Circulating vaccine derived polio virus type 2 outbreak and response in Yemen, 2021-2022, a retrospective descriptive analysis.

BACKGROUND: The outbreaks of circulating Vaccine Derived Polio Viruses (cVDPVs) have emerged as a major challenge for the final stage of polio eradication. In Yemen, an explosive outbreak of cVDPV2 was reported from August 2021 to December 2022. This study aims to compare the patterns of cVDPV2 outbreak, response measures taken by health authorities, and impacts in southern and northern governorates. METHOD: A retrospective descriptive study of confirmed cases of VDPV2 was performed. The data related to cVDPV2 as well as stool specimens and environmental samples that were shipped to WHO-accredited labs were collected by staff of surveillance. Frequencies and percentages were used to characterize and compare the confirmed cases from the southern and northern governorates. The average delayed time as a difference in days between the date of sample collection and lab confirmation was calculated. RESULTS: The cVDPV2 was isolated from 227 AFP cases reported from 19/23 Yemeni governorates and from 83% (39/47) of environmental samples with an average of 7 months delayed from sample collection. However, the non-polio AFP (NPAFP) and adequate stool specimen rates in the north were 6.7 and 87% compared to 6.4 and 87% in the south, 86% (195) and 14%(32) out of the total 227 confirmed cases were detected from northern and southern governorates, respectively. The first and second cases of genetically linked isolates experienced paralysis onset on 30 August and 1st September 2021. They respectively were from Taiz and Marib governorates ruled by southern authorities that started vaccination campaigns as a response in February 2022. Thus, in contrast to 2021, the detected cases in 2022 from the total cases detected in the south were lower accounting for 22% (7 of 32) of compared to 79% (155 of 195) of the total cases the north. CONCLUSION: A new emerging cVDPV2 was confirmed in Yemen. The result of this study highlighted the impact of vaccination campaigns in containing the cVDPV2 outbreak. Maintaining a high level of immunization coverage and switching to nOPV2 instead of tOPV and mOPV2 in campaigns are recommended and environmental surveillance should be expanded in such a risky country.

Prevalence of Diabetes Mellitus among Patients with Tuberculosis and Its Associated Factors in Sana'a, Yemen, 2021.

Diabetes mellitus (DM) is one of tuberculosis' (TB) ending barriers. TB patients with DM are at a higher risk than non-diabetes patients to develop complication, relapse and die. In Yemen, information on TB-DM comorbidity is lacking. This study aimed to determine the prevalence and associated factors of diabetes among TB patients at the National Tuberculosis Center (NTC) in Sana'a. A facility-based cross-sectional study was conducted. All TB patients aged >15 years who attended the NTC from July to November 2021 were screened for DM. Socio-demographic and behavioral information were collected through face-to-face interviews using questionnaires. A total of 331 TB patients were enrolled, 53% were males, 58% aged <40 years, and 74% were newly diagnosed with TB. Overall, DM prevalence was 18%. Higher rates of DM were found among TB patients that were male (OR = 3.0; 95% CI; 1.4-6.7), ≥50 years of age (OR = 10.8; 95% CI; 4.3-27.3), and those with a family history of diabetes (OR = 3.4; 95% CI; 1.6-6.9). Almost one fifth of TB patients had DM. The early detection of DM through immediate screening after a TB diagnosis and periodically during the course of treatment is crucial for TB patients' optimal care. Dual diagnostics for reducing the dual burden of TB-DM comorbidity is recommended.

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.

Circulating vaccine derived polio virus type 1 outbreak, Saadah governorate, Yemen, 2020.

