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Saving lives from cholera in drought-hit districts: WHO steps up vaccination campaign using oral cholera vaccines
Skilled health care workers explain the benefits of vaccination to communities living in camps for internally displaced persons before offering them life-saving vaccines. Credit: WHO/Ismael Taxta31 July 2022 – As a mother of 3 who is a full-time carer for her young children, when Nesteho falls ill, her household comes to a standstill. Earlier this year, after breakfast one day, the 32-year-old started to suffer from severe bouts of vomiting, with watery diarrhoea. At first, she suspected it may have been bad food, but after getting herself assessed and examined, with the help of a pharmacist she knew, she realized she might have had cholera. Many others in her neighbourhood had been suffering from cholera at the same time.
Somalia has been experiencing a protracted cholera outbreak, with uninterrupted transmission of the disease since 2017. This has left many Somalis like Nesteho, and their families, suffering from this disease, which is easily preventable.
Limited access to safe water and safe sanitation fuels situation
Cholera outbreaks occur when a large number of people have limited access to safe water and proper sanitation. With only 52% of Somalia’s population having access to improved drinking-water or safely managed drinking-water services, and the current drought making water even more scarce, communities struggle to keep waterborne diseases at bay. The drought has forced close to 1 million people to leave their homes in search of water, food and survival. Nesteho’s is one of these families, that now lives in a camp for internally displaced persons (IDPs) in the October section, in Hodan, Banadir region.
This year, from January to June, Somalia reported 8041 cases of suspected cholera and 37 associated deaths due to cholera. Many of these cases have been laboratory-confirmed. Around 54% of the people infected in 2022 were children under 2 years of age, 49% were female and 28% were reported to be severely dehydrated.
Cholera vaccination campaigns protecting Somalis
WHO supports the government to conduct vaccination campaigns to reduce the spread of cholera. Credit: WHO/Ismael TaxtaBefore the first round of a cholera vaccination campaign was conducted in Somalia, from 14 to 26 June 2022, with support from the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and other partners, Nesteho Muse Mohamed did not realize there was a vaccine for cholera. However, in June, she heard social mobilizers in sound trucks explaining the benefits of cholera vaccines. When she heard a knock at her door during the week of the campaign, Nesteho welcomed the vaccinators and made sure they vaccinated her whole family.
Somalia first began to administer oral cholera vaccines (OCV) in 2017, when the country had 78 865 cases and 1160 deaths reported due to cholera. Since then, the country has conducted a series of cholera vaccination campaigns in addition to other measures.
During the last OCV campaign, conducted from 14 to 26 June 2022, 4984 skilled health workers vaccinated 897 086 (96%) people aged one year and above, against a target of 934 511. They used microplans that serve as maps showing households, and made visits from house to house to vaccinate people over 5 days. They established fixed posts where access to communities was a challenge either due to insecurity or logistical problems. The campaign covered 9 hotspot districts in Banadir region, and the South West and Hirshabelle states.
Over a period of a week, more than 1250 social mobilizers, like the ones Nesteho heard, spread messages about the dates of the campaign and benefits of cholera vaccines. Around 396 supervisors and district-, state-and national-level technical experts supervised teams and monitored activities during the campaign.
Efforts to reduce the disease burden and deaths
A health worker prepares to vaccinate a child against cholera. Around 900 000 people aged one year and above were vaccinated in the first round of the cholera vaccination campaign. Credit: WHO/Ismael TaxtaAll cholera vaccination campaigns in Somalia are conducted by the Federal and State Ministries of Health and Human Services, in collaboration with experts from the water, sanitation and hygiene (WASH) and health clusters, WHO, UNICEF, and inter-ministerial departments. The use of OCVs are supplementary measures considered by the government and its partners to end cholera and reduce cholera-related deaths in the country, in addition to stepping up other proven public health measures, such as improving access to safe drinking-water and safe sanitation or WASH interventions. Other measures used are risk communication and community engagement, case management, and enhanced disease surveillance, all of which are part of the country’s strategy to end cholera. This national cholera prevention and control strategy was crafted in 2019, with the aim of reducing cholera-related deaths by 90% in 2030.
