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Background: In Yemen; initial surveillance of COVID-19 focused primarily on patients with symptoms or severe disease, and, as such, the full spectrum of the disease, are not clear that make the epidemiology of COVID-19 is uncertain. To the best of our knowledge, this is the first seroprevalence study done in Yemen to measure the seroprevalence of anti-SARS-CoV-2 antibodies in the general population by sex and age group in Aden, Yemen. Methods: It is a one-time cross-sectional investigation among 2000 participants from all age groups from four districts in Aden at southern Yemen. A multi-stage sampling method used. Data collected by using a well-structured questionnaire and blood sample were collected. Healgen COVID-19 IgG/IgM Rapid Test Cassette was used in all participants. All positive RDT and 14% of the negative RDTs underwent ELISA test (WANTAI SARS-CoV-2 Ab Elisa Kit). Results: A 549 out of 2001 participants were RDT positive and proved by ELISA giving the prevalence of COVID-19 infection to 27·4% and specifically the prevalence of IgG was 25%. The prevalence of asymptomatic COVID-19 infection in all the study group was 7·9%. The highest prevalence was observed in Al-Mansurah district (33·4%). Regarding socio-demographic factors females, housewives and history of contact with COVID-19 patients have significant higher prevalence rates (32%, 31% and 39% respectively). Interpretation: high prevalence of SARS-CoV-2 antibodies was reported. Household contacts are the main factors for transmission. Enhancing population immunity is recommended by introducing COVID-19 vaccine. Funding: The study was funded from WHO/ EMRO. Aden Office Declaration of Interest: None to declare. Ethical Approval: This study was approved by the University of Yemen.

International audience

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014–2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons. Keywords: Influenza, Pandemic, PIP framework, Surveillance, Eastern Mediterranean Region

Background: Influenza surveillance systems in the Eastern Mediterranean Region have been strengthened in the past few years and 16 of the 19 countries in the Region with functional influenza surveillance systems report their influenza data to the EMFLU Network. This study aimed to investigate the epidemiology of circulating influenza viruses, causing SARI, and reported to the EMFLU during July 2016 to June 2018. Methods: Data included in this study were collected by 15 countries of the Region from 110 SARI sentinel surveillance sites over two influenza seasons. Results: A total of 40,917 cases of SARI were included in the study. Most cases [20,551 (50.2%)] were less than 5 years of age. Influenza virus was detected in 3995 patients, 2849 (11.8%) were influenza A and 1146 (4.8%) were influenza B. Influenza A(H1N1)pdm09 was the predominant circulating subtype with 1666 cases (58.5%). Other than influenza, respiratory syncytial virus was the most common respiratory infection circulating, with 277 cases (35.9%). Conclusion: Influenza viruses cause a high number of severe respiratory infections in EMR. It is crucial for the countries to continue improving their influenza surveillance capacity in order detect any unusual influenza activity or new strain that may cause a pandemic. Keywords: Influenza, Human, Severe acute respiratory infections, Sentinel surveillance, EMFLU Network, Eastern Mediterranean Region

Influenza causes significant morbidity and mortality worldwide. Owing to its ability to rapidly evolve and spread, the influenza virus is of global public health importance. Information on the burden, seasonality and risk factors of influenza in countries of the World Health Organization Eastern Mediterranean Region is emerging because of collaborative efforts between countries, WHO and its partners over the past 10 years. The fourth meeting of the Eastern Mediterranean Acute Respiratory Infection Surveillance network was held in Amman, Jordan on 11–14 December 2017. The meeting reviewed the progress and achievements reported by the countries in the areas of surveillance of and response to seasonal, zoonotic and pandemic influenza. The first scientific conference on acute respiratory infection in the Eastern Mediterranean Region was held at the same time and 38 abstracts from young researchers across the Region were presented on epidemiological and virological surveillance, outbreak detection and response, influenza at the animal-human interface, use and efficacy of new vaccines to control respiratory diseases and pandemic influenza threats. The meeting identified a number of challenges and ways to improve the quality of the surveillance system for influenza, sustain the system so as to address pandemic threats and use the data generated from the surveillance system to inform decision-making, policies and practices to reduce the burden of influenza-associated illnesses in the Region. Keywords: EMARIS, Influenza, Eastern Mediterranean Region, WHO

