From detection to response: a critical narrative review of infectious disease surveillance and outbreak preparedness in Somalia

1 Introduction

Infectious disease surveillance and outbreak preparedness constitute the backbone of global health security, enabling early detection of pathogens before they escalate into epidemics or pandemics with cross-border consequences (1, 2). The COVID-19 pandemic starkly demonstrated how quickly localized outbreaks can overwhelm health systems and disrupt economies worldwide, reinforcing the imperative for countries to build surveillance architectures compliant with the WHO International Health Regulations (IHR 2005), which obligate member states to develop core capacities for detecting, assessing, reporting, and responding to public health emergencies of international concern (3). Emerging and re-emerging infectious diseases, compounded by climate variability, urbanization, and population mobility, have intensified the frequency and complexity of outbreak threats globally, disproportionately burdening fragile and conflict-affected states that lack the institutional continuity, financing, and workforce needed to sustain routine surveillance functions (4).

Somalia exemplifies this disproportionate vulnerability (4). Decades of civil conflict since 1991 dismantled national health infrastructure, displaced millions of people, and left the country with human resource densities markedly below WHO minimum thresholds, alongside patchy surveillance coverage concentrated in urban centers while rural and displaced populations remain underserved (5). Recurrent outbreaks of cholera, measles, and poliovirus some occurring annually along flood-prone river basins have persisted despite improvement efforts, reflecting the compounding influence of climate shocks, insecurity, and chronic underinvestment in water, sanitation, and hygiene (WASH) infrastructure (5). At the same time, Somalia has registered meaningful institutional progress: the phased rollout of the Integrated Disease Surveillance and Response (IDSR) system since 2021, the establishment of a Field Epidemiology Training Program (FETP), and growing collaboration among the Federal Ministry of Health and Human Services, the National Institute of Health, WHO, UNICEF, and the African Field Epidemiology Network (AFENET) (5, 6). These developments signal a critical juncture at which Somalia’s surveillance system could transition from a reactive, alert-driven posture toward a resilient, anticipatory model of epidemic intelligence.

Accordingly, this review critically assesses the evolution, current functionality, and remaining limitations of infectious disease surveillance and outbreak preparedness in Somalia. Specifically, it asks three questions: (1) to what extent has Somalia progressed toward the surveillance and response capacities expected under the International Health Regulations (IHR 2005) and WHO surveillance frameworks; (2) why have improvements in facility-based reporting not translated consistently into alert verification, laboratory confirmation, investigation, and response and (3) what lessons from other fragile and conflict-affected settings can inform a feasible, context-specific pathway for Somalia? By addressing these questions, the review moves beyond describing existing challenges to identify the structural mechanisms that continue to limit the translation of surveillance information into public health action.

2 Methods

2.1 Review design and rationale

This study used a structured narrative review to synthesize evidence on infectious disease surveillance and outbreak preparedness in Somalia. The approach was selected to integrate epidemiological studies, surveillance evaluations, outbreak reports, policy documents, and international health-security frameworks. The review examined surveillance capacity across detection, reporting, verification, investigation, laboratory confirmation, information sharing, and response, while considering contextual factors including insecurity, displacement, climate variability, fragmented governance, and external financing.

2.2 Literature search strategy

A structured search was conducted in PubMed/MEDLINE, Scopus, and Web of Science. Additional evidence was identified from the WHO Institutional Repository for Information Sharing (IRIS), WHO regional resources, Government of Somalia documents, and reports from relevant international and humanitarian organizations. Reference lists of key publications and policy documents were also reviewed.

Search terms combined concepts related to “Somalia,” “Somaliland,” infectious disease surveillance, integrated disease surveillance and response (IDSR), outbreak preparedness and response, early warning, event-based and community-based surveillance, laboratory surveillance, One Health, International Health Regulations (IHR), health security, and major infectious diseases including cholera, measles, polio, malaria, and tuberculosis.

Grey literature was included because important information on Somalia’s surveillance systems and program implementation is not consistently available in peer-reviewed literature. Relevant WHO assessments, Joint External Evaluation (JEE) reports, national health-security documents, surveillance evaluations, and official program reports were therefore considered alongside peer-reviewed evidence.

