Malawi’s Cholera Outbreak and Combating It

Cholera, a bacterial disease causing severe diarrhea and dehydration, is usually spread through water. It is caused by the bacterium known as Vibrio cholera. Cholera is fatal if not treated right away. In an epidemic, the source of the contamination is usually the feces of an infected person who has consumed contaminated water or food. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water.

Malawi shares international borders with Tanzania, Zambia, and Mozambique and has an estimated population of 19.65 million as of 2021. The southeastern African country has only 2 physicians per 100,000 people, and the average life expectancy is 39 years. Malawi is characterized by a heavy burden of disease, as evidenced by high levels of child and adult mortality rates and the high prevalence of diseases such as tuberculosis, malaria, HIV/AIDS, and other tropical illnesses. The landlocked country is currently facing its worst cholera outbreak in two decades, with 42,422 cases and 1384 deaths as of February 12, 2023. This is the deadliest outbreak of cholera in the country’s history, as the report stated. More commitment is needed for surveillance as well as prevention to eliminate the deadly cholera bacteria, which is spread by dirty water.

Cholera, a bacterial disease causing severe diarrhea and dehydration, is usually spread through water. It is caused by the bacterium known as Vibrio cholera. Cholera is fatal if not treated right away. In an epidemic, the source of the contamination is usually the feces of an infected person who has consumed contaminated water or food. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water.

The United States’ Centers for Disease Control and Prevention (CDC) said: “An estimated 1.3 to 4 million people around the world get cholera each year, and 21,000 to 143,000 people die from it. People who get cholera often have mild symptoms or no symptoms, but cholera can be severe. Approximately 1 in 10 people who get sick with cholera will develop severe symptoms such as watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours. According to the information obtained from the World Health Organization website, “Last year, cholera killed more than 3,000 people in 12 African countries, with more than half the victims dying in Malawi’s record outbreak” (WHO, 2023).

Founded in 1948, WHO is a specialized agency of the United Nations responsible for international public health. In February 2023, the World Health Organization’s (WHO) Chief, Tedros Adhanom Ghebreyesus, said that “23 countries across the world were experiencing cholera outbreaks, with a further 20 countries that share land borders with them at risk” (Ghebreyesus, 2023). “In total, more than one billion people around the world are directly at risk of cholera” (Ghebreyesus, 2023).

In a similar vein, the United Nations Children’s Fund (UNICEF), a UN organization mandated to protect the rights of every child, especially the most disadvantaged, reported that, “despite the continuing efforts in the national cholera outbreak response and the need to intensify efforts, significant gaps exist. This includes the urgent need to “strengthen the surveillance system for early detection and management; increase quality case management at cholera treatment units; provide critical supplies required to manage cholera cases and for water treatment, personal hygiene, and water storage at the household level; increase timely community engagement and dissemination of communications around cholera prevention and positive hygiene practices” (UNICEF, 2023);

Between 1998 and 2020, Malawi experienced seasonal outbreaks of cholera, and the bacterial disease is endemic in the country, with the southern region known as a hotspot for these recurrent outbreaks. Southern Malawi is low-lying, flat, and prone to flooding during the rainy season. This outbreak is atypical, which means that epidemics typically start in the rainy season, but last year the epidemic began in the dry season. The arrival of the rain only accelerated the spread of the waterborne contagion. The outbreak has since spread countrywide, putting at risk more than 10 million people, including more than five million children.

Notwithstanding the fact that Malawi has carried out two oral cholera vaccination campaigns, a global surge in cholera outbreaks means vaccine supplies are under strain. Rudolf Schwenk, the country representative for the UN Children’s Fund, UNICEF, said in a recent press briefing that “Malawi is experiencing the deadliest cholera outbreak in its recorded history. The country is also struggling to respond to a polio outbreak and ongoing COVID-19 cases across the nation, adding that “resources are limited, the health system is overburdened, and health workers are stretched to their limits” (Schwenk, 2023).

