Supporting “The Backbone of Public Health” in Somalia 

Khaliif Abdullahi Nouh says he chose to become an immunization specialist with the Federal Ministry of Health in Somalia because “immunization is the backbone of public health,” he says. “It is very, very interesting and important.”

Immunization is definitely a priority in Somalia, where more than 1.5 million children are estimated to be zero-dose – meaning they have not received a single dose of any routine childhood vaccine, like the diphtheria, polio, and tetanus vaccine. In fact, the challenges of disease outbreaks like measles are ever-present, he notes, due to large internally displaced populations (IDP) (estimated to be more than 2 million) plus ongoing conflict, a food crisis exacerbated by the war in Ukraine, and climate-change induced drought (an estimated three million livestock died in 2022 from lack of water).

Given the multiple challenges in the country that make it prime for disease outbreaks, Nouh says, “it means that whatever you are doing with immunization will have a result and a benefit for the community.”

Creating a plan for immunization catch-up

Nouh was selected as one of the grantees of the COVID-19 Recovery for Routine Immunization Programs Fellowship offered by the Sabin Vaccine Institute and the World Health Organization, which aims to support immunization professionals by strengthening their capacity to plan and implement immunization programming. His plan was to vaccinate 700 zero-dose children in IDPs and the poor urban community in Garowe  City, the capital of Puntland state in northeastern Somalia.

Noah and his team’s results wildly exceeded expectations. In the four months of the project, which was implemented this year, they reached 1,743 zero-dose children with their first dose of the pentavalent vaccine (which immunizes against five diseases: diphtheria, pertussis, tetanus, hepatitis B and Hib.). On top of that, they provided an additional 3,890 second and third doses of pentavalent vaccine, reached 2,000 children with their first or second polio vaccine dose, plus another 1,600 with measles vaccine. In addition, they provided 2,230 doses of Vitamin A supplementation, given to increase young children’s chances of survival and reduce the severity of childhood illnesses. About 2,000 mothers received either their first-ever or booster tetanus vaccines as well.

Integration of services key to success

Nouh credits collaborations with the Puntland State Ministry of Health (MOH) and the regional health authority for their help, as the MOH contributed funds for the first round of the campaign, trained the vaccinators, and provided vaccines for the campaign. He also notes several important steps that helped overcome vaccine hesitancy and brought parents to some of the remote temporary vaccination sites that were set up to provide vaccines.

“Somalia is a Muslim community, and we used female vaccinators because we realized they would have more access to reach other females,” he says, noting 26 of the project’s 27 vaccinators were women. “Most of the caretakers are mothers and married, and females can more easily interact with and persuade other females or enter the house.”

The team also used “social mobilizers” who walked through communities in advance to let people know when and where a mobile immunization site would be set up. Integrating vaccinations with other services – in this case, Vitamin A supplementation – also helped.

Nouh says that although interest in vaccines dropped after the COVID-19 pandemic, as immunization rates fell and diseases like measles and diphtheria become more prevalent, “It seems that the immunization demand is increasing among the population.” He also credits demand-generating activities by the MOH and others, especially in main urban and IDP settlements, with boosting local interest in vaccines.

Next steps amidst continued challenges

Nouh is hoping to capitalize on the success of this project with other campaigns in other regions of the country and introducing more vaccines, such as the pneumococcal conjugate vaccine (PCV) and rotavirus vaccines, as early as next year. He also led a study that was published this year in BMC Global and Public Health on a successful pilot for fractional dosing of inactivated polio vaccines (fIPV) using a novel intradermal needleless injection device. Increasing IPV vaccination is important to control occasional cases of vaccine-derived polio from the oral polio vaccine used previously.

Still, Nouh notes that in a country with large populations that are either too remote to access health facilities, in the middle of conflict zones or constantly on the move, challenges remain reaching all children with routine vaccination. “Facilities do not have sufficient resources to reach these remote populations,” he says. “In many areas the only option we have is catch-up campaigns.”

He is optimistic that the improvements seen with his project and others will inspire innovations that make a difference. “Maybe because of the shortage of resources, a lot can be integrated at one time,” he says. “Nutrition, treatment of communicable diseases. If a team is going to the community, let them provide all the services. These are the lessons learned, and it will make a difference.”