%0 Journal Article %@ 2369-2960 %I JMIR Publications %V 8 %N 3 %P e32831 %T Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: Multicountry Retrospective Study %A Lami,Faris %A Elfadul,Maisa %A Rashak,Hiba %A Al Nsour,Mohannad %A Akhtar,Hashaam %A Khader,Yousef %A Hussein,Ahmed M %A Naciri,Mariam %A Samy,Sahar %A Ghaleb,Yasser %A Taha,Hana %A Hussein,Alaa %A Ali,Nameer A %A Hussein,Raheem %A Ikram,Aamer %A Rahman,Fazal ur %A Khan,Mohammad Mujeeb %A Adam,Reema %A Ahmed,Abdulrazaq Yusuf %A Afifi,Salma %+ Public and Tropical Health Programs, Epidemiology and Biostatistics, University of Medical Sciences and Technology, Airport Avenue, PO Box 12810, Khartoum, 11111, Sudan, 249 924622759, melfadul7@gmail.com %K critical outcomes %K COVID-19 %K severity %K mortality %K outcome %K risk factor %K retrospective %K implementation %K demographic %K pattern %K trend %K risk %D 2022 %7 15.3.2022 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The establishment of empirical evidence in the Eastern Mediterranean Region necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of patients with COVID-19. Objective: This study aims to assess the patterns of COVID-19 severity and mortality in seven countries, and to determine the risk factors of COVID-19 severity and mortality. Methods: This multicountry study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study includes data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors. Results: A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (n=1021, 24.7%) and diabetes (n=939, 22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity. Conclusions: The study confirms the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases. %M 34736222 %R 10.2196/32831 %U https://publichealth.jmir.org/2022/3/e32831 %U https://doi.org/10.2196/32831 %U http://www.ncbi.nlm.nih.gov/pubmed/34736222 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 12 %P e27266 %T Risk Factors Associated with a Dengue Fever Outbreak in Islamabad, Pakistan: Case-Control Study %A Mehmood,Amjad %A Khalid Khan,Fawad %A Chaudhry,Ambreen %A Hussain,Zakir %A Laghari,Mumtaz Ali %A Shah,Ijaz %A Baig,Zeeshan Iqbal %A Baig,Mirza Amir %A Khader,Yousef %A Ikram,Aamer %+ Field Epidemiology and Laboratory Training Program, Park Road, Chak Shehzad, Islamabad, 44000, Pakistan, 92 519255302, ambr.chaudhry@gmail.com %K dengue fever %K DENV-2 %K outbreak investigation %K Islamabad %K Pakistan %K outbreak %K epidemiology %K disease surveillance %K surveillance %K vector %D 2021 %7 30.12.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: On October 23, 2016, 79 dengue fever cases were reported from the Union Council Tarlai to Federal Disease Surveillance and Response Unit Islamabad. A team was established to investigate the suspected dengue outbreak. Objective: The aim of this study was to determine the extent of the outbreak and identify the possible risk factors. Methods: Active case finding was performed through a house-to-house survey. A case was defined as an acute onset of fever ≥38℃ in a resident of Tarlai from October 2 to November 11, 2016, with a positive dengue virus (nonstructural protein, NS-1) test and any of the two of following signs and symptoms: retroorbital/ocular pain, headache, rash, myalgia, arthralgia, and hemorrhagic manifestations. A structured questionnaire was used to collect data. Age- and sex-matched controls (1:1) were identified from residents in the same area as cases. Blood samples were taken and sent to the National Institute of Health for genotype identification. Results: During the active case search, 145 cases of dengue fever were identified by surveying 928 houses from October 23 to November 11, 2016. The attack rate (AR) was 17.0/10,000. The mean age was 34.4 (SD 14.4) years. More than half of the cases were male (80/145, 55.2%). Among all cases, 29% belonged to the 25-34 years age group and the highest AR was found in the 35-44 years age group (35.6/10,000), followed by the 55-64 years age group (35.5/10,000). All five blood samples tested positive for NS-1 (genotype DENV-2). The most frequent presenting signs/symptoms were fever and headache (both 100%). Stagnant water around houses (odds ratio [OR] 4.86, 95% CI 2.94-8.01; P<.001), presence of flower pots in the home (OR 2.73, 95% CI 1.67-4.45; P<.001), and open water containers (OR 2.24, 95% CI 1.36-3.60; P<.001) showed higher odds among cases. Conversely, use of bed nets (OR 0.44, 95% CI 0.25-0.77; P=.003), insecticidal spray (OR 0.33, 95% CI 0.22-0.55; P<.001), door screens (OR 0.27, 95% CI 0.15-0.46; P<.001), mosquito coil/mat (OR 0.26, 95% CI 0.16-0.44; P<.001), and cleanliness of the house (OR 0.12, 95% CI 0.05-0.26; P<.001) showed significant protective effects. Conclusions: Stagnant water acting as breeding grounds for vectors was identified as the probable cause of spread of the dengue outbreak. Establishment of surveillance and an early reporting system along with use of protective measures against the vector are strongly recommended. %M 34967753 %R 10.2196/27266 %U https://publichealth.jmir.org/2021/12/e27266 %U https://doi.org/10.2196/27266 %U http://www.ncbi.nlm.nih.gov/pubmed/34967753 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 12 %P e32203 %T Presenting Characteristics, Comorbidities, and Outcomes Among Patients With COVID-19 Hospitalized in Pakistan: Retrospective Observational Study %A Akhtar,Hashaam %A Khalid,Sundas %A Rahman,Fazal ur %A Umar,Muhammad %A Ali,Sabahat %A Afridi,Maham %A Hassan,Faheem %A Saleh Khader,Yousef %A Akhtar,Nasim %A Khan,Muhammad Mujeeb %A Ikram,Aamer %+ Yusra Institute of Pharmaceutical Sciences, Zaraj Housing Society, Opposite DHA Phase 2 Gate III, Main G T Road, Islamabad, 44000, Pakistan, 92 3215272489, hashaamakhtar@gmail.com %K COVID-19 %K indicators %K symptoms %K risk factors %K comorbidities %K severity %K Pakistan %D 2021 %7 14.12.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: COVID-19 became a pandemic rapidly after its emergence in December 2019. It belongs to the coronavirus family of viruses, which have struck a few times before in history. Data based on previous research regarding etiology and epidemiology of other viruses from this family helped played a vital role in formulating prevention and precaution strategies during the initial stages of this pandemic. Data related to COVID-19 in Pakistan were not initially documented on a large scale. In addition, due to a weak health care system and low economic conditions, Pakistan’s population, in general, already suffers from many comorbidities, which can severely affect the outcome of patients infected with COVID-19. Objective: COVID-19 infections are coupled with a manifestation of various notable outcomes that can be documented and characterized clinically. The aim of this study was to examine these clinical manifestations, which can serve as indicators for early detection as well as severity prognosis for COVID-19 infections, especially in high-risk groups. Methods: A retrospective observational study involving abstraction of demographic