Epidemiological Profile and Clinical Outcomes of Laboratory-Confirmed Measles Cases in Somalia: Insights from the National Public Health Reference Laboratory (NPHRL)

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Measles transmission is endemic across all 18 administrative regions, coverage has stagnated at roughly 46%, far below the 95% threshold required. This retrospective study will characterize the epidemiological and clinical profiles of all laboratory-confirmed measles cases processed at the NPHRL from 2018 to 2024, with specific attention to primary outcomes, exposure variables, and vaccination status. Method This was a cross-sectional study that involved retrospective review at the National Public Health Reference Laboratory (NPHRL) in Mogadishu, all lab-confirmed measles cases in the federal member states and regions from 2018 to 2024, The data were cleaned and analyzed using SPSS version 26. Result The study included 6,859 measles cases reported across Somalian showed that the majority (45.79%) 13–23-year age group, status, an overwhelming majority (93.2%), while 29.28% tested negative and were unvaccinated the likelihood of measles infection of all other states was significantly lower than that of Benadir. For instance, Galmudug had the least odds (AOR = 0.04; 95% CI: 0.03–0.06; p < 0.001). Conclusion These findings provide critical insights into the high burden of measles in Somalia. Laboratory-confirmed cases show a concentration in Benadir, The case fatality rate of 8.8 percent and the strong association between death and measles positivity reflect severity compounded by malnutrition. Together, the results underline an urgent need for targeted and meet regional elimination goals. Measles Somalia epidemiology laboratory-confirmed cases National Public Health Reference Laboratory vaccination coverage unvaccinated populations infants case fatality rate Benadir region laboratory-supported surveillance Figures Figure 1 Introduction Measles is a highly contagious, airborne viral disease that remains one of the world’s leading causes of vaccine-preventable childhood mortality despite the availability of a safe, inexpensive vaccine( 1 – 3 ).The virus is transmitted through respiratory droplets and can remain viable in the air or on surfaces for up to two hours( 4 ). Global measles incidence climbed to an estimated 10.3 million cases in 2023-20 % highe than in 2022( 5 ). During the first quarter of 2025, the United States alone reported 800 new confirmed cases( 6 ).Within the WHO African Region, sustained transmission has been documented in 14 Member States, highlighting immunity gaps and the urgent need for catch-up vaccination and strengthened case-based surveillance( 7 ). Somalia is especially vulnerable to measles because of prolonged conflict, recurrent humanitarian crises, and limited access to healthcare( 8 ).Recurrent droughts further elevate child mortality and exacerbate long-term socio-economic setbacks( 9 ). Measles transmission is endemic across all 18 administrative regions, indicating persistent, nationwide circulation of the virus( 10 ). National first-dose measles-containing-vaccine (MCV1) coverage has stagnated at roughly 46 %, far beow the 95 % threshod required for herd protection and a major driver of recurring outbreaks ( 11 ). Robust Laboratory-supported surveillance is essential for characterizing measles epidemiology, confirming outbreaks, and guiding control strategies, particularly in pursuit of regional elimination goals( 12 ).The National Public Health Reference Laboratory (NPHRL) in Mogadishu is the country’s apex facility for measles serological diagnosis, forming the backbone of national surveillance( 13 ). Nevertheless, Somalia’s system is constrained by under-reporting, irregular specimen collection, and logistical barriers( 14 ). A comprehensive analysis of the systematically generated NPHRL dataset is therefore critical for evidence-based intervention planning. This retrospective study will characterize the epidemiological and clinical profiles of all laboratory-confirmed measles cases processed at the NPHRL from 2018 to 2024, with specific attention to primary outcomes, exposure variables, and vaccination status. Methods Study Design and Setting This was a cross-sectional study that involved retrospective review at the National Public Health Reference Laboratory (NPHRL) in Mogadishu, Somalia. The study included all lab-confirmed measles cases in the federal member states and regions from 2018 to 2024. The NPHRL is the national reference laboratory for surveillance and diagnosis of regulating epidemic diseases, such as measles. Data Sources and Study Population Data was extracted from a national surveillance database within NPHRL that includes demographic, clinical, laboratory, and epidemiological data for all suspected and confirmed measles cases. The variables in the dataset were the patient's age, sex, state of residence, whether the patient was vaccinated, travel history, and the patient's clinical outcome (recovery and death). Inclusion and Exclusion Criteria All laboratory-confirmed cases of measles during the study period with complete demographic and clinical data were included. Cases without complete information regarding diagnosis or outcome were excluded. Variables and Definitions Primary outcome : Clinical outcome (recovery or death) Exposure variables : Age group, sex, geographic region, measles vaccination status, and travel history Vaccination status was categorized as vaccinated , unvaccinated , or underage for vaccination (under 9 months) Data Analysis The data were cleaned and analyzed using SPSS version 26. Demographic and clinical characteristics were summarized using descriptive statistics (frequencies, percentage). Univariate two-degree-or-more-of-separation logistic and multivariate logistic analyses were conducted to determine the factors associated with measles infection and adverse outcomes. Crude odds ratios (COR) and adjusted odds ratios (AOR) with their 95% confidence intervals (CI) were presented. P < 0.05 was considered statistically significant. Ethical Considerations Ethical approval was granted by the Research and Ethics Committee (REF: NIH/IRB/09/JAN/2025) of the National Institutes of Health, Ministry of Health and Human Services. All patient data were anonymized and used solely for surveillance and research purposes. Results The study included 6,859 measles cases reported across Somalia from 2018 to 2024. The majority of cases were from Benadir (43.7%), followed by Southwest (13.8%) and Hirshabelle (11.7%). Age distribution showed that the majority of the participants (45.79%) fell within the 13–23-year age group, the 1–12-year age group represented 25.85% of participants, Infants aged less than 1 year accounted for 18.76%, and Adults aged above 23 years made up only 9.59% of the population. Males slightly outnumbered females (51.8% vs. 48.2%). In terms of vaccination status, an overwhelming majority (93.2%) were unvaccinated, while only 3.9% were vaccinated. A very low proportion of participants reported recent travel (0.3%). Clinical outcomes indicated that 8.8% of confirmed measles cases resulted in death, with a majority (91.2%) recovered. As shown in Table 1 . Of the total tested individuals, 70.72% were confirmed positive for measles, while 29.28% tested negative. See Fig. 1 . Infants (< 1 year) and young adults (13–23 years) had significantly higher odds of measles infection compared to those over 23 years. For infants, the adjusted odds ratio (AOR) was 1.3 (95% CI: 1.02–1.65; p = 0.033), and for those aged 13–23, AOR = 1.3 (95% CI: 1.03–1.65; p = 0.030). Children aged 1–12 years did not show a significant association. There was no statistically significant difference in measles positivity by gender. Males and females had equivalent odds of being infected (AOR not significant). Measles infection was highly correlated with vaccination status. The odds of acquiring measles among unvaccinated compared to vaccinated cases was 1.5 times (AOR = 1.5; 95% CI: 1.07–1.96; p = 0.015). Similarly, children below the age where vaccination is recommended also had increased odds (AOR = 1.9; 95% CI: 1.14–3.02; p = 0.013). History of travel within 21 days was also not significantly associated with measles infection (AOR = 1.1; 95% CI: 0.46–2.77). The likelihood of measles infection of all other states was significantly lower than that of Benadir. For instance, Galmudug had the least odds (AOR = 0.04; 95% CI: 0.03–0.06; p < 0.001) while Puntland (AOR = 0.1), Somaliland (AOR = 0.2), and Southwest (AOR = 0.2) had a lower likelihood of occurrence implying geographical variance of case distribution. Fatality was independently related to the severity of infection. The odds of dying were 3.8 times very high for measles among death cases as opposed to those who recovered (AOR = 3.8; 95% CI: 2.83–4.96; p < 0.001), demonstrating severity and death from measles among high risk peoples. See Table 2 Table 1 Baseline characteristics of the study participants Variable Freq. Percent State Benadir 2,999 43.72 Galmudug 380 5.54 Hirshabele 802 11.69 Jubaland 632 9.21 Puntland 491 7.16 Somaliland 612 8.92 Southwest 943 13.75 Age(year) 23 658 9.59 Outcome Recovered 6,218 91.17 Death 602 8.83 Measles Vaccination Status Underage 205 2.99 Unvaccinated 6,389 93.15 Vaccinated 265 3.86 Gender Female 3,307 48.21 Male 3,552 51.79 Travel History (past 21 days) Yes 22 0.32 No 6,837 99.68 Table 2 Bivariate and multivariate logistic regression Analysis of factors associated with measles Variable Measles COR (95%CI) AOR((95%CI) P-value Age(year) Negative Positive < 1 308 (23.93%) 979 (76.07%) 1.8 (1.50,2.25) 1.3(1.02,1.65) 0.033 1–12 515 (29.05%) 1,258 (70.95%) 1.41(1.17,1.71) 1.1(0.90 ,1.37) 0.333 13–23 944(30.05) 2197(69.95%) 1.3(1.04,1.50) 1.2(0.95,1.43) 0.139 > 23 241 (36.63%) 417 (63.37%) Ref. Ref Gender Female 953 (28.82%) 2,354 (71.18%) Ref. Male 1,055 (29.70%) 2,497 (70.30%) 0.96 (0.86,1.06) Vaccination status Underage 40 (19.51%) 165 (80.49%) 3.5(2.31,5.36) 1.9(1.14,3.02) 0.013 Unvaccinated 1,846 (28.89%) 4,543 (71.11%) 2.1(1.64 ,2.69) 1.5 (1.07,1.96) 0.015 Vaccinated 122 (46.04%) 143 (53.96%) Ref. ref Travel history Yes 7 (31.82%) 15 (68.18%) Ref. No 2,001 (29.27%) 4,836 (70.73%) 1.1(0.46,2.77) State Benadir 379 (12.64%) 2,620 (87.36%) Ref. Galmudug 300 (78.95%) 80 (21.05%) 0.04 (0.03,0.05) 0.04 (0.03,0.06) 0.000 Hirshabele 194 (24.19%) 608 (75.81%) 0.5(0.37,0.55) 0.5 (0.39,0.58) 0.000 Jubaland 184 (29.11%) 448 (70.89%) 0.4 (0.29,0.43) 0.4 (0.31,0.47) 0.000 Puntland 326 (66.40%) 165 (33.60%) 0.1 (0.06,0.09) 0.1(0.05,0.08) 0.000 Somaliland 241 (39.38%) 371 (60.62%) 0.2(0.18,0.27) 0.2 (0.18 ,0.27) 0.000 Southwest 384 (40.72%) 559 (59.28%) 0.2(0.18,0.25) 0.2 (0.19,0.27) 0.000 Outcome Recovered 1,923 (30.93%) 4,295 (69.07%) Ref. Ref. Death 75 (12.46%) 527 (87.54%) 3.2(2.46,4.03) 3.8(2.83,4.96) 0.000 Discussions The study provides critical insights into the epidemiological and clinical profile of 6,859 laboratory-confirmed measles cases. The findings reveal a high burden of measles in Somalia, with 70.72% of tested individuals confirmed positive. Benaadir reported the highest proportion of cases (43.7%), followed by Southwest (13.8%) and Hirshabelle (11.7%), indicating significant regional variation in disease distribution. This geographical disparity aligns with studies from other conflict-affected settings, such as South Sudan, where regional differences in measles incidence were linked to variations in healthcare access and vaccination coverage ( 15 , 16 ). However, unlike studies in Ethiopia, which reported more uniform case distribution across regions, Somalia’s concentration in Benaadir suggests urban crowding and limited healthcare infrastructure increasing transmission ( 17 , 18 ). Suggests that Somalia’s marked geographic heterogeneity is driven not only by access to care but also by large population movements