Africa is experiencing an “exponential rise in cholera cases,” the World Health Organization (WHO) warned on February 9. “Exponential” is a frightening adjective, as 10 African countries are dealing with epidemics to varying degrees. In January alone, cholera cases “have already risen by more than 30% of the total caseload reached in the whole of 2022” across the continent, the WHO’s African office said.
While in the West only Nigeria and Cameroon are currently affected, central and eastern Africa are suffering more: The Democratic Republic of Congo (DRC), Burundi, Kenya, Ethiopia, Somalia, Mozambique, Zambia, and, most importantly, Malawi are all facing an outbreak.
On Monday, February 27, Malawi, a south-eastern African country of 20 million people, accounted for nearly half of the cases in the continent, with 49,207 reported cases and 1,564 dead since March 2022. In early December, the government called the epidemic a “public health emergency.”
Marion Péchayre is Doctors Without Borders (MSF)’s head of mission in Malawi and manages all of the NGO’s activity in the country. In an interview with The worldshe explained the challenges posed by the worst cholera epidemic in the country’s history when vaccines are unavailable.
Can you provide an update on the situation in Malawi?
Marion Pechayre A peak of almost 700 new cases per day was reached around February 3. Since then, the epidemic has been losing steam, counting less than 500 daily cases. This downward trend is constant, but we still do not know if the worst is behind us. The situation remains all the more delicate as it has started to rain heavily again. The rainy season, which lasts from November to April, makes the infection spread more easily. And we are still in the cyclone season. So we have to be very careful.
MSF has been on the front line since the beginning of the crisis, joined in early February by WHO teams and the NGO Save the Children. Can we say that the situation is under control?
Today, all 29 districts in the country are affected. As of mid-February, only two of them, Chikwawa and Nsanje, had the epidemic under control. These two southern districts, normally hit by cholera, vaccinated their population between May and October 2022 as a preventive measure. The two-dose oral vaccine they administered provides protection for three to five years. Today, nine districts have reported fewer than four cases of infection per day.
As soon as the first cases appeared in March, MSF doubled its teams on the ground to respond to the emergency by opening several cholera treatment centers (CTCs). We saw the epidemic move from the South to the North. We immediately requested vaccines from the International Coordinating Group (ICG), which manages the global emergency stockpile, and we started vaccinating in May as soon as we received the first doses. But that was not enough to stop the outbreak.
Cholera has hit the country on a recurrent basis since 1998. Why is this year’s epidemic more virulent?
It is a combination of several factors, some known, others exceptional. The first cause of contamination the lack of drinking water, sewage infrastructures and latrines in villages. You should know that Malawi is the poorest peaceful country in the world.
With the Covid crisis, its socio-economic situation deteriorated sharply. Then came the war in Ukraine and inflation, which soared to 27%. The currency, the Malawian kwacha, was devalued in May. In January 2022, Tropical Storm Ana flooded and destroyed large parts of the territory. The poor have become even poorer. Health deteriorates quickly in these circumstances, even more so in a country where the already underfunded healthcare system was undermined by Covid.
In a healthy person, cholera is like having gastroenteritis. But when you are unhealthy and undernourished, cholera can quickly become deadly. Vibrio cholera poisoning causes diarrhea and vomiting, which leave you dangerously dehydrated. Seeing people die from cholera is all the more tragic because treating the sick is extremely simple: You just need to rehydrate them orally or through IV.
Many have put forward the hypothesis that the increase in extreme climatic events is making the situation worse. What do you think about this?
I am not a climate expert, but we have seen more rainfall, in addition to two tropical storms. The water level of Lake Malawi has never been so high. Cholera usually develops from this large lake, which runs the length of the country and crosses over into Tanzania and Mozambique. Locals use its waters for fishing, drinking, irrigating crops, bathing and, unfortunately, also to relieve themselves. These conditions favor the reappearance of vibrio.
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However, this year the epidemic spread up North from the South, where the Mozambican border is, more than 100 kilometers from the lake. As we can see, we have to be very careful, because an outbreak can start in several places at the same time and it is always the result of several combined parameters. Moreover, genetic analyzes of the vibrio are underway to determine if the current bacteria are mutant or not. This could also explain why the epidemic is more virulent this year.
How can we explain that cholera is still rampant in the 21st century when there is a very effective vaccine?
The scarcity of cholera vaccines is the real issue. World production is very inadequate and now relies on only one manufacturer, the South Korean EuBiologics. We are managing the shortage of a vaccine that is considered unprofitable by the overwhelming majority of laboratories.
When, in January, MSF wanted to anticipate the outbreak, the IG could not supply us. First, because they can only do so when the first case is declared; second, because the production of the vaccine, although important and increasing, is insufficient. Finally, there is no intermediary procedure for preventive emergency campaigns, although all the indicators in Malawi justified raising the alarm.
To counter the shortage of cholera vaccines, the WHO decided in October 2022 to revise its vaccine strategy and switch to a single dose in order to immunize twice as many people. What are your thoughts on this?
We are facing a series of emergencies at once in countries that struggle with limited domestic resources and between international priorities: Covid, polio, HIV, measles, etc.
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Take polio, for example. For a single case detected in February 2022 [the first in 30 years, according to WHO Africa], millions of children in Malawi, in particular, were vaccinated by the WHO, because the UN agency is in the process of eradicating the disease. Even if we understand this approach and know that it is legitimate, we should ask ourselves how seriously the cholera epidemic and the vaccine shortage will hit Malawians. If GAVI, the international organization charged with improving vaccine equity, said, “We’ll buy double the number of doses,” manufacturers would start producing enough.
In addition to treating the sick and vaccinating them when the epidemic is already here, our strategy is based on educating communities and distributing chlorine, soap and toilet buckets, which we are doing with Unicef and other international players. But all these people deserve to be properly protected without waiting for the country to have the means to improve its sanitation infrastructure and access to drinking water.