In Somalia, staff and volunteers from the country’s long-running polio programme have been trained to detect COVID-19 cases. Here, a trainee learns how to use a COVID-19 tracking database on her phone.4 May 2020 – “The road to the mountain village was rough. It’s only 50 kilometres, but it took more than 3 hours,” says Dr Fatima Ismail, a disease surveillance officer working in Somaliland. “We were bouncing in the car.”

In early 2020, Dr Fatima’s team headed to a remote village near Djibouti to check on a small boy. The boy’s right arm and leg showed a kind of paralysis that sometimes indicates polio. “The village polio volunteer in this mountainous area, geographically inaccessible, found an acute flaccid paralysis (AFP) case,” Dr Fatima remembers. 

When children show signs of this paralysis, it’s critical to get stool samples to a laboratory to determine whether they have polio. Polio teams ride camels in the desert or donkeys in the mountains when they have to. They brave bombs to get samples out of conflict zones to laboratories. In brutally hot climates, they plug mini-freezers into car dashboards to keep samples cool. 

All over the world, polio surveillance systems that have been built up over decades track infection sources, evaluate symptoms and transport samples to the laboratory — despite distance, natural disasters, and sometimes war. Now, this network of disease surveillance — reaching into the most far-flung corners of the globe — is being tapped to address the COVID-19 pandemic.

“In Somalia, the polio programme pivoted its workforce of thousands of frontline staff to support the effort as the cases of COVID-19 spread. Rapid response teams — made up of disease surveillance officers, community health care workers and volunteers — were trained to educate people about the virus and to test suspected cases. By April 2020, the teams were deployed in the field,” said Dr Mamunur Malik, WHO Representative in Somalia.

"In Somalia’s remote villages, they know us as their polio teams, and once they see us, what comes to their minds is that we’re giving them information about polio,” says Mohamed*, a surveillance officer. “So we also give them information about COVID-19. Social mobilisers tell them about COVID-19 symptoms, how to prevent getting infected, physical distancing, cleaning their hands very well with running water and soap.”

The careful procedures that the teams learned for polio surveillance have been adapted for COVID-19, where the required sample is a naso-pharyngeal swab. “We’ve trained our surveillance people on the case definition and how to collect the samples correctly, from cases that meet the case definition of a suspected case of COVID-19,” says Dr Fatima. “It’s the same infrastructure. After, when we collect the samples from the patient, we send it to the laboratory in Hargeisa.”WHO has given the laboratory equipment and supplies to test samples for COVID-19".

"As with polio samples, the samples of COVID-19 have to be refrigerated, the ice packs should be VERY cold,” says Mohamed. Teams are used to monitoring the packs’ temperature, even in Somalia’s hot weather. 

“The logistical challenges we face with AFP/polio surveillance are still the same. This is the rainy season and the roads tend to be terrible,” says Mohamed. “You can’t get to certain places you normally get to, because of the situation on the road. Most of our vehicles can’t make it through the mud.” In those situations, teams work with other United Nations agencies to arrange special humanitarian flights to ship samples.

Frontline staff put their own lives on the line. In April 2020, the polio team lost a colleague due to COVID-19-related infection. Ibrahim Elmi Mohamed, who joined WHO in 2001, was working as a district polio officer in Lower Shabelle. His tragic death, one of many frontline staff around the world due to COVID-19, reminds us of the risks they face every day they go to work.

“Despite overwhelming challenges, teams are committed to continuing their polio work in tandem with the COVID-19 response. It is critical that polio surveillance continues during the pandemic, as Somalia is also fighting outbreaks of vaccine-derived polio type 2 and 3. With polio vaccination campaigns temporarily paused, the teams must be able to track any resulting spread of poliovirus and get ready to respond as soon as it is safe to do so,” says Dr Malik.

“All of us are still doing polio surveillance at the same time as we do surveillance for COVID-19," says Dr Fatima. “I used to hear from my colleagues that the polio surveillance system is the strongest disease surveillance system. Any polio surveillance team can work in the detection of COVID-19 cases because of the system’s structure, the capacity and experience of the teams.”

