Somalia Emergency Weekly Health Update The emergency weekly health update aims to provide an overview of the health activities conducted by WHO and health partners in Somalia. It compiles health information including nine health events (epidemiological surveillance) reported in Somalia, information on ongoing conflicts in some regions of Somalia and health responses from partners.

For further information please contact: Pieter Desloovere – WHO Communications Officer - [email protected] - T: +254 733 410 984

BULLETIN HIGHLIGHTS Reporting dates 15 - 21 September 2012 (reflecting Epidemiological week 37)

 Since 5 September, over 180 suspected cholera cases and 18 deaths have been reported from Hoosingow (most affected), Dhobley, Waraq and Afmadow. Ten stool samples were collected from Hoosingow in Badade district and four from Dhobley in , and are being tested in the lab. Preliminary results are expected on Saturday 22 September.

©HIJRA IN FOCUS STORY:

Dangerous pregnancy complications in Badbaado IDP camp,

For the past 10 months, Nadifo Mohamoud, a young mother, has been living in Badbaado IDP camp, Mogadishu. She has a small kiosk in front of her makeshift shelter and she vends clay-made ovens. Last Sunday, Nadifo’s mother ran to the Badbaado health clinic, supported by health partner HIJRA. Nadifo fainted while she was trying to cook food on an open fire near her makeshift shelter. Nadifo is 9 months pregnant and is expecting her baby any time. This is not her first pregnancy; she has already given birth to three children. Unfortunately, two of her children passed away before they reached Medical staff of HIJRA put Nadifo on a stretcher to the age of five. The medical staff of HIJRA quickly dispatched an bring her to the ambulance ambulance to the IDP camp, which wasn’t an easy task at all. The ©HIJRA medics were forced to leave the ambulance and take a stretcher on foot to find the unconscious mother in the camp.

A few minutes later, Nadifo was brought to the clinic where she got the necessary treatment. “She is suffering from hypoglycemia or low blood sugar” says Abba Yusuf Awies, HIJRA qualified midwife. “Without proper medical care, it may affect both the mother and the baby” she added. Since Nadifo is pregnant and did not eat well due to certain circumstances, her blood sugar had dangerously dropped down. Her condition was stabilized and few hours later she came out of her coma. Nadifo will remain in the clinic a few more days till she is fully recovered. “The last thing I can remember is when I was trying to put a kettle on the fire”, Nadifo recalls. “My mother told me later that an ambulance brought me here. I am very grateful for the help I got” she says. Nadifo is carried to the ambulance and later brought to the Badbaado health clinic in Mogadishu

EPIDEMIOLOGICAL SURVEILLANCE (EPI WEEK 37, 10 – 16 September 2012) © AVRO TIMELY REPORTING: Proportion of timely reporting sentinel sites by zone % Of the 196 facilities currently reporting to the 100 Communicable diseases Surveillance and Response (CSR) sentinel surveillance network, 192 reported 80 timely during week 37. All reporting facilities in 60 Puntland were timely. In Southern Somalia 97% (35 of 36), Central Somalia 96.7% (59 of 61) facilities 40 reported timely while in Somaliland, 98% (53 of 54) 20

facilities did report timely. Proportonfacilitiess of R. 0 SITUATION OVERVIEW: 14 16 18 20 22 24 26 28 30 32 34 36 Ongoing suspected outbreak of suspected cholera in Weeks Lower Jubba region is stabilizing but the case fatality Central Southern Puntland Somaliland rates remain high. Ten stool samples were collected from Hoosingow in Badade district and four from Dhobley in Afmadow district, now being processed in the lab. Preliminary results are expected on Saturday 22 September. On 17 September, three stool samples collected from cases presenting with suspected cholera in Dhobley MCH were tested using Cholera 0139 Smart ™ II – New Horizons Diagnostics Inc (Sensitive Membrane Antigen Rapid Test). All were negative for cholera. Tests are still available on ground and will continue to be used. More samples are expected. Since 5 September, over 180 cases and 18 deaths have been reported from Hoosingow (most affected), Dhobley, Waraq and Afmadow. Cross-border cases have been reported in Dadaab, Kenya. and Nugaal regions reported two cases of suspected cholera as during week 37. Number of regions reporting cases of suspected measles and confirmed malaria have increased significantly compared to week 36.