2.3 Eligibility criteria

Sources were eligible if they provided relevant information on infectious disease surveillance, outbreak preparedness, response, or health security in Somalia. Eligible evidence included peer-reviewed studies, surveillance evaluations, outbreak investigations, epidemiological studies, reviews, policy or program evaluations, and authoritative national or international reports.

Sources were excluded if they were unrelated to surveillance or preparedness, focused solely on clinical management, duplicated another source, or lacked sufficient information for interpretation. Where overlapping evidence was identified, greater weight was given to recent, authoritative, and methodologically informative sources.

2.4 Study selection and evidence synthesis

Retrieved records were screened for relevance using titles and abstracts, followed by full-text assessment where appropriate. Reference lists of relevant publications and policy documents were also examined to identify additional sources.

Evidence was synthesized thematically across seven domains: surveillance development and organization; infectious disease threats; alignment with WHO/IHR expectations; governance, financing, workforce, laboratory, data, and community surveillance; outbreak preparedness and response; digital surveillance; and One Health and global health security.

The synthesis was qualitative and comparative. Findings were interpreted across the surveillance-to-response pathway, with particular attention to the distinction between reporting capacity and subsequent alert verification, investigation, laboratory confirmation, information sharing, and public health action.

2.5 Critical appraisal and methodological limitations

No formal meta-analysis or standardized quantitative risk-of-bias assessment was undertaken because of the heterogeneous nature of the evidence. Instead, sources were considered according to methodological clarity, study design, source authority, recency, consistency, and relevance to Somalia. Greater weight was given to national surveillance evaluations, WHO assessments, JEE findings, official reports, and peer-reviewed studies with clearly described methods.

The evidence base was uneven across diseases, regions, and surveillance functions and relied partly on program reports and institutional assessments. Differences in reporting completeness, access, and implementation across federal member states may also limit direct comparison of findings. These limitations were considered when interpreting evidence and assessing national surveillance performance.

2.6 Analytical framework

The review assessed surveillance using a continuum from signal generation and reporting to alert verification, laboratory confirmation, epidemiological investigation, information analysis and sharing, and public health response. WHO and IHR frameworks were used as reference points for assessing surveillance and health-security capacity, while One Health principles guided assessment of human, animal, and environmental risks.

Digital technologies were considered enabling tools rather than independent indicators of surveillance maturity. Their contribution was therefore interpreted in relation to reporting quality, verification, laboratory linkage, workforce capacity, and response systems.

3 Results

3.1 Overview of infectious disease surveillance in Somalia

Somalia’s surveillance history is defined by discontinuity and reconstruction (4). Prior to 2008, the country lacked any functioning routine disease surveillance framework, a consequence of state collapse following the 1991 civil war (4). The Early Warning Alert and Response Network (EWARN), established in 2008 as an emergency-oriented system, became Somalia’s sole multidisease surveillance mechanism for over a decade, later deactivated between 2008 and 2016 amid conflict before being reactivated in 2017 during a severe drought and cholera emergency (7). While EWARN proved effective in facilitating rapid alert generation during crises, its provisional design was never intended to substitute for a permanent, integrated national surveillance architecture, and vertical, disease-specific systems for polio and malaria persisted alongside it, generating duplication and coordination gaps (4, 7).

A pivotal shift occurred following Somalia’s 2016 Joint External Evaluation of IHR core capacities, which revealed limited or no capacity across nearly all surveillance indicators, prompting development of the 2020–2024 National Action Plan for Health Security (NAPHS) that prioritized integrated disease surveillance as the central strategy for closing these gaps (4). Momentum accelerated during the COVID-19 pandemic, which exposed the costs of fragmented systems and catalyzed the establishment of incident management structures and emergency operations centers that later became foundational components of IDSR (4). Somalia formally established a functioning IDSR system in 2021, guided by a costed three-year operational plan spanning governance, information technology, laboratory networks, and surveillance-response functions, with the District Health Information Software 2 (DHIS2) tracker application selected as the national reporting platform (4, 8).

