Epidemiological Week 14 (Week ending 8th April, 2018)

Highlights Cumulative figures as of week 14  190 health facilities across submitted weekly  807,308 consultations from reports of epidemic-prone diseases in the electronic early week 1 to week 14. warning disease surveillance (EWARN) system in week 14.

 Total number of consultations increased from 54,445 in  2,090 cumulative cases of week 13 to 57,225 in week 14.  A total of 3,638 alerts were received. Of these, 297 were AWD/Cholera and 9 deaths confirmed as true alerts. since December 2017.  The highest numbers of diseases reported in week 14 were other acute diarrhoeas (1,937 cases), influenza like illness  4,647 cumulative cases of (1,472 cases) and severe acute respiratory illness (1,071 suspected measles cases since cases). the beginning of 2018.  A total of 214 new cases of suspected AWD/cholera no death were reported in week 14 compared to 112 AWD cases no deaths in week 13.  Of the 4,647 measles cases,  A cumulative total of 2,090 AWD/cholera cases, including 9 2,962 (64%) are under 5 years deaths have been reported since December 2017. while 1,685 (36%) are above 5  The number of reported measles cases decreased from 188 years. in week 13 to 146 cases in week 14.

Cumulative cases (Wk 1 – 14, Disease Wk12 2018 Wk13 2018 Wk14 2018 2018)

Total consultations 56448 54445 57255 807,308 Other Acute Diarrheas 1870 2110 1937 29527 Influenza Like Illness 1462 1656 1472 25,825 Severe Acute Respiratory 12,826 831 953 1071 Illness Suspected Measles 259 188 146 4647 Confirmed Malaria 212 225 223 3127 Acute Watery Diarrhoea 81 89 78 990 Bloody Diarrhea 63 71 67 708 Whooping Cough 66 38 61 639 Acute Jaundice 3 5 2 55 Suspected Meningitis 3 9 2 40 Diphtheria 0 0 0 23

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Neonatal Tetanus 0 0 0 17 Acute Flaccid Paralysis 0 0 0 1 Viral Hemorrhagic Fever 0 0 0 2

Total number of Consultations and Reporting sites Completeness of Reporting. Out of 265 health facilities expected to submit weekly reports of communicable diseases in the EWARN system across Somalia, 190 submitted reports in week 14, a completeness of reporting of 72%. A total of 54,445 consultations were recorded in week 14, 2018.

Fig1: Consultations and reporting sites, week 1 to 14, 2018 80,000 300 60,000 200 40,000 100

20,000 Consultations - 0 Sites Reporting WK1 Wk2 Wk3 WK4 WK5 Wk6 WK7 WK8 WK9 WK10 WK11 WK12 WK13 WK14 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018

Totoal Consultations Reporting Sites

Proportionate Morbidity

Other acute diarrhoeas (OAD), influenza like illness (ILI), severe acute respiratory illness (SARI), suspected measles and malaria are the commonest causes of morbidity across Somalia in 2018. In week 14, the highest numbers of diseases were other acute diarrhoeas (1,937 cases), influenza like illness (1,472 cases) and severe acute respiratory illness (1,071 cases).

Fig. 2. Commonest Causes of Morbidity during Week 1 to 14

3000 2500 2000 1500 1000 500 0 Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13 Wk14 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018

other acute Diaria influence like illness Severe Acute Respiratory Illness Suspected Measles Confirmed Malaria

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Situation Update of AWD/Cholera

AWD/Cholera situation in different regions of Lower Jubba , Hiiran, and Banadir.

Districts Reporting Cases in Week 14 Over the past 2 Weeks, there has been a significant increase in the number of AWD/Cholera cases reported in four regions (Banadir, Lower jubba, Middle Shabelle, and. In week 14, active transmission of AWD/cholera was reported in district of Middle Shabelle and Lower jubba district Kismayo as well as in 7 districts of Banadir region. In Hiraan, Kismayo and Jowhar affected communities are reportedly using contaminated water from open water sources. The AWD outbreak that was reported in Beletweyne in December 2017 is responsible for the spread to other regions that are all located at the banks of river shabelle. The Oral Cholera Vaccination that was implemented in 11 high risk districts of the central region has greatly contributed to the reduction in the number of new AWD/cholera cases according to last year.

