Yosr Ayedi,¹ Chahida Hariz,¹ Afef Skhiri¹ and Radhouane Fakhfakh¹

¹Department of Epidemiology and Biostatistics, Abderrahmane Mami Hospital, Ariana, Tunisia. (Correspondence to Yosr Ayedi: عنوان البريد الإلكتروني هذا محمي من روبوتات السبام. يجب عليك تفعيل الجافاسكربت لرؤيته.).

Abstract

Background: The Global Youth Tobacco Survey was conducted in Tunisia in 2001, 2007, 2010 and 2017.

Aims: To describe the trends in cigarette use among Tunisian adolescents and their exposure to second-hand smoke and tobacco advertising from 2001 to 2017.

Methods: The Global Youth Tobacco Survey is a school-based cross-sectional survey conducted by the World Health Organization. It uses a two-stage cluster sampling design to obtain a representative sample of students aged 13–15 years. A standardized questionnaire is used for data collection. The prevalence and 95% confidence intervals (CI) of ever and current cigarette use, exposure to second-hand smoke in and outside the home, and exposure to tobacco advertising were compared over the 4 years.

Results: Current cigarette use decreased from 11.1% (95% CI: 10.0–12.3%) in 2001 to 7.7% (95% CI: 6.5–9.0%) in 2017, P < 0.001. Exposure to second-hand smoke at home decreased from 62.5% (95% CI: 60.7–64.2%) to 46.7% (95% CI: 44.5–49.0%) over the same period, P < 0.001, but exposure outside the home increased from 65.4% (95% CI: 63.7–67.1%) in 2001 to 73.3% (95% CI: 71.2–75.3%) in 2017, P < 0.001. Exposure to anti-tobacco messages in the media fell from 87.8% (95% CI: 86.3–89.1%) in 2001 to 64.4% (95% CI: 62.2–66.5%) in 2017, P < 0.001.

Conclusion: While the prevalence of cigarette use and second-hand smoke exposure at home fell, exposure outside the home increased. Efforts are needed to ensure compliance with smoke-free laws to decrease the prevalence of second-hand smoke.

Keywords: tobacco use, tobacco smoke pollution, adolescent, prevalence, Tunisia.

Citation: Ayedi Y; Hariz C; Skhiri A; Fakhfakh R. Cigarette use and exposure to second-hand smoke and advertising in Tunisian adolescents, 2001 to 2017. East Mediterr Health J. https://doi.org/10.26719/emhj.23.075 Received:09/05/2022; accepted: 04/01/2023

Copyright © World Health Organization (WHO) 2023. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license https://creativecommons.org/licenses/by-nc-sa/3.0/igo

Introduction

Tobacco was the main cause of death in males in 2019 worldwide, responsible for 20% of deaths in males. For women, tobacco was the sixth leading cause of death worldwide, responsible 15.4% of all deaths in women (1). Worldwide, in 2019, about 1.14 billion people aged 15 years and older smoked cigarettes (2). Generally, regular adult smokers began smoking during adolescence and one third started at 14 years (3). People who smoke their first cigarette before the age of 18 years are more likely to become heavy smokers and nicotine dependent in the future, and are less likely to quit, which puts them at higher risk of lung cancer or other tobacco-induced diseases (4).Considerable effort has been made globally to control tobacco use by helping smokers to quit and preventing smoking initiation.

In 2004, 603 000 deaths were estimated to be related to second-hand smoke; 28% of these death occurred in children (6). The increase in people’s knowledge of the effects of tobacco use and second-hand smoke as a result of the media and anti-tobacco messages has helped tobacco control efforts (7). The World Health Organization (WHO) launched the Framework Convention on Tobacco Control (FCTC) in 2003, which was the first international treaty on tobacco control (8). In line with the FCTC, WHO introduced the WHO MPOWER measures: M for Monitoring tobacco use and prevention policies, P for Protecting people from tobacco smoke; O for Offering help to quit tobacco use; W for Warning about the dangers of tobacco; E for Enforcing bans on tobacco advertising, promotion and sponsorship; and R for Raising taxes on tobacco.

Tunisia started a national strategic plan to curb the epidemic of tobacco use in adults and young people in 1998. The strategy was further enforced by Tunisia’s ratification of the FCTC in 2010 (10). In Tunisia, the prevalence of smoking among adult males was reported to be 48.3% (95% confidence interval (CI): 46.3–50.3%) according to the Tunisian Health Examination Survey in 2016 (9). The Global Youth Tobacco Survey (GYTS) is a main component of the MPOWER plan of action. It is a multinational survey conducted by WHO (11) in more than 185 countries to monitor tobacco use among young people aged 13–15 years (12). In Tunisia, this survey has been conducted four times: in 2001, 2007, 2010 and 2017. To our knowledge, the GYTS is the only national survey that examined exposure to second-hand smoke and to the media and advertising in young people.