Surveillance records show that the number of cholera cases have decreased in Somalia in recent times, partly due to the success of vaccination campaigns.
In August 2022, the Federal Government of Somalia, with support from WHO and other partners, aims to conduct a second round of cholera campaign in the locations covered in the first round in June. This will ensure families like Nesteho’s can keep safe from cholera.
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“Our lives have changed; thanks to water that we now have in our camp”
Since it was rehabilitated on 16 June, over 19 500 people around the Salama borehole in North Galkayo can now access safe water again. Credit - WHO/Somalia 24 July 2022 – For just over a month, from 7 May to 16 June 2022, Fatumo Yusuf Diriye spent 3 hours every day, walking to and from the nearest water source, 6 km away, to fetch water for her family. As she could carry only 2 ‘jirigaans” or pails of water at a time, and had to wait her turn in a long queue, her family had to use this water sparingly. They resorted to using ashes or sand to clean their hands.
Fatumo knows that having to deal with unsafe water has contributed to her 3 children under 5 falling sick with diarrhoea many times before. On many occasions, she has had to rush them to the nearest health facility for support. This is one burden that families like Fatumo’s, who depend on her daily earnings from a local market, can do without.
Visit from the Government and WHO officials
One day, early in May 2022, Fatumo heard there was a team of high-level officials from the Government and World Health Organization (WHO) visiting the camp where she lived, in North Galkayo, to assess the effects of the ongoing drought. Even though she could not go to see them, later on, she heard a few community members had requested the heads of the high-level team to support them to fix 2 water pumps which were not functioning for longer than she could recall. The Salama water pump, which is a borehole close to Fatumo’s home, was one of them, and the Halaboqad borehole was the second one that hadn’t been functioning for quite some time.
The visiting high-level team was led by HE Dr Fawziya Abikar Nur, the Federal Minister of Health and Human Services, and HE Abdi Nasir Yusuf Haji, the Vice Minister of Health for Puntland state. Representing WHO, Dr Ahmed Al-Mandhari, WHO Regional Director for the WHO Eastern Mediterranean, and Dr Mamunur Rahman Malik, WHO Representative to Somalia, were also part of the team.
Delivering swiftly on a promise
WHO conducts regular surveillance to test water quality, as water is linked with public health. Credit - WHO/Somalia
Fatumo, who has been living in a camp for the internally displaced since 2017, had heard the WHO team agreed to provide support, but was not sure how this would pan out. To her joy and surprise, within a few days, an expert came by to assess the Salama borehole. Around a month later, the Salama borehole was functioning again.
“Our lives have changed thanks to having water now from the Salama borehole, for drinking and also for all our household purposes,” says Fatumo, as it takes her just 30 minutes to fetch water now. The Diriye family can now collect at least 4 buckets of water, as their source, the borehole, is just above half a kilometre away. Hers is just one of the families living in one of 6 camps and 2000 households that now have access to clean water from the Salama borehole.
With WHO’s interventions to rehabilitate both the Salama and Halaboqad boreholes, 19 716 people now have access to clean water. This will translate to clean drinking- water, fewer waterborne diseases, like cholera and diarrhoea, healthier populations, and better sanitation. By protecting their families from preventable diseases, Fatumo and many parents like her can devote their time and resources to raising their families instead of coping with the stresses related to fighting diseases.
Access to water is a recognized human right
Fatumo carries water back home to top up her supply for the day. Credit - WHO/Somalia Currently, only 52% of the population in Somalia has access to improved drinking-water (the population using safely managed drinking-water services). In the internally displaced persons’ (IDP) camps like Salama, this number is staggeringly low. Recurring droughts, such as the one ongoing, make water an even more scarce resource.
Around the world, WHO and the United Nations Children’s Fund (UNICEF) found that in 2019, 2.2 billion people lacked access to safely managed drinking-water services. In July 2010, the United Nations General Assembly recognized access to water and sanitation as a human right. The Health Assembly acknowledged that every human needs to access “between 50 and 100 litres of safe, acceptable and affordable water a day for personal and domestic uses”. The General Assembly also stated that families’ main water source should be within 1 km of their home and that it should not take longer than 30 minutes for a family to access water.
