WHO Report: Cholera kills 9 in Somalia in 3 months

MOGADISHU, March 30 (Xinhua) -- A cholera outbreak in four regions of Somalia has left at least nine people dead with 1,613 cases counted since December 2017, the UN health agency said on Friday.
The World Health Organization (WHO) said the outbreak started in Beletweyne, Hiraan Region then it spread to Banadir Region in early January and later to Lower Juba and Middle Shabelle in early February.

"WHO recommends improving access to safe water and sanitation to prevent cholera transmission. Reinforcing surveillance, particularly at the community level, is advised," said the UN health agency said in its latest report.

Cholera is a potentially fatal water-borne disease transmitted through contaminated water and/or food. It causes watery diarrhea and vomiting that can rapidly lead to death through severe dehydration.

Generally the cholera bacteria spreads in places with poor hygiene, where people do not use latrines to dispose off excreta, or do not wash their hands with soap or ash after defecation.
WHO advised that access to appropriate case management should be improved in the affected areas to decrease mortality, noting that the use of oral cholera vaccine (OCV) to limit the spread should also be considered.
WHO said that despite the control and prevention measures implemented during the last large cholera outbreak in 2017, the risk of the current outbreak is considered high at the national level because only 16 percent of the at-risk population was vaccinated during last year's OCV campaign, which is too low to provide population-level immunity.

The Horn of Africa nation has no public health system after nearly three decades of continuous conflict.
WHO said cholera is endemic in Somalia and continuous transmission was reported in the last few years. The last outbreak, which occurred in 2017, was one of the largest cholera epidemics the country has experienced with 78,000 cases, including 1,159 deaths were reported from 16 regions.

The outbreak reached its peak in April 2017 and gradually declined from June until August 2017, and only few sporadic suspected cases were recorded between October and November 2017.
WHO, however, said it does not recommend any restrictions on travel or trade to Somalia based on the information available.

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Fight against maternal and newborn deaths intensifies in Puntland

The Puntland State of Somalia is stepping up the fight against maternal and newborn births with the First Lady Dr. Hodan Said Isse taking lead in her capacity as Puntland's Goodwill Ambassador for the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA). 

The First lady, the Puntland Ministry of Health and UNFPA convened a high-level advocacy forum on the CARMMA on 19 March 2018 to rally political commitment and leadership in support of the new Acceleration Plan on Mother and Child for 2018 to 2021, and to increase public awareness about the seriousness of the problem of the maternal and neonatal death and morbidity.

Somalia has one of the highest lifetime risk of maternal deaths in the world, with women facing a one in 22 lifetime risk of maternal death. The maternal mortality ratio is estimated at 732 deaths per 100,000 live births.

In May 2009 the African Union launched the CARMMA to trigger concerted and increased action towards improving maternal and newborn health and survival across the continent. The main objective of CARMMA is to expand the availability and use of universally accessible quality health services, including those related to sexual and reproductive health that are critical for the reduction of maternal mortality. The focus is not to develop new strategies and plans, but to ensure coordination and effective implementation of existing ones. CARMMA aims to renew and strengthen efforts to save the lives of women who should not have to die while giving life. CARMMA believes in ensuring accountability: every single loss of a mother’s or child’s life should be reported.
Activities of the campaign include mobilizing the necessary political will to make the lives of women count, coordinating and harmonizing interventions around country-led plans/roadmaps and supporting ongoing efforts and initiatives to improve maternal, newborn and child health.
The advocacy forum in Puntland attracted high-level participation from the Ministry of Health, Ministry of Women Development and Family Affairs, UNFPA and other development partners, Puntland Midwifery Association, women and youth groups, media houses, education and health institutions, private sector and Somalis from the diaspora.

Speaking during the forum Dr. Isse emphasized the importance of a collective responsibility towards addressing the high maternal and neonatal mortality rates in Somalia.

"The key priority is to ensure that facilities are well-functioning, located where mothers can access them and services are being used by all women, including the most marginalized and underserved”, said the First Lady.