Fig 3. AWD/Cholera cases in Somalia March 2017-April 2018 4000 4.0 3500 3.5 3000 3.0 2500 2.5 2000 2.0 1500 1.5 1000 1.0 500 0.5

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Number of AWD/Cholera cases AWD/Cholera of Number

week 1 week 3 week 5 week week week 7 week 9

Week 9 Week

week week 11 week 13

Week 11 Week 13 Week 15 Week 31 Week 33 Week 35 Week 37 Week Week 17Week 19Week 21Week 23Week 25Week 27Week 29Week 39Week 41Week 43Week 45Week 47Week 49Week 51Week 1-Mar 1-Apr 1-May 1-Jun Jul.17 AugustSep.17 Oct.17 Nov.17Dec.17 Jan-18 Feb-18Mar.18April.18

Cases Total Deaths CFR (%) weeks

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Table 1. Summary of AWD/Cholera cases in different regions Week 13 Week 14 Cumulative as of Epi- Week 49, 2017, Wk 14. Region (26th -March 1st April (2th -8th April 2018) 2018 2018) Cases Deaths CFR Cases Deaths CFR Cases Deaths CFR (%) (%) (%) Hiraan 6 0 0.0 0 0 0.0 565 1 0.2

Banadir 32 0 0.0 58 0 0.0 598 2 0.3

Lower Jubba 35 0 0.0 135 0 0.0 512 4 0.8

Middle Shabelle 39 0 0.0 21 0 0.0 415 2 0.5

Total 112 0 0.0 214 0 0.0 2,090 9 0.4

*The AWD/Deaths reported in this table have not been confirmed by stool analysis.

Cholera Situation in Hiraan, Lower Jubba, Middle Shabelle and Banadir.  The AWD/Cholera outbreak in Banadir region started in week 1 of 2018 following reports of a similar outbreak in Hiraan. Banadir region is one of the regions with the highest concentration of internally displaced persons (IDPs) where access to safe water and sanitation facilities are limited. Of the 15 districts that make up Banadir region, 7 have so far reported cases and these are managed in Banadir CTC located in the capital Mogadishu. There have been an increased number of AWD/Cholera cases from 32 to 58 cases in the past 2 weeks.  Lower Jubba is one of the cholera hotspots in Somalia located at the border with Kenya in the South. The current AWD/Cholera outbreak in started in week 5 of 2018 in the IDP communities of Farjano where access to safe water and sanitation is also limited. The district is host to returnees from Kenya as well as those displaced by war in Middle Jubba. Even when Oral Cholera Vaccination (OCV) was implemented in Kismayo in March 2017, the reported cases of OCV did not receive the vaccine. This may be attributed to these being new cases that were absent during the time of the vaccination. Over the past week, the number of AWD/Cholera cases in Kismayo increased from 35 and no death to 145 that occurred in Farjano CTC and Kismayo General Hospital CTU  Middle Shabelle region has been one of the cholera hot spots for the past decade due to limited access to safe water and sanitation. The new AWD/Cholera outbreak in Middle Shabelle started in week 7 of 2018 and the most affected villages are Hantiwadag, Kumis, Bulo Sheik and Horseed. Of the 415 cases so far reported in Middle Shabelle, 48% are children below 5 years.

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Table 3. Number of AWD/Cholera week 14compared to cumulative cases Region District Week 14 Cumulative Cases Deaths Week 49/17-week 14/18 <2 yrs 2-5 ≥ 5 yrs <2 yrs 2 -5yrs ≥ 5 yrs cases Deaths CFR (%) years Banadir Darkenley 6 0 0 0 0 0 82 0 0.0 Daynile 5 1 4 0 0 0 96 2 2.1 HamarJabja 0 0 0 0 0 0 20 0 0.0 Hawlwadag 0 0 0 0 0 0 20 0 0.0

