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Enacting Zero Tolerance policy on the potential importation of Ebola into Somalia:

by Khalif Bile M.D.; Ph.D. 
[email protected]
Wednesday, November 05, 2014

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Methodology of spread of the Ebola Virus

The transmission of the Ebola virus among a population is attained through the direct and close physical contact with infected body fluids such as blood, faeces and vomit. The virus has also been detected in breast milk, urine and semen, while saliva and tears may carry some limited risk. The main symptoms that are mostly unspecific include: headache, vomiting, diarrhoea, lethargy, stomach pain, aching muscles or joints, difficulty in swallowing or breathing, hiccups and unexplained bleeding both internal and external [1]. Patients usually infect family members, health care workers and other patients before the disease is diagnosed [2]. At present there are no vaccines or medicines whose efficacy was tested and approved for human use, though serious efforts are being undertaken in this regard. Attention has been given recently to convalescent treatment, where the Ebola patient is given plasma from blood that is donated by a person who recovered from the disease. In countries with shattered health systems and with acute shortage of health personnel, these arrangements are difficult to organize and the outbreak could be disastrous.

2.     The Unprecedented Outbreak of Ebola Virus in West Africa

The current epidemic of Ebola started in Guinea in December 2013, and the World Health Organization (WHO) was officially notified of the rapidly evolving Ebola Virus Disease (EVD) outbreak on March 23, 2014. On August 8, the WHO declared the epidemic to be a “public health emergency of international concern [3].  From there the disease spread by land to Sierra Leone and Liberia, and by air to Nigeria through one traveller and by land to Senegal, also by a lone traveller. As of  the 14 October 2014, a total of 9216 confirmed, probable, and suspected cases of Ebola virus disease (EVD) have been reported in seven affected countries (Guinea, Liberia, Nigeria, Senegal, Sierra Leone, Spain, and the United States of America), and 4,555 deaths attributed to the EVD. Of the three most heavily affected West African countries, 55% of the cases were from Liberia, 26% from Sierra Leone, 19% from Guinea. [1]. The Ebola outbreaks in West Africa are apparently heading for a catastrophe, as since May 2014 the number of new cases has been doubling every 20-30 days as per WHO estimates with a high case fatality rate of about 50%. In addition to the high number of deaths, these countries are experiencing a severe economic blow both at community and state level, with panic and alarm.

3.     Somalia is inadequately prepared to face an Ebola Virus Outbreak

The epidemiological conditions in Somalia are highly conducive to Ebola transmission as corroborated by the following:

·     Somalia is a country that has been without an effective centralized government for 23 years; most of the health infrastructure has been destroyed; highly scarce human resources for health with a ratio per population  six times lower than the minimum that was set by WHO for a country for achieving the Millennium Development Goals targeting maternal and child survival and the control of important communicable diseases

·     The country lacks an adequate health infrastructure; equipment and supply of essential tools; special infectious diseases treatment centers with trained workforce; hospitals and health centers with adequate infection control procedures, and isolation wards to manage confirmed EVD cases or separate areas to retain suspected or probable cases who are negative, and whose symptoms’ duration has been less than 72 hours for retesting to rule out false positivity.

·     Of greater concern is that the laboratory facilities running confirmation tests to diagnose the Ebola virus such as the polymerase chain reaction (PCR) test are not available in the country, and samples need to be referred to Nairobi, Kenya, indicating the technical challenges facing the health system [4] and entailing a much longer time for diagnosis. 

·     The Somali population has a poor health care seeking behaviour, where often the traditional healing practices are first utilized, leading to serious delays in the diagnosis of Ebola suspected cases, especially when such symptoms are non-specific

·     A country where only 10% of its rural and 63% urban population has access to safe drinking water, explaining why the frequent acute watery diarrhoea and large cholera outbreaks  in the country

·     A country with close to one million internally displaced persons and over two million with severe food insecurity are experiencing miserable living conditions

·     A country where the prevailing insecurities are severely impairing access to large geographical areas

·     Finally, considering the witnessed fast spread of the Ebola outbreak, the needed international partners’ support, the number of needed skilled health workers and levels of unimpeded access and provision of necessary supplies and equipment is realistically hard to attain   

4.     The African Union Mission in Somalia (AMISOM) and the Risk of Ebola

The military component of AMISOM comprises of troops from Uganda, Burundi, Djibouti, Sierra Leone, Kenya and Ethiopia, deployed in six sectors of Central and Southern Somalia. Sierra Leone is one of the three West African countries really hit hard by the Ebola outbreaks. Indeed in Sierra Leone the disease has spread to all but one of the country’s 13 districts, with 1,184 deaths, including four doctors and 30 nurses. Following the Ebola disaster, the affected three West African countries were reported to be inflicted by restrictions in their social, business and economic activities. The relatively high mortality of health staff; the risk of staff not coming to work because of fear of infection and the population being scared of health facilities as potential sources of infection that has devastated the health services of these countries constitute a major source for concern. Serious national and international efforts are being made to interrupt the transmission of the Ebola virus in these countries and the prevention of its spread to other countries. While, the gigantic peace-making efforts of AMISOM in Somalia are commendable, the mission is expected also to ensure a zero tolerance to the importation of this deadly virus into the country. From this perspective, the Somali authorities, AMISOM and international partners have to work closely together to address the following:

4.1.          Recognizing the Somali health System as being Vulnerable to Ebola

In view of the above crucial realities and prevailing Somali health care system vulnerabilities, reflected by its limited capacity; the enormous access challenges to many geographical areas; the high mobility of the Somali population; the porous international borders of the country and the presence of UNISOM contingencies from the Ebola crisis regions of West Africa, the risk of uncontrollable disease importation by a single person infected by Ebola is very high. In such an unfortunate event, the disease could spread like a “forest fire” with unpredictable consequences and extremely high fatality rates. Accordingly, the national authorities and international partners should rise to the occasion and collectively strengthen the capacity of the health system to prevent an Ebola outbreak in the country.  