Districts reporting cholera cases Districts reporting measles cases Districts reporting malaria cases

SOUTHERN SOMALIA Table 1. Week 34 (20-26 August Week 35 (27 Aug-2 Sept Southern Somalia 2012) - Number of reporting 2012) - Number of reporting Week 36 (3 - 9 Sept 2012) - Week 37 (10 -16 Sept 2012) - (36 sentinel sites) sites 35 sites 36 Number of reporting sites 35 Number of reporting sites 35 Total cases *Proportional Total cases *Proportional Total cases *Proportional Total cases *Proportional Health Event (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity Susp. Cholera 0 0 6 (83.3) 0.1 1 (100) 0.01 2 (100) 0.03 Susp. Shigellosis 29 (65.5) 0.5 27 (81.5) 0.4 35 (80) 0.5 35 (71.4) 0.5 Susp. Measles 26 (100) 0.4 40 (90) 0.6 27 (81.5) 0.4 33 (84.8) 0.5 Acute Flaccid Paralysis 0 0 0 0 0 0 0 0 Susp. Hemorrh. Fever 0 0 0 0 0 0 0 0 Susp. Diphtheria 0 0 0 0 0 0 0 0 Susp. Whooping Cough 34 (70.6) 0.6 27 (88.9) 1.5 16 (93.7) 0.2 21 (81) 0.3 Confirmed Malaria 108 (54.6) 1.7 133 (57.9) 1.9 115 (65.2) 1.6 132 (57.6) 1.9 Neonatal Tetanus 0 0 0 0 0 0 0 0 All other consultations 5979 (48.5) 6739 (47.0) 6822 (48.5) 6740 (47.5) Total consultations 6176 (48.8) 7053 (47.3) 7016 (49.2) 6963 (48.1)

*Proportional morbidity is the number of cases for individual health event as a proportion of all consultations for the reporting week.

Trends of cases by age group and proportional morbidity Trends of cases by age group and proportional morbidity of for suspected cholera in Southern Zone week 1-37, 2012 % suspected measles in Southern zone from week 1-37, 2012 % 600 20 160 8 18 140 500 ≥5 yrs < 5 yrs p. morb 16 120 ≥5 yrs < 5 yrs p.morb 6 400 14 12 100

Cases 300 10 80 4 8 Cases 200 6 60 100 4 40 2

2 Proportionalmorbidity

proportionalmorbidity 20 0 0 0 0 Weeks 1 3 5 7 9 1113151719212325272931333537 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

Trends of cases by age group and proportional morbidity for confirmed Malaria in Southern Zone week 1-37, 2012 %

800 12 ≥5 yrs < 5 yrs P. morb 700 10 600 8 500 Cases 400 6 300 4 200

2 ProportionalMorbidity 100 0 0 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

While trends of suspected cholera cases reported in the sentinel sites have shown a decline since week 25, suspected cases have been reported in Afmadow and Badade districts. Between 5-16 September, a total of 93 cases and 11 deaths were reported in Hosingow village in Badade district. Suspected cases have also been reported in Dobley town in Afmadow district as well as Afmadow town. Sonce 18 September an estimated 35 cases were reported by partners in Afmadow town. More information is being gathered and samples will be collected as well.

Sentinel sites in 7 out of 18 districts reported suspected measles cases with stable trends. Trends in suspected shigellosis cases have also stabilized. Immunization activities have not been conducted in Southern Somalia for the past three years. The suspected whooping cough cases have also stabilized at high levels. The proportional morbidity of confirmed malaria cases remains high at almost 2%.

CENTRAL SOMALIA

Table 2. Week 34 (20-26 August 2012) Week 35 (27 Aug-2 Sept Week 36 (3 - 9 Sept 2012) - Week 37 (10 -16 Sept 2012) Central Somalia - number of reporting sites 2012) - Number of reporting Number of reporting sites - Number of reporting sites 61 sentinel sites 61 sites 58 57 59 Total cases *Proportional Total cases *Proportional Total cases *Proportional Total cases *Proportional Health Event (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity Susp. Cholera 186 (52.7) 1.2 156 (72) 1 138 (71.7.) 0.9 114 (71.9) 0.7 Susp. Shigellosis 53 (79.2) 0.3 31 (80.6) 0.2 27 (92.6) 0.2 25 (72) 0.2 Susp. Measles 111 (74.8) 0.7 164 (73.8) 1 134 (86.6) 0.8 97 (91.7) 0.6 Acute Flaccid Paralysis 0 0 0 0 0 0 0 0 Susp. Hemorrh. Fever 0 0 0 0 0 0 0 0 Susp. Diphtheria 0 0 0 0 0 0 0 0 Susp. Whooping Cough 23 (86.9) 0.1 11 (100) 0.1 32 (87.5) 0.2 51 (82.3) 0.3 Confirmed Malaria 309 (30.7) 2 287 (34.5) 1.8 186 (22) 1.1 294 (34.7) 1.8 Neonatal Tetanus 2 (100) 0.01 2 (100) 0.01 5 (100) 0.03 8 (100) 0.05 15049 15657 All other consultations 14565 (43) (44.2) (41.5) 15740 (43) 15700 16179 16329 Total consultations 15249 (43.4) (44.7) (42.1) (43.6)

*Proportional Morbidity is the number of cases for individual health event as a proportion of all consultations for the reporting week.