into the capital during drought and insecurity. The study’s finding that 93.2% of cases were unvaccinated underscores the critical role of low measles vaccine coverage (46%) in driving outbreaks, consistent with global data from the WHO African Region, where coverage below 95% correlates with sustained measles transmission ( 19 ). In contrast, studies from high-income countries like the United States, with 800 cases in 2025, show outbreaks primarily among unvaccinated pockets within otherwise high-coverage settings, highlighting Somalia’s broader systemic vaccination gaps ( 20 ). Children aged 1–12 years formed the largest group (25.9%), followed by infants under 1 year (18.8%), with infants and young adults (13–23 years) showing significantly higher odds of infection (AOR 1.3 for both groups). This age distribution mirrors findings from Nigeria, where young children were disproportionately affected due to delayed or missed vaccinations ( 21 ), but differs from European outbreaks, where older adolescents and adults predominated due to waning immunity ( 22 ). The high infection risk among infants under 1 year, who are typically ineligible for vaccination, emphasizes the need for immunization strategies. The study found that unvaccinated individuals had 1.5 times higher odds of measles infection (AOR 1.5, p = 0.015), and infants ineligible for vaccination had 1.9 times higher odds (AOR 1.9, p = 0.013), reinforcing vaccination as a critical protective factor. This is consistent with a 2023 study in the Democratic Republic of Congo, where unvaccinated children faced significantly higher infection risks ( 23 ). The case fatality rate of 8.8% is notably high, with death cases showing 3.8 times higher odds of severe outcomes (AOR 3.8, p < 0.001). This is comparable to findings from Ethiopia, where lack of vaccination and increased contact elevated measles mortality ( 24 ), another study showed at least one significant associated with CFR for 15 indicators including level of healthcare availability and malnutrition ( 25 ). The elevated mortality in Somalia likely reflects compounding factors such as malnutrition, recurrent droughts, and conflict-related healthcare disruptions, which exacerbate disease severity. These findings highlight the urgent need for targeted vaccination campaigns, particularly in high-burden regions like Benadir, and strategies to protect infants, such as supplemental immunization for pregnant women. The high proportion of unvaccinated cases calls for strengthening routine immunization programs and addressing barriers like conflict and logistical constraints. The elevated case fatality rate underscores the importance of improving case management and addressing underlying risk factors like malnutrition. Limitations, such as potential under-reporting due to surveillance gaps, suggest the true burden may be higher, necessitating enhanced case-based surveillance as recommended by WHO. Future research should explore the role of maternal immunization and the impact of conflict on vaccination delivery to inform tailored interventions in Somalia’s fragile context. Conclusion These findings provide critical insights into the high burden of measles in Somalia. Laboratory-confirmed cases show a concentration in Benadir, and an overwhelming majority were unvaccinated, while infants under 1 year and young adults aged 13–23 years faced increased odds of infection. The case fatality rate of 8.8 percent and the strong association between death and measles positivity reflect severity compounded by malnutrition, recurrent droughts, and conflict-related healthcare disruptions. Together, the results underline an urgent need for targeted vaccination campaigns, strengthened routine immunization, improved case management, and enhanced laboratory-supported surveillance if Somalia is to meet regional elimination goals. Declarations Conflicts of Interest The authors declare no conflicts of interest regarding the publication of this paper. Ethical approval We obtained approval from the Institutional Review Board of the Ministry of Health and Human Services gave the ethical approval for the study with the approval number (REF: NIH/IRB/09/JAN/2025) Consent study is retrospective and does not involve human participants or individual-level data requiring consent. Data availability De-identified data can be obtained from the corresponding author Sources of funding This research received no specific grant from funding agencies in the public, commercial or not-for-profit sectors. Descriptions for experiments No experiments involving human or animal subjects were conducted. This study is based on a narrative review of published literature and publicly available data sources. Acknowledgments We would like to extend our sincere gratitude to our co-authors for their time, effort, and valuable contributions to this research project. Special thanks to the management and staff of the National Public Health Reference Laboratory (NPHRL) for their dedication and support throughout the study. References Minta AA, Ferrari M, Antoni S, Lambert B, Sayi TS, Hsu CH, et al. Progress Toward Measles Elimination — Worldwide, 2000–2023. MMWR Morb Mortal Wkly Rep [Internet]. 2024 Nov 14 [cited 2025 May 30];73(45):1036–42. Available from: http://www.cdc.gov/mmwr/volumes/73/wr/mm7345a 4.htm?s_cid=mm7345a4_w Camilloni B, Stracci F, Lio MC De, Mencacci A, Cenci E, Bozza S. Measles immunity in healthcare workers of an Italian hospital. 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Population-Level Risk Factors Related to Measles Case Fatality: A Conceptual Framework Based on Expert Consultation and Literature Review. Vaccines (Basel) [Internet]. 2023 Aug 1 [cited 2025 Jul 9];11(8):1389. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10458804/ Additional Declarations No competing interests reported. Supplementary Files AuthorControbution.