ObjectiveThe primary objectives were to determine the magnitude of COVID-19 infections in the general population and age-specific cumulative incidence, as determined by seropositivity and clinical symptoms of COVID-19, and to determine the magnitude of asymptomatic or subclinical infections.Design, setting and participantsWe describe a population-based, cross-sectional, age-stratified seroepidemiological study conducted throughout Afghanistan during June/July 2020. Participants were interviewed to complete a questionnaire, and rapid diagnostic tests were used to test for SARS-CoV-2 antibodies. This national study was conducted in eight regions of Afghanistan plus Kabul province, considered a separate region. The total sample size was 9514, and the number of participants required in each region was estimated proportionally to the population size of each region. For each region, 31–44 enumeration areas (EAs) were randomly selected, and a total of 360 clusters and 16 households per EA were selected using random sampling. To adjust the seroprevalence for test sensitivity and specificity, and seroreversion, Bernoulli’s model methodology was used to infer the population exposure in Afghanistan.Outcome measuresThe main outcome was to determine the prevalence of current or past COVID-19 infection.ResultsThe survey revealed that, to July 2020, around 10 million people in Afghanistan (31.5% of the population) had either current or previous COVID-19 infection. By age group, COVID-19 seroprevalence was reported to be 35.1% and 25.3% among participants aged ≥18 and 5–17 years, respectively. This implies that most of the population remained at risk of infection. However, a large proportion of the population had been infected in some localities, for example, Kabul province, where more than half of the population had been infected with COVID-19.ConclusionAs most of the population remained at risk of infection at the time of the study, any lifting of public health and social measures needed to be considered gradually.

Respiratory syncytial virus (RSV) is a leading cause of mortality and morbidity in young infants, little was known on its circulation types and patterns in Morocco. We conducted a prospective study using sentinel-based influenza surveillance to detect RSV by real time PCR in patients with acute respiratory infections, enrolled during two seasons (2014/15, 2015/16). During September 2014-April 2016, we obtained 1450 specimens, of which 267(18.4%) tested positive for RSV. The proportion of positive RSV infection was higher in patients hospitalized with acute respiratory infection compared to those with mild symptoms in out-patient clinics. The proportion of RSV infection was highest in children aged 0-6 months (45%; P0.001). Higher positivity rate was observed between months of December and March. RSV remains important viral etiological agent causing influenza-like illness and severe acute respiratory infections especially among infants in Morocco. Further surveillance, is required to understand better the risk factors of RSV infections.تجوال الفروس المِخلوي التنفي في المغرب خال الأعوام 2014-2016: نتائج مأخودة من نظام لترصد فروس الإنفلونزا.عبد الرحمان بيموحن، فاطمة الفلكي، حسن احزماض، زكية الركراكي، سميرة بنكروم، آمال بركات.عى الرغم من أن الفروس المخلوي التنفي يعتر أحد الأسباب الرئيسية للوفيات والمراضة في أوساط صغار الرضع فلم يكن معروفاً سوى القليل عن أناط وطُرُز تجواله في المغرب. أجرينا دراسة استباقية باستخدام ترصد الإنفلونزا للكشف عن الفروس المخلوي التنفي بواسطة "تفاعل البلمرة المتسلسل – "الزمن الحقيقي" لدى مرضى مصابن بأمراض تنفسية حادة سُجلوا خال موسمين (2014-2015، 2015-2016). من الفرة ما بن سبتمبر/أيلول 2014 إلى أبريل/نيسان 2016 حصلنا عى 1450 عينة، ثبتت إصابة 267 (%18.4) منها بالفروس المخلوي التنفي. وكانت نسبة العدوى المثبتة بالفروس المخلوي التنفي أعى لدى المرضى الذين أدخلوا إلى المستشفى لإصابتهم بمرض تنفي حاد مقارنة مع المصابن بأعراض خفيفة في العيادات الخارجية. وكانت أعى نسب العدوى بالفروس المخلوي التنفي لدى الأطفال الذين تراوح أعمارهم بن 0 و 6 أشهر (4%45؛ p0.001 ). وقد لوحظ ارتفاع في معدل الإيجابية بن ديسمبر/كانون الأول و مارس/آذار. لا يزال الفروس المخلوي التنفي عاماً سببياً فيروسياً مهاً يسبب أمراضاً شبيهة بالإنفلونزا وأمراضاً تنفسية حادة وخيمة؛ خصوصاً في أوساط الرضع في المغرب. المطلوب مزيد من الترصد - باستخدام النظام الحالي – للوصول إلى فهم أفضل لوبائيات العدوى بالفروس المخلوي التنفي ولعوامل خطر الإصابة به.Circulation du virus respiratoire syncytial au Maroc de 2014 à 2016 : constatations provenant du système de surveillance virologique sentinelle de la grippe.Bien que le virus respiratoire syncytial (VRS) soit l’une des principales causes de mortalité et de morbidité chez les jeunes nourrissons, les modes et les tendances de la circulation de ce virus au Maroc sont très peu connus. Nous avons réalisé une étude prospective en recourant à la surveillance de la grippe basée sur des sites sentinelles dans le but de dépister le VRS grâce à la PCR en temps réel chez des patients souffrant d’infections respiratoires aiguës recrutés au cours de deux saisons (2014-2015 et 2015-2016). De septembre 2014 à avril 2016, nous avons prélevé 1450 échantillons, parmi lesquels 267 (18,4 %) se sont avérés positifs au VRS. La proportion d’infections positives au VRS était plus élevée chez les patients hospitalisés pour une infection respiratoire aiguë que chez les patients en consultation externe souffrant de légers symptômes. Cette proportion était la plus élevée chez les enfants de 0 à 6 mois (45 % ; p0,001). Le pic du taux de positivité a eu lieu de décembre à mars. Le VRS demeure un agent étiologique viral important au Maroc, responsable de syndromes de type grippal et d’infections respiratoires aiguës sévères, en particulier chez les nourrissons. Une surveillance renforcée est indispensable pour mieux comprendre les facteurs de risque des infections à VRS.

