Malawi Cholera & Floods Flash Appeal 2023 (Revised in March following Cyclone Freddy) (February - June 2023)

Crisis Overview

FLOODS

The Tropical Cyclone Freddy weather system brought torrential rainfall to southern Malawi from 12 to 15 March 2023, causing devastating floods and mudslides and leaving a trail of destruction across 15 districts—including Balaka, Blantyre District, Blantyre City, Chikwawa, Chiradzulu, Machinga, Mangochi, Mulanje, Mwanza, Neno, Nsanje, Phalombe, Thyolo, Zomba and Zomba City. Over 1,000 people were killed, according to the President, and many more were injured. Critical infrastructure, including homes, health facilities, schools, roads, bridges, food stores and markets were damaged or destroyed. At least 44 roads were damaged—of which 16 are major roads, 17 are secondary roads, and 10 are tertiary roads—and over 40 bridges were damaged.

Over 2.2 million people were affected by the heavy rains and floods caused by the Tropical Cyclone Freddy weather system, according to the Government, of whom an estimated 1.3 million people are in the most urgent need of assistance in prioritized districts, according to humanitarian partners . This was calculated—as a subset of the overall number of people affected—utilizing satellite imagery to identify the areas that were hardest-hit by the floods and the number of people located within, and adjacent to, these areas in the 10 most-affected districts. Of the 1.3 million people in urgent need in the immediate aftermath of the storm, over 600,000 people were located in Traditional Authorities (TAs) that were inaccessible by road or boat. Within the 1.3 million people in need, nearly 276,000 children under age 5, and almost 92,500 pregnant and Pregnant and Lactating Women (PLW) are in need of humanitarian support in 15 affected districts.

Cyclone Freddy caused widespread damage to homes, as floods, with over 659,000 people displaced—including over 323,000 males and 336,200 females—across 747 displacement sites at the peak of the crisis. Families who lost everything require non-food items to restart their lives, while camp coordination and camp management is a priority, especially in large displacement sites, to ensure equitable access to services and protection and preserve displaced people’s dignity. At the same time, efforts to ensure that any returns or resettlement are safe, dignified, voluntary and informed will be critical.

At least 1.3 million people will require urgent food and livelihoods support following the impact of the flooding on agriculture, livestock and household food stocks. More than 200,000 hectares of agricultural land were impacted—including nearly 81,700 hectares submerged and over 120,400 hectares washed away—and over 1.4 million livestock were affected, exacerbating food insecurity in the affected districts. Most households lost their food stocks due to floods which soaked and washed away food commodities. Tropical Cyclone Freddy hit the region at a time when more than 2 million people in southern Malawi were already facing Crisis (IPC Phase 3) levels of food insecurity. In addition, maize prices—which were already 214 per cent higher than the same time last year and 195 per cent above the five-year average—are likely to increase in the aftermath of the storm, according to FEWSNET.

Freddy caused major damage to health facilities, with at least 65 health centres affected, of which 10 health centres were rendered non-functional, 41 were partially damaged but functional, and 14 were not accessible due to damaged roads or bridges. Support is required to restore services in the damaged health centres, replenish essential drugs, and re-establish the cold chain, especially to assist the most vulnerable who require care, including the sick, people with disabilities, people living with HIV/AIDS, the elderly, pregnant and lactating mothers and children under age 5. At the same time, the arrival of Freddy has placed immense strain on a healthcare system that was already struggling to respond to the worst cholera outbreak in Malawi’s recent history, on the back of COVID-19 and other disease outbreaks.

Access to safe water and sanitation was also severely affected by Freddy, particularly for displaced people living in collective centres, as well as people surrounded by flood waters. Widespread standing floodwaters, damage to water, sanitation and hygiene (WASH) infrastructure and facilities, and large-scale displacement all increased the risks of water- and vector-borne diseases, including cholera, as well as respiratory illnesses. Open defecation is expected to increase whilst access to safe and clean water has decreased.

