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.

Knowledge on and preventive practices of cholera in Al-Mahweet - Yemen, 2018: a cross-sectional study.

Yemen has experienced one of the world's worst cholera outbreaks in the recent history of cholera records. This study aims to identify knowledge and practices among people of Al-Mahweet governorate toward cholera infection, which can play a critical role in reducing cholera morbidity and shaping the public health response. A cross-sectional study was conducted in an area of high cholera prevalence in 2018 using structured questionnaires. Most community respondents were able to correctly identify the symptoms and risk factors of cholera. While 65% of the respondents in this study knew that proper disposal of human waste is an essential measure of cholera prevention, only 11% of the respondents knew that proper washing of fruits and vegetables lowers the risk of cholera infection. About 62.5% of households did not treat water for safe drinking. Water was scarce in about 30% of households and near-home defecation was observed in about 23%. In conclusion, this study reveals several gaps in different aspects of hygienic and preventive practices including water treatment, waste disposal, and defecation practices. Cholera response should contain comprehensive health promotion interventions to improve the public's knowledge and enhance healthy practices. Stakeholders should support communities with sustainable water and sanitation systems.

Mind the gap: an analysis of core capacities of the international health regulations (2005) to respond to outbreaks in Yemen.

BACKGROUND: Yemen that has been devastated by war is facing various challenges to respond to the recent potential outbreaks and other public health emergencies due to lack of proper strategies and regulations, which are essential to public health security. The aim of this study is to assess the implementation of the International Health Regulations (IHR 2005) core capacities under the current ongoing conflict in Yemen. METHODS: The study simulated the World Health Organization (WHO) Joint External Evaluation (JEE) tool to assess the IHR core capacities in Yemen. Qualitative research methods were used, including desk reviews, in-depth interviews with key informants and analysis of the pooled data. RESULT: Based on the assessment of the three main functions of the IHR framework (prevention, detection, and response), Yemen showed a demonstrated or developed capacity to detect outbreaks, but nevertheless limited or no capacity to prevent and respond to outbreaks. CONCLUSION: This study shows that there has been poor implementation of IHR in Yemen. Therefore, urgent interventions are needed to strengthen the implementation of the IHR core capacities in Yemen. The study recommends 1) raising awareness among national and international health staff on the importance of IHR; 2) improving alignment of INGO programs with government health programs and aligning both towards better implementation of the IHR; 3) improving programmatic coordination, planning and implementation among health stakeholders; 4) increasing funding of the global health security agenda at country level; 5) using innovative approaches to analyze and address gaps in the disrupted health system, and; 6) addressing the root cause of the collapse of the health services and overall health system in Yemen by ending the protracted conflict situation.

Assessment of electronic disease early warning system for improved disease surveillance and outbreak response in Yemen.

BACKGROUND: Diseases Surveillance is a continuous process of data collection, analysis interpretation and dissemination of information for swift public health action. Recent advances in health informatics have led to the implementation of electronic tools to facilitate such critical disease surveillance processes. This study aimed to assess the performance of the national electronic Disease Early Warning System in Yemen (eDEWS) using system attributes: data quality, timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility, and representativeness, based on the Centres for Disease Control & Prevention (US CDC) standard indicators. METHODS: We performed a mixed methods study that occurred in two stages: first, the quantitative data was collected from weekly epidemiological bulletins from 2013 to 2017, all alerts of 2016, and annual eDEWS reports, and then the qualitative method using in-depth interviews was carried out in a convergent strategy. The CDC guideline used to describe the following system attributes: data quality (reporting, and completeness), timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility and representativeness. RESULTS: The finding of this assessment showed that eDEWS is a resilient and reliable system, and despite the conflict in Yemen, the system is still functioning and expanding. The response timeliness remains a challenge, since only 21% of all eDEWS alerts were verified within the first 24 h of detection in 2016. However, identified gaps did not affect the system's ability to identify outbreaks in the current fragile situation. Findings show that eDEWS data is representative, since it covers the entire country. Although, eDEWS covers only 37% of all health facilities, this represents 83% of all functional health facilities in all 23 governorates and all 333 districts. CONCLUSION: The quality and timeliness of responses are major challenges to eDEWS' functionality, the eDEWS remains the only system that provides regular data on communicable diseases in Yemen. In particular, public health response timeliness needs improvement.

