Hospital acquired infections in Mogadishu: A review of infection prevention and control practices, and implications for antimicrobial resistance

Abstract

Healthcare associated infections (HAIs) remain a major but under documented threat to patient safety in low resource and conflict affected settings. Somalia’s prolonged health system fragility increases vulnerability to HAIs and the concurrent escalation of antimicrobial resistance (AMR). This minireview synthesises available evidence on infection prevention and control (IPC) practices in Mogadishu hospitals and examines implications for AMR. A narrative review was undertaken using empirical studies and grey literature from Mogadishu hospitals (including Benadir, Macaani and De Martino), complemented by international guidance and surveillance reports. Sources describing IPC practices, compliance indicators, HAI patterns, or AMR related outcomes were included and synthesised thematically. Globally, HAI prevalence is reported at approximately 7% in high income settings and 10%-15% in low and middle-income settings. In Mogadishu, formal HAI surveillance remains limited; available studies indicate low IPC compliance, including hand hygiene after wound care (46%) and routine glove use (23%) in a tertiary facility. During the coronavirus disease 2019 period, satisfactory IPC compliance was reported in 58.3% of healthcare workers at De Martino Hospital, with poorer adherence among ancillary staff. Basic water, sanitation, and hygiene and IPC supplies (including water, soap, alcohol-based hand rubs and appropriate waste segregation materials) were inconsistently available across facilities. These gaps coincide with a high national AMR burden; a global burden analysis estimated 8400 deaths attributable to bacterial AMR in Somalia in 2019. HAIs in Mogadishu hospitals constitute a substantial yet largely preventable public health problem. Strengthening IPC governance, supplies, training and surveillance is essential to reduce HAIs and mitigate AMR.

Key Words: Somalia; Healthcare associated infections; Infection prevention and control; Antimicrobial resistance; Patient safety; Fragile health systems; Health systems strengthening; Health equity; Climate change adaptation; Fragile and conflict-affected states

Core Tip: This minireview demonstrates that hospital-acquired infections are a substantial, yet largely unmeasured, threat in Mogadishu’s resource-constrained hospitals, where hand hygiene, waste segregation, isolation capacity, and staff training remain critically weak. By explicitly linking these infection prevention and control (IPC) gaps to escalating antimicrobial resistance and high preventable mortality, the paper argues for urgent national IPC standards, hospital-level IPC committees, routine surveillance, and integrated antimicrobial stewardship as cost-effective levers to protect patients, staff, and the wider community.

INTRODUCTION

Healthcare associated infections (HAIs) constitute a profound and persistent threat to patient safety in healthcare systems globally, with their impact felt most acutely in environments characterized by limited resources and institutional fragility. These infections are responsible for a substantial proportion of preventable morbidity and mortality, contribute to prolonged hospital admissions, escalate healthcare expenditures, and intensify the challenge posed by antimicrobial resistance (AMR). In settings where infection prevention and control (IPC) mechanisms are underdeveloped or inconsistently implemented[1,2], the intra-facility transmission of pathogens becomes a significant - though often under-recognized - driver of poor clinical outcomes[3-6].

Somalia provides a compelling case study of these issues, as the country’s healthcare system has been shaped by decades of conflict, persistent institutional weaknesses, chronic workforce shortages, and infrastructural inadequacies. These systemic challenges have severely hampered the establishment and sustainability of effective IPC programmes. In Mogadishu, where both referral and district hospitals operate under continual resource constraints, the risk of HAIs is particularly pronounced. Despite the gravity of the situation, the available evidence remains fragmented, with relevant data dispersed across individual facility evaluations, academic dissertations, grey literature, and policy documents. There is a notable lack of comprehensive, integrated analyses that specifically examine HAIs and IPC practices within Somalia’s health system. Local evidence from Mogadishu hospitals and broader HAI overviews further indicate that these structural vulnerabilities translate into tangible gaps in infection prevention, staff preparedness, and patient safety[7-11].

The urgency of addressing HAIs is heightened by the escalating threat of AMR. Deficiencies in core IPC practices - such as insufficient hand hygiene, inadequate sterilisation and disinfection protocols, suboptimal environmental cleaning, poor waste management, and inconsistent use of personal protective equipment (PPE) - create conditions that facilitate the transmission of healthcare-associated pathogens[12-15]. In Somalia, these risks are compounded by limited access to laboratory diagnostics and weak antimicrobial stewardship frameworks[12]. International and regional guidance further underscores that weak IPC systems amplify preventable harm and undermine health system performance[16-18].

This minireview undertakes a systematic synthesis of the available evidence regarding HAIs, IPC practices, and their relationship with AMR in Mogadishu, Somalia[19-21]. It draws on local and regional literature on healthcare-associated infection and infection control in Africa and comparable low-resource settings[22-24]. By rigorously consolidating the current literature and contextual information, the review aims to clarify the scale, scope, and specific characteristics of the problem. It seeks to identify critical gaps in both practice and systemic capacity, and to articulate strategic priorities for enhancing infection prevention, improving hospital quality, and safeguarding patient safety in a context marked by health system fragility[25-27]. Through this evidence-based approach, the review aspires to inform future research directions, policy initiatives, and clinical interventions that will contribute to building a more resilient and responsive healthcare system in Somalia[28-30].

In summary, the complex interplay between HAIs, IPC deficiencies, and AMR in Somalia underscores the urgent need for coordinated action. Strengthening IPC infrastructure, expanding laboratory diagnostic capacity, promoting antimicrobial stewardship, and fostering a culture of safety within healthcare facilities are essential steps toward mitigating these risks. By addressing these challenges holistically, stakeholders can help ensure better health outcomes and greater system resilience in Somalia’s hospitals and clinics.

Objectives and scope of the minireview

In response to these urgent challenges, this minireview synthesises existing evidence on HAIs, IPC practices, and their implications for AMR in Mogadishu, Somalia. The primary objective is to consolidate and critically appraise the currently available literature and contextual data, thereby clarifying the magnitude and nature of the problem. The review seeks to identify major gaps in practice and systemic capacity, and to highlight strategic priorities for strengthening infection prevention, hospital quality, and patient safety in a fragile health system context. Through this evidence-based approach, the review aims to inform future research, policy development, and clinical practice, contributing to enhanced resilience against HAIs and AMR in Somalia.