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7338762","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":504974975,"identity":"ac8293ea-4eac-40b2-bd0d-db01e213630b","order_by":0,"name":"Saadaq Adan Hussein","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYHACA8YGBmYGBgnmA0COhAwpWtgSQFp4SNHCYwDiEdYi335448cZNdbyurN7Pr+6UWPBw8B++OgGvFacSSuW3HAs3XDbnbPbrHOOAR3Gk5Z2A68WhhwDyQdshxm33cjdZpzDBtQiwWOGV4t8/xvjnw/+HbbfdiPnmXHOPyK0MNzIMZPc2HY4EaiF+XFuGxFaDG48K7Oc2ZeevO1Gmhlzbp8EDxshv8j3J2++2fPN2nbbjeTHn3O+1cnxsx8+ht9hSIBNAkwSqxwEmD+QonoUjIJRMApGDgAAC+lNRvHG4UoAAAAASUVORK5CYII=","orcid":"","institution":"Benadir University","correspondingAuthor":true,"prefix":"","firstName":"Saadaq","middleName":"Adan","lastName":"Hussein","suffix":""},{"id":504974978,"identity":"93895190-8532-4d09-9321-1aacbac3d75a","order_by":1,"name":"Marian Muse Osman","email":"","orcid":"","institution":"Benadir University Institute of Research and Development","correspondingAuthor":false,"prefix":"","firstName":"Marian","middleName":"Muse","lastName":"Osman","suffix":""},{"id":504974979,"identity":"c3a5b51b-0c1b-4ff2-acb0-1147f0080891","order_by":2,"name":"Yahye Sheikh Abdulle Hassan","email":"","orcid":"","institution":"Jamhuriya University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Yahye","middleName":"Sheikh Abdulle","lastName":"Hassan","suffix":""},{"id":504974980,"identity":"d5df08a3-fd23-4bab-bf8c-c675d6b40ea6","order_by":3,"name":"Abdirahman Moallim Ibrahim","email":"","orcid":"","institution":"Jazeera University","correspondingAuthor":false,"prefix":"","firstName":"Abdirahman","middleName":"Moallim","lastName":"Ibrahim","suffix":""}],"badges":[],"createdAt":"2025-08-10 12:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7338762/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7338762/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89984062,"identity":"39ce7b49-1bc4-4c56-b5ee-01c5c217840d","added_by":"auto","created_at":"2025-08-27 06:35:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29833,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverall Proportion of Lab-confirmed Measles Cases, 2018-2024\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7338762/v1/a2b0eb70fc6d848dac996346.png"},{"id":94729903,"identity":"a12e8b20-84b3-43ee-8a48-7923ab0e8592","added_by":"auto","created_at":"2025-10-30 07:05:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":848117,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7338762/v1/989f5661-b49d-4c71-ba93-ccc167118a1b.pdf"},{"id":89984064,"identity":"41f38f52-521f-4146-b295-d5708c8323ff","added_by":"auto","created_at":"2025-08-27 06:35:48","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":83708,"visible":true,"origin":"","legend":"","description":"","filename":"AuthorControbution.docx","url":"https://assets-eu.researchsquare.com/files/rs-7338762/v1/109928d5a30e42d37375450b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiological Profile and Clinical Outcomes of Laboratory-Confirmed Measles Cases in Somalia: Insights from the National Public Health Reference Laboratory (NPHRL)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMeasles is a highly contagious, airborne viral disease that remains one of the world\u0026rsquo;s leading causes of vaccine-preventable childhood mortality despite the availability of a safe, inexpensive vaccine(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).The virus is transmitted through respiratory droplets and can remain viable in the air or on surfaces for up to two hours(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Global measles incidence climbed to an estimated 10.3\u0026nbsp;million cases in 2023-20 % highe than in 2022(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). During the first quarter of 2025, the United States alone reported 800 new confirmed cases(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).Within the WHO African Region, sustained transmission has been documented in 14 Member States, highlighting immunity gaps and the urgent need for catch-up vaccination and strengthened case-based surveillance(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSomalia is especially vulnerable to measles because of prolonged conflict, recurrent humanitarian crises, and limited access to healthcare(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).Recurrent droughts further elevate child mortality and exacerbate long-term socio-economic setbacks(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Measles transmission is endemic across all 18 administrative regions, indicating persistent, nationwide circulation of the virus(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). National first-dose measles-containing-vaccine (MCV1) coverage has stagnated at roughly 46 %, far beow the 95 % threshod required for herd protection and a major driver of recurring outbreaks (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRobust Laboratory-supported surveillance is essential for characterizing measles epidemiology, confirming outbreaks, and guiding control strategies, particularly in pursuit of regional elimination goals(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).The National Public Health Reference Laboratory (NPHRL) in Mogadishu is the country\u0026rsquo;s apex facility for measles serological diagnosis, forming the backbone of national surveillance(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Nevertheless, Somalia\u0026rsquo;s system is constrained by under-reporting, irregular specimen collection, and logistical barriers(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). A comprehensive analysis of the systematically generated NPHRL dataset is therefore critical for evidence-based intervention planning.\u003c/p\u003e\u003cp\u003eThis retrospective study will characterize the epidemiological and clinical profiles of all laboratory-confirmed measles cases processed at the NPHRL from 2018 to 2024, with specific attention to primary outcomes, exposure variables, and vaccination status.