Hodan 4 3 6 0 0 0 160 0 0.0 Karaan 0 0 0 0 0 0 13 0 0.0 Madina 5 1 14 0 0 0 133 0 0.0 waberi 3 1 1 0 0 0 28 0 0.0 Shibis 0 0 0 0 0 0 3 0 0.0 HamarWeine 2 0 0 0 0 0 8 0 0.0 Heliwaa 1 0 1 0 0 0 7 0 0.0 Wardigley 0 0 0 0 0 0 17 0 0.0 Yaqshid 0 0 0 0 0 0 11 0 0.0 Middle Jowhar 10 2 9 0 0 0 415 2 0.5 Shabelle Hiran Beletweyne 0 0 0 0 0 0 522 1 0.2 BuloBarde 0 0 0 0 0 43 0 0.0 Lower Kismayo 59 29 47 0 0 0 512 4 0.8 Jubba Total 95 37 82 0 0 0 2,090 9 0.4

Response Activities Implemented During Week 14

Coordination and Leadership.  Coordination meetings where held between the state ministries of Health in Hir- Shabelle and Jubba land for AWD/Cholera response Case management and Oral Cholera Vaccination  The cholera treatment facilities in Middle Shabelle, Banadir, Hiraan and Lower Jubba have been opened to manage AWD/Cholera cases reported from affected districts.  Following the completion of the first round of oral cholera vaccination campaign in Afmadow and Hudur, a second round of OCV in the same areas will be conducted from 22nd to 31st March 2018. Surveillance and Laboratory Investigations  A total of 4 regional Rapid Response Teams in affected regions have been deployed to verify and investigate AWD/Cholera rumours in all the affected regions and districts.  AWD/Cholera alerts are being received from different regions using the newly activated EWARN system.

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Water Sanitation and Hygiene  Community education was conducted in over-crowded areas of Banadir, Jowhar, Kismayo and Beletweyne districts.  Water trucking and water chlorination was implemented in 6 villages affected by AWD cholera in Jowhar.

Measles Situation

Districts Reporting Measles Case: Week 14 The number of suspected measles cases decreased from 188 cases in week 13 to 146 cases in week 14. Cumulatively, 4,647 cases of suspected measles have been reported across Somalia since the beginning of 2018. Of the 4,647 measles cases, 2,962 (64%) are under 5 years while 1,685 (36%) are above 5 years. The most affected regions include Galgadud (1,052 cases), Bay (610 cases) Banadir (721 cases), (429 cases), and Sool (352 cases (See Table 4 below).

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0 Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13 Wk14 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018

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Table4 : Summary of Suspected measles cases by region week 1 - 14, 2018

Cumulative cases Region Wk11 2018 Wk12 2018 Wk13 2018 Wk14 2018 (Wk 1 – 14)

Awdal 0 0 0 0 11 5 2 3 2 114 Banadir 44 46 51 30 721 Bari 2 - - - 90 Bay - 32 27 12 610 Galgaduud 115 96 11 0 1052 - - 2 2 18 Hiraan - 6 13 16 80 8 11 9 13 135 13 10 13 23 215 - 11 5 5 74 Middle Shabelle 7 1 2 2 56 Mudug 12 18 29 24 429 Nugaal 0 2 - 1 183 Sanaag 0 - 1 0 150 Sool 8 8 3 12 352 Togdher 15 - - - 163 Waqoyi Galbed 18 16 19 4 194 Grand Total 247 259 188 146 4647

Measles Outbreak Response Activities  The Federal Ministry of Health in collaboration with WHO, UNICEF and other partners launched the measles vaccination campaign in Mogadishu and Somaliland on 11th March 2018 to vaccinate 3.7 million children aged 6 months to 10 years in South Central and Somaliland.  The measles vaccination campaign was also conducted in Puntland in January 2018. 933,690 children aged 6 months to 10 years were vaccinated.

