Among the cases of TB in Somalia that have failed to respond to
treatment, 40.8% are reported as being MDR-TB. Among new cases, the rate
is 5.2%. These rates translate into about 500 cases of MDR-TB a year.
These are just the known cases - i.e. people who return to clinics and
are then diagnosed. The real rate is certainly much higher. (In
comparison, the MDR-TB retreatment rate in Kenya is estimated to be
Somalia has been unstable for over 20 years, ever since the collapse
of the central government following the overthrow of the late president
Said Barre. One of the first institutional casualties of the instability
was the collapse of the health system.
TB in Somalia is an old problem. Poverty, the practice of living in
crowded family homesteads, the abundance of dust and smoke, and poor
health care have all contributed to creating high TB prevalence. Many
(if not most) families in Somalia have some experience of TB.
A sign of how ubiquitous and well known TB is in Somalia is that it
was one of the only reasons individuals were allowed to cross between
zones controlled by different warring factions when the violence in
Somalia was at its peak. Both sides knew relatives who needed treatment,
so the patients were allowed to cross over.
An almost entirely unregulated private "health" sector in the south
of Somalia has led to widespread mistreatment, poor treatment or
non-treatment. It is very easy to set up a clinic or a pharmacy, and the
government has few resources (a) to decide if someone has
qualifications to run it; or (b) to check on the stock of medicines that
are being handed out. However, this is likely to change in future as
health authorities impose controls.
The MDR-TB emerged from long histories of broken treatment regimens -
caused by a combination of stocks out, slow diagnosis and poor
The figure of 10.2% MDR-TB overall rate comes
from a study by researchers, affiliated with the World Health
Organization (WHO) and WVI, published in March 2013. It appears that it
was only after this study became available that the WHO's Green Light
Committee had the information it needed to approve MDR-TB medicines for
According to Dr Vianney Rusagara, the Global Fund Programme Director
at WVI-S, the details of known MDR-TB patients from the study and
diagnoses of MDR-TB using GeneXpert are being mapped now, and new
treatment targets are being set. Currently, little is known about where
the TB and MDR-TB cases are. What is known is that the disease knows no
regional boundaries, and is not primarily found in any one religious
group or community. It is not known whether TB and MDR-TB is primarily a
rural or an urban problem; the disease appears to be everywhere.
Dr Rusagara said that, initially, there will be sufficient resources
to treat about 60 patients per year. However, he said, being able to
treat more than 250 patients a year would have a much more significant
impact on the epidemic. Treating a patient for MDR-TB requires a
considerable investment, not only for the medicines, but also for
adherence programmes and patient follow-up. The costs are even higher in
an unstable environment like the one in Somalia.
Dr Rusagara said that WVI-S and the government authorities will be
looking for more money for the TB programme for 2014. Preparation has
begun for a Phase 2 application to Global Fund; the major focus will be
on treating more MDR-TB patients. (Somalia has received Global Fund
support for its TB programme from Round 3, 7 and 10.)
The funding proposals were all in the non-CCM category, as there is
no CCM in Somalia. In the absence of a CCM, the Somalia Health Sector
Committee provides oversight. The sub-recipients for the grants include
12 International NGOs, 10 local or regional NGOs and two UN agencies.
"World Vision works with other partners to implement the grant," Dr
Rusagara said. "They include the WHO, which provides TB training,
storage of supplies and distribution; and Comitato Collaborazione
Medica, an Italian NGO, which provides supervision and M&E services
jointly with national TB programme staff who also provide links with the
Ministry of Health."
Dr Rusagara said that the TB grants from the
Global Fund have enabled Somalia to make great progress in tackling TB.
However, he added, there is still much more to do. "At the beginning of
Round 3, there were 37 TB treatment facilities and now there are 64
facilities, ranging from TB management units to large TB hospitals," Dr
Dr Rusagara added that the average treatment success rate for TB in
Somalia through the facilities funded by the Global Fund and other
partners has been about 89% over the last seven years. This is
considered excellent, particularly for a conflict area.
However, it is estimated that at least half of all people with active
TB do not seek care in the public health sector clinics. These
patients, who may self-diagnose, seek treatment at private clinics or
pharmacies without having had a proper diagnosis. Some of the private
clinics and pharmacies experience stock-outs, and many fail to educate
their clients on treatment protocols. In some cases, their medicines are
substandard. This may explain the high prevalence of MDR-TB in the
retreatment cases. In one instance, it was also found that "the drugs
sampled and tested from some of the open-market sites showed low
bio-availability for both rifampicin and isoniazid. This certainly
contributes to resistance," Dr Rusagara said.
Because of the high prevalence of MDR-TB, plans have been drawn up to
control the disease. Treatment protocols and guidelines have been
developed, as have recording and reporting tools. Staff at facilities
have been trained to manage MDR-TB.
"A total of 66 staff has now been trained or retrained," Dr Rusagara
said. "An admission ward in Hargeisa for MDR TB was renovated and plans
for referral are in place, while patient follow-up plans are being
In addition, a culture laboratory has been established in Hargeisa.
Plans have been put in place to monitor MDR-TB - including through drug
sensitivity testing to be conducted outside Somalia. External quality
assurance for laboratories is being performed.
Other strategies are also being used to increase awareness of the
need for people to seek treatment from in the public health sector
clinics. As well, there is considerable pressure on the Somali
authorities to ban the sale of anti-TB medicines in private pharmacies.
Somaliland and Puntland, two of the regions in Somalia, have formal bans
in place, but enforcing them is a challenge. In addition, the TB
programme is also working with the private sector to promote referrals
to the public clinics.
"The response has picked some momentum, but it has a long way to go," Dr Rusagara said.