Publisher Correction: Genomic insights into the 2016-2017 cholera epidemic in Yemen.

In the HTML version of this Letter, the affiliations for authors Andrew S. Azman, Dhirendra Kumar and Thandavarayan Ramamurthy were inverted (the PDF and print versions of the Letter were correct); the affiliations have been corrected online.

Genomic insights into the 2016-2017 cholera epidemic in Yemen.

Yemen is currently experiencing, to our knowledge, the largest cholera epidemic in recent history. The first cases were declared in September 2016, and over 1.1 million cases and 2,300 deaths have since been reported1. Here we investigate the phylogenetic relationships, pathogenesis and determinants of antimicrobial resistance by sequencing the genomes of Vibrio cholerae isolates from the epidemic in Yemen and recent isolates from neighbouring regions. These 116 genomic sequences were placed within the phylogenetic context of a global collection of 1,087 isolates of the seventh pandemic V. cholerae serogroups O1 and O139 biotype El Tor2-4. We show that the isolates from Yemen that were collected during the two epidemiological waves of the epidemic1-the first between 28 September 2016 and 23 April 2017 (25,839 suspected cases) and the second beginning on 24 April 2017 (more than 1 million suspected cases)-are V. cholerae serotype Ogawa isolates from a single sublineage of the seventh pandemic V. cholerae O1 El Tor (7PET) lineage. Using genomic approaches, we link the epidemic in Yemen to global radiations of pandemic V. cholerae and show that this sublineage originated from South Asia and that it caused outbreaks in East Africa before appearing in Yemen. Furthermore, we show that the isolates from Yemen are susceptible to several antibiotics that are commonly used to treat cholera and to polymyxin B, resistance to which is used as a marker of the El Tor biotype.

Revising the essential package of health services through stakeholder alignment, Somalia.

Problem: The fragmented health sector in Somalia, burdened by financial challenges and an inadequate regulatory system, struggles to provide equitable essential health services to the entire population. Approach: To revise an essential package of health services that stakeholders could support and that aligned with stakeholders' financial and technical resources, the federal health ministry invited all key stakeholders in 2020 to participate in the revision process of the essential package. The ministry distributed a concept note to invited stakeholders, describing the scope and purpose of the revision process of the essential package. The note also contained a timeline and the expected contribution of each stakeholder. Stakeholders nominated representatives based on their technical expertise and knowledge of the health sector in Somalia. Local setting: The health sector in Somalia involves multiple stakeholders, including the health ministry and many development partners. The private sector plays a substantial role in health-care provision. Public spending is an estimated 17% of the total health expenditure. Relevant changes: After an 18-month revision process, the health ministry and development partners agreed to prioritize high-impact, cost-effective services and use a progressive realization of the package to improve access and coverage. The implementation strategy considers the health system and operational capacity of service providers, particularly in security-compromised areas. Lessons learnt: The approach showed that inclusivity, collaboration and transparency were of importance for a successful revision of the package. These achievements in consensus-building and priority alignment advance the government's pursuit of equitable and comprehensive health care for all.

Screening of ZIKA virus infection among dengue-like illness patients with negative RT-PCR for dengue virus in Punjab - Pakistan.

OBJECTIVE: To detect ZIKV using reverse transcription-polymerase chain reaction (RT-PCR) among clinical samples tested negative for Dengue virus (DENV) by RT-PCR in Punjab, 2016. METHODS: A descriptive cross-sectional study was carried out for duration of two months. Total of 506 samples were collected within seven days from onset of illness from all over hospitals of Punjab, Pakistan of which 350 were selected simply randomly to test for presence of ZIKV by using "Trioplex Real-Time RT-PCR Assay (Trioplex)". Cohen's kappa coefficient (κ) and 95% confidence interval (CI) were used to assess the degree of concordance between DENV positive results of non-structural protein 1 (NS1) and IgM solid-phase enzyme immunoassay (ELISA). RESULTS: No samples were positive for any ZIKV, DENV or Chikungunya virus (CHIKV) by Trioplex. Among the 350 samples, 26 samples were positive concordant and the degree of concordance between NS1- and IgM-ELISA was 13% and κ coefficient was -0.71 (95% CI -0.79, -0.63). CONCLUSION: At study time, no samples were positive for ZIKV. Strengthening laboratory capacity to confirm arboviruses for Punjab's laboratories is warranted. Trioplex RT-PCR has 100% sensitivity so there are nominal chances of false negative results. Establishing syndromic surveillance for Zika and conducting a sero-surveillance survey for Zika in areas with high human and Aedes mosquito density are recommended in Punjab.