Statistics from UNICEF showed that as of February 12, there were 42,427 cases and 1,384 deaths cumulatively, with a CFR of 3.26 percent. During the week, 27 districts reported 3,861 cases, including 130 deaths, with a CFR of 3.37 percent. There was a 22 percent decrease in cases and a 19 percent decrease in fatalities in the reporting week compared to the previous week, which may correspond to the surge in multi-sectoral interventions by the government and partners, especially in high-burden districts like Lilongwe, Blantyre, and Mangochi. However, the pattern of the downward trend cannot be determined at this point, with new districts like Balaka showing an increase in cases. Also, the three districts that are most affected are Mangochi (7,562 cases and 121 deaths), Lilongwe (7,129 cases and 418 deaths), and Blantyre (6,143 cases and 186 deaths).

The Cyclone Freddy Factor

Cyclone Freddy, which apparently occurred recently and was the longest-lasting and highest-ACE-producing tropical cyclone ever recorded worldwide, has moved on from Malawi, but it has left behind it a trail of destruction and the risk of an unprecedented cholera outbreak. Experts believe that the development will likely create additional life-threatening challenges for communities that are already struggling as the rainy season reaches its height, combined with the fact that it is now the annual lean season in Malawi, where many families have to cope with scant resources (UN, 2023). Freddy made landfall in Madagascar on February 21st, according to reports. From there, the storm moved on to Mozambique and then back across the Indian Ocean. On March 11, it reached Mozambique for the second time and then moved on to Malawi.

Aside from that, Palal Areman, the deputy operations team lead for Save the Children’s (a leading humanitarian organization for children) Emergency Health Unit in Blantyre in southern Malawi, stated that “the country was dealing with a big situation with the cholera outbreak and resources had been stretched.” The normal health-care routine has been completely disrupted by Cyclone Freddy. Children are traumatized by the cyclone; they were brought to hospitals with head injuries, broken limbs, and bruises, while others looked worried or had no family members (Areman, 2023).

During the month of March, “temporary tents put up to treat cholera patients have been destroyed, putting medical services out of reach for many.” “I believe that in the long run, with water disruption, broken pipes, and water contamination very likely, cholera cases will almost certainly rise,” Areman added.

Combating It

Environmental health officers are responsible for monitoring and enforcing health and hygiene legislation. They also investigate when there’s an incident, such as pollution, a noise problem, toxic contamination, a pest infestation, or an outbreak of food poisoning. Semu Kholola, a principal environmental health officer for Mangochi, noted in a local newspaper report that the cases are mainly occurring along the lakeshore areas where safe water and sanitation are problems. “As a district, we are trying our level best to make sure that we contain the cases by providing the necessary care so that those infected get treatment” (Kholola, 2023).

Apart from treatment, according to Kholola, there are several interventions that the hospital has put in place, such as sensitizing the community, vaccinating Malawians, providing chlorine to households, using clean toilets, and implementing other hygiene measures.

An assessment of the situation in Malawi by the International Federation of Red Cross and Red Crescent Societies (IFRC), a global humanitarian aid organization, indicated that “due to the high rate of transmission, the disease is now affecting people across multiple geographical areas. Fishing communities along the lake represent some of the most at-risk communities due to the limited availability of safe drinking water, the sandy terrain that increases the risk of latrines collapsing during the rainy season, and the widespread use of lake water for drinking purposes. Children, who tend to spend many hours swimming in the lake, are also at higher risk from the contaminated water. Transmission routes from the lake have contributed to the spread of the outbreak in other parts of the country, including gatherings at lakeshore fish markets and the movements of urban populations towards the lake for tourism purposes, which could have contributed to the spike in cases. Mozambique shares a border with Malawi through the lake and has already reported some cholera cases. Therefore, it is necessary to extend border coordination between the two countries (IFRC, 2023).