BACKGROUND: Yemen has faced one of the worst humanitarian crises in the world since the start of the war in 2015. In 2020; 30 Vaccine Derived Polio Virus type 1 (VDPV1) isolates were detected in Saadah governorate. The aims are to characterize the outbreak and address the gaps predisposing the emergence and circulation of VDPV1 in Saadah governorate, Yemen. METHOD: A retrospective descriptive study of confirmed cases of VDPV1 between January and December 2020 was performed. Surveillance staff collected data from patient cases, contacts, as well as stool specimens that shipped to WHO accredited polio labs. Data of population immunity was also reviewed. The difference in days between the date of sample collection, shipment, and receiving lab result was used to calculate the average of delayed days for lab confirmation. RESULTS: From January to December 2020, a total of 114 cases of acute flaccid paralysis (AFP) were reported from 87% (13/15) districts, and cVDPV1 was confirmed among 26% (30) AFP cases. 75% (21) were < 5 years, 73% (20) had zero doses of Oral Polio Vaccine (OPV). The first confirmed case (3%) was from Saadah city, with paralysis onset at the end of January 2020 followed by 5 cases (17%) in March from another four districts, 8 cases (27%) in April, and 13 (43%) up to December 2020 were from the same five districts in addition to 3 (10%) form three new districts. The lab confirmation was received after an average of 126 days (71-196) from sample collection. The isolates differ from the Sabin 1 type by 17- 30 VP1 nucleotides (nt) and were linked to VDPV1 with 13 (nt) divergence that isolated in July 2020 from stool specimens collected before one year from contacts of an inadequate AFP case reported from Sahar district. CONCLUSION: The new emerging VDPV1 was retrospectively confirmed after one year of sample collection from Sahar district. Delayed lab confirmation, as well as the response and low immunization profile of children against polio, were the main predisposing factors for cVDPV1 outbreak. This outbreak highlights the need to maintain regular biweekly shipments to referral polio labs in the short-term, and the exploration of other options in the longer-term to enable the Yemen National Lab to fully process national samples itself.

Influenza circulating viruses, positivity rate and risk factors for influenza associated severe acute respiratory infection during 2018/2019 winter season, Yemen.

BACKGROUND: The burden of seasonal influenza in conflict counties is exacerbated due to limited resource and collapse of health system. During 2018 /2019 season, two-fold increase in the incidence of influenza was reported in Yemen with 22% case fatality of severe acute respiratory infection (SARI). The aims are to analyze the influenza circulating viruses, positivity rate and risk factors for hospitalizing influenza associated-SARI. METHODOLOGY: We used a retrospective analytical study based on surveillance data. All reported patients during 2018/2019 season, fulfilling the WHO cases definition for SARI or influenza like illness (ILI), and had laboratory result from the National Laboratory were included. Influenza positivity rate was calculated, all SARI and ILI patients with positive influenza were included for further analysis by univariate and multivariate binary logistic regression. Crude and adjusted Odds ratio (AOR), 95% confidence interval and P-value < 0.05 were used for statistically significant. RESULTS: Out of 2186 patients enrolled, 768 patients were tested for influenza viruses,: 19% were children < 15 years, 15% were ≥ 65 years, 69% males and 18% had co-morbidity with chronic diseases. Patients with SARI were 37% and 63% were ILI patients. Influenza viruses were detected in 411 (53.5%), 68% were influenza A subtype (H1N1)pdm09, 27% influenza B and 5% was influenza A not subtyped. The influenza positivity was significantly higher in SARI compared to ILI for patients < 15 years (95% vs, 66%, p < 0.001), and patients ≥ 65 years (83% vs. 56%, p < 0.002), respectively. The highest positivity for influenza type A and B reached 44% and 33% for patients ≥ 65 years and < 15 years, respectively. The risk factors for influenza-associated SARI in multivariate analysis included age < 5 [AOR 2.8] and ≥ 65 years old [AOR 3.1] compared to age 5- < 25 years, diabetes [AOR 4.7], heart diseases [AOR 3.1] and chronic respiratory diseases [AOR 5.0]. CONCLUSION: The influenza positivity during 2018/2019 winter season was high in Yemen and varied by age distribution. Influenza subtype A (H1N1) pdm09 was the predominant and co circulated with influenza B. An influenza vaccination program for the risk group is necessary. Strengthening lab capacity to detect respiratory pathogens and further prospective study for more comprehensive picture are recommended.

Intestinal schistosomiasis among schoolchildren in Sana'a Governorate, Yemen: Prevalence, associated factors and its effect on nutritional status and anemia.