A Review of Asymptomatic and Subclinical Middle East Respiratory Syndrome Coronavirus Infections.

The epidemiology of Middle East respiratory syndrome coronavirus (MERS-CoV) since 2012 has been largely characterized by recurrent zoonotic spillover from dromedary camels followed by limited human-to-human transmission, predominantly in health-care settings. The full extent of infection of MERS-CoV is not clear, nor is the extent and/or role of asymptomatic infections in transmission. We conducted a review of molecular and serological investigations through PubMed and EMBASE from September 2012 to November 15, 2018, to measure subclinical or asymptomatic MERS-CoV infection within and outside of health-care settings. We performed retrospective analysis of laboratory-confirmed MERS-CoV infections reported to the World Health Organization to November 27, 2018, to summarize what is known about asymptomatic infections identified through national surveillance systems. We identified 23 studies reporting evidence of MERS-CoV infection outside of health-care settings, mainly of camel workers, with seroprevalence ranges of 0%-67% depending on the study location. We identified 20 studies in health-care settings of health-care worker (HCW) and family contacts, of which 11 documented molecular evidence of MERS-CoV infection among asymptomatic contacts. Since 2012, 298 laboratory-confirmed cases were reported as asymptomatic to the World Health Organization, 164 of whom were HCWs. The potential to transmit MERS-CoV to others has been demonstrated in viral-shedding studies of asymptomatic MERS infections. Our results highlight the possibility for onward transmission of MERS-CoV from asymptomatic individuals. Screening of HCW contacts of patients with confirmed MERS-CoV is currently recommended, but systematic screening of non-HCW contacts outside of health-care facilities should be encouraged.

Revision of clinical case definitions: influenza-like illness and severe acute respiratory infection.

The formulation of accurate clinical case definitions is an integral part of an effective process of public health surveillance. Although such definitions should, ideally, be based on a standardized and fixed collection of defining criteria, they often require revision to reflect new knowledge of the condition involved and improvements in diagnostic testing. Optimal case definitions also need to have a balance of sensitivity and specificity that reflects their intended use. After the 2009-2010 H1N1 influenza pandemic, the World Health Organization (WHO) initiated a technical consultation on global influenza surveillance. This prompted improvements in the sensitivity and specificity of the case definition for influenza - i.e. a respiratory disease that lacks uniquely defining symptomology. The revision process not only modified the definition of influenza-like illness, to include a simplified list of the criteria shown to be most predictive of influenza infection, but also clarified the language used for the definition, to enhance interpretability. To capture severe cases of influenza that required hospitalization, a new case definition was also developed for severe acute respiratory infection in all age groups. The new definitions have been found to capture more cases without compromising specificity. Despite the challenge still posed in the clinical separation of influenza from other respiratory infections, the global use of the new WHO case definitions should help determine global trends in the characteristics and transmission of influenza viruses and the associated disease burden.

La formulation de définitions précises de cas cliniques fait partie intégrante d'un processus efficace de surveillance de la santé publique. Alors que ces définitions devraient, dans l'idéal, s'appuyer sur un ensemble standardisé et fixe de critères de définition, elles nécessitent souvent une révision pour tenir compte des nouvelles connaissances relatives à la maladie concernée et des améliorations apportées aux tests diagnostiques. Pour être optimales, les définitions de cas doivent aussi établir un équilibre entre sensibilité et spécificité qui reflète leur utilisation aux fins prévues. À la suite de la pandémie de grippe H1N1 de 2009-2010, l'Organisation mondiale de la Santé (OMS) a lancé une consultation technique sur la surveillance mondiale de la grippe. Cela a conduit à des améliorations concernant la sensibilité et la spécificité de la définition de cas pour la grippe ­ c'est-à-dire une maladie respiratoire dont seule la symptomatologie reste à définir. Le processus de révision n'a pas seulement modifié la définition du syndrome de type grippal pour inclure une liste simplifiée des critères le mieux à même de prédire une infection grippale, il a également permis de clarifier le langage utilisé dans la définition pour en améliorer l'interprétation. Par ailleurs, afin de tenir compte des cas sévères de grippe qui nécessitaient une hospitalisation, une nouvelle définition de cas a été introduite concernant l'infection aigüe sévère des voies respiratoires dans tous les groupes d'âge. Il a été constaté que les nouvelles définitions reflétaient davantage de cas, sans pour autant compromettre la spécificité. S'il est vrai que la distinction clinique de la grippe des autres infections respiratoires continue de poser problème, l'utilisation mondiale des nouvelles définitions de cas de l'OMS devrait permettre de dégager des tendances mondiales concernant les caractéristiques et la transmission des virus grippaux ainsi que la charge de morbidité qui leur est associée.