features, presenting symptoms, and adverse clinical outcomes for 1812 patients with COVID-19 was conducted. Patients were admitted to the four major hospitals in the Rawalpindi-Islamabad region of Pakistan, and the study was conducted from February to August 2020. Multivariate regression analysis was carried out to identify significant indicators of COVID-19 severity, intensive care unit (ICU) admission, ventilator aid, and mortality. The study not only relates COVID-19 infection with comorbidities, but also examines other related factors, such as age and gender. Results: This study identified fever (1592/1812, 87.9%), cough (1433/1812, 79.1%), and shortness of breath (998/1812, 55.1%) at the time of hospital admission as the most prevalent symptoms for patients with COVID-19. These symptoms were common but not conclusive of the outcome of infection. Out of 1812 patients, 24.4% (n=443) required ICU admission and 21.5% (n=390) required ventilator aid at some point of disease progression during their stay at the hospital; 25.9% (n=469) of the patients died. Further analysis revealed the relationship of the presented symptoms and comorbidities with the progression of disease severity in these patients. Older adult patients with comorbidities, such as hypertension, diabetes, chronic kidney disease, and asthma, were significantly affected in higher proportions, resulting in requirement of ICU admission and ventilator aid in some cases and, in many cases, even mortality. Conclusions: Older adult patients with comorbidities, such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease, are at increased risk of developing severe COVID-19 infections, with an increased likelihood of adverse clinical outcomes. %M 34710053 %R 10.2196/32203 %U https://publichealth.jmir.org/2021/12/e32203 %U https://doi.org/10.2196/32203 %U http://www.ncbi.nlm.nih.gov/pubmed/34710053 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 11 %P e27626 %T Evaluation of the National Tuberculosis Surveillance System in Sana’a, Yemen, 2018: Observational Study %A Al kalali,Fadwa Salem Ahmed %A Mahyoub,Essam %A Al-Hammadi,Abdulbary %A Anam,Labiba %A Khader,Yousef %+ Yemen Field Epidemiology Training Program, Ministry of Public Health and Population, Mazda St, Al Hasaba, Sana’a, 12093, Yemen, 967 778005123, fadwa20102011@yahoo.com %K evaluation %K surveillance system %K tuberculosis %K Yemen %D 2021 %7 30.11.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Tuberculosis remains a public problem that is considered one of the top causes of morbidity and mortality worldwide. The National Tuberculosis Control Program in Yemen was established in 1970 and included in the national health policy under the leadership of the Ministry of Public Health and Population to monitor tuberculosis control. The surveillance system must be evaluated periodically to produce recommendations for improving performance and usefulness. Objective: This study aims to assess the usefulness and the performance of the tuberculosis surveillance system attributes and to identify the strengths and weaknesses of the system. Methods: A quantitative and qualitative evaluation of the national tuberculosis surveillance system was conducted using the Centers for Disease Control and Prevention’s updated guidelines. The study was carried out in 10 districts in Sana’a City. A total of 28 public health facilities providing tuberculosis services for the whole population in their assigned catchment areas were purposively selected. All participants were interviewed based on their involvement with key aspects of tuberculosis surveillance activities. Results: The tuberculosis surveillance system was found to have an average performance in usefulness (57/80, 71%), flexibility (30/40, 75%), acceptability (174/264, 66%), data quality (4/6, 67%), and positive predictive value (78/107, 73%), and poor performance in simplicity (863/1452, 59%) and stability (15%, 3/20). In addition, the system also had a good performance in sensitivity (78/81, 96%). Conclusions: The tuberculosis surveillance system was found to be useful. The flexibility, positive predictive value, and data quality were average. Stability and simplicity were poor. The sensitivity was good. The main weaknesses in the tuberculosis surveillance system include a lack of governmental financial support, a paper-based system, and a lack of regular staff training. Developing an electronic system, securing governmental finances, and training the staff on tuberculosis surveillance are strongly recommended to improve the system performance. %M 34851294 %R 10.2196/27626 %U https://publichealth.jmir.org/2021/11/e27626 %U https://doi.org/10.2196/27626 %U http://www.ncbi.nlm.nih.gov/pubmed/34851294 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 11 %P e32639 %T Public Health Surveillance Systems in the Eastern Mediterranean Region: Bibliometric Analysis of Scientific Literature %A Saad,Randa K %A Al Nsour,Mohannad %A Khader,Yousef %A Al Gunaid,Magid %+ Global Health Development|Eastern Mediterranean Public Health Network, Abdallah Ben Abbas St, Building No. 42, Amman, Jordan, 962 781665060, randaksaad@gmail.com %K public health %K surveillance %K Eastern Mediterranean Region %K bibliometric analysis %K literature %K research %K review %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The Eastern Mediterranean Region (EMR) hosts some of the world’s worst humanitarian and health crises. The implementation of health surveillance in this region has faced multiple constraints. New and novel approaches in surveillance are in a constant state of high and immediate demand. Identifying the existing literature on surveillance helps foster an understanding of scientific development and thus potentially supports future development directions. Objective: This study aims to illustrate the scientific production, quantify the scholarly impact, and highlight the characteristics of publications on public health surveillance in the EMR over the past decade. Methods: We performed a Scopus search using keywords related to public health surveillance or its disciplines, cross-referenced with EMR countries, from 2011 to July 2021. Data were exported and analyzed using Microsoft Excel and Visualization of Similarities Viewer. Quality of journals was determined using SCImago Journal Rank and CiteScore. Results: We retrieved 1987 documents, of which 1927 (96.98%) were articles or reviews. There has been an incremental increase in the number of publications (exponential growth, R2=0.80) over the past decade. Publications were mostly affiliated with Iran (501/1987, 25.21%), the United States (468/1987, 23.55%), Pakistan (243/1987, 12.23%), Egypt (224/1987, 11.27%), and Saudi Arabia (209/1987, 10.52%). However, Iran only had links with 40 other countries (total link strength 164), and the biggest collaborator from the EMR was Egypt, with 67 links (total link strength 402). Within the other EMR countries, only Morocco, Lebanon, and Jordan produced ≥79 publications in the 10-year period. Most publications (1551/1987, 