Introduction
Yemen’s health care system has been severely weakened by prolonged conflict, resulting in critical gaps in toxicology services. Poisonings, chemical exposures, and drug overdoses remain underreported despite rising mortality and complications. Effective toxicological care has proven lifesaving globally, yet Yemen’s health care facilities lack the infrastructure, antidotes, and trained personnel necessary to address these emergencies. This burden is further exacerbated by extensive pesticide use in agriculture and the risk of chemical exposure in war zones.
Studies from other conflict zones, such as Syria, highlight similar challenges. During the Syrian war, the use of chemical weapons such as sarin, chlorine, and mustard gas caused devastating public health consequences, with 97.6% of deaths occurring among non-combatants. The long-term effects of chemical exposure, including neurological and respiratory complications, often went untreated due to insufficient resources. These lessons emphasize the need for antidotes, protective equipment, and poison centers to mitigate the impact of toxicological emergencies.1, Reference Rodriguez-Llanes, Guha-Sapir and Schlüter2
Limited local research reflects the gravity of the situation in Yemen. A cross-sectional study in Sana’a identified acute poisoning as a significant public health problem with high morbidity and mortality caused by exposure to toxic substances.Reference Al-Mahbashi and Howilah3 Similarly, research from Aden revealed that organophosphate poisoning, one of the most common toxicological emergencies in Yemen, is often mismanaged due to a lack of antidotes and diagnostic tools.Reference Gabali and Al-Gefri4 According to the WHO directory, no official poison control centers or call centers exist in Yemen; instead, a few poison laboratory centers operate in major cities, but they are limited in scope, underfunded and inaccessible, leaving much of the population vulnerable to delayed treatment and poor outcomes.
This study evaluates the availability, functionality, and readiness of toxicology services in Yemen. By identifying systemic challenges and proposing evidence-based recommendations, it aims to provide practical strategies to improve toxicology services in this fragile health care setting.
Methods
Study Design
This cross-sectional, mixed-methods study utilized online surveys, key informant interviews, and facility audits in Yemen. The study was conducted between September and October 2024 and combined both quantitative and qualitative approaches to provide a comprehensive assessment of toxicology services.
Study Population
-
• Health care workers: Physicians, nurses, emergency responders, and supporting staff involved in managing toxicological cases.
-
• Key Informants: Hospital administrators, heads of emergency departments, and policymakers.
-
• Facilities: Health care facilities providing emergency services, including public and private hospitals and clinics.
Sampling Strategy
-
• Facility Selection: A purposive sampling method was employed to include a diverse range of health care facilities across different regions of Yemen. This included facilities in both urban and rural areas, as well as public and private hospitals that manage toxicological emergencies. Key cities were specifically targeted for on-site interviews due to their larger populations and greater likelihood of encountering toxicological cases. These cities included Aden (the current capital of Yemen), Sana’a, Taiz, Hadramout. One of the co-authors, based in Aden, personally visited majority of the large hospitals in the city—both public and private facilities that manage a high volume of emergency cases—as well as accessible neighboring cities such as Abyan, Shabwah, Lahj, and Al-Dhalea. During these visits, interviews were conducted with heads of emergency departments, medical directors, and administrative managers. The fieldwork also extended to the poison center and central laboratory, the Faculty of Medicine and Health Sciences, and meetings with representatives of the Ministry of Public Health and Population in the capital. Due to limited resources, the ongoing armed conflict, and prevailing security constraints, interviews in other cities—including Sana’a, Taiz, Hadramout—were conducted remotely via video conversation, telephone call, and online communication platforms such as WhatsApp and email.
-
• Respondent Selection: The primary respondents were health care workers directly involved in toxicology case management (physicians, nurses, and emergency responders), as well as hospital administrators and policymakers responsible for decision-making. For the online survey, non-probability convenience sampling approach was used. Invitations were disseminated through both official institutional WhatsApp groups and non-official health care workers’ social groups, in addition to medical forums and professional society networks, including the Yemeni Association of Emergency and Disaster Medicine.
