Epidemiologic Characteristics and Predictors of Mortality in Somalia’s 2024 Cholera Outbreak

Abstract

Background

Cholera remains a persistent public health threat in fragile and conflict affected settings where inadequate water, sanitation, and hygiene infrastructure, population displacement, and climate shocks contribute to recurrent outbreaks. Somalia has experienced cyclical cholera epidemics for decades, yet recent national level analyses of mortality predictors remain limited.

Methods

A retrospective analysis of national cholera surveillance data was conducted using line lists from cholera treatment centers across Somalia for the period January to December 2024. Suspected and confirmed cases were defined according to national guidelines. Demographic, clinical, nutritional, environmental, and laboratory variables were analyzed. Multivariable logistic regression was used to identify factors associated with mortality.

Results

A total of 21,945 suspected cholera cases and 138 deaths were reported, corresponding to a case fatality rate of 0.6%. Children under five years accounted for 42% of cases. In the adjusted analysis, use of river water compared with piped water had an adjusted odds ratio of 2.34 (95% CI: 1.12–4.87). Severe dehydration had an adjusted odds ratio of 5.67 (95% CI: 3.21–10.01), and malnutrition had an adjusted odds ratio of 2.12 (95% CI: 1.17–3.83). Residence in Jubaland compared with Banadir had an adjusted odds ratio of 1.91 (95% CI: 1.05–3.47). Children aged 5–14 years and individuals aged 15–44 years had lower adjusted odds of death compared with children under five years. Laboratory confirmation was limited.

Conclusion

The 2024 cholera outbreak in Somalia was characterized by substantial pediatric burden and marked differences in mortality by water source, nutritional status, dehydration severity, and region. Strengthening water safety, expanding access to timely case management, integrating nutrition services, improving surveillance capacity, and implementing targeted oral cholera vaccination in high-risk areas are critical to reducing cholera mortality and advancing long term control efforts in Somalia.

Introduction

Cholera continues to represent one of the most persistent public health challenges in fragile and low-resource settings, where water, sanitation, and hygiene systems are either absent or severely compromised. The disease is caused by Vibrio cholerae and can lead to acute watery diarrhea, dehydration, and death within hours if untreated [1]. Despite being preventable and treatable, cholera remains a global threat, with an estimated 1.3 to 4 million cases and 21,000 to 143,000 deaths reported annually. These figures are widely understood to be underestimates, largely due to surveillance gaps and chronic underreporting [2].

The persistence of cholera is closely linked to contexts of poverty, displacement, and conflict, where access to safe water and sanitation is disrupted. Somalia is emblematic of this intersection. The country has experienced cholera outbreaks for decades, shaped by protracted conflict, weak governance, widespread displacement, and repeated climate shocks such as floods and droughts [3]. Heavy rains, often intensified by El Niño events, frequently contaminate water sources and overwhelm fragile infrastructure, creating conditions conducive to recurrent transmission [4].

Somalia’s 2017 cholera outbreak was particularly devastating, with 78,784 reported cases and 1,159 deaths [5]. While subsequent years saw improved surveillance and better case management, outbreaks have continued to occur in predictable patterns, often concentrated in areas with poor sanitation and dense displacement camps [6]. In 2024, Somalia experienced one of its largest cholera outbreaks in recent history, with 21,945 suspected cases and 138 deaths, corresponding to a case fatality rate of 0.6% [3].

Prevention strategies in Somalia have relied heavily on emergency responses such as water trucking, temporary sanitation facilities, and oral cholera vaccine campaigns. While lifesaving, these interventions rarely achieve sustainable impact because they do not address structural determinants of risk and are often constrained by supply challenges, insecurity, and competing health priorities [7]. Surveillance systems remain fragile, with case reporting heavily dependent on syndromic data, while limited laboratory capacity weakens early detection and confirmation [2].

Children are disproportionately affected by cholera, both globally and in Somalia. Malnutrition, which remains widespread, significantly increases vulnerability to diarrheal diseases and worsens outcomes [8–10]. Women and girls may also be disproportionately exposed because of gendered responsibilities such as collecting water, preparing food, and caregiving, which often increase contact with unsafe water sources [6, 9–11].

The 2024 outbreak therefore offers a critical opportunity to examine how demographic, environmental, and structural factors shaped cholera transmission and mortality in Somalia. This paper situates the outbreak within the global literature and comparable fragile settings, while drawing lessons for prevention and long-term control.