However, the Presidential Taskforce on COVID-19 and Cholera announced a delay in the opening of schools in Blantyre and Lilongwe districts. The Minister of Health in Malawi, Khumbidze Chiponda, who is also the co-chairperson for the Presidential Taskforce for COVID-19 and cholera, said in a daily update statement on January 16, 2023, that “the two-week delay was meant to provide time and opportunity for learning institutions, various ministries, and stakeholders to carry out assessments of the situation of water, sanitation, and hygiene in schools, put in place plans to increase access to safe water, strengthen alternative ways to support sanitation and hygiene in peri-urban areas, and to support uninterrupted learning in schools” (Chiponda, 2023).

Furthermore, in February 2023, President Lazarus Chakwera launched another campaign, pledging to reduce the transmission and mortality rate of the water-borne illness. According to Chakwera, the spread is largely due to people in the country not practicing good hygiene. He said, “And because the behavior is not changing, the situation has become dire.” “So far, over 1,300 funerals have happened around the country because of cholera. And the disease is still spreading at an alarming rate. We are getting between 500 and 600 cholera cases every day in our health facilities throughout the country” (Chakwera, 2023).

The campaign, known as “Tithetse Kolera” or “Let’s End Cholera,” focuses on repairing water kiosks across the country and helping people construct toilets in their homes.

Early in March 2023, the Ministry of Local Government, Unity, and Culture begins reviving the National Clean-Up Day, starting with a reminder to all relevant stakeholders that the day is observed every second Friday of each month, as noted in a press statement signed by Secretary for Local Government, Unity, and Culture, James Chiusiwa. Chiusiwa said, “With the increase of registered cholera cases in Malawi, which is fuelled by unhygienic practices, the ministry urges all stakeholders in the public and private sectors, CSOs, and the general public at large to identify surroundings where the cleaning and greening activities will be observed on Friday, March 10, 2023” (Chiusuwa, 2023). While all households, institutions, and communities are advised to have large containers large enough to keep their waste. “The general public’s failure to properly handle waste is illegal under the laws of Malawi” (Chiusuwa, 2023).

Meanwhile, social and cultural norms and beliefs influence how Malawians prevent and treat cholera. “As with most diseases, home remedies are often the first line of treatment. Formal health care to treat cholera is often sought only after care attempts have been made at home. Seeking traditional healing is another common first-line treatment option, especially in rural areas. It is estimated that 70% of people rely on traditional medicine as their primary health care, and this may lead to delayed healthcare-seeking at a health facility as it is often believed that results from traditional healing can take up to a few days after treatment. Health decision-making is influenced by a number of factors, including the type of symptoms, the disease etiology, the nosology, and people’s perceptions of the health care system in relation to specific diseases. However, in the context of the current cholera outbreak, there is little evidence on the extent to which people use traditional medicine. Moreover, little is known about what kind of traditional medicine is used for cholera treatment” (Eva et al., 2022).

To reduce this menace, “almost fifteen thousand (14,817) people were reached through preventive cholera messages through household visits by the radio listeners done by group and youth volunteers. The critical contents discussed with the community members through household visits were the importance of drinking safe water, using clean latrines or toilets, using oral rehydration solution (ORS), and the need to visit health facilities. In addition, a community dialogue was held in the Pfupa villages of Mwanza district’s Nthache Traditional Authority (TA) in collaboration with the Center for Development Communication (CDC) and the District Health Office to encourage pregnant women to use proper water and sanitation” (UNICEF, 2023).

Nonetheless, the country is now seeing a drop in cases, largely because of an anti-cholera campaign its government launched in February 2023. Positively, Malawi has also seen a drop in the fatality rate, from 3.3% in August to 1.8% now, still above the WHO target rate of 1 percent. The country’s Minister of Health, Khumbize Kandodo Chiponda, confirmed that progress has been made. He said: “The numbers have significantly gone down” (Chiponda, 2023). He further stated that “about three weeks or two weeks ago, we were having about 700 or 800 cases on a daily basis. But as of now, there are about 200, sometimes 300. Even people who are dying from cholera, the numbers have gone down” (Chiponda, 2023). He also stated that “as reported, the locals and health experts worry that trend could quickly reverse in Freddy’s wake” (Chiponda, 2023). Unfortunately, the World Meteorological Organization says Cyclone Freddy, which started in February, is likely the longest ever.