REVIEW DESIGN

This manuscript is a narrative review synthesising evidence on HAIs, IPC practices, and AMR in Mogadishu, Somalia. A narrative approach was chosen because the available local evidence base is heterogeneous and includes grey literature, small facility assessments and academic theses.

Information sources and search strategy

Evidence was identified from PubMed, Google Scholar and institutional repositories, supplemented by World Health Organization (WHO)/Centers for Disease Control and Prevention (CDC) guidance and Somali health system documents. Searches combined terms related to HAIs (e.g., “hospital acquired infection”, “healthcare associated infection”), IPC (e.g., “hand hygiene”, “PPE”, “sterilisation”, “waste management”), and Somalia/Mogadishu. Reference lists of relevant sources were screened to identify additional materials.

Eligibility criteria

Sources were eligible if they: (1) Reported IPC practices or compliance indicators, HAI patterns, or AMR related outcomes; and (2) Were conducted in Mogadishu hospitals or in comparable low resource settings where findings were used for contextual benchmarking. Peer reviewed articles, academic theses, and relevant institutional reports published in English were included.

Study selection and synthesis

The characteristics of the included studies are summarized in Table 1. Across database and grey literature searches, 28 records were identified. After screening titles/abstracts and assessing full texts for relevance, 14 key sources were included in the synthesis (Figure 1). Data were extracted on study setting, design, population, IPC indicators and key results. Because of methodological heterogeneity, meta analysis was not feasible; findings were synthesised thematically and compared with international benchmarks.

Figure 1 Literature identification and selection process. The figure illustrates the narrative review selection process, including identification (n = 28 records), screening (n = 18), eligibility assessment (n = 14), and final inclusion. IPC: Infection prevention and control; HAI: Healthcare-associated infection; AMR: Antimicrobial resistance; HCW: Healthcare worker; PPE: Personal protective equipment; COVID-19: Coronavirus disease 2019; HIC: High-income country; LMIC: Low- and middle-income country.

Table 1 Summary of included studies.

Data sources	Hospital	Design	Sample	Key findings	Ref.
Macaani Hospital (2022)	Macaani	KAP survey	Nurses (n approximately 120)	80% lacked HAI awareness	[8]
Benadir Hospital (2017)	Benadir	Observational	HCWs	Hand hygiene < 50%	[9]
Benadir and Osman Fiqi (2022)	Mixed	KAP survey	HCWs	82.9% unaware of HAIs	[10]
De Martino Hospital (2024)	De Martino	Cross-sectional	HCWs	IPC compliance 58.3%	[7]
WHO Somalia (2020)	National	Report	-	HCW COVID-19 infection high	[19]
GBD-AMR (2019)	National	Modelling	-	8400 AMR deaths	[26]

KAP: Knowledge, attitude, practice; HAI: Healthcare-associated infection; HCW: Healthcare worker; IPC: Infection prevention and control; COVID-19: Coronavirus disease 2019; WHO: World Health Organization; GBD: Global burden of disease; AMR: Antimicrobial resistance.

PREVALENCE AND BURDEN OF HAIS IN MOGADISHU HOSPITALS

From a global standpoint, HAIs represent a substantial challenge, particularly within resource limited healthcare systems. Empirical evidence indicates that patients admitted to hospitals in low and middle-income countries are approximately twice as likely to acquire an HAI compared to their counterparts in high income settings[31-34].

Applying the WHO’s global prevalence estimate 15 HAIs per 100 patients in acute care within low and middle-income countries to a typical Mogadishu hospital ward of 40 patients suggests that as many as six patients may be affected by an HAI at any given time. Despite the absence of formal surveillance mechanisms in Somalia, regional data and localised hospital observations strongly suggest a high rate of HAIs in principal Mogadishu hospitals.

In lieu of official statistics, insights from healthcare worker perceptions and limited scale surveys serve as indirect indicators. For example, at Macaani Hospital, a district level facility in Mogadishu, over 80% of nursing staff surveyed reported being unaware of ongoing HAIs in their institution, indicating a probable under recognition or under reporting of such infections.

Among respondents who acknowledged awareness, respiratory tract infections were most frequently cited (22.9%), followed by urinary tract infections (18.6%) and surgical site infections (17.1%). Bloodstream and gastrointestinal infections were also mentioned, albeit less commonly. These findings are consistent with broader epidemiological trends in which pneumonias, urinary tract infections, and surgical site infections predominate among HAIs.

A 2022 investigation encompassing Benadir Hospital the largest tertiary referral centre in Mogadishu and Osman Fiqi Hospital similarly highlighted the frequent occurrence of respiratory and surgical site infections, in addition to gastrointestinal and bloodstream infections. Strikingly, in this study, 82.9% of healthcare workers reported no awareness of HAIs within their facility, underscoring a critical absence of infection surveillance and feedback mechanisms. Nevertheless, approximately 17% of staff did confirm the presence of HAIs, affirming their regular occurrence.

Direct point prevalence studies whereby all inpatients are assessed for HAIs on a single day have not been published for Mogadishu. However, extrapolation from comparable environments offers useful context: A 2015 Ethiopian hospital survey reported an HAI prevalence of roughly 14%, while a Kenyan district hospital and a Tanzanian referral hospital reported 6.0% and 14.8% respectively in similar timeframes.

Given Somalia’s protracted conflict and severe resource constraints, it is plausible that HAI prevalence in major Mogadishu hospitals resides at the upper end of this spectrum (an estimated 10 20%). A dissertation focused on Macaani Hospital further posited that Somalia’s incidence of nosocomial infections exceeds that of developed countries, though the precise magnitude remains undetermined due to limited data. Nonetheless, the prevailing consensus is that the HAI burden is substantial and likely surpasses that observed in better resourced contexts.