Intestinal schistosomiasis is a neglected tropical disease, causing morbidity and mortality in tropical and subtropical countries. Despite the frequent implementation of mass drug administration with praziquantel, the reinfection with Schistosoma mansoni is still common in Yemen. In addition, there is a scarcity of information on the impact of S. mansoni on nutritional status and anemia among schoolchildren. The present study aimed to determine prevalence and risk factors of intestinal schistosomiasis and investigate its impact on nutritional status and anemia among schoolchildren in Sana'a Governorate, Yemen. It was conducted in 2018 on 445 schoolchildren aged 5-15 years. Biodata, socio-economic, demographic, behavioral and environmental data were collected using a standard questionnaire. S. mansoni was identified and quantified by microscopic examination of Kato-Katz fecal smear. Hemoglobin concentration and anthropometric measurements were estimated using standard methods. The prevalence of S. mansoni was higher in Al-Haimah Al-Dakheliah (33.9%) than Bani Mater (1.4%). Household without tap water (Adjusted Odds Ratio (AOR) = 2.9, 95% Confidence interval (CI): 1.12, 7.55, P = 0.028) was the independent risk factor of the infection. The prevalence of wasting and stunting was 25.0% (95%CI: 21.2%, 29.2%) and 45.8% (95%CI: 41.2%, 50.5%), respectively. The prevalence of underweight among schoolchildren aged 5-10 years was 27.3% (95%CI: 21.9%, 33.4%). The prevalence of anemia was 31.7% (95%CI: 27.5%, 36.2%) with 0.5%, 21.1% and 10.1% being severe, moderate and mild anemia, respectively. S. mansoni (AOR = 4.1, 95%CI: 2.16, 7.84, P < 0.001) and early adolescence (AOR = 6.8, 95%CI: 4.26, 10.82, P < 0.001) were independent predictors of stunting among schoolchildren. The early adolescent schoolchildren (AOR = 3.1, 95%CI: 1.86, 4.97, P < 0.001) and children from families with low (AOR = 2.1, 95%CI: 1.01, 4.15, P = 0.046) or moderate wealth (AOR = 2.3, 95%CI: 1.11, 4.77, P = 0.026) were significantly more wasted. Early adolescence (AOR = 1.8, 95%CI:1.14, 2.78, P = 0.011), female (AOR = 1.6, 95%CI: 1.03, 2.43, P = 0.038) and Al-Haimah Al-Dakheliah District (AOR = 3.4, 95%CI: 1.20, 9.55, P = 0.021) were independent risk factors for anemia. The study findings indicate highly focal prevalence of schistosomiasis in Sana'a Governorate with a public health significance that varies from low to high risk. Approximately half of schoolchildren were stunted, which was associated with S. mansoni infection and early adolescence. One quarter of schoolchildren were wasted with early adolescent schoolchildren and children from poor families being at high risk of wasting. Anemia was a moderate public health threat affecting the female and the early adolescent schoolchildren. The study suggests the implementation of control measures to combat schistosomiasis and integrated diseases control programmes to improve the health status of schoolchildren in Sana'a Governorate.

Incidence, Trend, and Mortality of Human Exposure to Rabies in Yemen, 2011-2017: Observational Study.

BACKGROUND: Rabies remains a neglected and poorly controlled disease throughout the developing world, particularly in Africa and Asia, where most human rabies deaths occur. OBJECTIVE: This study aimed to describe the epidemiology of rabies exposures, its trend, and its geographical distribution in Yemen. METHODS: Cumulative data from a rabies surveillance system for the period 2011-2017 were obtained from the National Rabies Control Program as paper-based annual reports. Data included the number of persons bitten by a suspected rabid animal, their gender and age, and the result of the animal's laboratory test. Human cases were defined as those exposed to rabies virus bitten by a suspected rabid animal, exposed to a confirmed rabid animal and then received postexposure prophylaxis (PEP), and deaths occurred after exposure to a confirmed rabid animal after having rabies symptoms during 2011-2017. RESULTS: From 2011 to 2017, a total of 76,049 persons were bitten by a suspected rabid animal. Of these, 21,927 (28.83%) were exposed to positively confirmed rabid animals and then received PEP, and 295 (0.38%) rabies-related deaths occurred. Of all cases with rabies exposure, 50,882 (66.91%) were males. The most affected age group by animal bites (31,816/76,041, 41.84%), positive exposure (8945/21,927, 40.79%), and rabies deaths (143/295, 48.47%) was 5-14 years. Rabies vaccines and immunoglobulins quantities were least available in 2016 and 2017. The annual incidence rate of exposure to animal bites and rabies exposure was 50 and 14 per 100,000, respectively. The annual mortality rate was 2 per 1,000,000. The highest incidence rate of animal bites was in Dhamar (112 per 100,000) and Ibb (94 per 100,000), whereas the highest incidence of exposed cases was in Amanat Al Asimah (40 per 100,000) and Ibb (37 per 100,000). Mortality rate was the highest in Amanat Al Asimah (6 deaths per 1,000,000) followed by Ibb and Dhamar (4 deaths per 1,000,000 in both). CONCLUSIONS: Rabies remains a worrying health problem in Yemen with higher percentage reported among children and males. Targeting school-age populations by education, communication, and information campaigns about preventive measures is strongly recommended. An electronic system should be introduced to improve reporting. It is important to have a sufficient supply of vaccines and immunoglobulins in control units, especially in the at-risk or impacted governorates. Future studies are suggested to determine incidences and risk factors of disease progression.