4.2.           Implementing the National Contingency Plan for Ebola Response 

The health authorities should lend serious attention to the recently developed National Contingency Plan for Ebola Response in Somalia, in close collaboration with WHO and other health partners. In this regard, the health authorities must strengthen disease surveillance at all critical levels; improve Ebola related health data collection systems; build epidemic management committees and rapid response teams at every health authority level; strengthen infection control measures with the urgent construction of isolation wards; ensure that all hospitals warrant the availability of necessary supplies, especially the personal protective equipment;  organize the necessary laboratory facilities with prompt zonal confirmation testing facilities with PCR capacities and accelerate health workforce training on key measures recommended for infection control and epidemic preparedness. 

4.3.           Enhancing Ebola Screening in International and Domestic Airports of the Country

 To avert the risk of Ebola importation, the government has to introduce the entry screening in all airports that are reached by international and domestic flights, as well as the land border crossings. It must be realized that a large number of Somalis are residing or frequently traveling to countries, from where Ebola outbreaks were reported in the past, such as South Sudan, Uganda and Democratic republic of Congo, or countries bordering to Ebola-inflicted ones. These measures are also necessary to keep the regular and safe flow of the vital international humanitarian and development support and their implementing International aid and development workers.    

4.4.           Withholding the soldiers of the Ebola crisis country until the end of the outbreak is declared 

  The AMISOM’s role in assisting the national authority to establish conditions for effective governance; provide meaningful support to security in large geographical areas of the country; help in the delivery of basic services and protect national institutions is fully credited by the Federal Government. However, there is a substantive legitimate expectation that UNSOM forces will protect the country from the risk of Ebola importation. In this regard, the statement made on October 17, 2014 by the Special Representative of the Chairperson of the African Union Commission (SRCC) for Somalia, that no soldier from the Sierra Leonean contingent will be deployed to Somalia without stringent screening and that the battalion that was to be deployed in Somalia on 4th July 2014 was accordingly halted was a decision in the right direction. The ASRCC stated also that an isolation ward will be established in AMISOM Level II Hospital, along with the training of the AMISOM medical personnel to raise their preparedness capacity against Ebola. While acknowledging the importance of these measures, they fall short of eliminating the risk of Ebola importation by Sierra Leone battalion. Considering the current situation in the three West African countries, and the WHO prediction that in future, there will be doubling of the Ebola cases every 3-4 weeks, the challenges are indeed enormous and formidable[5]. With the prevailing exceptional epidemiological, security and challenging governance situations in Somalia, there should be a collective moral demand to undertake the most extreme preventive measures to avert the importation of the disease. 

Quarantining the contingents to be deployed for a time period equivalent to 21 days of the incubation period would seem technically judicious. However, in a country where the disease is widely spread, the forceful isolation of an entire battalion and its complete preclusion from any family, friends and fellow soldiers’ contacts is rather difficult. Likewise, it is close to impossible to ensure that no one of the battalion had no contacts with someone who had contacts with a known or unknown probable Ebola case or with a person who recently had contact with such cases, considering the level of the reported disruptions in the country. Accordingly, the deployment of any forces from Sierra Leone, or from any other country in which an Ebola case was firmly detected, should be withheld, until the country is declared to be free of Ebola. According to WHO this is attained after a period of 42 days, with active case-finding in place, and no new cases detected. This aspiration was proclaimed on 17 October, 2014 by the Somali Federal Health Minister who stressed “not to bring troops from West African countries reeling under the deadly virus”, corroborating the above outlined epidemiological conclusion [6].  

From these analyses and recommendations, we may conclude that the only way to prevent the importation of this deadly disease into a country in crisis like Somalia is by implementing the above stringent measures of withholding the deployment of any forces from Sierra Leone, until the country is declared to be free of Ebola. These actions will undoubtedly contribute to the global public health security.




2.     Thomas R. Frieden, M.D., M.P.H., Inger Damon, M.D., Ph.D., Beth P. Bell, M.D., M.P.H., Thomas Kenyon, M.D., M.P.H., and Stuart Nichol, Ph.D. Ebola 2014 — New Challenges, New Global Response and Responsibility. N Engl J Med 2014; 371:1177-1180September 25, 2014DOI: 10.1056/NEJMp1409903

3.     WHO Ebola Response Team. Ebola Virus Disease in West Africa- The First 9 Months of the Epidemic and Forward Projections. N Engl J Med 2014; 371:1481-1495October 16, 2014DOI: 10.1056/NEJMoa1411100

4.     G Fitzpatrick, F Vogt, O B Moi Gbabai, B Black, M Santantonio, E Folkesson, T Decroo, M Van Herp. Describing readmissions to an Ebola case management centre (CMC), Sierra Leone, 2014. Eurosurveillance, Volume 19, Issue 40, 09 October 2014

5.     Global Alert and Response (GAR), WHO. Ebola in West Africa: heading for catastrophe? Strong control measures needed to stop steep climb in cases. http://www.who.int/csr/disease/ebola/ebola-6-months/west-africa/en/

6.     No troops from Ebola-affected countries for Somalia. New Vision, Friday 17, 2014 http://www.newvision.co.ug/news/660789-no-troops-from-ebola-affected-countries-for-somalia.html

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