She said it was also important to intensify awareness raising on maternal and child health issues through community initiatives, radio and TV, social media, documentaries, and advocacy forums.
Dr. Isse also said that since the beginning of 2018, she has participated in two fundraising events, in collaboration with the Somali diaspora. 

"We have raised $ 90,000 for improving maternal and child health facilities in Somalia and an additional $ 190,000 in support of maternity care for Somali-Americans in Virginia and Minnesota”, said the CARMMA Goodwill Ambassador.

The Minister of Health, Dr. Abdinasir Osman Isse, provided an overview of the overall strategic progress and vision for CARMMA 2018 to 2021 and thanked the CARMMA Goodwill Ambassador and UNFPA for working tirelessly on the CARMMA initiative.

"We have achieved tangible progress in tackling maternal and neonatal mortality in Puntland State of Somalia with the support from UNFPA. For instance, we have supported life-saving emergency maternity and neonatal care facilities and outreach maternity services across Puntland. We have also supported six midwifery schools and as a result, 255 midwifery students have graduated and now work in rural areas”, said the Minister of Health.

He said the Ministry of Health is committed to implementing the new Acceleration Plan on Mother and Child Health for 2018 to 2021. "We want to ensure that every single woman has access to skilled birth attendance in Puntland State,” said Dr. Osman Isse.
Minister of Women Development and Family Affairs, Honourable Maryan Ahmed Ali also pledged support towards the CARMMA and highlighted the positive link between women’s development and maternal health.

"Increasing women’s access to resources and ensuring a wide range of opportunities such as adequate access to information, education and employment, will surely lead to a healthier and empowered society. Women’s access to health care is not a privilege, it’s a right and our ministry is committed to do its part in ensuring that women from all corners of Puntland are well informed and are empowered to seek health care,” stated Honourable Ali.

Director General of Puntland Diaspora Affairs Agency (PDAA), Omer Shere, shared various success stories of how the Somali diaspora has contributed to improving the maternal and child health situation in Puntland. "The Somali diaspora constructed health facilities, supported fistula repair surgeries and brought life-saving medical equipment, such as oxygen concentrators and incubators,” said Mr. Shere, adding: "our agency welcomes the new Acceleration Plan on Mother and Child Health. We are committed to mobilizing more resources and attract more diaspora expertise to the country.”

UNFPA Reproductive and Maternal Health Programme Specialist in Puntland Ms. Jihan Salad thanked the national leadership and dignitaries for their efforts and commitment to improving the health of Somali mothers and children in Puntland.

"In close collaboration with the CARMMA Goodwill Ambassador, the Ministry of Health and other ministries, UNFPA pledges its support to the achievement of three universal and people-centered transformative results; end preventable maternal deaths, end the unmet need for birth spacing, and end gender-based violence and harmful practices,” said Ms. Salad.

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AU Mission in Somalia reorients its military medical personnel on the management of casualties in conflict zones

Mogadishu, 28 March 2018 - A team of 39 military medical personnel from the African Union Mission in Somalia (AMISOM) have successfully completed a three-day orientation on emergency evacuations, management of casualties and trauma patients, in highly stressed environments.

The orientation, undertaken by medical personnel operating in combat zones, is part of the AU Mission’s medical support plan aimed at ensuring that all its medical personnel are well versed in battlefield First Aid, casualty evacuations and care, handling drug stockpiles and disposal of medical waste.
Facilitators at the three-day orientation comprised of officials from the United Kingdom’s military training team.

“This mission is going to expose you to injuries that are predominantly IED-type injuries, which some of you are not familiar with,” Retired Gen. Fidza Dludlu, the AMISOM Head of Mission Support told participants on the last day of the medical workshop.

The Force Medical Officer Lt. Col. Dr. Boniface Mandishona, attributed most injuries in combat zones, to the use of Improvised Explosive Devices by the enemy. IEDs remain the biggest threat to civilian populations and security forces in Somalia.

“As you know, the biggest weapon in our Mission area, which is being used by Al-Shabaab, are Improvised Explosive Devices. We get nasty injuries and some of these new staff are not exposed to the type of injuries that we get. So this conference gives them an opportunity to interact with our training team, who will then impart the knowledge that is necessary for us to improve on troops’ health and ability in the mission area,” Dr. Mandishona explained.