Structured Online Surveys for Health Care Workers
The survey was designed to assess the availability, functionality, and challenges of toxicology services in health care facilities in Yemen. The questionnaire was divided into 4 sections: demographic information, availability of toxicology services, functionality of services, and challenges encountered in toxicological emergencies. The questions were a combination of multiple-choice, Likert scale, and open-ended questions to capture both quantitative and qualitative data. The questionnaire was developed following consultations with experts in toxicology and emergency medicine to ensure its relevance and comprehensiveness. Additionally, the survey questions concerning toxicology resources and functionality were informed by WHO guidelines on poison control centers and emergency response protocols to align with international standards.5
The online survey was distributed through WhatsApp groups, SMSs, and emails to health care professionals across various regions of Yemen. This method was chosen because of the ongoing conflict, which made many areas inaccessible for in-person data collection. The use of WhatsApp and email allowed for the participation of health care workers in both urban and rural areas, including those in conflict-affected regions, ensuring a broad and representative sample. A pilot study was conducted to test the clarity and reliability of the questions, with feedback used to refine the final version of the survey.
Key Informant Interviews and On-Site Facility Audits
To gain a comprehensive understanding of the challenges and needs of toxicology services in Yemen, both key informant interviews and on-site facility audits were conducted in accessible cities. The interviews were held with heads of emergency departments, hospital administrators, and policymakers to explore the status of toxicology services, barriers to service provision, strategies for handling mass poisoning incidents, and human, financial, and technical resource needs. The discussions also focused on future strategic directions for improving toxicology services in the country.
Complementing the interviews, on-site facility audits provided a hands-on assessment of the physical resources and infrastructure supporting toxicology services. The audits examined the availability of antidotes for common poisonings, diagnostic equipment, standardized protocols for managing poisoning cases, and the adequacy of trained personnel in handling toxicological emergencies. Educational materials for poisoning prevention patients were also evaluated.
Together, the interviews and facility audits addressed potential gaps from the online survey, offering in-depth qualitative insights and ensuring a robust and reliable dataset for understanding and improving toxicology services in Yemen. These on-site methods provided additional verification and context to the online survey data, enhancing the overall robustness of the study.
Data Collection and Analysis
Data were collected using a mixed-methods approach. An online survey was administered through Kobo Toolbox, complemented by in-person interviews and facility audits.
Quantitative data were analyzed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were generated to summarize the availability of toxicology services, antidote supplies, diagnostic equipment, and the most commonly encountered toxicological emergencies. Frequencies and percentages were calculated for categorical variables such as the presence of trained personnel, antidote availability, and the existence of protocols. Associations between facility type, geographic location, and the availability of resources or training were assessed using Chi-square tests, with Fisher’s exact test applied when expected cell counts were fewer than 5.
Qualitative data derived from key informant interviews were analyzed thematically to identify recurring challenges and resource needs across health care facilities. These findings were used to complement and contextualize the quantitative results.
Results
A total of 158 health care workers participated in the online survey, with the majority coming from public hospitals (53.2%), followed by private hospitals (29.7%), clinics (8.9%), and field-based facilities (7%). Most respondents were based in urban areas (72.2%). Toxicology services were reported to be unavailable in 72.4% of facilities, and 78.8% did not have a dedicated toxicology unit (Figure 1). Among the facilities offering toxicology services, only 6.4% provided coverage 24/7, whereas 62.2% operated within a limited number of hours. In terms of resources, 57% of facilities had antidotes for common poisonings, but only 17.4% had diagnostic equipment, and only 14.9% had standardized protocols for managing toxicological emergencies. Educational programs for poisoning prevention in patients were available in only 10.7% of the facilities. Pesticide poisoning was the most common toxicological emergency (73.1%), followed by chemical exposure (58.3%) and drug overdose (49.1%). Snake envenomation (42.6%) and animal bites (27.8%) were also frequently encountered. Major challenges in managing toxicological emergencies included a lack of antidotes (80.8%), insufficient diagnostic tools (85.4%), and inadequate staff training (81.5%). Furthermore, only 14.9% of facilities had protocols for handling mass poisoning incidents, and 73.7% had never conducted emergency drills. Most health care workers (80%) had not received formal training in toxicology or poisoning management, although 25.4% had completed formal courses, and 32.5% had participated in e-learning lectures. Access to poison control centers was reported as unavailable by 70.1% of respondents, and 57.7% indicated that their region lacked referral laboratories for toxicology screening.