To complement this, the UN Sustainable Development Goal (SDG) 6 aims to ensure availability and sustainable management of water and sanitation for all. This will reduce the burden of waterborne diseases, and advance progress towards universal health coverage.
Health Cluster pivots cross-cluster collaboration for delivery of integrated service package among underserved communities
17 July 2022 – In 2021, Somalia barely had time to take its eye off the COVID-19 pandemic, when the ongoing severe drought crept up. As a result, many Somali communities, over 40% of whom are known to live rural and nomadic lifestyles, lost their livestock and crops.
Health Cluster Coordinator for Somalia Ms Erna-Roelofje Christina Van Goor visits a hospital in Dhushamareb to view health services being offered, Galgaduud, June 2022. Credit: WHO Somalia/Fouzia BanoTo deliver a multifaceted response to the ongoing drought, Somalia’s Health Cluster has been working hand in hand with international and national health agencies in the country.
Delivering a joint response with partners
Led by the World Health Organization (WHO), the Health Cluster convened regular meetings with partners, including the federal and state ministries of health, where the Organization shared updates on the drought situation and the anticipated public health impacts. These meetings offered partners a platform to discuss their response activities related to the drought, in addition to gaps and challenges.
The Health Cluster has also been participating in inter-cluster platforms. Led by the United Nations Office for Humanitarian Affairs (OCHA), stakeholders’ inter-cluster response for drought entailed the reconstitution of the Drought Operations Coordination Centre. The Health Cluster is playing a key role in coordinating the overall health response in the country and working hand in hand with the water, sanitation and hygiene (WASH) and nutrition clusters for programmatic integrations.
Health Cluster partners have so far benefited from 2 rounds of Somalia Humanitarian Fund allocations, that amounted to approximately US $9 million to respond to the drought, targeting the most severely affected populations. These allocations have taken advantage of the cross-cluster collaboration, with most funding channeled to integrated health, nutrition and WASH projects.
Visiting the most hard-hit drought-affected areas
The Health Cluster serves as a coordinating body for health actors across Somalia to ensure the most vulnerable people have access to health services, Istanbul internally displaced persons camp, Jubaland, May 2022. Credit: WHO Somalia/AreteThe Health Cluster participated in inter-cluster caravan missions to various drought-affected areas to assess the health situation, identify gaps and opportunities for support. The areas visited include Bardhere, Luuq and Elwak in Gedo region, Garowe, Hargeisa and Jowhar, among other areas severely affected by the drought. From these missions, the Cluster observed the high prevalence of waterborne disease outbreaks, mainly due to a lack of sufficient clean water and hygiene services.
Suspected measles cases were also observed in most areas, including in camps for internally displaced persons (IDPs), where families complained about rashes and high-grade symptoms. The team noted large numbers of people suffering from malnutrition, which is known to be a key contributing factor in susceptibility to diseases, especially among children under 5.
Mental health and gender-based violence risks during drought
Mental health and psychosocial support services remain a key gap in internally displaced persons camps, with children showing signs of trauma and depression, as noted by the Cluster. The emotional impact of changes to family and community life appears to have affected children’s lives in the camps at alarming rates. Interaction with women in the camps revealed high cases of gender-based violence, mostly attributed to the lack of shelter as most newly arrived women and girls sleep outdoors.
As a result of these missions and observations made, funding allocation has been better prioritized to reach the most vulnerable populations in these severely affected areas. An integrated approach to the response to drought has been noted as the most effective and efficient way of providing assistance. These caravan missions have also provided an opportunity to monitor partners’ interventions related to health. However, as the agencies struggle to step up effective drought response, the needs of the underserved communities are clearly outpacing the available services.
Turning hope into happiness: rehabilitating boreholes in a hard-to-reach area in Somalia shows promises of a happy life
Children and adults queuing to collect water from the newly rehabilitated Salama borehole, North Galkayo, Puntland, 2 July 2022. Credit: WHO Somalia6 July 2022 – Water is a key prerequisite to safe hygiene and sanitation practices and — by that measure — good health and dignity. However, a large proportion of the Somali population has limited access to this valuable resource. Estimates from a survey conducted by the government and UN in 2014 state that 24% of Somalis live in rural areas, 23% follow nomadic lifestyles, and 15% (around 2.6 million) live in camps for the internally displaced. This means most communities living across Somalia’s expansive, dry landscape rely on rivers, wells, water trucks and boreholes to access water of compromised quality. The ongoing drought, which is the worst the Horn of Africa has witnessed in four decades, has placed water even further out of reach.
