Drivers of Cholera Mortality in Somalia: Insights from a 2024 National Epidemiological Study

Background Cholera remains a persistent threat in fragile and conflict-affected settings, where inadequate water, sanitation, and hygiene (WASH) systems, population displacement, and climate shocks create conditions for recurrent outbreaks. Somalia has long faced cyclical cholera epidemics, yet few analyses have systematically examined recent trends. Methods We conducted a retrospective analysis of national surveillance data on suspected cholera cases reported to the Federal Ministry of Health in 2024. Demographic, clinical, and environmental predictors of mortality were examined using multivariable logistic regression. Results A total of 21,945 suspected cholera cases and 138 deaths were reported in 2024 (case fatality rate [CFR] 0.6%). Children under five accounted for 42% of cases and carried the highest mortality risk. Patients in Jubaland had nearly double the odds of death compared to Banadir. Use of river water was strongly associated with mortality (aOR 2.34, 95% CI 1.12–4.87). Malnutrition doubled the risk of death, while severe dehydration increased mortality odds almost sixfold. Laboratory confirmation was limited, and rapid diagnostic test (RDT) positivity was not independently associated with death. Conclusion Breaking the cycle of recurrent cholera outbreaks in Somalia requires sustained, multisectoral investments beyond emergency responses. Priorities include strengthening WASH infrastructure, decentralizing case management, expanding nutrition support, and implementing targeted oral cholera vaccination campaigns. Lessons from Yemen, Haiti, and the Democratic Republic of Congo illustrate that integrated approaches can curb cholera even in conflict-affected settings.