The training oriented the medical personnel on aspects of emergency trauma handling in the frontline - which include learning ways of stopping excessive bleeding and proper handling of fractures, to ensure injured troops are safely evacuated to hospitals.

The training benefitted diverse groups drawn from all AMISOM sectors, among them military commanders, senior medical officers, principal nursing officers, laboratory technicians and pharmacists.
Maj. Gen. Salvatore Harushimana, the AMISOM Deputy Force Commander in-charge of Support and Logistics, called on participants to use skills learnt, to better manage emergencies in conflict zones.
A participant, Captain Biira Kabonesa, the Principal Nursing Officer at the AMISOM Level II Hospital in Mogadishu, described the training as insightful and useful.

“I will share with others the knowledge given to me during the three-day sessions,” she said.

“You cannot be trained enough. Our troop medics, our paramedics, they need more training and we will do that, according to what we have received,” another participant, Captain Dr. Severin Irambona, the Burundian contingent medical officer based in Jowhar, HirShabelle state added.

END

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Egypt donates two tonnes of medical supplies to Somalia: Egyptian ambassador

The Egyptian embassy in Somalia delivered two tonnes of medical supplies to the Somalian health ministry on Friday, Egypt's ambassador to Somalia Walid Ismail said in a statement on Sunday.
The humanitarian aid shipment was donated by the Egyptian Agency of Partnership for Development (EAPD), which is part of the Egyptian foreign ministry.

Ismail said the aid was donated as a matter of "brotherly relations" between the two countries, as Egypt helps a partner to combat drought and related diseases, as well as severe injuries resulting from terrorist atacks.

Somalia is suffering from a prolonged, devastating civil war between the government and radical militant groups.
Egypt has been providing aid to help the Somali government cope with the consequences of the conflict.

In May 2017, the Egyptian Armed Forces sent a military transport plane with food and medical supplies to Somalia.

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Bridging the Primary Healthcare gaps of two IDP Camps in Togdheer Region

Introduction

  Taakulo Somaliland Community (TASCO) implemented an Integrated Emergency Response WASH, Nutrition, Health, Food Security and Education program for  drought affected communities through life-saving assistance, livelihood support and protection services in Jame’adka Ainanshe and Ali Awad villages in Oodweyne District funded by the Somali Humanitarian Fund (SHF).

 We’ve made possible and approached to work closely with the local communities, the beneficiaries and the administration of those designated areas for the proper utilization of the program, minimizing risk on human lives as a result of worsening droughts and to establish mutual understanding for the need of  immediate intervention to prevent further progress and deteriorated humanitarian situations in the ground. 

Dr. Mohamed Y. Dualeh, examining a child suffering from Measles in medical outreach in Jame'ada Ainaanshe

IDPs camps hosts the most vulnerable and poor communities whom cannot receive treatment by their own resources, that meant, they cannot able to buy medicines and travel long way the  nearest town to seek medical help, so despite of having many treatable conditions they are still forced by the circumstance to continue suffering from it, and sometimes complicating to a worsen medical illness as a result of missing healthcare facility in their villages, for that reason, TASCO attempted to fill the gaps in primary healthcare facilities in two desperate IDP camps and its surrounding villages by deploying two mobile health and nutrition teams and providing essential medical supply to reach most vulnerable comhmunities, pregnant and lactating women and children in all ages. Thanks to SHF for funding this project as we would not be able to reach these people without their support.

  We have trained and recruited two health and nutrition teams each deployed to specific location in those two villages, which are supposed to work 5 full days in the ground and return to their families in weekends, whom their primary duty is to help malnourished children and pregnant lactating mothers with nutritional supplies from both MoHD and UNICEF, and also immunize children from preventable diseases, and raise community awareness on realization to reach expected outcome or put into action from all anticipating results in executing this program. 

We are here going to list and share some impediments and lessons learnt during our launching event in which SHF considered to get their humanitarian efforts.