Key findings of the toxicology survey in Yemen.
Private hospitals reported better access to antidotes (65%) than did public hospitals (50%) and had a higher percentage of diagnostic equipment availability (25% vs. 10%). When comparing urban and rural facilities, urban centers are generally better resourced. Approximately 70% of urban facilities had access to antidotes, whereas 82% of rural facilities lacked them. Furthermore, 55% of the urban facilities had diagnostic equipment, whereas only 20% of the rural facilities had diagnostic equipment (Figure 2).
Comparison of toxicology services: (A) urban vs. rural and (B) public vs. private facilities.
The data indicate that pesticide poisoning (73.1%) and chemical exposure (58.3%) are the most common toxicological emergencies in Yemen, particularly in cities such as Aden, Sana’a, Taiz, and Hadramout (Figure 3).
Common toxicological emergencies encountered by city in Yemen.
Resources and Training across Facility Types and Locations
Statistical tests (chi-square test and Fisher’s exact test) revealed no significant differences in the availability of resources (antidotes, diagnostic equipment, standardized protocols, and educational programs) or training opportunities (formal courses, workshops, on-the-job training, and eLearning modules) across different types or locations of facilities providing toxicology services (Table 1). These findings suggest that the distribution of resources and training programs is generally uniform, regardless of facility type or geographic location. This uniformity may indicate either a widespread lack of variation in service provision or consistent gaps in resource and training availability across all settings.
Correlation between resources/training availability and facility types/locations
Key Informant Insights and Facility Audit Results
The key informant interviews and facility audits revealed significant gaps in toxicology services across both the public and private sectors in Yemen. The absence of specialized infrastructure, trained personnel, and diagnostic tools for managing poisoning cases has emerged as a major challenge. Furthermore, no standardized protocols exist for handling mass poisoning incidents, and resources such as antitoxins and educational materials are severely lacking. There is a pressing need for government intervention, public–private partnerships, and structured policies to improve toxicology services (Table 2).
Key informants and facility audits results
Discussion
Resource Gaps and Infrastructure Deficiencies
This study highlights critical deficiencies in Yemen’s toxicology services, particularly in resource availability, workforce training, and preparedness for toxicological emergencies. The findings reveal significant resource gaps: only 57% of facilities had antidotes, and just 17.4% had diagnostic tools. Urban facilities were better resourced than rural ones, with 70% of urban facilities having antidotes compared to 18% in rural areas, and 55% possessing diagnostic equipment versus 20% in rural areas. These disparities are especially concerning given the higher prevalence of pesticide poisoning in rural areas, where agricultural activities dominate. These results emphasize the uneven distribution of resources and the need for targeted interventions in underserved regions. The correlation between limited resources and poor toxicology management observed in this study aligns with similar findings from conflict-affected countries such as Sudan and Syria where resource constraints have consistently undermined health care delivery.Reference Rahamtalla, Medani and Salih6, Reference Fouad, Sparrow and Tarakji7
Workforce Preparedness and Training Needs
The findings also underscore the workforce’s lack of preparedness, with only 20% of health care workers reporting formal toxicology training. Training disparities were evident across facility types and locations, with urban facilities reporting higher rates (30%) compared to rural ones (12%), and no health care workers in private hospitals having received training. Although private hospitals have better access to resources, the absence of trained personnel reduces their ability to effectively manage toxicological cases. These findings suggest that training programs, even in well-resourced facilities, are critical to improving outcomes. Some initiatives have attempted to address this gap, such as Yemeni physicians’ participation in the MENATOX conferences held in Turkey and Oman, as well as an online Yemeni conference that included toxicology modules. However, these efforts were sponsored by non-governmental organizations rather than being part of a national strategy. While they provided valuable exposure, they were limited in scale and not integrated into a structured or sustained training framework. Consequently, most health care workers continue to lack access to standardized toxicology education.