We monitored phenotypic and genotypic susceptibility of influenza viruses circulating in Morocco during 2014-2015 to oseltamivir and zanamivir. Throat and nasal swab specimens were collected from outpatients (with influenza-like illness) and inpatients (with severe acute respiratory illness) and tested for influenza viruses using real-time reverse transcription polymerase chain reaction. Positive samples were inoculated in MDCK cells and virus phenotypic susceptibility to neuraminidase inhibitors (NAIs) was assessed using fluorescent NA inhibition. Of 440 specimens, 135 were positive for influenza B Yamagata-like virus, 38 were A(H1N1)pdm09 and 25 were A(H3N2). Sixty influenza B viruses isolated from MDCK cells showed no significant resistance to NAIs. However, two of these strains, B/Morocco/176H/2015 and B/Morocco/CP10/2015, showed reduced susceptibility to oseltamivir. The two influenza B viruses with reduced susceptibility to oseltamivir show that ongoing NAI susceptibility surveillance is essential.اكتشاف فيروسات إنفلونزا B ذات حساسية منخفضة لمثبطات النورامينيداز في المغرب خلال موسم 2014-2015.فاطمة الفلكي، حسن احزماض، عبد الرحمان بيموحن، زكية الركراكي، سميرة بنكروم، يوسف بكري، آمال بركات.تهدف هذه الدراسة إلى رصد خصائص الحساسية المتعلقة بالنمط الظاهري والنمط الجيني لفيروسات الإنفلونزا في المغرب خال موسم 2014-2015 للدوائن المثبطن للنورامينيداز، اوسيلتاميفير وزاناميفر. جُعت العينات (مسحات حلقية أو أنفية) من مرضى خارجين (بأعراض ما يشبه الإنفلونزا) ومرضى داخلين (بأعراض مرض تنفي حاد وخيم)، وفُحصت عينات فيروسات الإنفلونزا A و B باستخدام مقايسات "تفاعل البلمرة المتسلسل – الزمن الحقيقي" في الزمن الحقيقي البسيط. ولُقِّحت العينات الإيجابية عى خلايا مادين- داربي كانن كيدني، وقيمت خصائص حساسية النمط الظاهري للفيروسات المستفرَدة لمثبطات النورامينيداز باستخدام مقايسة تثبيط النورامينيداز المتألق. من أصل 440 عينة كانت 135 (%31) عينة إيجابية لفروس الإنفلونزا B الشبيه بياماجاتا، وكانت 38 (%8) عينة A(H1N1)pdm09، و 25 (%6) عينة كانت A(H3N2)). لقد وجد أن ستين فيروساً من فيروسات الإنفلونزا B التي استُفردت عى MDCK وفُحصت حساسيتها لمثبطات النورامينيداز لم تظهر أي مقاومة تذكر لمثبطات النورامينيداز المتوفرة. واثنان من فيروسات الإنفلونزا B - / B 2015 Morocco/176H/2015 و B/Morocco/CP10/، وهما سالتان استثنائيتان اشتملت عليها فيروسات الإنفلونزا B التي استفردت في MDCK - أظهرا انخفاضاً في الحساسية للأوسيلتاميفير. إن وجود اثنن من فيروسات الإنفلونزا B الجوالة أثناء موسم 2014-2015 في المغرب حساسيتهما منخفضة للأوسيلتاميفير يُظهر أن الترصُّد المستمر للحساسية لمثبطات النورامينيداز أمر ضروري.Maroc : dépistage de virus de la grippe B présentant une sensibilité réduite à l’inhibiteur de la neuraminidase durant la saison 2014-2015.Nous avons surveillé le profil de sensibilité phénotypique et génotypique des virus de la grippe à l’oseltamivir et au zanamivir durant la saison 2014-2015 au Maroc. Des échantillons ont été prélevés (par frottis de gorge ou écouvillonnage du nez) chez des patients externes (présentant un syndrome de type grippal) et chez des patients hospitalisés (présentant une infection respiratoire aiguë sévère). Ils ont été soumis au test de détection des virus de la grippe A et B via la méthode d’analyse RT-PCR simplex en temps réel. Les échantillons positifs ont été inoculés à des cellules rénales canines Madin-Darby (MDCK) et le profil de sensibilité phénotypique des virus isolés aux INA a été évalué au moyen du test d’inhibition de la neuraminidase (NA) par fluorescence. Sur 440 échantillons, 135 (31 %) étaient positifs au virus de la grippe B de type Yamagata, 38 (8 %) à celui de la grippe A(H1N1)pdm09 et 25 (6 %) à celui de la grippe A(H3N2). Soixante virus de la grippe B isolés sur les culture de cellules MDCK et soumis au test de sensibilité aux INA n’ont démontré aucune résistance significative aux INA. Toutefois, deux de ces souches, la B/Maroc/176H/2015 et la B/Maroc/CP10/2015, ont démontré une sensibilité réduite à l’oseltamivir. Les deux virus de la grippe B ayant une sensibilité réduite à l’oseltamivir montrent l’importance d’une surveillance permanente de la sensibilité à l’inhibiteur de la neuraminidase.

