According to the Africa Centres for Disease Control and Prevention (Africa CDC), cholera cases across Africa surged past 300,000 last year, the highest number recorded in 25 years. The figure is more than a statistic; it is a stark warning that a preventable and easily treatable disease continues to exploit gaps in water, sanitation, and health systems across the continent.

From densely populated urban settlements to remote, flood-prone villages, cholera resurfaces whenever heavy rains overwhelm fragile infrastructure, and poverty limits access to clean water.

In Malawi, where seasonal flooding regularly contaminates water sources and displaces families, authorities are working to stay ahead of the threat. On January 22, the government launched a three-day oral cholera vaccination campaign aimed at reducing the risk of a fresh outbreak as heavy rains intensified.

Health workers fanned out across vulnerable districts, setting up temporary vaccination sites in schools and community centres, urging families to protect themselves before case numbers begin to climb.

Cholera is a severe diarrheal disease caused by bacteria transmitted through contaminated food or water. It can kill within hours if left untreated, yet it is both preventable with safe water and sanitation and treatable with prompt rehydration therapy. Despite this, the disease continues to claim lives across Africa, exposing deep inequalities in access to basic services.

Between 1998 and 2024, Malawi recorded 149,146 cholera cases and 4,333 deaths. Its deadliest outbreak struck in 2022, infecting 59,376 people and killing 1,772, the worst in the nation’s history.

At the height of that crisis, global vaccine shortages left Malawi scrambling for doses, underscoring the vulnerability of low-income countries during worldwide health emergencies.

Many residents, such as parents who took their children to get the vaccination, said that fear of the disease is pushing them to act. Others stressed that vaccines alone were not enough and called for ongoing community education, improved water access, and better preparation.

Malawi’s Vaccination Response

In Malawi’s commercial capital, Blantyre, health officials focused part of the three-day rollout on Chilomoni township, a densely populated area where at least 17 cholera cases and one death were reported.

While residents can buy clean water from private taps, many turn to a nearby stream polluted with human and animal waste when they cannot afford it. Health officials warn that using this water for drinking, cooking, and washing is increasing the spread of cholera, especially in poorer communities with limited access to safe water.

The government planned to begin with 24,000 oral vaccine doses, prioritising the most vulnerable groups, though officials acknowledge far more doses are needed. In a country of more than 20 million people, with hundreds of thousands living in flood-prone, high-risk districts, this represents only a small fraction of those potentially exposed to cholera.

Personal Stories from the Outbreak

For families like Beatrice Chirwa’s, cholera is not an abstract fear; it is a lived reality. Last September, when her young daughters fell ill with severe diarrhoea and fever, she initially dismissed their symptoms as a normal stomach problem. “Their body temperature was very high,” she later recalled. Only after seeking care at Machinga Health Centre did she learn they had cholera.

“Cholera is such a big problem here. I’m just grateful that my children survived,” she said as she returned with them for vaccination.

Her story echoes across affected districts, where fear of the disease is pushing parents to act. Others, however, stress that vaccines alone are not enough. They called for sustained community education, improved water access, and better preparedness before the next rainy season arrives.

Scale of the Outbreak and Emergency Response

Malawi’s Ministry of Health reports that the disease re-emerged in September 2024 in several hotspot districts. Since then, there have been 301 reported cholera cases and 15 deaths. The affected districts included Chitipa, Karonga, Balaka, and Machinga.

In response, authorities drew from the global vaccine stockpile to protect priority areas. Emergency vaccination efforts included 720,000 doses of oral cholera vaccine distributed through fixed vaccination sites and community outreach teams.

Dr Wilfred Chalamila Nkhoma, co-chairperson of the Presidential Taskforce on Public Health Emergencies, emphasised in conversation with Gavi, that vaccines play a role in protecting both those at risk and survivors, noting “you can get cholera more than once even after you recover.”

Floods, Unsafe Water, and Why Cholera Keeps Coming Back

Heavy rains and flooding repeatedly compromise water sources and sanitation systems — conditions that cholera exploits. Vaccines can reduce immediate risk, but outbreaks continue to flare in communities where clean water is scarce, and drainage systems fail.

Cholera has been recorded in Malawi since 1973, with major surges in recent years. The 2022 epidemic, with 59,376 infections and 1,772 deaths, was declared a National Public Health Emergency. It was eventually brought under control through vaccination campaigns and community awareness drives. Still, poor water quality, inadequate sanitation, and limited hygiene infrastructure persist, allowing the disease to return.

In Machinga District, near Lake Chirwa, residents understand that vulnerability is built into their geography. Movement between lakeshore areas and surrounding villages increases exposure risk when health services are stretched thin. Local health workers report shortages of essential supplies, including chlorine for disinfecting water, forcing facilities to depend on distant district hospitals and contributing to preventable deaths.

Health System Capacity and Preparedness

Health officials say they are building on lessons from past outbreaks. Strengthening peripheral health facilities to detect and manage cholera early is now a priority. Early deployment of response teams and mobilisation through traditional leaders has also proven critical in containing the spread.

At the community level, engagement is central. For Elias Wisiki, a resident of Alikunde village, the decision to get vaccinated was shaped by nearly losing a cousin to cholera. “It’s like it happened yesterday,” he said. When he heard village announcements about the campaign, he did not hesitate. “I don’t want this to ever happen to my family again.”

Many households are already taking preventive measures, treating drinking water with chlorine and practicing handwashing where possible. But these steps depend on consistent access to supplies — something not always guaranteed.

Malawi’s Five-Year Cholera Control Plan

Beyond emergency response, Malawi has adopted a long-term strategy aimed at ending cholera as a recurring public health crisis. The Malawi Multi-sectoral Cholera Control Plan (MMCCP) sets out a national framework to shift from reactive outbreak control to sustained prevention and elimination, with the total cost of implementing the five-year plan estimated at USD 99.9 million.

 Led by the Presidential Taskforce on Public Health Emergencies, the plan targets the underlying drivers of cholera, including unsafe water and sanitation, weak infrastructure, and climate-related risks such as flooding. Interventions are concentrated in 118 Traditional Authorities identified as Priority Areas for Multi-sectoral Interventions (PAMIs), where the burden of cholera is highest and which account for the vast majority of cases and deaths nationwide.

The strategy is built around core pillars that include the expansion of climate-resilient water, sanitation, and hygiene (WASH) services, the implementation of pre-emptive oral cholera vaccination campaigns in high-risk areas, the strengthening of disease surveillance and early warning systems, and the improvement of outbreak preparedness and rapid response capacity.

The MMCCP aims to cut annual cholera incidence by 90% by 2030 and to keep the case fatality rate below 1%, in line with global elimination targets set by the World Health Organisation (WHO). If fully funded and implemented, the plan provides a roadmap for combining vaccines, safe water, and stronger health systems to move Malawi closer to eliminating cholera as a persistent public health crisis.