Epidemiological investigation of dengue fever outbreak and its socioeconomic determinants in Banadir region, Somalia.

BACKGROUND: Dengue has become an alarming global problem and is endemic in many countries, particularly in tropical and subtropical countries. The aim of this study was to investigate dengue fever outbreak in Banadir Region, Somalia, to understand the risk factors (time, place, personal characteristics). METHODS: A descriptive cross-sectional study was undertaken to determine the levels of circulating anti-dengue virus antibodies and DENV NS1 antigen among Banadir Region residents, while a questionnaire survey was conducted to understand the clinical and demographic characteristics of the patients. RESULTS: A total of 735 febrile patients were studied, with 55.6% men and 44.3% women. The majority of the participants were children aged 14 years and younger. Among them, 10.8% tested positive for IgM antibodies against dengue virus (DENV), while the prevalence of DENV NS1 antigen was 11.8%. Fever and myalgia were the most common symptoms observed in the DENV-positive patients. CONCLUSIONS: A dengue fever outbreak has been confirmed in Banadir region, Somalia. This study provides information on the most affected districts and identifies risk factors contributing to DF outbreaks. The study recommends improving outbreak readiness and response, particularly in surveillance and laboratory diagnostics, by fostering intersectoral collaboration and establishing regulatory frameworks for financial and operational participation.

Using non-exceedance probabilities of policy-relevant malaria prevalence thresholds to identify areas of low transmission in Somalia.

BACKGROUND: Countries planning malaria elimination must adapt from sustaining universal control to targeted intervention and surveillance. Decisions to make this transition require interpretable information, including malaria parasite survey data. As transmission declines, observed parasite prevalence becomes highly heterogeneous with most communities reporting estimates close to zero. Absolute estimates of prevalence become hard to interpret as a measure of transmission intensity and suitable statistical methods are required to handle uncertainty of area-wide predictions that are programmatically relevant. METHODS: A spatio-temporal geostatistical binomial model for Plasmodium falciparum prevalence (PfPR) was developed using data from cross-sectional surveys conducted in Somalia in 2005, 2007-2011 and 2014. The fitted model was then used to generate maps of non-exceedance probabilities, i.e. the predictive probability that the region-wide population-weighted average PfPR for children between 2 and 10 years (PfPR2-10) lies below 1 and 5%. A comparison was carried out with the decision-making outcomes from those of standard approaches that ignore uncertainty in prevalence estimates. RESULTS: By 2010, most regions in Somalia were at least 70% likely to be below 5% PfPR2-10 and, by 2014, 17 regions were below 5% PfPR2-10 with a probability greater than 90%. Larger uncertainty is observed using a threshold of 1%. By 2011, only two regions were more than 90% likely of being < 1% PfPR2-10 and, by 2014, only three regions showed such low level of uncertainty. The use of non-exceedance probabilities indicated that there was weak evidence to classify 10 out of the 18 regions as < 1% in 2014, when a greater than 90% non-exceedance probability was required. CONCLUSION: Unlike standard approaches, non-exceedance probabilities of spatially modelled PfPR2-10 allow to quantify uncertainty of prevalence estimates in relation to policy relevant intervention thresholds, providing programmatically relevant metrics to make decisions on transitioning from sustained malaria control to strategies that encompass methods of malaria elimination.

Long-lasting insecticidal nets (LLINs) use among household members for protection against mosquito bite in Mogadishu districts.

Understanding long-lasting insecticidal nets (LLINs) utilization is important in monitoring and quantifying the impact of past and current prevention and control efforts of malaria. A cross-sectional study was carried out on a sample of 409 households in Mogadishu, to estimate the LLIN use and assess barriers to its utilization. A standardized questionnaire was used to collect data on demographics, malaria-related knowledge, and the use of preventive measures. LLINs use was assessed using multivariable generalized estimating equations with adjustment for clustering of study participants within the same household. Out of 409 households only 155 (37.9%) owned LLINs. Out of 237 owned LLINs, 199 (84.0%) were used. Median household size being 6.0 (3.0), intra-household net accessibility was low, with one net (42.6%) frequent. Most nets were from mass distribution (55.7%) and obtained '12 months ago'. Un-partnered respondents (unadjusted odds ratio [OR] 0.34, 95% CI 0.14, 0.82; p = 0.017) compared with partnered (married) respondents, large-sized household (adjusted OR 0.83, 96% CI 0.74-0.94; p = 0.002). There was marginal evidence of a greater odds of LLIN utilization among respondents knowledgeable of the correct cause of malaria, that is, mosquito bites (AOR 3.19, 95% CI 0.77, 13.2; p = 0.11) but was not statistically significant. Among households owning nets, most of the LLINs were hung the night prior to the survey (7.9% versus 98%) and was associated with greater marginal odds of utilization (p<0.001). Ownership of LLINs is insufficient in Mogadishu districts affecting household-level access and utilization. If this is not checked, this could weaken the progress made on malaria control efforts. LLIN utilization was modest and largely driven by recently acquired nets showing a desire to utilize them despite low coverage. These imply that mass and facility-based distribution, and awareness campaigns will remain relevant, but efforts for willingness-to-pay for LLINs should be strengthened to sustain coverage and replacements of worn-out nets.

