Yemen Advanced Field Epidemiology Training Program: An Impact Evaluation, 2021.

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

Public health impacts of an imminent Red Sea oil spill.

The possibility of a massive oil spill in the Red Sea is increasingly likely. The Safer, a deteriorating oil tanker containing 1.1 million barrels of oil, has been deserted near the coast of Yemen since 2015 and threatens environmental catastrophe to a country presently in a humanitarian crisis. Here, we model the immediate public health impacts of a simulated spill. We estimate that all of Yemen's imported fuel through its key Red Sea ports would be disrupted and that the anticipated spill could disrupt clean-water supply equivalent to the daily use of 9.0-9.9 million people, food supply for 5.7-8.4 million people and 93-100% of Yemen's Red Sea fisheries. We also estimate an increased risk of cardiovascular hospitalization from pollution ranging from 5.8 to 42.0% over the duration of the spill. The spill and its potentially disastrous impacts remain entirely preventable through offloading the oil. Our results stress the need for urgent action to avert this looming disaster.

Field Epidemiology Training Program Response to COVID-19 During a Conflict: Experience From Yemen.

COVID-19 pandemic has underscored the need for a well-trained public health workforce to save lives through timely outbreaks detection and response. In Yemen, a country that is entering its seventh year of a protracted war, the ongoing conflict severely limited the country's capacity to implement effective preparedness and response measures to outbreaks including COVID-19. There are growing concerns that the virus may be circulating within communities undetected and unmitigated especially as underreporting continues in some areas of the country due to a lack of testing facilities, delays in seeking treatment, stigma, difficulty accessing treatment centers, the perceived risks of seeking care or for political issues. The Yemen Field Epidemiology Training Program (FETP) was launched in 2011 to address the shortage of a skilled public health workforce, with the objective of strengthening capacity in field epidemiology. Thus, events of public health importance can be detected and investigated in a timely and effective manner. During the COVID-19 pandemic, the Yemen FETP's response has been instrumental through participating in country-level coordination, planning, monitoring, and developing guidelines/standard operating procedures and strengthening surveillance capacities, outbreak investigations, contact tracing, case management, infection prevention, and control, risk communication, and research. As the third wave is circulating with a steeper upward curve than the previous ones with possible new variants, the country will not be able to deal with a surge of cases as secondary care is extremely crippled. Since COVID-19 prevention and control are the only option available to reduce its grave impact on morbidity and mortality, health partners should support the Yemen FETP to strengthen the health system's response to future epidemics. One important lesson learned from the COVID-19 pandemic, especially in the Yemen context and applicable to developing and war-torn countries, is that access to outside experts becomes limited, therefore, it is crucial to invest in building national expertise to provide timely, cost-effective, and sustainable services that are culturally appropriate. It is also essential to build such expertise at the governorate and district levels, as they are normally the first respondents, and to provide them with the necessary tools for immediate response in order to overcome the disastrous delays.

Yemen field epidemiology training programme: a tool for strengthening the public health workforce.

BACKGROUND: The shortage of skilled public health workers, especially epidemiologists, remains an important challenge for building effective public health systems in many low-income countries, including Yemen. To address this need, in 2011 the Ministry of Public Health and Population established the Yemen Field Epidemiology Training Programme (Y-FETP). AIMS: To describe the Y-FETP and its strengths and challenges in addressing Yemen's National Health System (NHS) needs. METHODS: We describe the structure and functions of the Y-FETPs and analyse the achievements and challenges of the first 7 years of programme implementation as they relate to the NHS. RESULTS: The Y-FETP is a postgraduate competency-based training with the objective of strengthening capacity in field epidemiology so that events of public health importance can be detected and investigated in a timely and effective manner. Since its establishment, the Y-FETP has successfully trained 30 health professionals in advanced field epidemiology. Furthermore, trainees investigated over 100 outbreaks, analysed and evaluated 95 surveillance systems, conducted 30 planned studies and presented 70 oral and poster presentations at national and international conferences. The main challenges are low retention of graduates by the NHS and financial unsustainability. CONCLUSIONS: The Y-FETP has strengthened the capacity of the Yemen health workforce and has been instrumental in supporting the NHS, especially during the war and the current crisis and health emergency as the security situation deteriorated and access to outside experts becomes limited. The programme provides a practical example of health systems strengthening through health workforce capacity development that can be replicated in countries with similar health workforce capacity challenges.

Health in Yemen: losing ground in war time.

