Friday, May 22, 2020

Djibouti is Treating All COVID Patients with Chloroquine, But Scientists Urge Caution

ADDIS ABABA - Djibouti has more than 1,800 COVID-19 cases, making it the African country with the highest number of cases per 100,000 people. But more than 1,000 of those cases have already recovered and only nine people have died from the disease. The head of Djibouti’s main COVID-19 response center says systematically giving COVID-19 patients the anti-malarial drug chloroquine is the main reason for the country's low death rate.  But even scientists who see evidence of the efficacy of chloroquine caution on their use.
Ever since Djibouti discovered its first case of coronavirus in late March, the World Health Organization and the government has rolled out an aggressive program to test and trace those who have come in contact with COVID-19 patients. The approach has led to Djibouti recording 77 cases per 100,000 people, the highest in Africa.  

But a death rate of only 0.5 percent, health officials in the country say, is at least in part due to the use of the antibiotic azithromycin, used for the treatment of bacterial infections, and chloroquine, an anti-malarial drug known to reduce fever and inflammation.  
Morocco, where 194 people have died and the number of coronavirus cases is at more than 7,100,  has also followed that method and recorded a death rate of just 2.7 percent, lower than the global average of 7 percent.  
U.S. President Donald Trump was criticized this week after he said he had been taking the antimalarial drug hydroxychloroquine, despite warnings it might be unsafe.  
Despite some observational optimism, scientists say it is still too early to attribute low death rates to antimalarial drugs. Sultan Ayoub Meo, a professor in clinical physiology at the King Saud University in Saudi Arabia, told VOA via a messaging app that since December there had been nearly 300 peer reviewed articles published on chloroquine and hydroxychloroquine. The articles are based on the findings of just five clinical trials, four of which came out in favor of using antimalarial drugs to fight the coronavirus. 

“Although the literature is supporting, I must say being a physician, being a scientist, that these entire studies, their sample size is not sufficient to reach a proper conclusion. I think the science community must have to conduct large sample size clinical trials globally,”  he said.
Ayoub Meo said that while many people living in Southeast Asia and Africa were already using antimalarial drugs, the true extent of their side effects when used to treat the coronavirus is unknown. He added that such drugs can cause so-called "conduction disorders" that disrupt the electrical system that makes the heart beat and controls its rhythm, especially for people above the age of 55. 
Ahmed Zouiten, World Health Organization representative for the Djibouti country office, told VOA via a messaging app that while the WHO has no scientific evidence to support the use of antimalarial drugs to treat COVID-19, observationally their use alongside antibiotics does seem to be working in Djibouti’s case. 
“So for us, the treatment with chloroquine and all that, we until today do not have evidence that it is something that is functional," he said. "We see that we have very good outcomes of that treatment today in Djibouti but WHO cannot just work on observation, WHO works on evidence.”  
Pushed on whether Djibouti’s decision to treat everyone with antibiotics and antimalarial drugs was working, Zouiten said the strategy did seem to be have a positive impact. 

“The treatment itself does seem to be working, because people when they are put on treatment they do not develop much symptoms," he said. "Although I said earlier we do not work with observation, the indicators are talking. Very low mortality and very low number of symptomatic [cases].”  
Another reason for Djibouti’s apparent success, Zoutien said, is that the government has “a very, very aggressive testing strategy” and an even more aggressive approach to contact tracing. Before patients can leave the hospital, they need to test negative two times within 48 hours. 
Dr. Maad Nasser Mohammed, a specialist in tropical infections who is responsible for Djibouti’s main COVID-19 response center at the Arta Regional Hospital 40 kilometers from the capital city, confirmed the Djiboutian approach of treating all positive cases with antibiotics and anti-malarial drugs. 
He said most patients suffered from loss of taste, a cough and a fever but did not experience the type of breathing problems that has come to typify more serious bouts of the coronavirus seen elsewhere in the world. Offering one explanation, he said “chloroquine anti-malarial drugs act positively on the virus.”  
“That’s what we think, though nothing has confirmed it,” he said.

Tuesday, May 19, 2020

One hospital for 15mn in the world's ‘worst prepared’ country

With only one dedicated COVID-19 hospital for 15 million people, Somalia is bracing for a catastrophic coronavirus outbreak, doctors warn.
The single hospital equipped for coronavirus patients, located in the capital city of Mogadishu, has only 20 ICU beds, according to Dr. Deqo Mohamed, a senior doctor working at the hospital.