78.06%) were affiliated with EMR universities. Most journals were categorized as medical journals, and the highest number of articles were published in the Eastern Mediterranean Health Journal (SCImago Journal Rank 0.442; CiteScore 1.5). Retrieved documents had an average of 18.4 (SD 125.5) citations per document and an h-index of 66. The top-3 most cited documents were from the Global Burden of Diseases study. We found 70 high-frequency terms, occurring ≥10 times in author keywords, connected in 3 clusters. COVID-19, SARS-CoV-2, and pandemic represented the most recent 2020 cluster. Conclusions: This is the first research study to quantify the published literature on public health surveillance and its disciplines in the EMR. Research productivity has steadily increased over the past decade, and Iran has been the leading country publishing relevant research. Recurrent recent surveillance themes included COVID-19 and SARS-CoV-2. This study also sheds light on the gaps in surveillance research in the EMR, including inadequate publications on noncommunicable diseases and injury-related surveillance. %M 34723831 %R 10.2196/32639 %U https://publichealth.jmir.org/2021/11/e32639 %U https://doi.org/10.2196/32639 %U http://www.ncbi.nlm.nih.gov/pubmed/34723831 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 10 %P e32559 %T Excess Mortality During the COVID-19 Pandemic in Jordan: Secondary Data Analysis %A Khader,Yousef %A Al Nsour,Mohannad %+ Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Alramtha-Amman Street, Irbid, 22110, Jordan, 962 796802040, yskhader@just.edu.jo %K COVID-19 %K excess mortality %K pandemic %D 2021 %7 7.10.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: All-cause mortality and estimates of excess deaths are commonly used in different countries to estimate the burden of COVID-19 and assess its direct and indirect effects. Objective: This study aimed to analyze the excess mortality during the COVID-19 pandemic in Jordan in April-December 2020. Methods: Official data on deaths in Jordan for 2020 and previous years (2016-2019) were obtained from the Department of Civil Status. We contrasted mortality rates in 2020 with those in each year and the pooled period 2016-2020 using a standardized mortality ratio (SMR) measure. Expected deaths for 2020 were estimated by fitting the overdispersed Poisson generalized linear models to the monthly death counts for the period of 2016-2019. Results: Overall, a 21% increase in standardized mortality (SMR 1.21, 95% CI 1.19-1.22) occurred in April-December 2020 compared with the April-December months in the pooled period 2016-2019. The SMR was more pronounced for men than for women (SMR 1.26, 95% CI 1.24-1.29 vs SMR 1.12, 95% CI 1.10-1.14), and it was statistically significant for both genders (P<.05). Using overdispersed Poisson generalized linear models, the number of expected deaths in April-December 2020 was 12,845 (7957 for women and 4888 for men). The total number of excess deaths during this period was estimated at 4583 (95% CI 4451-4716), with higher excess deaths in men (3112, 95% CI 3003-3221) than in women (1503, 95% CI 1427-1579). Almost 83.66% of excess deaths were attributed to COVID-19 in the Ministry of Health database. The vast majority of excess deaths occurred in people aged 60 years or older. Conclusions: The reported COVID-19 death counts underestimated mortality attributable to COVID-19. Excess deaths could reflect the increased deaths secondary to the pandemic and its containment measures. The majority of excess deaths occurred among old age groups. It is, therefore, important to maintain essential services for the elderly during pandemics. %M 34617910 %R 10.2196/32559 %U https://publichealth.jmir.org/2021/10/e32559 %U https://doi.org/10.2196/32559 %U http://www.ncbi.nlm.nih.gov/pubmed/34617910 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 9 %P e28005 %T Clinical, Laboratory, and Imaging Features of COVID-19 in a Cohort of Patients: Cross-Sectional Comparative Study %A Qaisieh,Rami %A Al-Tamimi,Mohammad %A El-Hammuri,Naser %A Shalabi,Marwan %A Kilani,Muna M %A Taha,Hana %A Al-Muhtaseb,Abdallah %A Alfarrajin,Ibrahim %A Abu Shaqra,Marwan %A Hamdan,Almothana %+ Department of Basic Medical Sciences, Faculty of Medicine, Hashemite University, Damascus Highway, Zarqa, Jordan, 962 5 3903333, mohammad.altamimi@hu.edu.jo %K COVID-19 %K gender %K clinical %K laboratory %K imaging %K SARS-CoV2 %K Jordan %D 2021 %7 21.9.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The clinical, laboratory, and imaging features of COVID-19 disease are variable. Multiple factors can affect the disease progression and outcome. Objective: This study aimed to analyze the clinical, laboratory, and imaging features of COVID-19 in Jordan. Methods: Clinical, laboratory, and imaging data were collected for 557 confirmed COVID-19 patients admitted to Prince Hamzah Hospital (PHH), Jordan. Analysis was performed using appropriate statistical tests with SPSS version 24. Results: Of the 557 COVID-19 polymerase chain reaction (PCR)-positive cases admitted to PHH, the mean age was 34.4 years (SD 18.95 years; range 5 weeks to 87 years), 86.0% (479/557) were male, 41% (29/70) were blood group A+, and 57.1% (93/163) were overweight or obese. Significant past medical history was documented in 25.9% (144/557), significant surgical history in 12.6% (70/557), current smoking in 14.9% (83/557), and pregnancy in 0.5% (3/557). The mean duration of hospitalization was 16.4 (SD 9.3; range 5 to 70) days; 52.6% (293/557) were asymptomatic, and 12.9% (72/557) had more than 5 symptoms, with generalized malaise and dry cough the most common symptoms. Only 2.5% (14/557) had a respiratory rate over 25 breaths/minute, and 1.8% (10/557) had an oxygen saturation below 85%. Laboratory investigations showed a wide range of abnormalities, with lymphocytosis and elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer the most common abnormalities. Ground glass opacity was the most common imaging finding. Men had a significantly higher frequency of symptoms, incidence of smoking, reduced hemoglobin, increased monocyte %, elevated creatinine levels, and intensive care unit admissions compared with women (P<.05). Hospitalization duration was associated with increased age, male gender, symptom score, history of smoking, elevated systolic blood pressure, elevated respiratory rate, and elevated monocyte %, CRP, ESR, creatinine, and D-dimer (P<.05). Conclusions: Most COVID-19 cases admitted to PHH were asymptomatic. Variabilities in symptoms, signs, laboratory results, and imaging findings should be noted. Increased age, male gender, smoking history, and elevated inflammatory markers were significantly associated with longer duration of hospitalization. %M 34081600 %R 10.2196/28005 %U https://publichealth.jmir.org/2021/9/e28005 %U https://doi.org/10.2196/28005 %U http://www.ncbi.nlm.nih.gov/pubmed/34081600 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 9 %P e31930 %T Morocco's National Response to the COVID-19 Pandemic: Public Health Challenges and Lessons Learned %A Barkia,Abdelaziz %A Laamrani,Hammou %A Belalia,Abdelmounaim %A Benmamoun,Abderrahman %A Khader,Yousef %+ Department of Public Health, Jordan University of Science and technology, Alramtha-Amman street, Irbid, 22110, Jordan, 962 796802040, yskhader@just.edu.jo %K COVID-19 %K public health %K challenges %K prevention %K control %K infectious disease %D 2021 %7 17.9.2021 %9 Viewpoint %J JMIR Public Health Surveill %G English %X This report aimed to provide an overview of the epidemiological situation of COVID-19 in Morocco and to review the actions carried out as part of the national response to this pandemic. The methodology adopted was based on literature review, interviews with officials and actors in the field, and remote discussion workshops with a multidisciplinary and multisectoral working group. Morocco took advantage of the capacities already strengthened within the framework of the application of the provisions of the International Health Regulations (IHR) of 2005. A SWOT analysis made it possible to note that an unprecedented political commitment enabled all the necessary means to face the pandemic and carry out all the response activities, including a campaign of relentless communication. Nevertheless, and despite the efforts made, the shortage of human resources, especially those qualified in intensive care and resuscitation, has been the main drawback to be addressed. The main lesson learned is a need to further strengthen national capacities to prepare for and respond to possible public health emergencies and to embark on a process overhaul of the health system, including research into innovative tools to ensure the continuity of the various disease prevention and control activities. In addition, response to a health crisis is not only the responsibility of the health sector but also intersectoral collaboration is needed to guarantee an optimal coordinated fight. Community-oriented approaches in public health have to be strengthened through more participation and involvement of nongovernmental organizations (NGOs) and civil society in operational and strategic planning. %M 34388104 %R 10.2196/31930 %U https://publichealth.jmir.org/2021/9/e31930 %U https://doi.org/10.2196/31930 %U http://www.ncbi.nlm.nih.gov/pubmed/34388104 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 7 %P e27621 %T Performance of the Severe Acute Respiratory Illness Sentinel Surveillance System in Yemen: Mixed Methods Evaluation Study %A Alkholidy,Ghamdan Gamal %A Anam,Labiba Saeed %A Almahaqri,Ali Hamoud %A Khader,Yousef %+ Yemen Field Epidemiology Training Program, Ministry of Public Health and Population, Alsteen St, Bldg 23, Sana'a, Yemen, 967 771530764, ghamdangamal@gmail.com %K evaluation %K surveillance %K Centers for Disease Control and Prevention guidelines %K severe acute respiratory illness %K Yemen %D 2021 %7 9.7.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The national severe acute respiratory illness (SARI) surveillance system in Yemen was established in 2010 to monitor SARI occurrence in humans and provide a foundation for detecting SARI outbreaks. Objective: To ensure that the objectives of national surveillance are being met, this study aimed to examine the level of usefulness and the performance of the SARI surveillance system in Yemen. Methods: The updated Centers for Disease Control and Prevention guidelines were used for the purposes of our evaluation. Related documents and reports were reviewed. Data were collected from 4 central-level managers and stakeholders and from 10 focal points at 4 sentinel sites by using a semistructured questionnaire. For each attribute, percent scores were calculated and ranked as follows: very poor (≤20%), poor (20%-40%), average (40%-60%), good (60%-80%), and excellent (>80%). Results: As rated by the evaluators, the SARI surveillance system achieved its objectives. The system’s flexibility (percent score: 86%) and acceptability (percent score: 82%) were rated as “excellent,” and simplicity (percent score: 74%) and stability (percent score: 75%) were rated as “good.” The percent score for timeliness was 23% in 2018, which indicated poor timeliness. The overall data quality percent score of the SARI system was 98.5%. Despite its many strengths, the SARI system has some weaknesses. For example, it depends on irregular external financial support. Conclusions: The SARI surveillance system was useful in estimating morbidity and mortality, monitoring the trends of the disease, and promoting research for informing prevention and control measures. The overall performance of the SARI surveillance system was good. We recommend expanding the system by promoting private health facilities’ (eg, private hospitals and private health centers) engagement in SARI surveillance, establishing an electronic database at central and peripheral sites, and providing the National Central Public Health Laboratory with the reagents needed for disease confirmation. %M 34255695 %R 10.2196/27621 %U https://publichealth.jmir.org/2021/7/e27621 %U https://doi.org/10.2196/27621 %U http://www.ncbi.nlm.nih.gov/pubmed/34255695 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 7 %P e27627 %T Risk Factors of Cholera Transmission in Al Hudaydah, Yemen: Case-Control Study %A Qaserah,Abdulqawi Mohammed %A Al Amad,Mohammed Abdullah %A Al Serouri,Abdulwahed Abduljabbar %A Khader,Yousef Saleh %+ Rapid Response Team, Yemen Ministry of Public Health and Population, P.O. Box 299, Al-Hasabah, Sana'a, Yemen, 967 772435532, aabuhosam33@gmail.com %K cholera %K outbreak %K risk factors, Yemen %K Field Epidemiology Training Program %D 2021 %7 5.7.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X 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. %M 36260393 %R 10.2196/27627 %U https://publichealth.jmir.org/2021/7/e27627 %U https://doi.org/10.2196/27627 %U http://www.ncbi.nlm.nih.gov/pubmed/36260393 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 6 %P e27623 %T Incidence, Trend, and Mortality of Human Exposure to Rabies in Yemen, 2011-2017: Observational Study %A Abdulmoghni,Rihana Taher %A Al-Ward,Ahmed Hasan %A Al-Moayed,Khaled Abdullah %A AL-Amad,Mohammed Abdullah %A Khader,Yousef S %+ Yemen Field Epidemiology Training Program, Ministry of Public Health and Population, Al-Asbahy Area, Al-Sabain District, Sana'a, Yemen, 967 775242320, dr.rihana@ymail.com %K rabies %K incidence %K trend %K mortality %D 2021 %7 22.6.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X 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. %M 34156339 %R 10.2196/27623 %U https://publichealth.jmir.org/2021/6/e27623 %U https://doi.org/10.2196/27623 %U http://www.ncbi.nlm.nih.gov/pubmed/34156339 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 6 %P e27625 %T The Rotavirus Surveillance System in Yemen: Evaluation Study %A Lardi,Eman Abdullah %A Al Kuhlani,Sharaf Sharaf %A Al Amad,Mohammed Abdullah %A Al Serouri,Abdulwahed Abduljabar %A Khader,Yousef Saleh %+ Field Epidemiology Training Program, Ministry of Public Health and Population, AL-Hasaba, Mazda street, Sana'a, Yemen, 967 771866574, eman2020-2020@hotmail.com %K Rotavirus %K surveillance system %K evaluation, Yemen %D 2021 %7 8.6.