Certain high risk hospital departments in Mogadishu warrant particular attention. Surgical wards commonly report post operative wound infections, attributed by surgeons to delayed patient presentations, the predominance of emergency procedures, and insufficient access to sterile supplies. Maternity units may experience elevated rates of puerperal sepsis and neonatal infections, especially given the scarcity of sterile delivery kits and neonatal intensive care resources. Intensive care units (ICUs) such as the minimally resourced ICU at Benadir Hospital are susceptible to classic device associated infections, including ventilator associated pneumonia, catheter associated urinary tract infections, and central line associated bloodstream infections.

Data from the International Nosocomial Infection Control Consortium indicate that device related HAI rates in developing countries are several times higher than reference rates in the United States. For instance, some developing country ICUs have reported ventilator associated pneumonia rates of 22.9 per 1000 ventilator days, compared to approximately 3-4 per 1000 in the United States. While specific ICU infection rates for Mogadishu are lacking, the reported practice of ventilator circuit reuse, absence of closed suctioning systems, and minimal respiratory therapy support suggest that device related HAIs may be particularly prevalent.

With respect to aetiology, there is limited laboratory surveillance cataloguing HAI pathogens in Mogadishu. However, small culture series and findings from regional laboratories indicate that the predominant pathogens are likely similar to those identified elsewhere: Gram negative bacteria such as Klebsiella pneumoniae, Escherichia coli, Pseudomonas species, and Acinetobacter (implicated in pneumonias, urinary tract, and wound infections); and Gram positive organisms, notably Staphylococcus aureus (including methicillin resistant strains, Methicillin resistant Staphylococcus aureus), in wound and device associated infections[35,36].

Literature reviewed in the Macaani Hospital attitude, and practice (KAP) study identified Klebsiella species and Staphylococcus aureus as the most frequently isolated HAI pathogens in teaching hospitals Staphylococcus aureus is a well recognised cause of post surgical and intravenous catheter related infections, while Klebsiella and Escherichia coli are major contributors to neonatal sepsis, urinary tract infections, and ventilator associated pneumonias.

The lack of consistent hand hygiene and environmental cleaning facilitates the transmission of these organisms among patients and staff. Additionally, a significant proportion of these isolates in developing countries display resistance to first line antibiotics a topic further explored in the context of AMR. Fungal HAIs (e.g., Candida bloodstream infections) may also occur, particularly in ICUs, though specific data are lacking.

Regarding outcomes, precise figures for HAI attributable mortality in Mogadishu hospitals are unavailable. However, extrapolating from international data: If 10%-15% of inpatients acquire an HAI and approximately 10% of these patients succumb to the infection, nosocomial infection mortality could approach 1%-2% of total hospital admissions. In a high-volume institution such as Benadir Hospital, which admits several thousand patients annually, this could translate into dozens of potentially preventable deaths each year.

For those who survive, HAIs frequently result in prolonged hospitalisation commonly extending stays by 5-14 days for infections such as surgical site or bloodstream infections. Historical data from Latin America indicate that a 10% hospital wide infection rate was associated with an average additional 10 days of hospitalisation per affected patient and a tripling of hospital care costs. In Somalia, extended hospital stays impose further financial burdens on families who are often responsible for purchasing medications and supplies and exacerbate bed shortages in already overstretched facilities.

Beyond the direct clinical and economic impacts, the prevalence of HAIs may also undermine public confidence in the healthcare system if hospitals are perceived as sources of infection. In conclusion, although detailed epidemiological data are lacking, all available evidence points to a frequent and severe problem of HAIs in Mogadishu hospitals. The types of infections and implicated organisms are consistent with those reported in other developing nations, but the overall magnitude may be even greater due to more pronounced resource constraints. The considerable HAI burden directly contributes to increased morbidity and mortality among patients, underscoring the urgent need for targeted interventions to improve IPC in these healthcare settings.

IPC PRACTICES AND ADHERENCE IN MOGADISHU

Robust IPC measures are fundamental for mitigating HAI. Regrettably, the available evidence indicates that IPC protocols within Mogadishu’s hospitals are inadequately followed, with compliance hampered by deficiencies in both resources and expertise[37,38]. Core IPC domains - including hand hygiene, decontamination, reprocessing, and standard precautions - are well established in international guidance[39-42]. Recent African evidence also suggests that targeted IPC interventions can improve compliance even in resource-constrained settings[40].

Hand hygiene

Appropriate hand hygiene encompassing the washing of hands with soap and water or the application of alcohol-based hand rub prior to and following patient contact is universally regarded as the pre-eminent strategy for preventing HAIs. In Mogadishu, the rate of compliance with hand hygiene protocols is conspicuously low. Observational research at Benadir Hospital (2017) revealed that numerous wards lacked functional sinks and a ready supply of soap; even where these facilities existed, their use by healthcare personnel was infrequent. Notably, in two surveyed wards where sinks and soap were present, staff were seldom observed engaging in handwashing, with 37.5% of staff never washing their hands and the remainder doing so only sporadically. Alcohol based hand rubs were absent from seven out of nine surveyed wards.

Consequently, opportunities for hand hygiene were consistently neglected. When healthcare workers were queried regarding handwashing frequency post wound dressing, 46.2% admitted to rarely performing this essential practice, with only a minority reporting routine or consistent compliance. Qualitative responses from Macaani Hospital similarly revealed that overburdened nursing staff often omitted handwashing between patients, citing time constraints and intermittent access to soap or water as principal barriers.

In contrast, a study at a tertiary hospital in Kenya reported that 79% of staff claimed to wash hands between patients, though direct observation frequently contradicted these self reports. In Mogadishu, both observed behaviour and self reporting converge to indicate extremely poor hand hygiene adherence, likely below 50% of recommended instances and potentially even lower, given infrastructural deficits.

The De Martino coronavirus disease 2019 (COVID-19) IPC study quantified hand hygiene compliance at 55.4% (where compliance was defined as “always or most of the time” undertaking required hand hygiene), suggesting that outside pandemic conditions, rates may be even further diminished. The absence of systematic audits and the scarcity of alcohol-based rubs impede sustained improvement. Importantly, no Somali hospital has participated in the WHO Hand Hygiene “My 5 Moments” initiative or conducted formal hand hygiene campaigns, in contrast to international practice.