Training of Health and Nutrition Teams

  In an implementing and starting working on exercising of our ambition for efficient responding of humanitarian needs and better healthcare indices in those two remote villages; TASCO employed and trained 10 local healthcare workers which consist of 4 qualified nurses, 2 qualified midwifes and 4 Auxiliary Nurses which are supposed to work in two different mobile health and nutrition teams and each team is expected to work in certain area of the project scopes namely above. 

Mobile HNT trainees with some government officials, including the deputy Governor; the Mayor and other members

 The staff were firstly selected and delegated by the District Health Office in Oodweine and then  have been examined and approved by our Health and Nutrition department in support from one senior officer from the Central level of the Ministry of Health. After then, they have been trained with Integrated Management of Acute Malnutrition (IMAM) and Extended program on Immunization (EPI) teachings under the field experts from the Ministry of Health.

Some of Mobile Health teams receiving practical training in Oodweine MCH

 According to the pre and post test evaluations and field exposure teachings in Oodweine MCH, the participants made significant improvement and demonstrated excellence in understanding the concept of save health and nutrition practice and proper delivery of the supply to its right people.Some MHNT members with their facilitators in hand on training in Oodwine MCH    

Huge break in medical care settings

 TASCO implemented SHF funded project and discovered that the need to arrange and send teams of health and nutrition is not just enough to fulfill and complete the break of medical needs in those villages, and there should be a further intervention and strengthening of the involvement by creating high level of medical alerts, advocating for the communities and to occupy some basic medical needs from our administration resources.

 For example, we had met an old mother in her seventies complaining of shortness of breath, generalized edema, insomnia, polyarthralgia, dysuria and urinary incontinency, a complex array of symptoms with characteristic and transient early diastolic precordial murmur suggesting that she had serious heart and kidney disorder that could be preventable , so as a matter of emergency we had arranged her trip to go to Burao for further medical care, diagnosis and management and TASCO sponsored all of her traveling and treatment costs.

No Ambulance, Health Posts and MCH

 As we are working on fulfilling spaces on healthcare delivery to the remotest and in most needy areas by means of staffing skilled and trained health and nutrition teams.

With our three Land cruisers and other strong wind blowing loose sand and dirty from a dry surface by creating dust storms which is common in arid and semi-arid regions that sometimes forced drivers to stay far away each other to see the road, we eventually reached our destinations and begun distributing free medicines to sick people in all ages; still, it seems that this doesn’t help them anymore, as there is no health post, no MCH for pregnant mothers and children and no ambulance ready for them when it comes to lift severely malnourished children and complicated pregnant mothers to well equipped and advanced facilities which are far from their locations, so as a result we must use our vehicles to occupy this need and to be used for transportation for those in emergency medical attention. We are extending our gratitude to SHF who enabled us to do this live saving interventions.

Medical staffs in the outreach measuring MUAC from a child

  On the second day of our field work at Ali Awad IDP camp, a fortunate mother of her early twenties started symptoms of labour, complaining a painful contractions or tightenings that may be irregular in strength and frequency, and may stop and start. There was no either ultrasound machine, nor was any other means for proper diagnostic tool, but on abdominal palpation the fetal head found above the mother’s umbilicus as a hard, smooth, rounded mass, which gently felt on between your hands. This is very likely to be the baby’s head and is often seen when the fetus lies with its buttocks in the lower part of the birth canal, and its buttocks and/or the feet are the presenting parts during delivery, which is fraught with danger, but her relatives firstly refused to be taken to Odweine MCH, which was the nearest one. And after 4 hours of caring under our Mobile Health and Nutrition Teams, eventually they’ve agreed to take her, and next they had arrived to Oodweine by our vehicle followed with our qualified midwife and one nurse , she had gave birth a healthy boy with no complication in the following night.

Burden of Malnourished Children

  These IDP villages and the similar ones with the same living standard is considered to be unsafe when it comes with children, as a result of poor livelihood conditions, lack of nutritious foods from the animal sources and agricultural products; many children started severe wasting and growth failure featuring nutritional defects with high prevalence of infections among children.