International models, such as South Korea’s and Japan’s mandatory toxicology training programs, demonstrate how structured educational initiatives can bridge gaps in knowledge and preparedness.Reference Park, Kim and Nam8, Reference Konishi, Enomoto and Hayashi9 Applying similar programs in Yemen, particularly through e-learning or in-service training modules tailored to resource constraints, could enhance the capacity of health care workers. Furthermore, incorporating specialized emergency response training, such as Hazardous Materials (HAZMAT) courses, would provide frontline workers with the practical skills needed to manage chemical, biological, and radiological exposures. Embedding such structured training within hospital preparedness programs would substantially improve Yemen’s resilience against toxicological emergencies.
Challenges in Standardizing Toxicology Protocols
A significant challenge identified in this study is the lack of standardized protocols for managing toxicological emergencies, including large-scale incidents such as chemical spills, mass poisonings, or infection outbreaks. Despite the heightened risk of such events in a conflict-affected setting like Yemen, where infrastructure is fragile and agricultural and industrial toxins are prevalent, only 9.5% of public hospitals and no private hospitals reported having formalized guidelines. This gap was even more pronounced in rural areas, where resources are already critically limited. The absence of standardized protocols leaves health care providers reliant on improvised responses, increasing the likelihood of inconsistent care and suboptimal outcomes during emergencies. Lessons from other low-resource settings, such as Ethiopia and Nigeria, reveal how the absence of structured protocols can exacerbate the consequences of toxicological disasters.Reference Asrie, Atnafie and Getahun10, Reference Joda, Ajetunmobi and Olugbake11 Yemen’s vulnerability to conflict-related toxicological incidents underscores the urgent need for national guidelines tailored to its unique context. Establishing such protocols, supported by training and resource allocation, would not only enhance preparedness but also ensure more consistent and effective emergency responses across all facility types.
The Burden of Pesticide Poisoning and Chemical Exposures
The high prevalence of pesticide poisoning (73.1%) and chemical exposure (58.3%) observed in this study highlights the urgent need to strengthen toxicology services in Yemen. Aden and Sana’a reported the highest number of cases, reflecting not only their large populations, extensive agricultural activity, and industrial exposures, but also their role as national referral centers for toxicological emergencies. However, limited diagnostic capacity and underreporting in other urban and rural areas suggest that the actual burden is likely far greater than documented.
Local studies support these findings. A study from Sana’a city involving 177 patients showed pesticides (30.5%), household items (22%), and food poisoning (20.9%) as the most common toxic agents, with the majority of cases from rural areas.Reference Al-Mahbashi and Howilah3 In Aden, a pediatric study identified kerosene ingestion (34.9%) as the leading cause of childhood poisoning,Reference Huda12 while another study on organophosphate exposure reported a 26% mortality rate, particularly among young females.Reference Gabali and Al-Gefri4 Khat use as a coping mechanism during crises further complicates the toxicological and mental health landscape.Reference Saleh, Wazaify and Khoshnood13
Regionally, similar patterns were encountered. In Palestine, an analysis of 290 pesticide-related calls to a Poison Control Center showed that young adults (20-30 years) were the most affected group, with organophosphates implicated in nearly one-third of exposures. Importantly, more than half of these cases (51.7%) were deliberate self-poisonings, highlighting the strong association between pesticide availability and intentional harm in the region.Reference Sawalha, O’Malley and Sweileh14 In Iran, a large retrospective study involving 1,567 patients reported an overall decline in pesticide poisoning but disproportionately high mortality from herbicides (23.2%), alongside strong links between multi-pesticide exposures and prior suicide attempts.Reference Eizadi-Mood, Mahvari and Akafzadeh Savari15 In Qatar, a 3-year pediatric study identified household products and medications as the leading toxic agents, with most cases occurring in children under 5 years of age.Reference Ahmed, AlJamal and Mohamed Ibrahim16 Collectively, these findings parallel the situation in Yemen, where unrestricted access to pesticides and limited mental health resources amplify the risk of intentional and fatal poisonings.