The aim of our study was to identify the trends in cigarette use in Tunisian adolescents from 2001 to 2017 and to describe their exposure to second-hand smoke and the media and advertising related to tobacco.

Methods

Study design

The GYTS is a cross-sectional, descriptive and school-based survey conducted by WHO. It uses a two-stage cluster sample design to obtain representative samples of students aged 13–15 years. In Tunisia, the age 13–15 years old matches students in the seventh, eighth and ninth school grades. In the GYTS, the complete list of all public schools is sent to the tobacco centre at the United States Centers for Disease Control and Prevention (CDC) where schools are chosen randomly in proportion to the number of students enrolled in the specified grade. Then, classes are randomly chosen according to the city population and size (one or two classes per school).

The GYTS in Tunisia are carried out in April and May of each survey year. Physicians and nurses of medical schools are responsible for data collection, under the direction of the entity Medicine School and University, which takes care of the health of students in schools and universities. The surveys are funded by WHO. Each student in the age range 13–15 years range (seventh, eighth and ninth grades) in the selected classes who is present in the class on the day of survey is eligible to participate in the study.

Questionnaire

The GYTS survey uses a standard methodology and the questionnaire was validated by CDC and WHO experts (13). It contains core questions about the main tobacco concerns focusing on:

• prevalence of all smoked tobacco products and conventional cigarettes

• smokers’ access to tobacco products

• smokers’ behaviours related to stopping smoking

• exposure to the media and advertising

• exposure to second-hand smoke.

The questionnaire has been translated into Arabic and then re-translated into English and sent back to CDC for further checks to ensure accuracy and reliability. It was first pretested with a focus group of adolescents to endure the translation was pertinent and precise. The questionnaire contained 69 questions in 2001, 63 questions in 2007, 70 questions in 2010 and 63 in 2017: 27 questions are common to all four surveys.

We focused on trends in the prevalence of conventional cigarette smoking and exposure to second-hand smoke and to the media and advertising.

Measures

Ever cigarette smoker was defined as someone who had ever smoked cigarettes, even if they had only taken one or two puffs in their lives. Current cigarette user was defined as someone who had smoked cigarettes anytime during the past 30 days, that is, had given any answer other than 0 days to the question, “In the past 30 days, how many days did you smoke cigarettes?”

Participants were considered to have been exposed to second-hand smoke inside the home if they gave any answer other than 0 days to the question, “In the past 7 days, how many days have people smoked in your home, in your presence?” Similarly, they were considered exposed outside the home if they gave any answer other than 0 days to the question and “In the past 7 days, how many days have people smoked in your presence in places other than in your home?”

Consent

Oral consent of the parents of the students is taken the day before the survey.

Data analysis

Anonymized data were available at the official CDC site (https://nccd.cdc.gov/GTSS/rdPage.aspx?rdReport=OSH_GTSS.ExploreByLocation&rdRequestForwarding=Form). We analysed the data using R version 4.2.0 and R studio version 2022.07.01 software. In each survey, adjusted and weighting factors were applied to each student record to adjust for the probability of selection and non-response (by school, class and student).

The weighting factor was: W = W1 × W2 × F1 × F2 × F3 × F4, where: W1 = the reverse of probability of selection of the school; W2 = the reverse of probability of selection of the class within the school; F1 = adjustment factor of non-response of schools according to size (large, medium, small); F2 = adjustment factor of class calculated by school; F3 = adjustment factor of student non-response calculated within this class; and F4 = adjustment factor post-stratification calculated by sex and grade.

The weighting factor was applied through the survey package of R Studio. Unweighted numbers of students were inserted in tables. Indicators were described using weighted percentages reflecting the population estimates. We calculated the 95% confidence intervals (CI) for each proportion. The association between two qualitative variables was assessed with the chi-squared test. Trends were assessed using the Cochrane Armitage trend test. A two-sided 5% significance level was used for all calculations.

Results

From 2001 to 2017, the number of schools included in the survey increased from 50 to 67. The overall response rate varied from 94.1% (2942/3127) in 2001 to 92.9% (1863/2005) in 2017 (Table 1).