Eventually, the World Health Organization has called for Africa to step up the fight against cholera. There is an urgent need to improve access to safe water, sanitation, and hygiene, as WHO advised Malawi earlier in 2023. WHO recommends improving access to safe drinking water and sanitation infrastructure, providing proper and timely case management of cholera cases, and improving infection prevention and control in healthcare facilities. Promotion of preventive hygiene practices and food safety in affected communities is the most effective means of controlling cholera. Targeted public health communication messages are a key element of a successful response. OCV should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera (WHO, 2023).

In addition, using the past model for eradicating cholera in Europe, Dr. Merawi Aragaw, the Head of the Emergency Preparedness and Response Unit at the Africa Centers for Disease Control and Prevention, said “African outbreaks can be stopped if governments take a well-coordinated, collective, and multi-sectoral approach like Europe did 150 years ago, which helped that continent virtually eliminate the waterborne disease. He opined that the approach would center on improving water and sanitation infrastructures across Africa” (Aragaw, 2023).



Africa News (2023). “Cholera kills over 1,200 in Malawi, WHO urges strong interventions.” Retrieved from

Africa News (2023). “Cyclone Freddy: Fears that Malawi’s cholera outbreak will spiral.” Retrieved from

Aljazeera (2023). “Cyclone Freddy death toll in southeast Africa surpasses 500.” Retrieved from

Centers for Disease Control and Prevention (CDC). “Cholera – Vibrio cholera infection.” Retrieved from,of%20sewage%20and%20drinking%20water

Eva Niederberger, Soha Karam and Leah Tanner (2022). “Social, Behavioural And Community Dynamics Related To The Cholera Outbreak In Malawi.” Retrieved from

Gavi (2023). “Malawi’s worst cholera epidemic in decades sparks massive demand for vaccines As Malawi continues to struggle.” Retrieved from,a%20new%20disease%20in%20Malawi

International Federation of Red Cross and Red Crescent Societies (2023). “Malawi: Cholera Response – Emergency Appeal.” Retrieved from

Nyasa Times (2023). “Malawi: Mangochi District Hospital Reports 6,756 Cholera Cases, 103 Deaths Since July 2022.” Retrieved from

Nyasa Times (2023). “Malawi: Ministry Reviving National Clean-Up Day.” Retrieved from

Reuters (2023). “Malawi cholera death toll crosses 1,300: health official.” Retrieved from

Reuters (2023). “Malawians fear storm Freddy could make deadliest cholera outbreak worse.” Retrieved from

Save the Children’s Emergency Health (2023). Cyclone Freddy: Fears Cholera Outbreak Will Spiral In Malawi As Healthcare, Water Supplies Disrupted.” Retrieved from

The Lancet (2022). “Malawi takes on cholera outbreak amid cyclone devastation.” Retrieved from

UNC Institute for Global Health and Infectious Diseases. “Malawi.” Retrieved from

United Nations (UN) (2023). “Tropical cyclone Freddy set to further weaken cholera-hit Malawi.” Retrieved from

United Nations Children’s Fund (UNICEF) (2022). “UNICEF and WHO step up efforts to contain Cholera in Malawi and call for additional funds and support.” Retrieved from

United Nations Children’s Fund (UNICEF) (2023). “Malawi Cholera Flash Update 07.” Retrieved from

Voice of America (2023). “Africa: Ministers in Malawi Discuss Cholera Outbreaks.” Retrieved from

Voice of America (2023). “Malawi Launches Campaign to End Deadly Cholera Outbreak.” Retrieved from

World Health Organization (2023). “Disease Outbreak News; Cholera – Malawi.” Retrieved from



Writer and researcher at Alafarika for Studies and Consultancy.

Similar Topics