Malawi is the first country in Africa to utilize the recently updated Global Task Force for Cholera Control tool to identify priority areas for multi-sectoral interventions (PAMIs, also called hotspots) for cholera control. A timely approach as the country embarks on a roadmap to develop a multi-sectoral cholera control strategy.

Dr Fred Kapaya, a cholera expert from World Health Organization African Regional Office (AFRO) supports Member States in the region with cholera preparedness and response. He elaborates the stepwise actions commenced to identify PAMIs with an orientation of the tools and procedures by AFRO. Followed by one month of data collection covering a 6-year period from 2018 to 2023 for each geographical unit. The cholera data was complemented by a compilation of vulnerability indicators for each geographical unit. Evaluation of the data took into consideration historical events of natural disasters (cyclones, floods), climate, proportion of households accessing safe water, sanitation coverage, population density, ongoing urban migration, and importation of cross border cholera cases from neighboring countries.

He explained the second step involved application of multiple dimensions of cholera burden; incidence, mortality, persistence, and cholera test positivity to score each unit. A numeric threshold was applied to categorize levels of priority, leading to production of a list of PAMIs (hotspots). The third step was a national stakeholder meeting to validate the priority list of cholera hotspot areas requiring multi-sectoral interventions (PAMIs).

“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”, Dr Kapaya said.

Mangochi, Nsanje, Chikwawa and some parts of Lake Chirwa in Zomba remain the four districts among others with recurrent and consistent sporadic cases in Malawi. Cholera and other waterborne diseases are known to proliferate in the rainy season mostly due to poor waste management and water, sanitation hygiene practices. These districts contribute a significant number of hotspots.

Ronnex Nguwo the Integrated Disease Surveillance and Response (IDSR) Coordinator for Nsanje district, indicated multi-sectoral interventions have worked significantly in reducing cholera cases in Nsanje, a district which is still currently registering sporadic cholera cases. Nsanje is spread across two riverbanks, the west bank and east bank of the Shire River with high populations inhabiting the banks with makeshift houses, their source of water being the river, with low coverage of sanitation facilities like pit latrines and waste pits. The district borders Mozambique which hosts communities with similar characteristics that trade and coexist between the two countries bearing consistent cross border cases.

Boniface Grim, Assistant Environmental Officer at Chikwawa District Hospital, emphasizes 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. Grim highlights the key role played by the Emergency Medical Team, which comprised various healthcare professionals and coordination teams. This team, deployed by the Ministry of Health with support from the WHO, worked closely with communities and officials to manage cases, track them into Mozambique through surveillance, provide behavior change messages, and distribute essential WASH (Water, Sanitation, and Hygiene) resources. This comprehensive approach had a profound impact reducing number of new cholera cases in the district.

Grim underscores 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.

WHO Malawi’s Country Preparedness and IHR Officer, Dr. Gertrude Chapotera explains 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 emphasizes 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, with the aim of identifying and addressing the specific needs of each area.

WASH Project Manager for Amref Health Africa, Young Samanyika underscores the holistic nature of this approach in containing cholera in Malawi. He points 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 President and Cabinet (OPC), stresses 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.