La elaboración de definiciones precisas de los casos clínicos es una parte fundamental de un proceso efectivo de la vigilancia de la salud pública. Aunque tales definiciones deberían, idealmente, estar basadas en una recopilación estandarizada y fija de criterios de definición, a menudo necesitan una revisión para reflejar el nuevo conocimiento de la enfermedad existente y las mejoras en las pruebas de diagnóstico. Las definiciones óptimas de los casos también deben tener un equilibrio entre sensibilidad y especificidad que refleje su uso previsto. Después de la pandemia de gripe H1N1 en 2009-2010, la Organización Mundial de la Salud (OMS) inició una consulta técnica para la vigilancia mundial de la gripe. Esto dio lugar a mejoras en la sensibilidad y la especificidad de las definiciones de los casos de gripe, es decir, una enfermedad respiratoria que carece de una sintomatología definitoria singular. El proceso de revisión no solo modificó la definición de las enfermedades similares a la gripe para incluir una lista simplificada de los criterios que demostraron ser más predictivos de la infección por gripe, sino que también aclaró el lenguaje utilizado para la definición, con el fin de mejorar su interpretación. Para englobar los casos graves de gripe que requirieron hospitalización, también se desarrolló una nueva definición de los casos de la infección respiratoria aguda grave en todos los grupos de edad. Se ha descubierto que las nuevas definiciones engloban más casos sin comprometer la especificidad. A pesar del desafío que todavía plantea la separación clínica de la gripe de otras infecciones respiratorias, el uso global de las nuevas definiciones de los casos de la OMS debería ayudar a determinar las tendencias mundiales en las características y transmisión de los virus de la gripe y la carga de la enfermedad asociada.

Current and future distribution of Aedes aegypti and Aedes albopictus (Diptera: Culicidae) in WHO Eastern Mediterranean Region.

BACKGROUND: Aedes-borne diseases as dengue, zika, chikungunya and yellow fever are an emerging problem worldwide, being transmitted by Aedes aegypti and Aedes albopictus. Lack of up to date information about the distribution of Aedes species hampers surveillance and control. Global databases have been compiled but these did not capture data in the WHO Eastern Mediterranean Region (EMR), and any models built using these datasets fail to identify highly suitable areas where one or both species may occur. The first objective of this study was therefore to update the existing Ae. aegypti (Linnaeus, 1762) and Ae. albopictus (Skuse, 1895) compendia and the second objective was to generate species distribution models targeted to the EMR. A final objective was to engage the WHO points of contacts within the region to provide feedback and hence validate all model outputs. METHODS: The Ae. aegypti and Ae. albopictus compendia provided by Kraemer et al. (Sci Data 2:150035, 2015; Dryad Digit Repos, 2015) were used as starting points. These datasets were extended with more recent species and disease data. In the next step, these sets were filtered using the Köppen-Geiger classification and the Mahalanobis distance. The occurrence data were supplemented with pseudo-absence data as input to Random Forests. The resulting suitability and maximum risk of establishment maps were combined into hard-classified maps per country for expert validation. RESULTS: The EMR datasets consisted of 1995 presence locations for Ae. aegypti and 2868 presence locations for Ae. albopictus. The resulting suitability maps indicated that there exist areas with high suitability and/or maximum risk of establishment for these disease vectors in contrast with previous model output. Precipitation and host availability, expressed as population density and night-time lights, were the most important variables for Ae. aegypti. Host availability was the most important predictor in case of Ae. albopictus. Internal validation was assessed geographically. External validation showed high agreement between the predicted maps and the experts' extensive knowledge of the terrain. CONCLUSION: Maps of distribution and maximum risk of establishment were created for Ae. aegypti and Ae. albopictus for the WHO EMR. These region-specific maps highlighted data gaps and these gaps will be filled using targeted monitoring and surveillance. This will increase the awareness and preparedness of the different countries for Aedes borne diseases.

Cholera in Yemen: concerns remain over recent spike but control efforts show promise (Editorial).

October 2018 would be two years since the world came to know of the first case of cholera in war-torn Yemen. Soon after, the outbreak developed at an unprecedented scale and turned into one of the worst historical cholera events in terms of cases reported. By the end of September 2018, more than one million suspected cases had been reported across the country in all but one governorate, where approximately 60% of these cases remained concentrated in roughly half of the 330 districts in the country.