Conventional cigarettes

The male to female ratio was about the same in the 4 years: 0.97 in 2001 and 0.93 in 2017. In 2001, about 23.0% (95% CI: 21.5–24.5%) of the respondents had tried to smoke a cigarette, even if only one or two puffs: 35.4% (95% CI: 32.9–37.9%) of boys and 11.4% (95% CI: 9.9–13.1%) of girls. This proportion increased to 25.0% (95% CI: 23.1–27.1%) in 2017, with the increase greater in boys: 38.8% (95% CI: 35.6–42.0%) in boys and 11.6% (95% CI: 9.6–13.8%) in girls. However, these increases were not significant (P > 0.05).

As for current cigarette use, the prevalence decreased significantly from 11.1% (95% CI: 10.0–12.3%) in 2001 to 7.7% (95% CI: 6.5–9.0%) in 2017 (P < 0.001). In boys over the same period, the prevalence of smoking decreased from 19.1% (95% CI: 17.1–21.2%) to 14.2% (95% CI: 12.1–16.7%; P < 0.001). In girls, the prevalence decreased from 3.6% (95% CI: 2.8–4.7%) to 1.4% (95% CI: 0.8–2.4%; P < 0.001) (Table 2).

Exposure to second-hand smoke

Between 2001 and 2017, exposure to second-hand smoke at home in the 7 days before the survey decreased significantly from 62.5% (95% CI: 60.7–64.2%) to 46.7% (95% CI: 44.5–49.0%; P < 0.001). This reduction was significant for both boys and girls (P < 0.001) (Table 3).

Exposure to second-hand smoke outside the home increased significantly between 2001 and 2017, from 65.4% (95% CI: 63.7–67.1%) to 73.3% (95% CI: 71.2–75.3%; P < 0.001). This exposure increased significantly for both boys and girls (P < 0.001) (Table 3).

Most respondents were in favour of implementing smoke-free places by law, although this support fell significantly from 87.0% (95% CI: 85.7–88.2%) in 2001 to 81.8% (95% CI: 80.0–83.5%) in 2017 (P < 0.001), and decreased for both boys and girls (P < 0.001) (Table 3)

Exposure to the media and advertising

Exposure to anti-tobacco messages in the media deceased from 87.8% (95% CI: 86.3–89.1%) in 2001 to 64.4% (95% CI: 62.2–66.5%) in 2017 (P < 0.001). This exposure decreased significantly for both boys and girls (P < 0.001) (Table 4). However, exposure to anti-tobacco messages at sports and cultural events increased significantly, from 34.2% (95% CI: 32.5–35.9%) in 2001 to 72.2% (95% CI: 70.1–74.2%) in 2017 (P < 0.001). This exposure increased significantly for both boys and girls (P < 0.001) (Table 4). Two thirds of students (67.3%; 95% CI: 64.7–69.8%) had seen advertising for tobacco use in 2010. This proportion fell significantly to 43.7% (95% CI: 41.2–46.2%) in 2017 (P < 0.001). This exposure decreased significantly for both boys and girls (P < 0.001) (Table 4). The proportion of respondents who had had received free promotional cigarettes was small and did not change significantly over the years (Table 4).

Discussion

The GYTS is one of the most important tobacco monitoring tools and helps countries implement the MPOWER package. The questions are in line with the MPOWER package and focus on important aspects of tobacco use and tobacco control. Monitoring the prevalence of tobacco use over time is essential to identify changes and link the national tobacco control strategy to the current situation.

Conventional cigarettes

One in four students had ever tried to smoke a cigarette: one boy out of three and one girl out of 10. In the United States, data from the National Youth Tobacco Survey from 2014 to 2016 showed that 21% of adolescents had ever tried to smoke a cigarette (14). The GYTS in the United Arab of Emirates in 2013 focused on expatriate adolescents only and reported that 32% of boys had tried to smoke a cigarette, at a mean age of 12–13 years (15). A previous Tunisian national survey, which included 4172 adolescents aged 12–20 years from public and private schools, reported that among students aged 12–14 years, 26.9% had tried to smoke a cigarette in their lives (16). In the Sfax region in the south of Tunisia, ever cigarette smoking was reported in 16.7% of school students (32.6% of boys and 5.9% of girls) (17). Our findings are similar to these studies and indicate a high prevalence of cigarette experimentation among boys and girls in Tunisia.

