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RISK ANALYSIS
Prioritized hazard and its historical impact
Cholera remains a significant public health threat in Somalia, with recurrent outbreaks over the past decade (see Annex 1, Figure 1). The country has experienced continuous transmission since 2016, with notable surges following droughts, during the Gu (April-June) and Deyr (October-December) rainy seasons. In 2017, Somalia faced one of its most severe cholera epidemics, reporting approximately 78,000 cases and 1,159 deaths, with a case fatality rate (CFR) of 1.5%.2 Climate disasters, including droughts, floods, rising temperatures and El Niño phenomena, have exacerbated the cholera situation since 2022, with further escalation in 2023, when over 18,304 cases were reported, disproportionately affecting children under five. By March 2024, cholera had spread to 32 districts, recording a CFR of 1.2%, surpassing the acceptable emergency threshold (See also Annex 1, Figure 2).
Disaggregated data on CFR by age group is limited. However, available reports indicate that children under five years old were significantly affected and high rates of malnutrition among children lead to high CFRs.4 In epidemiological week 2 (8-14 January 2024), 67.8% of the 474 new cholera cases were among children below five years, with an overall CFR of 1.2% during that period (WHO). Similarly, in week 3 (15-21 January 2024), 66.7% of the 108 new cholera cases were among children below five years, with an overall CFR of 0.9% (WHO). In week 6 (5-11 February 2024), 57.1% of the 429 new cases were in children under five (WHO). As of August 2024, approximately 17,000 cholera cases were recorded across 30 districts in all seven states of Somalia, with children comprising a substantial proportion (59%) of those affected (UNICEF). These trends highlight the heightened vulnerability of young children to cholera during the outbreak. However, specific CFR data segmented by detailed age groups beyond under-five children were not available in the reviewed sources.
The Somalia Humanitarian needs and response Plan projects AWD/Cholera cases “to reach similar or slightly higher levels in 2025, compared to 2024” and points out a historically above average CFR.
The impacts of cholera on mortality and morbidity are profound. The rapid transmission of the disease, particularly in settlements and urban areas, coupled with gaps in surveillance, delays in diagnosis and treatment, has led to significant impacts, disproportionally affecting vulnerable groups. Cholera outbreaks have overburdened the already fragile health system in Somalia, stretching resources thin and limiting access to care for other conditions, further undermining health outcomes.
Several factors contribute to the endemic nature of cholera in Somalia. Limited access to clean water and sanitation forces communities to rely on contaminated sources, driving transmission. Poor sanitation facilities, especially in rural areas, lead to environmental contamination, while high population mobility due to seasonal factors, conflict, drought, and floods exacerbates the spread. Overcrowded settlements, particularly in internally displaced persons (IDP) camps, lack adequate water, sanitation, and hygiene (WASH) infrastructure, creating conditions conducive to outbreaks.
Somalia’s National Cholera Strategy emphasizes a multisectoral approach to cholera prevention and control, with key pillars including WASH improvements, strengthened healthcare services, and community engagement. The Somali Red Crescent (SRCS), aligning with this strategy, in collaboration with its movement partners, has prepared for and responded to frequent disasters9, including cholera outbreaks (e.g., most recent DREF Operation MDRSO01710). However, challenges persist, as response activities often face delays due to gaps in resources for better preparedness, including prepositioning, and readiness for early actions.
The IFRC emphasizes the importance of anticipatory actions to prevent cholera outbreaks. These efforts align with the Global Task Force on Cholera Control’s (GTFCC) strategy to reduce cholera deaths by 90% by 2030. Strengthening WASH infrastructure, enhancing healthcare access, and further building on SRCS community-based surveillance (CBS) system are critical measures to mitigate cholera’s devastating impact and to support the national ambitions in the cholera prevention and control.