Responding to COVID-19 in Somalia: 6 months of resilience and strength: the story in pictures, March-September 2020

Responding to COVID-19 in Somalia: Progress Report 6 months of resilience and strength March-September 2020 WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: Responding to COVID-19 in Somalia: 6 months of resilience and strength: the story in picture, March-September 2020 / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2020 Identifier: ISBN: 978-92-9274-447-2 | ISBN: 978-92-9274-448-9 (online) Subjects: COVID-19 | Betacoronavirus | Disease Outbreaks | Pictorial Work Classification: NLM WC 505 This publication was originally published under ISBN: 978-92-9022-352-8, 978-92-9022-353-5 _______________________________________________________________ © World Health Organization 2020 Some rights reserved. 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Photo credits: WHO/SOMALIA Design and Printing: UNON, Publishing Services Section, Nairobi Responding to COVID-19 in Somalia: Progress Report 6 months of resilience and strength March-September 2020 Contents A message from the WHO Representative in Somalia 5 Setting the scene 7 Strengthening coordination and collaboration 8 Establishing a preparedness and response structure 8 Supporting coordination of the response 8 Sharing information and building trust 9 Partnering for an efficient response to COVID-19 10 Detecting cases 12 Developing capacity for testing 12 Enabling real-time data transmission 13 Detecting COVID-19 cases: commitment of health workers 13 Reaching the “silent” districts 14 Managing cases and scaling up treatment 17 Isolating and caring for COVID-19 cases 17 Improving access to medical oxygen for COVID-19 patients 18 Generating knowledge to improve our response 21 Communicating with people 22 Timeline of key COVID-19 related developments in Somalia, January-September 2020 24 Looking ahead 28 5RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Racing against time Six months on from the detection of the first case of COVID-19 in Somalia, our message is clear: we have come a long way, but the fight against COVID-19 is far from over. We must remain vigilant, engaged, inspired by what we have done in the past 6 months, prepared and focused until everyone is safe. Together with Somalia’s Federal Ministry of Health and Human Services and our partners, we have worked hard to suppress the virus, limit community spread and slow the transmission of the disease in a fragile setting. Time will tell how successful we have been. This report is a summary of the work that we did as part of our responsibility, commitment and organizational obligation to protect vulnerable people in Somalia and keep the country safe. Time was vital in our work in the last six months. We made sure that whatever we did was measurable and had an impact. Every life that was saved or case that was avoided through our collective work and efforts in these 6 months should inspire us to build back better, and make sure that the health system of Somalia recovers better and stronger and that we are better prepared for the next “unknown”. On this journey, we have built strategic collaborations that have strengthened our response, today and for years to come. We have seized opportunities to innovate in unprecedented ways by embracing digital technology and social media. And we have also been reminded of the real need to strengthen Somalia’s health system so that any potential outbreak in the future can be effectively prevented or managed. Today, I stand humbled, proud and determined. Humbled by the incredible resilience and strength of the people of Somalia as they face yet another crisis with dignity and courage. Proud of what WHO and my colleagues have achieved, working around the clock and doing what was needed to battle this outbreak. We have lost three Somali colleagues to COVID-19. Their bravery and sacrifices will never be forgotten and I share my sincere condolences with their families over the loss we are all experiencing together. Finally, I am determined, together with the rest of the Somalia country office, to work with Somalia’s Federal Ministry of Health and Human Services and our partners to contain this outbreak to the best of our ability and to continue laying the building blocks for Somalia’s future and more resilient health system. It is only together that we can do this. We can only end this pandemic if we can end it in settings like Somalia Dr Mamunur Rahman Malik, WHO Representative for Somalia. A message from the WHO Representative in Somalia © WHO 6 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH © WHO COVID-19 in Somalia: summary of the data On 16 March 2020, Somalia recorded its first confirmed case of coronavirus disease 2019 (COVID-19). In a matter of weeks, the disease spread to all states of the country with most cases reported in Banadir region, followed by Somaliland and Puntland. The outbreak developed rapidly during April, May and June 2020 but, since late June, the numbers of confirmed COVID-19 cases and deaths have gradually declined. In August 2020, 114 cases of COVID-19 cases were confirmed in Somalia, a decrease of 60% compared with 287 cases recorded in July 2020. The positivity rate of tested cases was 2,2%, also a substantial drop compared with the rate of 50–60% reported in mid-June 2020. Between 16 March and 12 September 2020, 24 935 suspected cases of COVID-19 were tested in Somalia, of which 3389 were confirmed as positive for COVID-19, and 98 deaths were recorded as COVID-19 related. Most confirmed cases (83%) were aged between 20 and 60 years, with a median age of 32 (range 1 to 110) years and 74% of the confirmed cases were males. 7RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH On 16 September 2020, Somalia marked 6 months since its first laboratory-confirmed case of COVID-19. With this report, the World Health Organization’s (WHO) Somalia country office looks back on how it responded to the needs of the country during one of its worst public health crises and considers what challenges and opportunities lie ahead. While the COVID-19 epidemic has swept through the world and overwhelmed some of the most developed health systems, few countries have feared its potentially devastating impact as much as Somalia. Ranked 194 out of 195 on the Global Health Security Index1, Somalia’s health system has been weakened by decades of civil war, insecurity, and chronic droughts, floods and disease outbreaks. It has just two health care workers per 100 000 people and 15 intensive care unit beds for a population of more than 15 million. In March 2020, Somalia had no ventilators for oxygen therapy and lacked an integrated disease surveillance system able to detect, diagnose and facilitate a rapid response to an outbreak. On 16 March 2020, a Somali student returning to Mogadishu from abroad became Somalia’s first confirmed case of COVID-19. Three days later, a second case was confirmed – another traveller arriving in Mogadishu by airplane. Within a month, there were 80 laboratory-confirmed COVID-19 cases in Somalia, including some with no history of travel. This confirmed that the virus was spreading within communities. With 2.6 million internally displaced people and daily unmonitored cross-border movements by nomadic communities, this community transmission could have potentially devastating consequences. With no proactive testing and Setting the scene © WHO 1 Global Health Security Index: building collective action and accountability. Nuclear Threat Initiative and Johns Hopkins University; 2019 (https://www.ghsindex.org/wp-content/uploads/2020/04/2019-Global-Health-Security-Index.pdf, accessed 20 July 2020). 