Real-Time Surveillance in Emergencies Using the Early Warning Alert and Response Network.

Humanitarian emergencies often result in population displacement and increase the risk for transmission of communicable diseases. To address the increased risk for outbreaks during humanitarian emergencies, the World Health Organization developed the Early Warning Alert and Response Network (EWARN) for early detection of epidemic-prone diseases. The US Centers for Disease Control and Prevention has worked with the World Health Organization, ministries of health, and other partners to support EWARN through the implementation and evaluation of these systems and the development of standardized guidance. Although protocols have been developed for the implementation and evaluation of EWARN, a need persists for standardized training and additional guidance on supporting these systems remotely when access to affected areas is restricted. Continued collaboration between partners and the Centers for Disease Control and Prevention for surveillance during emergencies is necessary to strengthen capacity and support global health security.

Closing the knowledge gaps on MERS: three and half years since its detection, what have we learnt and what needs to be done urgently? (Editorial).

The Middle East respiratory syndrome coronavirus (MERS-Cov), first detected in 2012, continues to cause health concerns owing to the grave uncertainties that have surrounded the virus since it emerged. Three and half years after the first known human infection was detected, cases continue to be reported every month, over 85% of which have been from Saudi Arabia and other countries in the Arabian Peninsula. Despite its low levels of transmission, the virus presents an uncertain future as a number of critical knowledge gaps on the source and route of transmission have hindered the global response to this emerging infection.

Preparedness for Ebola: Can it transform our current public health system? (Editorial).

The devastating Ebola outbreak that raged in west Africa most of 2014 and 2015 has finally come to an end. The epidemic reached unprecedented levels with far reaching implications for global health security. The epidemic, which started in December 2013, killed more than 11 000 people and infected at least 28 600, more than the total deaths and cases combined reported in the entire history of the disease. In addition, it resulted in an unquantified increase in indirect mortality as well as severe societal consequences.

Influenza in the Eastern Mediterranean Region: identifying the unknowns for detection and control of epidemic and pandemic threats (Editorial).

Acute respiratory illnesses and influenza-like illnesses (ILI) are a significant cause of morbidity and mortality worldwide. Data from developed countries reveal that seasonal influenza can affect up to 15% of the population presenting with upper respiratory tract infections and may result in up to 500 000 deaths worldwide annually. Despite their public health importance, little was known about the aetiology of these illnesses in the countries of the WHO Eastern Mediterranean Region (EMR).

Mental health crisis in Somalia: a review and a way forward.

BACKGROUND: Somalia has been without an effective government since the collapse of the military regime in 1991. Years of conflict, disasters, and insecurity have all contributed to very low scores for most health indicators due to poor governance, protracted conflict, underdevelopment, economic decline, poverty, social and gender inequality, and environmental degradation. The three-decade long protracted conflict has led to widespread psychosocial trauma, social deprivation and substance abuse with devastating consequences on mental health. A WHO study showed Somalia has one of the highest rates of mental illness in the world. The main aim of this study is to assist policy makers in setting priorities for the design and delivery of interventions to promote mental health and psychosocial wellbeing in Somalia. METHODS: The study uses a systematic mapping technique (from January 1991 to May 2020) and data collected from public domain, to collect, collate, and present mental health data mainly from WHO's Global Health Observatory. Since there is no primary database for Somalia's public health research, the bibliographic databases used for mental health in this study included Medline, PubMed, CINAHL, PsycINFO, and Google Scholar. Data were extracted using techniques for web data mining for public health. RESULTS: Systematic mapping of mental health-related issues in Somalia showed that policy-related determinants and mental health services dominated (74.4%), followed by the disaster-related determinants and women's health consequences (39.3%). The ratio of the number of beds for mental health in general hospitals (per 100,000 population) in Somalia in 2017 is 0.5 compared to the Eastern Mediterranean region (EMR) at 6.4 and globally at 24. One of the biggest casualties of the civil war was loss of essential human resources in healthcare as most either fled the country or were part of the victims of the war. CONCLUSIONS: The vast scale of the mental health problems in Somalia and the priority setting guidelines for interventions to address the issues outlined in this paper, prompt a dire need that the Somali government and its national/international partners should prioritize and emphasize the need to invest in the prevention and the treatment of mental illness across the country.

Investing in mental health in Somalia: harnessing community mental health services through task shifting.