Women will be particularly impacted by reduced access to safe water and unsanitary conditions as they will have to walk longer distances to access safe water, face reduced access to necessities for their menstrual hygiene management, and use crowded latrines in communal spaces, increasing the risk of gender-based violence.
Children’s lives were upended by the crisis, with access to school, adequate nutrition and protection all hampered by the storm. At least 550 primary schools and 74 secondary school were affected in 15 districts, disrupting the education of over 724,800 learners.

At least 408 schools in flood-affected areas were used as shelters for displaced families, who occupied at least 1,481 classrooms.

Over 99,500 children under age 5 and more than 52,700 pregnant and lactating women were displaced from their homes and are living in camps. Urgent action is needed to conduct mass nutrition screenings and ensure that integrated nutrition and health services—such as immunization, Vitamin A supplementation and complementary food support—are provided, alongside nutritional support. The floods are undermining the resilience and psychosocial wellbeing of children and their caregivers, leaving many experiencing distress, with limited or strained support systems.

The heavy rains and floods have increased protection concerns, including sexual exploitation and abuse (SEA). Marginalised people, people with disabilities, the elderly, women and unaccompanied children, experience greater difficulties in accessing essential aid and services, and are vulnerable to abuse, violence and exploitation at points of assistance during disasters. In the aftermath of Freddy, safety issues have reportedly arisen—particularly in displacement sites—particularly due to the lack of adequate, gender-segregated toilets and bathing facilities, mixed sleeping arrangements between men, women and children in displacement sites, lack of lighting in camps, long distances to sanitary facilities and sources of energy for cooking, and the sudden increase of responders deployed for immediate assistance. Gender discrimination places women and girls, particularly adolescent girls, at additional risk, including to child marriage and other forms of sexual abuse and exploitation such as rape, harassment and trafficking. Existing services, helplines and referral pathways for protection services, including PSEA, child protection and gender-based violence (GBV), are limited in their capacity to respond to the increased needs and urgently require additional resources to scale up.

CHOLERA

Malawi is facing its deadliest cholera outbreak in recorded history and its largest in the last two decades, leaving 4.8 million people in need of assistance in 15 priority districts. The outbreak was officially declared on 3 March 2022, after the first case was reported in Machinga district at the end of February 2022. By 18 February 2023, the outbreak had claimed the lives of more than 1,400 people, with more than 45,400 cases recorded, and had an overall case fatality rate (CFR) of 3.21 per cent, more than three times the emergency threshold. The current outbreak has already surpassed the 2001-2002 epidemic, which was the worst in the country’s recent history, that registered 33,000 cases and 1,000 deaths.

The outbreak escalated exponentially in late-2022 and early-2023.

In the early months of the outbreak, the number of monthly cases remained below 60, but this increased to more than 300 cases in May, nearly 800 cases in August and more than 2,000 cases in October. The start of the rainy season in November 2022 saw a rapid escalation in the outbreak—with more than double the number of cases (more than 4,700) compared to October (more than 2,000)— and cases then rose precipitously in the first weeks of January 2023, with an average growth rate of 16 per cent per week.

Communities living by and around Lakes Malawi, Malombe, Chiuta and Chilwa have been most severely affected by the outbreak, as they rely on the lakes for their drinking and cooking water supply.

Although the outbreak was initially limited to the southern part of the country, it has since spread to all 29 districts of Malawi, including areas that were cholera-free for more than a decade. However, 10 of the 29 districts have contributed over 80 per cent of cases and nearly 82 per cent of the deaths. Eight out of these ten districts— Mangochi, Salima, Nkhata Bay, Nkhotakota, Balaka, Machinga, Rumphi and Dedza—are lake districts, while the other two—Blantyre and Lilongwe—are major urban centres. Three districts—Mangochi, Lilongwe and Blantyre—accounted for nearly 50 per cent of the total cholera cases in the country, recording more than 29,600 out of almost 57,600 cases, and over 52 per cent of the total deaths (899), as of 12 April. Mangochi had the highest cumulative cases (8,479) and Lilongwe accounted for the highest number of deaths (558).