Visit to camps for internally displaced persons
On a bright, sunny morning on 10 May 2022, a high-level mission from Somalia’s Federal Ministry of Health and Human Services, the Puntland state Ministry of Health and the World Health Organization (WHO) visited North Galkayo to assess the health situation brought about by the drought.
Led by HE Dr Fawziya Abikar Nur, the Federal Minister of Health and Human Services, and HE Abdi Nasir Yusuf Haji, the Vice Minister of Health for Puntland state, the team included Dr Ahmed Al-Mandhari, the Regional Director for the WHO Eastern Mediterranean Regional Office and Dr Mamunur Rahman Malik, WHO Representative to Somalia.
Dr Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean, and Dr Mamunur Malik, WHO Representative to Somalia, visiting the Salama borehole when it was not functioning, North Galkayo, 10 May 2022. Credit: WHO Somalia/Fouzia Bano
During a visit to two camps for internally displaced persons (IDPs)– the Salama and Halaboqad camps – the team observed that the communities living there had no access to water. At the Salama camp, a borehole that used to provide water to around 2000 households and 12 000 people residing in six camps was broken. Similarly, the borehole at the Halaboqad camp, which usually serves around 7716 people, was not functioning as its water pump required solar batteries or a generator and pipes to carry water.
When delivering promises turns into happiness
The local communities, while meeting Dr Al-Mandhari and Dr Malik, raised their attention of the acute water shortage they were facing in the camp. After seeing the plight of the local communities and believing that access to safe water is a human right for everyone, everywhere, Dr Ahmed Al-Mandhari and Dr Malik committed to support the rehabilitation of two boreholes in both camps, which can permanently solve the acute water crisis faced by marginalized community members. Within the same week, WHO arranged for engineers to assess both boreholes.
In a month’s time, by 16 June 2022, both boreholes were rehabilitated, and a total of around 19 716 people living in both locations now have access to safe water, which has already started to change the life of these communities. This intervention will significantly reduce the prevalence of diseases among communities being served in addition to meeting their daily needs for water. The communities are happily using safe water from this borehole for all their household needs and thanking WHO for delivering its promises to safeguard lives of their children and elderly people.
WHO urges partners to redouble efforts
During his mission, Dr Ahmed Al-Mandhari urged partners to redouble efforts to support Somali communities during this trying time.
Rehabilitation efforts at the Halaboqad borehole after the high-level visit, North Galkayo, June 2022. Credit: WHO Somalia “It is really very heart-breaking to see the impact of drought. Let us come together to save lives,” said Dr Ahmed Al-Mandhari, the WHO Regional Director for Eastern Mediterranean Regional Office. “We see children, mothers and families suffering due to the shortage of water and food. I have seen young babies emaciated and admitted in hospitals due to malnutrition and related complications, such as pneumonia. These are all not just numbers, but human lives, and future generations of Somalia suffering from drought and the related impact of it – physical, mental, emotional or psychological. Let us all work towards fulfilling the spirit and values of the WHO Eastern Mediterranean Region vision 2023: health for all by all – calling for solidarity and action.”
“Currently, 3.5 million people in Somalia lack adequate access to water,” said Dr Mamunur Malik. “This increases communities’ chances of contracting diseases like cholera and diarrhoea. We are hereby appealing to both the health and the water, sanitation and hygiene (WASH) clusters in Somalia to work hand in hand to protect Somalis from preventable diseases and give them access to safe water and sanitation services, which are their human right.”
A lady draws water for her household from the Salama borehole, North Galkayo, July 2022, Credit: WHO SomaliaDr Malik added that WHO estimates that for every US $1 that donors and partners spend today to prevent and prepare for epidemics in Somalia, it will save US$ 35 in response to epidemics. Early action saves more lives, he emphasized.