Methods

Study Design and Setting

We conducted a retrospective cross-sectional study of the 2024 cholera outbreak in Somalia, encompassing all seven federal member states: Banadir, Jubaland, Hir-Shabelle, Southwest, Galmudug, Puntland, and Somaliland. The analysis included both rural and urban settings to ensure broad geographic representation. Somalia’s health system is decentralized, and outbreak response activities are coordinated jointly by the Federal Ministry of Health and state-level health authorities in collaboration with international partners.

Data Sources and Case Definition

Data were obtained from two primary sources: the national cholera surveillance line list, the official database compiled by the Ministry of Health (MoH), and supplementary records from operational cholera treatment centers (CTCs). The national line list is a standardized, case-based reporting system in which individuals are included upon meeting the suspected case definition and being registered at a CTC or designated reporting facility. Each record uses a uniform template to capture demographic, clinical, laboratory, and environmental information. The study population was restricted to individuals who accessed CTCs, and therefore may not fully represent all community cases, including mild cases or those unable to reach health facilities.

Cholera Case Classification

To classify patients according to the standard epidemiological hierarchy of suspected, probable, and confirmed cases, definitions were applied in accordance with national surveillance protocols and adaptations of World Health Organization guidance for outbreak settings.

Suspected cases were defined as any patient aged five years or older presenting with acute watery diarrhea, with or without vomiting, in a declared outbreak area. For patients under five years of age, a suspected case was defined as any presentation with acute watery diarrhea.

Confirmed cases were defined as suspected cases with laboratory confirmation of Vibrio cholerae serogroups O1 or O139 from a stool specimen by culture or polymerase chain reaction testing.

A formal probable case category was not used for individual patient inclusion in the final national line list. Cases transitioned directly from suspected to confirmed status upon receipt of positive culture or PCR results. Rapid diagnostic tests were used for initial screening and clinical triage at CTCs, but RDT results alone did not define a separate probable case category for inclusion in the analysis.

Variables and Measurements

The dataset included demographic variables (age, sex, and region of residence), clinical features (watery diarrhea, vomiting, abdominal pain, dehydration severity, and comorbidities), nutritional status for children under five years of age assessed using mid upper arm circumference (MUAC), and laboratory data (RDT results, stool culture results, and serotype identification). Environmental indicators included household water source, access to latrines, and availability of handwashing facilities with soap or ash. Oral cholera vaccination status was also recorded.

Dehydration was categorized as mild, moderate, or severe based on clinical assessment at presentation. Nutritional status for children under five years followed World Health Organization MUAC thresholds: severe acute malnutrition (MUAC < 11.5 cm), moderate acute malnutrition (MUAC 11.5–12.5 cm), and normal nutritional status (MUAC > 12.5 cm). Household water sources were categorized as piped or tap water, river water, surface water (ponds or lakes), open wells, and other or unknown sources.

Data Management and Quality Control

All data were entered into Microsoft Excel by trained health facility staff and verified at state and federal levels prior to analysis. Inconsistent entries were cross-checked against original facility registers. Missing values were assessed for randomness, and variables with more than 30% missing data were excluded from multivariable analyses. For nutritional status, missing MUAC values were included as a separate category in descriptive analyses but excluded from adjusted models.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 26. Categorical variables were summarized using frequencies and percentages, and continuous variables were summarized using means and standard deviations. Bivariate associations between independent variables and mortality were assessed using the chi-square test, with statistical significance defined as p < 0.05.

Multivariable logistic regression was used to identify factors associated with mortality. Variables included in the adjusted model were those with p ≤ 0.20 in bivariate analysis or those considered epidemiologically relevant based on prior literature. Adjusted odds ratios with 95% confidence intervals were reported. Collinearity diagnostics were performed, reference categories were selected based on lowest risk or most common category, and model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test.

Results

A total of 21,945 patients were included in the analysis of the 2024 cholera outbreak across seven federal member states in Somalia (Banadir, Jubaland, Hir-Shabelle, Southwest, Galmudug, Puntland, and Somaliland), representing the national burden captured through the centralized surveillance system for the period from January to December 2024. Of this total, 138 deaths were recorded, resulting in an overall case fatality rate (CFR) of 0.6%.