Background The global burden of pediatric severe respiratory illness is substantial, and influenza viruses contribute to this burden. Systematic surveillance and testing for influenza among hospitalized children has expanded globally over the past decade. However, only a fraction of the data has been used to estimate influenza burden. In this analysis, we use surveillance data to provide an estimate of influenza-associated hospitalizations among children worldwide. Methods and Findings We aggregated data from a systematic review (n = 108) and surveillance platforms (n = 37) to calculate a pooled estimate of the proportion of samples collected from children hospitalized with respiratory illnesses and positive for influenza by age group (, The substantial global burden of influenza infections in children is revealed by Lafond and colleagues. Children in developing countries are 3 times more likely to be hospitalised and treatments vary. This study highlights the need for vaccination programs in the young., Editors' Summary Background Acute lower respiratory infections—bacterial and viral infections of the lungs and airways (the tubes that take oxygen-rich air to the lungs)—are major causes of illness and death in children worldwide. Pneumonia (infection of the lungs) alone is responsible for 15% of deaths among children under five years old and kills nearly one million young children every year. Globally, infections with respiratory syncytial virus and with Streptococcus pneumoniae are associated with about 25% and 18.3%, respectively, of all episodes of severe respiratory infection in young children. Another infectious organism that contributes to the global burden of respiratory disease among children is the influenza virus. Every year, millions of people become infected with this virus, which infects the airways and causes symptoms that include a high temperature, tiredness and weakness, general aches and pains, and a dry chesty cough. Most infected individuals recover quickly, but seasonal influenza outbreaks (epidemics) nevertheless kill about half a million people annually, with the highest burden of severe disease being experienced by elderly people and by children under five years old. Why Was This Study Done? Annual immunization (vaccination) can reduce an individual’s risk of catching influenza, but before a country implements this preventative measure, policymakers need reliable estimates of the burden of influenza in their country. Although such estimates have been calculated for resource-rich countries with temperate climates, where influenza largely occurs in the winter, few estimates of influenza burden are available for resource-limited countries, which has hampered informed consideration of vaccination for influenza prevention in many settings. Recently, however, there has been a global expansion of systematic surveillance and testing for influenza virus among patients admitted to hospital for severe respiratory infection. Here, the researchers use this expanded surveillance data to provide an estimate of influenza-associated hospitalizations among children worldwide between 1982 and 2012. Specifically, they undertake a systematic review to identify published research articles on influenza-associated respiratory disease in hospitalized children, and, by aggregating the data from these articles with data collected by hospital-based influenza surveillance, they calculate a pooled estimate of the proportion of children hospitalized with respiratory disease who are positive for influenza. What Did the Researchers Do and Find? Using predefined search criteria, the researchers identified 108 published research articles that provided information on influenza-associated respiratory illness among hospitalized children. In addition, the Global Respiratory Hospitalizations–Influenza Proportion Positive (GRIPP) working group provided 37 hospital-based influenza surveillance datasets. By aggregating the data from these sources using a statistical approach called meta-analysis, the researchers calculated that, overall, influenza was associated with 9.5% of hospitalizations for severe respiratory infection among children under 18 years old worldwide, ranging from 4.8% among children under six months old to 16.4% among children aged 5–17 years. The researchers also calculated that, on average over the study period, influenza resulted in about 374,000 hospitalizations annually among children under one year old (including 228,000 hospitalizations among children less than six months old) and nearly one million hospitalizations annually among children under five years old. Finally, the researchers calculated that influenza-associated hospitalization rates among children under five years old over the study period were more than three times higher in resource-limited countries than in industrialized countries (150 and 48 hospitalizations, respectively, per 100,000 children per year). What Do These Findings Mean? Differences in hospitalization practices, in applications of case definitions, and in influenza testing protocols between settings may affect the accuracy of these findings. Specifically, the approach taken by the researchers may mean that their estimate of the total burden of severe respiratory disease due to influenza is an underestimate of the true situation. Even so, these findings suggest that influenza is an important contributor to hospitalizations for severe respiratory illness among children worldwide. Increasing influenza vaccination coverage among young children and pregnant women could, therefore, reduce the contribution that influenza makes to hospitalizations for respiratory infections among children. Importantly, the estimates of the burden of influenza provided by these findings can now be used by countries considering influenza vaccination programs for children and/or pregnant women to help them investigate the possible health and cost implications of such programs and should also stimulate further research into the development of effective influenza vaccines for young children. Additional Information This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001977. The UK National Health Service Choices website provides information about respiratory infections, seasonal influenza, influenza vaccination, and influenza vaccination in children The World Health Organization provides information on seasonal influenza (in several languages) and on influenza vaccines The US Centers for Disease Control and Prevention also provides information for patients and health professionals on all aspects seasonal influenza, including information about vaccination, and about children, influenza, and vaccination; its website contains a short video about personal experiences of influenza Flu.gov, a US government website, provides access to information on seasonal influenza and vaccination MedlinePlus has links to further information about influenza and about vaccination (in English and Spanish)