2 COVID-19 Situation Report, Somalia, Issue 27 (12 September 2020). Federal Ministry of Health, Somalia and World Health Organization; 2020. tracking strategy immediately put in place, clusters of cases quickly developed, particularly in Banadir and Somaliland. In the first 6 months of the epidemic, there were 3389 laboratory-confirmed cases of COVID-19 in Somalia, including 98 associated deaths2. While these numbers are far fewer than those of much of Europe or North America, they hide a much more concerning reality. Because of the very low capacity for testing nationally, the inaccessibly of large parts of the country because of insecurity and the stigma attached to the virus within communities, there is concern that the available data on COVID-19 do not provide an accurate picture of the spread and scale of the virus in Somalia. As Somalia continues its fight against one of the most serious disease outbreaks the country has ever experienced, taking stock of what has worked in combatting COVID-19, what challenges remain and what still needs to be done is more important than ever. The health of the people in Somalia for decades to come depends on assessing and understanding these factors. 8 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Establishing a preparedness and response structure In January 2020, immediately after WHO declared COVID-19 a public health emergency of international concern, the WHO country office in Somalia started plans to prepare for and tackle the likely introduction of the virus into the country. From early February, the office started working with Somalia’s Federal Ministry of Health and Human Services, UN agencies and partners on improving preparedness for prevention and early detection of imported cases, management of suspected and confirmed cases and a possible outbreak in the country. Supporting coordination of the response Having provided critical technical input to the development of Somalia’s national response plan for COVID-193 and the UN and partners’ preparedness and response plan for Somalia4, WHO served as a key technical advisor in the coordination and implementation of these plans. At the national level, a strategic coordination platform was set up between WHO, Somalia’s health authorities, the UN, donors and partners. A technical incident management system team was created within the WHO Somalia country Strengthening coordination and collaboration 3 National Emergency Preparedness and Response Plan for COVID-19 in Somalia. Mogadishu: Federal Ministry of Health and Human Services; 2020. 4 Somalia country preparedness and response plan (CPRP) – COVID-19. UN and partners’ support towards the immediate humanitarian and socioeconomic consequences of COVID-19. April 2020 (https://fscluster.org/sites/default/files/documents/somailiacprp_final_subow_26_april_1.pdf, accessed 30 June 2020). office and it supported the creation of similar technical and management structures in Somalia’s Federal Ministry of Health and Human Services. WHO has been playing a key role in advising and contributing to these systems. Coordination with and technical support to other UN agencies and nongovernmental organizations was also scaled up through weekly coordination meetings with the UN COVID-19 technical task force and weekly meetings with the Health Cluster where partners could share information, guidance and their response plans on the COVID-19 outbreak. Throughout this outbreak, WHO was also asked by the Somali Health Donor Group and Somalia Humanitarian Donor Group to present a situation analysis of COVID-19 every 2 weeks. The aim of the situation analysis was to brief the groups on the evolving trajectory of the epidemic, the © WHO 9RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH In focus: incident management system team of the WHO country office Since February 2020, before the first COVID-19 case was even confirmed in Somalia, the WHO country office for Somalia had set up its own incident management system team. The aim of the team was to enhance the coordination of WHO’s response to the outbreak, monitor the quality of the response and epidemic progression by analysing epidemiological data, and guide a data-driven decision process for containment of the outbreak. The team worked tirelessly, meeting three times and then two times a week via video conferencing. These meetings of the incident management system team have provided a critical opportunity to share information, review progress and plan essential response activities across the country. Through the system, adaptations to WHO’s response activities are collectively discussed and on-the-spot decisions are taken, which ensures a flexible response to the dynamic and urgent situation. The team’s structure has also facilitated the inclusion of staff from different programmes, in particular from the polio programme which has decades of experience in disease surveillance at the community level. As about 40 staff connect every week, from Baidoa to Islamabad, these meetings allow those involved to feel engaged and encouraged to continue the important work against COVID-19 in Somalia. © WHO effect of ongoing interventions on the epidemic curve, funding gap, and the strategies needed to tackle the outbreak and ensure continued access to essential health care services for the Somali population. In addition to these presentations, the WHO Somalia Representative has also regularly briefed and provided technical advice and guidance to donors and diplomats to inform funding decisions. Sharing information and building trust Timely and reliable information on the outbreak is critical to health and humanitarian actors in Somalia. Therefore, in late March, WHO Somalia and the Ministry of Health and Human Services of the Federal Government of Somalia started publishing a weekly situation report on the COVID-19 outbreak. This report outlines the epidemiological evolution of the virus, and sets out key activities undertaken and areas to prioritize in the fight against the COVID-19 outbreak in Somalia. A second important information tool developed is the online dashboard on COVID-19 in Somalia, which presents key data and maps on COVID-19. 