Malawi: Vaccination in Response to Flooding
The first case of cholera in Malawi was reported in 1973, however, from 1977 to 2012, Malawi experienced annual outbreaks. In 2012 specifically, cholera was widespread in the southern region, with a reported 1,806 cases and 38 deaths. Currently, cultural norms and poor water, sanitation and hygiene conditions continue to impact cholera in the country.
In 2015, Malawi experienced extreme flooding, leading to the displacement of approximately 100,000 people in the Southern region. Due to concerns that flooding might cause a cholera outbreak in the 19 internally displaced persons (IDP) camps and surrounding areas, the Malawi Ministry of Health (MOH) declared a state of disaster and made the decision to implement a cholera vaccination campaign.
 Msyamboza, K. P., Kagoli, M., Chipeta, S., & Masuku, H. D. (2014). Cholera outbreaks in Malawi in 1998-2012: social and cultural challenges in prevention and control. The Journal of Infection in Developing Countries, 8(06), 720-726.
- The Malawi MOH submitted an application for the oral cholera vaccine (OCV) Shanchol from the Global Stockpile for Malawi’s first-ever mass vaccination campaign. The MOH received 210,000 doses from the International coordination Group (ICG) emergency stockpile and 110,000 from the international Vaccine institute (IVI), which was already working in the country and intending on using the vaccine.
- The reactive cholera vaccine campaign targeted all persons one year old or older in IDP camps and surrounding communities. Awareness of the campaign was spread through criers, word of mouth between friends and neighbors and by health workers. Health workers administered the vaccine.
- The campaign reached approximately 150,000 people. Overall, vaccination coverage with at least one dose in the IDP camps was 93%. Of those living in the camps and surrounding areas, 78% were vaccinated with two doses, 15% with one dose, and only 6.3% were unvaccinated.
- Due to the risk of complications from cholera infection during pregnancy, the MOH, in consultation with the WHO and other partners, made the decision to include pregnant women in the vaccination campaign. The World Health Organization (WHO) recommends considering pregnant women for vaccine if they are vulnerable to cholera infection however, pregnant women have largely been excluded from clinical trials of oral cholera vaccine (OCV) due to limited data on its safety during pregnancy. Therefore, given the lack of definitive evidence, the vaccine label is cautious about its use during pregnancy.
 For more information on the safety of OCV in pregnant women read In Brief: Cholera and the Use of Oral Cholera Vaccines in Pregnant Women.
- Stakeholder Support: The Malawi MOH held several discussions and presentations regarding the efficacy and use of OCV before deciding to implement the vaccine in country. Having the support of key stakeholders and OCV champions was essential in approving the use of OCV.
- Health System: Malawi uses field health workers to deliver basic health services, including vaccines, at the community-level. The OCV campaign used these health workers to administer the vaccine. Local health workers often tap into existing health systems, including personnel and resources, contributing to the efficiency of OCV campaigns.
- Transportation: Due to flooding in the southern region, many roads were impassable. Therefore, boats turned out to be the only way to reach certain communities. Given that the MOH did not have boats, they partnered with local police stations and other partners to reach these communities. This issue highlights the need for partnering with agencies outside of the health sector and preparing for unforeseen logistical challenges.
- Surveillance: Local laboratory capacity, including adequate supplies, personnel, and staff capacity all feed into successful surveillance systems for accurate and timely results.
- Registers: Paper-based registries of vaccine administration posed operational challenges as they took time to look up individual records and fill out personal information, creating long lines. Organizations implementing campaigns should consider appropriate, context- specific methods to obtain the necessary information in the most efficient way.
- Media: Media outlets reported that the vaccine was not recommended for pregnant women, citing the language on the vaccine packaging that states: "The vaccine is therefore not recommended for use in pregnancy. However, Shanchol is a killed vaccine that does not replicate, is given orally and acts locally in the intestine. Therefore, in theory, Shanchol should not pose any risk to the human fetus." In response to public concerns, the Malawi MOH met with media outlets to explain that the WHO approves the use of the vaccine for pregnant women. This scenario highlights the importance of communication with local media outlets before vaccination begins to prevent the spread of misinformation.
- Community Mobilization: Prepare media outlets, community leaders, criers or public announcers, and other influential stakeholders for community mobilization with accurate information about the vaccine and the importance of receiving the vaccine for preventing the spread of cholera.
- Advocacy: Advocate for the use of OCV among influential stakeholders. Identify OCV champions to support and lead advocacy efforts with decision-makers. Use vaccine effectiveness and other data to make the case.
Contributors: Mohammad Ali, Johns Hopkins University DOVE Project; Maurice Mwesawina, MOH Malawi; Allyson Nelson, Johns Hopkins University DOVE Project; David Sack, Johns Hopkins University DOVE Project; Anne Ballard, Johns Hopkins University DOVE Project.