A boy with Trachoma living in Jame'adka Ainaanshe 

•  Notably, cases with Trachoma which is known to be a public health problem in 41 developing countries, and is responsible for the blindness or visual impairment of about 1.9 million people in the world are found in these IDP camps. Similarly, we have seen 5 children affected with measles in Jame’adka Ainanshe ID camp and one measles case in Ali Awad village with the support of SHF 

A child receiving Vit. A supplement in the hands of our Mobile Health and Nutrition healthcare worker.

By: Dr. Mohamed Y. Dualeh, MD

The Threat of Antimicrobial Resistance in Infectious Disease Prevention and Control in Somaliland

1.        Introduction
Antimicrobial resistance (AMR) is the development of resistance (microbes not responding to the administered drugs) in microorganisms—bacteria, viruses, fungi and parasites—to an antimicrobial medicine to which it was previously sensitive (WHO, 2015). AMR in a wide range of infectious agents is a growing public health threat of huge concern to countries and to many sectors. 

Especially alarming is the rapid global spread of multi-resistant bacteria that cause common infections and that resist treatment with existing antimicrobial medicines. There were 39.5 million deaths in the developing world where 4.123 Billion (78%) of the world population lived in 1992 and 9.2 million of the deaths were estimated to have been caused by infectious and parasitic disease (Murray & Lopez, 1997).

Although the discovery of first antimicrobials against bacteria (Antibiotics) in 1930s was a major breakthrough in the prevention and treatment of killer infections, warnings from the development of potential resistance to the new antibiotics surfaced. For instance, Alexander Fleming (the founder of penicillin) said in his Nobel prize acceptance speech 

“it is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them…there is the danger that the ignorant man may easily under-dose himself and, by exposing his microbes to nonlethal quantities of the drug, make them resistant” (Fleming, 1945).

Our ability to develop and mass-produce over 25 classes of antimicrobials in seventy years may seem monumental—indeed, many hailed the new antibiotic era as the end of infectious diseases. But, truth is, Microbes have infinitely more opportunities to gain resistance genes than we have to create new antimicrobials (Laxmanirayan, 2013). The speed of emergence of multi drug resistant pathogens globally outmatches the pace of discovery of new antimicrobials.

 There have been no successful discoveries of new classes of antibiotics since 1987 (Patel & Banomo, 2013). For example, just three years after Fleming’s warning, 38% of Staphylococcus aureus strains in one London hospital were penicillin-resistant ( Barber & Rozwadowska-Dowzenko, 1948) and roughly 90% of strains in the UK ( Johnson, et al., 2012) and nearly all of those in the US, while in some communities more than 50% of strains are resistant to methicillin (Klevens, 2007). 

The burden of AMR is very high in developing countries though due to the lack of sufficient body of research available as well as rudimentary healthcare systems with limited surveillance strategies/ programs on antimicrobial resistance which makes exact quantifications of the extent of AMR difficult as in the case in Somaliland.For instance, For example, in Matlab and Dhaka, Bangladesh, over 95% of Shigella dysenteriae isolates were resistant to multiple first line drugs (Hussain & Rahman, et. al., 1998).

 In Somalia in a cholera epidemic in 1985-6, there was a case fatality rate of 13% because the initially sensitive V cholerae quickly acquired plasmid encoded resistance to ampicillin, kanamycin, streptomycin, sulphonamides, and tetracycline (Coppo, et. al., 1995).
Therefore, considering facts presented here, multiple stakeholder cooperation is needed at national (as in Somaliland) as well as international level to fight against this serious threat facing the mankind.
2.                 Burden of Antimicrobial Resistance
a)                 Impact on Health Outcomes
Deaths from acute respiratory infections, diarrheal diseases, measles, AIDS, malaria and tuberculosis account for more than 85% of the mortality from infection worldwide (WHO,1999) and resistance to first-line drugs in the pathogens causing these diseases ranges from zero to almost 100% ( WHO,2001).
 Resistance frequently leads to a delay in the administration of microbiologically effective therapy, which may be associated with adverse outcomes (Kollef, Sherman, Ward & Fraser, 1999).

The impact on particularly vulnerable patients is most obvious, resulting in prolonged illness and increased mortality (Who, 2014). Infections caused by antibiotic-resistant bacteria are believed to result in higher mortality rates, longer durations of hospital stays, and higher health care costs compared to those that result from infections with their antibiotic-susceptible counterparts (Holmberg, et. al., 1987). 

