VZCZCXRO4623
RR RUEHDE RUEHROV RUEHTRO
DE RUEHNR #0720/01 0431019
ZNR UUUUU ZZH
R 121019Z FEB 07
FM AMEMBASSY NAIROBI
TO RUEHC/SECSTATE WASHDC 7443
INFO RUCNSOM/SOMALIA COLLECTIVE
RUEHRN/USMISSION UN ROME 0090
RHEHNSC/NSC WASHDC
RHMFIUU/CJTF HOA
RHMFIUU/CDR USCENTCOM MACDILL AFB FL
RUEKJCS/SECDEF WASHINGTON DC
RUEKJCS/JOINT STAFF WASHINGTON DC

UNCLAS SECTION 01 OF 04 NAIROBI 000720 
 
SIPDIS 
 
AIDAC 
 
USAID/DCHA FOR MHESS, WGARVELINK, LROGERS 
DCHA/OFDA FOR KLUU, GGOTTLIEB, AFERRARA, ACONVERY, 
CGOTTSCHALK, KCHANNELL 
DCHA/FFP FOR WHAMMINK, JDWORKEN 
AFR/AFR/EA FOR JBORNS 
STATE FOR AF/E AND PRM 
STATE/AF/E FOR NGARY 
STATE/F FOR ASISSON 
STATE/PRM FOR AWENDT, MMCKELVEY 
NSC FOR TSHORTLEY 
USUN FOR TMALY 
BRUSSELS FOR PLERNER 
GENEVA FOR NKYLOH 
USMISSION UN ROME FOR RNEWBERG 
 
SIPDIS 
 
E.O. 12958:  N/A 
TAGS: EAID PREF PHUM PREL SO
 
SUBJECT:  SOMALIA DART SITUATION REPORT 13 - CHOLERA 
UPDATE 
 
REFS:  A) NAIROBI 00255  B) NAIROBI 00594  C) NAIROBI 
00380 
 
NAIROBI 00000720  001.2 OF 004 
 
 
SUMMARY 
 
¶1.  A suspected cholera outbreak has affected more than 
600 people and resulted in as many as 40 deaths in 
southern and central Somalia.  UN and non-governmental 
organizations (NGOs) working in the health sector have 
responded to the outbreak quickly, collecting 
biological samples to confirm the presence of the 
cholera bacterium, tracking suspected cases, and 
establishing cholera treatment facilities.  However, 
aid agencies fear that if the current cholera outbreak 
is not contained, it could spread into Mogadishu, where 
insecurity limits emergency activities.  End Summary. 
 
BACKGROUND 
 
¶2.  Cholera is a waterborne disease that is endemic to 
Somalia and usually surfaces in the dry season, when 
water for hygiene is scarce.  However, the latest 
outbreak was caused by flood waters that damaged water 
and sanitation facilities in November and December of 
¶2006.  In late December, the U.N. World Health 
Organization (WHO) confirmed cases of cholera in 
Kismayo District, Lower Juba Region, followed by an 
outbreak in Jilib District, Middle Juba Region.  The 
December cholera cases were quickly contained by health 
agencies. (REF A) 
 
¶3.  Most health services in southern Somalia, including 
managing disease outbreaks, are provided by WHO, other 
UN agencies, and NGOs.  WHO's role is to undertake 
surveillance, develop and implement preparedness plans, 
provide technical support, and coordinate activities 
focusing on communicable diseases.  NGOs manage the 
actual disease outbreaks by establishing treatment 
centers and disseminating public information. 
 
¶4.  There is some disagreement within the humanitarian 
community over whether or not the cholera outbreaks in 
Somalia since January are actually cholera.  The USAID- 
supported NGO International Medical Corps (IMC) has 
positively identified at least one sample from Hiraan 
as cholera, but samples from patients exhibiting 
cholera-like symptoms in Middle Shabelle Region have 
come up negative in tests.  The USG Disaster Assistance 
Response Team (DART) is referring to this disease as 
cholera; even though not all cases have tested positive 
for the cholera bacterium, the signs and symptoms are 
consistent with the case definition of cholera. 
 
