Crisis Overview
Malawi is facing its deadliest cholera outbreak in recorded history and its largest in the last two decades, leaving 4.8 million people in need of assistance in 15 priority districts. The outbreak was officially declared on 3 March 2022, after the first case was reported in Machinga district at the end of February 2022. By 18 February 2023, the outbreak had claimed the lives of more than 1,400 people, with more than 45,400 cases recorded, and had an overall case fatality rate (CFR) of 3.21 per cent, more than three times the emergency threshold. The current outbreak has already surpassed the 2001-2002 epidemic, which was the worst in the country’s recent history, that registered 33,000 cases and 1,000 deaths.
The outbreak has escalated exponentially in recent months. In the early months of the outbreak, the number of monthly cases remained below 60, but this increased to more than 300 cases in May, nearly 800 cases in August and more than 2,000 cases in October. The start of the rainy season in November 2022 saw a rapid escalation in the outbreak—with more than double the number of cases (more than 4,700) compared to October (more than 2,000)—and cases then rose precipitously in the first weeks of January 2023, with an average growth rate of 3 per cent per week.
Communities living by and around Lakes Malawi, Malombe, Chiuta and Chilwa have been most severely affected by the outbreak, as they rely on the lakes for their drinking and cooking water supply.
Although the outbreak was initially limited to the southern part of the country, it has since spread to all 29 districts of Malawi, including areas that were cholera-free for more than a decade. However, 10 of the 29 districts have contributed 80.3 per cent of cases and 81.7 per cent of the deaths. Eight out of these ten districts—Mangochi, Salima,
Nkhata Bay, Nkhotakota, Balaka, Machinga, Rumphi and Dedza—are lake districts, while the other two—Blantyre and Lilongwe—are major urban centres. Three districts—Mangochi, Lilongwe and Blantyre— accounted for 49.7 per cent of the total cholera cases in the country, recording more than 22,500 out of 45,400 cases, and 52.4 per cent of the total deaths (763), as of 18 February. Mangochi had the highest cumulative cases (7,831) and Lilongwe accounted for the highest number of deaths (449).
Fishing communities, children, women and girls (especially those who care for sick family members), are at increased risk of contracting cholera and are also facing specific consequences due to the crisis. Fishing communities—especially men and boys—are at particularly high-risk as they use lake waters as a source of drinking water (including while fishing) and for defecation, cooking and bathing, including while fishing, according to a study based on the oral cholera vaccination campaign in these communities in 2016 by Sauvageot et al. Children have been affected by the outbreak, with 41 per cent (9,982) of cholera cases and 20 per cent (142) of cholera deaths being children under 18 years of age, as of 31 January 2023. The outbreak has also interrupted children’s education, with the Ministry of Education temporarily postponing the reopening of schools in Blantyre and Lilongwe in January 2023, affecting nearly 932,000 primary school students and more than 55,600 secondary school students. Gender roles heighten women and girls’ exposure to cholera, as they care for sick family members, clean latrines, fetch and handle untreated water and prepare food. Vulnerability in women and girls in Malawi is exacerbated by unequal power relations and social and economic disadvantages that also heighten the risk of sexual exploitation and abuse. Some 44 per cent of all cholera cases were female as of 13 February 2023. Malawi is home to 56,300 refugees and asylum seekers, most of whom live in the Dzaleka refugee camp, where they are at heightened risk of cholera due to overcrowding, the poor WASH situation, and low cholera vaccination rates among refugees and host communities.
The key drivers of the escalating outbreak are use of unsafe water sources, limited access to safe sanitation and hygiene facilities, and poor food hygiene and hygienic practices, particularly limited handwashing with soap at critical times, including after contact with Cholera cases. An estimated 7 million people in Malawi (30 per cent of the population) do not have access to safe drinking water, while more than 80 per cent of households drink contaminated water, according to UNICEF. Access to sanitation is also a key challenge, as 76 per cent of the population does not have improved sanitation and 17 million people (92 per cent) do not practice handwashing with soap and water. Barriers to handwashing include affordability and availability of soap, especially for rural households. Remembering when to wash hands was also pointed out as a barrier to handwashing, in a study carried out among rural communities in Malawi by Chidziwisano et al.
The cholera outbreak is also taking place at a time when many impacted communities are still struggling to recover from the effects of Tropical Storms Ana (January 2022) and Gombe (March 2022). Extreme weather events—such as storms, cyclones, and floods—act as a vulnerability multiplier, destroying Water, Sanitation and Hygiene (WASH) infrastructure and increasing challenges in access to safe water and sanitation. Repair of damaged water infrastructure is a costly venture and most facilities destroyed during Tropical Storm Ana and Cyclone Gombe remain in a state of disrepair, leaving communities that previously had access to clean water without safe sources and increasing their risk of cholera. In the wake of the two storms, many public and private latrines collapsed, putting pressure on the remaining, already inadequate, facilities.
The outbreak is also impacting communities that are facing heightened food insecurity and malnutrition. During the peak of the lean season (between October 2022 and March 2023), 3.8 million people in Malawi (20 per cent of the population) are expected to endure Crisis food insecurity (IPC Phase 3), with 21 districts classified in Crisis, according to the latest Integrated Phase Classification analysis. In 2022, all districts experienced late onset and early cessation of rainfall coupled with localized dry spells, while Southern Region districts were affected by cyclones. Communities are also navigating the continued impact of the war in Ukraine on food prices, potential reduced internal food production due to high prices of inputs and possible climatic shocks, and reduced labour opportunities and wages.
Looking ahead, experts anticipate that, unless urgent, intensified action is taken to scale-up the response, between 64,000 and 100,000 cases could be reported in the next three months. However, the high number of cholera cases and large geographic spread of the outbreak have strained response capacities, against a backdrop of a weakened health system, which was already overstretched by competing disease outbreaks, including COVID-19 and Polio. Health officials expect a large portion of the cases will require hospitalization in Cholera Treatment Units (CTUs) yet, only 42 per cent of the CTUs in the country (140 out of 344) are operational.
Source: UN Office for the Coordination of Humanitarian Affairs