Epidemiological Week 27 (Week ending 8th July, 2018) Highlights Cumulative figures as of week 27 • A total of 224 health facilities submitted weekly • 1,522,140 consultations from week 1 reports of epidemic-prone diseases in week 27. to week 27. • Total number of consultations decreased from 55,343 • 5,733 cumulative cases of in week 26 to 51,625 in week 27. AWD/Cholera and 40 deaths since • A total of 257 alerts were received. 33 of these alerts were confirmed as true alerts in week 27. December 2017. • The highest numbers of diseases reported in week 27 • 8,573 total alerts were received, 464 were other acute diarrhoeas (2,486 cases), influenza of these, were confirmed as true like illness (1,342 cases) and severe acute respiratory alerts from week 1 to week 27, 2018. illness (1,173 cases). • 6,149 cumulative cases of suspected • A total of 151 new cases of suspected AWD/cholera measles cases since Jan 2018. Of the with no death were reported in week 27 compared to 344 AWD cases including 1 death in week 26. 4,068 (66%) are under 5 years while 2,081 (34%) are above 5 years. • A cumulative total of 5,733 AWD/cholera cases1, including 40 deaths have been reported since • 7,193 cumulative cases of Malaria December 2017. were reported since Jan 2018, 3,119 • The number of reported measles cases slightly (43%) are under 5 years, while increased from 58 in week 26 to 61 cases in week 27. 4,074(57%) are above 5 years. Table 1. Summary of Alerts for epidemic prone diseases Disease Wk24 Wk25 Wk26 Wk27 Cumulative cases (Wk 1 – 27, 2018 2018 2018 2018 2018) Total consultations 44,883 55256 55343 51625 1,522,140 Other Acute Diarrheas 2,411 2556 2599 2486 63995 Influenza Like Illness 1,298 1678 1195 1342 45,828 Severe Acute Respiratory 26,687 1,059 1279 1212 1173 Illness Suspected Measles 72 92 58 61 6149 Confirmed Malaria 337 476 226 189 7193 Acute Watery Diarrhoea 55 58 76 13 1999 Bloody Diarrhea 180 131 107 62 2298 Whooping Cough 45 34 58 45 1284 Acute Jaundice 2 5 16 7 117 Suspected Meningitis 1 0 3 3 79 Diphtheria 0 0 2 0 45 Neonatal Tetanus 1 2 0 0 23 1 The Cases of AWD/Cholera in the eWARN system are collected from sentinel sites. while the cases of AWD/cholera in Sitrep are collected from temporary CTC sites which doesn't include the Sentinel sites Page 1 of 22 Acute Flaccid Paralysis 2 0 0 0 13 Viral Hemorrhagic Fever 1 0 0 1 5 Completeness of Reporting & Reporting Rate Overall, a total of 224 (62%) health facilities submitted their weekly reports on time of the 364 active health facilities in Somalia. In Somaliland, 76 (100%) health facilities (HFs) of the 76 active health facilities submitted reports in week 27. As shown in Table 5, in Puntland, 45(64%) health facilities of the 70 active Health facilities submitted reports in week 27, while no reports were received from Sool region (4HFs) of Puntland. As shown in Table5 and Fig1 below, In South central, 103(47%) health facilities of 218 active health facilities submitted reports in week 27, while no report were received from Bay region for the last two weeks. Fig1: Completness of reporting Somaliland Puntland SCZ 100 80 60 40 20 Percentage of the HFs submitted report report submitted HFs the of Percentage 0 24 25 26 27 Epi-week Proportionate Morbidity As shown in figure 2; 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 27, the highest numbers of diseases were other acute diarrhoeas (2,486 cases), influenza like illness (1,342 cases), severe acute respiratory illness (1,173 cases), Suspected measles (61 cases) and Confirmed Malaria (189 cases). Fig2: Commonest Causes of Morbidity during Week 1 to 27 3,000 2,000 1,000 0 Wk24 Wk25 Wk26 Wk27 other acute Diaria influence like illness Severe Acute Respiratory Illness Suspected Measles Confirmed Malaria Page 2 of 22 AWD/Cholera situation in Somalia Following the heavy rains that have led to the floods in the Juba land and Shabelle basins, there has been an observed increase in the number of new AWD/Cholera cases (fig 4). The cholera outbreak that started in December 2017 in Beletweyne along river Shabelle has spread to Jowhar, Kismayo, Afgoye Merka and Banadir. The cholera spread is expected to increase due to the floods that have Fig3: District reporting cases in week 27 led to contamination of water sources in the flood affected regions. Floods have also led