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Table 5. Cumulative Summary of Epidemic-prone Diseases in different Districts of Somalia as of Week 1-14, 2018

Regions District SARI ILI AWD BD OAD DIPH WC MEAS NNT AFP AJS VHF MAL MENG OC Total_cons

Awdal Total 0 4735 11 72 1650 0 0 11 0 0 0 0 6 2 17810 24298 Baki 0 582 0 28 116 0 0 0 0 0 0 0 0 0 1596 2322 Borama 0 2993 11 41 1098 0 0 7 0 0 0 0 2 0 11750 15902 Lughaya 0 109 0 2 96 0 0 0 0 0 0 0 0 0 886 1093 Zeila 0 1051 0 1 340 0 0 4 0 0 0 0 4 2 3578 4981 Bakool Total 78 23 0 36 232 0 11 114 0 0 0 0 250 0 29608 30352 Elberde 0 6 0 0 48 0 0 0 0 0 0 0 0 0 5455 5509 Huddur 5 0 0 11 42 0 0 1 0 0 0 0 76 0 4142 4277 Tayeeglow 11 8 0 0 26 0 0 6 0 0 0 0 30 0 802 883 Waajid 29 6 0 10 39 0 6 12 0 0 0 0 33 0 6796 6931 Wajid 33 3 0 15 77 0 5 95 0 0 0 0 111 0 12413 12752 Banadir Total 3721 5743 623 34 8848 0 9 721 0 0 0 0 514 12 227744 247969 Abdiaziz 0 23 0 0 62 0 0 0 0 0 0 0 0 0 4829 4914 Boondhere 0 0 18 0 161 0 0 23 0 0 0 0 0 0 4713 4915 Dayniile 0 0 0 0 113 0 0 7 0 0 0 0 0 0 7622 7742 Dharkinley 386 788 0 0 1270 0 0 40 0 0 0 0 0 0 13247 15731 Hamar Jab 165 354 0 2 356 0 1 7 0 0 0 0 1 0 8775 9661 Jab Hamar 66 161 0 0 650 0 0 10 0 0 0 0 0 0 6226 7113 Weyne Hodan 2 0 0 0 35 0 0 0 0 0 0 0 4 0 5147 5188 Howl-wadaag 0 0 0 0 0 0 0 5 0 0 0 0 1 0 20665 20671 Huruwaa 1139 2661 8 2 2601 0 0 363 0 0 0 0 3 12 28370 35159 Kaaraan 10 69 0 0 46 0 0 1 0 0 0 0 0 0 11182 11308 Kahda 56 470 0 0 258 0 0 1 0 0 0 0 0 0 1004 1789 Shibis 0 0 0 0 307 0 0 8 0 0 0 0 0 0 4495 4810 Waberi 0 0 0 0 33 0 0 0 0 0 0 0 0 0 10348 10381 Wadajir 1134 1138 597 1 1630 0 2 207 0 0 0 0 494 0 60312 65515 Wardhigley 12 0 0 13 806 0 6 30 0 0 0 0 11 0 26200 27078 Yaqshid 751 79 0 16 520 0 0 19 0 0 0 0 0 0 14609 15994 Bari Total 81 1020 5 10 572 0 0 90 0 0 0 0 335 0 27435 32683 Banderbayla 35 153 1 0 20 0 0 1 0 0 0 0 0 0 746 956

