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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In the absence of testing facilities for COVID-19, the WHO staff are involved in safe packaging and transportation of samples collected across the country to the testing laboratory at KEMRI. So far, over 50 samples from the suspected cases have been collected and tested at the refence laboratory for COVID-19 The WHO country office is supporting the Ministry of Health and Human Services of the Federal Government of Somalia, as well as all state health authorities to scale up operational readiness for early detection and response to large scale community transmission from coronavirus disease (COVID-19).

As of 6 April, the government has officially reported 7 laboratory-confirmed cases of COVID-19, 2 of these cases were reported from Somaliland. While 6 of these reported cases have travel history before they became sick or were quarantined, the investigation on the remaining case suggests that the case might have been locally acquired as the case has no travel history. This clearly shows that the country is now entering into a different transmission phase where further human-to-human transmission from COVID-19 can be expected. Given the fragility of the health systems, security situation in the country, weak surveillance system and insufficient number of skilled health workforce in the country, there are heightened risk that cases may go undetected or undiagnosed if community transmission begins as a result of wide spread of the virus.

Since the beginning of COVID-19 outbreak in January 2020, WHO has geared up its preparedness and operational readiness measures in the country helping the government to pre-position personal protective equipment for the first responders and health care workers to treat an initial 500 cases, train over 800 health care workers on early recognition, detection and investigation of cases, expand its early warning disease surveillance system to pick up the suspected cases rapidly, support the establishment of screening facilities at 21 designated points of entry across the country to cover over 75 000 returnee travellers and above all facilitating testing of the COVID-19 cases using the BSL-2 laboratory facilities at the Kenya Medical Research Institute (KEMRI) in Nairobi.

As the cases gradually build up and the country moves to a different epidemiological transmission patterns where human-to-human transmission is more likely, the priority for now is to avert large-scale community transmission through scaling up testing of all suspected COVID-19 cases, irrespective of travel history, aggressive contact tracing and efficient management of all close contacts using appropriate measures such as isolation and quarantine of all suspected cases and close contacts and scaling up risk communication activities to target the high-risk population.

In the coming days, WHO’s support will also include setting up 3 testing facilities in the country, additional isolation facilities to cover over 1000 suspected cases and mobilizing over 1200 trained health workforce for contact tracing and contact management. WHO’s work continues in Somalia to keep the country safe and protect the vulnerable despite the weakened health systems ravaged by years of war and neglect.

8 December 2019 – The first phase of a nationwide integrated polio and measles vaccination campaign has concluded in Somalia having achieved high coverage. WHO in collaboration with the Federal Ministry of Health and UNICEF launched the first phase of the campaign from 24 to 28 November 2019, targeting more than 1.7 million children under the age of five for polio vaccination and more than 1.5 million children aged six to 59 months for measles vaccination and vitamin A supplementation. This is the first time that an integrated campaign such as this has happened in Somalia. Vaccinators went from door to door to reach every child with life-saving vaccines, leaving no one behind.

The campaign was particularly focused on children in districts with high concentrations of internally displaced persons and nomadic communities due to the need to improve routine immunization coverage among these populations and reach those missed during routine immunization programmes. These population groups often have higher mobility and are therefore at increased risk for transmission of these diseases.

More than 17 000 skilled community vaccinators, frontline health workers and social mobilizers took part in the campaign. At the end of it, a total of 751,811 children had received polio vaccine (84% of the target), 671,381 had received the measles vaccine (82% of the target), 481,332 (66% of the target) had received deworming tablets and 666,182 children (82% of the target) had received vitamin A capsules. A total of 20,000 children also received their first dose (zero dose) of vaccine. The remaining unvaccinated children of the 1.7 million targeted for polio vaccination and the more than 1.5 million targeted for the measles vaccine will be reached during the second phase of the campaign in December.

During the campaign, staff from the Federal Ministry of Health, WHO, UNICEF and nongovernmental partners were deployed in different districts to monitor the campaign. All had been trained prior to the campaign on supportive supervision, conducting parent surveys and making rapid convenience assessments.

As part of campaign monitoring, 1656 households were visited and 5042 children (under the age of 5) were assessed for both polio and measles vaccination through a three-way verification process: recall, fingermark and presence of vaccination card. Social mobilization prior to the campaign demonstrated high success, with 980 mothers surveyed at vaccination sites during the campaign reporting bringing 95% of their children to the sites and 92% were aware of the campaign before it started. Only 79 fever and rash cases amongst the vaccinated children were reported by the mothers during the survey. No other adverse event following immunization were reported during the campaign.

Every year over 170,000 Somali children miss out on life-saving vaccines. This means that one in every 10 children do not receive life-saving vaccines. Unacceptably, it is often those most at risk – the poorest, the most marginalized, and those affected by conflict or forced from their homes – who are persistently missed.

Integrated vaccination campaigns are important for increasing immunity among children and avoiding the devastating consequences of these entirely preventable diseases on individuals, families, the local economy and health security in the Region.

The nationwide integrated campaign for measles and polio vaccination was funded by Gavi, the Vaccine Alliance. WHO thanks Gavi and other partners for supporting the routine immunization programme in Somalia.