Climate Variability, Urbanization, Water Insecurity, and Cholera in Somalia (2000-2025): A Thematic Narrative Review

Cholera remains endemic in Somalia with epidemic spikes linked to water insecurity, climate variability, and rapid urbanization. This narrative synthesis characterizes epidemiological patterns and structural determinants of cholera transmission.

Systematic narrative review following PRISMA guidelines retrieved literature from PubMed, Scopus, Web of Science, and gray sources (WHO, UNICEF, UN-Habitat, Somali Ministry of Health, Water, sanitation, and hygiene (WASH) Cluster) for English-language publications (2000-2025) on cholera epidemiology, water security, and urbanization in Somalia. Thematic synthesis used Thomas and Harden's inductive framework. Quality appraisal applied CASP checklist for mixed-methods research.

Three intersecting determinants drive endemic cholera: (1) chronic water insecurity from recurrent droughts and unsafe informal sources; (2) rapid urbanization and informal settlements without adequate Water, sanitation, and hygiene (WASH) infrastructure; and (3) fragile surveillance systems. Hotspots cluster in riverine districts (Shabelle, Juba) and urban peripheries (Mogadishu, Baidoa). Children under 5 and internally displaced persons experience disproportionate burden. Oral cholera vaccine reduced case fatality rates from 1.5% (2017) to 0.1% to 0.6% (2024-2025), yet endemic transmission persists.

Cholera control requires integrated multi-sectoral interventions. Priorities include: (1) linking climate and Water, sanitation, and hygiene Water, sanitation, and hygiene (WASH) monitoring; (2) transitioning to climate-resilient piped water infrastructure; (3) formalizing internally displaced person settlements with planned Water, sanitation, and hygiene (WASH) infrastructure; (4) strengthening surveillance and laboratory capacity; and (5) establishing cross-sectoral coordination across health, urban planning, water resources, and climate adaptation.