Risk factors for diphtheria in Sana'a, Yemen, 2019: a matched case-control study.

Objective: To identify risk factors for diphtheria related to sociodemographic, immunization and household status, and source of infection in Sana'a. Methods: A retrospective matched case-control study (1:2 ratio) was conducted. Cases were defined as patients who met the World Health Organization's definition of confirmed diphtheria living in Sana'a between January and November 2019. Controls were defined as subjects without a history of diphtheria infection, living in the same neighbourhood, and matched with cases by age and sex. Crude odds ratios, adjusted odds ratio (aOR) and 95% confidence intervals (CI) were calculated to evaluate associations between risk factors and diphtheria. Results: In total, 76 confirmed cases and 152 controls were enrolled in this study. Multi-variate analysis found significant associations between diphtheria infection and sharing a bedroom with at least two people (aOR 2.8, 95% CI 1.2-6.6), non-vaccination (aOR 2.6, 95% CI 1.2-6.0) and contact with a diphtheria case (aOR 10.6, 95% CI 2.6-43.6). Conclusions: This study found that vaccination, not sharing a bedroom with at least two people, and isolation of diphtheria cases to prevent contact with non-infected individuals were the most important measures for protection of the community from diphtheria. Raising community awareness about vaccination, transmission and preventive measures is recommended.

Diphtheria resurgence in Sada'a-Yemen, 2017-2020.

BACKGROUND: Diphtheria is a contagious vaccine-preventable disease that contributes to the high morbidity and mortality among under 5 children, especially in Yemen. As a consequence of war and collapse of the health system, a fatal epidemic occurred at the end of 2017. This study aims to describe the epidemiology of diphtheria by time, place, and person and vaccination status of affected children. METHODS: A study was conducted in Sada'a governorate by using accumulative line list of diphtheria from November 2017 to September 2020 at electronic Integrated Disease Early Warning System (eIDEWS). The case definition of WHO was adopted. Data was analyzed by Microsoft Excel and Epi info- version 7.2 and multivariable logistic analysis used for identifying significant associated factors. RESULTS: 747 cases were met of WHO case definition. The annual peak of cases started during week 31 and weak 49. Males were slightly more than females (51% vs 49%) and about 35% of cases involved children aged 10 to < 15 years. The overall incidence of diphtheria and case fatality rate (CFR) were 69/ 100,000 and 6.4%, respectively. The highest CFR was among age groups under 5 years 11% (P < 0.001) and among females was 8%. Dysphagia and swollen lymph nodes were the predominant symptoms 98%, 92%, respectively. Based on the Vaccination status, the percentage of unvaccinated and unknown were 53% and 41% respectively, with CFR 11% among cases who received one dose. Furthermore, the most case were from Sahar 40% with case fatality rate 8% and the highest CFR was significantly higher among cases in border and ongoing conflict district (P < 0.05). CONCLUSIONS: The findings highlight that diphtheria is still an ongoing cause of morbidity and mortality among under 5 children in Sada'a that is rising with the low diphtheria immunization coverage. Therefore, concomitant efforts should now focus on improving and monitoring routine immunization across all age groups and healthcare services, especially in borders and continuing conflict districts.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: Multicountry Retrospective Study.

BACKGROUND: The establishment of empirical evidence in the Eastern Mediterranean Region necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of patients with COVID-19. OBJECTIVE: This study aims to assess the patterns of COVID-19 severity and mortality in seven countries, and to determine the risk factors of COVID-19 severity and mortality. METHODS: This multicountry study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study includes data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors. RESULTS: A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (n=1021, 24.7%) and diabetes (n=939, 22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity. CONCLUSIONS: The study confirms the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

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.

Mental health impacts of COVID-19 on healthcare workers in the Eastern Mediterranean Region: a multi-country study.

BACKGROUND: Healthcare workers (HCWs) fighting against the COVID-19 pandemic are under incredible pressure, which puts them at risk of developing mental health problems. This study aimed to determine the prevalence of depression, anxiety, and stress among HCWs responding to COVID-19 and its associated factors. METHODS: A multi-country cross-sectional study was conducted during July-August 2020 among HCWs responding to COVID-19 in nine Eastern Mediterranean Region (EMR) countries. Data were collected using an online questionnaire administered using KoBo Toolbox. Mental problems were assessed using the Depression, Anxiety, and Stress Scale (DASS-21). RESULTS: A total of 1448 HCWs from nine EMR countries participated in this study. About 51.2% were male and 52.7% aged ≤ 30 years. Of all HCWs, 57.5% had depression, 42.0% had stress, and 59.1% had anxiety. Considering the severity, 19.2%, 16.1%, 26.6% of patients had severe to extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants' residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. Furthermore, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores. CONCLUSIONS: Mental problems were prevalent among HCWs responding to COVID-19 in EMR. Therefore, special interventions to promote mental well-being among HCWs responding to COVID-19 need to be immediately implemented.