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X 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. %M 34100759 %R 10.2196/27625 %U https://publichealth.jmir.org/2021/6/e27625 %U https://doi.org/10.2196/27625 %U http://www.ncbi.nlm.nih.gov/pubmed/34100759 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 6 %P e27590 %T Epidemiology of Diphtheria in Yemen, 2017-2018: Surveillance Data Analysis %A Moghalles,Suaad Ameen %A Aboasba,Basher Ahmed %A Alamad,Mohammed Abdullah %A Khader,Yousef Saleh %+ Yemen Field Epidemiology Training Programme, Ministry of Public Health and Population, Hadh Street, Sana'a, 00967, Yemen, 967 735 800 572, smughalles@gmail.com %K diphtheria %K epidemiology %K incidence %K case fatality rate %D 2021 %7 2.6.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: As a consequence of war and the collapse of the health system in Yemen, which prevented many people from accessing health facilities to obtain primary health care, vaccination coverage was affected, leading to a deadly diphtheria epidemic at the end of 2017. Objective: This study aimed to describe the epidemiology of diphtheria in Yemen and determine its incidence and case fatality rate. Methods: Data were obtained from the diphtheria surveillance program 2017-2018, using case definitions of the World Health Organization. A probable case was defined as a case involving a person having laryngitis, pharyngitis, or tonsillitis and an adherent membrane of the tonsils, pharynx, and/or nose. A confirmed case was defined as a probable case that was laboratory confirmed or linked epidemiologically to a laboratory-confirmed case. Data from the Central Statistical Organization was used to calculate the incidence per 100,000 population. A P value <.05 was considered significant. Results: A total of 2243 cases were reported during the period between July 2017 and August 2018. About 49% (1090/2243, 48.6%) of the cases were males. About 44% (978/2243, 43.6%) of the cases involved children aged 5 to 15 years. Respiratory tract infection was the predominant symptom (2044/2243, 91.1%), followed by pseudomembrane (1822/2243, 81.2%). Based on the vaccination status, the percentages of partially vaccinated, vaccinated, unvaccinated, and unknown status patients were 6.6% (148/2243), 30.8% (690/2243), 48.6% (10902243), and 14.0% (315/2243), respectively. The overall incidence of diphtheria was 8 per 100,000 population. The highest incidence was among the age group <15 years (11 per 100,000 population), and the lowest incidence was among the age group ≥15 years (5 per 100,000 population). The overall case fatality rate among all age groups was 5%, and it was higher (10%) in the age group <5 years. Five governorates that were difficult to access (Raymah, Abyan, Sa'ada, Lahj, and Al Jawf) had a very high case fatality rate (22%). Conclusions: Diphtheria affected a large number of people in Yemen in 2017-2018. The majority of patients were partially or not vaccinated. Children aged ≤15 years were more affected, with higher fatality among children aged <5 years. Five governorates that were difficult to access had a case fatality rate twice that of the World Health Organization estimate (5%-10%). To control the diphtheria epidemic in Yemen, it is recommended to increase routine vaccination coverage and booster immunizations, increase public health awareness toward diphtheria, and strengthen the surveillance system for early detection and immediate response. %M 34076583 %R 10.2196/27590 %U https://publichealth.jmir.org/2021/6/e27590 %U https://doi.org/10.2196/27590 %U http://www.ncbi.nlm.nih.gov/pubmed/34076583 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e28594 %T An Overview of the Treatment Options Used for the Management of COVID-19 in Pakistan: Retrospective Observational Study %A Akhtar,Hashaam %A Akhtar,Samar %A Rahman,Fazal-Ul %A Afridi,Maham %A Khalid,Sundas %A Ali,Sabahat %A Akhtar,Nasim %A Khader,Yousef S %A Ahmad,Hamaad %A Khan,Muhammad Mujeeb %+ Yusra Institute of Pharmaceutical Sciences, Yusra Medical and Dental College, Zaraj Housing Society, Opposite DHA Phase 2 Gate III, Main GT Road, Islamabad, 44000, Pakistan, 92 515709447, hashaamakhtar@gmail.com %K COVID-19 %K antibiotics %K Pakistan %K multidrug resistant infections %K antibiotic resistance %K first wave %D 2021 %7 27.5.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Since the first reports of COVID-19 infection, the foremost requirement has been to identify a treatment regimen that not only fights the causative agent but also controls the associated complications of the infection. Due to the time-consuming process of drug discovery, physicians have used readily available drugs and therapies for treatment of infections to minimize the death toll. Objective: The aim of this study is to provide a snapshot analysis of the major drugs used in a cohort of 1562 Pakistani patients during the period from May to July 2020, when the first wave of COVID-19 peaked in Pakistan. Methods: A retrospective observational study was performed to provide an overview of the major drugs used in a cohort of 1562 patients with COVID-19 admitted to the four major tertiary-care hospitals in the Rawalpindi-Islamabad region of Pakistan during the peak of the first wave of COVID-19 in the country (May-July 2020). Results: Antibiotics were the most common choice out of all the therapies employed, and they were used as first line of treatment for COVID-19. Azithromycin was the most prescribed drug for treatment. No monthly trend was observed in the choice of antibiotics, and these drugs appeared to be a random but favored choice throughout the months of the study. It was also noted that even antibiotics used for multidrug resistant infections were prescribed irrespective of the severity or progression of the infection. The results of the analysis are alarming, as this approach may lead to antibiotic resistance and complications in immunocompromised patients with COVID-19. A total of 1562 patients (1064 male, 68.1%, and 498 female, 31.9%) with a mean age of 47.35 years (SD 17.03) were included in the study. The highest frequency of patient hospitalizations occurred in June (846/1562, 54.2%). Conclusions: Guidelines for a targeted treatment regime are needed to control related complications and to limit the misuse of antibiotics in the management of COVID-19. %M 33945498 %R 10.2196/28594 %U https://publichealth.jmir.org/2021/5/e28594 %U https://doi.org/10.2196/28594 %U http://www.ncbi.nlm.nih.gov/pubmed/33945498 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27609 %T Notes From the Field: The Combined Effects of Tocilizumab and Remdesivir in a Patient With Severe COVID-19 and Cytokine Release Syndrome %A Ali,Sabahat %A Khalid,Sundas %A Afridi,Maham %A Akhtar,Samar %A Khader,Yousef S %A Akhtar,Hashaam %+ Yusra Institute of Pharmaceutical Sciences, Zaraj