PPE and barrier precautions

The consistent application of gloves, gowns, aprons, masks, and eye protection is central to IPC, particularly for averting the transmission of blood borne and droplet pathogens. Reports from Mogadishu suggest erratic and insufficient use of PPE, predominantly due to supply constraints. At Benadir Hospital, masks, gowns, and aprons were generally absent from wards during the 2017 evaluation. Gloves were sporadically available, but their use was inconsistent, even for procedures such as phlebotomy or wound management.

The Benadir KAP survey found that only approximately 23% of healthcare workers reported always wearing gloves during patient contact, with others indicating occasional use or reserving gloves for perceived high risk situations reflecting either complacency or rationing amid limited supplies. PPE usage improved during the COVID-19 response at De Martino Hospital, with a 2022 study reporting overall PPE compliance at 55.9%; nonetheless, this implies that recommended PPE was omitted in roughly 44% of cases, even during a global health emergency.

Among non-clinical staff (e.g., cleaners, porters), PPE adherence was extremely poor, with most not routinely wearing masks or gloves despite significant exposure risks. For example, cleaners managing COVID-19 patient areas frequently lacked gloves or used only cloth masks. In routine operations, cleaners often handle medical waste or soiled linens with unprotected hands, and nurses may administer injections or initiate intravenous lines without gloves if supplies are inadequate.

A particularly hazardous practice is observed in the handling of sharp instruments: Ideally, needles should not be recapped and must be disposed of in puncture resistant containers. However, at Benadir, 55.8% of staff admitted to routinely recapping used needles manually, and 63.5% reported the absence of suitable sharps disposal containers. Such lapses in injection safety and PPE use expose staff to needlestick injuries and blood borne pathogens (e.g., hepatitis, human immunodeficiency virus), perpetuated by the lack of safety engineered devices and insufficient training. These findings demonstrate that standard precautions minimum IPC practices such as glove use, hand hygiene, and safe sharps disposal are not universally observed among Mogadishu’s healthcare personnel.

Sterilisation and disinfection of equipment

Ensuring the proper reprocessing of medical instruments and thorough disinfection of patient care environments is essential for IPC. Direct data are limited, but anecdotal accounts from Benadir and other hospitals highlight significant challenges.

Central sterile supply departments are often inadequately equipped; autoclaves, while present, are frequently non-operational due to power outages or maintenance deficits. In some instances, instruments are merely boiled or cleaned with antiseptic solutions as a provisional measure.

The 2017 Benadir assessment reported that sterilisation protocols were inconsistently applied; for example, dressing forceps and scissors were sometimes only dipped in alcohol or bleach between uses, rather than being autoclaved after each patient. Environmental cleaning was similarly insufficient: Dust and bodily fluid spills were not always addressed promptly, likely owing to understaffing and shortages of cleaning supplies. Only 30.8% of staff reported regular use of proper disinfectants (e.g., chlorine solutions) for surface cleaning, and 69.2% acknowledged never employing colour coded cleaning systems or dedicated equipment for infectious areas. These practices are problematic, as high contact surfaces can harbour pathogens responsible for cross infection.

The lack of routine disinfection permits the persistence of pathogens within the ward environment, facilitating ongoing transmission. However, some external assistance during the COVID-19 pandemic did provide hospitals with training in chlorine-based disinfection for isolation areas, which may have marginally enhanced knowledge in that context.

Biomedical waste management

Appropriate disposal of medical waste is crucial for both safety and IPC. Observations at Benadir Hospital revealed a troubling scenario: Biomedical waste was collected within the hospital without segregation, with sharps, contaminated materials, and general waste intermixed in open bins or plastic bags. Colour coded bins for infectious vs non-infectious waste were not utilised, and over 63% of staff reported the unavailability of appropriate waste containers.

Waste frequently accumulated in hospital courtyards or ward corners until removal, heightening the risk of environmental contamination and injury. A hospital administrator acknowledged the absence of an infection control policy and, by extension, a formal waste management plan. This is emblematic of broader challenges: Somalia lacks regulated medical waste facilities, leaving hospitals to contend with unsafe disposal practices such as open air dumping or burning, which endanger staff, waste handlers, scavengers, and the wider community.

The overall assessment categorised Benadir’s waste management as “very poor”, a designation likely applicable to most Mogadishu hospitals. Such conditions contribute to accidental needlestick injuries, which staff may underreport due to stigma or lack of post exposure protocols, and facilitate environmental dissemination of resilient pathogens.

Variations in compliance by staff category

A salient observation from the De Martino compliance study was the marked disparity in IPC adherence among different staff groups. Clinical staff doctors and nurses demonstrated significantly higher compliance with IPC measures than ancillary personnel. Specifically, during COVID-19 IPC practices, 72.3% of doctors and 67.3% of nurses/paramedics exhibited “good compliance”, compared to only 5.7% of non-clinical staff (e.g., cleaners, porters). The adjusted odds of good compliance were 12-fold higher in physicians and 21-fold higher in nurses relative to ancillary staff.

This disparity likely reflects differences in educational attainment, IPC training, accountability, and integration within clinical teams; ancillary staff, who are often informally employed or paid daily wages, may lack access to PPE and critical information about infection risks. Studies from neighbouring countries corroborate these findings, with non-clinical personnel in Uganda and Ghana similarly displaying low adherence to IPC protocols.

The implication is clear: IPC initiatives must encompass all hospital staff, as the safety of the healthcare environment depends on universal participation. In Somalia, ancillary staff including cleaners and security personnel are at elevated risk of infection due to limited knowledge and adherence when handling suspected patients, as was tragically observed during the COVID-19 pandemic when cleaners and ambulance drivers in Mogadishu experienced high infection rates.

Knowledge and attitudinal deficits

Underlying these behaviours is a pronounced deficit in IPC knowledge among healthcare workers. Knowledge, KAP surveys revealed that while rudimentary awareness exists, comprehensive understanding is lacking. At Macaani Hospital, nurses were questioned about HAI prevention; although some recognised the standard definition of an HAI and the importance of hand hygiene, few possessed detailed knowledge regarding antiseptic procedures or the necessity for surveillance. Notably, 80% of nurses did not recognise hospital waste as infectious, and a similar proportion were unaware of standard precautions guidelines.