Mohamed agrees. “My surveillance coordinator said don’t leave the AFP surveillance behind, follow that normal routine, don’t forget it and leave it aside.’”

As Somalia grapples with the COVID-19 pandemic, its trained teams are working quickly to prevent the spread of both COVID-19 and polioviruses. “What gives me hope in the COVID-19 response is when I look behind and I see what we have done with the polio teams, the impact we’ve had on so many lives,” says Mohamed. “We face everything and we overcome it.”

*Family name withheld for security reasons

23 April 2020 – The number of confirmed COVID-19 cases continues to rise in Somalia, including associated deaths attributed to coronavirus disease. While the number of cases increase, there is increasing demand on the health system for patient care. When health systems are strained and overwhelmed, especially in fragile and vulnerable settings like in Somalia where adequate mechanical ventilators and other critical care support for patient care are basic, rudimentary or absent, mortality from the outbreak may increase substantially over time. Since the beginning of the outbreak, 7 associated deaths out of 135 cases were reported by the Government in Somalia as of 19 April 2020.

The COVID-19 epidemic in Somalia will disrupt life-saving health services and health care resources, including essential supplies and health manpower, need to be re-prioritized and re-directed towards reducing mortality as a result. It is also crucial to maintain other life-saving health services particularly maternal and child essential health care services and services for other vulnerable groups. During the 2014–2015 Ebola outbreak, analyses suggest that the increased number of deaths caused by measles, malaria, HIV/AIDS, and tuberculosis attributable to health system failures exceeded deaths that were directly attributable to Ebola virus disease. If viral transmission cannot be decreased, a patient surge and increasing demand for care could be overwhelming, putting an enormous strain on the fragile health system and severely impacting other life-saving services such as immunization, maternal care and other services aimed at limiting deaths from preventable diseases.

Maintaining key health interventions

Over the years, the country has made several health sector gains. The country has remained free from wild poliovirus since 2014. Without maintaining time-sensitive and active surveillance system for acute flaccid paralysis (AFP) throughout the country, including environmental surveillance, polio could resurge. In 2019, WHO staff from the polio eradication programme helped reach over 3 million children under 5 with lifesaving polio vaccine, collected 75 sewage samples and also detected 361 AFP cases. If these polio activities are not maintained or sustained even during this period of COVID-19, this will push back all the gains made over the years in the country to end polio.

Maintaining essential health services during this ongoing COVID-19 outbreak will also be critical to save lives from other ongoing infectious diseases threats in the country such as measles and cholera. The cholera outbreak continues to kill and so far in 2020, cholera has claimed 11 lives and made another 2600 people sick. Any disruption of essential care and other key health interventions for managing cholera and other infectious disease threats may lead to an upsurge of cases and excess deaths. Maintaining these critical and life-saving services is the only way to end cholera by 2030 and limit avoidable deaths from this disease by 90%.

Dr Mamunur Rahman Malik, the WHO Representative for Somalia said, “While there is a need to fight with this virus on all fronts, we also need to ensure that essential health services are maintained to save lives. Our gains in protecting children against vaccine-preventable diseases, our victory in eradicating polio virus from the country, our focus on leaving no one behind in our efforts to achieve universal health care coverage will be lost forever if we can not support the health system to meet the increased demand for health care for COVID-19 and yet maintain the health services that are life saving in nature. Countries will need to make difficult decisions to balance the overwhelming demands of responding directly to COVID-19, while simultaneously engaging in coordinated action to maintain essential health service delivery”.

Partners

Working in partnership with other United Nations agencies such as the United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), International Organization for Migration (IOM), the United Nations Office of the High Commissioner for Refugees (UNHCR) and the United Nations World Food Programme (WFP), the country office is supporting health authorities to improve and maintain essential health services for mothers, women, children, people with physical disability and older people, especially in internally displaced and refugee camps while balancing, the extra demand to respond to COVID-19. The primary health care centres which are the bedrock of essential health care in Somalia have been supported with personal protective equipment for the health care workers managing these centres as an incentive to keep them open while making sure that workers have the training and knowledge to do triage for COVID-19 for high-risk patients, refer them to other facilities and maintain routine health care services.

