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.

Survival analysis of all critically ill patients with COVID-19 admitted to the main hospital in Mogadishu, Somalia, 30 March-12 June 2020: which interventions are proving effective in fragile states?

OBJECTIVES: To determine risk factors for death in patients with coronavirus disease 2019 (COVID-19) admitted to the main hospital in Somalia, and identify interventions contributing to improved clinical outcome in a low-resource and fragile setting. METHODS: A survival analysis was conducted of all patients with COVID-19 admitted to the main hospital in Somalia from 30 March to 12 June 2020. RESULTS: Of the 131 patients admitted to the hospital with COVID-19, 52 (40%) died and 79 (60%) survived. The main factors associated with the risk of in-hospital death were age ≥60 years {survival probability on day 21 was 0.789 [95% confidence interval (CI) 0.658-0.874] in patients aged <60 years vs 0.339 (95% CI 0.205-0.478) in patients aged ≥60 years}, cardiovascular disease [survival probability 0.478 (95% CI 0.332-0.610) in patients with cardiovascular disease vs 0.719 (95% CI 0.601-0.807) in patients without cardiovascular disease] and non-invasive ventilation on admission (patients who were not ventilated but received oxygen were significantly more likely to survive than patients who were ventilated; P<0.001). CONCLUSION: Considering the risk factors (age ≥60 years, presence of cardiovascular disease and use of non-invasive ventilation) is critical when managing patients with severe COVID-19, especially in low-resource settings where availability of skilled healthcare workers for critical care units is limited. These findings also highlight the importance of use of medical oxygen for severely ill patients, and the critical aspect of deciding whether or not to ventilate critical patients with COVID-19 in order to improve clinical outcome.

Preliminary findings of COVID-19 infection in health workers in Somalia: A reason for concern.

BACKGROUND: Somalia, a country with a long history of instability, has a fragile healthcare system that is consistently understaffed. A large number of healthcare workers (HCWs) have become infected during the coronavirus disease-19 (COVID-19) pandemic. OBJECTIVE: This report presents the preliminary findings of COVID-19 infection in Somali HCWs, the first of such information from Somalia. METHODS: This preliminary retrospective study analysed available data on infection rates among Somali HCWs. RESULTS: As of 30 September 2020, 3700 cases of COVID-19, including 98 deaths, had been reported in Somalia; 191 (5%) of these cases were HCWs. During the first 180 days of the outbreak, 311 HCWs were tested for COVID-19 and 191 tested positive (positivity rate: 61%). During the epidemic's peak, HCWs represented at least 5% of cases. Of the 191 infected cases, 52 (27%) were doctors, 63 (33%) were nurses, seven (4%) were laboratory technicians, and 36% were other staff. CONCLUSION: More information must be sought to put measures in place to protect the health and safety of HCWs in Somalia's already understaffed and fragile healthcare system.