Age Distribution

Age distribution showed that children aged 1 to 5 years accounted for the largest proportion of cases at 44.5%. Infants represented 14.2%, and children aged 6 to 15 years accounted for 17.9%. Adults comprised smaller shares, including 12.7% aged 16 to 30 years, 5.7% aged 31 to 45 years, and 5.0% aged over 45 years. As shown Table 1.

Table 1.

Age group distribution of patients

Age Group	Number of Patients (n)	Percentage (%)
< 1 Year	3,111	14.2
1 to 5 Years	9,761	44.5
6 to 15 Years	3,933	17.9
16 to 30 Years	2,783	12.7
31 to 45 Years	1,250	5.7
> 45 Years	1,107	5.0
Total	21,945	100%

Sex Distribution

Females constituted a slightly larger proportion of the study population, accounting for 51.8% of all reported cases, while males accounted for 48.2%. The distribution of cases between sexes differed significantly across age categories (p < 0.001).

Geographic Distribution of Cases

Geographically, cholera cases were unevenly distributed among the federal states. The majority of cases originated from Southwest State, accounting for 33.5% (n = 7,344) of all reported infections. Hir-Shabelle accounted for 19.0% (n = 4,169), and Jubaland accounted for 17.8% (n = 3,903). In contrast, Galmudug State contributed 0.7% (n = 163) of total cases. Banadir and Puntland accounted for 12.0% and 9.3% of cases, respectively, while Somaliland accounted for 7.7%. Differences in case distribution across states were statistically significant (p < 0.001). Figure 1 presents a comparison of state-level case distributions.

Fig. 1.

Heat map showing the distribution of reported cases by state in Somalia, with colour intensity indicating the proportion of total cases contributed by each state

Clinical characteristics, and Prevalence of Symptoms

The most frequently reported clinical feature was watery diarrhea, documented in 94.3% (n = 20,689) of cases. Dehydration was reported in 91.2% (n = 20,020) of patients. Vomiting occurred in 67.1% (n = 14,735) of cases, and abdominal pain was reported by 44.9% (n = 9,863). General body weakness was documented in 28.2% (n = 6,180) of patients.

Non-classic symptoms were infrequently reported. Fever was documented in 0.9% (n = 195) of cases, blood in stool in 0.7% (n = 152), and headache in 0.1% (n = 15). Other symptoms were recorded in 1.8% of cases (n = 392), as shown in Fig. 2.

Fig. 2.

Clinical characteristics, and prevalence of symptoms

Co-morbidity of Case and Nutrition Status among Children < 5 Years

Comorbidity status was unknown for 82.9% (n = 18,198) of records. Among cases with documented underlying conditions, malnutrition was the most frequently reported comorbidity, accounting for 3.3% (n = 723) of all patients. Other comorbidities were infrequently reported, including general body weakness (0.5%, n = 117) and fever (0.1%, n = 12). Chronic conditions were rare, with diabetes (n = 4) and typhoid fever (n = 1) each accounting for less than 0.05% of cases.

Nutritional assessment using mid-upper arm circumference (MUAC) among children under five years showed that 5.2% were moderately malnourished and 4.2% were severely malnourished. MUAC measurements were missing for 29.6% of children in this age group (Fig. 3).

Fig. 3.

Describing the co-morbidities with cholera

Source of Water for Domestic Use

Information on household water sources was available for all patients. Tap water was the most frequently reported source, used by 50.9% of patients (n = 11,171). River water was reported by 16.8% (n = 3,690), open wells by 8.9% (n = 1,956), and berkads by 7.9% (n = 1,723). Surface water sources, including ponds and lakes, accounted for 5.5% (n = 1,216). Water trucks were reported by 2.5% (n = 546), while tanker water accounted for 2.1% (n = 455). Borehole water and rainwater were each reported by 0.1% of patients. Water source was recorded as unknown for 5.3% of cases (n = 1,153) (Fig. 4).

Fig. 4.

Source of water for domestic uses

Case Confirmation

Rapid diagnostic tests were performed in 43.4% of patients, among whom 14.0% tested positive. Stool culture was conducted in 2.0% of cases, with 1.1% yielding confirmed positive results. The overall case fatality rate was 0.6%. Mortality was highest among patients aged over 45 years (1.1%) and lowest among infants (0.3%) (Fig. 5).

Fig. 5.