Factors associated with the cholera outbreak in Al-Mahweet-Yemen: Analytic Study.

INTRODUCTION: The emergence of cholera in 2016 in Yemen, worsened the morbidity and mortality of diarrheal diseases, particularly among children under five. Multiple outbreaks in Yemen are triggered by years of conflict and the collapse of basic infrastructure including water supply and sanitation systems. This study aims to assess factors associated with the cholera outbreak, in a cholera-prone region, in Al-Mahweet, Yemen. METHODOLOGY: We conducted a multivariate analysis of the data collected through a household survey of 384 households in Al-Mahweet, Yemen. RESULTS: Families with children under five years, large households, and those living in Al Mahweet district were associated with a higher incidence of cholera. Water treatment by boiling, filtering, and chlorination as a protective practice against cholera showed a borderline significance, while other WASH practices including regular hand washing, open defection, safe water source, and improved sanitation facilities were statistically insignificant. Community awareness of cholera transmission and prevention measures showed no association with cholera incidence. CONCLUSIONS: Findings suggest that living conditions, including large households and lack of access to treated water, increase the risk of cholera. Interventions to increase access to treated water and improve the hygienic conditions of large households are of central importance. Affected communities must receive effective educational campaigns that are adjusted to change hygienic practices and improve knowledge of cholera transmission and protection measures.

Community health volunteers' performance in rural areas of Yemen: a community-based satisfaction survey.

Objectives: Many developing countries utilize the services of community health volunteers (CHVs) to enhance healthcare services in underserved regions. Evaluating client satisfaction with CHVs' performance is crucial for ensuring the effective utilization of their services. This study aims to assess clients' satisfaction with the provision of basic reproductive health services by CHVs in the governorates of Ibb and Al Mahweet, Yemen. Materials and Methods: A cross-sectional study was conducted, collecting data via structured questionnaires administered by trained data collectors to clients of CHVs. A total of 510 households were interviewed, with 255 from each governorate, distributed across 30 clusters (villages). Each governorate comprised 15 clusters in 12 districts (six districts in Ibb and five in Al Mahweet, excluding one district for security reasons). Within each cluster, 17 households were randomly selected for interviews. Descriptive analysis was performed using the SPSS version 22. Results: The majority of the clients were female (84.7%), most were aged 20-39 years (55.7%), and more than half of them had received at least primary education (54.2%). The study findings indicate that a significant proportion of respondents were highly satisfied with CHVs' performance (93%). Almost all respondents confirmed that CHVs resided in their villages (94%) and were easily accessible for consultation (99%). Most of the respondents (97%) expressed trust in the CHVs, stating that they were helpful to all villagers and treated them well. Additionally, nearly all the respondents reported easy access to services (98.6%), although a considerable percentage experienced a gap of three months or more since their last interaction with a CHV (39.1%). Conclusion: The CHVs contribute to the well-being of the rural populations in Yemen by delivering satisfactory services, particularly regarding family planning. However, ensuring the sustainability of the CHV programs remains a challenge, which requires attention from the program managers and decision makers in the Yemeni healthcare sector.

Analyzing Yemen's health system at the governorate level amid the ongoing conflict: a case of Al Hodeida governorate.

