key: cord-0855139-hpatuzcs authors: Al-Sakkaf, Ehab; Ghaleb, Yasser; Al-Dabis, Esmail; Qairan, Mohammed; Al-Amad, Mohammed; Al-Serouri, Abdulwahed; Al-Kohlani, Abdulhakim title: First COVID-19 Cases with High Secondary Infection among Health Workers, Sana’a Capital, April 2020: Lessons Learned and Future Opportunities date: 2021-04-22 journal: Int J Infect Dis DOI: 10.1016/j.ijid.2021.04.022 sha: a348f078265080e11d98627ea20de3bd47ca40af doc_id: 855139 cord_uid: hpatuzcs Objectives Confirm existence of COVID-19 outbreak, conduct contact tracing, and recommend control measures. Methods Two COVID-19 cases in Sana’a Capital were met the WHO case definition. Data were collected from cases and contacts who were followed for 14 days. Nasopharyngeal swabs were taken for confirmation by Polymerase Chain Reaction (PCR). Results Two confirmed Yemeni male patients aged 20 and 40 years who had no travel history were admitted to hospital on 24 April 2020. Regarding the first patient, symptoms started on April 18th, 2020 then improved and discharged on May 5th while the second patient’s symptoms started on April 22nd but died on April 29th, 2020. Both cases had 54 contacts, 17 (32%) were health workers (HWs) that gave secondary attack rate (sAR) of 12% compared to 5% among other contacts. Four contacts (7%) were confirmed by PCR, two of them were HWs and needed admission. Conclusions First COVID-19 outbreak was confirmed among Yemeni citizens who had no travel history and with high sAR among HWs. Strict infection control among HWs should be ensured. Physical distancing, mask-wearing with appropriate disinfecting measures should be promoted especially among contacts. There is a need to strengthen national capacities to assess, detect, and respond to public health emergencies. Coronaviruses are a family of viruses that can cause illnesses such as the common cold, Severe Acute Respiratory Syndrome (SARS), and Middle East Respiratory Syndrome (MERS) (Mayo clinic, 2020). On December 29 th , 2019, the first four cases were reported with Novel Coronaviruses Infected Pneumonia at Seafood Wholesale Market in Wuhan city, China (Jin et al., 2020) . On March 12 th , 2020, WHO announced the COVID-19 is a world Pandemic (Cucinotta and Vanelli, 2020) . The SARS disease that caused by Corona 2 virus is refer by the International Committee for Classification of Viruses as SARS-CoV-2 (WHO, 2020a). People with COVID-19 have a wide range of symptoms ranging from asymptomatic mild symptoms to severe illness (CDC, 2020a) . The common clinical features of COVID-19 are fever, cough, pneumonia, fatigue, and shortness of breath Song et al., 2020) . Around 80% of COVID-19 patients have mild symptoms and recovered without any medication (WHO, 2020b) . According to CDC, the incubation period for COVID-19 is thought to extend to 14 days, with a median time of 4-5 days from exposure to symptoms onset (Guan et al., 2020; Lauer et al., 2020) . COVID-19 is spread mainly from person to person through close contact, and some asymptomatic people may be able to spread the virus (CDC, 2020b) . It crosses the country's borders without any respect and spread very quickly as a pandemic (Cucinotta and Vanelli, 2020) . Globally, the COVID-19 pandemic is now a major health threat and based on the WHO report at the end of February 2021, 113,467,305 have been reported as confirmed cases in almost all countries and regions around the world, including more than 2,520,550 deaths (WHO, 2020c). In the Eastern Mediterranean Region, all countries of the region have been affected by the COVID-19 pandemic and by the end of February 2021 the total confirmed cases were 6,388,249 while most of the confirmed cases were concentrated in Iran, Iraq, Pakistan, Morocco and United Arab Emirates (EMPHNET, 2020). In Yemen, the first confirmed case was reported from the South on April 10 th , 2020 at Hadramout governorate among Yemeni citizen working in the port of Ash Shihr city in the seventh decade of his life. The symptoms of cases appeared after contact with workers of shipping vessels and the result of the laboratory test was positive by Polymerase Chain Reaction (PCR) (Alshaikhli et al., 2020) . From Northern governorates, the first notification was received on April 25 th by the General Directorate of Surveillance at the Ministry of Public Health and Population (MoPHP) from the Sana'a Capital surveillance officer regarding the presence of two COVID-19 suspected cases at the COVID-19 isolation center of Al-Kuwait University Hospital, Sana'a Capital. On April 26 th, 2020, a team from Field Epidemiology Training Program (FETP) was deployed to investigate and confirm the presence of COVID-19 outbreak, conduct contact tracing and make recommendations for prevention and control. The two suspected cases were interviewed using the WHO case definition (WHO, 2020d) where demographic characteristics and clinical data were collected. The list of contacts was developed using the contact definition of the European Centre for Disease Prevention and Control (Ecdc) (Ecdc, 2020) . The contacts were classified according to exposure into close and causal contact and according to the occupation into Health Workers (HWs) and non-health workers. Data on demographic characteristics and exposure were collected from contacts at the quarantine sites. A nasopharyngeal swab was collected from all cases and contacts and sent for confirmation by Commented [def1]: Thanks for this important comment, and after discussing this point with all authors we prefer to put only the reference of the WHO case definition because of the following: 1.WHO case definition of COVID-19 it's too long (suspected, probable, and confirmed) and will take a wide space in the methodology as the following: Suspect case A. A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), AND a history of travel to or residence in a location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset. OR B. A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to symptom onset; OR C. A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND requiring hospitalization) AND in the absence of an alternative diagnosis that fully explains the clinical presentation. Description of cases Table 1 shows the socio-demographic and clinical characteristics of the two suspected patients. Both patients were confirmed as COVID-19 cases by PCR on April 26 th, 2020. The first patient was admitted to the inpatient department and dramatically improved with a downward trend in his inflammatory markers. The patient was discharged on day 13 of admission. The