Trends of cases by age group and proportional morbidity for Trends of cases by age group and proportional morbidity suspected cholera in Central Zone week 1-37, 2012 % for confirmed Malaria in Central Zone week 1-37, 2012 % ≥5 yrs < 5 yrs p. morb 600 20 600 ≥5 yrs < 5 yrs p. morb 10 18 500 16 500 8 400 14 12 400

Cases 6 300 10 Cases 300 8 4 200 6 200 4 100 proportionalmorbidity

2 100 2 Proportionalmorbidity 0 0 0 0 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

Trends of cases by age group and proportional morbidity of suspected measles in Central zone from week 1-37, 2012 %

160 ≥5 yrs < 5 yrs p.morb 8 140

120 6

100

80 4 Cases 60 40 2 Proportionalmorbidity 20 0 0 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

Suspected cholera cases have consistently declined in recent weeks with majority of cases being reported in Banadir region (95.6%). Similar trends have been observed with suspected shigellosis cases albeit at lower levels. Alerts of increasing suspected cholera cases were reported from Cadaado and Guriel districts in Galgadud region and upon investigation it was established that the cases were not clinically compatible with the standard case definition. As a result no samples were collected. WHO maintains a stock of transport media and rapid tests in Galcacyo ready for use whenever there are rumors in the surrounding areas. For two consecutive weeks, suspected measles cases have declined. However, in Marka, suspected measles cases are increasing. In Banadir region, Huriwa and Wadajir districts reported most of the suspected measles cases and both districts have seen declines in recent weeks.

Whooping cough cases are increasing in Huriwa district, which has also experienced measles outbreak. The district has been receiving IDPs from the underserved southern regions fleeing where there is armed conflict. All regions, except Hiraan, reported confirmed malaria cases although 83.3% of cases were reported in Banadir region. SOMALILAND

Table 3. Week 34 (20-26 August Week 35 (27 Aug-2 Sept Week 36 (3 - 9 Sept 2012) - Somaliland 2012) - Number of reporting 2012) - Number of reporting Number of reporting sites Week 37 (10 -16 Sept 2012) - 54 sentinel sites sites 54 sites 54 54 Number of reporting sites Total cases *Proportional Total cases *Proportional Total cases *Proportional Total cases *Proportional Health Event (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity Susp. Cholera 0 0 0 0 0 0 0 0 Susp. Shigellosis 29 (58.6) 0.8 16 (50) 0.4 27 (59.3) 0.6 16 (56.3) 0.4 Susp. Measles 5 (100) 0.1 8 (50) 0.2 0 0 0 0 Acute Flaccid Paralysis 0 0 0 0 0 0 0 0 Susp. Hemorrh. Fever 0 0 0 0 0 0 0 0 Susp. Diphtheria 0 0 0 0 0 0 0 0 Susp. Whooping Cough 0 0 0 0 0 0 0 0 Confirmed Malaria 0 0 0 0 0 0 0 0 Neonatal Tetanus 0 0 0 0 0 0 0 0 All other consultations 3686 (50.9) 4526 (43.7) 4500 (42.1) 4106 (46.6) Total consultations 3720 (51) 4550 (43.6) 4527 (42.2) 4122 (45.6)

*Proportional Morbidity is the number of cases for individual health event as a proportion of all consultations for the reporting week. Trends of cases by age group and proportional morbidity for suspected cholera in Somaliland week 1-37, 2012 Trends of cases by age group and proportional morbidity of % suspected measles in Somaliland from week 1-37, 2012 % 160 8 600 20 18 140 7 500 16 120 ≥5 yrs < 5 yrs p.morb 6 400 ≥5 yrs < 5 yrs p. morb 14 12 100 5 Cases 300 10 80 4 8 Cases 60 200 6 3 100 4 40 2

2 proportionalmorbidity 20 0 0 1 0 Proportionalmorbidity Weeks 0 1 3 5 7 9 1113151719212325272931333537 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

Sixteen suspected shigellosis cases were reported mostly in 2 facilities in Lasanod district which reported 13 of the 16 cases reported in week 37.