Our findings show that the prevalence of current cigarette use in adolescent Tunisians has decreased over time, overall and for boys and girls. According to the last Youth Risk Behavior Survey in the United States conducted in 2019, a significant decrease in current cigarette use had occurred among students in the ninth grade (14–15 years), from 13.5% in 2009 (18) to 3.8% in 2019 (19). In a 45-country analysis of GYTS data in 2013 and 2014, the median global prevalence of current cigarette use across all countries was 6.8% (9.7% in boys and 3.5% in girls), which is lower than the prevalence in our four surveys overall and for boys, but higher than current cigarette use we found for girls. Given the findings of the 2017 GYTS in Tunisia, the country has the fourth highest prevalence of adolescent cigarette use in the Middle East and North African region, after Jordan (2014 GYTS), Lebanon (2013 GYTS) and Qatar (2013 GYTS) (20). Other studies of North African countries showed that a greater proportion of Tunisian boys smoked than Egyptian, Libyan, Moroccan and Sudanese boys (21). In Malaysia, the prevalence of current cigarette use decreased from 19.9% in 2003 to 14.8% in 2016, which is almost double of the prevalence in our study (22). In Morocco, Tunisia’s neighbour, the current cigarette use among 13–15-year-old schoolchildren increased from 3.0% in 2006 to 5.2% in 2010, but both are lower than the prevalence in Tunisian schoolchildren (23). In the city of Sousse in Tunisia, the results of a cross-sectional survey in 2013–2014 in 16 public schools found that 4.5% of participants were cigarette users, which is lower than the national prevalence in the GYTS surveys (24). Even though cigarette consumption in Tunisian schoolchildren fell from 2001 to 2017, it is nonetheless still high and needs to be tackled to reduce the its prevalence further.

Exposure to second-hand smoke

Second-hand smoke outside the home in adolescents increased from 2001 to 2017. A study in 131 countries found that exposure to second-hand smoke outside the home was 57.6% in 2018 and it had not decreased from 1999 – it remained the same in 46 of 131 countries (35.1%) and increased in 40 (30.5%). This increase was found in almost all WHO regions (exposure was 59.4% for exposure at least one day a week in the Middle East and North Africa region) and in countries that did not ratify the FCTC (25). The overall exposure to second-hand smoke in public places among non-smoking adolescents was 44.2% across 168 countries from 1999 to 2008. The exposure was higher in boys than girls. Exposure ranged from 39.8% in the Middle East and North Africa region to 73.7% in the European region (26). In Africa, from 2006 to 2011, exposure to second-hand smoke among adolescents was 39.0%; it ranged from 24.9% in Cape Verde to 80.4% in Mali, with no differences between the sexes (27). These results show that exposure to second-hand smoke in Tunisia is among the highest in the world.

The proportion of students in favour of laws that establish smoke-free places decreased for both sexes. Tunisia established its first tobacco law (no. 98-17) in February 1998 which aimed to protect people from tobacco harm. Article 10 of this law prohibits smoking in public places (28). This law was enforced by the decree of November 1998 (29), decree of September 2009 (30) and ratification of the FCTC in 2010. Article 8 of the FCTC calls for countries to adopt and implement effective national legislations to protect people from exposure to tobacco in indoor and outdoor public places (8). However, the compliance of Tunisians and respect of these laws seem to be weak given the high rates of exposure to second-hand smoke outside the home (31). In the most recent report of MPOWER in the Middle East and North Africa region, Tunisia had a score of 1 out of 3 for smoke-free places, which means only up to two public places were completely smoke free (32). A longitudinal study found evidence that, in addition to positive impact on exposure to second-hand smoke, laws on smoke-free places led to a possible decrease in smoking prevalence (33).

Exposure to the media and advertising

In the 2001 Tunisian GYTS, a greater proportion of respondents were exposed to anti-tobacco messages in the media (internet, magazines, television) than respondents in the 2017 GYTS. This result is similar to findings in Greece (34), Italy (35) and Myanmar (36). A longitudinal study in the United States found a positive effect of anti-tobacco messages on teenagers’ susceptibility to smoke. In fact, this exposure decreased the susceptibility to smoke by 2 or 3 years (37). From 2010 to 2017, the proportions of students exposed to cigarette advertising at points of sale decreased. A systematic review in 2009 concluded that exposure to promotion of cigarette use at points of sale increased the odds of ever smoking, frequent smoking or occasional smoking (38). This explains why the tobacco industry spends around 80% of their advertising budget on promotions at points of sale (39). Article 13 of the FCTC calls for countries to ban every kind of tobacco promotions, advertisings and sponsorships. In Tunisia, law no. 98-17 forbids all types of promotion of tobacco products in public places, but it does not include a ban on promotion at points of sale (28).

Strengths and limitations

A strength of our study is that the GYTS is the only standardized worldwide survey on tobacco use and attitudes in adolescents aged 13–15 years. In addition, the GYTS is a national survey conducted in all governorates and cities in the country. Furthermore, the sample size of students who answered the questionnaire was large and the response rates were always more than 92%.