Surveillance

While EWARN – the early warning disease surveillance system – currently covering 535 out of 1075 health facilities in the country with an estimated 6.5 million population coverage, has been expanded to cover not only 14 epidemic-prone diseases, but to include the case definition of COVID-19 as another reportable health condition. The system enhancement has allowed WHO to monitor the trend of severe acute respiratory infection as a proxy for COVID-19, but the addition of distinct case definition of COVID-19 in the EWARN has been useful to capture any suspected case early.

Maintaining the routine immunization services for childhood diseases remain another key challenge, especially during physical distancing. However, efforts are under way to support health facilities deliver immunization services yet maintain social/physical distancing. A country where one in every 10 children does not receive life-saving vaccines, the suspension or breakdown of routine immunization services will have a devastating toll on the lives of vulnerable children in the country. Last year, WHO supported health authorities to reach out to every child with life-saving vaccines resulting in reaching out to 462 050 children under 1 year out of 602 195 (77%) completing the 3 doses of the pentavalent vaccine, while 430 275 (71%) received the measles-1 vaccine. Any disruption of routine immunization services will be a severe set back in making every child count.

A well-organized and prepared health system has the capacity to maintain equitable access to essential service delivery throughout an emergency, limiting direct mortality and avoiding increased indirect mortality. With the current situation of COVID-19 where caseloads are increasing and the pressure is mounting on the health system, the capacity to maintain routine service delivery, in addition to managing increased demand for COVID-19 patient care, needs to be maintained at any cost to protect the health gains achieved over the year. The WHO country office is supporting that to happen through strategic shifts ensuring that increasingly limited resources provide maximum benefit for the population.

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Our operations response to COVID-19 is supported by ECHO, United Kingdom Department for International Development, United Nations Central Emergency Response Fund, Embassy of Switzerland and Italian Development Cooperation.

23 April 2020 – In Somalia's COVID-19 response, being ahead of the curve is the only way to stop transmission and limit spread of the virus in the community. Enhancing active surveillance and expanding its geographic coverage to include both the private and public sector using a syndromic-based approach is the best way to detect cases early.

In Somalia, in the absence of any routine disease surveillance system, EWARN is doing what it was intended to do and what the system did best in other outbreak situations.   

EWARN, a disease surveillance system for epidemic-prone disease, was initially launched in Somalia in 2008 but due to operational difficulties was halted only to be reactivated by WHO together with federal and state health authorities in 2017 as a real-time password protected web-based electronic surveillance system. This reactivation came after one of the worst cholera outbreaks in Somalia in the past decade when there was no reliable disease surveillance system in the country to monitor, detect and respond to the cholera outbreak and other epidemic-prone diseases and health threats.

By 2019, an estimated 6.5 million people, including 2 million internally displaced people, were covered by the EWARN system. Currently, 535 out of 1075 health facilities across the country are covered by EWARN; 64% of these facilities submit their EWARN reports on time and 74% of the reports are complete. In 2019 alone, 74 new health facilities were added to the EWARN system. A record 4 789 832 consultations were reported in 2019 through the EWARN system. Knowledge of patient consultations and population coverage helps WHO and other health partners to measure the consultation rate and identify gaps in health care access in vulnerable populations. In 2019, the system triggered over 18 000 outbreak alerts, of which 883 were verified through field investigation by WHO and the health authorities.

In a country like Somalia which has a fragile health system, EWARN has been able to detect and prevent epidemics in real time in drought-affected districts, camps for internally displaced people in different states, including their host communities, and districts inaccessible to humanitarian agencies or the government. As the system relies on electronic data collection using a mobile phone-based application data on epidemic-prone diseases can be regularly collected and collated, even from insecure and inaccessible areas of the country, This would not have been possible if EWARN relied on a paper-based system for data collection.