Housing Society, Main GT Road, Islamabad, 44000, Pakistan, 92 3215272489, hashaamakhtar@gmail.com %K COVID-19 %K remdesivir %K treatment %K tocilizumab %D 2021 %7 19.5.2021 %9 Notes from the Field %J JMIR Public Health Surveill %G English %X SARS-CoV-2 is known to cause severe bilateral pneumonia and acute respiratory distress syndrome or COVID-19 in patients, which can be debilitating and even fatal. With no drugs or vaccines available yet, a wide range of treatment regimens used are being repurposed. The need of the hour is to analyze various currently available regimens and devise a treatment plan that is most effective for COVID-19. Here we describe the case of a 68-year-old man with hypertension and diabetes, exhibiting symptoms of cough and shortness of breath, who presented at the emergency department of our hospital. Chest computed tomography revealed bilateral ground glass opacities that were indicative of COVID-19, and a computed tomography score of 24 was indicative of severe pulmonary pneumonia. He tested positive for COVID-19. His treatment regimen included the use of convalescent plasma, oxygen therapy, steroids, high-dose antibiotics, broad-spectrum antiviral remdesivir, and anti–interleukin-6 monoclonal antibody (Tocilizumab) at various stages of the disease. Oxygen supplementation was required at the time of admission. The patient initially developed a cytokine release storm, and oxygen supplementation was initiated to manage his condition. Supportive care and multiple treatment regimens were used to successfully recover the patient’s health. With a rapid increase in number of confirmed cases worldwide, COVID-19 has become a major challenge to our health care system. With no available vaccines currently, the establishment of a combination of therapeutic drugs that effectively reduce disease progression is of utmost importance. %M 34009133 %R 10.2196/27609 %U https://publichealth.jmir.org/2021/5/e27609 %U https://doi.org/10.2196/27609 %U http://www.ncbi.nlm.nih.gov/pubmed/34009133 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27638 %T Impact of the Protracted War in Yemen on the Acute Flaccid Paralysis Surveillance System: Retrospective Descriptive Analysis %A Al-Dubaiee,Riham %A AL Qassimi,Mutaher %A Al-Dar,Ahmed %A Al Serouri,Abdulwahed %A Khader,Yousef %+ Ministry of Public Health and Population, Al-Hasaba, Mazda street, Sana'a, Yemen, 967 776417333, rihamm10@yahoo.com %K acute flaccid paralysis %K surveillance indicators %K war %K Yemen %D 2021 %7 19.5.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Highly sensitive acute flaccid paralysis (AFP) surveillance, which includes immediate case investigation and specimen collection, is critical for achieving global polio eradication. In Yemen, the Acute Flaccid Paralysis Surveillance System (AFPSS) was launched in 1998 to achieve the polio eradication target. Although Yemen was certified as a polio-free country in 2009, the protracted war since 2015 has placed the country at risk for polio reemergence. Objective: The objectives of this analysis were to evaluate the performance of the Yemen AFPSS at both the national and governorate levels, and to assess the impact of the ongoing war on the performance. Methods: Retrospective descriptive analysis was performed on Yemen secondary AFP surveillance data for the years 2014 (before the war) and 2015-2017 (during the war). Data comprising all children <15 years old reported as having AFP were included in the analysis. AFP surveillance performance was evaluated using World Health Organization–specified AFP surveillance indicators. Results: At the national level, all indicators were met before and after the war except for “lab results received within ≤28 days,” which was unmet since the war erupted. Furthermore, the indicator “stool specimens arriving at a central level within ≤3 days” was unmet after the war but only in 2017. At the governorate level, although the indicators “adequacy” and “stool specimens arriving at the laboratory in good condition” were met before the war in all governorates, the former indicator was unmet in 9 (41%) governorates since the war erupted and the latter indicator was also unmet in 9 governorates (41%) but only in 2017. Conclusions: The findings show that some AFP surveillance indicators were negatively impacted by eruption of the war in Yemen due to closure of the Sana’a capital airport and postponement of sample shipment to the reference laboratory, which remained under long-term poor storage conditions. To ensure rapid detection of polio cases, improving specimen collection, storage, and transportation, together with proper and timely shipment of specimens to the reference laboratory should be considered. %M 34009132 %R 10.2196/27638 %U https://publichealth.jmir.org/2021/5/e27638 %U https://doi.org/10.2196/27638 %U http://www.ncbi.nlm.nih.gov/pubmed/34009132 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e28517 %T Pakistan’s Response to COVID-19: Overcoming National and International Hypes to Fight the Pandemic %A Akhtar,Hashaam %A Afridi,Maham %A Akhtar,Samar %A Ahmad,Hamaad %A Ali,Sabahat %A Khalid,Sundas %A Awan,Sajid Mahmood %A Jahangiri,Shahzaib %A Khader,Yousef Saleh %+ Yusra Institute of Pharmaceutical Sciences, Yusra Medical and Dental College, Zaraj Housing Society, Opposite DHA Phase 2 Gate III, Main GT Road, Islamabad, 44000, Pakistan, 92 3165163945, hashaamakhtar@gmail.com %K community health %K coronavirus %K COVID-19 %K epidemic %K epidemiology %K Pakistan %K pandemic %K public health emergency of international concern %D 2021 %7 19.5.2021 %9 Viewpoint %J JMIR Public Health Surveill %G English %X The COVID-19 outbreak started as pneumonia in December 2019 in Wuhan, China. The subsequent pandemic was declared as the sixth public health emergency of international concern on January 30, 2020, by the World Health Organization. Pakistan could be a potential hotspot for COVID-19 owing to its high population of 204.65 million and its struggling health care and economic systems. Pakistan was able to tackle the challenge with relatively mild repercussions. The present analysis has been conducted to highlight the situation of the disease in Pakistan in 2020 and the measures taken by various stakeholders coupled with support from the community to abate the risk of catastrophic spread of the virus. %M 33877048 %R 10.2196/28517 %U https://publichealth.jmir.org/2021/5/e28517 %U https://doi.org/10.2196/28517 %U http://www.ncbi.nlm.nih.gov/pubmed/33877048 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27268 %T Morbidity and Mortality Associated with Typhoid Fever Among Hospitalized Patients in Hyderabad District, Pakistan, 2017-2018: Retrospective Record Review %A Fatima,Munaza %A Kumar,Santosh %A Hussain,Mudassar %A Memon,Naveed Masood %A Vighio,Anum %A Syed,Muhammad Asif %A Chaudhry,Ambreen %A Hussain,Zakir %A Baig,Zeeshan Iqbal %A Baig,Mirza Amir %A Asghar,Rana Jawad %A Ikram,Aamer %A Khader,Yousef %+ National Institute of Health Pakistan, Park Road, Chak Shehzad, Islamabad, 