The Benadir/Osman Fiqi study found that most participants lacked awareness or formal training on HAIs, with only about 17% reporting prior training or substantial knowledge of IPC a finding consistent with the Macaani study. Attitudes towards IPC were generally positive, with over 90% of healthcare workers affirming the importance of HAI prevention as part of their professional responsibility; however, many perceived that hospital leadership failed to prioritise IPC and that practical constraints impeded compliance.

Common sentiments included “we know hand washing is important, but there is often no water or soap”, and “we are willing to wear PPE, but the hospital should provide it”. This demonstrates that motivation is present but is undermined by systemic barriers. Despite positive attitudes, the translation into practice is limited by entrenched challenges and a sense of resignation, as exemplified by the remark, “in Somalia, that’s just how things are”. Selected infection prevention and control compliance indicators derived from the reviewed evidence are summarized in Table 2.

Table 2 Key infection prevention and control compliance indicators in Mogadishu hospitals.

Indicator	Compliance
Hand hygiene after wound care	Approximately 46%
Availability of soap/alcohol rub	Inconsistent
Routine glove use	Approximately 23%
Proper sharps disposal	< 40%
Waste segregation	Rare

Summary and implications

In aggregate, IPC adherence in Mogadishu’s hospitals is alarmingly deficient, particularly in hand hygiene and standard precautions. Quantitatively, satisfactory hand hygiene occurs in less than half of opportunities; use of gloves, masks, and gowns is inconsistent; needles are routinely recapped; and cleaning and disinfection protocols are inadequate. There is a conspicuous absence of hospital wide surveillance or regular audits to monitor compliance, resulting in a lack of feedback and reinforcement for staff.

The prevailing safety culture is embryonic, with many staff failing to integrate IPC into their daily routines due to insufficient training and the absence of formal policy. The ramifications of poor compliance are directly reflected in elevated HAI rates; for instance, performing hand hygiene in only 20%-30% of recommended instances substantially increases the risk of pathogen transmission.

The frequent reuse of needles and inadequately sterilised equipment heightens the risk of outbreaks, such as hepatitis B, which have been informally reported in Mogadishu’s injection clinics. Most hospitals lack a dedicated infection control team to coordinate improvements, and Benadir Hospital, as confirmed in 2017, does not have an infection control practitioner or committee. Without designated personnel, compliance monitoring, and accountability mechanisms, practices remain unchanged.

A noteworthy observation from the COVID-19 period is that targeted training interventions can modestly enhance compliance: At De Martino Hospital, healthcare workers who received training in COVID-19 IPC demonstrated significantly higher compliance scores than those without training. Younger staff and those with higher education levels also exhibited better adherence. These findings underscore the urgent necessity for systematic, facility wide training programmes to bolster IPC knowledge and practice.

In conclusion, IPC practices in Mogadishu’s hospitals are grossly inadequate, marked by low adherence to essential precautions and exacerbated by shortages in supplies and infrastructure. Compliance varies across staff categories but remains suboptimal universally. These deficiencies facilitate the frequent occurrence of HAIs, as transmission pathways are rarely interrupted by preventive measures. The evidence highlights an immediate need to enhance both the knowledge base (via comprehensive training) and the material resources (through provision of requisite supplies and facilities) for effective infection prevention in these healthcare settings.

The persistently low compliance with IPC protocols and the elevated risk of HAI in Mogadishu’s hospitals can be attributed to a complex interplay of systemic, organisational, and resource related constraints. These factors collectively create an environment in which even the most well-intentioned healthcare professionals face significant obstacles to implementing optimal IPC practices. Drawing upon available literature and local assessments, the principal barriers can be summarised as follows.

Lack of IPC policies, leadership, and organisational structure: The absence of formalised IPC programmes is a critical impediment across major public hospitals in Mogadishu. For instance, Benadir Hospital operates without an infection control committee or official IPC policy, resulting in a lack of standard operating procedures, dedicated enforcement teams, and clear guidance for staff.

International recommendations, such as the WHO’s core IPC components, advocate for structured, management supported IPC programmes in all acute care facilities; however, these are largely non-existent in the Somali context. Hospital administrators, often preoccupied with immediate clinical demands, may lack both the training and resources required to prioritise IPC.

Furthermore, until recently, no national IPC guidelines existed, with a preliminary national manual only drafted around 2019-2020 with external support and yet to be comprehensively implemented. The absence of regulatory oversight or accreditation mechanisms means hospitals are not held accountable for IPC standards, further undermining programme development and sustainability.

Deficiencies in training and IPC awareness: A recurring theme is the paucity of adequately trained personnel in IPC. Somalia lacks specialised infection control practitioners, and most healthcare workers receive only cursory IPC instruction during their initial education. According to regional data, over 90% of Somali health workers have never participated in in service IPC training. Studies consistently report that between 60% and 80% of healthcare workers have not received formal instruction in infection prevention, resulting in significant knowledge and skills deficits. Many staff are unfamiliar with basic concepts such as the WHO’s ‘5 Moments for Hand Hygiene’ or correct procedures for using alcohol-based hand rubs. The absence of an IPC focal person or ongoing educational initiatives perpetuates these gaps. Evidence from neighbouring countries underscores the importance of continuous education in sustaining compliance an approach not yet institutionalised in Somalia.

Critical resource limitations: Resource scarcity remains one of the most visible and consequential barriers to IPC. Many hospitals contend with inconsistent water supplies, with some wards relying on stored water in buckets. Essential items such as soap, disinfectants (chlorine, alcohol), gloves, and gowns are frequently in short supply due to chronic underfunding. For example, a 2017 assessment at Benadir Hospital found that several wards lacked soap entirely and that alcohol-based hand rub was absent in most areas[9]. More recent national facility assessment findings also indicate persistent gaps in water, sanitation, and hygiene and IPC readiness across Somali health facilities[43].

Such shortages render compliance with hand hygiene and PPE protocols impossible. Likewise, a lack of sharps containers and adequate waste disposal materials forces staff to improvise, sometimes discarding hazardous waste inappropriately. The limited availability of sterile instruments has resulted in the reuse of inadequately reprocessed devices. These constraints are fundamentally linked to minimal hospital budgets, in which IPC supplies are often deprioritised in favour of more immediate needs such as medications and staff salaries.