According to Carmeli, et. al., (1999), there is an association between antibiotic resistance and adverse outcomes on the order of a 1.3–2-fold increase in mortality, morbidity, and cost for patients with resistant versus susceptible infections.
          

Figure 1: Global attributable mortality to AMR

Projections of the future deaths due to AMR based on the current trends are described in the following figure 2.

b)                Impact on Economy
Antimicrobial resistance affects all areas of health, involves many sectors and has an impact on the whole of society. Antimicrobial resistance is a drain on the global economy with economic losses due to reduced productivity caused by sickness and higher costs of treatment (WHO, 2015). Antibiotic resistance has a significant health and economic implications, increasing national investment spending and reducing global GDP by 0.4 to 1.6 % (World Economic Forum, 2013). The annual societal cost-of-illness for AMR is considered to be roughly $55 billion for the US alone (Smith & Coast, 2013).

In an American study in 2008 of attributable medical costs for antibiotic resistant infections, it was estimated that infections in 188 patients from a single healthcare institution cost between $13.35 and $18.75 million dollars (Roberts, et. al., 2009). 

3.     Factors associated with occurrence of AMR
                   i.           Patient factors: self-medication of antimicrobials, patient’s level of education and awareness about safe use of antibiotics, poor adherence to prescribed medications (these factors are all highly prevalent in Somaliland).
                 ii.           Irrational use of antimicrobials including lack of standard antimicrobial prescribing policies/guidelines
               iii.           Advertising and promotions: allows pharmaceutical companies to advertise drugs directly to public.
               iv.           Economic factors: people may buy cheap and low quality medicines due to out-of- pocket situations
                 v.           The burden of substandard and counterfeit medicines worldwide: these may contain quantities less than required for effective antimicrobial activity (above MICs/MBCs), thereby exposing low concentrations to pathogens and promoting resistance.
               vi.           Lack of public health policies towards the containment of antimicrobial resistance nationwide as well regulations for promotion of rational use of antimicrobials.
             vii.           Lack/poor surveillance of the burden as well as trends of antimicrobial resistance (e.g. routine such surveillance is lacking in Somaliland).

4.     Impact Of AMR On Public Health Efforts To Control And Prevent Communicable Diseases
AMR resistance has substantially decreased our ability in controlling several important diseases, leading not only to economic losses, but also to social damages in the Public Health field (Munir and Xagoraraki, 2011; Wiesch et al., 2011).

The effect of AMR on public health summarized:
a)     It hinders the ability of public health measures to control the burden of infectious diseases as infections due to resistant pathogens prevail ( e.g. the challenges posed by MDR-TB associated with longer treatment periods, higher costs of therapies by using expensive second line drugs, reduced cure rates- decline from 80-90% in non-MDR cases to less than 50% in cases due to MDR-T.B; this is a global challenge as well as to the the Somaliland national TB program ,in particular, with rising prevalence of MDR-T.B.).

b)     It is associated with increased spending in healthcare and burden on national and institutional health budgets.

c)     It is associated with increased morbidity and mortality attributed to infectious diseases (e.g. Nosocomial infections and the challenge of MRSA/VRSA).

d)    If not contained from the current trend, the world may live similar era when a simple infection such as typhoid or plague had caused widespread epidemics/pandemics.

5.     Recommendations, Way Forward

•  AMR is a major threat to public health and coordinated efforts are needed nationally as well as globally to lessen and reverse its burden by Strengthen interdisciplinary cooperation and developing holistic strategies and action plans ( Somaliland can take an active role in for instance, WHO endorsed global strategy for containment of AMR). 
• Routine antimicrobial resistance surveillance is vital and urgently required to fight against AMR.( Somaliland should cooperate with international partners engaged in surveillance programs for this problem; e.g. WHO international surveillance program for AMR). 
• Improving regulatory frameworks based on internationally agreed principles and standards (Codex, OIE) 
• Reducing the need for antimicrobials in animal husbandry, by improving animal health disease prevention and good practices along the chain  
• Public health education and raising awareness (among veterinarians, value chain actors including producers and the public) about AMR 
• Developing appropriate policies/guidance on the prudent and responsible use of antimicrobials in animal husbandry  
• Rational prescribing and use of antimicrobials is a golden strategy to fight the AMR threat.( self medication as well as the use of antibiotics for conditions not requiring so is highly prevalent in Somaliland and the government must act to address this problem) 
• Supporting research to generate data on the prevalence and trends in AMR, as well as supporting risk assessment, risk management and risk communication in the AMR area . The research data available on the magnitude as well as the health and economic implications of AMR through quality studies employing sound and standardized methodologies is limited globally and lacking in regard to Somaliland and shows the underestimation/lack of required attention to this problem.

