Epidemiologic Characteristics and Predictors of Mortality in Somalia's 2024 Cholera Outbreak.

BACKGROUND: Cholera remains a persistent public health threat in fragile and conflict affected settings where inadequate water, sanitation, and hygiene infrastructure, population displacement, and climate shocks contribute to recurrent outbreaks. Somalia has experienced cyclical cholera epidemics for decades, yet recent national level analyses of mortality predictors remain limited. METHODS: A retrospective analysis of national cholera surveillance data was conducted using line lists from cholera treatment centers across Somalia for the period January to December 2024. Suspected and confirmed cases were defined according to national guidelines. Demographic, clinical, nutritional, environmental, and laboratory variables were analyzed. Multivariable logistic regression was used to identify factors associated with mortality. RESULTS: A total of 21,945 suspected cholera cases and 138 deaths were reported, corresponding to a case fatality rate of 0.6%. Children under five years accounted for 42% of cases. In the adjusted analysis, use of river water compared with piped water had an adjusted odds ratio of 2.34 (95% CI: 1.12–4.87). Severe dehydration had an adjusted odds ratio of 5.67 (95% CI: 3.21–10.01), and malnutrition had an adjusted odds ratio of 2.12 (95% CI: 1.17–3.83). Residence in Jubaland compared with Banadir had an adjusted odds ratio of 1.91 (95% CI: 1.05–3.47). Children aged 5–14 years and individuals aged 15–44 years had lower adjusted odds of death compared with children under five years. Laboratory confirmation was limited. CONCLUSION: The 2024 cholera outbreak in Somalia was characterized by substantial pediatric burden and marked differences in mortality by water source, nutritional status, dehydration severity, and region. Strengthening water safety, expanding access to timely case management, integrating nutrition services, improving surveillance capacity, and implementing targeted oral cholera vaccination in high-risk areas are critical to reducing cholera mortality and advancing long term control efforts in Somalia.