Background: Yemen is regarded as one of the Middle East's poorest countries. Decades of political, economic, and social difficulties have culminated in the current protracted conflict. As a result, the globe experienced its worst humanitarian catastrophe. The ongoing war has affected several public services, notably the health sector, which is operating at less than half its capacity. This study aims to examine Yemen's health system at the governorate level (Al Hodeida) amidst the current conflict. It analyzes current challenges and produces suggestions for enhancement. Methods: The study used qualitative research methods such as Key Informant Interviews (KIIs) and document analysis. The study used WHO's health systems framework to measure health system performance. Twelve KIIs were conducted via Skype with several health stakeholders. In addition, documents were analyzed to inform the subject guide, generate themes, and aid in the triangulation of results. Results: According to the study findings, the governorate health system managed to offer a minimum level of healthcare services while making some advances in outbreak control jointly with other partners. One of the main difficulties confronting the governorate's health system is a severe lack of financial resources forcing it to rely entirely on external aid. Furthermore, other significant deficiencies include inadequate health system organogram, low reporting capacities, insufficient funding, and scarcity of health professionals. Conclusion: Yemen's frail health system has been weakened by almost eight years of insecurity and conflict. If the current scenario continues, most of Yemen's health system's operations and indicators will likely deteriorate. On the other hand, progress in some areas, such as primary healthcare (PHC) services and disease management, is remarkable. However, for better performance, Yemen's health system leadership and stakeholders should seek a holistic strategy to improve the entire dimensions of the health system.

Exploring the Role of Infodemics in People's Incompliance with Preventive Measures during the COVID-19 in Conflict Settings (Mixed Method Study).

The evolving availability of health information on social media, regardless of its credibility, raises several questions about its impact on our health decisions and social behaviors, especially during health crises and in conflict settings where compliance with preventive measures and health guidelines is already a challenge due to socioeconomic factors. For these reasons, we assessed compliance with preventive measures and investigated the role of infodemic in people's non-compliance with COVID-19 containment measures in Yemen. To this purpose and to triangulate our data collection, we executed a mixed method approach in which raw aggregated data were taken and analyzed from multiple sources (COVID-19 Government Response Tracker and Google COVID-19 Community Mobility Reports), then complemented and verified with In-depth interviews. Our results showed that the population in Yemen had relatively complied with the governmental containment measures at the beginning of the pandemic. However, containment measures were not supported by daily COVID-19 reports due to low transparency, which, together with misinformation and lack of access to reliable sources, has caused the population not to believe in COVID-19 and even practice social pressure on those who showed some compliance with the WHO guidelines. Those results indicate the importance of adopting an infodemic management approach in response to future outbreaks, particularly in conflict settings.

Knowledge, attitudes, and practices toward COVID-19 prevention in Yemen: a community-based cross-sectional study.

Background: Pandemics, especially in fragile war-torn countries like Yemen, challenge their already strained health systems. Community adherence to pandemic prevention measures is necessary to curb the severity and spread of emerging pandemics - which is influenced by factors, such as people's knowledge and attitudes toward the pandemic. No studies in Aden have been published on the communities' knowledge, attitudes, and practices (KAP) toward COVID-19 prevention to date. To understand adherence to pandemic prevention measures in contexts with fragile health systems, this study investigated KAP of Yemeni participants toward the COVID-19 pandemic. Methods: We conducted face-to-face semi-structured questionnaires among 400 eligible participants whom were identified for participation in this study through systematic household sampling from eight districts in Aden, Yemen. Eligible participants were Yemeni community members who were ≥ 18 years, living for more than 10 years in Yemen, and were willing to voluntarily participate in the study. The questionnaire included questions surrounding the participants' COVID-19 knowledge (e.g., awareness of spread and prevention), attitudes (e.g., willingness to accept the vaccine or other prevention measures), and prevention practices during the pandemic (e.g., mask wearing, social distancing, vaccine uptake). Total KAP scores were calculated. Univariate and bivariate statistical analyses were conducted using STATA 13 software. Results: From January to May 2021 we conducted 400 questionnaires with Yemeni community members. The average age was 41.5 ± 14.5 years (range 18-86 years). The results demonstrated that the participants in this study had an intermediate knowledge (53%) and fair attitude (58%) scores. However, participants reported very poor COVID-19 prevention practices- with only 11% demonstrating these practices. Only 25% (100/400) practiced social distancing, 25% (98/400) wore a mask, and only 6% (27/400) of participants accepted (at least one dose of) the COVID-19 vaccine. Factors associated with increased knowledge were being male, married, and surprisingly those having a primary and middle school education levels (p < 0.05). Also participants who were diagnosed with COVID-19 or had a family member diagnosed with COVID-19 (vs. those not diagnosed OR = 2.08, 95% CI 1.07-3.78, p < 0.05) were more likely to know that the vaccine protects against severe COVID-19 infection and were more likely to apply good practices such as accepting the vaccine (OR = 2.65, 95% CI 1.17-6.00, p < 0.05) compared to those who were not. Conclusion: These findings raise awareness for the need of community-oriented education programs for COVID-19 which considers associated factors to improve the level of public knowledge, attitudes, and practices.

