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Flatten in 


Somalia serves as a particularly challenging example of a fragile state that has benefited from international collaboration and north-south partnerships. The country faces many challenges, including the presence of extremist groups, large numbers of internally displaced persons (IDPs), and a strained healthcare system dealing with a considerable burden of both communicable and non-communicable diseases. At the onset of COVID-19, the federal government of Somalia set up hotlines and awareness campaigns for disseminating and gathering COVID-19 information in its capital city, Mogadishu. However, incomplete and inadequate health surveillance information, as well as a lack of data from IDP camps, has biased the government-collected data, and confounded resource allocation decisions. One potential solution to such problems is modeled in the partnership between the City of Mogadishu, locally titled the Benadir Regional Administration (BRA) and Flatten, a Canadian not-for-profit organization, which provides digital data solutions and insights to governmental bodies to help fight COVID-19.


The Flatten platform enables a straightforward collection of comprehensive data on COVID-19 symptoms, as well as socio-demographic factors, economic factors, COVID-19 knowledge, and mobility metrics. The BRA recruited 392 local volunteers for syndromic surveillance and used the Flatten digital survey platform to survey 106,591 persons. These volunteers have been trained in public health practices and in the use of Flatten’s locally-customized online digital survey tools. They surveyed households and IDP camps using a population-based systematic sampling strategy that the BRA team developed. It is critical to adapt solutions to local contexts, and not the other way around. To overcome literacy and digital access barriers, the survey is being delivered face-to-face, using appropriate health protection policies in compliance with government regulations, and not via the internet, to overcome literacy and digital access barriers.


Knowledge transfer between international organizations with syndromic surveillance capabilities is now urgently needed to help bolster local COVID-19 response teams in LMICs, such as Somalia, while empowering long-term benefits. The BRA has leveraged this data to make informed decisions to build wash stations across the city (being the most demanded request to be respondents). By making this data openly available, it opens up opportunities to develop time-series models to dynamically forecast changes in prevalence, systemically map survey features with COVID-19 risk and provide insight into how well machine learning, statistical, and epidemiological models can perform in LMICs. The significant utility that syndromic surveillance provides, yields a compelling case for a broadened international scaling-up of syndromic surveillance LMICs. 

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