Warning Alarm on Public Health: Resistance to anti-tuberculosis drugs growing in Somalia

Gene specialist Samira Alrahman Abrahim investigates samples in the laboratory of the Hargeisa tuberculosis hospital. Photo: Joonas Lehtipuu.

Finland participated in the fight against the spread of tuberculosis (TB) in Somalia already before the Somali Civil War in the 1980s. The war complicated efforts to handle the tuberculosis situation, but efforts to eradicate the disease is now continuing.

Idris Muser Walays, aged 55, is sitting on a hospital bed. He has been hospitalised for 40 days.

"I was very sick before I came to hospital. I couldn't walk and had breathing difficulties."

Idris Muser Walays (aged 55) is treated for a serious tuberculosis in the Hargeisa Hospital in Somaliland. Photo: Joonas Lehtipuu.

This is the first time that Walays has been admitted to the Hargeisa Tuberculosis Hospital in Somaliland. He has contracted a serious form a tuberculosis, which has spread not only to lungs but also to all internal organs. Difficult cases like the one Walays has can be treated in only few hospitals in Somalia.
Somalia is one of the high TB burden countries (high burden country, HCB) in Africa. In 2016, more than 14,000 people were diagnosed with the disease but many cases continue to remain undetected.  The Hargeisa Hospital treats over 2,000 patients a year.
"Poor population groups are at increased risk of TB infection, which is why the disease is common in Somalia.  Undernourishment, poor general health and poor living conditions make people vulnerable to the disease and its spread."
In many countries, the most vulnerable people, including the elderly, children and HIV-positive, contract the disease.

"In Somalia, the disease is often diagnosed among the adult population, which is exceptional," Abdullahi says.

Tuberculosis is a droplet infection. One person with the bacteria may infect as many as 15 others around him or her and these then pass on the disease to others. In the end, all villagers may be affected. Abdi Yusuf Ahmed, aged 85, came to the hospital to have treatment for tuberculosis for the first time in his life. Ahmed tells that tuberculosis is endemic in the village.
"We saw many patients with tuberculosis who were coughing but as we were not aware of how the infection is contracted we didn't know to avoid them."
During the Civil War, hardly any health care was available in rural areas for decades. Misconceptions about the disease were also common.

"In my childhood, parents told that people could contract the disease by drinking camel milk. We are wiser than that now."

Hargeisa Tuberculosis Hospital in Somaliland. Photo: Joonas Lehtipuu.

Increasing resistance to drugs is a cause for concern

Dr. Adam Abdullahi says that the biggest concern in Somaliland is the increase of drug-resistant tuberculosis.

"Our hospital is the only one beside hospitals in the capital city of Mogadishu and in Puntman state where drug-resistant tuberculosis can be treated."

The World Health Organization (WHO) estimates that the incidence of multidrug-resistant tuberculosis in Africa is one of the highest in Somalia. Over eight per cent of the new cases are drug-resistant. Moreover, as many as 47 per cent of patients coming to be treated for a second time carry a drug-resistant strain of the disease. The main reason for the increase of the drug-resistance is treatment with wrong medication and patients' failure to complete the course of medication because of lack of knowledge or money. Tuberculosis requires a long course of treatment, even for as long as over six months. In a poor country, few patients can afford long treatments.

"We treat approximately 300 patients with a multidrug-resistant form of tuberculosis every year and manage to cure about 83 per cent of them," Abdullahi estimates.

The laboratory determines which strains are drug-resistant

Patients must leave their shoes at the door and wear rubber shoes provided by the laboratory. They must cover their hair under a cap and wear a respiratory equipment and  a disposable protective gown. No one is allowed to walk into the TB laboratory located in the hospital area without permission. A laboratory funded by the Finnish Physicians for Social Responsibility (PSR) organisation functions as a national reference laboratory.  The laboratory staff diagnoses TB samples sent from all parts of the country and determines which ones are drug-resistant.

"Earlier laboratories' incapacity to determine which cases are drug-resistant constituted the bottleneck for treating patients. In the course of the past couple of years, treatment has become much more effective because we know which drug suits the patient," says Farhan Mohammed Osman, Assistant Manager of the laboratory.

According to Osman, the laboratory has managed to step up its procedures thanks to new, effective microscopes provided by Finland.

Minttu-Maaria Partanen
The author of the article is a freelance journalist

FACTS:
Results of Finland's anti-tuberculosis work

• Finland supported Somalia before the eruption of the Civil War in the 1980s. At that time, there was a National TB programmes (NTP), which led to a marked drop in the incidence rate. Finland's work to fight tuberculosis was then considered to be among the most advanced in the entire African continent.
• Finland supports work to fight tuberculosis in Somalia for example through the Physicians for Social Responsibility (PSR) organisation.
• The PSR diagnoses and treats TB patients in the biggest tuberculosis clinics in Mogadishu and Hargeisa. In Somaliland, the PSR maintains a national tuberculosis laboratory.
• In 2016, the PSR was engaged in approximately 8 per cent of all TB cases that were diagnosed. 83 per cent of them were cured.

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