Institutional responsibility is distributed across the Federal Ministry of Health and Human Services, six federal member state health authorities, the National Institute of Health, subnational laboratories, and international partners including WHO, UNICEF, AFENET, and the US CDC, reflecting a decentralized governance architecture consistent with Somalia’s federal system (9). A 2024–2025 mixed-methods evaluation found that all federal member states had achieved functional electronic IDSR at the facility level and met the WHO benchmark of at least 80 percent reporting timeliness and completeness, with the notable exception of Banaadir region, were timeliness fell to 44 percent (4). However, only 46.5 percent of public health alerts reported through IDSR had been verified nationally, with substantial interstate variation ranging from 33 to 67 percent, indicating that facility-level reporting gains have outpaced the system’s capacity for alert verification, outbreak investigation, and response the functions most critical to translating detection into timely action (9). Community-based surveillance (CBS) and event-based surveillance (EBS), both essential complements to facility-based reporting for detecting signals from informal and hard-to-reach populations, remained non-operational as of late 2024, representing a significant structural gap given that over 2.6 million internally displaced persons reside in settings largely outside routine facility catchment areas (10). This evolution illustrates a system that has achieved credible technical and governance foundations while still lacking the depth of laboratory linkage, data verification, and human resource capacity required for full IHR compliance (4).

Taken together, the evidence indicates that Somalia has moved from an emergency-oriented surveillance model toward a more integrated national architecture, but this transition remains incomplete (4). The most important change has been institutional rather than technological surveillance is increasingly embedded within national structures, standardized reporting mechanisms, and a broader health-security agenda (4, 5, 8). However, the available evidence suggests that the system is currently stronger at generating and transmitting facility-based signals than at validating those signals, confirming them through laboratory networks, investigating outbreaks, and ensuring timely response (4, 11, 12). This distinction is important because reporting performance alone should not be interpreted as equivalent to surveillance effectiveness under the IHR (3). WHO’s surveillance framework emphasizes not only early warning and reporting but also event verification and investigation, analysis, information sharing, and the capacity to translate surveillance into public health action (3).

3.2 Current infectious disease threats and outbreak patterns

Somalia continues to face a diverse and overlapping infectious disease burden shaped by recurrent outbreaks, low population immunity, climate variability, population displacement, and weaknesses in health-system and environmental infrastructure. Cholera and acute watery diarrhea (AWD) remain among the country’s most persistent epidemic threats, with sustained transmission associated with flooding, drought, displacement, and inadequate water, sanitation and hygiene (WASH) conditions (13, 14). During the first months of 2024, more than 4,380 cholera cases and 54 deaths were reported across 32 districts, with a case fatality rate of 1.2% (15, 16).

Rather than representing isolated epidemic events, the recurrence of cholera indicates that repeated detection and emergency response have not consistently translated into sustained reduction of underlying transmission risks. The relationship between climate shocks, population movement, limited surveillance reach, and inadequate WASH infrastructure is illustrated in Figure 1.

Vaccine-preventable diseases provide a second indication of persistent weaknesses in prevention and surveillance. Measles remains endemic, with routine immunization coverage estimated at approximately 20%, leaving substantial numbers of children susceptible to outbreaks (13, 17).

Between September 2021 and January 2023, FETP-trained officers investigated 54 measles outbreaks, of which 50 were confirmed, together with 17 cholera outbreaks (18). Polio transmission, including circulating vaccine-derived poliovirus, has also persisted, despite repeated vaccination activities (19). However, the experience of large-scale campaigns reaching more than 1.7 million children for polio and 1.5 million for measles demonstrates that Somalia can mobilize substantial operational capacity when resources, coordination, and implementation are aligned (20). The contrast between these episodic successes and persistent transmission suggests that the major challenge is not the absence of response capacity, but its continuity and integration with routine surveillance and prevention systems.