BACKGROUND: The effect of the ongoing war in Yemen on maternal and child health (MCH) has not been comprehensively assessed. Providing a situational analysis at the governorate level is critical to assist in planning a response and allocating resources. METHODS: We used multiple national- and governorate-level data sources to provide estimates of 12 relevant MCH indicators in 2016 around child vaccination, and child and maternal nutritional status, and the change in these estimates for the period 2013-2016 based on shock variables including change in gross domestic product, burden of airstrikes per 1000 population, change in access to untreated water sources and unimproved toilets, and change in wheat flour prices. We also used findings from the Global Burden of Disease 2016 study. RESULTS: Vaccine coverage decreased for all antigens between 2013 and 2016 among children 12-23 months. The largest decrease, 36·4% for first-dose measles vaccine, was in Aden. Among children under the age of five, incidence of diarrhea was at 7·0 (5·5-8·9) episodes per person-year. The prevalence of moderate and severe child anemia ranged from 50·9% (24·9-73·1) in Sana'a City to 97·8% (94·1-99·2) in Shabwah in 2016. Prevalence of underweight among women of reproductive age ranged from 15·3% (8·1-24·6) in Sana'a city to 32·1% (24·1-39·7) in Hajjah, with a national average of 24·6% (18·7-31·5). CONCLUSIONS: The war and siege on Yemen has had a devastating impact on the health of women and children. Urgent efforts to secure food, essential medicines, antibiotics, deworming medicine, and hygiene kits, and cold chains for immunization are needed. Yemen is in dire need of clean water and proper sanitation to reduce the spread of disease, especially diarrhea.

Diarrheal Diseases Hospitalization in Yemen before and after Rotavirus Vaccination.

The study aims to assess the impact of rotavirus vaccine introduction on diarrheal diseases hospitalization and to identify the rotavirus genotypes most prevalent before and after vaccine introduction among children ≤ 5 years of age. Rotarix™ ® rotavirus vaccine is currently licensed for infants in Yemen and was introduced in 2012. The vaccination course consists of two doses. The first dose is administrated at 6 weeks of age and the second dose is completed by 10 weeks. Based on a longitudinal observational study, we assessed the impact of vaccination on rotavirus hospitalization before and after vaccination among children ≤ 5 years of age at the Yemeni-Swedish Hospital (YSH) in Taiz, Yemen. Prevaccination covered January 2009-July 2012 during which 2335 fecal samples were collected from children ≤ 5 years old. Postvaccination covered January 2013-December 2014 during which 1114 fecal samples were collected. Rotavirus was detected by Enzyme Linkage Immunosorbent Assay (ELISA). The incidence of rotavirus hospitalization decreased from 43.79% in 2009 to 10.54% in 2014. Hospitalization due to rotavirus diarrhea was reduced by 75.93%. Vaccine coverage increased from 23% in 2012 to 72% in 2014. Also, the results showed that the most predominant genotypes in prevaccination period were G2P[4] (55.0%), followed by G1P[8] (15.0%), while in postvaccination period G1P[8] (31%) was the predominant genotype, followed by G9P[8] (27.5%). In conclusion, rotavirus vaccination in Yemen resulted in sharp reduction in diarrheal hospitalization. A successful rotavirus vaccination program in Yemen will rely upon efficient vaccine delivery systems and sustained vaccine efficacy against diverse and evolving rotavirus strains.

Overview of cervical cancer screening practices in the extended Middle East and North Africa countries.

National Organized Cervical Cancer Screening (NOCCS) programs are lacking in most of the "Extended Middle East and North Africa" (EMENA) countries. Consequently, most cervical cancers are diagnosed late and are associated with high mortality. In fact, in most of these countries, national mortality data are unknown due to the absence of population-based mortality registries. Most countries of the EMENA practice more or less limited opportunistic, cytology-based, screening tests, which often lack quality assurance and follow-up care. A few countries, within the initiation of a National Cancer Control Plan, have just started to implement organized screening programs using, for cervical cancer detection, visual inspection with acetic acid (Morocco) or cytology (Turkey). Moreover, most countries of the EMENA lack national guideline, as well as resources for the management of abnormal cytologic screening (or any other screening test). The main obstacle for the implementation of NOCCS is a lack of political understanding to support such public health programs and provide the necessary resources. Other obstacles that hinder the participation of women in cervical screening include a lack of knowledge of the disease, socio-religious and cultural barriers, and geographic and economic difficulties in accessing medical services. These countries are already convinced that prevention of cervical cancers in women who have cervical intraepithelial neoplasia is possible through various screening and treatment algorithms, but most countries still need to invest in well organized programs that can reduce cervical cancer incidence and mortality in women. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Extended Middle East and North Africa Region" Vaccine Volume 31, Supplement 6, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Prospects and challenges in the introduction of human papillomavirus vaccines in the extended Middle East and North Africa region.