The Rotavirus Surveillance System in Yemen: Evaluation Study.

BACKGROUND: Rotavirus (RV) kills over 185,000 children <5 years every year and is responsible for over one-third of all child diarrheal deaths worldwide. The Rotavirus Surveillance System (RVSS) in Yemen was launched in 2007 at five sentinel sites to monitor the impact of the vaccine on RV morbidity and mortality. OBJECTIVE: This study aimed to determine the usefulness of the RVSS, assess its performance, and identify the strengths and weaknesses of its implementation. METHODS: The Centers for Disease Control and Prevention's updated guidelines on evaluating a public health surveillance system were used to evaluate the RVSS. In this assessment, qualitative indicators, such as usefulness, flexibility, stability, simplicity, and acceptability, were assessed through in-depth interviews with stakeholders at the central level and semistructured questionnaires with the sentinel site coordinators. The indicators for quantitative attributes-sensitivity, positive predictive value (PPV), completeness, and timeliness-were assessed by reviewing the results of laboratory samples and a random sample of case report forms. The scores for the indicators were expressed as poor (<60%), average (60% to <80%), and good (≥80%). RESULTS: The overall usefulness score of the RVSS was 73%, indicating an average rank. The RVSS was rated as having good flexibility (91%) and stability (81%), and average simplicity (77%) and acceptability (76%). In terms of quantitative attributes, the system was poor for sensitivity (16%), average for PPV (73%), and good for completeness (100%) and timeliness (100%). CONCLUSIONS: Although the system attributes were flexible, stable, capable of providing quality data, and performing timely data reporting, some attributes still needed improvements (eg, usefulness, simplicity, acceptability, and PPV). There is a need for a gradual replacement of donor funds with government funds to ensure sustainability. The RVSS in Yemen strongly requires a progressive increase in the number of sites in governorates and sensitivity enhancement.

Risk factors for measles outbreak in Ataq and Habban districts, Shabwah governorate, Yemen, February to May 2018.

BACKGROUND: Recent conflict and war in Yemen lead to collapse of the health system, decrease of immunization coverage and spread of many outbreaks. On May 22, 2018, the surveillance officer in Shabwah governorate reported an increased number of suspected measles. On May 24, 2018, a team from Yemen-Field Epidemiology Training Program was sent to investigate. The aims were to describe the outbreak, determine the risk factors for measles infection and recommend control measures. METHODOLOGY: A descriptive followed by case-control study design (1:2 ratio) were performed. National Measles Surveillance Program case definition and predesigned questionnaire were used to collect data from 73 cases and 146 controls. Attack rate (AR), adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) were calculated. P value < 0.05 was considered as the cut point for significant. Epi info version 7.2 was used. RESULTS: A total of 73 suspected cases were found. Almost 53% were from Habban district, 63% were males and 56% were among age group < 5 years. The overall AR was 82/100,000 population. Measles was significantly associated with contact with case (aOR = 27.3, 95% CI:1.3-551.7), malnourished children aged 6-60 months (aOR = 24.9, 95% CI;1.9-329.6) and unvaccinated children (aOR = 17.2, 95% CI:2.9-100.7). The six collected blood samples found to be positive for measles IgM. CONCLUSIONS: Measles outbreak in Ataq and Habban districts was confirmed. Contact with measles cases, malnutrition and un-vaccination were the potential contributing factors of measles outbreak in Shabwah governorate. An urgent vaccination campaign with health education interventions are highly recommended. Reactivation of the outreach immunization services and strengthening surveillance and response systems are top priority to take place at district and governorate levels.