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis was a cross-sectional study that involved retrospective review at the National Public Health Reference Laboratory (NPHRL) in\u0026ensp;Mogadishu, Somalia. The study included all lab-confirmed measles cases in the federal member states and regions from\u0026ensp;2018 to 2024. The\u0026ensp;NPHRL is the national reference laboratory for surveillance and diagnosis of regulating epidemic diseases, such as measles.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Sources and Study Population\u003c/h3\u003e\n\u003cp\u003eData was\u0026ensp;extracted from a national surveillance database within NPHRL that includes demographic, clinical, laboratory, and epidemiological data for all suspected and confirmed measles cases. The variables in the dataset were the patient's age, sex, state of residence, whether the patient\u0026ensp;was vaccinated, travel history, and the patient's clinical outcome (recovery and death).\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eAll laboratory-confirmed cases of measles during the study period with\u0026ensp;complete demographic and clinical data were included. Cases without complete information\u0026ensp;regarding diagnosis or outcome were excluded.\u003c/p\u003e\n\u003ch3\u003eVariables and Definitions\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePrimary outcome\u003c/b\u003e: Clinical outcome (recovery or death)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eExposure variables\u003c/b\u003e: Age group, sex, geographic region, measles vaccination status, and travel history\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eVaccination status\u003c/b\u003e was categorized as \u003cem\u003evaccinated\u003c/em\u003e, \u003cem\u003eunvaccinated\u003c/em\u003e, or \u003cem\u003eunderage for vaccination\u003c/em\u003e (under 9 months)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe data were cleaned\u0026ensp;and analyzed using SPSS version 26. Demographic and clinical characteristics were summarized using\u0026ensp;descriptive statistics (frequencies, percentage). Univariate two-degree-or-more-of-separation logistic\u0026ensp;and multivariate logistic analyses were conducted to determine the factors associated with measles infection and adverse outcomes. Crude odds ratios (COR) and adjusted odds ratios (AOR) with their 95% confidence intervals (CI) were presented. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003eEthical approval was granted by the Research and Ethics Committee (REF: NIH/IRB/09/JAN/2025) of the National Institutes of Health, Ministry of Health and Human Services. All patient data were anonymized and used solely for surveillance and research purposes.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 6,859 measles cases reported across Somalia from 2018 to 2024. The majority of cases were from Benadir (43.7%), followed by Southwest (13.8%) and Hirshabelle (11.7%). Age distribution showed that the majority of the participants (45.79%) fell within the 13\u0026ndash;23-year age group, the 1\u0026ndash;12-year age group represented 25.85% of participants, Infants aged less than 1 year accounted for 18.76%, and Adults aged above 23 years made up only 9.59% of the population. Males slightly outnumbered females (51.8% vs. 48.2%). In terms of vaccination status, an overwhelming majority (93.2%) were unvaccinated, while only 3.9% were vaccinated. A very low proportion of participants reported recent travel (0.3%). Clinical outcomes indicated that 8.8% of confirmed measles cases resulted in death, with a majority (91.2%) recovered. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the total tested individuals, 70.72% were confirmed positive for measles, while 29.28% tested negative. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eInfants (\u0026lt;\u0026thinsp;1 year) and young adults (13\u0026ndash;23 years) had significantly higher odds of measles infection compared to those over 23 years. For infants, the adjusted odds ratio (AOR) was 1.3 (95% CI: 1.02\u0026ndash;1.65; p\u0026thinsp;=\u0026thinsp;0.033), and for those aged 13\u0026ndash;23, AOR\u0026thinsp;=\u0026thinsp;1.3 (95% CI: 1.03\u0026ndash;1.65; p\u0026thinsp;=\u0026thinsp;0.030). Children aged 1\u0026ndash;12 years did not show a significant association. There was no statistically significant difference in\u0026ensp;measles positivity by gender. Males\u0026ensp;and females had equivalent odds of being infected (AOR not significant). Measles infection was highly correlated with\u0026ensp;vaccination status. The odds of acquiring measles among unvaccinated compared to vaccinated cases was 1.5 times (AOR\u0026thinsp;=\u0026thinsp;1.5; 95% CI:\u0026ensp;1.07\u0026ndash;1.96; p\u0026thinsp;=\u0026thinsp;0.015). Similarly, children below the age where vaccination is recommended also had increased odds (AOR\u0026thinsp;=\u0026thinsp;1.9; 95%\u0026ensp;CI: 1.14\u0026ndash;3.02; p\u0026thinsp;=\u0026thinsp;0.013). History of\u0026ensp;travel within 21 days was also not significantly associated with measles infection (AOR\u0026thinsp;=\u0026thinsp;1.1; 95% CI: 0.46\u0026ndash;2.77).\u003c/p\u003e\u003cp\u003eThe likelihood of measles infection of all other states was significantly lower than that of\u0026ensp;Benadir. For instance, Galmudug had the least odds (AOR\u0026thinsp;=\u0026thinsp;0.04; 95% CI: 0.03\u0026ndash;0.06; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u0026ensp;while Puntland (AOR\u0026thinsp;=\u0026thinsp;0.1), Somaliland (AOR\u0026thinsp;=\u0026thinsp;0.2), and Southwest (AOR\u0026thinsp;=\u0026thinsp;0.2) had a lower likelihood of occurrence implying geographical variance of case distribution. Fatality was independently related to the severity of\u0026ensp;infection. The odds of dying were 3.8 times very high for measles among death cases as opposed to those who recovered (AOR\u0026thinsp;=\u0026thinsp;3.8; 95%\u0026ensp;CI: 2.83\u0026ndash;4.96; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), demonstrating severity and death from measles among high risk peoples. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of the study participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFreq.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eState\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenadir\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2,999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e380\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e802\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e632\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e491\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSomaliland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e612\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e943\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge(year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1,287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1,773\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e658\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6,218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e602\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMeasles Vaccination Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnvaccinated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6,389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaccinated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,307\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTravel History (past 21 days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6,837\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e99.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBivariate and multivariate logistic regression Analysis of factors associated with measles\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMeasles\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCOR (95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAOR((95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e308 (23.93%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e979 (76.07%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8 (1.50,2.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.3(1.02,1.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e515 (29.05%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,258 (70.95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.41(1.17,1.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.1(0.90 ,1.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.333\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e944(30.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2197(69.95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3(1.04,1.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.2(0.95,1.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.139\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e241 (36.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e417 (63.37%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e953 (28.82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,354 (71.18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,055 (29.70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,497 (70.30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.96 (0.86,1.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVaccination status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40 (19.51%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e165 (80.49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.5(2.31,5.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9(1.14,3.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnvaccinated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,846 (28.89%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,543 (71.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1(1.64 ,2.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.5 (1.07,1.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaccinated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e122 (46.04%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e143 (53.96%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTravel history\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (31.82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15 (68.18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,001 (29.27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,836 (70.73%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1(0.46,2.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eState\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBenadir\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e379 (12.64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,620 (87.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e300 (78.95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80 (21.05%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.04 (0.03,0.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.04 (0.03,0.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e194 (24.19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e608 (75.81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5(0.37,0.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.39,0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e184 (29.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e448 (70.89%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4 (0.29,0.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.4 (0.31,0.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e326 (66.40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e165 (33.60%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1 (0.06,0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.1(0.05,0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSomaliland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e241 (39.38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e371 (60.62%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2(0.18,0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.2 (0.18 ,0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e384 (40.72%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e559 (59.28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2(0.18,0.