Malawi has been experiencing frequent cholera outbreaks since it reported the first case in 1973. The most significant outbreaks occurred in the cholera seasons of 1998/1999 and 2001/2002. The worst outbreak occurred recently in 2022/2023 with 53,020 cases and 1,586 deaths (3%CFR). These outbreaks have been common around lake Chilwa in Machinga, Zomba and Phalombe, the Lower Shire in Chikwawa and Nsanje and Lakeshore districts from Mangochi up to Karonga.

Malawi is vulnerable to cholera due to poor WASH the situation which is worsened by frequent weather events, such as cyclones, storms, floods, landslides, and droughts. Four Cyclones namely Idai, Anna, Gombe, and Freddy experienced within a space of 5 years from 2019 caused serious damage to WASH infrastructure and health facilities worsening the risks and occurrence of cholera.

When WHO and Global Task Force Cholera Control (GTFCC) launched Ending Cholera strategy – a Global Roadmap to end cholera by 2030 Malawi required to come up with Priority Areas for Multi Sectoral Interventions (PAMIs). This was the initial step towards formulating the National Cholera Control Plan according to Global Task Force on Cholera Control (GTFCC). Malawi was the first country in AFRO to use the new tool in identifying these areas for cholera control. The areas (Traditional Authorities) were those with high priority index values calculated using epidemiological indicators including number of cases and deaths recorded over 5 year-period and other vulnerability such as natural disasters, risk of cross border infection and high population density, that if prioritized and targeted with multi sectoral interventions would reduce future cholera cases and deaths.

 The PAMIs were identified using the following information: -

• Data on cholera outbreaks from 2018 to 2023
• Calculated cholera priority values for all geographical units across the country
• Selection of priority areas based on priority index values for multi-sectoral interventions.

This process led to the identification 80 TAs which had experienced 86% of cases and 58% of deaths from 2018. There was a validation workshop which led to the identification of an additional 39 Tas. The TAs that had the highest priority index score of 9 based on the initial Minimum Index Score were: Kapeni, Kuntaja, Machinjiri (Blantyre), Kachindamoto (Dedza), Chitukula, Kalumbu (Lilongwe), Mlomba (Machinga), STA Lulanga (Mangochi) Kambwiri, Maganga, Kululanga (Salima).

The validation workshop by all relevant stakeholders recommended the addition of 38 more TAs among which the priority was Chigalu (Blantyre), Mposa (Machinga), Chilipa, Mtonda (Mangochi), Mabuka (Mulanje), Mankhambira (Nkhatabay), Malengachazi (Nkhotakota) and Masasa (Ntcheu). A total of 118 TAs were identified as PAMIS in 20 districts in Malawi. It was recommended that these PAMIS for Malawi should be prioritized in the development of the Malawi 5 Year Integrated National Cholera Control Plan 2024-2030 (NCP) and annual planning by all Stakeholders such as District Councils. It was also recommended that the review of the PAMIS should be an ongoing process. Routine interventions should continue in all TAs regardless of PAMIS status. As one of the first countries to identify its PAMIs, Malawi has been critical in sharing information with other countries in the region who are set to identify their areas for prioritised multi-sectoral interventions for cholera control.