Cutaneous Leishmaniasis Outbreak Investigation in Hajjah Governorate, Yemen, in 2018: Case-Control Study.

BACKGROUND: Cutaneous leishmaniasis (CL) is endemic in Yemen. About 4440 cases were reported in 2019. On July 23, 2018, a Hajjah governorate surveillance officer notified the Ministry of Public Health and Population about an increase in the number of CL cases in Bani-Oshb, Kuhlan district, Hajjah governorate. On July 24, 2018, Yemen Field Epidemiology Training Program sent a team to perform an investigation. OBJECTIVE: We aimed to describe a CL outbreak in Hajjah governorate and determine its risk factors. METHODS: A descriptive study and case-control study (1:1 ratio) were conducted. Cases included people who met the suspected or confirmed case definition of the World Health Organization and lived in Bani-Oshb subdistrict during the period from August 2017 to July 2018. Controls included people living for at least 1 year in Bani-Oshb without new or old skin lesions. Crude odds ratios (cORs) and adjusted odds ratios (aORs) with 95% CI were used to test the significance of associations. RESULTS: We identified 30 CL cases. Among the 30 patients, 7 (23%) were younger than 5 years, 17 (57%) were 5 to 14 years, 17 (57%) were females, and 23 (77%) had one lesion. The attack rate was 7 per 1000 population in the age group <15 years and 1 per 1000 population in the age group ≥15 years. On bivariate analysis, the following factors were significantly associated with CL: female gender (cOR 5.2, 95% CI 1.7-16.5), malnutrition (cOR 5.2, 95% CI 1.7-16.5), not using a bed net (cOR 14.5, 95% CI 1.7-122.4), poor house lighting (cOR 6.4, 95% CI 2.1-19.7), poor house hygiene (cOR 11.2, 95% CI 3.1-40.7), poor sanitation (cOR 14.5, 95% CI 1.7-122.4), living in houses without window nets (cOR 5.2, 95% CI 1.3-21.2), plantation around the house (cOR 6.5, 95% CI 2.1-20.5), animal barn inside or close to the house (cOR 9.3, 95% CI 1.9-46.7), raising animals (cOR 8.1, 95% CI 1.6-40.7), and having animal dung in or near the house (cOR 6.8, 95% CI 1.7-27.7). The following risk factors remained significant on multivariate stepwise analysis: female gender (aOR 22.7, 95% CI 1.6-320.5), malnutrition (aOR 17.2, 95% CI 1.3-225.8), poor house hygiene (aOR 45.6, 95% CI 2.5-846.4), plantation around the house (aOR 43.8, 95% CI 1.9-1009.9), and raising animals (aOR 287.1, 95% CI 5.4-15205.6). CONCLUSIONS: CL was endemic in Hajjah governorate, and an increase in cases was confirmed. Many individual, housing, and animal related factors were shown to contribute to CL endemicity. Implementation of control measures directed toward altering the factors favoring contact among vectors, reservoirs, and susceptible humans is strongly recommended to control future outbreaks.

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.

Risk Factors of Cholera Transmission in Al Hudaydah, Yemen: Case-Control Study.

BACKGROUND: Yemen has recently faced the largest cholera outbreak in the world, which started at the end of 2016. By the end of 2017, the cumulative reported cases from all governorates reached 777,229 with 2134 deaths. Al Hudaydah was one of the most strongly affected areas, with 88,741 (18%) cases and 244 (12%) deaths reported. OBJECTIVE: The aim of this study was to determine the risk factors associated with cholera transmission in Al Hudaydah city, Yemen. METHODS: From December 1, 2017 to January 10, 2018, a total of 104 patients with cholera (57 women and 47 men) who presented at cholera treatment centers in Al Hudaydah city with three or more watery stools in a 24-hour period and with moderate or severe dehydration were identified for inclusion in this study. Each case was matched by age and gender with two controls who were living in the neighboring house. A semistructured questionnaire was used to collect data on behavioral and environmental risk factors such as drinking water from public wells, storing water in containers, consumption of unwashed vegetables or fruits, and sharing a toilet. RESULTS: The median age of the cases and controls was 20 years (range 5-80) and 23 years (range 5-85), respectively. Only 6% of cases and 4% of controls were employed. Multivariate analysis showed that eating unwashed vegetables or fruits (odds ratio [OR] 7.0, 95% CI 1.6-30.6, P=.01), storing water in containers (OR 3.0, 95% CI 1.3-7.3, P=.01), drinking water from a public well (OR 2.5, 95% CI 1.1-5.7, P=.02), and using a public toilet (OR 5.2, 95% CI 1.1-24.4, P=.04) were significantly associated with cholera infection risk. CONCLUSIONS: The cholera transmission risk factors in Al Hudaydah city were related to water and sanitation hygiene. Therefore, increasing awareness of the population on the importance of water chlorination, and washing fruits and vegetables through a health education campaign is strongly recommended.