References
Barber M, Rozwadowska-Dowzenko M: Infection by penicillin-resistant staphylococci. Lancet. 1948, 2 (6530): 641-644.
Coppo A, Colombo M, Pazani C, Bruni R, Mohamud KA, Omar KH, et al. Vibrio cholerae in the horn of Africa: epidemiology, plasmids, tetracycline gene amplification, and comparison between 01 and non-01 strains. Am J Trop Med Hyg. 1995; 53:351–359.
Fleming A: Penicillin. Nobel Lecture, December 11, 1945. 1945, Available from: http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf
Holmberg, S. D., S. L. Solomon, and P. A. Blake. 1987. Health and economic impacts of antimicrobial resistance. Rev. Infect. Dis. 9:1065-1078.
Hossain MA, Rahman M, Ahmed QS, Malek MA, Sack RB, Albert MJ. Increasing frequency of mecillinam-resistant shigella isolates in urban Dhaka and rural Matlab, Bangladesh: a 6 year observation. J Antimicrob Chemother. 1998;42:99–102.
Johnson AP, Davies J, Guy R, Abernethy J, Sheridan E, Pearson A: Mandatory surveillance of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in England: the first 10 years. J Antimicrob Chemother. 2012, 67 (4): 802-809. 10.1093/jac/dkr561.
Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S: Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007, 298 (15): 1763-1771. 10.1001/jama.298.15.1763.
Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999; 115:462–74.
Laxminarayan R: Personal communication. 2013
Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet. 1997;349:1269–1276. 
Patel G, Bonomo RA: "Stormy waters ahead": global emergence of carbapenemases. Front Microbiol. 2013, 4: 48-xx.
Roberts, RR, Hota B, Ahmad I, Scott RD II, Foster SD, Abbasi F, Schabowski S, Kampe LM, Ciavarella GG, Supino M, Naples J, Cordell R, Levy SB, Weinstein, RA. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin. Infect. Dis. 2009; 49:1175-84
Smith R, Coast J: The true cost of antimicrobial resistance. BMJ. 2013, 346: f1493-10.1136/bmj.f1493
World Health Organization. WHO report on infectious diseases: Removing obstacles to healthy development.Geneva, 1999. WHO/CDS/99.1

By: Saed Ahmed

Medical logistician & Chief Pharmacist at MAS children Hospital,

Culturally relevant tools needed to improve diabetes care in immigrant Somali communities

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with Carol Brunzell, RDN, LD, CDE, about developing a picture-based carbohydrate-counting resource for people with type 1 diabetes in a Somali community in the United States. Brunzell is an expert on providing specialized medical nutrition therapy to adult and pediatric patients with type 1 and type 2 diabetes, cystic fibrosis- related diabetes, diabetes in pregnancy and diabetes with celiac disease and other comorbidities. 
She has traveled with her pediatric diabetes endocrine team to East Africa for the past several years teaching diabetes management to health care professionals and working with children with type 1 diabetes in clinics.

How did this project get started?

Brunzell: I work with both children and adults with type 1 diabetes as a dietitian and diabetes educator. In the pediatric side of my job, I work with a team of endocrinologists and nurse diabetes educators. Over the years, we have seen increasing numbers of Somali pediatric patients with type 1 diabetes as the immigrant population has grown. Minnesota has approximately 38,500 Somali residents and is home to the largest Somali population in the United States. In one study, type 1 diabetes prevalence was estimated at about 1 in 400 Somali children and adolescents. 
Similarly, in Finland, which is also home to a large Somali immigrant population, investigators found that the incidence of type 1 diabetes in Somali children is similar to that of the general pediatric population in Finland. Control of diabetes has been noted to be poorer in Somali youths compared to non-Somali youths with type 1 diabetes attending the same clinics.