Fishing communities, children, women and girls (especially those who care for sick family members), are at increased risk of contracting cholera and are also facing specific consequences due to the crisis. Fishing communities—especially men and boys—are at particularly high-risk as they use lake waters as a source of drinking water (including while fishing) and for defecation, cooking and bathing, including while fishing, according to a study based on the oral cholera vaccination campaign in these communities in 2016 by Sauvageot et al. Children have been affected by the outbreak, with 41 per cent (9,982) of cholera cases and 20 per cent (142) of cholera deaths being children under 18 years of age, as of 31 January 2023. The outbreak has also interrupted children’s education, with the Ministry of Education temporarily postponing the reopening of schools in Blantyre and Lilongwe in January 2023, affecting nearly 932,000 primary school students and more than 55,600 secondary school students. Gender roles heighten women and girls’ exposure to cholera, as they care for sick family members, clean latrines, fetch and handle untreated water and prepare food. Vulnerability in women and girls in Malawi is exacerbated by unequal power relations and social and economic disadvantages that also heighten the risk of sexual exploitation and abuse. Some 44 per cent of all cholera cases were female as of 13 February 2023. Malawi is home to 56,300 refugees and asylum seekers, most of whom live in the Dzaleka refugee camp, where they are at heightened risk of cholera due to overcrowding, the poor WASH situation, and low cholera vaccination rates among refugees and host communities.
The key drivers of the escalating outbreak are use of unsafe water sources, limited access to safe sanitation and hygiene facilities, and poor food hygiene and hygienic practices, particularly limited handwashing with soap at critical times, including after contact with Cholera cases. An estimated 7 million people in Malawi (30 per cent of the population) do not have access to safe drinking water, while more than 80 per cent of households drink contaminated water, according to UNICEF. Access to sanitation is also a key challenge, as 76 per cent of the population does not have improved sanitation and 17 million people (92 per cent) do not practice handwashing with soap and water. Barriers to handwashing include affordability and availability of soap, especially for rural households.

Remembering when to wash hands was also pointed out as a barrier to handwashing, in a study carried out among rural communities in Malawi by Chidziwisano et al.

The cholera outbreak is also taking place at a time when many impacted communities are still struggling to recover from the effects of Tropical Storms Ana (January 2022) and Gombe (March 2022). Extreme weather events—such as storms, cyclones, and floods—act as a vulnerability multiplier, destroying Water, Sanitation and Hygiene (WASH) infrastructure and increasing challenges in access to safe water and sanitation. Repair of damaged water infrastructure is a costly venture and most facilities destroyed during Tropical Storm Ana and Cyclone Gombe remain in a state of disrepair, leaving communities that previously had access to clean water without safe sources and increasing their risk of cholera. In the wake of the two storms, many public and private latrines collapsed, putting pressure on the remaining, already inadequate, facilities.

The outbreak is also impacting communities that are facing heightened food insecurity and malnutrition. During the peak of the lean season (between October 2022 and March 2023),

3.8 million people in Malawi (20 per cent of the population) are expected to endure Crisis food insecurity (IPC Phase 3), with 21 districts classified in Crisis, according to the latest Integrated Phase Classification analysis. In 2022, all districts experienced late onset and early cessation of rainfall coupled with localized dry spells, while Southern Region districts were affected by cyclones. Communities are also navigating the continued impact of the war in Ukraine on food prices, potential reduced internal food production due to high prices of inputs and possible climatic shocks, and reduced labour opportunities and wages.

Looking ahead, experts anticipate that, unless urgent, intensified action is taken to scale-up the response, between 64,000 and 100,000 cases could be reported in the next three months. However, the high number of cholera cases and large geographic spread of the outbreak have strained response capacities, against a backdrop of a weakened health system, which was already overstretched by competing disease outbreaks, including COVID-19 and Polio.
Health officials expect a large portion of the cases will require hospitalization in Cholera Treatment Units (CTUs) yet, only 42 per cent of the CTUs in the country (140 out of 344) are operational.