International audience; Introduction: In Africa, the burden of influenza is largely unknown since surveillance schemes exist in very few countries. The National Institute of Hygiene in Morocco implemented a sentinel network for influenza surveillance in 1996. Methodology: Epidemiological and virological surveillances were established and influenza viruses circulating in Morocco were characterised. Four practice-specific indicators were collected during the 1996-1997 season and nasopharyngeal swabs were collected from patients with an influenza-like illness during a three-year period (between 1996 and1998). Laboratory diagnosis was done by viral isolation. The isolates were characterized by hemagglutination- and neuraminidase-inhibition assays and by sequencing the hemagglutinin gene and phylogenetic analysis. Results: Among a total of 673 specimens, 107 (16%) were positive for influenza virus. Seasonal influenza strains were isolated from November to February. Antigenically, A(H1N1), A(H3N2) and B isolates were related to the vaccine strains. Genetically, one 1996/97 isolate A/Rabat/33/96 and the 1997/98 A(H3N2) isolates clustered with the new drift variant A/Sydney/5/97, a vaccine component of the 1998/99 season. Conclusions: These results indicate a seasonal circulation of influenza in Morocco concentrated between November and February. Further, the results demonstrate the importance of including the maximum number of countries in influenza surveillance to contribute to the definition of the influenza vaccine composition.