We have over 1,50 [updated as of 19 May] cases confirmed and almost 70 percent of daily testing comes back positive. That can tell you how severe the outbreak is and how it's getting worse,” said Dr. Mohamed, an adviser to the Somali prime minister’s COVID-19 taskforce, in an interview with Al Arabiya English.
The World Health Organization (WHO) warned last month Africa may become the next epicenter of the coronavirus pandemic. Somalia has the second highest number of cases in East Africa after Djibouti, and also has one of the world’s weakest health care systems.

Medical resources are scarce, according to Dr. Mohamed, who said there are only four PCR testing machines in the entire country. By the time Somalia receives more supplies, it will be too late, she added.
We are expecting more resources, but the whole world is in scarcity. The WHO is saying they are trying to bring more resources, but by the time they bring them, it is going to be too late, she said.
Worst prepared country
Somalia is the worst prepared country to deal with coronavirus, according to US-based think tank RAND’s infectious disease vulnerability index published in February. Somalia ranked 194 of 195 countries in the Johns Hopkins Global Health Security Index for 2019.

Somalia’s coronavirus response is not just inhibited by a lack of medical equipment and supplies. Preventative measures are impossible to implement in the war-torn country. Social distancing, facial masks, and working from home are not possibilities for the Somali population. Attempts to impose coronavirus restrictions, such as a curfew, have been met with protests.

“The majority don’t practice social distancing and don’t wear masks,” said Dr. Mohamed. “And we cannot stop people from going out to work because of their daily income, which is 2 to 3 [US] dollars.”

The country has been embroiled in conflict for three decades, with an estimated 2.6 million people currently internally displaced.

Somalia’s most vulnerable

This vulnerable population is a focus for Dr. Mohamed, who is working with colleagues from Yale University and the University of Cambridge to assess the health of internally displaced people (IDPs) in the Mogadishu area, who are living in camps with poor sanitary conditions.

Little information on the health profile of refugees and IDPs exists in Somalia, according to Jude Alawa, a Rotary Scholar and Yale University Fox Fellow at Cambridge who is working with Dr. Mohamed to assess IDP camps in the country, identify the most at-risk individuals, and prevent the spread of infection.

Alawa said the goal of their work is to provide the government and non-governmental organizations with information to strategize the best methods to support displaced populations in Somalia during the COVID-19 outbreak, and beyond.

Dr. Mohamed said that there has already been collaboration between medical and governmental sectors in the country, which may be the only good outcome of COVID-19.
For the first time in my life, in my practice of fourteen years of medicine in Somalia, the government and private sector are asking us what to do, said Dr. Mohamed.

“This will be the first time we will be focusing on reform. We want to make sure we used this opportunity to rebuild the healthcare system in Somalia,” she added.

"In such difficult circumstances, there are often local heroes who step up and respond, according to Dr. Kaveh Khoshnood from the Yale University School of Public Health and a colleague of Dr. Mohamed.

“Our role as members of the international public health community is to support such local heroes,” said Dr. Khoshnood, adding that the local community is much more likely to trust and listen to local health care workers like Dr. Mohamed than outsiders. -- Al Arabia English

By Emily Judd


The “Cruel Beast” of Covid-19: maternal care during pandemic, the disease's unknowns effect

Edna Adan, one of the world’s most famous advocates for women’s health, a former Somaliland Foreign Minister, a former WHO officer responsible for training midwives in 22 countries, and founder of the country’s Edna Adan University Hospital, is angry.
Edna Adan, founder of the Edna Adan University Hospital and a prominent women's health advocate, oversees a student midwife. (Photo courtesy of Edna Adan)
In particular, she’s disturbed by what she sees as a worldwide neglect of beleaguered Somaliland, both before and after Covid-19 appeared. “I hope that anger comes through that message that I’m giving you,” she told Direct Relief during a recent conversation.
The organization reached out to Adan to find out how Covid-19 is affecting maternal care and midwifery in her hospital.
But for the autonomous region of Somaliland, what Adan refers to as the “cruel beast” of coronavirus is just one of many concerns, among them one of the highest maternal mortality rates in the world; widespread poverty; and the legacy of a devastating civil war that killed hundreds of thousands before the country declared independence from Somalia in 1991.
In a wide-ranging conversation, Adan spoke about improvised protective gear, a lack of coronavirus-related guidance and information, and humanitarian responsibility.

