By Dr. Mohamed Bobe, Health Technical Specialist-Community Health and Pneumonia Focal Point Save the Children,  Somalia.

Globally, pneumonia and diarrhea claim the lives of an estimated 1.22 million young children each year, equivalent to over 140 children dying every hour or 3,350 deaths each day. This means, these two infectious diseases are responsible for an estimated 23% of all deaths of children under five worldwide[i].

Somalia is among 15 countries in which over 70% of under-5 deaths from pneumonia and diarrhea occur. That shocking figure is falling more slowly than for other major killers, and too slowly for the world to achieve the Sustainable Development Goal (SDG) to end preventable childhood deaths[ii].

To guide countries in developing integrated approaches to controlling the two greatest causes of child morbidity and mortality, WHO and UNICEF developed the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)) in 2009. According to International Vaccine Access Center(IVECs) 2022 pneumonia and diarrhea progress report, Somalia scored the lowest progress with a score of 23 among the highest burden 15 countries and made no progress in the past year. There were 25,476 deaths from pneumonia and diarrhea in children under 5, equating to 40 / 1000 live births in that same year according to the report[iii].

Unique challenge of the fragile Somali health system:

In Somalia 24% and 19% of all child deaths under the age of five are due to pneumonia and diarrhea respectively. PCV and RVV are not introduced into the routine EPI of Somalia yet[iv]. The WHO-UNICEF Estimates of National Immunization Coverage (WUENIC) reported alarmingly low coverage of Measles vaccination in 2022 (46% for 1^st dose and 8% for 2^nd dose)[v]. The most recent Demographic Health Survey data (December 2021) revealed 60% of children received no vaccinations at all, 12% receiving the third dose of the Penta vaccine, and just 26% of children receiving the third Polio dose. Overall, just 11% of children had received all required vaccines[vi].

Widespread poverty, a grossly underdeveloped health system which is unable to deliver adequate level and quality of care, inadequate health financing, inequalities between the rural and urban areas, and ongoing clan conflicts and recurrent droughts has turned Somalia/Somaliland into one of the world’s most difficult environments for child survival. This is bluntly reflected in the poor child and maternal health conditions: maternal mortality ratio of 396 per 100,000 live births, neonatal mortality of 44 per 1000, infant mortality rate of 72 per 1000 live births and under-5 mortality of 91 per 1000 live births (SHDS 2020).

 The high prevalence of malnutrition in the country: the stunting rate among children under 5 years of 20.7%,  and  acute malnutrition was13.5%, among  under the 5 years of age children,  and exclusive breastfeeding rate of 30% (SHDS 2020) significantly  increases  the risk of morbidity and mortality of the Somali children from pneumonia and diarrhea.

Somalia needs to reduce the under-five Child Mortality Rate from 119 to 25 by 2030 to achieve the Sustainable Development Goal (SDG) 3.2. This will require a massive increase in the annual rate of decline of child deaths from 3% to 17%. Reductions in child pneumonia and diarrhea deaths can make a significant contribution to this goal and need to fall from the current annual 14,200 to 2,300 by 2025. The data suggest that introduction and rapid scale-up of the pneumococcal conjugate vaccine (PCV) and rotavirus vaccines are urgent priorities – with special focus for the almost 300,000 “zero-dose” children.

In 2017, in the lead-up to its 100^th anniversary, Save the Children launched its centenary commitment on fighting childhood pneumonia. Ever since, Save the Children conducted a pilot nasopharyngeal carriage and social contact survey in Digaale internally displaced person camp in partnership with the London School of Hygiene and Tropical Medicine to establish an evidence base for the optimal use of PCV for humanitarian crisis settings, rolled out Integrated Community Case Management (iCCM) common approach to scale up access to treatment for pneumonia, diarrhea and other common childhood illness and led advocacy breakthrough with GAVI on the introduction of PCV in Somalia as Gavi accepted removing the 70% coverage for routine immunization threshold for Somalia to qualify for PCV introduction.

Also In 2023 at the 2^nd Global Forum on Childhood Pneumonia in Madrid Save the Children together with other partners made a breakthrough in removing the co-financing requirement of the new vaccines from GAVI for Somalia. Save the Children Somalia started a pilot on the integration of management of acute malnutrition into iCCM as iCCM+ to leverage on iCCM to scale up access to treatment for malnutrition at community. Save the Children also did great strive on the advocacy of oxygen access, amoxillin availability at community, WASH services, air pollution reduction and commemoration of World Pneumonia Day since 2018 in Somalia.

In 2018 at the commemoration of world pneumonia day in Hargeisa, the first commemoration of the day in Somalia/Somaliland, we told the MOH and community participants of the events that introduction of the pneumonia vaccine (PCV) into the routine EPI is one of the most impactful strategies to reduce pneumonia morbidity and mortality among the Somali children and that we need to work on that jointly. I never thought that it will be that soon to realize the achievement of such important vaccine access in Somalia/Somaliland even though I myself was among the first people to tell that! It is now a fact that the PCV together with rotavirus vaccine will be introduced to Somalia in 2024! . The Introduction of PCV and Rotavirus vaccination in Somalia could save 3-5.000 children’s lives every year. Between 2024 and 2030, these vaccinations will avert the death of 35,000 Somali children under the age of five! (GAVI).

Opportunity in hand:

The Mérieux Foundation, Every Breath Counts, Save the Children, the Malaria Consortium, and the International Vaccine Access Center (IVAC) are bringing together national, regional, and international stakeholders to support introducing PCV and Rotavirus vaccine introduction in four selected countries (Chad, Guinea, Somalia and South Sudan) as well as to address relevant challenges and explore solutions in a workshop in mid-September (September 13-15, 2023). (source: PCV and RVV Workshop Flyer-v8_SL.pdf). In this upcoming workshop, stakeholders will discuss the latest epidemiological evidence, lives saved analysis, financing options, Gavi application support, and best practices considering the unique challenges of fragile and conflict affected countries for the successful introduction and sustained high coverage of these two new vaccines (PCV and RVV).