10 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH The dashboard is updated every day, therefore giving an up-to-date picture of the evolution of the outbreak. In addition, WHO has shared regular information through topical information notes on COVID-19, press releases and monthly infographics of key activities undertaken in response to the COVID-19 outbreak. Together, these communications have contributed to generating reliable information on the evolution of the outbreak and response needs in Somalia. They have also helped develop accountability and build trust with key partners – areas that are critical to WHO in the delivery of its mandate in Somalia. These documents can be found at the following links: Somalia COVID-19 dashboard: https://bmgf.maps.arcgis.com/ apps/opsdashboard/index.html#/ d0d9a939c5fa401caa3a7447e72b2017 COVID-19 information notes: http://www.emro.who.int/somalia/information- resources/information-notes.html Covid-19 monthly infographics: http://www.emro.who.int/somalia/donors- partners/index.html COVID-19 risk communication materials: http://www.emro.who.int/somalia/information- resources/multimedia.html Press releases: http://www.emro.who.int/somalia/news/index. html Partnering for an efficient response to COVID-19 Responding to the COVID-19 pandemic has challenged the biggest economies of the world and the leading humanitarian and health agencies, and required swift and large-scale operations. In Somalia, the response mounted by health authorities, UN agencies and humanitarian partners would have been impossible without the partnerships and collaborations formed in the early weeks of the outbreak. One such collaboration was that of the European Union (EU) and the WHO. With the EU having previously supported the Universal Health Coverage (UHC) Partnership for Somalia, the EU Delegation to Somalia and WHO established a bilateral technical coordination mechanism in order to enhance their joint response to the COVID-19 outbreak. Through this mechanism, the EU provided logistical and flight support to . Hobyo Badan Eyl Jariban Afmadow Burao Berbera Bardera Taleh Erigavo Burhakaba Las Anod Garowe El Afwein Dinsor Gardo El Waq Zeila Baidoa Ainabo Badade Hudun Tieglo Mahas Qandala Kismayo Elgaras Dangoroyo Hargeisa Luuq Iskushuban Dusamreb El Barde Adado Bulo Burti Hagar El Bur Sablale Hudur Bardale Bossaso Buaale Lughaya Adale Alula Ufeyn Belet Weyne Salagle El Dhere Bender Bayla Owdweyne Afgoi Bargaal Buhodle Burtinle Sheikh Wajid Waciya Jalalaqsi Galkayu South Baki Sakow Jilib East Rako Guriel Jowhar Mahaday Brava Hara Dhere Wanleweyne Mataban Hafun Gabiley Burdubo Galhareri Balanbale Rabdure Garbahare Balad Galkayu North B/Gubadle Galad Aden Yabal Qoryoley Gedwein Goldogob Belet Hawa Qansah Dere Galinsor Abudwaq Borama Kurtunwaarey Marka Warsheikh Runingod Jilib West Raga Elle Dolo Awdheegle Jamaame East Jamaame West Danyile BANADIR ETHIOPIA KENYA DJIBOUTI 16 MARCH – 12 SEPTEMBER 202030 AUGUST – 12 SEPTEMBER 2020 Laboratory-confirmed COVID-19 cases Reported COVID-19 deaths Recovered cases Close contacts identified Suspected COVID-19 cases tested Jointly published by the Ministry of Health and Human Services, Federal Government of Somalia and WHO Somalia Country Office COVID-19 Situation Report - Somalia Issue 27 (6 – 12 SEP 2020) KEY HIGHLIGHTS KEY INDICATORS Between 6 and 12 September 2020, a total of 2 279 suspected cases of COVID-19 were tested, of which 27 (23 male and 4 female) were confirmed to be positive. 1 death was also reported during this reporting week from Somaliland. The districts with the highest attack rate were Madina, Garowe, Wardegle and Waberi with an attack rate of 187, 146, 131 and 110 per 100 000 population respectively. Since 16 March, a total of 3,389 laboratory-confirmed cases of COVID-19 including 98 associated deaths were reported in Somalia. The large majority (83%) of cases are aged between 20 and 60 years, with a median age of 33 (ranging from 1 to 110 years) and 74% of the confirmed cases have been male. The majority (54%) of samples tested have come from the Banadir region, followed by Somaliland (28%). The weekly positivity rate has decreased to from 1.9% last week to 1.2% this reporting week. The cumulative positivity rate, since the start of the outbreak, has also declined gradually and as of this week, the rate stands at 15% while the cumulative case fatality rate stands at 2.9%. COVID-19 CASES IN SOMALIA AS OF 12 SEPTEMBER 2020EPI CURVE OF COVID-19 CASES IN SOMALIA, 16 MARCH-12 SEPTEMBER 2020 Confirmed Cases Deaths CFR Case fatality rate (CFR) 2,279 27 1 65 0 1.5% 22,369 3,389 98 4,074 3,607 2.8% 1 - 10 51 - 100 101 - 150 151 - 186 No case reported 1 - 50 cases reported 51 - 150 cases reported 151 - 300 cases reported 301 - 599 cases reported Attack rate per 100K population Reported COVID-Cases by district Legend 12 1413 1615 1817 20 2219 21 2423 26 28 30 March April May June July Aug Sep Nu m be r o f c on fir m ed ca se s a nd d ea th Ca se fa ta lit y ra te (% ) Epidemiological weeks 0 2 4 6 8 10 12 14 0 50 100 150 200 250 300 350 400 3225 27 29 31 33 34 35 36 37 Please access to Federal Ministry of Health's COVID-19 dasborad for updated information: https://moh.gov.so/en/covid19/ Page | 1 11RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH WHO and the health ministry to rapidly transport vital equipment, medical supplies and COVID-19 samples throughout Somalia, and WHO provided technical assistance and advice to ongoing and forthcoming EU activities. Furthermore, the European Civil Protection and Humanitarian Aid Operations provided US$ 1.9 million to WHO’s COVID-19 preparedness and response operations in Somalia. A second important partnership that contributed to WHO’s work to combat the spread of COVID-19 in Somalia was with the UN World Food Programme (WFP). Somalia initially lacked the ability to test COVID-19 samples in the country, and so WFP’s support in shipping samples of © WHO suspected cases to neighbouring countries for testing was critical in the early days of the epidemic. Having facilitated the transport of three machines for polymerase chain reaction (PCR) testing to Mogadishu, Hargeisa and Garowe, WFP, with the support of the Logistics Cluster and UN Humanitarian Air Services, then transported COVID-19 samples from remote locations in Jubaland, Hirshabelle, Galmudug and Southwest State to these laboratories. WFP has also supported WHO in airlifting essential medical supplies from Mogadishu and Nairobi to remote locations. In the first 6 months of the outbreak, WFP shipped 12,6 tonnes of COVID-19 related items throughout the country. 12 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Detecting cases Developing capacity for testing Since Somalia had no capacity to test suspected samples of the virus or to diagnose cases, WHO Somalia negotiated with the Kenya Medical Research Institute to test samples of suspected COVID-19 from Somalia. After the samples were collected by the authorities, WHO processed, stored and shipped them to Kenya, with the support of WFP, for testing. In parallel, WHO worked with health authorities and partners to build Somalia’s testing capacity for COVID-19 – a critical need as part of WHO’s strategy to “test, trace, track and treat”. An important achievement as a result of cooperation between WHO Somalia, the Ministry of Health and Human Services, the Italian Development Cooperation and partners was the rapid procurement of three real-time reverse transcription polymerase chain reaction (rRT- PCR) machines to test samples for COVID-19 for Mogadishu’s National Public Health Reference Laboratory, and the laboratories in Hargeisa, Somaliland, and Garowe, Puntland. The PCR test is considered the gold standard for testing of COVID-19 samples, and the three laboratories currently have the capacity to test over 2400 samples a day. In addition to these 3 laboratories, further PCR testing capacity has been developed in 5 other locations throughout the country. The ability to conduct tests and hence obtain results faster is important in breaking COVID-19 transmission. In addition to procuring this