Exploring Potential Determinants of Mosquito Net Ownership and Use in Somalia: A Cross-Sectional Study.

In Somalia, malaria remains a major public health threat. Understanding what influences the ownership and use of mosquito nets is of vital importance to accelerate malaria prevention efforts in the country. To explore the potential determinants of mosquito net ownership and use, this study conducted a secondary data analysis of the Somalia Micronutrient Survey 2019. Survey participants were identified through the multi-stage stratified cluster sampling, and logistic regression was performed for bivariate and multivariate analysis. The results suggested that household head's age, educational attainment, household size, employment status of household members, socioeconomic status, geographic regions and type of residence are significantly associated with mosquito net ownership (p < 0.05). The analysis also highlighted household head's age as an influential factor to mosquito net use. By further exploring and understanding the psychosocial determinants of mosquito net ownership and use, malaria prevention interventions can be made more effective in Somalia.

Evaluation of the electronic Early Warning and Response Network (EWARN) system in Somalia, 2017-2020.

BACKGROUND: In 2008, Somalia introduced an electronic based Early Warning Alert and Response Network (EWARN) for real time detection and response to alerts of epidemic prone diseases in a country experiencing a complex humanitarian situation. EWARN was deactivated between 2008 to 2016 due to civil conflict and reactivated in 2017 during severe drought during a cholera outbreak. We present an assessment of the performance of the EWARN in Somalia from January 2017 to December 2020, reflections on the successes and failures, and provide future perspectives for enhancement of the EWARN to effectively support an Integrated Disease Surveillance and Response strategy. METHODS: We described geographical coverage of the EWARN, system attributes, which included; sensitivity, flexibility, timeliness, data quality (measured by completeness), and positive predictive value (PPV). We tested for trends of timeliness of submission of epidemiological reports across the years using the Cochran-Mantel-Haenszel stratified test of association. RESULTS: By December 2020, all 6 states and the Banadir Administrative Region were implementing EWARN. In 2017, only 24.6% of the records were submitted on time, but by 2020, 96.8% of the reports were timely (p < 0.001). Completeness averaged < 60% in all the 4 years, with the worst-performing year being 2017. Overall, PPV was 14.1%. Over time, PPV improved from 7.1% in 2017 to 15.4% in 2019 but declined to 9.7% in 2020. Alert verification improved from 2.0% in 2017 to 52.6% by 2020, (p < 0.001). In 2020, EWARN was enhanced to facilitate COVID-19 reporting demonstrating its flexibility to accommodate the integration of reportable diseases. CONCLUSIONS: During the past 4 years of implementing EWARN in Somalia, the system has improved significantly in timeliness, disease alerts verification, and flexibility in responding to emerging disease outbreaks, and enhanced coverage. However, the system is not yet optimal due to incompleteness and lack of integration with other systems suggesting the need to build additional capacity for improved disease surveillance coverage, buttressed by system improvements to enhance data quality and integration.

One Health education in Kakuma refugee camp (Kenya): From a MOOC to projects on real world challenges.

Today, the world counts millions of refugees but only a fraction of them have access to higher education. Despite the multiple public health problems in refugee camps and the need to build local capacities to prevent and combat them, University level courses in public health are largely unavailable for refugees. This paper describes the development, implementation and evaluation of an innovative two-module blended-learning programme on One Health in Kakuma refugee camp (Kenya). This programme combines: (I) Interdisciplinary and multi-expert MOOC on "Global Health at the Human-Animal-Ecosystem interface"; (II) peer-to-peer learning involving students from University of Geneva Master of science in Global Health and research collaborations around specific and locally-relevant problems; (III) online mentoring and lecturing by experts from the Institute of Global Health of the University of Geneva in Kakuma. A total of 67 refugees applied to Module 1; 15 started the Module 1 in October 2017, of these 14 completed it and 6 passed the exams, finally five students started the Module 2 in October 2018 which they all passed in February 2019. Five student-led collaborative projects were developed focusing on the conception of a community-based monitoring system for prevalent diseases in the camp. With such a pedagogic approach, the programme provides an overview on Global Health challenges at the human-animal-ecosystem interface and the importance of the One Health approach, and introduces students to scientific research through interdisciplinary and international collaborations and innovation. The high number of applicants and positive feedback from students in Kakuma show the interest in One Health education in the camp. This learning experience ultimately aims at building local knowledge and capacity fostering "One Health" champions to reinforce local and national health system. This framework for One Health education could be potentially scaled up to other camps in Africa and the world.