Globally, high rates of pesticide poisoning persist in countries such as Sri Lanka and Bangladesh due to unregulated pesticide use.Reference Van Der Hoek, Konradsen and Athukorala17, Reference Khatun, Islam and Sachi18 By contrast, nations with strict regulations and effective public health campaigns, such as Germany, report significant declines.Reference Moebus and Bödeker19, 20
Taken together, these data highlight the urgent need for Yemen to adopt context-specific interventions, including public awareness campaigns on pesticide safety, improved storage practices, access to antidotes, and expanded rural diagnostics. Integrating mental health services into toxicology care is equally critical to address the overlapping risks of substance use and intentional self-poisoning.
Limitations
This study is subject to several limitations. First, the reliance on self-reported survey data introduces the risk of recall bias. Second, access restrictions to certain regions due to ongoing conflict reduce the representativeness of the findings. Third, in the absence of reliable hospital records in some facilities, reliance on previously published studies may not fully reflect the current toxicological patterns in Yemen. The small sample size and focus on specific geographic areas also limit the generalizability of the results. In addition, data collection through online self-administered surveys distributed via WhatsApp groups restricted participation to individuals with internet access, likely excluding rural or underserved populations. Finally, because the survey link was circulated openly on social media rather than targeted to specific participants, the total number of eligible respondents could not be determined, preventing the calculation of a precise response rate.
Despite these challenges, the results of this study provide a foundation for actionable interventions. The observed disparities in resource availability, training, and protocol implementation clearly point to the need for targeted, context-specific solutions. For example, the data showing urban-rural resource gaps and limited diagnostic tools directly support the recommendation to prioritize resource allocation to underserved rural areas. Similarly, the findings on inadequate training rates among health care workers highlight the necessity of implementing scalable training programs tailored to Yemen’s health care context. Finally, the lack of protocols for managing toxicological emergencies directly informs the call for developing national guidelines, which would standardize care and improve outcomes.
Conclusion
This study highlights critical gaps in Yemen’s toxicology services, with over 70% of facilities lacking dedicated services and 85.4% without diagnostic tools. The disproportionate impact on rural regions, where pesticide poisoning is prevalent, and the widespread lack of training among health care providers expose significant vulnerabilities. Immediate, low-cost interventions such as mobile poison consultation services, basic toxicology training for health care workers, and targeted public health campaigns on pesticide safety can significantly reduce morbidity and mortality. Additionally, developing national protocols for toxicological emergencies and conducting regular emergency drills will enhance preparedness for mass poisoning incidents. Partnerships with international organizations, including the WHO, can support these efforts by providing resources, technical expertise, and scalable digital training solutions. While long-term solutions such as establishing poison control centers are crucial, incremental improvements tailored to Yemen’s resource-constrained environment can drive meaningful progress and improve toxicological outcomes across the country.
Acknowledgments
We would like to express our sincere gratitude to the Research and Ethics Committee at the Faculty of Medicine and Health Sciences, University of Aden, for granting ethical approval (Research Code: REC-208-2024) for this study. Their support and guidance in ensuring adherence to the International Conference of Harmonization (ICH)—Good Clinical Practice Guidelines have been invaluable.
Author contribution
Waheeb Naser contributed to the conceptualization, study design, development of the survey tool, data analysis, interpretation, discussion, manuscript drafting, and critical revision. Mohammed Abdurabu: Data collection, literature review, and manuscript review. Munuir Alsheikh: Data collection, literature review, and manuscript review. Yavuz Yigit contributed to manuscript editing, critical revision, and final preparation of the draft for submission. Waleed Salem contributed to survey development, provided supervision, contributed to the discussion, offered recommendations, and the final manuscript review and approval. All authors contributed to drafting, reviewing, and approving the final manuscript for publication.
Funding statement
None.
Competing interests
All the authors declare that they have no conflicts of interest related to this study. The research was conducted independently without any external influence on the study design, data collection, analysis, or interpretation.
Ethical consideration
This study adhered to ethical principles for research involving human participants. Participation in both the online survey and on-site interviews was entirely voluntary. Informed consent was obtained prior to conducting the interviews, and respondents were assured of their anonymity. No personal identifying information was collected at any stage of the research. The study proposal was reviewed and approved by the Research and Ethical Committee of the Faculty of Medicine and Health Sciences, Aden University (Research Code: REC-208-2024), in compliance with all relevant ethical guidelines.
Open access