equipment, WHO Somalia funded the strengthening of the three laboratories, set up biosafety practices, provided essential supplies – including protective equipment for laboratory staff – conducted staff training in technical areas such as COVID-19 testing, and deployed four international virologists to provide technical support. WHO has also covered the salaries of 11 laboratory staff and provided financial support for recurring operational costs. In order to further expand testing capacity in the country, eight tuberculosis centres with GeneXpert testing capabilities were supplied with COVID-19 testing cartridges and were able to provide a back-up option, besides the three PCR- equipped laboratories, to test COVID-19 samples in Kismayo, Belet Hawa, Dhusamreb, Jowhar, BeletWeyne, Baidoa and Mogadishu. This was achieved in close coordination with the National Tuberculosis Control Programme. While these efforts have undeniably contributed to reducing transmission of COVID-19 across the country, they have also helped develop the country’s overall diagnostic capacity and its health system. © WHO 13RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Enabling real-time data transmission Since timeliness and accuracy of alerts were crucial in the response to the COVID-19 outbreak, WHO Somalia was quick to make use of the latest technology to enable real-time data transmission in support of rapid and accurate decision-making. First, in order to scale up and improve surveillance in health facilities, WHO Somalia added COVID-19 to the list of immediately notifiable diseases in its Early Warning, Alert and Response Network (EWARN) – a health facility-based disease surveillance system for epidemic-prone diseases operated in conjunction with federal and state health authorities. The country office also expanded the number of health facilities reporting through EWARN, from 535 in mid-March to 691 by mid-September 2020 and trained 404 health care workers on the EWARN system. Between 16 March and 12 September, 1009 alerts of suspected COVID-19 cases were received through EWARN, 702 of which were investigated. While still ongoing, the expansion and implementation of the EWARN system has greatly improved the real-time detection, investigation, verification and reporting of COVID-19 in Somalia. The system has also facilitated the timely sharing of relevant information with partners in order to guide response activities and monitor disease trends across the country. Second, community-level reporting of COVID-19 has been facilitated using the Open Data Kit platform, which allows data from the field to be sent in real time to WHO and health authorities for informed and rapid decision-making. Through the Open Data Kit, data entered through mobile technology by community and district health workers are immediately transmitted to a central server. Alerts of suspected cases and their location are immediately generated and transmitted, thus facilitating monitoring and follow up. Given the potential for the rapid spread COVID-19 and its seriousness, these technological solutions were quickly scaled up in support of COVID-19 surveillance activities. The challenge ahead will be to strengthen the quality of the reporting and equitably extend its geographical range, as well as to incorporate this information into efforts to build an integrated disease surveillance system in Somalia. Detecting COVID-19 cases: commitment of health workers Containing the spread of COVID-19 requires a robust strategy and system to detect cases, test suspected COVID-19 cases, isolate confirmed cases and trace their contacts. This is typically done by a country’s integrated disease surveillance system – a system that Somalia lacked when the COVID-19 outbreak started. At the forefront of the COVID-19 surveillance system in Somalia were 2409 community health workers, who were trained on case finding and contact tracing related to COVID-19. These health workers are the community component of the rapid response teams. Every day they brave difficult environments and conditions and the © WHO 14 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH threat of violence in order to raise awareness about COVID-19, identify suspected cases to be tested, follow up on confirmed cases recovering at home and trace people who have been in contact with known cases to monitor their symptoms and test when required. When a suspected case is identified during these visits, the community health workers alert district rapid response teams, located in 51 priority districts. These teams quickly investigate the suspected case and take appropriate action for testing and case management as per the country’s standard operating procedure. Getting just a few samples to one of the country’s three laboratories able to test for COVID-19 can involve days of planning and travelling – working out routes, organizing transport, maintaining a strict cold chain despite intense heat and respecting strict safety precautions. In addition to supporting the investigation and follow up of suspected COVID-19 cases found in the community, the district-level teams undertake several other important activities, including: coordinating and supervising the community response activities; carrying out active surveillance visits to the prioritized health facilities on a regular basis to search for cases, ensuring data quality; and conducting on-the-job training for doctors and health-facility focal points for surveillance. State and regional response teams coordinate and support the planning of the COVID-19 response in their respective geographic areas. Every COVID-19 sample collected and tested in Somalia represents a victory over the odds. It is a testament to the thousands of health workers, logisticians and support staff working round the clock in very difficult conditions, who every day make the impossible happen. Any victory over the virus is their victory. Reaching the “silent” districts As of early August 2020, about half of the districts of Somalia (58 out of 118) had not tested any suspected case of COVID-19 – meaning that there was no information on the epidemic in a geographical area where over 4 million people live (over a quarter of the population of Somalia). © WHO © WHO 15RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Mr COVID-19 takes on the virus in Awdal and neighbouring villages Fifty-year-old Sa’ad Adam Madar is known as Mr COVID-19 in his village. As part of a rapid response team in Zeila, Awdal, Sa’ad visits about 40 houses a day to search for people with COVID-19 and children with acute flaccid paralysis or polio-like symptoms. “I prepare myself before I knock on a door, as most families ask me why I’ve come to visit as ‘coronavirus is over’. Once I explain to them that the virus is still around, they become calmer and listen to me,” says Sa’ad. Before he starts his day, Sa’ad prepares his tools – a facemask and soap so he can wash his hands when he gets a chance. He enlists support from his community committees and the team lead of a local mother and child health clinic in his search for cases of COVID-19 and acute flaccid paralysis. Sometimes, Sa’ad has to walk 3–4 km to reach different settlements and families. But Sa’ad enjoys what he does. “It gives me joy when Somalis and people across the border listen to me. Somali