The cholera case reported by the district hospital in Malawi’s southern region on 3 March 2022 was the first of the 2021-2022 season, and a warning of what was to come: the worst cholera outbreak recorded in the African country in decades.
By Charles Mpaka/IPS
Cholera has gripped Malawi for almost a year, with cases registered in all 29 districts and rising.
In an unprecedented development, cases have risen sharply, even during the summer months, when diagnoses are not expected and the country is not prepared to do battle with the disease.
By the 4th of this month, 704 people had already died and 21,000 cases had been registered, according to official data. The case fatality rate stands at 3.4 per cent, above the recommended rate of less than one per cent.
Maziko Matemba, executive director of the Health and Rights Education Programme (HREP), a local civil society organisation, said the situation is alarming and keeps the country in a “spiralling health crisis”.
“We started 2022 hoping to recover from the devastation of Covid-19. Then tropical storm Ana set us back in January. And in March, cholera set in, and it’s been going on for 10 months now, getting worse as time goes on. We haven’t had a cholera outbreak for a long time,” Matemba told IPS.
Fears are growing that the spread of the disease will be even greater with the onset of the rainy season, when cases tend to increase in Malawi.
Tropical Storm Ana played a major role in this latest outbreak, according to experts. The storm affected 16 districts, including Machinga, where the first cholera case was recorded in March, and Nsanje, a flood-prone district and one of the first areas to report cholera cases in 2022.
A final report on the impact of the storm by the Department of Disaster Management revealed that in these 16 districts, more than 53,000 latrines were destroyed and 337 wells, 206 taps and eight gravity-fed water supply systems were damaged.
According to the Department, this resulted in low sanitation coverage, limited access to safe water and poor hygiene practices, with some locations and communities reporting open defecation and contamination of the few available water sources.
According to the report, this situation has raised the risk of the spread of cholera and other communicable diseases.
“Therefore, safe water supply, sanitation and hygiene services are needed immediately to address the problems resulting from poor water quality. In addition, toilets need to be rehabilitated to prevent waterborne and infectious diseases.
Malawi has not recovered from the disaster, said Matemba.
“The lack of recovery of the destroyed water and sanitation infrastructure at the time created conditions conducive to the spread of cholera. This is coupled with a weak prevention system. We tend to take prevention rather casually,” he lamented.
Save Kumwenda, an environmental health expert, said that in addition to water, sanitation and hygiene problems, there is evidence that temperature and rainfall influence cholera outbreaks: temperature controls epidemics and rainfall acts as a dispersal mechanism.
“There are also socio-economic conditions, which are key factors in outbreaks as they increase exposure to pathogens,” said Kumwenda, an associate professor at Malawi University of Business and Applied Sciences (MUBAS).
According to him, the situation could worsen because in the rainy season, rains spread the bacteria through contamination of water bodies and food.
The outbreak has hit Malawi’s two main cities hardest: Lilongwe, the capital, and Blantyre, the commercial city.
For example, in the 7 days between 29 December 2022 and 4 January 2023, Malawi recorded 2773 cholera cases and 137 deaths. Of these, Blantyre and Lilongwe account for 47% of new cases and 53% of new deaths.
According to Kumwenda, this is because the two cities, with problems of solid waste management and old sewerage systems, have large peri-urban areas where residents rely on wells, boreholes and river water, heavily contaminated with faecal matter from toilets, broken septic tanks, broken sewer pipes and open defecation.
He added that most homes in these areas do not have proper toilets and many rely on shared toilets.
In addition, most of these households cannot afford to pay for water from cisterns for both drinking and domestic use. Therefore, they prioritise potable water for drinking only and non-potable water for other uses, resulting in contamination of food and utensils, while polluting the available drinking water.
“The other reason for the high number of cholera cases in these cities is the large number of people who live on piecework, which relies on food sold in markets, where hygiene and sanitation conditions are poor,” he explained.
The government’s response was to delay the start of school for two weeks in and around both cities. Malawi started the 2022 school year on 3 January.
Health Minister Khumbize Kandodo Chiponda said in a statement that opening the schools would undermine efforts to contain the outbreak, given that cholera is transmitted from person to person through contaminated food, water and inadequate sanitation facilities, a feature that exists in schools.
“The confluence of students, especially in pre-schools, primary and secondary schools, increases the chances of an uncontrolled spread of cholera-causing vibrio bacteria,” he said.
During the two-week delay, the government will conduct a comprehensive assessment and improve the water and sanitation situation in schools in both cities.
To provide a national response, among other measures, the government pledged to open more treatment centres where there are cholera outbreaks, employ more staff at treatment centres, intensify hygiene promotion and assess water quality in selected areas.
In November last year, Malawi launched a reactive oral cholera vaccination campaign targeting 2.9 million people over the age of one.
Kumwenda said Malawi needs to act quickly to stop the outbreak before the onset of the rainy season, as there is clear evidence of the impending emergency due to the increase in cases during the warmer months.
However, to control the disease in the long term, the country will need to invest in research to devise evidence-based interventions.
“This will ensure that investments always target interventions that achieve maximum benefits. We need to understand the main drivers of the epidemic and also identify the reservoirs of the cholera-causing bacteria. This knowledge will help us to easily prevent the recurrence of outbreaks,” said Kumwenda, chairperson of the Environmental Health Association of Malawi, an environmental health think tank.
