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.

Placental malaria, anaemia and low birthweight in Yemen.

A cross-sectional study was conducted during the period of August 2007-April 2008 at Al-Wahda Teaching Hospital in Yemen to investigate prevalence and risk factors for placental malaria and anaemia and their effects on birthweight. Sociodemographic characteristics were gathered, maternal haemoglobin was measured and blood films were examined for malaria. Newborn birthweight was recorded. Out of 900 parturient women, malaria blood films were positive in 32 (3.6%) cases: in six sets of peripheral, placental and cord samples; in 15 placental and cord samples; and in 11 placental samples only. Malaria was not associated with age and parity, but it was significantly associated with history of fever [odds ratio (OR) 8.5, 95% CI 3.7-19, P<0.001], rural residence (OR 2.5, 95% CI 1.1-5.3, P=0.01) and rainy season (OR 5.1, 95% CI 1.7-15.2, P=0.003). Overall, 694 (77.1%) out of these 900 women had anaemia (Hb<11g/dl) and 16 (1.8%) patients had severe anaemia (Hb<7g/dl). Anaemia was not associated with age, parity and malaria. Low birthweight was significantly associated with malaria (OR 5.7, 95% CI 1.7-18.5; P=0.004). Thus, preventive measures (bednets and intermittent preventive treatment) should be employed for pregnant women regardless of their age or parity.