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

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.