Our University of Minnesota Health pediatric diabetes team embarked on this project to develop culturally relevant education materials to assist families and children in managing their diabetes. The team was led by pediatric endocrinologist Muna Sunni, MBBCh, MS. The goal was to develop a tool, which would be widely available online free of charge, to assist patients in our own clinics as well as in other immigrant communities around the world and for patients with diabetes in Somalia.

What were some obstacles that led to the development of these materials?

Susan Weiner

Brunzell: Managing type 1 diabetes is especially challenging for immigrant families coming from countries with few resources. Language barriers and variable education levels of parents, with low literacy rates particularly among women who are typically the primary caregivers, in addition to social barriers and stressors make management more challenging. Somali families identified carbohydrate counting for traditional Somali foods especially difficult due to lack of resources available affecting their ability to manage their child’s diabetes effectively. 

What foods comprise the typical Somali diet?

Brunzell: The traditional diet includes a variety of foods that vary slightly from region to region in Somalia. Typical carbohydrates consumed include rice, spaghetti, soor (Italian polenta) and a variety of breads: canjeero/lahoh (thin unsweetened pancake), malawah (thin sweet pancake), muufo (similar to cornbread) roti (flatbread) and sabaayad (chapati). Other grains consumed alone or in breads are oatmeal, barley, teff and sorghum. The breads may be served with added oil, butter, sugar, honey, sweet tea, or spiced meat and vegetable stews (suqaar). Proteins consist of beef, goat, lamb, camel, goat liver and kidney, chicken, fish and eggs. Vegetables are commonly eaten in stews or soups, in addition to salads.
 A banana is traditionally served with lunch. A wide variety of fruits are consumed. Beverages consist of very sweet teas (chai), juice with added sugar, and milk. Oil is used liberally in cooking and is added to many foods. Dinner is served late, around 9 p.m., and may consist of beans or beans mixed with various grains called cambuulo and/or roti. American foods may be more commonly consumed at the later meal along with traditional Somali food. A variety of special sweets and other fried snack foods are served during Ramadan.

Carol Brunzell

What process did you use to develop these materials?

Brunzell: Traditional Somali foods were selected for this project after gathering information from hundreds of food recall questionnaires from Somali adults and children, discussions with a local Somali dietitian, home visits with Somali volunteers who prepared traditional meals with project staff, attendance at lectures on Somali food and culture given by members of the Somali community, and visits to local Somali grocery stores and restaurants. We also searched the internet for Somali diet information and recipes. I prepared the most common foods from a traditional Somali cookbook. 

I made carbohydrate calculations using the USDA National Nutrient Database for Standard Reference and Nutrition Facts labels on food packages. Calculations of the carbohydrate content of traditional foods were made by preparing individual food items, measuring total yield and total carbohydrates of all ingredients and dividing by the number of servings and the serving size to be consumed. All prepared foods were measured using standard measuring cups or weighed on a digital scale for carbohydrate estimation. For prepared foods purchased without a nutrition facts label, carbohydrate content was estimated using similar foods with known carbohydrate and weighed on a digital scale.

What has been the reaction from the Somali community?

Brunzell: It has been heartwarming to see the reaction of patients and parents to this guide. They are so happy to see a carbohydrate-counting guide with their traditional foods. I continuously ask for their feedback and if I have missed any foods. So far, everyone is very pleased and tells me I have included all the typical foods. We have also recorded nine diabetes education videos spoken or dubbed in Somali, which will be freely available at a later date.

 I made one video on nutrition, carbohydrate counting, and how to calculate insulin doses based on an insulin-to-carbohydrate ratio for sample meals and snacks. It was a great pleasure to be a part of this project and to learn so much about Somali foods and the community, and people are genuinely appreciative. The link to the carbohydrate guide and article is listed below.

Source: Healio Endocrine Today