44000, Pakistan, 92 519255302, ambr.chaudhry@gmail.com %K antimicrobial resistance %K complications %K control drug resistance %K extensive drug resistance %K hospitalization %K Hyderabad %K ileal perforation %K medical records %K microbiological %K morbidity %K mortality %K Pakistan %K prevention %K typhoid %D 2021 %7 17.5.2021 %9 Short Paper %J JMIR Public Health Surveill %G English %X Background: Hyderabad, Pakistan, was the first city to witness an outbreak of extensively drug resistant (XDR) typhoid fever. The outbreak strain is resistant to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporin, thus greatly limiting treatment options. However, despite over 5000 documented cases, information on mortality and morbidity has been limited. Objective: To address the existing knowledge gap, this study aimed to assess the morbidity and mortality associated with XDR and non-XDR Salmonella serovar Typhi infections in Pakistan. Methods: We reviewed the medical records of culture-confirmed typhoid cases in 5 hospitals in Hyderabad from October 1, 2016, to September 30, 2018. We recorded data on age, gender, onset of fever, physical examination, serological and microbiological test results, treatment before and during hospitalization, duration of hospitalization, complications, and deaths. Results: A total of 1452 culture-confirmed typhoid cases, including 947 (66%) XDR typhoid cases and 505 (34%) non-XDR typhoid cases, were identified. Overall, ≥1 complications were reported in 360 (38%) patients with XDR typhoid and 89 (18%) patients with non-XDR typhoid (P<.001). Ileal perforation was the most commonly reported complication in both patients with XDR typhoid (n=210, 23%) and patients with non-XDR typhoid (n=71, 14%) (P<.001). Overall, mortality was documented among 17 (1.8%) patients with XDR S Typhi infections and 3 (0.6%) patients with non-XDR S Typhi infections (P=.06). Conclusions: As this first XDR typhoid outbreak continues to spread, the increased duration of illness before hospitalization and increased rate of complications have important implications for clinical care and medical costs and heighten the importance of prevention and control measures. %M 33999000 %R 10.2196/27268 %U https://publichealth.jmir.org/2021/5/e27268 %U https://doi.org/10.2196/27268 %U http://www.ncbi.nlm.nih.gov/pubmed/33999000 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27442 %T Cutaneous Leishmaniasis Outbreak Investigation in Hajjah Governorate, Yemen, in 2018: Case-Control Study %A Nassar,Abdulkareem Ali %A Abdelrazzaq,Mahmood Hasan %A Almahaqri,Ali Hamoud %A Al-Amad,Mohammed Abdullah %A Al Serouri,Abulwahed Abduljabbar %A Khader,Yousef Saleh %+ Sana'a City's Public Health and Population Office, Yemen Ministry of Public Health and Population, Al-Thawra District, Sana'a, Yemen, 967 777228977, abdulkareemnassar@gmail.com %K cutaneous leishmaniasis %K outbreak %K risk factors %K Yemen %K Field Epidemiology Training Program %D 2021 %7 14.5.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X 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. %M 33988521 %R 10.2196/27442 %U https://publichealth.jmir.org/2021/5/e27442 %U https://doi.org/10.2196/27442 %U http://www.ncbi.nlm.nih.gov/pubmed/33988521 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27276 %T Risk Factors of Extensively Drug Resistant Typhoid Fever Among Children in Karachi: Case-Control Study %A Vighio,Anum %A Syed,Muhammad Asif %A Hussain,Ishfaque %A Zia,Syed Masroor %A Fatima,Munaza %A Masood,Naveed %A Chaudry,Ambreen %A Hussain,Zakir %A Iqbal Baig,Mirza Zeeshan %A Baig,Mirza Amir %A Ikram,Aamer %A S Khader,Yousef %+ Field Epidemiology and Laboratory Training Program Pakistan, National Institute of Health, Park Road, Chak Shahzad, Islamabad, 44000, Pakistan, 92 519255307, anumvighio@gmail.com %K case-control study %K drug resistance %K extensively drug resistant typhoid fever %K risk factors %K typhoid fever %D 2021 %7 11.5.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Extensively drug resistant typhoid fever (XDR-TF) has been responsible for an ongoing outbreak in Pakistan, which began in November 2016. Objective: This study aimed to determine the risk factors associated with XDR-TF. Methods: This age- and sex-matched case-control study was conducted during May-October 2018 in Karachi. All patients with XDR-TF were identified from the laboratory-based surveillance system data. Cases included patients aged <15 years living in Karachi with culture-positive Salmonella enterica serovar Typhi with resistance to chloramphenicol, ampicillin, trimethoprim/sulfamethoxazole, fluoroquinolones, and third-generation cephalosporins. Age- and sex-matched controls included children free from the symptoms of TF, aged under 15 years, and residing in Karachi. All controls were recruited from among those who attended outpatient clinics. Results: A total of 75 cases and 75 controls were included in this study. On univariate analysis, the odds of having XDR-TF were 13-fold higher among participants who used piped municipal water than among those who did not (odds ratio [OR] 12.6, 95% CI 4.1-38.6). The use of bore water was significantly associated with XDR-TF (OR 5.1, 95% CI 1.4-19.0). Cases were more likely to report eating French fries with sauce (OR 13.5, 95% CI 3.9-47.0) and poppadum (OR 3.4, 95% CI 1.7-6.7) from street vendors than controls. Boiling water at home was negatively associated with XDR-TF (OR 0.3, 95% CI 0.2-0.7). On multivariate analysis, 2 factors were independently associated with XDR-TF. Using piped municipal water (OR 10.3, 95% CI 3.4-30.4) and eating French fries with sauce from street vendors (OR 8.8, 95% CI 2.1-36.2) were significantly associated with an increased odds of XDR-TF. Conclusions: Community water supply and street food eating habits were implicated in the spread of the superbug S typhi outbreak, which continues to grow in Karachi. Therefore, it is recommended to improve the community water supply to meet recommended standards and to develop a policy to improve the safety of street food. In addition, health authorities are required to conduct mass vaccination for TF among high-risk groups. %M 33973861 %R 10.2196/27276 %U https://publichealth.jmir.org/2021/5/e27276 %U https://doi.org/10.2196/27276 %U http://www.ncbi.nlm.nih.gov/pubmed/33973861 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27412 %T The Impact of Implementing the Egypt Pandemic Preparedness Plan for Acute Respiratory Infections in Combating the Early Stage of the COVID-19 Pandemic, February-July 2020: Viewpoint %A Abu El Sood,Hanaa %A Abu Kamer,Shimaa Ali %A Kamel,Reham %A Magdy,Hesham %A Osman,Fatma S %A Fahim,Manal %A Mohsen,Amira %A AbdelFatah,Mohamad %A Hassany,Mohamed %A Afifi,Salma %A Eid,Alaa %+ Department of Epidemiology and Surveillance, Preventive Sector, Ministry of Health and Population, 3 Magles Elshaab St, Cairo, , Egypt, 20 01282833078 ext 002, hanaaabuelsood@hotmail.com %K pandemic preparedness %K Egypt %K ARI %K epidemic mitigation %K COVID-19 %D 2021 %7 7.5.2021 %9 Viewpoint %J JMIR