Staffing constraints and workload pressures: The severe shortage of healthcare personnel leads to excessive workloads, with nurses frequently responsible for 20-30 patients per shift. Such conditions make adherence to IPC practices, such as performing hand hygiene or changing PPE between patients, impractical. Overcrowded wards, which often exceed recommended nurse to patient ratios, further complicate infection control efforts.

Cleaning staff are similarly overextended, covering multiple wards or large areas, which undermines the thoroughness and frequency of environmental cleaning. The lack of physical space precludes effective patient isolation, with beds often added to already full wards, including corridor areas. Although recommendations have been made to address overcrowding, practical constraints make their implementation challenging.

Facility layout and structural deficiencies: Hospital infrastructure in Mogadishu is frequently outdated and ill-suited to current IPC requirements. Many facilities suffer from poor ventilation, cramped ward layouts, and a lack of dedicated isolation rooms. There are often no designated areas for donning and doffing PPE, and critical units such as operating theatres and ICUs may be compromised by unreliable utilities and inadequate physical barriers. Only an estimated 30% of Somali health facilities have access to improved water and sanitation on site, severely limiting the feasibility of basic hygiene practices. The physical design of these facilities thus undermines efforts to maintain IPC standards.

Prevailing Cultural and behavioural norms: Longstanding exposure to resource poor, crisis oriented healthcare settings has led to a normalisation of substandard practices among many Somali healthcare workers. In the absence of strong leadership and role models, there is a diminished emphasis on IPC, and lapses are often overlooked. While surveys reveal that most workers acknowledge the importance of IPC in principle, many express a sense of resignation, believing that infections are inevitable under current constraints.

Hierarchical workplace cultures may also inhibit lower ranking staff, such as cleaners, from advocating for adherence to IPC protocols or raising concerns about unsafe practices. Additionally, the involvement of family members in direct patient care often without IPC knowledge can further compromise infection control.

Deficits in surveillance and data collection: The lack of systematic surveillance for HAIs and IPC compliance presents a significant challenge. Most hospitals do not routinely monitor infection rates or track relevant microbiological data, leading to an underestimation of the problem and a lack of targeted interventions.

The absence of surveillance also means there is no mechanism for providing feedback to clinicians or for identifying and addressing outbreaks. International reports highlight that surveillance is one of the least implemented IPC components in low and middle-income countries, with Somalia specifically identified as requiring development of national IPC policies and data systems to strengthen the health sector’s response to HAIs and AMR.

Economic and political instability: Broader contextual factors, including chronic underfunding, reliance on external donors, and ongoing political instability, further impede efforts to improve IPC. Limited government investment in healthcare infrastructure and training, coupled with weak regulatory frameworks, means that critical elements such as antibiotic stewardship and hospital licensing for hygiene standards are not enforced. Although recent years have seen the establishment of focal points for IPC and AMR within the Ministry of Health, tangible improvements at the facility level remain slow to materialise.

Interplay of barriers: An illustrative scenario

To illustrate the compounded effect of these barriers: A nurse in Mogadishu seeking to implement good IPC practices faces understaffing (workload pressures), lack of water or hand sanitiser (resource shortages), insufficient training (knowledge gaps), absence of clear guidelines (policy deficiencies), and no accountability mechanisms (lack of surveillance and managerial oversight). In such circumstances, even motivated staff are likely to struggle and may become demoralised over time.

Summary of key barriers identified in Mogadishu hospitals

Financial constraints: Insufficient funding for IPC supplies, infrastructure, and training. Human resource shortages: Understaffing and excessive workloads undermine compliance with IPC practices. Policy and enforcement gaps: Absence of guidelines, dedicated IPC teams, and managerial oversight. Training deficiencies: Inadequate IPC education for the majority of healthcare workers. Cultural and behavioural norms: Acceptance of suboptimal practices and weak patient safety culture. Material shortages: Lack of essential supplies such as water, soap, disinfectants, PPE, and sterilisation equipment. Infrastructure limitations: Inadequate facility design and maintenance, especially regarding water, sanitation, and hygiene. Each of these barriers is significant in its own right; together, they constitute a formidable challenge to improving IPC standards. The evidence indicates that without comprehensive action to address these systemic issues, efforts to enhance specific practices such as hand hygiene campaigns are likely to yield limited and unsustainable improvements.

Associations Between suboptimal IPC practices and AMR. A significant and concerning consequence of inadequate IPC is the facilitation and dissemination of antimicrobial resistant organisms. This issue is particularly pronounced in healthcare facilities in Mogadishu, where interactions between HAI and AMR represent an escalating crisis. The following analysis outlines several mechanisms by which insufficient IPC measures are contributing to AMR in this context: Increased infection rates and antibiotic utilization: Elevated rates of HAIs necessitate greater use of antibiotics.

In Somali hospitals, nearly all suspected infections are managed empirically with antibiotics, often broad-spectrum agents, due to limited capacity for culture-based diagnostics. For instance, surgical site infections routinely prompt the initiation of antibiotics such as third generation cephalosporins or amoxicillin clavulanate, and severely ill patients may receive multiple antibiotics, sometimes including carbapenems or colistin administered empirically.

Such widespread antibiotic use imposes substantial selective pressure favoring resistant strains. Observational studies document that up to 90% of patients in certain Mogadishu hospital wards receive at least one antibiotic at any given time, frequently for prophylactic or empirical purposes.

This cycle perpetuates further resistance as each preventable HAI increases overall antibiotic exposure within the facility. Transmission dynamics of resistant pathogens: Ineffective IPC allows resistant organisms to propagate among patients and staff without constraint. Methicillin resistant Staphylococcus aureus, for example, can rapidly disseminate in the absence of adequate hand hygiene and contact precautions. Over time, such pathogens may become endemic within the hospital environment. Similar risks apply to resistant Gram-negative bacteria like extended-spectrum beta-lactamase (ESBL) producing Escherichia coli and Klebsiella species.