The development of effective and safe human papillomavirus (HPV) vaccines provides a great opportunity to prevent a devastating disease, cervical cancer, and a host of other related diseases. However, the introduction of these vaccines has been slow in the Extended Middle East and North Africa (EMENA) region. Only one country has introduced the vaccine and few countries plan HPV vaccine introduction in the coming 5 years. Several factors influence the slow uptake in the region, including financial constraints, weak infrastructure for adolescent vaccine delivery, competition with high priority vaccines, and lack of reliable data on the burden of HPV disease. Other barriers include cultural and religious sensitivities, as the vaccines are offered to prevent a sexually transmitted disease in young girls. Recommendations to enhance HPV vaccine introduction in EMENA countries include establishing a regional joint vaccine procurement program, enhancing the adolescent vaccination platform, documenting the burden of cervical cancer, strengthening local National Immunization Technical Advisory Groups and designing Information, Education and Communication material that address cultural concerns. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Extended Middle East and North Africa Region" Vaccine Volume 31, Supplement 6, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Critical issues in implementing a national integrated all-vaccine preventable disease surveillance system.

In 2007, the World Health Organization published the Global Framework for Immunization Monitoring and Surveillance (GFIMS) outlining measures to enhance national surveillance for vaccine preventable diseases (VPDs). The GFIMS emphasized that VPD surveillance should be integrated and placed in a 'unified framework' building upon the strengths of existing surveillance systems to prevent duplication of activities common to all surveillance systems and to minimize human resource and supply expenditures. Unfortunately, there was little experience in actually developing integrated VPD surveillance. We describe the process of developing operational guidance for ministries of health to implement such an integrated surveillance system for multiple VPDs.

Validity of medical record documented varicella-zoster virus among unvaccinated cohorts.

BACKGROUND: A varicella diagnosis or verification of disease history by any healthcare provider is currently accepted for determining evidence of immunity by the Advisory Committee on Immunization Practices (ACIP). OBJECTIVE: To examine the accuracy of medical record (MR) documented varicella history as a measure of varicella-zoster virus (VZV) immunity among unvaccinated individuals born after 1980. We also assessed methods to practically implement ACIP guidelines to verify varicella history using medical records. STUDY DESIGN: As part of a larger cross-sectional study conducted at three Philadelphia clinics from 2004-2006, we recruited 536 unvaccinated patients aged 5-19 y (birth years: 1985-2001). Varicella history was obtained from three sources: parent/patient interview, any MR documentation (sick and well visits) and MR documentation of a sick visit for varicella. All participants were tested for VZV IgG. For each source and three age groups (5-9, 10-14, 15-19 y old), positive predictive value (PPV) was calculated. Specificity of varicella history was compared between different sources using McNemar's Chi-square. RESULTS: Among participants aged 5-9, 10-14 and 15-19 y the PPV for any MR documentation and sick visit diagnosis were 96% and 100%, 92% and 97%, and 99% and 100%, respectively. The specificity for sick visit documentation was higher than any MR documentation and patient/parent recall among all age groups; however, these differences were only statistically significant when comparing sick visit documentation to parent/patient recall for 10-14 y olds. CONCLUSION: Sick visit documentation of varicella in the MR is an accurate predictor of varicella seropositivity and useful for confirming disease history among unvaccinated persons (birth years: 1985-2001). This method is a practical way to verify varicella history using the ACIP guidelines.

Lessons from the 2006 Louisiana health and population survey.

The 2005 hurricane season caused extensive damage and induced a mass migration of approximately 1.1 million people from southern Louisiana in the United States. Current and accurate estimates of population size and demographics and an assessment of the critical needs for public services were required to guide recovery efforts. Since forecasts using pre-hurricane data may produce inaccurate estimates of the post-hurricane population, a household survey in 18 hurricane-affected parishes was conducted to provide timely and credible information on the size of these populations, their demographics and their condition. This paper describes the methods used, the challenges encountered, and the key factors for successful implementation. This post-disaster survey was unique because it identified the needs of the people in the affected parishes and quantified the number of people with these needs. Consequently, this survey established new population and health indicator baselines that otherwise would have not been available to guide the relief and recovery efforts in southern Louisiana.

Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries.

OBJECTIVE: To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal. METHODS: Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability. FINDINGS: Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3-85.6) in Peru, 88.9% (95% CI: 84.7-92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0-97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4-81.6) to 87.8% (95% CI: 84.3-91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4-73.4) to 83.3% (95% CI: 79.3-87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine. CONCLUSION: High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.

