2/2012
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Lennart Brander

Tuberculosis in Somalia

TB is still a serious disease in Somalia, but the HIV-situation is better than in most Sub-Saharan countries.

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It can affect all parts of the human body, but the most likely target are the lungs. The disease is transmitted from one person to another by coughing or sneezing. Cough, often with bloodstained expectoration, fever, loss of appetite and weight are typical symptoms of lung TB. The diagnosis of TB is confirmed by bacteriological methods, direct microscopy or culture of sputum.

Patients harboring drug sensitive bacteria can usually be cured with a combination of antibiotics if the patient takes the drugs in prescribed order. In general, the TB situation is worsened by poverty, famine, bad housing and war and by co-infection with the human immunodeficiency virus (HIV).The greatest threat to a successful TB-program is the high frequency of HIV-infection in many countries and the increasing number of patients with multi-drugresistant TB (MDR-TB).

The prevailing view has been that TB was introduced into Sub-Saharan Africa by European colonists, but modern research has shown that the general conception of Africa as virgin soil for tuberculosis cannot be supported by available evidence.

There is evidence that TB was present in East Africa at the time of the earliest European entries into the area. How and when TB came to Somalia is not known. TB may have been present for many centuries, perhaps introduced by Egyptian travelers, Portuguese sailors or Arab merchants, even before the conquest of the European powers in the second half of the 19th century.

TB globally today

According to the World Health Organization (WHO) both the absolute number of new TB cases and the incidence per 100.000 population has decreased somewhat during the last few years. In 2010 there were an estimated 8.8 million incident cases of TB globally, equivalent to 128 cases per 100.000 population.

Most of the cases occurred in Asia (59 percent) and Africa (26 percent). 1.1 million (13 percent) of these patients were among people living with HIV and 82 percent of them were living in the African region. Prevalence numbers measure the total number of TB cases at a given moment and according to WHO there were an estimated 12 million prevalent cases of TB in 2010 in the world. Of these 650.000 were estimated to be MDR-TB. Approximately 1.4 million patients died of TB the same year.

Of the new cases 3.4 percent and among the previously treated cases 20 percent were estimated to be MDR-TB (WHO 2011). In 2009 the rate of treatment success for new cases of sputum smear-positive TB was 87 percent.

The present TB situation in Somalia

In 2009 there were an estimated 26.000 incident cases of TB in Somalia, equivalent to 290 cases per 100.000 population. About 14.000 of these patients are estimated to be smear-positive. 11.271 cases were detected and of these 6.000 were smear-positive. That means that less than 50 percent of all TB-cases were detected. There were an estimated 48.000 prevalent cases in 2010 (513/100.000). The annual risk of infection of TB 2006 was found to be 2,2 percent.

The number of patients with HIV/TB combined infection is uncertain – for instance Ahmed Askar found in his thesis 2008 10.9 percent of examined cases to be HIV-positive. A countrywide study in 2010-2012 showed a frequency of MDR-TB to be 5.4 percent in new cases and 46.4 in previously treated cases. That is a clear increase from 2007 when the respective numbers were 1.8 percent and 10 percent. Almost 90 percent of the TB patients in Somalia were successfully treated in 2010.

From these numbers can be deduced that TB is still a serious disease in Somalia, but the HIV-situation is better than in most Sub-Saharan countries. On the other hand, MDR-TB is already a serious problem and will probably increase in the next few years.

In Finland, on the contrary, the TB situation is quite different. In 2011 326 new cases were detected or 6.1/100.000. 25 percent of them were foreign born. Six patients (2 percent) were HIV-positive. 251 patients had positive culture tests and 94 percent of them were completely sensitive to all TB drugs. Five cases of MDR-TB were found, three of them in foreign born persons.

Finnish support in the 1980s

The Finnish Anti-tuberculosis Association (nowadays called Filha) implemented 1981-1990 a comprehensive TB-project in Somalia. The activities started as a pure humanitarian project in a refugee camp in Qorioley in southern Somalia, but was later expanded to five of the eighteen regions of Somalia.

It was later developed into an educational project and many Somali doctors, nurses, laboratory and roentgen technicians and other staff were trained in the diagnostics and treatment of tuberculosis. Hospital buildings, ambulatories, laboratories and x-ray departments were renovated and equipped. TB-drugs and laboratory and x-ray material was procured by the project.

At most the Finnish personnel in Somalia comprised of almost thirty persons, doctors, nurses, laboratory and x-ray technicians, administrators, health educators, librarians, pharmacists and technical personnel. The project was probably the biggest Finnish health project ever in a developing country with a total cost of about 40 million euro in the present currency.

Kismayo TB-hospital in 1988.