Our study has some limitations. Smoking behaviour and exposure to second-hand smoke were self-reported and no quantitative method was used to confirm the students’ responses, which may introduce biases. In addition, only students in public schools were included, thus students in private schools or adolescents who were not in school were not represented. Students in private schools and teenagers who don’t go to schools represent about 10% of Tunisian adolescents according to a 2015 report (40).

Conclusions

WHO recommends that countries implement a monitoring survey every 5 years. It has been 5 years since the last GYTS in Tunisia and a new GYTS survey is needed. In addition, efforts to ensure complete compliance with smoke-free laws are needed to decrease the prevalence of second-hand smoke. Finally, a complete ban of point of sales promotions is strongly recommended to decrease the exposure of vulnerable young people to this tobacco advertising.

Acknowledgements

This study was a collaborative project of WHO, CDC and the Ministry of Health of Tunisia. We thank the study participants and research assistants.

Funding: None.

Competing interests: None declared.

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Mutaawe Lubogo,¹ Buliva Evans,² Abubakar Abdinasir,² Elnossery Sherein,² Tayyab Muhammad,² Ahmed M. Mohamed,³ Aden Hussein,³ Fayez Abdulrazeq² and Malik Sk Md Mamunur¹

¹World Health Organization, Somalia Country Office, Mogadishu, Somalia.

²Emergency Programme, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

³Federal Ministry of Health, Mogadishu, Somalia. (Correspondence to Mutaawe Lubogo: عنوان البريد الإلكتروني هذا محمي من روبوتات السبام. يجب عليك تفعيل الجافاسكربت لرؤيته.).

Abstract

Background: Somalia reported repeated cholera outbreaks between 2017 and 2019. These outbreaks were attributed to the presence and occurrence of multiple risk factors for cholera, which made response challenging.

Aims: To describe the challenges faced by Somalia in responding to cholera outbreaks between 2017 and 2019 and provide lessons for Somalia and other countries with a similar context on how to better prepare for future outbreaks.

Methods: We reviewed outbreak response reports, surveillance records and preparedness plans for cholera outbreaks in Somalia from January 2017 to December 2019 and other relevant literature. We present data on cholera-related response indicators including cholera cases and deaths and case fatality rates in the 3 years. Qualitative data were collected from five focus group discussions and 10 key informant interviews to identify challenges, interventions and lessons learnt from the Somali experience.

Results: In 2017, 78 701 cholera cases and 1163 related deaths were reported (case fatality rate 1.48%), in 2018, 6448 cholera cases and 45 deaths were reported (case fatality rate 0.70%), while in 2019, 3089 cases and four deaths were reported in Somalia (case fatality rate 0.13%). The protracted conflict, limited access to primary health care, and limited access to safe water and proper sanitation among displaced populations were the main drivers of repeated cholera outbreaks.

Conclusions: Periodic assessment of response to and preparedness for potential epidemics is essential to identify and rectify gaps within current systems. Somalia’s experience offers important lessons for countries experiencing complex humanitarian emergencies that may help prevent and control future cholera outbreaks.

Keywords: cholera, disease outbreaks, emergencies, Somalia.

Citation: Lubogo M; Evans B; Abdinasir A; Sherein E; Muhammad T; Mohamed AM; Hussein A, et al. Response to cholera outbreaks, Somalia, 2017–2019: challenges, interventions and lessons learnt. East Mediterr Health J. https://doi.org/10.26719/emhj.23.078  Received: 24/05/2022; accepted: 05/01/2023

Copyright © World Health Organization (WHO) 2023. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license https://creativecommons.org/licenses/by-nc-sa/3.0/igo

Introduction

Cholera is a disease of inequity, affecting the world’s most vulnerable and marginalized communities. It is an epidemic-prone disease of global importance (1). The global burden of cholera is unknown because of underreporting (2), but an estimated 3–5 million cholera cases every year cause 100 000–120 000 deaths (3). In the Eastern Mediterranean Region of the World Health Organization (WHO), cholera remains a public health concern, especially in countries facing complex emergencies. In the past decade, 14 out of the 22 countries in the Eastern Mediterranean Region have reported cholera cases; in Afghanistan, Djibouti, Iraq, Pakistan, Somalia, Sudan and Yemen, the numbers have reached epidemic proportions. The regional burden of cholera is also difficult to capture because of weak surveillance systems and underreporting of cases (4). Nevertheless, the number of cases is estimated to be around 188 000 a year (3). In Somalia and other counties in the Horn of Africa, cholera outbreaks are spreading at an alarming rate and affecting communities already suffering from conflicts and droughts (5). Controlling cholera is crucial to achieve the Sustainable Development Goals which call for the good health and well-being of all and a reduction in inequity (6).