As the country grapples with increased transmission of COVID-19, the EWARN system has been rolled out to another 200 health facilities, including all privately owned medical facilities which are admitting and treating patients with acute respiratory diseases of unknown origin. Using online training platforms adapted to the country need and context, the WHO country office through its Public Health Emergency Officers is conducting training at each of these newly enroled health facilities, including the private sector hospitals on use of syndromic case definition for COVID-19 and early recognition and reporting of suspected case. The training also includes data entry and reporting using both the web-based application and mobile platform of the EWARN system. In addition to 14 epidemic-prone diseases that are already included in the system (e.g. waterborne, vaccine-preventable, vector-borne and mixed transmission diseases), the case definition for COVID-19 has been added as the newly reportable health condition in the EWARN as part of roll out.  

Event-based surveillance

Another important innovation for the EWARN roll out during this period of COVID-19 has been the addition of event-based surveillance system which is intended to capture non-specific and other respiratory diseases of unknown origin in the EWARN for triggering alert and appropriate investigation.  

Understanding the evolution and transmission dynamics of any epidemic remains a challenge even in countries with good health system and functioning surveillance system. Somalia, a country with fragile health systems and with no routine disease surveillance system, the challenges are immense and overwhelming. The EWARN data on COVID-19 cases (either suspected or confirmed) will provide a snapshot of epidemic size, geographic spread and stages which is important for understanding and analyzing the effectiveness of response strategies for containment and suppression of the virus.  

The other main advantage of EWARN being rolled out for COVID-19 is the use of its GPS coordinates which will allow alerts of the location of a suspected case or event of a cluster of cases to be precisely pinpointed and automatically displayed on the electronic dashboard. This will eventually help in efficient contact tracing and identifying more suspected cases in the vicinity of the alert of this event or a spectacled case.

Since the EWARN system is supported by a mobile app linked to its web-based platform, local health workers in inaccessible areas will also be able to use the app to submit real-time data on COVID-19 electronically thus overcoming security and geographic barriers.

As the roll out begins, a weekly bulletin will also be generated automatically from the system, which will show all alerts but also distilled for COVID-19 by health facility and geographic location.

The EWARN surveillance system continues to transform the way Somalia detects an epidemic disease including the COVID-19 in the absence of any routine disease surveillance system in a very complex setting. In addition, to disease detection and monitoring, the data generated from EWARN for COVID-19 will be useful for understanding the burden and help to prioritize, plan, implement and monitor the health emergency response in the country. Like what has been done in the past, the EWARN continues to keep the country safe and protect the vulnerable by early detection and response to epidemic threats posed by COVID-19 in the country. The success and experience of EWARN, as an early warning disease surveillance system during this period of COVID-19 will be useful for other emerging health threats as the country transitions from a state of protracted crisis to early recovery and development.  The current work of WHO country office in responding to COVID-19 is also a demonstration of WHO’s commitment to and capability of supporting the health needs of the Somali people especially in a crisis of this scale.

The implementation of the EWARN system has greatly improved the detection, verification, investigation and reporting of diseases of public health importance in the country in real time, and the sharing of relevant health information with health partners and stakeholders to guide response activities and monitor the trends of these diseases across the country.

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As the COVID-19 pandemic escalates the WHO country office has helped Somalia rapidly build and scale up the testing capacity for COVID-19 in Somalia.

In March 2020, when the country’s first case of COVID-19 was laboratory-confirmed in Somalia, the country had no capacity for testing and diagnosis of COVID-19. WHO sent nasopharyngeal swab from 4 returnee travellers, all Somali citizens, to Kenya Medical Research Institute (KEMRI) in Nairobi which has an accredited Biosafety Level-2 (BSL-2) laboratory for viral and emerging pathogens supported by WHO and the United States Centers for Disease Prevention and Control. On 16 March, WHO received the laboratory test result of these 4 samples, of which one tested positive. This was the first reported case of COVID-19 in Somalia which was travel-associated.