The activities of the project were gradually expanded to Mogadishu, Kismayo, Baidoa, Hargeysa. Burao, Gebiley, Berbera, El Ahmed, Merca, Burhakaba and Jamame. TB-polyclinics were established and TB-wards renovated. Forlanini hospital underwent extensive improvements and was developed into a well-functioning training center. Many lectures, seminars and courses were organized. Thirteen Somali doctors were sent to Finland for training in respiratory diseases and some members of the paramedical staff were trained in other countries than Somalia.

TB-doctors at Forlanini hospital in 1988.

During the ten years the project existed about 60.000 patients were started on treatment and 35.000 of these patients were cured. The last years of the project almost 80 percent of the patients were cured. The high amount of defaulters was a problem but HIV was not yet a threat and very few patients were drug-resistant.

In 1988 the civil war started in the north of the country and the project activities were gradually abandoned. In 1990 the war came closer to the capital and in December the expatriate staff had to leave the country for security reasons and the project was officially finished.

At that time the renovations had been almost completed, hundreds of persons trained and all practical work transferred to local staff. The plan was to continue in a smaller scale for the next few years with economical support and the presence of only a few Finnish experts.

Unfortunately all hospital and outpatient department buildings were looted and the equipment stolen during the last period of the war and immediately afterwards. The plans to start the training of specialists in respiratory diseases together with the University of Tampere could not be accomplished.

The children`s ward at Forlanini hospital in 1988.

Although it is frustrating that all material investments in the TB-sector were destroyed, it has to be noted that the knowledge and knowhow transferred to numerous members of the local personnel has not disappeared.

In 2009 I tried to localize as many of the Somali doctors as possible who had been working in the project at some time during the 1980s. Information was obtained concerning 27 doctors. Of them seven were working directly with TB-patients in Somalia, many of them in leading positions. Six were working in private practice in Mogadishu or Hargeysa, six had died and eight were living outside Somalia. Also many nurses and laboratory and x-ray technicians were working in the health sector in Somalia.

Even if the project was abruptly ended and the procured material destroyed, the long term impact of the project was reasonably positive. The great number of educated medical staff was the most important result, but also the administrative structures created by the project were useful when the TB-work restarted mid-1990s.

The knowledge of TB among both medical and lay persons accomplished by intensive health education is probably still present. Before 1980 probably very few Finns knew anything about Somalia and Finland was probably quite unknown to most Somalis. Thanks to the TB-project and other Finnish projects Finland still has a good reputation in Somalia, a fact that now, 20 years later, may help present Finnish activities in the country.

The period after the fall of Siad Barre in 1991

After some chaotic years in the beginning of the 1990s WHO together with various NGOs gradually started the anti-tuberculosis activities again in 1995. From a modest start the program expanded fast to cover the whole country a few years later.

From 2004 the National TB programmes (NTP) have been largely financed by the Global Fund against AIDS, Tuberculosis and Malaria (GFATM) together with many international NGOs. The system is organized by World Vision which is the principal recipient of Global Fund money. The organization is complicated by the fact that Somalia politically is divided in three parts, Somaliland, Puntland and South-Central area. All three zones have their own Ministry of Health and their own National TB programme (NTP).

The NTPs in Somalia are implementing directly observed treatment, short course (DOTS) in about 60 centers countrywide with at least one center in each of the 18 regions and major district localities. The results of the treatments have been remarkably good considering the present political and economic situation. The fact that less than half of the estimated number of new cases are detected annually is probably due to the fact that a big part of the population is nomadic and to the fact that thousands of persons are displaced in their own country or living in refugee camps abroad.

Some TB centers have resources for HIV testing and even to treat patients with combined HIV/TB infection with both TB drugs and anti-retro viral drugs (ARV). Until now culture and drug resistance investigations have not been possible in Somalia but will probably be started in 2012. Many TB patients are treated at private clinics especially in Mogadishu and Hargeysa, and not all of them cooperate with the NTPs.

The PSR project

The Finland-Somalia Association (Suomi-Somalia Seura) organized a fact-finding mission to Somaliland in 2000 and later supported some smaller TB projects in Mogadishu and Somaliland. In 2006 a Finnish NGO, Physicians for Social Responsibility (Lääkärin Sosiaalinen Vastuu), PSR or in Finnish LSV, started a pilot project in Mogadishu with a TB laboratory and later took over a TB outpatient clinic in Mogadishu. For security reasons the laboratory was moved in 2009 to Hargeysa, where also a new TB center was started in 2010.

The present PSR project started in 2008 and has recently been prolonged to the end of 2014. It is financially supported by the Finnish Ministry for Foreign Affairs (MFA) and by the Global Fund.

After some difficulties and bad performance of the staff in the beginning, the Mogadishu clinic now functions very well. The clinic in Hargeysa has functioned excellently ever since the start in July 2010. PSR has, with money from the Finnish MFA and the Global Fund, built a laboratory in Hargeysa in connection with the local TB hospital.