Direct Relief: What were maternal and child health like in Somaliland before Covid-19 appeared?
Adan: Maternal and child health before, during, and God knows, after corona, was never good.
Somaliland is a country that has known a long civil war with Somalia – an 11-year civil war that ended in 1991 and it had destroyed everything that Somaliland had.
It had killed a quarter of a million of our people. It put a million of our people, a quarter of our population, into refugee camps. It killed many of our health professionals. And when we liberated the country in 1991, we inherited a country that had 95% of the infrastructure destroyed. A country leveled to the ground.
Somaliland is a country that does not enjoy international recognition. We don’t have a seat in the United Nations. We don’t have a seat with the World Health Organization. We don’t have a seat with the African Union. We don’t have a seat in the Arab League.
We do not belong anywhere, but we still have to care for 4 million Somalilanders who have a right to decent health care.
So a country that is poor, a country that has known war for 11 years, a country that has been denied recognition for 30 years. That’s 41 years of living in exile, living in a no-man’s land, living in a country that’s not on the map.
The answer is: deplorable. Health care is deplorable in Somaliland.
Now that the cruel beast of corona has come around as well, it’s just going to make it worse. Women die of causes that pregnant women should not die of. They die of infections. They die of postpartum hemorrhage. They die of eclampsia. Eclampsia kills many of them because too few women, maybe one out of 10, will have a prenatal examination, will be seen by a health professional.
So whatever problems she gets, she just deals with it the best she can, or maybe through a traditional birth attendant.

Direct Relief: Tell me about the care you’re providing in the hospital.
Adan: We’re training midwives, we’re training doctors, we’re training nurses, and we’re trying to introduce professional healthcare. We’re doing it as best we can and we’re trying to fill that vacuum.
If you take a pyramid as an example, the base is the broadest. We’re trying to fill the base of the pyramid, or as much of the country as possible, with people who’ve had some training either in nursing or midwifery.
There are still pockets that have no midwives at all. We continue to train midwives, but now we need to raise the bar.
We have seven training schools in Somaliland today, each one training nurses and midwives. So we’re not a lone ranger anymore. But we need to improve the standards.

Direct Relief: How is Covid-19 affecting the care that you provide?
Adan: There are 129 [updated as of 19 May] confirmed cases that the government has announced. But I suspect that there are many more undiagnosed, unknown cases. People are nursing their family members in their homes, not understanding the danger of cross-infection, and I am suspecting that…12 is a gross under-estimation.
We’ve seen more women delivering in the hospital, which is good. But we see a lot of complicated cases.
Last night we had somebody who was sent from Burao, which is the center of the country. That’s a six, seven-hour drive across Somaliland to come here. She was bleeding. She delivered, the baby is fine and she’s fine, but she could have died on the way.
In the middle of the night, we also had a woman who had a placenta previa. Since yesterday, in the last 24 hours, we’ve done four Caesarian sections. A clump of complicated cases are being sent here because some of the smaller clinics, the maternity centers, have shut down.
Anybody who comes across an obstetrical problem sends them to us, which – I’m glad we’re here for that, for them, but I fear it’s going to be a big load on us.

Direct Relief: What are your midwives doing differently? Is the virus making it harder for them to do their jobs effectively?
Adan: Well, we don’t have any PPE to start with, so what can be the difference? They’re wearing gloves. They always wore gloves. We made some homemade shields from lamination paper. We improvised masks out of it. We tied a band on the top so the person can tie the band around the neck and you have the plastic shield in front. I’m wearing my own cloth mask, which we make.
Today, we received 6,000 surgical masks. Thank God. That’s a blessing. We had a training from MSF two days ago to try to train some of our staff for whatever eventualities.
[But] it’s a big mess. It’s a very uncertain world everywhere. And if the big countries with all the resources and all of the knowledge and all the expertise are suffering as much as they’re suffering, it doesn’t take much imagination to understand how a poor isolated, post-conflict country in Africa can be faring.

Direct Relief: Do you think that the virus will have an effect on outcomes for mothers and children?
Adan: I’m sure. Mothers are breathing. They will breathe, they’ll get droplets. Family members will infect them. I hope not, but regardless of whether they’re pregnant or not, young or old – the virus doesn’t know the difference between a pregnant woman and not pregnant. Whatever the community gets, the pregnant women will get.
But as far as our midwives are concerned, we were already taking precautions in case the woman in labor is HIV positive. So now, we’re not going to be watching out for just her blood and her vaginal secretions, we have to worry about her droplets and her cough and her sneeze. So it’s a double worry.
And we have to resuscitate newborn babies, we’re giving oxygen to the mothers if they need oxygen. We have to make sure we don’t use the mask again for another woman because who knows? This one could be corona positive and we don’t want to infect the next one. It requires more vigilance. It requires being more alert, taking more precautions.
We don’t know much. This is an unknown beast.