A RDT results, B Serotype of cholera isolated, C laboratory results, and D mortality

Multivariable Logistic Regression

Table 2 presents the results of the multivariable logistic regression analysis of factors associated with mortality. Relative to piped water, the adjusted odds ratio for death among patients reporting river water as the household water source was 2.34 (95% CI: 1.12–4.87). The adjusted odds ratio for severe dehydration compared with no dehydration was 5.67 (95% CI: 3.21–10.01), and malnutrition defined as MUAC < 12.5 cm had an adjusted odds ratio of 2.12 (95% CI: 1.17–3.83). Compared with Banadir, residence in Jubaland had an adjusted odds ratio of 1.91 (95% CI: 1.05–3.47). Using children aged 0–4 years as the reference group, the adjusted odds ratio was 0.64 (95% CI: 0.41–0.99) for ages 5–14 years and 0.52 (95% CI: 0.29–0.92) for ages 15–44 years. For individuals aged ≥ 45 years, the adjusted odds ratio was 1.12 (95% CI: 0.53–2.34). The adjusted odds ratio for RDT positivity was 1.41 (95% CI: 0.88–2.25).

Table 2.

Multivariable logistic regression of factors associated with cholera mortality, Somalia, 2024

Variable	aOR	95% CI	95% CI
Age group
5–14 years vs 0–4 years	0.64	0.41–0.99	0.046
15–44 years vs 0–4 years	0.52	0.29–0.92	0.024
≥45 years vs 0–4 years	1.12	0.53–2.34	0.768
Region
Hirshabelle vs Banadir	1.47	0.89–2.42	0.132
Jubaland vs Banadir	1.91	1.05–3.47	0.034
Southwest vs Banadir	1.08	0.52–2.26	0.837
Galmudug vs Banadir	1.32	0.64–2.73	0.449
Puntland vs Banadir	0.92	0.39–2.16	0.847
Somaliland vs Banadir	0.88	0.34–2.30	0.794
Household water source
River vs piped	2.34	1.12–4.87	0.023
Unprotected well vs piped	1.76	0.83–3.75	0.137
Other sources vs piped	1.58	0.72–3.46	0.250
Clinical and nutritional factors
Severe dehydration vs none	5.67	3.21–10.01	<0.001
Malnutrition (MUAC <12.5 cm) vs normal	2.12	1.17–3.83	0.013
RDT positive vs negative	1.41	0.88–2.25	0.154

Discussion

The 2024 cholera outbreak in Somalia provides an important lens through which to examine the intersection of biological vulnerability, environmental exposure, and structural fragility. Although the national case fatality rate was relatively low, the patterning of risk by age, water source, nutritional status, and region points to persistent inequities that shape who becomes ill and who dies. The findings from Somalia are consistent with global experience, while also adding context to how climate variability and displacement interact with weak systems to sustain cholera transmission.

Children and the Burden of Mortality

Children under five years of age carried the greatest burden of disease and mortality, a pattern repeatedly observed in cholera endemic settings in Africa and Asia [12, 13] Rapid fluid losses, limited physiologic reserves, and challenges in early recognition combine to increase risk in this age group, and this vulnerability is further compounded by undernutrition. Malnutrition impairs gut integrity and immune function, reduces tolerance to dehydration, and is associated with more severe clinical courses and poorer outcomes [13–15] Experiences from South Sudan and Yemen demonstrate similar dynamics, where food insecurity and conflict amplified cholera mortality among children, even when treatment points were available but not equitably accessed [12, 13] Linking cholera case management with routine nutritional screening and therapeutic feeding in high risk areas is therefore not an optional add on but a core mortality reduction strategy.

Water Source and Cholera Mortality

In this analysis, reliance on river water was independently associated with increased odds of death, underscoring the continued importance of untreated surface water as a driver of severe outcomes during cholera outbreaks. River and other open water sources in Somalia are highly susceptible to fecal contamination, particularly during periods of flooding, when sanitation systems are overwhelmed and runoff contaminates drinking water. Households using these sources may also experience delays in accessing care and challenges in maintaining safe water storage, increasing the risk of severe dehydration and adverse clinical outcomes.

Piped water served as the reference category in the multivariable analysis and was not associated with increased mortality in this dataset. This finding is consistent with the protective role of improved water infrastructure when systems are functional and adequately chlorinated. However, evidence from other cholera affected settings indicates that even improved water systems can become compromised during outbreaks due to intermittent supply, inadequate chlorination, or contamination during household storage, particularly in fragile and conflict affected environments [15–17]. While such failures were not directly demonstrated in this analysis, they highlight the importance of routine water quality monitoring, consistent chlorination, and water safety planning as part of cholera preparedness and response.