to blockage of access of health services which will contribute to delayed health seeking by the affected populations with. Over the past 2 weeks, there has been decrease in the number of AWD/Cholera cases reported in Lower Shabelle, Banadir and Lower Jubba; the regions that are affected by floods. In week ending 8th July, active transmission of AWD/cholera was reported in Kismayo district in Lower Jubba, Afgoye Kurtunwarey, Brava and Merka in Lower Shabelle as well as in 14 districts of Banadir region (Darkenly, Daynile, Hodan, Madina, Waberi, HamarWeine, Hamarjabjab, Wardhigley, Shibis,Yaqshid, Abdiaziz, Kaaran, Huruwa, and Howlwadag districts) (fig 3). In Kismayo, affected communities especially in Farjano IDP are reportedly using contaminated water due to floods. As shown in table 1, there was a decrease in the number of cases reported from 344 in week 26 to 151 in week 27. The Oral Cholera Vaccination that was implemented in 11 high risk districts in 2017 of the central region has greatly contributed to the reduction in the number of new AWD/cholera cases compared to the same time in 2017(fig 4). Fig4: AWD cholera trends in Somalia 2017/18 2000 Cases Deaths CFR (%) 4.0 1800 3.5 1600 1400 3.0 1200 2.5 1000 2.0 Cases 800 1.5 600 400 1.0 200 0.5 0 0.0 Case Fatality Rate(%) 26 28 30 32 34 36 38 40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 2018 epi week Page 3 of 22 Table 2. Summary of AWD/Cholera cases in different regions States Week 26 Week 27 Cumulative as of 8th July 2018 Regions Ending 1st July 18 Ending 8th July 18 Cases Deaths CFR (%) Cases Deaths CFR (%) Cases Deaths CFR (%) Banadir 124 1 0.8 75 0.0 0.0 2246 18 0.8 Jubba land L/ Jubba 97 0 0.0 59 0.0 0.0 2101 15 0.7 South west L/ Shabelle 18 0 0.0 5 0.0 0.0 289 4 1.4 Hir- M/Shabelle 105 0 0.0 12 0.0 0.0 532 2 0.4 shabele Hiraan 0 0 0.0 0 0 0.0 565 1 0.2 Total 344 1 0.3 151 0.0 0.0 5733 40 0.7 NB.Deaths are included among cases. Banadir Region is not a state Cholera Situation in Lower Jubba, Lower & Middle Shabelle and Banadir. • Banadir region which included Mogadishu city has one of the highest concentrations of refugees where access to safe water and proper sanitation is limited. The AWD/Cholera outbreak in Banadir region started in January 2018 following reports of similar outbreak in Beletweyne district of Hiraan region. Of the 17 districts that make up Banadir region, 14 have so far reported cases which have been managed in Banadir CTC located in the capital Mogadishu. There has been decrease in the number of AWD/Cholera cases from 124 cases including 1 death to 75 cases with no death in the past 2 weeks. More than 52% of the AWD cases reported in Banadir are children below 5 years of age. • In Lower Jubba, The AWD/Cholera outbreak started in week 5 of 2018 in the IDP communities of Farjano in Kismayo, where access to safe water and sanitation is limited. The reported cases of AWD/Cholera did not receive OCV which was implemented in Kismayo in March 2017. The persons may have been absent during the OCV campaign. Over the past week, the number of AWD/Cholera cases in Lower Jubba has decreased from 97 cases with no deaths to 59 cases with no death. More than 51% of the cholera cases reported from Lower Jubba are children below 2 years. • The AWD/Cholera outbreak in Lower Shabelle region started in week 17 of 2018and Afgoye and Merka district started in week 27-2018, as a result of displacement of people due to floods that have been reported in this regions. Brave is the most affected district and cases are being managed in lower Shabelle. More than 60% of the cases reported in Brave are children below 2years. • In Middle shabelle, it has been reported a new outbreak of AWD/Cholera in the same villages that were affected before. During week 27, a total of 12 cases with no deaths were reported of which 58% of them are children below 2 years old. The affected villages include Hantiwadag, Bulo Seikh and Horseed. Page 4 of 22 AWD/Cholera cases and floods Following heavy rains in Ethiopia and Somalia, flash floods have been reported in the basins of Juba and Shabelle in 4 states. An estimated 718,000 people have been affected of which 220,000 have been displaced. Floods contribute to contamination of water sources as well as disruption of health services which are precursors of cholera outbreaks.