The Impact of War in Yemen on Immunization Coverage of Children Under One Year of Age: Descriptive Study.

BACKGROUND: After 2 years of war that crippled the capacity of the Yemeni National Health System and left only 45% of health facilities functioning, Yemen faced increasing vaccine-preventable disease (VPD) outbreaks and may be at high risk of polio importation. OBJECTIVE: The aim of this study was to determine the impact of the 2015 war on the immunization coverage of children under 1 year. METHODS: Data on vaccination coverage for 2012-2015 were obtained from the national Expanded Program on Immunization (EPI). The vaccination coverage was calculated at the national and governorate levels by dividing the number of actually vaccinated children by the estimated population of children under 1 year. RESULTS: Although there was an increase from 2012 to 2014 in the national coverage for penta-3 vaccine (82% in 2012 vs 88% in 2014) and measles vaccine (70% in 2012 vs 75% in 2014), the coverage was still below the national target (≥95%). Furthermore, the year 2015 witnessed a marked drop in the national coverage compared with 2014 for the measles vaccine (66% in 2015 vs 75% in 2014), but a slight drop in penta-3 vaccine coverage (84% in 2015 vs 88% in 2014). Bacillus Calmette-Guérin vaccine also showed a marked drop from 73% in 2014 to 49% in 2015. These reductions were more marked in governorates that witnessed armed confrontations (eg, Taiz, Lahj, and Sa'dah governorates). On the other hand, governorates that did not witness armed confrontations showed an increase in coverage (eg, Raymah and Ibb), owing to an increase in their population because of displacement from less secure and confrontation-prone governorates. CONCLUSIONS: This analysis demonstrated the marked negative impact of the 2015 war on immunization coverage, especially in the governorates that witnessed armed confrontations. This could put Yemen at more risk of VPD outbreaks and polio importation. Besides the ongoing efforts to stop the Yemeni war, strategies for more innovative vaccine delivery or provision and fulfilling the increasing demands are needed, especially in governorates with confrontations. Enhancing EPI performance through supportable investments in infrastructure that was destroyed by the war and providing decentralized funds are a prerequisite.

Evaluation of outpatient therapeutic programme (OTP) for treatment of severe acute malnutrition in Yemen: a focus on treatment default and its risk factors.

OBJECTIVES: This study aimed to measure the treatment default rate among children with severe acute malnutrition (SAM) who were admitted to the outpatient therapeutic programme (OTP) in Yemen and determine its risk factors. METHODS: A prospective study was conducted among children with SAM who were newly admitted to the 11 OTPs in primary health centres of Sana'a city. A pretested semistructured questionnaire was used for data collection at admission and at after 2 months of admission to the OTP. Univariate and multivariate analysis using binary logistic regression were used to analyse the risk factors of treatment default. RESULTS: This study included 339 SAM children. Of those, 186 (55%) children discharged as defaulters, 141 (42%) were cured, and 12 (3%) were transferred to other treatment sites. Many factors related to poor accessibility, poor satisfaction with staff and system, and treatment and acceptability of OTP services factors were significantly associated with treatment default. Having difficulty to attend OTP every week (OR 8.4), unavailability of medication during follow-up visits (OR 5.0), not liking to eat Plumpy'Nut (OR 5.8), and not gaining weight since the start of treatment (OR 9.3) were the strongest predictors of treatment default. CONCLUSIONS: This study showed a high default rate among SAM children in Sana'a city. Factors related to poor accessibility, poor satisfaction with staff and system, and factors related to treatment and acceptability of OTP services were significantly associated with high default rate. Expansion of OTP services and training OTPs staff on SAM treatment protocols are highly recommended.