Taken together, these findings emphasize that reducing cholera mortality in Somalia requires both limiting reliance on high risk surface water sources and ensuring that existing piped water systems consistently deliver safe drinking water, especially during periods of flooding, displacement, and heightened transmission risk [6, 9].

Regional Inequities and Fragile Health Systems

Regional variation in mortality suggests unequal access to timely and effective care. Areas affected by flooding, displacement, and insecurity experienced higher fatality. Evidence from the Democratic Republic of Congo and Yemen shows that geographic inequities in staffing, supply chain reliability, and referral systems contribute to uneven outcomes [18, 19] Somalia’s experience supports the need for regionally tailored responses rather than uniform national approaches. Surge staffing, prepositioned supplies, and rapid referral from peripheral facilities may reduce mortality where access barriers are greatest.

Surveillance Gaps and the Challenge of Underestimation

Surveillance in Somalia relies largely on syndromic reporting, and limited laboratory confirmation constrains validation of transmission patterns. Global evidence indicates that such gaps can delay response and underestimate true disease burden, particularly in settings where multiple diarrheal pathogens co circulate [13, 20] Expanding decentralized rapid diagnostic testing, maintaining sentinel culture capacity, and integrating laboratory data into routine reporting can improve situational awareness and guide antimicrobial stewardship. The objective is not laboratory confirmation of every case, but sufficient confirmation to validate trends, detect shifts in circulating serotypes, and trigger timely interventions.

Climate Variability and Displacement

The outbreak occurred during a period of heavy rainfall and flooding. Floodwaters can contaminate surface and shallow groundwater while displacing communities into crowded shelters with limited hygiene infrastructure. Evidence from Mozambique, Bangladesh, and modelling studies in East Africa confirms that El Niño events and flooding shift cholera risk geographically [21–23] Drought also contributes to risk by increasing dependence on untreated water sources. Climate informed cholera control therefore requires early warning triggers, flood resilient WASH planning, and seasonal preparedness measures [24, 25].

The Role and Limits of Oral Cholera Vaccines

ucing incidence and mitigating outbreaks when targeted to high risk areas and combined with WASH interventions [7, 11, 26]. The low reported coverage among patients in Somalia suggests missed opportunities. Although stockpile limitations and operational constraints remain, experiences from Haiti and Zambia demonstrate that high coverage is achievable in insecure or resource limited settings when coordination is strong and logistics are adapted to context [26, 27]. Preventive campaigns in known hotspot areas, integration with maternal and child health services, and sustained community engagement may improve uptake. Oral cholera vaccination is not a substitute for safe water, but it can provide a protective buffer while longer term systems are strengthened.

Gender, Caregiving, and Exposure

Women and girls frequently bear responsibility for water collection, food preparation, and caregiving. These roles increase contact with unsafe water sources and may delay care seeking, particularly when mobility is limited by insecurity or household obligations. Evidence from humanitarian settings shows that designing WASH infrastructure and risk communication around these realities improves access and effectiveness and indirectly protects children under their care [28, 29]. Practical measures include safe and well-lit water points close to households, attention to privacy and safety in latrine placement, and meaningful inclusion of women in community WASH committees.

Lessons From Other Fragile Settings

Somalia’s experience mirrors patterns observed in Yemen, South Sudan, and the Democratic Republic of Congo. In these settings, recurrent cholera outbreaks have been driven by long standing structural weaknesses rather than isolated environmental events, and reliance on reactive measures alone has failed to prevent resurgence [26, 28, 30]. Countries that have achieved more durable reductions in cholera burden have combined oral cholera vaccination with reliable access to safe water, routine chlorination, and community level hygiene programs. These efforts have been strengthened by improved surveillance systems and the systematic use of data to guide targeted interventions [13, 27, 31].

Taken together, these lessons indicate that cholera in Somalia is not only an acute infectious disease emergency but also a reflection of deeper inequities in access to essential services. Short term reductions in mortality depend on timely rehydration and appropriate case management, while long term prevention requires sustained progress in safe water provision, climate resilient sanitation, integrated nutrition support, and regular, targeted use of oral cholera vaccines in high-risk areas. Scientific knowledge is not the primary barrier. Instead, the central challenges relate to institutional capacity, financing, and the ability to deliver equitable services amid ongoing instability.