Other infectious diseases add further complexity to Somalia’s surveillance requirements. Malaria and other vector-borne diseases are influenced by changing rainfall and temperature patterns, which may alter transmission intensity and seasonality and increase the need for surveillance that can detect environmental and epidemiological changes (21). Tuberculosis remains a major burden, with WHO estimating approximately 43,000 incident cases and 11,000 deaths in a recent reporting year (22, 23). Limited diagnostic capacity and incomplete laboratory linkage may contribute to under-detection and constrain surveillance of drug-resistant disease (22). At the same time, Somalia’s pastoralist population, extensive human-livestock interaction, and climate-related ecological changes create conditions for zoonotic and emerging disease risks that may not be adequately captured by predominantly human health-based surveillance systems (24).

Overall, the disease profile demonstrates that Somalia’s outbreak risk is driven by interacting rather than isolated threats. Figure 1 summarizes the major health-system and environmental drivers underlying this pattern. The implication for surveillance is that monitoring individual diseases alone is insufficient: effective preparedness requires the capacity to identify changes in population immunity, environmental conditions, laboratory-confirmed disease, population movement, and community-level signals and to connect these signals to timely preventive and response measures.

3.3 Assessment of Somalia’s surveillance capacity against WHO/IHR expectations

Available evidence indicates that Somalia has made important progress in establishing core surveillance structures, but this progress is uneven across the surveillance-to-response pathway (Table 1). The establishment of IDSR and electronic reporting represents substantial progress in routine surveillance, while important gaps remain in alert verification, laboratory-supported confirmation, community-level detection, and timely investigation (4, 5, 10–12). When viewed against the core surveillance functions emphasized by the IHR 2005, these findings suggest that Somalia has strengthened the capacity to generate and transmit surveillance information more rapidly than the capacity to verify, investigate, and act on that information (3, 4).

Table 1. Assessment of Somalia’s infectious disease surveillance capacity against WHO/IHR expectations.

3.4 Challenges limiting effective surveillance and outbreak preparedness

Somalia’s surveillance weaknesses are deeply interdependent, such that progress in one domain is frequently undermined by persistent deficits in another (11). Governance fragmentation is foundational: the federal architecture distributes outbreak authority across six-member states and numerous partners, producing duplicated assessments, delayed release of essential commodities, and inconsistent application of technical guidelines across jurisdictions (12). This is compounded by a financing model in which international donors cover roughly half of national health expenditure, and IDSR implementation surveys have identified financing as the weakest thematic area, scoring only 15 percent progress against WHO benchmarks compared to substantially higher scores for governance, guidance, and information technology (4, 12). This financing gap directly constrains workforce development, since human resources implementation also scored only 16 percent in the same assessment, reflecting Somalia’s health worker density of fewer than 0.4 doctors, nurses, and midwives per 10,000 population against a WHO minimum threshold of 23 per 10,000 (11, 12).

Laboratory and diagnostic capacity remain similarly constrained, limiting the system’s ability to confirm alerts generated through facility-based reporting; the 2024 IDSR evaluation explicitly identified poor laboratory capacity and weak linkage between surveillance data and laboratory confirmation as recurring implementation barriers across all federal member states (12). Data systems, although improved through DHIS2 deployment, remain only partially automated, with immediate case-based reporting still dependent on manual transmission in many districts and only 46.5 percent of alerts undergoing verification, indicating that data generation has outpaced data utilization (12). Community engagement is arguably the most underdeveloped domain: community-based and event-based surveillance mechanisms were not yet operational as of late 2024, despite their proven relevance in a country where displaced populations and nomadic communities frequently fall outside facility catchment areas (11). Security instability and humanitarian access constraints intersect with all of these deficits, as insecurity limits supportive supervision visits, disrupts cold-chain logistics, and, combined with displacement affecting over 2.6 million people, creates persistent blind spots in surveillance coverage precisely where outbreak risk is highest (11, 12) (Table 2).

Table 2. Major challenges affecting infectious disease surveillance and outbreak preparedness in Somalia.