Unfortunately, the opening of the laboratory has been delayed because of technical problems and complicated procurement of equipment. Training of laboratory personnel in fluorescence microscopy has been performed in the laboratory and the laboratory is already performing rapid culture and resistance determinations with the new geneXpert technology. Before the end of 2012 the laboratory should be in full function.

When this is accomplished the laboratory will be the only lab in Somalia doing cultures of TB bacilli and drug resistance tests. Thus the project will be able to serve the NTPs in Somalia when they are planning to start treatment of MDR-TB. This year both PSR clinics will start testing TB patients for HIV in accordance with the recommendations of the WHO.

Dr Ahmed Guled in front of the laboratory in Hargeysa in 2010.

In 2011 there were 4.456 visits at the TB clinic in Mogadishu. 174 cases of TB were found and started on adequate treatment. The PSR TB- clinic in Hargeysa was attended by 2646 clients in 2011 and 222 were found to have active TB and put on treatment. In 2010 302 TB patients were treated at the PSR clinics with a success rate of 83 percent in Mogadishu and 84.6 percent in Hargeysa.

In 2011 PSR together with London School of Hygiene and Tropical Diseases and the NTP of Somaliland received a grant from the WHO connected TB Reach programme to improve the detection of TB cases in Somaliland. This will be accomplished by introducing fluorescence microscopy in sputum smear investigations instead of using the 100-year old Ziehl-Neelsen method and by making the collection of sputum sampler quicker. The laboratory technicians will then be able to examine more slides every day. In the cultures and resistance tests modern technology will be used, thus making the tests faster and more reliable.

Dr. Simo Granat, with long experience in practical project work, has been the director of the PSR project ever since the beginning of the PSR activities in Somalia. Dr. Ahmed Y. Guled is field coordinator stationed in Hargeisa. Dr. Guled has vast experience of clinical TB work since the beginning of the 1980s and he is also competent in TB laboratory work. A total of 35 locally recruited staff were working for the project at the end of 2011.

Smear microscopy at the TB clinic in Hargeysa in 2011.

Summary

Tuberculosis is still a serious disease in Somalia. On one hand, poverty, periods of famine and drought and armed conflicts contribute to the unfavorable situation. On the other hand, there are quite many competent doctors, nurses and laboratory technicians in Somalia and the network of TB clinics cover the greatest part of the country.

The HIV/TB and MDR/TB situation is alarming but still not catastrophic. WHO and World Vision together with many different foreign NGOs will hopefully continue their economic and technical support for many years since Somalia has presently no possibility to finance the TB-work itself.

There is an urgent need to detect the missing 50 percent of the estimated number of TB patients in Somalia. According to the recommendations of WHO all TB patients should be tested for HIV infection and treated with ARV-drugs if found positive. The search for MDR-TB should be intensified and treatment with appropriate second line drugs started. Before the end of this year, we hope that the PSR-project will be able to give reliable laboratory service to the MDR-TB treatment centers and function as a reference laboratory for the country. The PSR clinics both in Mogadishu and Hargeisa have got excellent marks from the agency (CCM-Italy) employed to evaluate and monitor the activities at the TB clinics. The clinics can therefore support the NTPs by setting example for other not quite so successful TB centers.

The health sector in Somalia still needs international support. The excellent cooperation between Somalia and Finland since the beginning of the 1980s will hopefully continue in the future. The many competent health workers in the Somali diaspora in Finland can certainly together with Finnish NGOs assist in creating a sustainable development in their country of origin.

Lennart Brander

The author is medical doctor and specialist in Internal Medicine and Lung Diseases, who lives in Helsinki. He participated in TB-projects in Somalia in 1987-88 and in Estonia, Latvia, the Republic of Karelia and Somalia in 1998-2012.

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Sources:

Abukar Ali Hilowle (2012). MDR Survey Report. Personal communication 5.1.2012.

Ahmed Haji Omar Askar (2008): TB and HIV coinfection in two districts in Somaliland. Diss. Tampere: Tampere University Press.

Daniel, T.M. (1998). The early history of tuberculosis in central East Africa: insights from the clinical records of the first twenty years of Mengo Hospital and review of relevant literature. International Journal of Tuberculosis and Lung Disease 2(10): 784–790.

Finnish Anti-Tuberculosis Association (1991). Somalia-Finland tuberculosis control and training project. Summary report 1980–1990.

Munim A. & Y. Rajab & A. Barker & M. Daniel & B. Williams (2006). Risk of Mycobacterium tuberculosis infection in Somalia: national tuberculin survey 2006. Eastern Mediterranean Health Journal 14(3): 518–530.

PSR-Finland (2011). Somalia project. Annual report.

WHO (2011). Global Tuberculosis Control. Geneva: WHO. http://www.who.int/tb/publications/global_report/2011/gtbr11_full.pdf