¶5.  WHO has advised all health agencies operating in 
Somalia not to refer to the current outbreak as cholera 
and to use instead the term acute watery diarrhea.  WHO 
believes that not enough samples have tested positive 
for the cholera bacterium in all suspected outbreak 
locations to merit calling it a cholera outbreak. 
Regardless, the disease exhibits the characteristics of 
cholera and is being treated as such. 
 
¶6.  Cholera can cause dehydration of varying degrees 
through loss of fluids and electrolytes as a result of 
diarrhea.  Young children and elderly are most 
susceptible to the effects of dehydration and case 
fatality rates are usually high in these age groups. 
 
NAIROBI 00000720  002.2 OF 004 
 
 
Cholera is treated by replacing fluids and salts lost 
as a result of diarrhea.  Patients can be treated with 
oral rehydration solution, a prepackaged mixture of 
sugar and salts that is mixed with safe drinking water 
and consumed in large amounts.  Severe dehydration 
cases require intravenous fluid replacement. 
Antibiotics shorten the course and diminish the 
severity of the illness, but rehydration is the first 
line of treatment. 
 
HIRAAN REGION 
 
¶7.  The number of suspected cholera cases in Hiraan 
Region's three districts has recently increased to 319 
people with 35 deaths.  The rise in cholera cases is 
directly related to the destruction of household and 
communal latrines and the contamination of water 
containers and wells during the November-December 
flooding along the Shabelle River, health agencies 
believe. 
 
¶8.  On January 26, USAID's Office of U.S. Foreign 
Disaster Assistance's (OFDA) NGO partner IMC reported 
that one sample from Belet Weyne had tested positive 
for cholera in the African Medical and Research 
Foundation's laboratory in Nairobi. 
 
¶9.  A total of 151 cholera patients have been treated 
at the Belet Weyne hospital, where IMC, Medecins Sans 
Frontieres (MSF)/Belgium, and WHO coordinated 
treatment.QIMC reports seven cholera-related deaths in 
their health facility in Belet Weyne.  As of February 
6, IMC reported that only two cholera patients remain 
in the hospital, and the Belet Weyne outbreak appears 
to be nearly contained. 
 
¶10.  WHO has reported an additional 16 cholera cases 
and nine deaths in rural villages in Belet Weyne 
District that were not reported by IMC because they 
were not treated at the IMC-managed hospital in town. 
 
¶11.  On February 7, WHO reported that cholera has 
affected 44 people in Jalalaxi District, also in Hiraan 
Region, with 14 deaths and 108 people in Bulo Burte 
District with five deaths since the disease first 
emerged in early January.  The Somali Red Cross Society 
(SRCS), MSF/Belgium, and WHO have established cholera 
treatment facilities and are coordinating health 
response activities.  However, the disease has not been 
confirmed in laboratory tests. 
 
¶12.  The recent rise in water-related diseases in the 
riverine areas of Hiraan Region has contributed to an 
increase in malnutrition in the affected communities, 
according to the recent multi-agency food security 
assessment released on January 31 (REF B). 
 
MIDDLE SHABELLE AND LOWER AND MIDDLE JUBA REGIONS 
 
¶13.  According to WHO, 248 suspected cholera patients, 
with five deaths, have been treated at the Jowhar 
hospital in Middle Shabelle Region as of February 7. 
MSF collected biological samples from patients in the 
hospital that were tested in Nairobi; these samples 
were found to be negative for cholera.  However, health 
agencies plan to collect and test additional samples in 
the coming days. 
 
NAIROBI 00000720  003.2 OF 004 
 
 
 
¶14.  In Jowhar, SRCS, INTERSOS, and MSF/Spain are the 
lead international health agencies.  WHO also has an 
emergency medical officer in Jowhar.  According to WHO, 
Jowhar hospital has sufficient supplies and it 
dispatched a cholera treatment kit on February 2, to 
augment existing medical supplies.  (One cholera kit 
provides oral rehydration salts, medicine, infusion 
supplies, buckets, and soap to treat 500 patients, 
including 100 severe cases.) 
 