3.5 Strengthening surveillance capacity: pathways for improvement

Strengthening Somalia’s surveillance capacity requires prioritizing the core functions that enable reliable detection, verification, investigation, and response. Digital technologies can support these functions, but they should be viewed as enabling tools rather than substitutes for foundational surveillance capacity. The customization of the DHIS2 tracker application has enabled standardized weekly aggregate reporting from hundreds of facilities and supports automated dashboards for epidemiological bulletin generation, while the immediate case-based reporting component remains only partially deployed on health workers’ mobile devices (5, 8).

Further expansion of mobile-enabled case-based reporting and geographic information systems could improve the timeliness and visualization of outbreak information, particularly when linked to displacement patterns and climate hazards (12). However, these tools are likely to have the greatest value when reporting quality, alert verification, laboratory linkage, and response functions are sufficiently reliable. Similarly, integrating hydro-meteorological early-warning information with IDSR alert thresholds could eventually support anticipatory actions such as pre-emptive WASH interventions and vaccination planning in high-risk districts (13).

Laboratory system strengthening is therefore a parallel priority, because the value of surveillance alerts ultimately depends on the capacity to confirm and characterize suspected events (12). Key needs include expanding diagnostic capacity beyond Mogadishu, establishing functional specimen transport networks between peripheral facilities and regional reference laboratories, and strengthening quality-assurance systems consistent with WHO laboratory network standards (12). Workforce development through the Field Epidemiology Training Program (FETP) has demonstrated measurable progress. Between September 2021 and January 2023, FETP trainees investigated 95 outbreaks, although only 51% were investigated within 48–72 hours of alert; ten graduates from the first cohort subsequently became co-mentors, supporting the development of national mentoring capacity (11, 25). By early 2025, six cohorts had graduated, with the sixth cohort focusing specifically on immunization service delivery and laboratory system strengthening (25). Expanding FETP toward intermediate and advanced levels, together with strengthening multidisciplinary rapid response teams able to combine epidemiological, laboratory, and risk-communication functions, could improve the country’s capacity to translate surveillance signals into timely investigation and response (11). Community-based surveillance provides an additional mechanism for extending surveillance beyond formal health facilities, particularly among displaced, mobile, and hard-to-reach populations (10). Evidence from Somaliland demonstrates the feasibility of this approach: a community-based surveillance program using trained community health volunteers and an SMS-based reporting platform generated 138 signals in a single year, with 83% verified and escalated to health authorities within 24 hours, triggering interventions such as oral rehydration distribution (10). These findings illustrate the potential contribution of community-level reporting to early event detection. Expanding community-based and event-based surveillance nationally, while maintaining links to formal verification and response structures, could help address important gaps in surveillance coverage. Sustained engagement with communities and trusted local leadership structures would further strengthen the acceptability and continuity of such approaches (11).

3.6 Integrating one health and global health security approaches

Somalia’s epidemiological profile, dominated by a large pastoralist economy with intensive human-livestock-environment interaction, makes a One Health approach not merely aspirational but epidemiologically necessary (26). Climate variability is intensifying zoonotic spillover risk by altering vector ecology, water availability, and livestock migration patterns, while simultaneously degrading the WASH infrastructure that constrains cholera transmission, creating compounding rather than isolated risk pathways (27, 28). Somalia’s current surveillance architecture remains oriented predominantly toward human clinical case detection, with limited formal integration of veterinary and environmental surveillance data despite explicit acknowledgment in recent reviews that One Health integration remains one of the critical unresolved system-level weaknesses alongside digital embedding and governance formalization (26).

Aligning Somalia’s surveillance strengthening agenda with international health security frameworks would accelerate this integration (12). The IHR 2005 core capacity requirements explicitly include zoonotic disease detection among mandatory surveillance functions, while the Global Health Security Agenda promotes joint external evaluations and multisectoral coordination mechanisms that Somalia has already partially adopted through its 2016 JEE and subsequent National Action Plan for Health Security (4). Establishing a functioning multisectoral coordination platform linking the Ministry of Health, veterinary services, and environmental authorities building on the existing IHR committee and technical working group structures already used for IDSR would provide an institutional entry point for operationalizing One Health surveillance without requiring entirely new governance architecture (26). Given that climate-driven displacement and disease transmission are demonstrably linked in Somalia’s recent epidemiological experience, embedding environmental and climate indicators into routine surveillance dashboards represents a practical, evidence-based extension of the current IDSR platform rather than a parallel undertaking (13, 27).