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.2 (0.19,0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,923 (30.93%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,295 (69.07%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75 (12.46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e527 (87.54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2(2.46,4.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.8(2.83,4.96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThe study provides critical insights into the epidemiological and clinical profile of 6,859 laboratory-confirmed measles cases. The findings reveal a high burden of measles in Somalia, with 70.72% of tested individuals confirmed positive. Benaadir reported the highest proportion of cases (43.7%), followed by Southwest (13.8%) and Hirshabelle (11.7%), indicating significant regional variation in disease distribution. This geographical disparity aligns with studies from other conflict-affected settings, such as South Sudan, where regional differences in measles incidence were linked to variations in healthcare access and vaccination coverage (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, unlike studies in Ethiopia, which reported more uniform case distribution across regions, Somalia\u0026rsquo;s concentration in Benaadir suggests urban crowding and limited healthcare infrastructure increasing transmission (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Suggests that Somalia\u0026rsquo;s marked geographic heterogeneity is driven not only by access to care but also by large population movements into the capital during drought and insecurity.\u003c/p\u003e\u003cp\u003eThe study\u0026rsquo;s finding that 93.2% of cases were unvaccinated underscores the critical role of low measles vaccine coverage (46%) in driving outbreaks, consistent with global data from the WHO African Region, where coverage below 95% correlates with sustained measles transmission (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In contrast, studies from high-income countries like the United States, with 800 cases in 2025, show outbreaks primarily among unvaccinated pockets within otherwise high-coverage settings, highlighting Somalia\u0026rsquo;s broader systemic vaccination gaps (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eChildren aged 1\u0026ndash;12 years formed the largest group (25.9%), followed by infants under 1 year (18.8%), with infants and young adults (13\u0026ndash;23 years) showing significantly higher odds of infection (AOR 1.3 for both groups). This age distribution mirrors findings from Nigeria, where young children were disproportionately affected due to delayed or missed vaccinations (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), but differs from European outbreaks, where older adolescents and adults predominated due to waning immunity (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The high infection risk among infants under 1 year, who are typically ineligible for vaccination, emphasizes the need for immunization strategies.\u003c/p\u003e\u003cp\u003eThe study found that unvaccinated individuals had 1.5 times higher odds of measles infection (AOR 1.5, p\u0026thinsp;=\u0026thinsp;0.015), and infants ineligible for vaccination had 1.9 times higher odds (AOR 1.9, p\u0026thinsp;=\u0026thinsp;0.013), reinforcing vaccination as a critical protective factor. This is consistent with a 2023 study in the Democratic Republic of Congo, where unvaccinated children faced significantly higher infection risks (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe case fatality rate of 8.8% is notably high, with death cases showing 3.8 times higher odds of severe outcomes (AOR 3.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This is comparable to findings from Ethiopia, where lack of vaccination and increased contact elevated measles mortality (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), another study showed at least one significant associated with CFR for 15 indicators including level of healthcare availability and malnutrition (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The elevated mortality in Somalia likely reflects compounding factors such as malnutrition, recurrent droughts, and conflict-related healthcare disruptions, which exacerbate disease severity.\u003c/p\u003e\u003cp\u003eThese findings highlight the urgent need for targeted vaccination campaigns, particularly in high-burden regions like Benadir, and strategies to protect infants, such as supplemental immunization for pregnant women. The high proportion of unvaccinated cases calls for strengthening routine immunization programs and addressing barriers like conflict and logistical constraints. The elevated case fatality rate underscores the importance of improving case management and addressing underlying risk factors like malnutrition. Limitations, such as potential under-reporting due to surveillance gaps, suggest the true burden may be higher, necessitating enhanced case-based surveillance as recommended by WHO. Future research should explore the role of maternal immunization and the impact of conflict on vaccination delivery to inform tailored interventions in Somalia\u0026rsquo;s fragile context.