Qualitative Review of National Nutrition Surveillance Systems in the Eastern Mediterranean Region.

The World Food Conference in 1974 emphasized the significance of establishing global nutrition surveillance to monitor and address nutritional challenges effectively. However, many countries, especially in the EMRO region, continue to encounter substantial difficulties in regularly generating disaggregated data on nutrition. The current study aimed to review the existing nutrition surveillance systems in the region and to identify their strengths and weaknesses, as well as the challenges they face in functioning optimally. METHODS: This study focused on the functional nutrition surveillance systems in eight Arab countries; namely Kuwait, Morocco, Oman, Palestine, Saudi Arabia, Sudan, Syria, and Yemen. The study's analysis involved utilizing primary data collected from both published and unpublished reports. Additionally, a structured checklist was employed to gather information from all countries involved in the study. Furthermore, interviews were conducted with the EMRO offices to gain deeper insights into the challenges, if any, that these nutrition surveillance systems face in functioning optimally. RESULTS: All countries use health facilities as a basic source of data for their nutrition surveillance, some countries triangulate their nutrition surveillance reports with data from other sources of information such as community or school surveys. Identified nutrition surveillance approaches are closely split between those who operate in stable settings and use routine health information systems (Morocco, Saudi Arabia, Oman, and Kuwait) and other countries that operate in fragile settings; for example, Yemen, Syria, Palestine, and Sudan struggle to provide early warning reports for rapid nutritional responses. CONCLUSIONS: Nutrition surveillance systems that utilize existing health information systems are the most sustained in the EMRO region. However, by integrating data from multiple sources, such as health facilities, surveys, and population censuses, countries can provide a holistic view of the nutritional situation, enhance their response to any emergency, and can leverage the infrastructure and resources already in place for health data collection and reporting. Collaboration between countries in the region through sharing experiences and success stories is important in order to reach a standardized system that can be implemented in different settings.

The National Health Cluster in Yemen: assessing the coordination of health response during humanitarian crises.

Yemen has been facing political, economic and social challenges since 1990. The fragility of Yemen's situation has led to a widespread conflict in 2015, resulting in the world's largest humanitarian crisis. Amid the humanitarian catastrophe and the collapsing health system, a platform for coordinating humanitarian health response, called the National Health Cluster, has expanded its operations across the country. The study aims to evaluate the performance of the National Health Cluster in Yemen between 2015 and 2019. A qualitative research design was employed, and ten semi-structured interviews with key Health Cluster stakeholders were conducted. The study applied the Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP) guide to evaluating humanitarian action using the Development Assistance Committee (DAC) criteria. Six evaluation criteria were selected: relevance, effectiveness, efficiency, effects, connectedness and participation. Inputs from interviews were manually transcribed and then analysed using NVivo 12 software. The study results indicate that the Health Cluster in Yemen has contributed to saving lives and strengthening the local health capacities in diseases surveillance. In addition, its positive effect was evident in improving the humanitarian health response coordination. Nevertheless, engaging health stakeholders, especially national organisations, was suboptimal. Exit strategies were lacking, while services to address mental health, non-communicable diseases, senior citizens and people with disabilities were not prioritised in the Health Cluster strategic plans and partners' response. To ameliorate Health Cluster performance, revising its objectives and establishing a cluster-specific rapid response funding mechanism are pivotal. Furthermore, preparing the national health system for recovery and actively engaging all stakeholders in the Health Cluster' response and strategic decisions would maximise its positive impact on Yemen's health system and population.

Clinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting.