people are nomadic – many of them move frequently – so when I reach out to Somalis along the border, they either spread the same messages on how to prevent COVID-19 to people on the Ethiopian side, or people from neighbouring areas come to listen to me. In fact, one of my best memories is when I reported a positive case of COVID-19 from the Ethiopian part of Hariirad village and helped that person get medical attention.” © WHO This gap in knowledge and understanding of the epidemic in Somalia was a serious concern and, given the country’s weak disease surveillance system, it meant that a large number of cases may be undetected and community transmission may be continuing unnoticed in these areas. With 14 of the 58 districts inaccessible because of security concerns or limited transport infrastructure, WHO set out to deploy special teams to investigate potential COVID-19 cases in the other 44 districts. Their role was to visit health facilities in these districts, review the trend in outpatient visits of people with fever and respiratory symptoms, systematically collect nasopharyngeal swabs from the districts (at least 15–20 samples per district), facilitate the testing of these samples by shipping them to Mogadishu, and devise an intervention plan based on the epidemiological and virological data collected. Between 15 August and 15 September 2020, 44 WHO staff were successfully deployed to 44 districts, where they trained 107 district health staff on COVID-19 sample collection and case investigation and collected 811 samples for testing. Of these, 445 had been tested for COVID-19 by 15 September, with 10 samples from 3 districts in Jubaland returning positive for the virus. Rapid response teams were sent to the affected districts to minimise the spread of the disease, and further efforts are being made to ensure all samples collected are tested. 16 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH © WHO COVID-19: just one of the problems facing internally displaced families After her family’s livestock was stolen in 2019, Faadumo, who was expecting a baby, and her husband and six children had to escape from their home in Hagar district, Lower Juba. They carried a few belongings and set off in search of a safe home. Life is hard for them at the new Kismayo camp for internally displaced people. About 20 families share one toilet, and it is difficult to access safe drinking-water and health facilities in the camp; there is only a mother and child health centre run by Save the Children International. One month ago, Faadumo fell ill. “When I came down with a fever, cough and shortness of breath, I thought it may be COVID-19, as I had heard a lot of community mobilizers explain the symptoms of COVID-19,” says Faadumo. “Community mobilizers asked me to visit Kismayo isolation centre where they tested me and took down my contact details. I tested negative. I am grateful I received painkillers from WHO at the isolation centre and learnt about COVID-19 from their teams so I can share my knowledge with people I know.” Faadumo and her husband don’t have work and the biggest challenges they say they have to deal with are poor shelters, the lack of education for their children, and the poor health of their children (one of their sons suffers from congenital congestive cardiac failure), as well as the regular challenge they all face – malnutrition. 17RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Managing cases and scaling up treatment Isolating and caring for COVID-19 cases Isolating suspected and confirmed cases of COVID-19 is a critical step in halting the spread of the disease. As such, between 16 March and August 2020, WHO supported 19 isolation centres across the country with training and capacity-building, as well as delivered close to 15 tonnes of medical material and equipment and distributed 11 710 sets of full personal protective equipment and 157 300 facemasks for health workers. In addition, WHO supported health authorities financially and operationally to manage four isolation centres in Kismayo, Baidoa, Jowhar and Dushamareb. Six months into the COVID-19 outbreak in Somalia, the isolation facilities across the country have been underutilized, as people affected by the virus have mostly stayed home. Most isolation centres, except the De Martino Hospital in Mogadishu, have barely reached 10% of their capacity. Societal norms, cultural practice and a high density of the population in main cities such as Mogadishu have also meant that home care have been difficult. This has resulted in active transmission of the virus in households. Most COVID-19 patients in Somalia only reach health facilities when severe respiratory symptoms have developed. Providing effective treatment for these patients has been all the more challenging because the health system had little capacity to treat these severe conditions. Recently, efforts have focused on preventing infections at the community level, reducing cross-infections in health facilities and providing appropriate outpatient care. For severe cases of COVID-19, specialized care is provided in designated isolation centres. Efforts have also been directed at improving understanding of the particulars of the disease in Somalia to enhance response activities. In Mogadishu’s De Martino Hospital, WHO has provided support to health teams in automating the hospital’s patient registration system for COVID-19 patients so that better quality data and information on patient survival and death can be recorded and analysed in real time to improve the care given. © WHO 18 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH In focus: protecting health care workers The protection of health care workers is vital to ensure the continuity of health services and the protection and well- being of vulnerable populations. Health workers are disproportionally exposed to the COVID-19 virus and, because of their closeness to patients, they can also spread the virus to people with pre-existing health conditions. In Somalia, data collected between 16 March and 15 September 2020 documented the testing of 311 health workers from public and private health facilities, 191 of whom tested positive for COVID-19. Most of the cases were aged between 20 and 40 years; there were two documented deaths of health workers. Of the confirmed cases, 64,3% were doctors and nurses and 35,7% were non-medical support staff (e.g. cleaners, security personnel). As the accuracy of the data is uncertain and stigma prevents people (even medical professionals) from getting tested, the real number of health workers who have had COVID-19 is likely to be much higher. Recently, efforts to prevent infection of health staff have concentrated on training medical staff on infection prevention and control measures and providing them with appropriate personal protective equipment. Particular attention is currently focused on understanding the risk factors of different professions – from laboratory technicians to cleaners – in order to best prevent infection in people working in health care. © WHO Improving access to medical oxygen for COVID-19 patients Medical oxygen plays a crucial role in improving health outcomes of patients with severe COVID-19. In early 2020, Somalia’s public sector hospitals had very limited medical oxygen available. WHO Somalia therefore took the ambitious decision to ensure the availability of oxygen in COVID-19 isolation centres across Somalia. In order to determine the availability of oxygen in the country, the WHO country office, together with the Ministry of Health and Human Services of the Federal Government of Somalia, conducted a 1-week rapid assessment in June of 23 public secondary-care hospitals across the country using WHO’s COVID-19 biomedical equipment inventory tool5. Based on the outcomes of this assessment, a two-phase-plan was devised to scale up medical oxygen. The first phase focused on the rapid procurement of 76 oxygen concentrators, pulse oximeters and other medical consumables to tackle immediate needs and save lives in 19 isolation centres across the country. The second phase, currently ongoing, will focus on boosting 5 Biomedical equipment for COVID-19 case management – inventory tool: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/WHO-2019-nCov-biomedical-equipment-inventory-2020.1, accessed 30 June 2020). 19RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH the oxygen supply with pressure swing adsorption (PSA) oxygen generation plants. The WHO country office is procuring three such plants as well as dedicated power generators – two for facilities in Mogadishu and one for a facility in Hargeisa. To house these units, the country office has worked with UN engineers on innovative solutions to “containerize” this oxygen. The advantage of this containerized plant is that these installations can be removed whenever needed and installed in other hospitals. On availability of funds, the WHO country office proposes to procure and install at least one PSA oxygen generation plant in each state and recruit a biomedical engineer to ensure in- country capacity-building for sustainability and maintenance of these plants. © WHO Given that pneumonia is the leading infectious disease killer of children in the world and that supplemental oxygen is important in treatment of childhood pneumonia, increasing Somalia’s capacity to provide oxygen therapy is a life-saving investment beyond COVID-19. WHO is prioritizing scaling up the availability of medical oxygen in its discussion with donors and will also closely monitor how to apply what has been learnt from this programme in future health interventions in Somalia. 20 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH In focus: recognizing the key role of women in responding to COVID-19 Through war, conflict and hardship, women have long been the backbone of Somali society. In recent years, they have also been instrumental in delivering health care across the country. In Mogadishu, the national laboratory is headed by Dr Sahra Isse Mohamed, Director of the National Public Health Reference Laboratory. Explaining how difficult it has been for her to work under pressure in the past few months, while COVID-19 spread in Somalia, Dr Sahra said, “I am happy to say that half of our team consists of qualified Somali women. Besides, even our Minister of Health, who is in charge of health in the country, is a woman.” Such leadership and involvement are reflected in the high representation of women among frontline health workers –almost 90% of WHO-supported community health workers are women. While women are very much at the forefront of the fight against COVID-19 in Somalia, COVID-19 data for Somalia seem to indicate that men are more affected by COVID-19 than women: 69% of suspected cases and 74% of confirmed COVID-19 cases are men. A possible reason for this gender difference is the underrepresentation of women in tested cases in Somalia, which could be due to fewer women accessing health facilities than men, possibly because of the lockdown in the country. Furthermore, women in Somalia may also be less exposed to the virus, which would explain their lower positivity rate (13% in women compared with 16% in men). In the coming months, WHO Somalia will investigate further the effect of gender in the COVID-19 outbreak in Somalia. Such knowledge is important to adapt risk communication and surveillance activities and to ensure equal access to testing and treatment for all health workers and patients alike, regardless of their gender. © WHO 21RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Rapidly generating solid data to support evidence based policy-making has rarely been so important as in the case of COVID-19. Three studies currently coordinated by WHO and partners aim to do just that. In collaboration with Banadir University, WHO is conducting a retrospective rapid mortality assessment and surveillance study, beginning in September. The study will use verbal autopsy to determine community deaths that were likely caused by COVID-19. This information will be used to inform the continued response to the outbreak, and will contribute to an electronic registry of deaths that will be introduced to support mortality surveillance in the future. A second study, also started in September 2020 with Banadir University, aims to rapidly assess the vulnerability to COVID-19 of frontline health professionals and the capacity of health facilities to deal with the workload produced by COVID-19. The availability and adequate use of personal protective equipment by health professionals in hospitals will be assessed as well as the infection prevention and control capacities of hospitals treating COVID-19 cases. Finally, WHO, together with the health authorities, will conduct a seroepidemiological survey of COVID-19 infections from October 2020. The number, proportion and role of mild or asymptomatic infections will be evaluated, to determine the true number of infections within the general population and understand transmission patterns. Generating knowledge to improve our response Together, these studies will help shape the COVID-19 response moving forward and health policy more broadly by increasing our understanding of COVID-19 and the mortality from the virus. They will also contribute to reducing transmission of the virus and developing a public health tool for mortality data. © WHO 22 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Communicating with people Engaging with communities about COVID-19 to inform them of the symptoms of the disease, ensure knowledge and compliance with personal protective measures and facilitate people’s access to testing and care services has been crucial in Somalia – and a focus of WHO’s activities in the country. As well as disseminating messages about COVID-19 at the community level through its 2409 trained health care workers, WHO has had an active presence on social media – in particular Facebook, Twitter, Instagram and WhatsApp – in an effort to reach younger people. WHO Somalia has adapted and translated messages from global and regional WHO platforms, and developed locally-relevant messages in partnership with the United Nations Children’s Fund (UNICEF) and health authorities. These messages address the stigma that keeps people away from health facilities, alleviate people’s fears about testing for the virus, and challenge cultural and societal norms prevent adequate management of suspected and confirmed cases. An estimated 20 to 25 new messages have been developed or adapted every month and disseminated to the Ministry of Health and Human Services and other partners to