Cholera outbreak in Malawi linked to COVID, floods, myths

Malawi-On January 11, 2023, 26-year-old Chawanangwa Simfukwe from Mpata was admitted to Karonga District Hospital, becoming one of two cholera patients registered in the district, writes Tiwonge Kampondeni, MANA.

Across Malawi, there were 589 new cases and 892 patients admitted to health facilities, with 17 deaths on that day alone.

Nationally, since the outbreak began in March of the previous year, there had been 22,759 cases and 750 deaths.

Although Simfukwe was discharged the following day, he was still haunted by the experience.

"I came here yesterday at noon. I was so weak, my legs hurt, and I had a running tummy. I couldn't control it. I thought I was going to die, but I was given a drip, and after a few hours, I started feeling much better," he says.

Simfukwe's face flushes with excitement when he learns he can go home.

However, he jokes about how he might have become infected, saying, "I have been forgetting to wash my hands after using the toilet (nkhaluwanga kugeza mmawoko pala nawerako ku chimbuzi). I have been eating vimbala (food leftovers from the previous day). I have also been drinking untreated water from the Towo River. But these are the things I have been doing all my life and I never got sick. Why should I get cholera now?"

To Simfukwe, it seems strange that he has to change his habits and start drinking treated water and practising good hygiene.

"They are saying I have to change. So, I don't have to eat chimbala chizizimu (cold food leftovers). I don't understand, but I am told it is an outbreak," he giggles.

Before leaving, Simfukwe sympathetically greets another cholera patient in the ward, 21-year-old Phyoka Msiska from Katili, and wishes him a speedy recovery. Msiska was still too weak to speak and could hardly move.

"I know that I am in the hospital, but I don't remember how and when I got here," he says.

Msiska's rice water stool fell into the bucket with a sound resembling that of a running water tap, in full view of onlookers.

Karonga District Hospital Clinical Technician Mercy Kalambo, one of the nurses attending to cholera patients, explains that all cholera patients at the hospital are treated at the Emergency Treatment Unit (Isolation Unit).

Kalambo notes that most cholera patients arrive at the hospital with severe dehydration, and the priority is to stabilize their condition.

"We had to administer IV fluid drips to Simfukwe and Msiska. When they improved, we switched to ORS. We also made sure that people who had contact with them at home and during transportation to the hospital took precautionary measures," she says.

Kalambo is pleased that almost 98 percent or 99 percent of the patients recover, although some cases experience reinfections.

"We treated a patient who was discharged but returned a few days later, very sick," Kalambo says.

For Simfuke and Msiska, their story is a sad one with a happy ending, as both patients fully recovered.

However, most communities in this lakeshore district use water from unsafe sources, lack toilets, and compromise on hygiene and sanitation.

According to the World Health Organisation (WHO), as of 29th January 2023, 26,000 cases and 660 deaths have been reported in 10 African countries facing outbreaks since the beginning of the year. Malawi is the hardest hit, with cholera cases reported in all 28 districts.

During a February ESAR RCCE Media Dialog - Africa's Cholera Outbreak: What Journalists Need to Know webinar, Public Health Expert Dr. Otim Patrick Ramadan, World Health Organisation (WHO) Regional (Africa) Epidemiologist based at WHO Emergency Hub in Nairobi, stated that for Malawi, the outbreak was caused by a combination of different factors.

Ramadan cited last year's flooding due to Tropical Cyclone Anna, COVID-19, which resulted in severe economic situations, and misinformation and myths as triggers for the spread of infections.

"Tropical Cyclone Anna, which occurred in January 2022, damaged water and sanitation infrastructure in the southern part of the country where the outbreak began. This contamination of water sources, flooding of latrines, and the spread of fecal water significantly increases the risk of a cholera outbreak," he says.

Ramadan observes that the implication of COVID-19 on Malawi's economy left the country with less capacity to give cholera the response it needed when the outbreak started, such as conducting mass vaccinations.

He adds that misinformation and myths also amplified the spread, as people did not get vaccinated due to fears of unfounded claims.

An environmentalist and president of the Association for Environmental Journalists (AEJ) in Malawi, Mathews Malata points out the linkage between poor hygiene, sanitation, and waste management, which he says have created a conducive environment for the spread of cholera.

“If we have indiscreet disposal of waste, what that means is that some of it goes into the soil, polluting the soil. It can also lead to the contamination of the groundwater and if you are drinking groundwater that is contaminated you are at risk of getting infected,” Malata says.

Chisomo Youth Organisation Director Davie Kitalu says they have taken an initiative to demonstrate to the communities their role to have clean surroundings.

Kitalu’s concern is that waste management remains an environmental challenge for this lakeshore district.

"Garbage is disposed of anyhow and most uncollected waste finds its way into the lake and other water sources after getting washed away with the rainfall. With the cholera outbreak, we have been cleaning the Karonga Market, and collecting waste from the streets. We hope the communities will be able to take care of their surroundings," Kitalu says.

Traditional Authority (T/A) Kalonga laments how democracy is making it hard to engage communities in good practices.

"There was a time a community member challenged me that he can't be forced to construct a toilet for his household. He told me that if I want him to construct the toilet I should pay him," Kalonga said.

Karonga-Chitipa Civic Education Expert officer for National Initiative for Civic Education Trust (NICE), Mabvuto Mkandawire is certain that a number of things that Malawi is grappling with, including cholera, require a mindset change.

"Mindset change is Malawi’s 2063 Vision first enabler. If only people would change by ensuring that they have toilets, use clean water, and take the vaccine, cholera would be a thing of the past. A number of people here in Karonga haven’t gone for vaccination because they feel it's not important. Some have their own beliefs," he said.

Among the initiatives, Karonga district led by the district hospital has been involved in good practices campaigns, awareness, and distribution of chlorine among others.

While Karonga and other districts have made progress in reducing cholera cases, there are fears that the recent flooding and infrastructure destruction due to tropical Cyclone Freddy could be a breeding ground for more cholera cases.

The cyclones pose a challenge to SDG 3 and SDG 6.