Strategies to vaccinate against cancer of the cervix: feasibility of a school-based HPV vaccination program in Peru.

Operational research using a mixed method, cross-sectional, case-study approach assessed the feasibility and health system impact of large-scale implementation of human papillomavirus (HPV) vaccination into routine vaccine delivery by the Ministry of Health in Peru. The strategy was school-based vaccination of fifth grade girls in 527 primary schools in Piura region. Our evaluation showed that school-based HPV vaccination is feasible without major changes in existing health systems. This was reflected in the opinions of health personnel, the lack of impact on other vaccine coverage, and the high HPV vaccine coverage documented in routine records and by an independent community-based survey.

Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination.

BACKGROUND: herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus and is often associated with substantial pain and disability. Baseline incidence of HZ prior to introduction of HZ vaccine is not well described, and it is unclear whether introduction of the varicella vaccination program in 1995 has altered the epidemiology of HZ. We examined trends in the incidence of HZ and impact of varicella vaccination on HZ trends using a large medical claims database. METHODS: medical claims data from the MarketScan databases were obtained for 1993-2006. We calculated HZ incidence using all persons with a first outpatient service associated with a 053.xx code (HZ ICD-9 code) as the numerator, and total MarketScan enrollment as the denominator; HZ incidence was stratified by age and sex. We used statewide varicella vaccination coverage in children aged 19-35 months to explore the impact of varicella vaccination on HZ incidence. RESULTS: HZ incidence increased for the entire study period and for all age groups, with greater rates of increase 1993-1996 (P < .001). HZ rates were higher for females than males throughout the study period (P < .001) and for all age groups (P < .001). HZ incidence did not vary by state varicella vaccination coverage. CONCLUSIONS: HZ incidence has been increasing from 1993-2006. We found no evidence to attribute the increase to the varicella vaccine program.

Varicella seroprevalence in the U.S.: data from the National Health and Nutrition Examination Survey, 1999-2004.

OBJECTIVE: We estimated the varicella seroprevalence among the U.S. population aged 6-49 years based on retested National Health and Nutrition Examination Survey (NHANES) specimens collected between 1999 and 2004--originally tested using a method unsuitable for detecting vaccine-induced immunity--and compared it with historical estimates. METHODS: We performed a confirmatory test suitable for detecting vaccine-induced immunity on all available specimens from 6- to 19-year-olds who originally tested negative (n = 633), and on 297 randomly selected specimens that had tested positive. Retest results superseded original results for determining seroprevalence. We assessed seroprevalence for the entire sample aged 6-49 years (n = 16,050) by participant demographic characteristics and compared it with historical estimates (NHANES 1988-1994). RESULTS: The percentage of false-negative results for the original test was higher for specimens from younger children (6-11 years of age: 27.5%; 12-19 years of age: 13.3%) and for specimens collected most recently (2001-2004: 26.0%; 1999-2000: 12.6%). The age-adjusted rate of varicella seroprevalence for 1999-2004 was 93.6% for 6- to 19-year-olds and 98.0% for adults aged 20-49 years compared with 90.0% and 98.1%, respectively, for 1988-1994. We found an increase in seropositivity between the survey periods, from 93.2% to 97.2% (p < 0.001) among 12- to 19-year-olds. For children, non-Hispanic black ethnicity and younger age were associated with lower seroprevalence in both survey periods. CONCLUSIONS: Varicella seroprevalence increased with age among children and was uniformly high in the U.S. adult population between 1999 and 2004. The original testing produced false-negative seroprevalence results among children's specimens collected between 1999 and 2004 from 6- to 19-year-olds.

Impact of varicella vaccine on varicella-zoster virus dynamics.

The licensure and recommendation of varicella vaccine in the mid-1990s in the United States have led to dramatic declines in varicella incidence and varicella-related deaths and hospitalizations. Varicella outbreaks remain common and occur increasingly in highly vaccinated populations. Breakthrough varicella in vaccinated individuals is characteristically mild, typically with fewer lesions that frequently do not progress to a vesicular stage. As such, the laboratory diagnosis of varicella has grown increasingly important, particularly in outbreak settings. In this review the impact of varicella vaccine on varicella-zoster virus (VZV) disease, arising complications in the effective diagnosis and monitoring of VZV transmission, and the relative strengths and limitations of currently available laboratory diagnostic techniques are all addressed. Since disease symptoms often resolve in outbreak settings before suitable test specimens can be obtained, the need to develop new diagnostic approaches that rely on alternative patient samples is also discussed.