Somalia + 8 more

WHO EMRO Weekly Epidemiological Monitor: Volume 13, Issue no 7; 16 February 2020

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Cholera in children in Somalia

During 2019, Somalia has recorded majority of cholera cases as occurring in children below 5 years of age and more so in children under 1 year of age. At the same period, the laboratory data for Somalia shows that 75% of laboratory -confirmed cholera cases occurred in children < 5 years of age (See table ).

Editorial note

Young children bear a high burden of cholera, especially in resource-poor regions of the world. Estimates of cholera in endemic areas (Africa, Asia, South America, and Central America) indicate in 3–5 million cases and 100,000–130,000 deaths per year. Young children, aged less than 5 years, are one of the most vulnerable groups, with an annual incidence rate of cholera 2–4 times higher than those found in the overall population.
In 2019 Somalia recorded 3 100 suspected cholera cases with 4 deaths (CFR 0.13% and AR 70.3). Of these cases, 65.71% were children below 5 years of age. 480 stools specimens were cultured, and 24.37% tested positive for V. cholera and out of these 75% were children under 5 years.
The trend of reported cases from 2019 till week 5-2020 shows that the number of the reported suspected under five year cases are much higher. The reported cases got peak initially during 2019 due to heavy rains and subsequent floods in the country and can be linked to limited availability of the safe drinking water and poor hygiene and sanitation. The second peak reported in the first few weeks of 2020 can be linked with poor water, sanitation and hygiene in the affected districts. Also additional new districts in Hiran and Lower Shabelle regions were confirmed new cholera outbreaks. Out of total cases reported from these two regions,

74.81% are children under five year as well. (See graph).
Somalia is making great efforts to improve surveillance of cholera, especially the epidemiology in children less than 5 years. Rapid Diagnostic Tests (RDTs) were used in the field and cholera treatment centers (CTCs) to test for cholera. Positive samples for V cholerae through RDTs were sent to the national public health laboratory in Mogadishu for culture. Samples which test negative by culture will be sent to Nairobi (KEMRI/AMREF) for further bacteriological tests. Once cholera outbreak in confirmed (by culture), the clinicians tend to randomly select every tenth patient for testing with RDT and culture. Additionally, all suspected cases occurring in children below 2 years of age will have their stool samples tested.
Response measures implemented by the MoH and partners include multisectorial coordination, active surveillance and case finding, case management at established cholera treatment centers, laboratory support through sample collection, shipment and analysis at the national reference, WASH, training of health workers, risk communication and community engagement, as well as conducting oral cholera vaccination campaign in six high risk districts reaching over 600,000 people above 1 year of age.
Current recommended case management for children includes, in addition to supportive treatment and re-hydration, use of the following antibiotic:

  • Ciprofloxacin 15mg/kg twice daily for three days, or

  • Azithromycin 20mg/kg Single dose single dose (recommended first-line therapy), or

  • Erythromycin 12.5mg/kg four times daily for three days

In endemic settings such as in Somalia, it is important that other causes of acute diarrhoea in children should also be investigated, as for; Viruses: Rotavirus, norovirus, adenovirus, astrovirus, caliciviruses, enterovirus; Bacteria: Salmonella, Shigella, Vibrio cholera, Escherichia coli (ETEC & EPEC), Campylobacter jejuni, Yersinia enterocolitica, Yersinia pseudotuberculosis, Clostridium difficile;
Protozoa: Giardia lamblia, Cryptosporidium, Entamoeba histolytica Although young children bear a high burden of the disease, currently available oral vaccines are used, but give a lower efficacy and shorter duration of protection in paediatric age-group than in adults.