MALAWI—Malawi has become the first African country to adopt the freshly updated methodology of the Global Task Force for Cholera Control in identifying priority locations for multi-sectoral interventions.

Cholera is a severe diarrhoeal infection caused by consuming food or water contaminated with the bacteria Vibrio cholerae.

Rising temperatures, both ambient and water temperatures, also increase the growth of Vibrio cholerae.

In cholera-endemic nations, an epidemic might be seasonal or sporadic, with a higher-than-expected number of cases.

Cholera is a severe diarrhoeal disease that can kill within hours if left untreated.

Researchers estimate that each year there are 1.3 to 4.0 million cases of cholera and 21,000 to 143,000 fatalities globally due to cholera.

According to The Rockefeller Foundation, Malawi’s outbreak, exacerbated by climate change, has affected all 29 districts in this 20-million-person country, resulting in over 1,600 deaths and 51,000 illnesses.

Communities along Lake Malawi, Lake Chilwa, and the flood plains of the Shire Valley, as well as the major centers of Lilongwe and Blantyre, are frequently affected.

The Malawi outbreak originated in districts devastated by Tropical Storm Ana and Tropical Cyclone Gombe, which together damaged or destroyed scores of water systems, inundated significant areas, and evacuated 190,000 people.

In March of this year, for example, Cyclone Freddy killed additional people and damaged water infrastructure, contributing to water contamination. This, combined with insufficient sewage and drinking water treatment, hastened the cholera outbreak.

Safe drinking water and sanitation are crucial for preventing and controlling the spread of cholera and other waterborne diseases.

For cholera control, this innovative technique employs PAMIs, also known as hotspots.

This approach is timely as the country develops a multi-sectoral cholera control plan.

Dr. Fred Kapaya, a cholera expert from the World Health Organization’s African Regional Office (AFRO), explained that the step-by-step process of identifying PAMIs began with AFRO’s orientation of the tools and procedures.

The data analysis included past events of natural catastrophes (cyclones, floods), climate, the proportion of households with access to safe water, sanitation coverage, population density, continuous urban migration, and the importation of cross-border cholera cases from neighbouring countries.

He further stated that the second phase involved ranking each unit based on various cholera burden parameters, such as incidence, death, persistence, and cholera test positivity.

A numerical threshold was used to designate priority levels, resulting in the production of a list of PAMIs (hotspots).

In the third step, a national stakeholder meeting was organized to validate the priority list of cholera hotspot locations that required multi-sectoral interventions (PAMIs).

Dr. Kapaya emphasized, “The aim of the process is to build stakeholder consensus on a comprehensive list for targeting sustainable multi-sectoral approaches in preparedness, response, and control of cholera in these hotspot areas to maximize investments.”

Mangochi, Nsanje, Chikwawa, and some parts of Lake Chirwa in Zomba remain the four districts with recurrent and consistent sporadic cases in Malawi.

Cholera and other waterborne diseases proliferate during the rainy season, mainly due to poor waste management, water, and sanitation hygiene practices. These districts contribute significantly to the number of hotspots.

Ronnex Nguwo, the Integrated Disease Surveillance and Response (IDSR) Coordinator for Nsanje district, indicated that multi-sectoral interventions have significantly reduced cholera cases in Nsanje.

 The district, spread across two riverbanks with high populations, registers sporadic cholera cases due to makeshift houses along the river, low coverage of sanitation facilities, and cross-border cases with Mozambique.

Boniface Grim, Assistant Environmental Officer at Chikwawa District Hospital, emphasized the importance of ongoing cholera supply distribution and the upgrade of treatment centers.

In Chikwawa, the influx of cross-border cases made these measures critical, with Grim noting the key role played by the Emergency Medical Team, supported by the Ministry of Health and WHO, in managing cases, tracking them into Mozambique, providing behavior change messages, and distributing essential WASH resources.

This comprehensive approach had a profound impact on reducing the number of new cholera cases in the district.

Grim underscored that focusing solely on healthcare would strain the already-burdened system. Therefore, multi-sectoral interventions that encompass infrastructure, awareness campaigns for behavior change, and cholera supplies are indispensable in effectively controlling cholera.

Dr. Gertrude Chapotera, WHO Malawi’s Country Preparedness and IHR Officer, explained that the mapping process is a crucial step in generating data and developing a multi-year cholera control plan.

PAMI utilizes geographical maps derived from the national census survey by the National Statistical Office to categorize data at the traditional authority level.

This approach allows for the identification of areas most affected by cholera, enabling precise prioritization of interventions by different partners and stakeholders.

With these maps, resources can be effectively directed to cholera hotspots, maximizing their impact in situations where resources are limited, especially in emergency preparedness.

Rossanie Dauchi from Self-Help Africa emphasized that this process is not only essential for Malawi but can serve as a model for other countries.

Key partners and stakeholders from various sectors must be involved in developing a cholera plan that goes beyond healthcare to address water, hygiene, sanitation, climate change, disaster management, infrastructure, cross-border relations, logistics, and financing.

A multi-sectoral approach is essential to complement case management and immunization efforts, aiming to identify and address the specific needs of each area.

Young Samanyika, WASH Project Manager for Amref Health Africa, underscored the holistic nature of this approach to containing cholera in Malawi.

He pointed out that sporadic cholera cases continue to emerge in most districts, indicating underlying causes that require attention. To achieve sustainable containment, interventions must extend beyond case management.

Dr. Bridon Mbaya, National Coordinator of the Presidential Task Force on COVID-19 and Cholera in the Office of the President and Cabinet (OPC), stressed the importance of multi-sectoral interventions towards cholera control due to complex factors contributing to cholera vulnerability.

These interventions encompass safe water supply, good hygiene practices, public awareness, education, and tailor-made interventions based on the burden of disease in each area.

By addressing these factors systematically and with precision, it is hoped that the cholera burden can be reduced by up to 80 percent, paving the way for containing cholera in the country.

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