Cholera is a multifactorial disease occurring and re-emerging frequently as a result of interaction between different risk factors (7). Identified risk factors fall into four main categories: (i) factors related to water and sanitation such as lack of rainfall and decreased vegetation cover (8), flooding leading to contamination of water sources (9), lack of adequate clean water and proper sanitation facilities because of inadequate infrastructure (10), and poor sanitary practices by communities at risk of cholera infections (11); (ii) sociodemographic factors such as poverty, overcrowding and living in a camp for refugees or internally displaced persons (12); (iii) behavioural factors such as open defecation and funeral practices such as washing the bodies of those who have died from cholera (13); and (iv) gaps in knowledge and false beliefs about cholera infection and transmission, oral cholera vaccines, and cholera case management (14).

In Somalia, the protracted conflict, drought and flooding have resulted in over 2.6 million people living in camps for internally displaced persons where access to safe water and proper sanitation is limited (15). Cholera is endemic in the country and outbreaks occur during both the drought and rainy seasons.

Most of the country, particularly the regions of Shabelle and Juba, is prone to flooding about twice a year leading to contamination of water sources. Moreover, in 2017, Somalia experienced severe drought that affected over 60% of the country and led to severe water and food shortages (16). It was estimated that more than 3 million people were at risk of starvation and malnutrition (17). The limited access to safe water and poor sanitation conditions contributed to Somalia’s worst cholera outbreak in a decade (2,18–20). In January 2017, the Federal Ministry of Health confirmed a cholera outbreak in the Hiran region following the isolation of Vibrio cholera, serotype Ogawa from stool samples of suspected cases. The epidemic spread rapidly to most districts and regions of Somalia and reached its peak during May and June 2017 (19).

This paper aimed to describe the main challenges faced by Somalia during the 2017–2019 cholera outbreaks, highlight Somalia’s response to those challenges with the support of WHO and other partners, and identify lessons learnt. The paper also provides guidelines on how to better prepare for future outbreaks in Somalia and other countries with complex humanitarian emergencies and poor operating environments.

Methods

We undertook a literature review specific to Somalia of available information on the cholera outbreaks of 2017–2019 with particular reference to: preparedness and response; focus group discussions and key informant interviews; and interpretation of the cholera-related indicators in the 3 years of the outbreaks.

Literature review and cholera indicators

The qualitative and quantitative review was undertaken to analyse decision-making, policy, and actions taken during the 2017–2019 cholera emergency in Somalia. The literature search included cholera preparedness and response plans, surveillance records, monitoring and evaluations reports, needs assessments reports, meeting notes, presentations, internal reports, peer-reviewed articles, and relevant grey literature. The data on key indicators including cases, deaths and case fatality rates (CFRs) were collected from the surveillance records of Somalia’s Early Warning and Response Network Surveillance System (EWARN) (21), WHO’s Global Health Observatory and published records (2,18), and cholera situation reports by the WHO Regional Office for the Eastern Mediterranean (19,22). The data were summarized and changes in the indicators over time are presented. A cholera case was defined as a suspected case with V. cholerae 01 and O139 confirmed by stool culture. The cholera CFR was defined as the proportion of cholera-related deaths among total cholera cases during 2017–2019 and was expressed as a percentage.

Focus group discussions and key informant interviews

Participants for 10 key informant interviews and five focus group discussions were selected purposively based on their prominent roles in the health services, and/or their acknowledged understanding and custodianship of the health care system. The key informant interviews and focus group discussions helped provide in-depth information/perspectives for the qualitative review.

Nineteen participants from eight regions in Somalia were included in the focus group discussions, which were held in Mogadishu in 2017 by a trained interviewer who guided the discussion based on pre-identified themes. The interviewer encouraged participants to express their thoughts and ideas freely without interruptions. Pre-identified themes for the focus group discussions included: outbreak detection/confirmation; organization of response; use of reactive oral cholera vaccines; information management; case management; mortality reduction; hygiene measures at the health facility level; involvement of the community to reduce the effect of the disease; surveillance; funeral practices; and three themes related to control of the environment – safe water, safe food and sanitation.

The key informant interviews were done in 2019 mainly with senior staff at the Federal Ministry of Health and with department heads at relevant international agencies who had extensive knowledge of their organization’s involvement in the cholera response.

