Reimagining tuberculosis detection in Somalia: from passive to active case finding

Dear

Editor,

Recent evidence suggests that how tuberculosis is found may determine whether control efforts succeed at all. In East African health facilities, the study by Mnyambwa and colleagues identified a central weakness in the tuberculosis care cascade: screening remains concentrated in outpatient and HIV clinics, while long patient pathways, symptom-based screening limits, supply interruptions, and workforce constraints allow infectious cases to be missed before diagnosis [1]. For Somalia, where health-system fragility and delayed presentation already narrow the window for timely diagnosis, this finding carries an unmistakable implication: tuberculosis control cannot depend mainly on patients arriving at facilities on their own.

Somalia's tuberculosis burden remains high despite reported progress. Recent Somalia-focused evidence reports an incidence of 246 cases per 100,000 in 2023 and a tuberculosis mortality rate of 68 per 100,000, while case detection was only 42%, leaving most affected individuals outside the reach of routine services [2]. Tuberculosis control in Somalia is further complicated by conflict, displacement, weak surveillance, fragmented and unevenly distributed services, and indirect patient costs that delay diagnosis and contribute to ongoing transmission [3]. The pluralistic health market adds another challenge: private providers deliver a large share of care, yet reporting and referral remain incomplete creating prolonged diagnostic pathways, increasing patient costs, and contributing to a surveillance blind spot for the national programme [2].

The policy response should therefore shift decisively from passive case finding to active case finding (ACF). Community-based ACF appears most useful when passive, facility-based detection has failed to reduce incidence sufficiently and when programmes aim to reach populations unlikely to seek care spontaneously [4]. In practice, Somalia could prioritize household contact investigation, door-to-door or camp-based symptom screening, mobile screening and sputum collection, and wider integration of screening into primary care, maternal-child health, and diabetes services rather than limiting detection to outpatient and HIV clinics [1], [4]. Community health workers are especially important in this transition because they can extend case finding, support sputum collection and transport, and strengthen treatment support beyond formal facilities; stronger CHW training, supervision, and integration with primary healthcare have been linked to better notification impact [5]. Somalia should also use simple digital notification pathways that connect community screening, private clinics, laboratories, and the national programme in real time [2], [3].

Active case finding is feasible even in fragile settings when it is designed around access rather than institutions alone. Evidence from community-based tuberculosis programmes suggests that sustainable active case finding depends on surveillance, workforce capacity, integration into health systems, and long-term operational support [4]. Broader ACF frameworks further emphasize strategic financing, multisectoral collaboration, community health worker involvement, rapid field-level diagnostics, and rigorous piloting in high-burden areas before scale-up [4]. In Somalia, that means aligning donor support behind a national ACF roadmap, strengthening public-private data-sharing, investing in local diagnostic and outreach capacity, and embedding tuberculosis screening within humanitarian and primary-care platforms [2], [3].

Somalia should no longer organize tuberculosis detection around the expectation that missed patients will eventually seek care. A more effective strategy is to identify cases earlier, diagnose closer to communities, and strengthen notification pathways across public and private sectors. In fragile and humanitarian settings, tuberculosis control advances not when facilities wait for patients to arrive, but when health systems actively reach populations that are least likely to access care and most likely to remain undiagnosed.

Declaration of Generative AI.

ChatGPT (OpenAI) was used to assist with language refinement, clarity, and readability, and to support the development of Fig. 1. The authors reviewed and edited all AI-assisted content and take full responsibility for the final content of the manuscript and figure.

Fig. 1.

Conceptual pathway from missed cases to stronger tuberculosis control.

CRediT authorship contribution statement

Abdirahman Mohamed Adan: Writing – review & editing, Writing – original draft, Conceptualization. Ahmed Mohamed Omar: Investigation, Conceptualization. Mohamed sharif Abdi: Validation, Investigation. Maryama Ahmed Ali: Visualization, Validation, Investigation. Yakub Burhan Abdullahi: Supervision.

Ethical approval

Not required.

Funding

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.