Direct Relief: Some have congratulated Somaliland for doing such a good job of containing the virus. Do you think that’s right, or do you think it’s a question of under-testing?
Adan: I think we have no tests anyway. We’ve only had tests for the last couple of weeks. That’s one thing.
The other thing is that there’s been a [lot of] government activity and awareness raising. The universities, the schools have been shut down. Public transportation has been limited. Some shops have been closed.
What we couldn’t test, we couldn’t count. [But] the country deserved to be congratulated, with its limited resources and its isolation by the rest of the world, to have done what it has done. I think Somaliland deserves to be congratulated for simply being alive.
Resources have been going to Somalia, but not to Somaliland. Somaliland has been isolated. Somaliland has been ostracized.
I’m upset because I don’t know who’s coming to the aid of my people. And I think my people have been dealt a very unfair deal by the rest of the world.
If we had tests, who knows how many cases would come up? Neighboring Djibouti is having a flood of cases. Somalia is having a flood of cases because they have testing facilities. Ethiopia is having a flood of cases, because the whole world is out there helping them.
Nobody has come to the help of the people of Somaliland. Or if they have, it’s been a little bit of humanitarian aid just to keep their consciences clear that they’ve helped somebody.
Who knows what corona is going to do? I don’t know. You don’t know. Your scientists don’t know. How should I know? An 82-year-old Somaliland woman in the Horn of Africa. How do I know what it’s going to do to pregnant women, if your scientists don’t know, if your obstetricians don’t know?

Research: Migrant women face greater health risks during pregnancy, childbirth

A Tampere University dissertation has found that some groups of migrant-background women have higher risks of health complications during pregnancy and delivery.

Women with Kurdish, Somali, South and East Asian, South American and Caribbean backgrounds had riskier pregnancies and births.

Research by doctoral health sciences candidate Kalpana Bastola found that while Russian-background women tended to have a lower body mass index (BMI) than women in the general population before pregnancy, women with Somali and Kurdish backgrounds tended to have a higher BMI than women in the general population.
Tuleva äiti tutkiin äitiyspakkauksen sisältöä.
Image: Henrietta Hassinen / Yle
She found that Kurdish-background women had higher odds of pregnancy-related diabetes, while Somali-background women had a greater risk of childbirth-related complications.
"The identified high risk-groups may need additional counselling on weight management and special attention in maternal and newborn care," Bastola said in a statement.
Women from sub-Saharan Africa, South Asia and East Asia had a higher risk of preterm birth, emergency caesarian section deliveries and low birthweight babies, according to the research. Meanwhile women with backgrounds from South America or the Caribbean had a greater risk of both elective and emergency caesarian deliveries.

Risks lower among Russia-background women

Women from Russia or the former Soviet Union had a generally lower risk of complications arising during pregnancy and childbirth as well as lower risk of neo-natal health problems, Bastola concluded.
"More research is needed to better understand the reasons and mechanisms behind these differences and to develop interventions for improving the health of the higher-risk groups," she said.
Titled "Health of pregnant migrant women and their newborns in Finland", Bastola's dissertation will be defended on Friday.
The health researcher analysed single births recorded in the Finnish Medical Birth Register between 2004 and 2014 as well as data from Statistics Finland and the Care Register for Health Care. She examined the records of 318 Russian, 583 Somali, 373 Kurdish and 243 women from the general population in Finland.

Monday, May 18, 2020

Monitoring and Evaluation in Global Health Course Online- University of Washington (USA)

Course Instructor: Nami Kawakyu, MPH, PhD (c)
Provider institution: University of Washington, Department of Global Health E-learning
Course Timeline: Starting: 6th July 2020 – 20th Sept. 2020; 12 weeks, 6-9 hours of learning per week 

