Diphtheria outbreak in Yemen: the impact of conflict on a fragile health system

BACKGROUND: War in Yemen started three years ago, and continues unabated with a steadily rising number of direct and indirect victims thus leaving the majority of Yemen’s population in dire need of humanitarian assistance. The conflict adversely affects basic socioeconomic and health conditions across the country. METHODS: This study analyzed the recent ongoing diphtheria outbreak in Yemen and in particular, the health system’s failure to ensure immunization coverage and respond to this outbreak. Data from the weekly bulletins of the national electronic Disease Early Warning System’s (eDEWS) daily diphtheria reports and district immunization coverage were analyzed. The number of diphtheria cases and deaths, and immunization coverage (DPT) were reviewed by district including the degree to which a district was affected by conflict using a simple scoring system. A logistic regression and bivariate correlation were applied using the annual immunization coverage per district to determine if there was an association between diphtheria, immunization coverage and conflict. RESULTS: The study results confirm the association between the increasing cases of diphtheria, immunization coverage and ongoing conflict. A total of 1294 probable cases of diphtheria were reported from 177 districts with an overall case fatality rate of 5.6%. Approximately 65% of the patients were children under 15 years, and 46% of the cases had never been vaccinated against diphtheria. The risk of an outbreak increased by 11-fold if the district was experiencing ongoing conflict p < 0.05. In the presence of conflict (whether past or ongoing), the risk of an outbreak decreased by 0.98 if immunization coverage was high p > 0.05. CONCLUSION: The conflict is continuously devastating the health system in Yemen with serious consequences on morbidity and mortality. Therefore, the humanitarian response should focus on strengthening health services including routine immunization procedures to avoid further outbreaks of life-threatening infectious diseases, such as diphtheria.