Both the focus group discussions and key informant interviews were audio-recorded and transcribed separately by two researchers. The transcribed data were analysed thematically by a researcher who was blind to the aims of the focus group discussions and key informant interviews.

Results

Cholera outbreaks in Somalia

In East Africa, particularly the Horn of Africa, and the Middle East, large cholera outbreaks with high mortality are frequently reported (18). The historic trend of cholera in Somalia has not been much studied (23). Although Somalia has long faced cholera outbreaks, the earliest record of a cholera outbreak appears in the WHO’s Global Health Observatory for 1970 (18). For the past 3 decades, almost all small-to-large cholera outbreaks in Somalia coincided with outbreaks globally and in the Eastern Mediterranean Region. However, except for the small-scale outbreaks in 2008–2010 and 2014–2015, the cholera cases, deaths and CFRs in Somalia were higher than the corresponding global and regional averages.

On average in the decade 2010–2019, 22 505 cholera cases and 379 deaths (CFR 1.68%) occurred in Somalia, which is higher than the regional average of 16 918 cases and 133 deaths (CFR 0.79%) and the global average of 9765 cases and 95 deaths (CFR 0.97%). The higher values of the indicators can be attributed to two large cholera epidemics of almost similar scale in Somalia, in 2011 and 2017. Except for in 2002, the cholera CFR in Somalia has always been higher than the global and regional CFR averages (2,18,19,22).

The 2017 cholera outbreak was the largest since 1970, with 78 701 cases and 1163 deaths, mainly among children younger than 5 years. The outbreak was more widespread and severe, encompassing 85 districts in 20 regions within the country, nine of which were classified as partially accessible (urban areas were accessible but not villages) because of political conflict (2,19,22). The highest incidence was in Bay region with 14 964 reported cases, while the lowest was in Sahil with only three cases reported (Figure 1 and Table 1). The overall CFR in 2017 was 1.48%. Of the 78 701 cases and 1163 deaths, 42 987 (56.42%) cases and 582 (51.86%) deaths were reported from the partially accessible regions (Table 1).

The highest peak of the 2017 outbreak was in epidemiological week 22 (29 May–4 June) when more than 5000 cases of cholera were reported. Thereafter, the number of reported cases declined gradually and reached its minimum of 144 cases in epidemiological week 47 (20 November–26 November). After that time, sporadic cases of cholera were reported during December 2017 (22) (Figure 2). This 2017 peak in cases was attributed to a series of unfavourable events that began with heavy rains which caused flash floods that led to contamination of water sources and displacement of communities to camps where access to safe water and proper sanitation was limited. After the flash floods, drought occurred in parts of Somalia, which led to food insecurity and malnutrition among children and resulted in lowered immunity to waterborne infections. Communities did not have enough time to fully recover from each of these hazards, and this situation, together with the weak health system, contributed to the repeated cholera outbreaks with varying degrees of severity.

Cholera cases continued to be reported in 2018 and 2019 (19,22), but the total number of cases was much lower than in 2017 (Table 1 and Figure 2). In 2018, the cumulative total of cholera cases was 6448 with 45 associated deaths (CFR 0.70%) in 23 districts from accessible regions (Banadir and Lower Shabelle) and partially accessible regions (Hiran, Lower Juba, Lower Shabelle, Middle Shabelle and Lower Shabelle) (19,22). In 2019, the cumulative total of cholera cases was 3089 with four associated deaths (CFR 0.13%) from 19 districts in Banadir region and the partially accessible regions of Gedo and Lower Juba (19,22). Overall, the ongoing cholera outbreak that started in December 2017 up to December 2019 has resulted in 13 818 cases and 72 deaths (CFR 0.52%), reported from three states of Somalia (Hirshabelle, Jubaland and South West) and Banadir region (19,24).

Discussion

According to WHO, preparedness, response and post-endemic activities collectively comprise three phases of effective cholera control (25). However, the level of preparedness is the most crucial phase of cholera control and essentially determines the success of an outbreak response (26). Therefore, we identified lessons learnt from the 2017–2019 cholera response in Somalia to provide recommendations on how to better prepare for and respond to future potential outbreaks in the country and other countries with poor operating environments during humanitarian emergencies.

A combination of factors led to Somalia’s severe 2017 cholera outbreak. Protracted conflict contributed to the weakening of Somalia’s health system. Conflict led to displacement of people to camps where access to safe water and sanitation is limited. Severe drought in 2016 and 2017 led to water shortages, displacement, food shortages and malnutrition in children younger than 5 years which in turn led to low immunity.

