COVID-19 surveillance in fragile health systems, armed conflict and humanitarian crisis, the case of Yemen

Background Yemen is a poor country facing armed conflict which significantly disrupted the Health System. Yemen reported fewer COVID-19 cases than neighbouring countries, yet the case fatality rate (19.6%) remained five times the global average. Conflict typically hinders surveillance, however obtaining representative mortality and morbidity indicators remains essential to efficacious epidemic planning. We aimed to explore challenges hindering COVID-19 surveillance in Yemen and opportunities for addressing them, to increase surveillance effectiveness in such conflict and resource-constraint settings. Methods Qualitative study question guide was used for in-depth interviewswith 30 healthcare workers who worked in Yemen’s surveillance system during the pandemic. Participants were recruited through in-country gatekeepers using a ‘snowball’ sampling technique. Thematic framework analysiswas used. Findings A basic level of preparedness existed following responses to previous epidemics, including activating Rapid Response Teams (RRTs), and electronic disease surveillance. Key challenges included the ongoing conflict, an unstable health system, minimal infrastructure restorations, misinformation, community incompliance, and inadequate laboratory diagnostics or transportation capabilities. Participants recommended addressing these barriers through strengthening RRTs, transportation and laboratory testing capacities, implementing community awareness campaigns, alongside improving primary health care services and inter-governorate governance. Conclusion Active community surveillance by RRTs supplemented with community volunteers is imperative and necessary nationwide. National community awareness campaigns on case detection, reporting, and addressing misinformation are essential to implementing such community surveillance. Increased utilization of mobile laboratories could enhance laboratory testing capacity in underserved areas. For each recommendation to be effectively implemented, the international community must provide sufficient resources and financial aid