Malawi Cholera Fact Sheet

Cholera Overview

Seventh pandemic cholera was first reported in Malawi in 1973. Since 1990, large-scale outbreaks were reported in 1990-1991, 1993, 1999, and 2002. The yearly trend shows that epidemics have decreased in magnitude since 2002 (Fig. 1).

Between 2001 and 2018, epidemiological surveillance reported 42,397 cases with 473 fatalities (case fatality rate ≈ 1.1%). The majority of suspected cases were reported in Southern Region (57%), where the districts that reported the greatest number of cases were Blantyre, Machinga, Chikwawa.

More recently, the most affected districts from 2014 to 2018 were Machinga (23%), Karonga (17%) and Chikwawa (14%).

The country has been affected by cross-border outbreaks, especially along the southern border with Mozambique and likely along the border with Tanzania albeit to a lesser degree (Fig. 2).3Table I. Epidemiological parameters of cholera outbreaks in primarily affected districts in Malawi, 2001-20182Figure 2. Cumulative cholera incidence by district in Malawi, 2001-20182Figure 3. Monthly cholera case numbers and precipitation levels in Malawi, 2015 – 20182,4Figure 1. Annual number of cases and case fatality rate in Malawi, 1990 – 2017

Cholera Distribution

From 2001 to 2018, Lilongwe District reported the highest proportion of cholera cases (27.8%). Lilongwe was affected by 11 outbreaks over the 18-year period, although the large majority of cases were reported from 2002 to 2009 (Fig. 4, Table I).

Blantyre District reported 16.4% of all cases, which were primarily reported between 2001 and 2012. Blantyre also reported 11 outbreaks over the study period (Fig. 4, Table I).

In the Lake Chilwa area, Machinga, Zomba and Phalombe accounted for a combined 13.9% of all cholera cases, where affected populations often involved fishing communities living on islands or floating homes on the lake. Since 2010, Lake Chilwa districts have accounted for 34.5% of all cases (Fig. 4, Table I).

In the Shire River floodplain, Chikwawa and Nsanje reported a combined 13.1% of all cases. Since 2010, this percentage has increased to 31.5%. Chikwawa was also the most often affected district with 14 outbreaks from 2001 to 2018 (Fig. 4, Table I).

In Northern Region, Karonga District reported 4.5% of all cases, which represents the highest proportion among districts along Lake Malawi

Strategic Recommendation

High-risk areas along national borders were located in zoneswhere cholera outbreaks spread between neighboringcountries, including Mozambique and to a lesser degreeTanzania (Table II, Fig. 4). This highlights the importance ofcross-border surveillance and coordinated response betweencountries in the region, especially in Southern Region andKaronga District.

In priority cholera foci, preparedness and response plansshould be developed and implemented including: (1)strengthening early detection and rapid response includingcommunity-based surveillance and cross-border alerts; (2)establishing multisectoral and cross-border coordinationmechanisms; (3) building outbreak management capacity; (4)targeted pre-positioning of supplies and (5) developing riskcommunication, social mobilization and community engagementplans with harmonized approaches and messaging (Table II –Type 1 - Type 3). In hard-to-reach areas, early rehydration (e.g.,community oral rehydration points) should be enhanced toreduce the CFR.

Sustainable water, sanitation, hygiene and social mobilizationactivities should be implemented in the six priority districtsregularly affected by cholera outbreaks, especially fishingcommunities of Lake Chilwa, residents of the Shire Riverfloodplain, overpopulated urban areas, and cross-borderdistricts with high population flux to and from Mozambique andTanzania (Table II – Types 1-2). The Type 1 and Type 2 priorityareas accounted for 71.8% of the disease burden.