Background: This study aims to describe the observable symptoms of children with COVID-19 infection and analyze access to real-time polymerase chain reaction (RT-PCR) testing among children seeking care in Yemen. Method: In the period of March 2020−February 2022, data were obtained from 495 children suspected to have been infected with COVID-19 (from a larger register of 5634 patients) from the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden, Yemen. Results: Overall, 21.4% of the children with confirmed COVID-19 infection were asymptomatic. Fever (71.4%) and cough (67.1%) were the most frequently reported symptoms among children, and children were less likely to have fever (p < 0.001), sore throat (p < 0.001) and cough (p < 0.001) compared to adults. A lower frequency of COVID-19-associated symptoms was reported among children with positive RT-PCR tests compared to children with negative tests. A lower rate of testing was conducted among children (25%) compared to adults (61%). Fewer tests were carried out among children <5 years (11%) compared to other age groups (p < 0.001), for children from other nationalities (4%) compared to Yemeni children (p < 0.001) and for girls (21%) compared to boys (30%) (p < 0.031). Conclusion: Understanding and addressing the cause of these disparities and improving guidelines for COVID-19 screening among children will improve access to care and control of the COVID-19 pandemic.

Forms of Health System Fragmentation During Conflict: The Case of Yemen.

The continuous and protracted conflict in Yemen has evolved into the worst humanitarian situation in modern history. All public structures in the country, including the health system and its basic functions, have been under tremendous pressures. One of the key obstacles to improve the health outcomes in Yemen is fragmentation of the health system. This study aims at exploring and documenting the forms of health system fragmentation in humanitarian and conflict-affected contexts by studying Yemen as a case study. We collected national qualitative data from key informants through in-depth interviews. A pool of respondents was identified from the Ministry of Public Health and Population, donors, and non-governmental organizations. Data were collected between May and June 2019. We interviewed eight key informants and reviewed national health policy documents, and references provided by key informants. Interviews were recorded, transcribed, and analyzed using qualitative content analysis. We further conducted a literature review to augment and triangulate the findings. Six themes emerged from our datasets and analyses, representing various forms of fragmentation: political, structural, inter-sectoral, financial, governance, and health agenda-related forms. Health system fragmentation in Yemen existed before the conflict eruption and has aggravated as the conflict evolves. The humanitarian situation and the collapsing health system enabled the influx of various national and international health actors. In conclusion, the protracted conflict and fragile situation in Yemen have accentuated the fragmentation of the health system. Addressing these fragmentations' forms by all health actors and building consensus on health system agenda are recommended. Health system analysis and in-depth study of fragmentation drivers in Yemen can be beneficial to build common ground and priorities to reduce health system fragmentation. Furthermore, capacity building of a health system is fundamental for the humanitarian development nexus, health system integration, and recovery efforts in the future.

Assessment of Micronutrient Situation among Reproductive-Age Women (15-49) and Under-Five Children in Sudan.

BACKGROUND: Micronutrient malnutrition is a form of undernutrition that causes diseases, and this is mainly due to insufficient intake of nutrients in daily foods. The status of micronutrients for people in Sudan remains scarce, and information is limited. The aim of this study is to highlight the status of micronutrients among women of reproductive age (15-49 years of age) and their children in Sudan. METHODS: This manuscript is a quantitative descriptive study, based on the data from Sudan Micronutrient Survey (SMS); it is part of the second round of the Simple Spatial Survey Method (S3M II) in Sudan (a total of 93,882 households). RESULTS: The level of consumption of vitamin A-rich foods was found to be moderate at 67.36% for reproductive-age women and low at 23.44% for under-five children. Similarly, consumption rate of vitamin B-rich foods among reproductive-age women was 62.13%, and low for children at 11.02%. The consumption of iron-, calcium-, and zinc-rich foods was moderate among women (66.75%, 47.69%, 69.72%, respectively) and very low in children (12.28%, 17.62%, 14.99%, respectively). The iron deficiency prevalence was 47% in non-pregnant women, 58% in pregnant women, and 54% in children. The prevalence of anemia was 30% in non-pregnant women, 37% in pregnant women, and 48% in children. Generally, urinary iodine concentration was inadequate in lactating and non-pregnant women as well as in pregnant women. Most indicators of micronutrients in Sudan for children and women of reproductive age were highly significant. Sudan needs more efforts to create an enabling environment through legislation, policies, and strategies to strengthen the nutrition-sensitive and specific interventions and improving status of micronutrients among women and children, focusing on food fortification, food supplements, and counseling on micronutrients intake for mothers during antenatal and postnatal services as well as raising community awareness.