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Bossaso 46 847 3 0 345 0 0 28 0 0 0 0 331 0 12188 16901 Carmo 0 6 0 0 4 0 0 0 0 0 0 0 2 0 634 668 0 0 0 0 24 0 0 0 0 0 0 0 0 0 1553 1577 Iskushuban 0 7 0 1 5 0 0 0 0 0 0 0 0 0 614 627 Qardho 0 0 0 9 127 0 0 45 0 0 0 0 2 0 6616 6799 Rakko 0 0 1 0 43 0 0 16 0 0 0 0 0 0 2164 2224 Ufeyn 0 7 0 0 2 0 0 0 0 0 0 0 0 0 374 383 Waciya 0 0 0 0 2 0 0 0 0 0 0 0 0 0 2546 2548 Bay Total 190 254 20 120 232 8 0 249 0 0 0 0 500 0 39618 41191 Baidoa 190 235 14 29 219 8 0 183 0 0 0 0 433 0 35622 36933 Berdale 0 0 6 5 6 0 0 10 0 0 0 0 30 0 1717 1774 Burhakaba 0 19 0 86 7 0 0 56 0 0 0 0 37 0 1547 1752 Qasax dhere 0 0 0 0 0 0 0 0 0 0 0 0 0 0 732 732 Galgadud Total 2481 577 1 2 713 0 152 1413 0 0 3 0 483 5 32793 38623 Abudwak 972 136 0 0 160 0 26 709 0 0 0 0 108 4 6970 9085 Adado 471 200 0 1 203 0 45 270 0 0 3 0 164 0 6509 7866 Balanbale 146 53 0 0 30 0 11 129 0 0 0 0 59 0 1694 2122 Dhuusamarre 476 73 1 1 93 0 16 146 0 0 0 0 64 0 9470 10340 eb El Bur 24 6 0 0 38 0 0 34 0 0 0 0 17 0 533 652 El Dere 281 55 0 0 144 0 20 61 0 0 0 0 34 1 6040 6636 Gelinsor 111 54 0 0 45 0 34 64 0 0 0 0 37 0 1577 1922 Gedo Total 36 1011 0 0 207 0 0 18 0 0 0 0 222 0 13517 15011 B/hawo 22 237 0 0 48 0 0 9 0 0 0 0 59 0 3369 3744 Doolow 8 280 0 0 53 0 0 4 0 0 0 0 52 0 3164 3561 Garbahaarey 1 184 0 0 36 0 0 0 0 0 0 0 38 0 2775 3034 Luuq 5 310 0 0 70 0 0 5 0 0 0 0 73 0 4209 4672 Hiraan Total 3489 2192 198 0 3244 0 10 80 0 0 0 0 81 2 37279 46575 Belet Weyne 1923 1596 192 0 2048 0 2 69 0 0 0 0 80 1 23539 29450 Bulo Burto 942 287 6 0 896 0 0 11 0 0 0 0 1 1 6216 8360 Jalalaqsi 524 99 0 0 241 0 0 0 0 0 0 0 0 0 1375 2239 Matabaan 60 147 0 0 36 0 0 0 0 0 0 0 0 0 2886 3129 Maxaas 40 63 0 0 23 0 8 0 0 0 0 0 0 0 3263 3397 Lower Total 655 0 33 82 724 1 17 135 0 0 0 0 78 0 41354 43079 Juba Afmadow 140 0 20 30 116 0 0 0 0 0 0 0 0 0 6162 6468 Hagar 61 0 0 4 76 0 0 29 0 0 0 0 0 0 1884 2054 Page 9 of 11