Public health workers' knowledge, attitude and practice regarding COVID-19: the impact of Field Epidemiology Training Program in the Eastern Mediterranean Region.

BACKGROUND: This study aimed to compare knowledge, attitude and practice (KAP) regarding COVID-19 between public health workers (PHWs) attended field epidemiology training program (FETP-trained) and those who did not attend FETP (non-FETP trained). METHODS: Multi-country cross-sectional survey was conducted among PHWs who participated in COVID-19 pandemic in 10 countries at EMR. Online questionnaire that included demographic information, KAP regarding COVID-19 pandemic was distributed among HCWs. Scoring system was used to quantify the answers, bivariate and Multivariate analysis performed to compare FETP-trained with non-FETP trained PHWs. RESULTS: Overall, 1337 PHWs participated, with 835 (62.4%) < 40 years of age, and 851 (63.6%) males. Of them, 423 (31.6%) had FETP, including that 189 (44.7%) had advanced level, 155 (36.6%) intermediate and 79 (18.7%) basic level training. Compared with non-FETP trained, FETP trained were older, having higher KAP scores. FETP participation was low in infection control, and PH laboratories. KAP mean scores for intermediate level attendees are comparable to advanced level. CONCLUSIONS: FETP-trained are having better KAP than non-FETP PHWs. Expanding the intermediate level, maintain the Rapid Response training and introduce the laboratory component are recommended to maximize the benefit from FETP. Infection control, antimicrobial resistance and coordination are areas where training should include.

First COVID-19 cases with high secondary infection among health workers, Sana'a capital, April 2020: Lessons learned and future opportunities.

OBJECTIVES: Confirm existence of COVID-19 outbreak, conduct contact tracing, and recommend control measures. METHODS: Two COVID-19 cases in Sana'a Capital met the WHO case definition. Data were collected from cases and contacts who were followed for 14 days. Nasopharyngeal swabs were taken for confirmation by Polymerase Chain Reaction (PCR). RESULTS: Two confirmed Yemeni male patients aged 20 and 40 years who had no travel history were admitted to hospital on 24 April 2020. Regarding the first patient, symptoms started on April 18th, 2020 then the patient improved and was discharged on May 5th, while the second patient's symptoms started on April 22nd but the patient died on April 29th, 2020. Both patients had 54 contacts, 17 (32%) were health workers (HWs). Four contacts (7%) were confirmed, two of them were HWs that needed hospitalization. The secondary attack rate (sAR) was 12% among HWs compared to 5% among other contacts. CONCLUSIONS: First COVID-19 outbreak was confirmed among Yemeni citizens with a high sAR among HWs. Strict infection control among HWs should be ensured. Physical distancing and mask-wearing with appropriate disinfecting measures should be promoted especially among contacts. There is a need to strengthen national capacities to assess, detect, and respond to public health emergencies.

Evaluation of Blood Transfusion Services in Public and Private Blood Bank Centers, Sana'a Capital, Yemen.

The aim of this study was to evaluate blood transfusion services (BTS) at the main blood banks (BBs) of the Sana'a Capital. The 4 main BBs at Sana'a Capital were evaluated according to the safe World Health Organization BTS standards. Qualitative and quantitative data were collected using semi-structured questionnaires covering 6 components: activities, quality assurance system (QAS) and training, donation, grouping and compatibility testing, components, and screening for transfusion-transmitted infections (TTIs). An overall mean percent score for BTS was calculated where <60% is considered unsatisfactory, 60% to 79.9% satisfactory, and ≥80% highly satisfactory. The 4 BBs screen for HIV, hepatitis B, and hepatitis C and perform all functions except therapeutic transfusion. While 75% of the staff in BBs had received training in biosafety and half of the staff had received training in Standard Operating Procedures (SOPs), no QAS in place at any of the 4 BBs. The 4 BBs depended on 71% of their transfusions on family donors. Two BBs do not perform reverse grouping and do not keep patient/donor samples for the required minimum 5 days. Only one BB achieved an overall high satisfactory score and one achieved a satisfactory score. Findings highlight the increasing challenges facing BTS in Sana'a Capital especially the lack of therapeutic transfusion, poor QAS, and predominant dependence on the family donors. Therefore, there is a need to develop and train staff on QAS and to increase awareness among public on importance of voluntary donation. A wider scale evaluation of BTS in Sana'a is recommended.