Data from neighboring regions indicate that a majority of Klebsiella isolates in ICUs are ESBL producers, attributed to cross transmission and excessive antibiotic use. Although systematic surveillance data from Somalia remain limited, anecdotal reports from local laboratories corroborate high rates of resistance, including over 70% oxacillin resistance among Staphylococcus aureus isolates and notable prevalence of ESBL positive Escherichia coli in urinary tract infections.

Without robust isolation procedures, pan resistant organisms can colonize patients and persist in the clinical environment, leading to challenging outbreaks. Additionally, movement of personnel between wards without proper PPE changes amplifies hospital wide dissemination.

Environmental reservoirs of AMR: Improper waste management, including unsegregated disposal of hospital effluent, contributes to the spread of AMR. Multi drug resistant bacteria have been detected in sewage and hospital waste globally, and it is plausible that similar patterns occur in Mogadishu, where untreated effluents likely enter public environments. This exacerbates the risk of resistant organisms and residual antibiotics contaminating the wider community, including water sources, thereby extending the reach of hospital generated resistance beyond institutional boundaries.

Healthcare worker colonization and transmission: Healthcare workers are at risk of acquiring and subsequently transmitting resistant organisms in settings with poor IPC. Documented cases during the COVID-19 pandemic highlighted healthcare worker infections as markers of inadequate IPC, and parallel trends with Methicillin resistant Staphylococcus aureus and other resistant pathogens suggest ongoing occupational exposure and secondary transmission.

Deficiencies in antimicrobial stewardship: Poor antibiotic stewardship commonly accompanies subpar IPC practices. Formal antimicrobial stewardship programmes are largely absent in Mogadishu hospitals, resulting in frequent prescribing of broad-spectrum antibiotics without supporting microbiological data. Drivers of misuse include the absence of standardized guidelines, over the counter antibiotic access, and a tendency to favor newer pharmacologic agents amid diagnostic uncertainty. Examples include inappropriate antibiotic use for viral infections and prolonged post-operative courses, further accelerating resistance development.

Impact on patient outcomes: The consequences of AMR are increasingly evident, with clinicians reporting infections unresponsive to locally available antibiotics. Somalia faces a high mortality burden attributable to resistant infections, estimated at approximately 28 deaths per 100000 annually. Delays in appropriate treatment, restricted access to advanced therapies, and increased prevalence of multidrug resistant infections contribute to adverse patient outcomes, including fatality and severe complications. The interplay between poor IPC and AMR forms a self-perpetuating cycle: Inadequate IPC → increased HAIs → escalated antibiotic use → enhanced resistance development. Increased resistance + poor IPC → broader spread of resistant HAIs → more complicated infections. Effective intervention necessitates improvement in both IPC measures and antibiotic stewardship. Current evidence suggests that Somalia faces challenges on both fronts, with IPC emerging as a particularly critical gap.

Key reference findings: The WHO 2022 report underscores the importance of strengthening IPC to combat AMR, linking effective infection control with substantial reductions in overall antibiotic consumption and resistance pressure. Commentaries on AMR in Somalia point to rampant inappropriate antibiotic use, reinforcing that new pharmaceuticals or restrictive policies alone are insufficient without concurrent advances in IPC. Research from Benadir recommends establishing and enforcing national IPC policies, coupled with staff training and waste management, as fundamental steps toward reducing microbial load and AMR spread.

Case illustration: An ICU patient who develops ventilator associated pneumonia caused by Acinetobacter baumannii exemplifies the risks: In a facility with strong IPC, this infection could be isolated and contained; in Mogadishu, however, inefficient control measures may result in rapid dissemination, selection for pan resistance, and elevated ICU mortality. Hospitals that serve as epicenters for drug resistant infections pose additional risk to communities through discharge of colonized patients and healthcare workers, blurring distinctions between hospital acquired and community acquired resistant pathogens. This minireview establishes a robust link between insufficient IPC in Mogadishu’s hospitals and the escalation of AMR in Somalia. Failures in infection prevention directly drive both the emergence and propagation of resistant organisms, worsening clinical outcomes and representing a long-term threat to public health. Addressing gaps in IPC must be central to any strategic effort to counteract AMR. Restrictive or pharmaceutical interventions alone will prove inadequate while HAIs continue to provide a reservoir for resistance.

DISCUSSION

This minireview demonstrates that hospitals in Mogadishu experience a substantial burden of HAIs driven by systemic deficiencies in IPC. Although precise prevalence estimates are unavailable, available data suggest HAI rates comparable to or exceeding those reported in other low-resource and post-conflict settings[44,45]. Reports of hospital outbreaks linked to contaminated clinical environments further illustrate how rapidly transmission can occur when IPC systems fail[46]. These findings are also consistent with broader evidence on device-associated infections and intensive care risk in resource-constrained settings[47-49]. WHO guidance indicates that HAI risk remains higher where minimum IPC requirements are not consistently implemented[50,51]. Evidence from hospital-wide improvement programmes and systematic reviews further shows that strengthening hand hygiene and structured IPC programmes can substantially reduce infection burden[52-54]. Somalia’s wider preparedness and health-system context underscores the need to integrate IPC with antimicrobial stewardship and surveillance[55,56]. This imperative is consistent with broader AMR calls for coordinated action, routine surveillance, and hospital stewardship standards[57-59].

The consistently low adherence to hand hygiene, PPE use, waste segregation, and device related precautions underscores the absence of functional IPC programmes. Similar challenges are reported in other fragile health systems across Sub-Saharan Africa; however, the magnitude in Mogadishu is exacerbated by prolonged conflict, critical workforce shortages, and infrastructural collapse.

Importantly, IPC failures directly contribute to Somalia’s exceptionally high burden of AMR. WHO and CDC (2023) highlight that effective IPC can reduce HAIs by up to 70% and significantly curb antibiotic consumption, positioning IPC as a cost-effective AMR mitigation strategy.

High burden of HAIs and its consequences

Despite the lack of formalised HAI surveillance, evidence from Mogadishu’s hospitals strongly suggests alarmingly high infection rates, likely at the upper range for low income and post conflict countries. Fragmented local data, including staff surveys and unit level observations, align with global reviews estimating average HAI prevalence in low-income settings at approximately 15%, with higher rates in ICUs. By contrast, Europe reports 7.1% and the United States 3.2% (2015).