Public Health Surveill %G English %X This article briefly describes Egypt’s acute respiratory infection (ARI) epidemic preparedness and containment plan and illustrates the impact of implementation of the plan on combating the early stage of the COVID-19 epidemic in Egypt. Pillars of the plan include crisis management, enhancing surveillance systems and contact tracing, case and hospital management, raising community awareness, and quarantine and entry points. To identify the impact of the implementation of the plan on epidemic mitigation, a literature review was performed of studies published from Egypt in the early stage of the pandemic. In addition, data for patients with COVID-19 from February to July 2020 were obtained from the National Egyptian Surveillance system and studied to describe the situation in the early stage of the epidemic in Egypt. The lessons learned indicated that the single most important key to success in early-stage epidemic containment is the commitment of all partners to a predeveloped and agreed-upon preparedness plan. This information could be useful for other countries in the region and worldwide in mitigating future anticipated ARI epidemics and pandemics. Postepidemic evaluation is needed to better assess Egypt’s national response to the COVID-19 epidemic. %M 33830932 %R 10.2196/27412 %U https://publichealth.jmir.org/2021/5/e27412 %U https://doi.org/10.2196/27412 %U http://www.ncbi.nlm.nih.gov/pubmed/33830932 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 5 %P e27606 %T Performance of the Neonatal Tetanus Surveillance System (NTSS) in Sana'a, Yemen: Evaluation Study %A Al-Jamrah,Khaled Mohammed %A Al Nabehi,Basheer Abdulgalil %A Almoayed,Khaled Abdullah %A Anam,Labiba Saeed %A Khader,Yousef S %+ Yemen Field Epidemiology Training Program, Ministry of Public Health and Population, Alhasabah Area, Althawrah District, Sana'a, Yemen, 967 777 950 053, khjamrah2010@gmail.com %K neonatal tetanus %K evaluation %K surveillance %K CDC guidelines %K Yemen %D 2021 %7 4.5.2021 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: The Neonatal Tetanus Surveillance System (NTSS) in Yemen was established in 2009 to identify high-risk areas, determine trends, and evaluate elimination activities. Since its launch, the NTSS had never been evaluated. Objective: This study aimed to assess the performance of NTSS and determine its strengths and weaknesses to recommend improvements. Methods: The US Centers for Disease Control and Prevention (CDC) guidelines were used for evaluating the NTSS. Stakeholders at the central, district, and facility levels were interviewed to rate the attributes of the NTSS. The percentage scores for attributes were ranked as poor (<60%), average (≥60% to <80%) and good (≥80%). Results: The overall usefulness score percentage was 38%, which indicates a poor performance. The performance of the NTSS was rated as average on flexibility (score percent: 68%) and acceptability (score percent: 64%) attributes and poor on stability (score percentage: 33%), simplicity (score percentage: 57%), and representativeness (score percentage: 39%) attributes. About 65% of investigation forms were completed within 48 hours of notification date. Data quality was poor, as 41% of the core variables were missing. Conclusions: The overall performance of the NTSS was poor. Most of the system attributes require improvement, including stability, simplicity, quality of data, and completeness of investigation. To improve the performance of NTSS, the following are recommended: capacity building of staff (focal points), strengthening NTSS through technical support and government funding to ensure its sustainability, establishing electronic investigation forms for improving the system data quality, and expansion of NTSS coverage to include all private health care facilities. %M 33944794 %R 10.2196/27606 %U https://publichealth.jmir.org/2021/5/e27606 %U https://doi.org/10.2196/27606 %U http://www.ncbi.nlm.nih.gov/pubmed/33944794 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 7 %N 4 %P e27433 %T Coinfection With SARS-CoV-2 and Influenza A(H1N1) in a Patient Seen at an Influenza-like Illness Surveillance Site in Egypt: Case Report %A Fahim,Manal %A Ghonim,Hanaa Abu El Sood %A Roshdy,Wael H %A Naguib,Amel %A Elguindy,Nancy %A AbdelFatah,Mohamad %A Hassany,Mohamed %A Mohsen,Amira %A Afifi,Salma %A Eid,Alaa %+ Department of Surveillance and Epidemiology, Ministry of Health and Population, 3 Magles El Shab Street, Cairo, , Egypt, 20 01222598200 ext 202, fahimmanal@yahoo.com %K influenza-like Illness %K pandemic %K SARS-CoV-2 %K COVID-19 %K influenza %K virus %K case study %K Egypt %K flu %K coinfection %K infectious disease %K surveillance %K outcome %K demographic %D 2021 %7 28.4.2021 %9 Short Paper %J JMIR Public Health Surveill %G English %X Background: Sentinel surveillance of influenza-like illness (ILI) in Egypt started in 2000 at 8 sentinel sites geographically distributed all over the country. In response to the COVID-19 pandemic, SARS-CoV-2 was added to the panel of viral testing by polymerase chain reaction for the first 2 patients with ILI seen at one of the sentinel sites. We report the first SARS-CoV-2 and influenza A(H1N1) virus co-infection with mild symptoms detected through routine ILI surveillance in Egypt. Objective: This report aims to describe how the case was identified and the demographic and clinical characteristics and outcomes of the patient. Methods: The case was identified by Central Public Health Laboratory staff, who contacted the ILI sentinel surveillance officer at the Ministry of Health. The case patient was contacted through a telephone call. Detailed information about the patient’s clinical picture, course of disease, and outcome was obtained. The contacts of the patient were investigated for acute respiratory symptoms, disease confirmation, and outcomes. Results: Among 510 specimens collected from patients with ILI symptoms from October 2019 to August 2020, 61 (12.0%) were COVID-19–positive and 29 (5.7%) tested positive for influenza, including 15 (51.7%) A(H1N1), 11 (38.0%) A(H3N2), and 3 (10.3%) influenza B specimens. A 21-year-old woman was confirmed to have SARS-CoV-2 and influenza A(H1N1) virus coinfection. She had a high fever of 40.2 °C and mild respiratory symptoms that resolved within 2 days with symptomatic treatment. All five of her family contacts had mild respiratory symptoms 2-3 days after exposure to the confirmed case, and their symptoms resolved without treatment or investigation. Conclusions: This case highlights the possible occurrence of SARS-CoV-2/influenza A(H1N1) coinfection in younger and healthy people, who may resolve the infection rapidly. We emphasize the usefulness of the surveillance system for detection of viral causative agents of ILI and recommend broadening of the testing panel, especially if it can guide case management. %M 33784634 %R 10.2196/27433 %U https://publichealth.jmir.org/2021/4/e27433 %U https://doi.org/10.2196/27433 %U http://www.ncbi.nlm.nih.gov/pubmed/33784634