¶15.  On February 7, WHO reported that the Kismayo 
cholera treatment facility in Lower Juba Region has 
been re-opened and has treated 36 cholera cases with 
two deaths since January 30.  WHO reports that there 
are adequate supplies but has requested NGOs to send 
experienced medical staff to Kismayo to assist with the 
outbreak.  Currently, Kismayo is at UN security phase 
four due to insecurity and access for humanitarian 
staff is restricted. 
 
¶16.  Additionally, more than 60 new suspected cholera 
cases have been reported by Mercy Corps and the SRCS in 
Jilib District, Middle Juba Region.  An MSF team is 
currently responding to the reports in Jilib with 
additional supplies.  The new cases in Jilib are not 
confirmed as cholera yet and further information is 
expected in the coming days. 
 
FEARS OF CHOLERA SPREADING 
 
¶17.  Current levels of insecurity in Somalia, a lack of 
in-country laboratory facilities, and limited capacity 
of WHO staff to collect samples, make it unlikely that 
all areas with an outbreak will have confirmed 
laboratory results.  However, operational health 
agencies are responding to the outbreak as if it were 
cholera. 
 
¶18.  UN agencies and health sector NGOs fear that if 
this outbreak is not contained, cholera could emerge in 
Mogadishu, where security conditions would limit access 
to health clinics and cholera treatment facilities.  If 
this were to happen, the spread within the city would 
be expected to be rapid and the number of cases and 
fatalities high, especially in the many areas with poor 
access to water and latrines. 
 
COMMENTS 
 
¶19.  Although Somalia has not experienced a cholera 
outbreak in the last two years, health agencies were 
relatively prepared for it.  After the flooding, WHO 
and the UN Children's Fund (UNICEF) pre-positioned 
cholera treatment kits throughout southern and central 
Somalia, which proved prescient when the conflict and 
closure of the Kenya-Somalia border stopped cross- 
border access (REF C). 
 
¶20.  The scale of this outbreak has revealed some 
weaknesses in the health sector in Somalia.  As health 
sector lead for Somalia, WHO routinely conducts disease 
surveillance activities and is responsible for 
collecting, analyzing, and disseminating timely 
information on diseases.  However, the conflicting 
information on cholera cases coming from WHO and NGOs 
indicate that the disease surveillance system needs 
 
NAIROBI 00000720  004.2 OF 004 
 
 
strengthening.  Some of the confusion on the number of 
cases of cholera stems from the inadequate knowledge 
among field staff on cholera case identification and 
management.  This outbreak has revealed a need to 
retrain field staff in proper case identification and 
management skills since there has not been a 
significant cholera outbreak in Somalia for several 
years and NGOs have experienced high staff turnover. 
 
¶21.  The exposed shortcomings will be dealt with by the 
Somali Support Secretariat health sector agencies, 
although relations among the lead health sector 
partners are visibly strained due to disagreement over 
different agencies' responsibilities in this outbreak. 
It is also apparent that the WHO network of district 
polio officers that have been tasked with identifying 
communicable disease outbreaks do not have the skills 
or capacity to deal with simultaneous outbreaks of 
cholera and Rift Valley fever.  WHO needs to improve 
field-level capacity quickly. 
 
¶22.  The DART is working closely with WHO and NGOs to 
ensure that health activities are implemented smoothly, 
and to identify ways to improve performance.  To 
address cholera and other health issues that impact 
vulnerable Somalis, OFDA has prioritized flood recovery 
interventions in the water, sanitation, and hygiene 
sector for UN and NGO funding. 
 
¶23.  The outbreaks in Hiraan, Middle Shabelle, Lower 
Juba, and Middle Juba regions are worrying, but USAID's 
partner IMC and other health agencies in the region 
have responded quickly and sufficiently.  Many health 
agencies were prepared for an increase in water-related 
diseases following the November-December flooding and 
the emergence of pockets of cholera is not unexpected 
in the context of Somalia.  However, if the disease 
spreads to coastal cities experiencing insecurity and 
political uncertainty, a new level of crisis may be 
reached. 
 
RANNEBERGER