The consequences of HAIs in Mogadishu are multifaceted. Extended hospital stays consume scarce bed capacity, delaying access for new patients. Families bear significant financial and emotional burdens due to prolonged admissions, out of pocket expenses, and preventable mortality. In this context, reducing HAIs is not only a clinical priority but also a socio-economic imperative.

IPC practices: International comparisons and opportunities

Mogadishu hospitals exhibit critically low IPC compliance. Hand hygiene rates are often below 20% in baseline observations, with some facilities reporting staff who “never” perform handwashing, far below the 21%-30% baseline reported in comparable West African hospitals and the 70%+ achieved in high income countries with targeted interventions. The temporary improvement to 55.4% at De Martino Hospital during the COVID-19 pandemic demonstrates that enhanced resources and training can drive progress.

Waste segregation and environmental cleaning practices are similarly deficient, with initial compliance often negligible. Experiences from Kenya and other low resource settings show that even basic interventions can double compliance rates. Historical evidence, such as the United States SENIC project, reinforces that active surveillance and structured IPC programmes can reduce HAIs by up to one third, underscoring the transformative potential for Somalia.

Systemic challenges to IPC implementation

Security instability, chronic underfunding, and high staff turnover impede the establishment of sustainable IPC programmes. The urgent focus on trauma and acute care frequently overshadows routine infection control practices. Behavioural adaptation is also required; for example, while alcohol-based hand rub is effective, cultural preferences for water-based handwashing may necessitate tailored approaches. Involving patients’ families and community caregivers is critical, as their engagement influences adherence and outcomes.

AMR: A growing threat

The intersection of high HAI prevalence and inadequate IPC accelerates the emergence of AMR in Somalia, which risks becoming a regional reservoir of resistant pathogens. Sub-Saharan Africa already has the highest AMR associated mortality globally, and local estimates suggest Somalia exceeds the regional average with approximately 55 deaths per 100000 population. Strengthening IPC and integrating it with antimicrobial stewardship are urgent steps to prevent avoidable infections and contain the spread of resistance.

Summary

The findings of this minireview reflect a convergence of systemic vulnerabilities: High HAI prevalence, poor IPC adherence, and escalating AMR. Leveraging evidence-based IPC strategies, as recommended by WHO and CDC (2023), offers a realistic pathway to mitigate these burdens. Even modest investments in surveillance, staff training, and basic infrastructure could yield substantial reductions in HAIs, improve patient outcomes, and enhance the resilience of Somalia’s health system.

CONCLUSION

Hospital acquired infections present a significant challenge within Mogadishu’s healthcare facilities, resulting in preventable patient morbidity, mortality, and increased healthcare expenditures. This minireview demonstrates that current IPC practices in Somali hospitals are notably insufficient, as evidenced by suboptimal hand hygiene adherence, inconsistent use of protective equipment, unsafe injection and waste management procedures, and inadequate infrastructure and policy support. These deficiencies manifest in high rates of surgical site infections, pneumonia, urinary tract infections, bloodstream infections, and other HAIs among patients in Mogadishu. Such infections not only prolong hospital stays but can also be fatal, with estimates suggesting that approximately one in ten affected individuals succumb to an HAI. Furthermore, the widespread occurrence of these infections contributes substantially to the rise of AMR, as hospitals facing uncontrolled infections and excessive antibiotic usage become reservoirs for resistant organisms. Somalia is already experiencing concerning levels of AMR, leading to thousands of deaths annually from drug resistant pathogens.

The evidence presented indicates that reinforcing IPC is imperative for Somalia’s healthcare system. Data suggests that comprehensive IPC programs can reduce HAI rates by 50%-70%, which concurrently helps limit the spread of resistant microorganisms. Enhancing IPC practices will result in saved lives, improved safety for healthcare workers, and preservation of crucial antimicrobial therapies. Additionally, strengthening IPC will boost public confidence in the health sector and underpin overall improvements in care quality.

Addressing the prevalence of HAIs in Mogadishu’s hospitals necessitates coordinated action across several domains: Establishing effective IPC policies and organizational frameworks, enhancing the skills and knowledge of healthcare professionals, ensuring dependable access to essential supplies and adequate facilities, and fostering an environment prioritizing safety and accountability. Integrating IPC initiatives with antimicrobial stewardship is essential for combating both HAIs and AMR. While resource constraints and systemic fragility pose challenges, the potential benefits are substantial every prevented infection safeguards lives, and controlling resistance protects future generations.

In summary, hospital acquired infections in Mogadishu exemplify a critical convergence of patient safety and public health concerns related to AMR, demanding prompt and sustained intervention. Hospital leadership, health authorities, and partners must implement evidence-based strategies to advance IPC. Achieving progress will require ongoing commitment, investment, and collaboration, ultimately resulting in healthier communities, safer clinical environments, and the continued effectiveness of antibiotics for Somalia’s population. Immediate action on IPC and HAI prevention is vital; postponement will exacerbate infection rates and resistance, while timely measures offer an opportunity to reverse these trends.

ACKNOWLEDGEMENTS

The authors express sincere appreciation to the Federal Ministry of Health and Human Services, Somalia for its ongoing efforts to institutionalise IPC and to integrate AMR surveillance into national reporting systems, despite operating in a fragile and resource constrained environment. We acknowledge the clinicians, nurses, infection control focal points, cleaners, and support staff of Benadir Hospital, De Martino Hospital, Macaani Hospital, and Osman Fiqi Hospital whose day-to-day realities informed many of the observations in this paper, especially on hand hygiene, PPE availability, and waste management. We are grateful to colleagues at RUGSAN Consultancies for technical peer discussion on health systems strengthening, and to academic partners at Darul Hikma University for encouraging the translation of Somali operational experience into publishable scholarship.

A number of IPC insights summarised here were generated during Somalia’s COVID-19 response (2020-2022); we therefore acknowledge the national taskforce, frontline responders, and WHO country office teams whose emergency IPC training packages served as catalytic models for routine care settings. This paper is dedicated to Somalia’s healthcare workers who acquire infections while serving patients in under resourced facilities.