Nutrition Assessment of Under-Five Children in Sudan: Tracking the Achievement of the Global Nutrition Targets.

BACKGROUND: Malnutrition places a heavy burden on the health, well-being, and sustainable development of populations in Sudan, especially a country affected by conflict, which continues to experience high levels of food insecurity, undernutrition, and micronutrient deficiencies; 3.3 million are acutely malnourished, with 522,000 children suffering from severe acute malnutrition and approximately 2.2 million children requiring treatment for moderate acute malnutrition. This study aims to describe the nutritional status of children under five years old and identify the progress toward the achievement of the Global Nutrition Targets. METHODS: This is a secondary data analysis of a quantitative survey, using the second-round of the Simple Spatial Survey Method (S3M II) in Sudan in the period 2018-2019. The analysis used an area-based sampling methodology in all 18 Sudanese states. Data from the WHO Tracking Tools of the Global Nutrition Targets was used to reflect the progress in achieving the targets in Sudan. RESULTS: Global stunting prevalence was at 36.35 percent including moderate stunting prevalence and severe stunting prevalence (21.25 percent and 15.06 percent respectively). Global wasting prevalence was 13.6 percent including moderate wasting prevalence and severe wasting prevalence (10.8 percent and 2.7 percent respectively). Sudan has made great progress in achieving the target of increasing exclusive breastfeeding. However, despite the welcome commitments by the Government and all stakeholders, Sudan is still struggling to implement strategies, policies, and regulatory measures to address malnutrition and achieve the Global Nutrition Targets in 2025 and the Sustainable Developmental Goals in 2030. Therefore, more than ever, there is a need for comprehensive, multi-sectoral action to address malnutrition in all its forms.

Ongoing diphtheria outbreak in Yemen: a cross-sectional and genomic epidemiology study.

BACKGROUND: An outbreak of diphtheria, declared in Yemen in October, 2017, is ongoing. We did a cross-sectional study to investigate the epidemiological, clinical, and microbiological features of the outbreak. METHODS: Probable cases of diphtheria that were defined clinically and recorded through a weekly electronic diseases early warning system (from 2017, week 22, to 2020, week 17) were used to identify trends of the outbreak (we divided the epidemic into three time periods: May 29, 2017, to June 10, 2018; June 11, 2018, to June 3, 2019; and June 4, 2019, to April 26, 2020). We used the line list of diphtheria reports for governorate-level descriptions. Vaccination coverage was estimated using the 2017 and 2018 annual reports by the national Expanded Programme on Immunization. To confirm cases biologically, Corynebacterium diphtheriae was isolated and identified from throat swabs using standard microbiological culture and identification procedures. We assessed differences in the temporal and geographical distributions of cases, including between different age groups. For in-depth microbiological analysis, tox gene and species-specific rpoB real-time PCR, Illumina genomic sequencing, antimicrobial susceptibility analysis (disk diffusion, E-test), and the Elek diphtheria toxin production test were done on confirmed cases. We used genomic data for phylogenetic analyses and to estimate the nucleotide substitution rate. FINDINGS: The Yemen diphtheria outbreak affected almost all governorates (provinces), with 5701 probable cases and 330 deaths recorded up to April 26, 2020. We collected clinical data for 888 probable cases with throat swab samples referred for biological confirmation, and genomic data for 42 positive cases, corresponding to 43 isolates (two isolates from one culture were included due to distinct colony morphologies). The median age of patients was 12 years (range 0·2-80). The proportion of cases in children aged 0-4 years was reduced during the second time period, after a vaccination campaign, compared with the first period (19% [95% CI 18-21] in the first period vs 14% [12-15] in the second period, p<0·0001). Among 43 tested isolates, 39 (91%) produced the diphtheria toxin and two had low level (0·25 mg/L) antimicrobial resistance to penicillin. We identified six C diphtheriae phylogenetic sublineages, four of which are genetically related to isolates from Saudi Arabia, Eritrea, and Somalia. Inter-sublineage genomic variations in genes associated with antimicrobial resistance, iron acquisition, and adhesion were observed. The predominant sublineage (30 [70%] of 43 isolates) was resistant to trimethoprim and was associated with unique genomic features, more frequent neck swelling (p=0·0029) and a younger age of patients (p=0·060) compared with the other sublineages. Its evolutionary rate was estimated at 1·67 × 10-6 substitutions per site per year, placing its most recent common ancestor in 2015, and indicating silent circulation of C diphtheriae in Yemen before the outbreak was declared. INTERPRETATION: In the Yemen outbreak, C diphtheriae shows high phylogenetic, genomic, and phenotypic variation. Laboratory capacity and real-time microbiological monitoring of diphtheria outbreaks need to be scaled up to inform case management and transmission control of diphtheria. Catch-up vaccination might have provided some protection to the targeted population (children aged 0-4 years). FUNDING: National Centre of the Public Health Laboratories (Yemen), Institut Pasteur, and the French Government Investissement d'Avenir Programme. TRANSLATION: For the Arabic translation of the abstract see Supplementary Materials section.