Recent reports of cholera resurgence in Sudan during ongoing conflict demonstrate similar patterns driven by disrupted WASH systems, mass displacement, and weakened surveillance. These parallels suggest that conflict affected regions across Africa share structural vulnerabilities that amplify cholera risk. Integrating lessons from Sudan provides additional insight into how fragility sustains recurrent outbreaks in Somalia and reinforces the importance of system focused, sustained approaches [32].

Limitations

This analysis has several limitations. First, the study population was restricted to patients who sought care at cholera treatment centers, which may have resulted in survival bias, as individuals who died before reaching health facilities or who experienced mild illness and did not seek care were not captured. Second, the analysis relied primarily on syndromic surveillance data, and laboratory confirmation was limited, raising the possibility of misclassification with other causes of acute watery diarrhea. Third, information on comorbidities and nutritional status was incomplete for a substantial proportion of patients, limiting the ability to fully assess underlying vulnerability. Fourth, environmental and household level variables, including water source and sanitation access, were self-reported and subject to reporting error. Finally, insecurity and access constraints in some regions may have contributed to underreporting and uneven data completeness across states.

Conclusion and Recommendations

The 2024 cholera outbreak in Somalia underscores the need to confront the structural determinants that sustain vulnerability to waterborne diseases. Although mortality was lower than in previous epidemics, marked disparities by region, water source, and nutritional status reveal persistent inequities in exposure and access to care. Young children, particularly those affected by malnutrition, faced the highest risk of death, underscoring the importance of integrating nutrition support into routine cholera preparedness and response. Findings related to household water sources highlight the need for continued attention to water safety management, including monitoring, chlorination, and safe storage, even where improved water systems are in place.

Achieving durable reductions in cholera mortality will require sustained investments beyond emergency response. National and regional authorities, supported by international partners, should strengthen climate resilient WASH infrastructure, expand decentralized laboratory and surveillance capacity, and implement targeted oral cholera vaccination campaigns in high-risk areas. Equitable prevention and treatment efforts must account for regional disparities, gender related vulnerabilities, and barriers to care. Private hospitals that treat cholera patients should also report and share data with the Federal Ministry of Health to ensure comprehensive national surveillance and timely response. Lessons from Yemen, the Democratic Republic of Congo, and the ongoing outbreak in Sudan demonstrate that resilience depends on rapid case management combined with long term commitments to equity, infrastructure, and system capacity [28, 30].

Somalia’s experience illustrates that cholera remains both a disease of inequity and an indicator of systemic neglect. Prioritizing safe water systems, targeted vaccination, integrated nutrition services, and reliable surveillance can help shift Somalia from reactive outbreak control toward sustained prevention. The global roadmap to end cholera by 2030 provides a useful framework, but progress will depend on political leadership, cross sectoral coordination, and sustained investment in local systems capable of withstanding conflict, climate shocks, and population displacement.

Author Contributions

Conceptualization: Abdimajid Said Siad, Mohamed Omar Warsame. Methodology: Abdimajid Said Siad, Muhammad Liaquat Raza. Formal Analysis: Abdiwali Ahmed Siyad, Mohamed Omar Warsame. Data Curation: Abdirizak Mohamud Yusuf, Mukhtar Bulale Muhumed. Investigation: Said Mohamed Hussein. Writing original Draft: Mohamed Omar Warsame, Aniqa Batool. Writing review & Editing: Abdimajid Said Siad, Marian Muse Osman, Muhammad Liaquat Raza. Visualization & Project Administration: Mohamed Ahmed Nor. Supervision: Abdimajid Said Siad.All authors read and approved the final manuscript.

Funding

None. This study received no external funding.

Data Availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request and in accordance with national data protection and data sharing guidelines. Data will be shared for non-commercial research purposes without compromising participant confidentiality.

Declarations

Ethical Approval

for this study was obtained from the National Institute of Health, Somalia, under protocol number NIH/IRB/44/JUNE/2025. The analysis was conducted using routinely collected national cholera surveillance data. All records were de identified prior to analysis, and no personal identifiers were retained. The study was conducted in accordance with national research ethics guidelines and the principles of the Declaration of Helsinki.

Consent for Publication

Not applicable.

Informed Consent

This study involved secondary analysis of routinely collected surveillance data. Individual informed consent was not required, as data were collected as part of standard public health response activities and were analyzed in de identified form.

Competing interests

The authors declare no competing interests.