4 Discussion

A coherent strategic roadmap for Somalia must sequence interventions according to feasibility and interdependence, moving deliberately from detection toward prediction, prevention, and rapid response (29). In the short term, priorities should center on consolidating existing IDSR gains: improving alert verification rates beyond the current 46.5 percent national average, closing the timeliness gap in underperforming states such as Banaadir, and completing nationwide deployment of mobile case-based reporting on the DHIS2 tracker platform (12). Expanding laboratory specimen referral networks and strengthening supportive supervision, even amid access constraints, would directly reinforce the weakest links currently undermining outbreak confirmation (12) (Table 3).

Table 3. Strategic priorities for strengthening outbreak preparedness in Somalia.

Medium-term priorities should focus on institutionalizing digital surveillance integration beyond pilot districts, expanding FETP toward intermediate and advanced training tiers to build a self-sustaining national epidemiological workforce, and strengthening the technical working group coordination mechanism that has shown signs of declining engagement over time (11, 12). Formalizing community-based and event-based surveillance nationally, drawing on the demonstrated Somaliland model, would close current rural and displacement-related detection gaps within this timeframe (10).

Long-term priorities require transitioning toward predictive surveillance systems that integrate climate, laboratory, and epidemiological data streams to anticipate outbreaks before case counts rise, alongside securing sustainable domestic health financing to reduce the current near-total dependence on donor funding that has constrained workforce and laboratory investment (27). Building a resilient national health security system ultimately requires institutionalizing One Health governance and embedding surveillance financing within Somalia’s broader health sector strategic planning rather than treating it as a donor-dependent vertical program (24, 30).

4.1 Limitations

This review has several limitations. First, as a narrative review, it does not provide a systematic or exhaustive synthesis of all available evidence and therefore cannot exclude selection or publication bias. Second, surveillance indicators and reporting definitions have changed over time, limiting direct comparison across years and across surveillance systems. Third, much of the available evidence comes from operational reports, program evaluations, and institutional documents rather than nationally representative empirical studies. Fourth, evidence is geographically uneven, with limited data from some states, rural populations, displaced communities, and insecure areas. Fifth, comparisons with other fragile settings should be interpreted cautiously because countries differ in governance, conflict intensity, surveillance architecture, population structure, and health-system financing. Finally, some recent evidence remains preliminary or subject to ongoing implementation changes. These limitations mean that the findings are best interpreted as a critical synthesis of available evidence rather than a definitive quantitative assessment of national surveillance performance.

5 Conclusion

Somalia has moved beyond the absence of a national surveillance architecture, but it has not yet achieved a surveillance system in which detection consistently leads to verification, investigation, response, and prevention. The evidence reviewed indicates that facility-based reporting and institutional structures have improved, while the critical downstream functions of laboratory confirmation, event verification, community detection, data use, and rapid response remain less mature. This uneven development explains why improved reporting can coexist with recurrent outbreaks.

For decision-makers, the priority should therefore not be to digitize the entire surveillance system before strengthening its foundations. The immediate objective should be to ensure that every important signal can be verified, investigated, and linked to an appropriate response. This requires sustained financing, trained and retained surveillance personnel, functional laboratory referral networks, community-based surveillance, and clearer coordination across national and subnational authorities. Once these foundations are reliable, digital tools can add value by connecting epidemiological, laboratory, climatic, environmental, and One Health information in support of anticipatory action. Somalia’s next phase of health-security development should consequently be judged not only by how much data the system generates, but by how effectively that information leads to timely action and reduced outbreak risk.

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Footnotes

Edited by: Martial Ndeffo, Texas A&M University, United States

Reviewed by: Nunzio Zotti, University of Pisa, Italy

Masdalina Pane, National Research and Innovation Agency (BRIN), Indonesia