WASH Infrastructure and Cholera Incidence in Somalia

Abstract

Access to safe water and sanitation (WASH) represents the primary defense against cholera. Despite the persistent prevalence of cholera in Somalia, there is a dearth of evidence on the impact of WASH in Somalia. This study employed a mixed-methods approach, including a survey of 134 households across ten cholera-affected districts, regression analysis of WASH influence over a 24-month period, a census of WASH services in health facilities, and interviews with 17 key informants. The regression analysis satisfied all required assumptions. To reduce variable overlap, we combined access to water and sanitation into a single WASH variable. This composite WASH variable demonstrated a strong association with cholera severity (B = −0.730, SE = 0.087, β = −0.418, t (130) = −8.35, p = .001). Individuals with access to WASH were significantly less likely to contract cholera or acute watery diarrhea (OR = 0.13, 95% CI [0.05, 0.36], p = .001). The model accounted for 67.8% of the variance in severity across Somalia (R² = 0.678, F (3,130) = 91.16, p = .001). Only 36.2% of health facilities had running water, and 41.4% had adequate sanitation. The primary causes of inadequate WASH services included malfunctioning water points, open defecation in densely populated areas, and water contamination during rainfall. Improving WASH should be a top priority, along with ongoing efforts in vaccination and health care. More investment is also needed in WASH systems that can withstand flooding in the Juba and Shabelle river basins to help reduce cholera cases by 2030.