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThese findings provide critical insights into the high burden of measles in Somalia. Laboratory-confirmed cases show a concentration in Benadir, and an overwhelming majority were unvaccinated, while infants under 1 year and young adults aged 13\u0026ndash;23 years faced increased odds of infection. The case fatality rate of 8.8 percent and the strong association between death and measles positivity reflect severity compounded by malnutrition, recurrent droughts, and conflict-related healthcare disruptions. Together, the results underline an urgent need for targeted vaccination campaigns, strengthened routine immunization, improved case management, and enhanced laboratory-supported surveillance if Somalia is to meet regional elimination goals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest regarding the publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained approval from the Institutional Review Board of the Ministry of Health and Human Services gave the ethical approval for the study with the approval number (REF: NIH/IRB/09/JAN/2025)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003estudy is retrospective and does not involve human participants or individual-level data requiring consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDe-identified data can be obtained from the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from funding agencies in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptions for experiments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo experiments involving human or animal subjects were conducted. This study is based on a narrative review of published literature and publicly available data sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to extend our sincere gratitude to our co-authors for their time, effort, and valuable contributions to this research project. Special thanks to the management and staff of the National Public Health Reference Laboratory (NPHRL) for their dedication and support throughout the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinta AA, Ferrari M, Antoni S, Lambert B, Sayi TS, Hsu CH, et al. Progress Toward Measles Elimination \u0026mdash; Worldwide, 2000\u0026ndash;2023. MMWR Morb Mortal Wkly Rep [Internet]. 2024 Nov 14 [cited 2025 May 30];73(45):1036\u0026ndash;42. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.cdc.gov/mmwr/volumes/73/wr/mm7345a\u003c/span\u003e\u003cspan address=\"http://www.cdc.gov/mmwr/volumes/73/wr/mm7345a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e4.htm?s_cid=mm7345a4_w\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCamilloni B, Stracci F, Lio MC De, Mencacci A, Cenci E, Bozza S. Measles immunity in healthcare workers of an Italian hospital. J Infect Public Health [Internet]. 2020 Aug 1 [cited 2025 May 30];13(8):1123\u0026ndash;5. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S1876034120304366\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S1876034120304366\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeasles \u0026ndash; Region of the Americas [Internet]. [cited 2025 May 30]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC10458804/\u003c/span\u003e\u003cspan address=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC10458804/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Measles, Somalia, epidemiology, laboratory-confirmed cases, National Public Health Reference Laboratory, vaccination coverage, unvaccinated populations, infants, case fatality rate, Benadir region, laboratory-supported surveillance","lastPublishedDoi":"10.21203/rs.3.rs-7338762/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7338762/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eMeasles is a highly contagious, airborne viral disease that remains one of the world\u0026rsquo;s to an estimated 10.3\u0026nbsp;million cases first quarter of 2025, the United States alone reported 800 new confirmed cases. Measles transmission is endemic across all 18 administrative regions, coverage has stagnated at roughly 46%, far below the 95% threshold required. This retrospective study will characterize the epidemiological and clinical profiles of all laboratory-confirmed measles cases processed at the NPHRL from 2018 to 2024, with specific attention to primary outcomes, exposure variables, and vaccination status.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eThis was a cross-sectional study that involved retrospective review at the National Public Health Reference Laboratory (NPHRL) in\u0026ensp;Mogadishu, all lab-confirmed measles cases in the federal member states and regions from\u0026ensp;2018 to 2024, The data were cleaned\u0026ensp;and analyzed using SPSS version 26.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eThe study included 6,859 measles cases reported across Somalian showed that the majority (45.79%) 13\u0026ndash;23-year age group, status, an overwhelming majority (93.2%), while 29.28% tested negative and were unvaccinated the likelihood of measles infection of all other states was significantly lower than that of\u0026ensp;Benadir. For instance, Galmudug had the least odds (AOR\u0026thinsp;=\u0026thinsp;0.04; 95% CI: 0.03\u0026ndash;0.06; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThese findings provide critical insights into the high burden of measles in Somalia. Laboratory-confirmed cases show a concentration in Benadir, The case fatality rate of 8.8 percent and the strong association between death and measles positivity reflect severity compounded by malnutrition. Together, the results underline an urgent need for targeted and meet regional elimination goals.\u003c/p\u003e","manuscriptTitle":"Epidemiological Profile and Clinical Outcomes of Laboratory-Confirmed Measles Cases in Somalia: Insights from the National Public Health Reference Laboratory (NPHRL)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:35:44","doi":"10.21203/rs.3.rs-7338762/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6dea6932-e75c-4983-aab3-b1a686b43ef0","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-30T00:23:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:35:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7338762","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7338762","identity":"rs-7338762","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}