Measles outbreak in Yemen amidst a humanitarian crisis: key challenges and recommendations

Introduction Measles is a highly contagious infectious disease caused by a paramyxovirus. It is acquired through direct contact with an infected person, and the air. The initial phase of infection is characterized by a high fever, runny nose, cough, red and watery eyes, and small white spots inside the mouth. A rash may subsequently develop1. The period of contagiousness is estimated to be from 5 days before the appearance of the rash to 4 days afterward. The illness may be transmitted in public spaces; even in the absence of person-to-person contact2. Mortality due to measles is secondary to serious complications that include blindness, encephalitis, diarrhea, subsequent dehydration, and pneumonia1. Before the introduction of the measles vaccine in 1963 and widespread vaccination, major epidemics occurred ~every 2–3 years and measles caused an estimated 2.6 million deaths each year. More than 140 000 people died from measles in 2018—mostly children under the age of 5 years, despite the availability of a safe and effective vaccine1. Despite the preventive measures and vaccination, it has become a significant public health problem and has impacted many regions of the world. For example, sub-Saharan Africa reported a 300% increase in measles cases between 2016 and 20183. Besides Africa, European countries, particularly Italy and Romania have the highest concentration of cases and have also been affected since 2017 by measles outbreaks4. An outbreak of measles in Yemen in the years 2011 and 2012 caused over 4300 cases and 155 deaths. This was attributed to the decline in healthcare facilities following the civil unrest5. Nasser et al. also reported outbreaks in multiple areas of Yemen in the year 2018 identifying malnourishment and a lack of immunization as significant risk factors6. An article published earlier this year reported a rise in measles cases in Yemen, triggering alarm about an outbreak of unprecedented scale7. Challenges currently faced by Yemen Civil war The 7-year civil war has pushed Yemen into an ever-worsening humanitarian crisis, which has left half of the country’s population with no access to food and an increasing poverty rate8. The United Nations (UN) reported that more than 3.6 million Yemenis had been displaced since 2015 due to conflict, famine, multiple diseases, and a lack of essential services9. Following the collapse of the economy, 148 hospitals have been destroyed or are being used for other purposes since 201510. About 230 000 children younger than 12 months have been reported by the WHO, to not have routine vaccinations in 201511. Dependence on foreign aid has also decreased the value of the Yemeni currency and caused surging inflation rates, further worsening the crisis. COVID-19 pandemic An additional major factor that has exacerbated the already declining state of the economy and the healthcare system is the COVID-19 pandemic. It was imperative from the start of the pandemic that all monetary and medical resources be directed toward the rehabilitation of those affected by the novel coronavirus. During this time, around 54% of the population faced food insecurity and a lack of access to vaccines threatened the immunity of the population as a whole10,12. Moreover, due to a lack of funding, the UN cut down on the aid at 300 health centers in Yemen, along with a reduction in food rations, which has pushed many Yemenis further into the pit of famine and malnutrition13. Measles outbreak According to the latest report by the UN’s Children Agency, 15 children have died from the measles virus this year alone while 1400 children are suspected to have the disease across war-torn Yemen14. Suspension of measles vaccination programmes in war-stricken areas or due to the COVID-19 pandemic has also resulted in an increased susceptibility of individuals, especially children, to acquiring measles infection. Combined with other challenges, including limited economic opportunities due to the civil war, fragile civil and medical infrastructure, the ongoing economic blockade, less efficient supply chain systems, and inadequate production of electricity, the current crisis has led to increased vulnerability of Yemenis to famine, food crisis, and infectious diseases amid the pandemic15. The ongoing crisis in Yemen is likely to result in a complete economic and humanitarian collapse, as well as an increase in infectious diseases such as cholera and diphtheria. Long-term food insecurity will exacerbate the famine and contribute to higher mortality rates. Furthermore, the already precarious situation of the Yemeni people will deteriorate further, posing a threat to the very existence of the country. Recommendations It is important to take a multifaceted approach to contain the measles outbreak in Yemen amid the ongoing war, food insecurity, and COVID-19 pandemic. Research activities should be carried out in order to acquire basic data that will help to improve health service delivery. There should be a more focused approach to preventive medicine to help to ensure scarce resources are allocated most effectively16. The concerted effort of international bodies like the World Food Program and UNICEF should focus on the provision of food and other essential supplies to combat malnutrition. An integrated rehabilitation approach with developmental works in agriculture, sewage system, healthcare provision, and education, are required in order to alleviate the living conditions of the Yemenis. Strengthening disease surveillance systems will help identify and track cases of measles, allowing for more targeted response efforts. Ensuring that as many people as possible are vaccinated against measles is critical for containing the outbreak. This can be challenging in a war-torn country like Yemen, but mobile vaccination clinics and other outreach efforts can help increase vaccination rates. India, which is also currently facing a measles outbreak, has now decided to offer an additional dose of MR vaccines to all children between the ages of 9 months and 5 years in vulnerable areas. This dose would be in addition to the primary vaccination schedule of two doses17. Such a measure, if promptly implemented in Yemen, may also prove to be fruitful. It will be critical to increase funding for vaccination efforts in Yemen in order to ensure that enough vaccines are available and that vaccination campaigns can be conducted effectively. This could include funding from international organizations, as well as support from donor countries. It is important to note here that these measures cannot be put into full force as long as Yemen remains war-stricken. Hence, negotiations to end the war should be restarted and prioritized. Only the combined efforts of the Yemeni government and international aid can combat this combined threat. Conclusions The prolonged civil war in Yemen has drastically depleted its resources resulting in malnourishment and in turn decreased immunity to fight off diseases. Moreover, because of this impoverished state and little to no healthcare status, there is a huge gap between children born and children receiving basic vaccinations such as the measles vaccine. All of this has resulted in a huge measles outbreak recently. Furthermore, whatever economic standings were left of the country was massively hit by the COVID-19 pandemic, pushing Yemen towards a complete economical and humanitarian collapse. It is of absolute necessity that international, national, and local efforts are made for the recovery of Yemen. Ethical approval No ethical approval was required for this study as it is a letter to the editor and not based on any human data. Consent No consent was required for this study. Sources of funding No financial support was received for this study. Author contribution All authors contributed to the conception and design of this study, drafting and critical revision of the article, and gave final approval for it. Conflicts of interest disclosure The authors declare to have no conflicts of interest and no financial interests related to the material of this manuscript. Research registration unique identifying number (UIN) None. Guarantor Sarya Swed.