second patient was admitted to the Intensive Care Unit (ICU) on April 24 th , 2020, and immediately put on a ventilator and ICU standard treatment where his chest x-ray was illustrated acute pneumonia in both lower lobes. His respiratory status deteriorated despite broad-spectrum antivirals, antibiotics, and intensive supportive care and died on day 6 of admission. The first patient had 21 contacts, 14 (67%) of them were males, 7 (33%) were HWs and two were confirmed by PCR with one of them was HW who need admission. The secondary attack rate (sAR) was 10%. The second patient had 33 contacts, of them 19 (58%) were males, 10 (30%) were HWs and two were confirmed by PCR where one was HW who need admission. The sAR was 6%. The sAR among HWs was 12% compared to 5% among other contacts. None of the contacts gave a history of travel or contact with a traveler. Table 2 shows the characteristics of contacts. Three out of the four confirmed cases were among close contacts. The fourth confirmed case was the shop owner where the second patient was working; however, he did not give a history of close contact with him. Yemen is one of the countries that suffer from the siege, war, and conflict for more than five years that debilitated health system leaving only a little capacity to respond. However, such a catastrophic situation was given as an explanation for the late COVID-19 arrival to Yemen (Kadi, 2020) . This study will help to lay down the lessons learned and future opportunities for In this study, we found one out of the six confirmed patients (17%) were needed ICU admission compared to (32%) in China (Huang et al., 2020) and none in Kurdistan, Iraq (Merza et al., 2020) . Such variation may be attributed to the difference in affected age groups and the presence of co-morbid chronic diseases. The clinical status of this patient had worsened and he deteriorated to death. It seemed possible that he had a weak immune response that led to Acute Respiratory Distress Syndrome that is well-known cause of death in COVID-19 (Lee, 2017; Prompetchara et al., 2020) . In our findings, there is no travel history for all patients and contacts. This attributed to the blockade imposed on Yemen in addition to the closure of Sana'a airport for a long time, where Yemen became isolated from all countries of the world (Kadi, 2020) . In addition, the number of contacts between men was higher than women. Incontrast , a study in Germany was showed that sex ratios reveal higher contact among women than men at working ages; the opposite holds true at old age (Dörre and Doblhammer, 2020) . However, a study in Taiwan showed that all types of contacts in the women were higher than men except in the household contacts where the men became higher (Cheng et al., 2020) . This can be explained by the fact that males constitute the majority of Yemen's workforce. Also, males have more contact with patients compared to females who stay a long period at home as a Yemeni traditional behaviour. Increasing age was associated with an increase in COVID-19 risk. Our result showed that more than half of the contacts were between the age group (18->35), this was nearly similar to other studies in Taiwan and South Korea (Cheng et al., 2020; Choe et al., 2020) . In contrast, other studies in China and the USA showed an increase in risk among elderly contacts (Huang et al., 2020; McMichael et al., 2020) . This might be due to, the Yemeni population pyramid indicates that 80% of the Yemeni peoples are less than 40 years old (Pelletier and Spoorenberg, 2015) and perhaps, they may be get infected with COVID-19 without showing any symptoms (asymptomatic) or show mild symptoms and recovered without admission or taken any medication. In contrast, the elderly group may have chronic diseases, and they may become ill. Furthermore, among contacts, the asymptomatic cases in this study were 50 % of confirmed cases and this result is quite similar to the finding reported in Iraq (Merza et al., 2020) . In contrast, another study in China showed four-fifths of cases are asymptomatic (Michael, 2020) . Yemen have weakened the surveillance system (Oxford Analytica Daily Brief, 2020). Furthermore, the stigma and the rumors about high mortality rates in COVID-19 isolation centers may prevent showing the actual size of the problem. Regarding the occupation, Health workers recorded the highest percentage, this result is similar to previous studies in the USA and WHO report (McMichael et al., 2020; WHO Africa Region, 2020) . This may be due to the higher exposure to the infected patients during the health care and also may be due to less cautious or non-proper usage of PPE. In a view of such high attack rate among HWs that has shown in this study and their carelessness in wearing PPE when dealing with cases and contacts in isolation and quarantine centers beside its unavailability, there is a strong need to ensure its availability and to impose its appropriate use by HWs especially those with contact with a suspected COVID-19 patient. Furthermore, disinfecting of the surfaces, treating patients in a separate ward or hospital with a separate team, and contact tracing and quarantine . Moreover, the Yemeni health system needs to learn lessons from other countries that had successfully contained and mitigated COVID-19, such as China, South Korea, Singapore, and Germany as well as to identify thresholds for "reopening," or relaxing, stay-at-home orders, and other restrictions. Nevertheless, our study has some limitations especially regarding the difficulty in collecting and accessing patients' files and the lack of some important investigations such as computerized tomography and other blood tests in isolation centers. Furthermore, the stigma and the rumors about high mortality rates in COVID-19 isolation centers could prevent showing the actual size of the problem. In conclusion, the first COVID-19 outbreak was confirmed among Yemeni citizens who had no travel history and with high sAR among HWs. Strict infection control among HWs should be ensured. Physical distancing, mask-wearing with appropriate disinfecting measures should be promoted especially among contacts. 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COVID-19 Situation update for the WHO Africa Region The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Authors would like to acknowledge the TEPHNET and EMPHNET as well as the General for their support to the Y-FETP. Also would thank all the medical, nursing, infection prevention, and laboratory teams at the COVID-19 isolation center along with.