The Ministry of Health and Human Services of the Federal Government of Somalia officially confirmed the first COVID-19 case in Somalia immediately after the test result was officially communicated by WHO to the Ministry.

Building testing capacity

Since then the WHO country office has shipped over 150 samples collected from different parts of the country to KEMRI and many of them have tested positive. Considering that the country would need to build its testing capacity rapidly for COVID-19 and decentralize laboratory testing in order to rapidly isolate and treat cases while tracking close contacts in line with WHO’s strategy to “Test, track and treat” for detecting and preventing community transmission, 3 laboratories with molecular testing facility were rapidly established by WHO in April with the financial support from the Italian Development Cooperation. These laboratories were established in Mogadishu, Garowe and Hargeisa. 

Partner support

This work truly reflected the global action and the power of solidarity for defeating our common enemy – COVID-19 – in one of the most fragile and vulnerable settings of Africa, a country which has been experiencing protracted conflict and political instability weakening the health system. While funds for purchase of molecular testing machine, the real-time reverse-transcription polymerase chain reaction (rRT-PCR) for equipping the 3 laboratories was provided by the Italian Development Cooperation, the machines were air-lifted by the United Nations Humanitarian Air Services (UNHAS) operated by the United Nations World Food Programme (WFP) directly from Nairobi to Mogadishu, Garowe and Hargeisa. The WHO country office funded the establishment of these laboratories, including ensuring biosafety practices, buying essential supplies, conducting training and providing molecular diagnostic assays to kick-start testing. The detection of COVID-19 with nucleic acid amplification tests (NAAT), such as RT-PCR is regarded as the ‘gold standard”.

On 9 April 2020, just 2 days after the world celebrated World Health Day acknowledging the contribution of nurses, midwives and other health workforce, the RT-PCR machine was handed over to Ministry of Health officials at the public health laboratory of Mogadishu by Dr Mamunur Rahman Malik, WHO Representative for Somalia. While thanking the Italian Development Cooperation for their support, Dr Malik commented “It is a testing moment for the world to come together to save lives and fight a common threat to our humanity. We thank our important partner the Italian Development Cooperation for their generous contribution to establish 3 functioning laboratories for testing of COVID-19. We also thank WFP for air-lifting the RT-PCR machine and other supplies from Nairobi to different locations in Somalia barring the lockdown and flight suspension in and out of Somalia”.

César V. Arroyo, Country Director and Representative of WFP Somalia said “We won’t stop until we can stop this virus. We are commited to working together to getting the vital medical supplies to front lines to attack this virus on all fronts. We must stand up to save humanity. We need action from all and for all.” 

The public health laboratories play a critical role in surveillance especially in case detection and case finding. Diagnostic testing for COVID-19 is critical to tracking the virus, and delaying and suppressing viral transmission. This is particularly important for Somalia as reducing transmission will reduce the burden on the fragile health systems in a country which has been chronically weakened due to protracted emergencies, under-investment and neglect.

Scaling up the public health response

While the virus was slow to reach the country compared to other parts of the world, case counts are growing rapidly every day in recent weeks and the virus continues to spread. Cases have also been reported and confirmed in remote areas. While WHO continues to work with the local health authorities in Somalia to scale up its public health response to ongoing transmission, establishment of 3 laboratories and scaling up its molecular testing capability is part of the strategy for decentralized testing across the country which will not only ramp up testing but ensure rapid identification of cases, the tracking down and quarantining of contacts and the isolation and treatment of patients as part of systematic strategy for containment.

In this interconnected world, we are only as strong as the weakest health systems. The current public health crisis is not the first and will not be the last. Recovery from this crisis of unprecedented scale must lead to building a better and resilient public health system in Somalia. Establishment of the public health laboratories with molecular testing capability which are decentralized will be an investment worthy of rebuilding a resilient health system in the country for control of any other emerging pathogens, including any novel respiratory pathogens in the future.

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