PUNTLAND

Table 4. Week 34 (20-26 August 2012) Week 35 (27 Aug-2 Sept Week 36 (3 - 9 Sept 2012) - Week 37 (10 -16 Sept 2012) Puntland - Number of reporting sites 2012) - Number of reporting Number of reporting sites - Number of reporting sites 45 sentinel sites 45 sites 45 45 45 Total cases *Proportional Total cases *Proportional Total cases *Proportional Total cases *Proportional Health Event (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity (% < 5 yrs) morbidity Susp. Cholera 3 (100) 0.1 1 (100) 0.02 1 (100) 0.02 9 (88.9) 0.2 Susp. Shigellosis 3 (33.3) 0.1 5 (60) 0.1 0 0 1 (0) 0.02 Susp. Measles 11 (81.8) 0.2 5 (80) 0.1 7 (85.7) 0.1 1 (100) 0.02 Acute Flaccid Paralysis 0 0 0 0 0 0 0 0 Susp. Hemorrh. Fever 0 0 0 0 0 0 0 0 Susp. Diphtheria 0 0 0 0 0 0 0 0 Susp. Whooping Cough 1 (100) 0.02 0 0 0 0 0 0 Confirmed Malaria 0 0 0 0 0 0 0 0 Neonatal Tetanus 0 0 0 0 0 0 0 0 All other consultations 5316 (44.4) 5713 (45.6) 5592 (43.9) 5710 (43.4) Total consultations 5334 (44.5) 5724 (45.7) 5600 (44) 5721 (43.5)

*Proportional Morbidity is the number of cases for individual health event as a proportion of all consultations for the reporting week.

Trends of cases by age group and proportional morbidity Trends of cases by age group and proportional morbidity of for suspected cholera in Puntland week 1-37, 2012 % suspected measles in Puntland from week 1-37, 2012 % 600 20 160 8 18 140 500 ≥5 yrs < 5 yrs p. morb 16 ≥5 yrs < 5 yrs p.morb 120 6 400 14 12 100 300 10 Cases 80 4

8 Cases 60 200 6 40 100 4 2

2 proportionalmorbidity 20 0 0 0 0 Proportionalmorbidity Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 Weeks 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37

Six facilities in Mudug and Nugal regions reported the 9 suspected cholera cases in week 37. The facilities had not reported cases in at least 4 weeks. Feedback is awaited on the status of investigation in the suspected cases.

CONFLICT-RELATED INJURIES Weapon related injuries reported in four major (Source: four major hospitals in hospitals in Mogadishu week 1- 37, 2012 Mogadishu) 240 200 From 1 January – 16 September 2012, 5062 casualties from weapon-related 160 injuries were treated in four hospitals in 120 Mogadishu, with 218 cases (4.3%) under Cases >5 years the age of five. A total of 97 deaths above 80 the age of five and 13 deaths below the 40 <5 years age of five years were registered. 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 Weeks

Breakdown of casualties treated in four major hospitals in Mogadishu, from 10 - 16 September 2012

Number of Number of Number of patients Number of Number of Number of casualties under Number Number of Number of operations transferred to Nairobi deaths in Casualties discharged the age of five of burns fractures chest injuries carried out or other place hospital 147 74 0 15 24 19 50 0 4

Breakdown of casualties treated in major hospitals of Middle and Lower Jubba region, from 9 - 15 September 2012

Number of casualties Number Number of Number of patients Number of Number of Number of under the Number Number of of chest operations transferred to Nairobi deaths in Casualties discharged age of five of burns fractures injuries carried out or other place hospital

Afmadow hospital 25 0 0 0 0 0 0 0 0 Kismayo General hospital 67 1 0 1 8 7 7 4 9 TOTAL 92 1 0 1 8 7 7 4 9

HEALTH RESPONSE

Activity data from 8-13 September 2012

During the reporting period, AFREC with the support of World Concern trained about five traditional birth attendants (TBA) and five community health workers on Joint and Nutrition Assistance. The initiative’s main objective is to educate mothers on breastfeeding practices, dietary diversity and the use of the locally available nutritional foods and good health practices.

Partner Region(s) or location Health intervention(s) Target Population Total consultations Female

Integrated Health and Nutrition 57 390 764 380 229 InterSoS Hospital 500 000 584 291 212 TB Center 250 000 7 4 1 Health Centers 90 000 570 308 343 Direct Aid Banadir, Gedo Health Centers 201 000 543 261 279 SHARDO Banadir, Bay Primary Health Unit 1 027850 393 248 103 Middle Shabelle Health Center 6169 770 375 301 Banadir Mobile Clinic 251 784 363 200 176 Banadir TB Treatment 129 062 46 19 1 HIJRA Banadir Mobile Team 12 360 226 130 82 Banadir, Lower Shabelle Health Centers (MCH/OPD) 163 673 1749 807 737 AFREC Health Centers 21 200 250 113 137 Somali Community Concern (SCC) Banadir, Galgaduud, Primary Health unit (health post) 1266 593 501 172 Middle Shabelle

*Whilst the information contained in this bulletin has been presented with all due care, it does not warrant or represent that the information is free from errors or omission.

© SOYDA

A child gets medical attention at the Save the Children health facility in , Bay region

An MCH managed by Muslim Hands medical teams provide treatment to IDPs The SCC health post in , and host communities in Mogadishu Mogadishu provides health services to men, women and children at the Majo IDP settlement

A mother and her two children at a WARDI health facility in Mogadishu