reach the greatest audience. In focus: reaching people directly through social media With partners Facebook and WhatsApp, WHO launched a dedicated messaging service in the Somali language in order to keep people safe from COVID-19 and counter misinformation. This easy-to-use messaging service has the potential to reach 2 billion people and enables WHO to put information directly into the hands of the people that need it, in an interactive and responsive way. WHO Somalia, together with Somalia’s Federal Ministry of Health and Human Services, supported the translation of WHO key messages on COVID-19 into the Somali language. The service can be accessed by a link that opens a conversation on WhatsApp: https://wa.me/41798931892?text=haye 23RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH 24 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360 380 400 MarchJanuary February June July August September 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 N um be r of C O VI D -1 9 ca se s 30 J an ua ry : C O VI D -1 9 de cl ar ed b y W H O D ir ec to r G en er al a s a P ub lic H ea lt h Em er ge nc y of In te rn at io na l C on ce rn (P H EI C ) 17 M ar ch : A ll sc ho ol s an d un iv er si tie s in S om al ia a re c lo se d, la rg e ga th er in gs a re p ro hi bi te d 18 M ar ch : S us pe ns io n of a ll in te rn at io na l f lig ht s to a nd fr om S om al ia 16 M ar ch : F ir st la bo ra to ry -c on fir m ed c as e of C O VI D -1 9 in S om al ia 25 M ar ch : T he c ou nt ry ’s fi rs t i so la tio n fa ci lit y in D e M ar tin o ho sp ita l a dm its it s fir st C O VI D -1 9 pa tie nt 5 A pr il: F ir st r ec or de d re co ve ry o f a C O VI D -1 9 pa tie nt in S om al ia 7 A pr il: E st ab lis hm en t o f f ir st L ab or at or y te st in g fo r C O VI D -1 9 in M og ad is hu 21 A pr il: F ir st R ap id R es po ns e Te am d ep lo ye d in S om al ia 11 M ar ch : C O VI D -1 9 ch ar ac te ri ze d as a p an de m ic . Ea rl y M ar ch : S cr ee ni ng a t a ir po rt s an d bo rd er c ro ss in gs in to S om al ia 5 M ar ch : S om al ia N at io na l C on tin ge nc y P la n fo r P re pa re dn es s an d R es po ns e to C or on av ir us (C O VI D -1 9) , M ar ch - J un e en do rs ed b y FM oH 36.5 27 A pr il: D at e of fu nc tio ni ng o f P C R b as ed la bo ra to ry in G ar ow e, P un tl an d 30 A pr il: D at e of fu nc tio ni ng o f P C R b as ed la bo ra to ry in H ar ge is a 16 M ay : S om al ia la nd b or de r w ith K en ya s hu t Ju ly : G en eX pe rt u se d fo r C O VI D -1 9 te st in g 12 J ul y: L oc kd ow n re st ri ct io ns li ft ed c ou nt ry -w id e 3 A ug us t: In te rn at io na l f lig ht s re su m e April May Epidemiological week ü Timeline of key COVID-19 related developments in Somalia, January-September 2020 25RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340 360 380 400 MarchJanuary February June July August September 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 N um be r of C O VI D -1 9 ca se s 30 J an ua ry : C O VI D -1 9 de cl ar ed b y W H O D ir ec to r G en er al a s a P ub lic H ea lt h Em er ge nc y of In te rn at io na l C on ce rn (P H EI C ) 17 M ar ch : A ll sc ho ol s an d un iv er si tie s in S om al ia a re c lo se d, la rg e ga th er in gs a re p ro hi bi te d 18 M ar ch : S us pe ns io n of a ll in te rn at io na l f lig ht s to a nd fr om S om al ia 16 M ar ch : F ir st la bo ra to ry -c on fir m ed c as e of C O VI D -1 9 in S om al ia 25 M ar ch : T he c ou nt ry ’s fi rs t i so la tio n fa ci lit y in D e M ar tin o ho sp ita l a dm its it s fir st C O VI D -1 9 pa tie nt 5 A pr il: F ir st r ec or de d re co ve ry o f a C O VI D -1 9 pa tie nt in S om al ia 7 A pr il: E st ab lis hm en t o f f ir st L ab or at or y te st in g fo r C O VI D -1 9 in M og ad is hu 21 A pr il: F ir st R ap id R es po ns e Te am d ep lo ye d in S om al ia 11 M ar ch : C O VI D -1 9 ch ar ac te ri ze d as a p an de m ic . Ea rl y M ar ch : S cr ee ni ng a t a ir po rt s an d bo rd er c ro ss in gs in to S om al ia 5 M ar ch : S om al ia N at io na l C on tin ge nc y P la n fo r P re pa re dn es s an d R es po ns e to C or on av ir us (C O VI D -1 9) , M ar ch - J un e en do rs ed b y FM oH 36.5 27 A pr il: D at e of fu nc tio ni ng o f P C R b as ed la bo ra to ry in G ar ow e, P un tl an d 30 A pr il: D at e of fu nc tio ni ng o f P C R b as ed la bo ra to ry in H ar ge is a 16 M ay : S om al ia la nd b or de r w ith K en ya s hu t Ju ly : G en eX pe rt u se d fo r C O VI D -1 9 te st in g 12 J ul y: L oc kd ow n re st ri ct io ns li ft ed c ou nt ry -w id e 3 A ug us t: In te rn at io na l f lig ht s re su m e April May Epidemiological week ü 26 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Reflecting, learning and improving What has worked so far PARTNERING with health authorities, other UN agencies, nongovernmental organizations and donors in order to capitalize on respective expertise and capacity LEADING as a technical reference point on the health aspects of the COVID-19 pandemic INFORMING in a timely manner on the evolution of the outbreak and the latest response gaps ENSURING COVID-19 testing capacity by working with the Kenya Medical Research Institute in Nairobi and rapidly procuring three polymerase chain reaction machines and establishing functional laboratories in Somalia BUILDING on the expertise and experience of the WHO polio programme to mount a quick and efficient response to COVID-19 in the community DEPLOYING just over 3600 trained staff to conduct surveillance activities at community, district, regional and state levels with the support of mobile and electronic tools for real-time transmission of data of COVID-19 alerts PROTECTING health workers and their ability to provide health care through training and delivery of personal protective equipment throughout Somalia at a time when the global supply chain was under strain USING WHO’S COVID-19 biomedical equipment inventory tool for facility readiness, in partnership with the Federal Ministry of Health and Human Services, to assess oxygen needs in Somalia and exploring the feasibility of setting up three oxygen generation plants to increase oxygen availability SUPPORTING the establishment of 19 isolation centres across the country and providing financial and operational support to four of these centres. © WHO continued... 27RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Our focus moving forward DRAWING on the latest knowledge, research, technology and networks to enhance the response to COVID-19 in Somalia ENGAGING FURTHER with donors, securing the necessary funds for the COVID-19 response and advocating for longer-term needs of health system strengthening EXPANDING laboratory testing capacity for COVID-19 and other epidemic-prone diseases to all states with additional polymerase chain reaction machines and the use of GeneXpert technology, and ensuring international certification of laboratories EXTENDING community-based and facility-based surveillance to more districts, including remote and insecure districts, and contributing to the establishment of an integrated disease surveillance system SCALING UP the training of health and community workers to improve the quality of the response to COVID-19 COMMUNICATING more effectively with communities, in particular internally displaced populations, on COVID-19 and preventative measures to counter the virus IMPROVING the ability of health facilities and field teams to collect, analyse and share good-quality and reliable data and trends on key diseases INCREASING and improving support to isolation and quarantine facilities for appropriate management of suspected and confirmed COVID-19 cases INCREASING the availability of oxygen support for COVID-19 patients with respiratory complications DEEPENING our understanding of risk factors for health workers and working to tackle them ENSURING that routine immunization and vaccination campaigns resume to prevent the resurgence and outbreak of vaccine-preventable diseases SECURING the necessary funds to ensure a good-quality and efficient response to the COVID-19 outbreak in Somalia © WHO 28 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH Looking ahead Having looked back at WHO’s response in the first 6 months of the COVID-19 outbreak in Somalia, it is important moving forward to consider the lessons learnt and ensure that they guide our ongoing response to this outbreak and to health interventions in Somalia more broadly. Attention must also immediately be directed to the impact the COVID-19 outbreak has had and is likely to have on access to health care more generally in Somalia. While Somalia has made progress in recent years in reducing under-5 mortality and maternal mortality and has eradicated wild poliovirus, the COVID-19 outbreak risks reversing these health gains as mothers, children and sick people have kept away from health centres because of lockdown measures, interruptions in services and fears of being infected by the virus. Indeed, available data from Somalia indicate a significant drop both in the number of children immunized and in immunization coverage in the first 6 months of 2020 compared with the same period in 2019. Since August 2020, WHO together with health authorities have resumed supplementary immunization campaigns against measles and polio in Somalia” Beyond the response to the COVID-19 outbreak and its immediate consequences, WHO and partners must also collaborate more than ever to tackle the critical gaps and weaknesses of Somalia’s health system. Strengthening primary health care, in particular the Essential Package of Health Services, will be crucial to achieving universal health coverage (UHC) in Somalia’s fragile and vulnerable context. Reforming Somalia’s aid structure and adopting a coherent humanitarian–development–peace nexus approach that reaches and benefits every Somali, regardless of where they live, will also improve the performance of the health system and manage people’s needs before, during and after crises. These are substantial projects that will require Somalia’s health partners to think big, act wisely and build back together. © WHO 29RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH WHO Somalia’s response to COVID-19: donors’ views Timely support from and collaboration with existing and new donors have been key to WHO Somalia’s response to the COVID-19 outbreak. This support includes generous resource contributions from: Global Affairs Canada; the Central Emergency Response Fund (CERF); the Foreign, Commonwealth and Development Office (FCDO); the European Union; the European Civil Protection and Humanitarian Aid Operations; GAVI, the Vaccine Alliance; German Cooperation; the Italian Agency for Development Cooperation; the Swiss Agency for Development and Cooperation; the World Bank and The Global Fund to Fight AIDS, Tuberculosis and Malaria. In order to ensure that we are delivering the most appropriate response, WHO Somalia asked donors for feedback on its response to COVID-19 to date in Somalia. Their comments indicate a clear recognition of WHO Somalia as a technical reference point for all health matters on the COVID-19 epidemic in Somalia, both for the international community, the Government and the Federal Ministry of Health and Human Services. The hard work undertaken by WHO Somalia was also recognized despite the significant obstacles, such as the complex and rapidly evolving epidemiological situation, underfunding of the response and the challenge in obtaining information from all parts of the country. Donors highlighted the following WHO activities: the support it provided to the development of the national COVID-19 response plans; its collaboration with the UN and other partners on rapid response teams, surveillance, procurement and installation the polymerase chain reaction machines and transportation of samples to reference laboratories; and its frequent updates on overall response activities. Recommendations from donors on the role WHO Somalia should continue to play throughout and beyond the COVID-19 period included: (i) providing coordination structures and up-to-date information to all stakeholders, and forging strong, supportive and efficient links between the Federal Ministry of Health and Human Services and other relevant Somali authorities and external partners; (ii) bringing together health officials and advising donors on the best collaboration to optimally support the response to COVID-19 in Somalia; (iii) drawing on and applying new knowledge and technology to support innovations in Somalia; and (iv) building on the credibility and relationships it strengthened and established during the COVID-19 epidemic to help Somalia move towards UHC and “health for all”. We thank all our donors for their vital support, feedback and recommendations. WHO Somalia will strive to meet their expectations, as well as those of the Somali health authorities and our key operational partners. It is these reflections, exchanges and collaborations that will bring about better health care for the Somali people. WHO Somalia would like to express its sincere gratitude to the donors listed below that have supported its operational response to COVID-19 in Somalia: 30 RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH WHO’s response to COVID-19 in Somalia in numbers During the first 6 months of the COVID-19 outbreak in Somalia, the following activities were supported by WHO: 5482 health workers were trained on COVID-19 surveillance, case management and risk communication** 9118 sample collection kits were distributed to federal member states** 22 369 samples were tested for COVID-19* 3959 samples were transported from inaccessible areas for testing** 11 710 sets of full personal protective equipment and 157 300 facemasks were distributed to federal member states** 19 isolation centres were supported for patient care* 691 health facilities have reported through the EWARN (Early Warning Response Network)* 2409 community health workers were deployed for case finding and contact tracing, visiting 2 101 321 households and delivering risk communication messages to 10 522 244 people* 918 rapid response teams were deployed to 51 priority districts for field investigation and sample collection* * Data reported for period 16 March – 12 September 2020 ** Data reported for period 16 March – 31 August 2020 31RESPONDING TO COVID-19 IN SOMALIA: PROGRESS REPORT - 6 MONTHS OF RESILIENCE AND STRENGTH © WHO World Health Organization (WHO) Country Office, Mogadishu, Somalia Correspondence: +252616695096; Email: emacosomwr@who.int; emacosomexr@who.int URL: http://www.emro.who.int/countries/somalia/index.html @WHO Somalia @WHOSom somaliawho