Malawi’s worst cholera epidemic in decades sparks massive demand for vaccines, as stocks run low

As Malawi continues to struggle with the prolonged and deadly outbreak, schools close in the worst-hit districts, and demand for scarce vaccines spikes. 

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A child taking oral cholera vaccine in Malawi. Credit: Gavi/2018
 

 

It was raining, but Esmie Mwanga was determined to make it to a clinic some kilometres away to get a cholera vaccine for herself and each of her children.

The 28-year-old lives in the slum township of Bangwe Ntopwa, in Blantyre, a hotspot in the epidemic that has been raging in Malawi since March of 2022. So far, the outbreak has infected almost 27,000 nationwide, killing 881. Despite efforts to slow the spread of the diarrhoeal disease, those numbers are rising at an accelerating pace .

"I have been particularly moved by the deaths of the people I know. Some of them were hesitant to get vaccinated."

Within just the past two weeks, Mwanga had lost an immediate neighbour and several others in her locality. "The departed were part of us; we shared many things in this community. This has scared me… I don't want myself or any of my family members to die of this preventable disease," Mwanga said.

Rising danger, rising demand, falling stocks

This is the second time in a year that cholera vaccines have been made available to Blantyre residents, after Malawi secured a tranche of 2.9 million doses from the Gavi-supported Global Oral Cholera Vaccine Stockpile in November. An earlier volley of vaccines rolled out in May – but Mwanga, like many others, was only moved to seek immunisation when the disease arrived at her doorstep.

"I heard about the vaccination campaign in May last year but I honestly took this disease lightly. I have been particularly moved by the deaths of the people I know. Some of them were hesitant to get vaccinated," Mwanga told me as we sheltered under the Bangwe Health Centre awning together earlier this month, watching the rain.

Mwanga and her two kids had each received a dose of OCV that afternoon. They were lucky: according to Blantyre District Environmental Health Officer (DEHO) Penjani Chunda, stocks are running low. "We are remaining with only a few doses to administer. Coverage is at around 80%," he says.

Malawi might be the epicentre of the African epidemic, but cholera is surging globally, with 31 countries reporting outbreaks since December. According to WHO, the global vaccine stockpile had run out by the end of that month.

The May campaign, launched by the Ministry of Health with the support of WHO and UNICEF, targeted 1.9 million people aged a year and older. But with the outbreak growing, demand has spiked, and caused a pivot in strategy.

Ministry of Health spokesperson Adrian Chikumbe explains, "There is high demand of vaccines in [the] hardest hit districts of Blantyre urban, Lilongwe and Likoma districts. We provided the first phase of the vaccines in May in eight districts and this was supposed to be the second dose. But due to the high demand, others have taken only one dose – which is still better than none."

Decisive action

Cholera, caused by the bacterium Vibrio cholerae and transmitted via contaminated food or water, is not a new disease in Malawi. But this outbreak is atypical. Where epidemics typically start in the rainy season, last year the epidemic began in the dry season. The arrival of the rains only accelerated the spread of the waterborne contagion.

At the end of the festive season holidays, the Presidential Taskforce on Covid-19 and Cholera announced a delay in opening of schools in Blantyre and Lilongwe districts.

"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 and to strengthen alternative ways to support sanitation and hygiene in peri-urban areas and to strengthen alternative ways to support uninterrupted learning in schools which was done," Minister of Health, Khumbidze Chiponda, who is also co-chairperson for the Presidential Taskforce for Covid 19 and Cholera, said in a daily update statement on 16 January 2023.

For students, yet another epidemic disruption

While schools in Blantyre and Lilongwe stayed shut, schools in other districts cautiously  reopened on 3 January 2023.

“It’s not compulsory that all children must get vaccinated but we encourage them to get vaccinated. It’s important so that schools should not close again due to this outbreak,"

"At my child's (boarding) school they told us not to give the children any precooked foods. They didn't force us but they told us that the children who received cholera vaccination at home should take their cards to school to be sure of their vaccination status. They were very strict that they searched each and every bag of returning students," said John Lawani, a Lilongwe parent.

Independent Schools Association of Malawi president Wycliff Chimwendo says the closure of schools has created a learning gap between students in the delayed districts, and those in other districts.

"Closure of schools does not help matters," he observes. "Dirty markets remained open; uncollected waste and blocked sewerage pipes have been unattended to when schools were closed. Why not address these matters first before punishing the innocent children and teachers? The school is the safest place for children because there are rules and sanitation is highly observed."

"We, however, encourage parents and guardians to vaccinate their children against cholera," Chimwendo says.

Parents reported mixed reactions to the school-closure policy. "Those in examination classes will have to catch up with their counterparts who opened earlier. Yet they will write the same national examinations," said Janet Kalinya, a Blantyre parent.

"The delay was necessary for the sake of young children in lower classes. It's hard for them to adhere to hygiene and sanitation measures. They can't make a sound judgment on what to consume or not. There are so many cooked foods which are sold along the streets which children can easily just pick and eat without considering hand-washing. The delay gave me an opportunity to have my child vaccinated against cholera," said Elizabeth Chingala, a Blantyre resident.

Alongside protecting her child through vaccination, Chingala says she ensures that her child has eaten enough before going to school. "I also give her a bottle of water for use in school."

Principal Secretary in the Ministry of Education, Science and Technology (MoeST), Chikondano Musa says the ministry has put in place standard operating procedures for schools and colleges to follow.

"It's not compulsory that all children must get vaccinated, but we encourage them to get vaccinated. It's important so that schools should not close again due to this outbreak," she said.

The ministry has confirmed cholera outbreaks in more than three schools as of the second week after school reopening in the less acutely-hit districts. UNICEF says 104 children have died of cholera.

"We appreciate the tireless efforts from frontline health and community workers to manage the influx of cholera cases. The spread of this outbreak is a threat to the health and wellbeing of children," said Rudolf Schwenk, UNICEF's Country Representative, in a recent press statement.


Twitter handle: @JosephineChinel