Our analysis of the trends in the number of cholera cases and deaths and the CFR shows that, despite many years of public health interventions, cholera is still a recurring and important risk to vulnerable communities in Somalia. In 2017, the country experienced the worst cholera outbreak in 5 years, with 78 701 cases and 1163 deaths, mostly in children younger than 5 years (18,19,22).

The Global Task Force for Cholera Control was established in 1991 and revitalized in 2011 as a result of the World Health Assembly resolution WHA64.15, which requested the WHO Director-General to strengthen WHO’s work in this area (27,28). Later in 2017, this task force lunched “Ending cholera: a global roadmap to 2030” and formulated a framework to achieve that target (6). In October 2017, a call to action to fight cholera through implementation of the global roadmap was made by 35 task force partners (27). Despite global efforts to end cholera in Somalia, cholera outbreaks are still reported since conflicts are still ongoing. Therefore, reassessment of cholera preparedness and response plans is important to achieve the goal to end cholera by 2030.

Several countries with complex emergencies have experienced repeated cholera outbreaks and successfully implemented response activities and interventions with the support of WHO and other partners. However these efforts faced challenges and obstacles (29–31). Although Somalia faces a similar situation (19), the humanitarian crisis in Somalia is characterized by multiple hazards occurring in quick succession without any time for full recovery from preceding hazards. Recognizing these challenges and exploring Somalia’s experiences is important to identify and bridge gaps within the current surveillance and response systems at both national and subnational levels. EWARN was launched in Somalia in 2010 but collapsed during ongoing conflict. Until 2017, no reliable surveillance system existed for timely detection of alerts of cholera and other epidemic-prone diseases. With the support of WHO, EWARN was re-activated in 2017 to provide timely detection and response alerts for cholera (32).

We identified several important challenges including: a weak health system; fragile water, sanitation and hygiene (WASH) infrastructure; difficulty in obtaining real-time information; poor resources; and limited funding. However, the most important challenge was conflict, which was responsible for all the other challenges. With support of WHO and other partners, Somalia was able to overcome these challenges and successfully responded to the cholera outbreaks in 2017–2019. However, these outbreaks will not be the last; therefore, ongoing support is vital for the prevention and early detection of, rapid response to and containment of future outbreaks.

Successful interventions that were implemented and contributed to the effective management of the cholera outbreak included: efficient leadership and coordination of epidemic preparedness and response plans at all levels; timely detection and response to alerts; timely dissemination of epidemiological information that was useful for public health action; comprehensive risk assessment; proper case management; enhancement of surveillance and laboratory capacities; strengthening of WASH preparedness; campaigns for community engagement, risk communication; and implementation of campaigns for preventive oral cholera vaccination. The impact of these interventions was evident by the reduction in the total number of cholera cases reported from 78 701 cases in 2017 to 6448 cases in 2018 and 3089 cases in 2019. Similarly, the CFR declined from 1.48% in 2017 to 0.70% in 2018 and 0.13% in 2019.

Based on the forecasting exercise conducted in Somalia in 2018, the total number of reported cases in 2018 was 37.08% less than the best case scenario in which 17 389 individuals were suspected to have cholera the same year. Similar successful experiences were reported from other countries such as Haiti which succeeded in controlling the cholera outbreak following the 2010 earthquake by prioritizing investment in safe water supplies and improved sanitation (33).

Recommendations

Based on our assessment of the experience of responding to the cholera outbreaks in Somalia, the following recommendations are proposed for the country and other countries with similar contexts.

1. Strengthen coordination and leadership to review and update preparedness and response plans for cholera.

2. Integrate diseases surveillance and response systems that include an early warning alert and response network to support timely detection of and response to any alerts of cholera and other epidemic-prone diseases.

3. Increase the number of people with access to safe water and proper sanitation through the establishment of sustainable water systems.

4. Raise awareness of communities in high-risk areas for cholera of the importance of adopting hygienic behaviour; and

5. Perform continuous risk assessments to identify hotspots for cholera and have plans to implement preventive cholera vaccination campaigns.

Acknowledgements

The authors thank the Federal Ministry of Health the Somalia for providing the cholera-related data and permission to submit this manuscript for publication in a peer reviewed journal.

Funding: None.

Competing interests: None declared.

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Tables and Figures

Table 1. Cases of and deaths from cholera and CFR, by region, during cholera outbreaks, Somalia, 2017–2019

Figure 1. Regions most affected by cholera, Somalia, 2017

Figure 2. Trend in cholera cases and case fatality rate during cholera outbreaks, Somalia, 2017–2019