Background:

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.

Methods:

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.

Findings:

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.

Conclusions:

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.

Plain Language Summary

How Unsafe Water, Crowded Cities and Climate Extremes Keep Cholera Spreading in Somalia, and What Needs to Change By 2030.

Cholera is a severe diarrhoeal disease that can kill within hours if untreated. It is completely preventable when people have safe water, toilets, and good hygiene. Yet in Somalia, cholera has continued to appear almost every year from 2000 to 2025. This review brings together information from scientific articles, UN agencies, and Somali government reports to explain why cholera keeps returning and what must change. We focus on three main issues: lack of safe water, very fast urban growth, and the effects of climate change. Somalia faces repeated droughts and floods. Drought dries up wells and forces families to use a tiny amount of often unsafe water. Later, heavy rains and floods wash human waste into rivers and shallow wells. At the same time, more people are moving into cities and informal camps for displaced people. These crowded settlements often lack piped water, drainage, rubbish collection, and safe toilets. As a result, one sick person’s waste can quickly contaminate the water used by many families, especially children. We also describe how the health system struggles with weak disease surveillance, limited laboratory capacity, and heavy dependence on emergency responses such as water trucking and temporary latrines. Our findings show that treating patients and giving cholera vaccines, while essential, are not enough. To break the cycle, Somalia needs reliable, climate-resilient water systems, safer planned settlements for displaced people, better sanitation, and earlier warning systems that link weather forecasts to cholera risk. Controlling cholera is therefore not only a medical issue but also a question of fair access to basic services and long-term investment in water, sanitation, and urban planning.