COVID-19 in Conflict: The devastating impact of withdrawing humanitarian support on universal health coverage in Yemen.

The authors warn that, in the context of Yemen, the closure of humanitarian lifesaving programmes and shifting support toward health security, i.e. to support COVID-19 response, at the expense of primary health care support, will undermine existing health system strengthening efforts, worsen the humanitarian crisis and will accentuate the impact of COVID-19. The authors urge the international community and the Government of Yemen to carefully consider a more comprehensive approach to support Yemen's COVID-19 response while maintaining, and strengthening, essential public health services.

Cholera Outbreak in Yemen: Timeliness of Reporting and Response in the National Electronic Disease Early Warning System.

INTRODUCTION: In Yemen, the largest cholera epidemic of modern times started in late 2016. By March 2018, more than one million cases had been reported. A national electronic Disease Early Warning System (eDEWS) for infectious disease surveillance was established in 2013. AIM: This study assessed the eDEWS's timelines for reported cholera cases. METHODS: Quantitative data published in eDEWS and the Weekly Epidemiological Bulletin of the Yemen Ministry of Health from March 2013 until March 2018 were analyzed. For assessing the early detection of cholera cases, 262 weekly bulletins were reviewed. The raw data of the immediately generated eDEWS alerts during the first outbreak wave were used to assess response timeliness. RESULTS: Reported cholera incidence peaked at 1,698 cases (first wave) in 2016 week 49, and then reached 46,667 cases (second wave) in 2017 week 26. The mean time period between reporting and the first response was 2.85 days. Only 31% of the eDEWS alerts were verified within the first 24 hours, and the majority (83%) were verified within one week. There were major differences in the timeliness between the governorates, ranging from 8%-62% for reporting within the first 24 hours. CONCLUSION: The eDEWS is able to detect and alert health authorities about cholera cases even under conditions of ongoing war and civil war, however, the timeliness of the response needs improvement.

Risk factors associated with the recent cholera outbreak in Yemen: a case-control study.

OBJECTIVES: The cholera outbreak in Yemen has become the largest in the recent history of cholera records, having reached more than 1.4 million cases since it started in late 2016. This study aimed to identify risk factors for cholera in this outbreak. METHODS: A case-control study was conducted in Aden in 2018 to investigate risk factors for cholera in this still-ongoing outbreak. In total, 59 cholera cases and 118 community controls were studied. RESULTS: The following risk factors were associated with being a cholera case in the bivariate analysis: a history of travelling and having had visitors from outside Aden Province; eating outside the house; not washing fruit, vegetables, and khat (a local herbal stimulant) before consumption; using common-source water; and not using chlorine or soap in the household. In the multivariate analysis, not washing khat and the use of common-source water remained significant risk factors for being a cholera case. CONCLUSIONS: Behavioural factors and unsafe water appear to be the major risk factors in the recent cholera outbreak in Yemen. In order to reduce the risk of cholera, hygiene practices for washing khat and vegetables and the use and accessibility of safe drinking water should be promoted at the community level.