How a major health campaign sprang Malawi out of its cholera emergency
Multiple countries in the eastern and southern region of Africa are battling cholera outbreaks. Malawi’s response to the epidemic has been a stand-out success.
- 10 May 2024
- 7 min read
- by Charles Pensulo , Gavi Staff
Patricia Namilonje, 46, lives just a few metres from Ndirande Clinic in Blantyre, southern Malawi. But it was only after a cholera epidemic hit the township that she became wary of the risks lurking in her immediate environment.
"At first, we were not as mindful of the disease. We could shake hands anyhow and share food even on the street," the mother of two said, standing on her veranda.
“Between January 2022 and April 2023, Malawi was seeing about 300 to 400 cases a week,” Ganizani said. “But in the entire period stretching from November 2023 to February 2024, there were only 218 cases countrywide, with two deaths. That’s significant progress.”
– Allone Ganizani, Deputy Director for Public Health at the Malawian Ministry of Health
Namilonje recalls that as dozens of locals – including her immediate neighbours – began to fall sick with cholera, health workers made the rounds, bringing information about the disease's spread, and chlorine to help contain contagion.
Dousing wildfires
The past few years have seen the global threat from the waterborne bacterium spike precipitously, with southern and eastern Africa hit particularly hard. More than 230,000 cholera cases and 4,000 deaths have been reported from 14 countries in the region since the start of 2023.
Malawi, which had previously all but eliminated the disease, had a rough 2022. In March that year, a cholera outbreak sprang up in Machinga district, soon spreading to all 29 health districts in the country. The month of November 2022 alone saw a staggering 4,766 cases. By August 2023, nearly 1,800 Malawians had lost their lives.
People Namilonje knew personally numbered among them, she says. "We're more careful now. We know why it is important to clean hands frequently and not share food anyhow. We've also been treating our water with chlorine which the health workers distribute."
Chlorine and caution have not been the only forces at work to curb Malawi's wildfire epidemic, however. In October 2023, the Ministry of Health and its international partners launched a large-scale campaign that married cholera and COVID-19 control efforts. According to Allone Ganizani, Deputy Director for Public Health at the Malawian Ministry of Health, the initiative has been a stand-out success.
"Between January 2022 and April 2023, Malawi was seeing about 300 to 400 cases a week," Ganizani said. "But in the entire period stretching from November 2023 to February 2024, there were only 218 cases countrywide, with two deaths. That's significant progress."
The campaign runs Malawi-wide
For just a little more than a fortnight after President Lazarus Chakwera flagged off the TIPEWE Cholera and COVID-19 campaign, on 30 October 2023, health workers trickled out into villages and towns across Malawi to beef up preventive measures against both diseases. They were armed with information, diagnostic know-how, chlorine, testing kits and, of course, vaccines.
A strategy known as "case area targeted intervention" or CASI, supported by UNICEF and other partners, complemented this approach. In other words, each reported cholera case received comprehensive follow-up at community level: the patient's home was disinfected and so were surrounding households. Moreover, families in the area were provided with essential sanitary materials, like pails and soap for handwashing, and equipment to make sure drinking water could be stored safely. The water source was also tested for residual chlorine and biological contaminants.
In areas that saw a higher incidence, teams established oral rehydration points staffed by volunteers, who were able to provide on-the-spot support.
By mid-November, 88% of households had heard the campaign's life-saving messages on hygiene, sanitation and epidemic disease transmission; 79% of families countrywide had received a 1% chlorine solution to make their drinking water safe. Ninety-five percent of targeted markets were cleaned up, and no fewer than 2,205 patients ill with diarrhoea – including 686 severe cases – were identified and treated, while 206,433 more people were vaccinated against COVID-19.
In the months since, the impact of that big push has been clear to health workers across the country. Thamu Chinula, a senior health surveillance assistant at Ndirande Health Centre in Blantyre, for instance, attributed a striking reduction in cholera cases to the campaign.
"At first we had a lot of cases before the campaign. In Ndirande alone,we had recorded 12 deaths, some here at the cholera treatment centre (CTC) and others in the community. The campaign has really assisted because now we have no cholera cases. This year only one child was admitted here," she said in an interview.
A relief in its own terms, that fall-off in cholera cases also had positive knock-ons, freeing up health workers like Chinula to catch up on vital work that had taken a backseat amid crisis. Countrywide, routine immunisation rates suffered during the worst of the cholera epidemic: coverage with the third dose of the basic diphtheria, tetanus, and pertussis-containing vaccine (DTP3), a conventional proxy marker for immunisation in general, had dropped to 86% in 2022, down from 93% in 2021, and 95% before the COVID-19 pandemic landed.
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"Our community workers went out door-to-door educating people about cholera, including how they can take care of their environment. We strongly advised them to have toilets, a waste bin and to use toilets properly. The challenge we have is the shortage of toilets, because [during] Cyclone Freddy many toilets fell down. We are trying to encourage them to rebuild, although many are still challenged economically," Chinula added.
Cholera in retreat
As the health workers wrapped up their campaign activities, storm clouds were breaking over Malawi. The season of rains and cyclones runs from November to April in the region, and risks accelerating cholera transmission: the disease is waterborne, and frequently spikes amid flooding. By late March 2024, WHO was describing neighbouring Mozambique, Zambia and Zimbabwe as being in "acute crisis" – but Malawi was notably absent from that list.
Cholera wasn't gone yet – but the outbreak was clearly flagging.
"We immediately saw the decline in terms of numbers of new cases reporting because […] of the interventions, and that led to declaring cholera no longer a disease of an emergency," Ganizani of the Ministry of Health, and focal person for the integrated campaign, told VaccinesWork.
A behind the-scenes glimpse at a rare campaign
COVID-19 taught the world that a rolling epidemic crisis imperils control of other diseases. Measles, often called the "canary in the coalmine", has spiked in the years since the pandemic struck: being highly infectious, the virus punches through quickly when gaps open in the immunisation safety net. It's often followed by other diseases, exploiting the same weaknesses in the health system.
A cholera outbreak following on from a global pandemic is a lot for a health system to cope with, Gavi's Malawi country team understood. Funding an integrated COVID-19 and cholera campaign – redeploying money initially earmarked just for the COVID-19 response – struck the team as an opportunity to right the dominoes before they fell, Senior Country Manager Jonna Jeurlink explains.
"It comes down to the importance of combining immediate outbreak response with efforts to foster long-term resilience," Jeurlink said.
"I think it is after that launch by the head of state [of this campaign], we really now had to figure in terms of interventions that would be very much relevant in preparation of the disaster-prone season or the rain season we are in now," he said.
Ganizani said the campaign also focused in on sources of water which were still not safe, meaning that communities were using them before bringing in the necessary interventions, like maintenance of broken-down water points and revamping of potable water kiosks.
"And it is at the same time that we are saying: COVID-19 is not eradicated or eliminated. We still have it around us. But if we see the decline in the numbers of cases, I think we are attributing it to the issue of the vaccination that we had. We had a lot of challenges, misconceptions around it, but the numbers of those that got the vaccination were actually increasing to what we call the herd immunity," he added.
"I think what we're seeing is a very important investment. It was quite expensive – but compared to the loss of life, which we are not actually seeing this time as it was last time, it's worth it," he said.
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