Jamaame 59 0 6 7 87 0 0 39 0 0 0 0 29 0 4224 4451 Kismayo 395 0 7 41 445 1 17 67 0 0 0 0 49 0 29084 30106 Lower Total 381 296 6 2 3035 4 10 215 0 0 0 0 355 0 63499 67803 Shabelle Afgoi 25 70 0 0 148 0 0 25 0 0 0 0 5 0 11048 11321 Kurtunwarey 14 0 0 0 567 0 0 19 0 0 0 0 18 0 7465 8083 Marka 147 2 6 0 1687 4 10 137 0 0 0 0 290 0 37865 40148 Qoryooley 41 0 0 0 338 0 0 31 0 0 0 0 36 0 6278 6724 Wanla Weyn 154 224 0 2 295 0 0 3 0 0 0 0 6 0 843 1527 Middle Total 25 0 0 30 290 5 139 81 0 0 0 0 82 0 5395 6047 Juba Bu'ale 5 0 0 4 65 0 31 17 0 0 0 0 0 0 1027 1149 Jilib 17 0 0 18 180 5 85 51 0 0 0 0 82 0 3572 4010 Salagle 3 0 0 8 45 0 23 13 0 0 0 0 0 0 796 888 Middle Total 24 295 70 45 1274 0 1 49 0 0 0 0 141 0 36290 38189 Shabelle Adale 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1786 1786 Bal'ad 1 272 18 14 294 0 1 31 0 0 0 0 67 0 15558 16256 Jowhar 15 0 52 31 756 0 0 18 0 0 0 0 63 0 10687 11622 Mahaday 0 15 0 0 78 0 0 0 0 0 0 0 5 0 2921 3019 Warsheikh 8 8 0 0 146 0 0 0 0 0 0 0 6 0 5338 5506 Mudug Total 174 36 12 19 1452 3 53 429 17 0 19 0 8 1 63048 65271 Galdogob 2 0 1 0 94 0 0 7 0 0 1 0 0 0 4419 4524 Galkacyo 147 0 11 15 769 1 36 291 0 0 0 0 4 1 39055 40330 Harardere 25 36 0 1 113 0 12 29 0 0 0 0 4 0 2636 2856 Hobyo 0 0 0 0 430 2 5 92 17 0 18 0 0 0 8542 9106 Jariiban 0 0 0 3 46 0 0 10 0 0 0 0 0 0 8396 8455 Nugaal Total 72 771 6 0 428 1 6 183 0 0 0 0 0 0 11165 12632 Burtinle 1 148 0 0 108 0 0 29 0 0 0 0 0 0 2197 2483 Dangorayo 1 28 0 0 34 1 0 0 0 0 0 0 0 0 1333 1397 Eyl 12 213 0 0 84 0 0 44 0 0 0 0 0 0 3111 3464 Garoowe 58 382 6 0 202 0 6 110 0 0 0 0 0 0 4524 5288 Sanaag Total 556 337 5 0 453 1 73 150 0 0 0 0 20 1 13805 15535 Badhan 248 90 0 0 161 0 1 132 0 0 0 0 20 0 2918 3577 Dhahar 41 1 0 0 6 0 0 3 0 0 0 0 0 0 394 445 Eil-afweine 220 133 5 0 204 1 0 7 0 0 0 0 0 0 5236 5850 Erigavo 47 113 0 0 82 0 72 8 0 0 0 0 0 1 5257 5663 Sool Total 38 2193 0 2 1604 0 30 352 0 0 0 0 32 0 19870 24121

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Bocame 0 0 0 0 5 0 0 2 0 0 0 0 0 0 222 229 Hudun 0 374 0 0 215 0 1 14 0 0 0 0 0 0 1962 2566 Lasacanod 38 1648 0 2 1328 0 29 334 0 0 0 0 32 0 16146 19557 Taleex 0 171 0 0 56 0 0 2 0 0 0 0 0 0 1540 1769 Togdher Total 195 1556 0 116 1250 0 16 156 0 0 5 0 2 8 13552 16856 Ainabo 1 61 0 24 80 0 0 0 0 0 0 0 0 0 1046 1212 Buhodle 23 86 0 36 88 0 0 5 0 0 0 0 0 0 1429 1667 Burao 145 1238 0 42 974 0 16 151 0 0 5 0 2 8 9927 12508 Odwayne 26 171 0 14 108 0 0 0 0 0 0 0 0 0 1150 1469 Waqoy Total 630 4786 0 138 3319 0 112 201 0 1 28 0 18 9 31831 41073 Galbed Ballayabane 110 184 0 15 105 0 23 9 0 0 0 0 0 1 1363 1810 Berbera 182 1778 0 2 1178 0 68 99 0 1 28 0 0 1 9644 12981 Gabiley 130 1387 0 54 961 0 5 15 0 0 0 0 3 0 3414 5969 Hargeisa 101 1045 0 67 821 0 14 72 0 0 0 0 15 7 15064 17206 Sheikh 107 392 0 0 254 0 2 6 0 0 0 0 0 0 2346 3107 Grand Total 12826 25825 990 708 29527 23 639 4647 17 1 55 0 3127 40 725613 807,308

SARI-Severe Acute respiratotyIllness,ILI-Influenza Like Illness,AWD-Acute Watery Diarrhoea,BD-Bloody Diarrhoea,Diph-Diptheria,WC-Whooping cough,Meas-Fever With Rash/Measles,NNT-Neonatal Tetanus,AJS-Acute Jaundice Syndrome,VHF-Viral HeamorrhagicFever,Mal-Confirmed Malaria,Men-Bacterial Meningi

For inquires please contact the Surveillance team, WHO country office in Somalia or Dr Mutaawe Lubogo, Epidemiologist, [email protected]

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