burials. We also analysed death notifications to the Civil Registry office over the same period. RESULTS: We collected 78 observations from 11 cemeteries. In all but one, a peak in daily burial rates was evident from April to July 2020. Interpolation and mixed model methods estimated ≈1500 excess burials up to 6 July, and 2120 up to 19 September, corresponding to a peak weekly increase of 230% from the counterfactual. Satellite imagery estimates were generally lower than Civil Registry data, which indicated a peak 1823 deaths in May alone. However, both sources suggested the epidemic had waned by September 2020. DISCUSSION: To our knowledge, this is the first instance of satellite imagery being used for population mortality estimation. Findings suggest a substantial, under-ascertained impact of COVID-19 in this urban Yemeni governorate and are broadly in line with previous mathematical modelling predictions, though our method cannot distinguish direct from indirect virus deaths. Satellite imagery burial analysis appears a promising novel approach for monitoring epidemics and other crisis impacts, particularly where ground data are difficult to collect.

'This diarrhoea is not a disease ' local illness concepts and their effects on mothers' health seeking behaviour: a qualitative study, Shuhair, Yemen.

BACKGROUND: Globally, about seven million children under the age of five died in 2011. Local illness concepts are thought to be related to inappropriate health-seeking behaviour, and therefore, lead to child mortality. The aim of this study was to contribute to the definition of common local illness concepts with their effects on health-seeking behaviour for common childhood illnesses. METHODS: A qualitative focus group study was conducted between April 1 and 6, 2013. Participants were drawn purposefully from the vaccination unit at Shuhair Health Centre in Yemen. Four focus group discussions were conducted. The total number of participants was 31 mothers with at least one child under the age of five with a history of fever, diarrhoea, cough, or difficulty breathing during the 14 days preceding the study. Data was collected and analysed using micro-interlocutor analysis. RESULTS: The mean age of the participants was 31 years (SD ± 4). There was remarkable concordance in local illness concepts across the focus groups. During focus group discussions, six local illness concepts (Senoon, lafkha, halib, didan, raqaba, and ayn) were mentioned. Local illness concepts determined the type of treatment. Most of these illnesses were not treated medically. Lafkha, halib, raqaba, and ayn were always classified as "not for medical treatment", whereas senoon and didan as sometimes "not for medical treatment". For medical symptoms, i.e. fever, diarrhoea, cough, and difficulty breathing, medical therapy was usually an option; these were classified as never or sometimes "not for medical treatment". Mothers trust in traditional medicine and believe that it is always beneficial and never harmful. The participants do not disclose traditional medicine use with their doctors because doctors oppose these practices and are not open enough to these types of treatment. CONCLUSIONS: Local illness concepts for common child illnesses are widespread, and they determine the type of treatment used. Interventions to improve children's health should use local illness concepts to educate parents. Traditional medicine as a treatment option in primary care should be considered.

Availability and prescription practice of anti-malaria drugs in the private health sector in Yemen.

INTRODUCTION: Although the government of Yemen changed the national policy for treating malaria in November 2005 from chloroquine to combination drugs in the form of artesunate + sulphadoxine-pyrimethamine (SP) as first line and lumefantrine + artemether as second line treatment for uncomplicated malaria, clinicians in public and private health facilities continued to prescribe chloroquine because their knowledge about the new treatment policy was poor. METHODOLOGY: A non-randomized trial of pre- and post-evaluation of the training and reporting interventions about prescription behaviors and availability of anti-malaria drugs among clinicians and pharmacists in the private sector in three governorates in Yemen was conducted. RESULTS: Adherence of clinicians in the private sector to the new national guidelines for anti-malaria drugs improved from 21% in pre-intervention period to 38% after the intervention for artesunate + SP being prescribed as the first-line treatment. Prescription of lumefantrine + artemether as the second-line anti-malaria treatment was also improved from 18% before the intervention to 22% post-intervention. Unfortunately the combination of halofantrine + SP continued to be frequently prescribed by clinicians in Sana'a city (18%). Artesunate + SP and quinine are increasing their marketing significantly from 8% in the pre-intervention period to 22% post-intervention (P-value 0.001). CONCLUSIONS: The study provides evidence of usefulness of the training intervention on the national guidelines for malaria treatment. Additionally, the involvement of private health-care providers in reporting procedures will promote the rational prescription and availability of anti-malaria drugs.

Dengue outbreak in Hadramout, Yemen, 2010: an epidemiological perspective.

We analyzed surveillance data of a dengue outbreak (2010) reported to the Hadramout Health Office (Yemen) and retrospectively analyzed dengue-related epidemiological and entomological events reported in Hadramout from 2005 to 2009. A total of 630 immunoglobulin M (IgM) -confirmed dengue cases of 982 febrile cases was reported during the period from February to June of 2010; 12 cases died, giving case fatality a rate of 1.9%. Among febrile cases, the highest proportion of dengue cases (37.3%) was reported in the 15- to 24-year-old age group. The overall attack rate was 0.89/1,000. The average number of cases reported by month over the preceding 5-year period compared with the 2010 data is consistent with endemicity of dengue in the region and supports epidemic designation for the dengue activity in 2010. Recognition of endemic dengue transmission and potential for substantial dengue epidemics highlight the need for consistent laboratory-based surveillance that can support prevention and control activities accordingly.