Course Overview
Want to harness the power of data to improve your global health program?
Improve your understanding of the necessary tools to develop and implement M & E frameworks for their global health programs, a critical element of any successful health program.
Course Objectives:
·         Define and distinguish between monitoring and evaluation.
·         Develop a program logic model to communicate an evidence-based program theory.
·         Develop an M&E plan to track progress of program activities toward objectives and assess program effectiveness.   
·         Develop quantitative and qualitative indicators and targets for an M&E plan.
·         Use relevant qualitative and quantitative data collection and analysis methods to track and evaluate program progress.
·         Identify the qualities of effective qualitative and quantitative data collection tools.
·         Describe how program data can be used for decision-making.
·         Apply ethical guidelines for data collection and reporting.
Module 1: An introduction to monitoring and evaluating in global health
o   Define monitoring and evaluation.
o   Distinguish between monitoring and evaluation.
o   Explain why M&E is important.
o   Identify monitoring best practices.
o   Explain how key M&E activities fit into a typical program cycle.
o   Describe strategies to address common concerns about program evaluation.
Module 2: Program theory and frameworks
o   Define what a program theory is.
o   Identify three program frameworks.
o   List the five main components of a logic model.
o   Develop evidence-based program outcomes that align with program impact.
o   Develop program outputs that align with program activities and outcomes.
Module 3: M&E plans
o   Describe what an M&E plan is and why it is an important aspect of program success
o   Explain the relationship between logic models and M&E plans
o   Define the key components of an M&E plan
o   Write SMART objectives
o   Name and explain the qualities of effective program indicators
o   Develop indicators and targets for an M&E plan according to specified criteria
o   Describe the 6 steps involved in developing and implementing an M&E plan
Module 4: Monitoring
o   Describe the basic steps to conducting effective program monitoring.
o   List three potential data sources for program monitoring.
o   Conduct descriptive analysis to summarize data for program monitoring.
o   Describe three data visualization methods to visualize data for action.
Module 5: Evaluation
o   Describe the main steps to conducting a program evaluation;
o   Explain when the five types of program evaluations are used;
o   Develop relevant program evaluation questions;
o   Describe three program evaluation methodologies;
o   Describe two quantitative designs commonly used in program evaluation;
o   Name one key element to successful dissemination of evaluation findings.
Module 6: Quantitative data collection methods
o   Explain quantitative sampling approaches, including what information is needed to calculate sample size.
o   Explain three principles of data collection.
o   Describe three data collection methods for program evaluation.
Module 7: Quantitative data analysis
o   List the five main measures of data quality.
o   Explain the importance of processing data for data analysis.
o   Distinguish between descriptive and inferential analysis.
Module 8: Qualitative data collection methods
o   Explain what qualitative data are and how they differ from quantitative data
o   List the advantages and disadvantages of using qualitative data in program M& E
o   Name and describe the steps involved in conducting a qualitative evaluation
o   Describe strategies for planning qualitative evaluations
o   Describe 7 commonly used qualitative sampling methods
o   Explain the criteria used to inform sample size for qualitative data collection
Module 9: Qualitative data analysis
o   Formulate effective open-ended questions to collect qualitative data
o   Explain the overall structure of interview and focus group discussion guides
o   Describe qualitative data collection methods (interviews, focus groups, and observations), when they are used, and their strengths and limitations
o   Distinguish between subjective and objective qualitative observation data
o   Define the 6 basic steps involved in thematic analysis
o   Describe elements to include in a codebook and why codebooks are important
o   Identify guidelines for writing up qualitative findings
Module 10:  Ethics
o   Explain what human subjects protections are and why they are important 
o   Name and define the three fundamental principles of ethics 
o   Explain what informed consent means and describe the key elements of a consent form
o   Distinguish between anonymity, confidentiality, and privacy and describe methods to protect each  
o   Describe best practices for safe data storage 
o   Describe key recommendations for sharing and presenting data in an ethical manner
Course Activities:
During the course, participants will be expected to:
Ø  Analyze problem statements and develop outcomes
Ø  Work with logic models
Ø  Write SMART objectives and indicators
Ø  Complete activities around data analysis and visualization (in Microsoft Excel)
Ø  Assess evaluation questions
Ø  Analyze qualitative methods
Ø  Choose sampling methods
Ø  Create open ended questions
Ø  Work on an M&E plan
Format: Learning Methodology
This online graduate-level course has video lectures, readings, discussion forums, quizzes, and assignments. During the site meetings, the group will review the materials and the Site Coordinator will facilitate guided questions for the group.  Where a site should be primarily people in the same geographic location, some organizations/sites include a few additional participants who work remotely and have found other methods to “meet” by using video conferencing software like Adobe Connect, Skype and Zoom. Other sites create WhatsApp groups to distribute local resources and information, to connect, share ideas and help one another.
The course is taught in English, participants should be comfortable with written and spoken English.
To be admitted, you must have a diploma in health related field or in the social science.
The course is most useful for health care professionals and public health specialists who have some experience in management and who wish to enhance their skills working with people and other organizational resources. The course is less well suited to individuals in entry-level positions in the workforce.
For those who are successfully completed the course will receive a formal printed Certificate of Completion on vellum paper with University of Washington seal mailed to them. We will ship them all together to your Site Coordinator.

More information
You can contact Dr. Mohamed Y. Dualeh, Somalia’s HeSMA SOM site coordinator for further details and guidance for your enrollment process in this phone number +252-65-9417945 with preferable in WattsApp texting or drop an E-mail to