Background: The increase of mental health issues globally has been well documented and now reflected in the United Nations' Sustainable Development Goals as a matter of global health significance. At the same time, studies show the mental health situations in conflict and post-conflict settings much higher than the rest of the world, lack the financial, health services and human resource capacity to address the challenges. Methods: The study used a descriptive literature review and collected data from public domain, mostly mental health data from WHO's Global Health Observatory. Since there is no primary database for Somalia's public health research, the bibliographic databases used for mental health in this study included Medline, PubMed, CINAHL, PsycINFO, and Google Scholar. Results: The review of the mental health literature shows one of the biggest casualties of the civil war was loss of essential human resources in healthcare as most either fled the country or were part of the victims of the war. Conclusion: In an attempt to address the human resource gap, there are calls to task-shift so that available human resource can be utilized efficiently and effectively. This policy paper discusses the case of Somalia, the impact of decade-long civil conflict on mental health and health services, the significant gap in mental health service delivery and how to strategically and evidently task-shift in closing the mental health gap in service delivery.

Adverse events following introduction of the ChAdOx1 nCoV-19 vaccine in Somalia in 2021: findings from a fragile setting and implications for the future.

Background: Vaccination against coronavirus disease 2019 (COVID-19) began in Somalia on 16 March 2021 with the Covishield (ChAdOx1 nCoV-19) vaccine. However, by the end of 2021, only a small percentage of the population had been fully vaccinated. As side effects play an important role in determining public confidence in vaccines and their uptake, this study aimed to examine reported adverse events following immunization (AEFIs) of vaccine recipients. Methods: This cross-sectional-survey-based study was conducted between March and October 2021 in Somalia. Vaccine recipients who were eligible to receive the first dose of the Covishield vaccine in the first phase of COVID-19 vaccination were eligible for study inclusion. P<0.05 was considered to indicate significance. Results: Of the 149,985 respondents who had received the first dose of the Covishield vaccine, 378 reported side effects. This represented a reported AEFI rate of 2.5 per 1000 population. Amongst those who reported adverse events, males (2.8 per 1000; P<0.001), respondents aged 35-49 years (3.3 per 1000; P=0.001) and teachers (3.5 per 1000; P=0.000) had higher rates of adverse events compared with females, other age groups and other occupations. Amongst population settlement types, a higher rate of AEFIs was observed amongst refugees (23.9 per 1000; P=0.000) and internally displaced populations (19 per 1000; P=0.000). Nearly half of the vaccine recipients who reported side effects (48%) reported one local symptom, and most symptoms were mild in nature. The probability of having acute and severe side effects was found to be 66% lower among males compared with females [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.26-0.73; P=0.002]. Respondents aged >60 years (OR 1.52, 95% CI 0.64-3.62; P=0.34) were more likely to develop acute and severe AEFIs. None of the study population reported any severe life-threatening symptoms or death. Conclusion: Some variables (sex, profession, age) put recipients at higher odds of acute and severe AEFIs, but the Covishield vaccine generally produced mild side effects in a small proportion of the vaccinated population in Somalia. This study confirms that COVID-19 vaccines are safe, and their benefits clearly outweigh any associated risk.

Survival analysis of all critically ill patients with COVID-19 admitted to the main hospital in Mogadishu, Somalia, 30 March-12 June 2020: which interventions are proving effective in fragile states?

OBJECTIVES: To determine risk factors for death in patients with coronavirus disease 2019 (COVID-19) admitted to the main hospital in Somalia, and identify interventions contributing to improved clinical outcome in a low-resource and fragile setting. METHODS: A survival analysis was conducted of all patients with COVID-19 admitted to the main hospital in Somalia from 30 March to 12 June 2020. RESULTS: Of the 131 patients admitted to the hospital with COVID-19, 52 (40%) died and 79 (60%) survived. The main factors associated with the risk of in-hospital death were age ≥60 years {survival probability on day 21 was 0.789 [95% confidence interval (CI) 0.658-0.874] in patients aged <60 years vs 0.339 (95% CI 0.205-0.478) in patients aged ≥60 years}, cardiovascular disease [survival probability 0.478 (95% CI 0.332-0.610) in patients with cardiovascular disease vs 0.719 (95% CI 0.601-0.807) in patients without cardiovascular disease] and non-invasive ventilation on admission (patients who were not ventilated but received oxygen were significantly more likely to survive than patients who were ventilated; P<0.001). CONCLUSION: Considering the risk factors (age ≥60 years, presence of cardiovascular disease and use of non-invasive ventilation) is critical when managing patients with severe COVID-19, especially in low-resource settings where availability of skilled healthcare workers for critical care units is limited. These findings also highlight the importance of use of medical oxygen for severely ill patients, and the critical aspect of deciding whether or not to ventilate critical patients with COVID-19 in order to improve clinical outcome.