BLANTYRE, MALAWI – As early as 6:30 am, Malawi’s community health workers are already scattered across urban and rural neighbourhoods, dressed in sky-blue uniforms with square cooler boxes slung over their shoulders.

For four days in mid-August, health surveillance assistants (HSAs) across the country walked from door to door, administering the novel oral polio vaccine (nOPV2) to all children under the age of 10.

The cold weather and drizzle did not stop frontline health workers from carrying out their mission.

“I take pride in providing such lifesaving vaccines to children. It’s not really about the money, but the passion I have to contribute to public health,” said Raymond Issa, an HSA under the Blantyre District Health Office (DHO). 

Polio is a highly infectious disease that can cause permanent paralysis. There is no cure, but it can be prevented by vaccinations.

On the first day of the campaign, Issa visited 180 homes in three neighbourhoods, looking for children to give the polio drops to.

By 7.50 am on the second day of the campaign, Issa had already collected his ice packs and barely had time to talk to Health Policy Watch.

“My team members are already waiting for me,” he said, rushing off alongside a community mobiliser to resume vaccinations for the day.

This is the fourth mass campaign in Malawi. It is targeting children under 10 years old following the detection of a polio case in an unvaccinated seven-year-old child in Blantyre in December 2025. 

To interrupt any ongoing transmission, health workers are administering the oral vaccine in line with Global Polio Eradication Initiative (GPEI) guidelines for supplementary immunisation.

Mass supplementary campaigns aim to interrupt circulation of poliovirus by immunising every young child – in Malawi’s case, all under-10s – with two doses of oral polio vaccine, regardless of their previous immunisation status.

The drive builds on past responses, including a drive in February 2022 after Malawi recorded its first wild polio case (type 1) in 30 years, the first in Africa since the continent was declared free of wild polio in 2020.

Community mobilisation

In M’bwana village, in the Chigalu Traditional Authority of rural Blantyre, Favour Divierious had already vaccinated 100 children by 9 am.

“The volunteer on our team did a great job mobilising communities. I managed to vaccinate many children because some mothers had organised them in one place,” said Divierious, who is also a HSA.

However, long distances present a persistent challenge. “This morning I have already walked eight kilometres. Sometimes I use a motorbike, but it is expensive because we usually do not receive allowances during the campaign.” 

As it is the school holidays, house-to-house distribution is necessary unlike during school time when health teams can administer doses directly in classrooms.

Beatrice James, of M’bwana village, was among those waiting to have her six-year-old daughter vaccinated.

“I first heard about this campaign from our community volunteer, though I didn’t know exactly when the HSA would arrive,” James said. “I was happy when she came. Even if there are a hundred immunisation rounds, I am ready for my child to receive every single one.”

Wastewater surveillance

Blantyre is a high-risk focal point for transmission due to its dense urban population and ongoing mobility.

“Blantyre children are at a higher risk,” explains Myless Mhango, Blantyre coordinator of the Ministry of Health’s (MoH) Expanded Programme on Immunisation (EPI). “We have polio in circulation due to the recent case, alongside probable unvaccinated children returning from South Africa.”

To cover the district, Mhango’s office has deployed 622 three-person vaccination teams and 144 supervisors. Their target is to vaccinate 527,320 children by reaching out everywhere, including in the local markets.

“Ninety percent of the mobilisers are community volunteers who help address vaccine hesitancy,” Mhango notes. “Some parents hesitate because they do not understand why their children need multiple vaccine doses.”

Environmental surveillance has highlighted how easily the virus circulates through urban hubs.

Speaking at a high-level health briefing ahead of the fourth campaign, Dr Mike Chisema, the Ministry of Health (MoH) EPI programme manager, explained that wastewater monitoring had uncovered the virus. 

Initial samples isolated the virus in Blantyre treatment plants in late 2025, before subsequent testing detected it in Lilongwe.

“When you have conducted a campaign round and isolate another virus, it is considered a breakthrough infection,” he explained. “If you see it in Blantyre across three sites and then again in Lilongwe, it entails movement of the virus – circulation – with potential transmission risk if coverage is incomplete.”

To capture accurate transmission data, health teams are scaling up acute flaccid paralysis (AFP) surveillance alongside wastewater sampling, despite limited infrastructure. “Not all districts have sewage plants for environmental surveillance, making field tracking crucial,” Chisema said.

During previous nationwide rounds involving nearly 9,000 field teams and 2,000 supervisors, Malawi reached over 7.07 million children under 10. However, evaluations flagged localised coverage gaps in districts like Thyolo and Mulanje. “These gaps indicate ongoing risk because unvaccinated children remain,” he cautions.

Multiple doses

Public health experts emphasise that multiple doses are essential to stop poliovirus mutation and achieve community-wide protection.

Speaking at the briefing, World Health Organization (WHO) Representative in Malawi, Dr Charles Njuguna, stressed that repeated vaccinations during outbreak responses are safe and necessary.

“Once strong population immunity is established, even children who are not fully vaccinated are protected by the vaccinated majority,” Njuguna said. “Until transmission is fully interrupted, every child everywhere must be reached. Polio anywhere is a threat to children everywhere.”

Dr Samuel Kondwani, GPEI Coordinator in MoH, highlights the ongoing risk despite progress. “Breakthrough cases have been detected within six months of previous efforts. There remains a lingering danger of importations,” he warns.

Because of persistent operational hurdles globally, the Global Polio Eradication Initiative (GPEI) Strategy 2022–2026 timeline has been extended to 2029 to ensure countries have adequate time to close immunity gaps.

Regulation planned to stop vaccine hesitancy

Pockets of ‘zero-dose’ children, those who have never received a single routine vaccine, remain a major barrier, largely driven by religious opposition to modern medicine.

“Religious hesitancy is a very serious issue contributing to zero-dose children,” said Mhango. “The child who contracted polio in Blantyre last December had never received any vaccine since birth. Unvaccinated children place all other children at risk.”

To address persistent refusals, the MoH is backing a major legislative overhaul. 

Malawi’s Secretary for Health, Dr Dan Namalika, said that the government aims to resolve religious opposition through a revised Public Health Act, which is scheduled for parliamentary debate soon.

The proposed law would mandate emergency child immunisations, providing legal grounds to intervene when parental refusal creates public health risks.

“We are obliged to protect every child through immunisation,” he emphasised. “We don’t need a hundred or a thousand cases to declare an outbreak.”

Anthony Masamba, MP, chair of the Parliamentary Committee on Health, confirmed that revisions to the Act are entering final stages.

“This Bill is addressing many issues,” Masamba told Health Policy Watch. “It includes mandatory immunisations for those who deny their children protection while endangering others.”

Supported by the WHO, UNICEF, Gavi, Rotary International, and the GPEI, among others, Malawi’s health workers remain focused on delivering the supplementary round, working door to door to protect every child and choke out poliovirus transmission permanently.

Regional successes

Meanwhile, Malawi can take heart from the fact that five African countries – Burundi, Ghana, Guinea-Bissau, Republic of Congo, and Uganda – have officially stopped the spread of their poliovirus type 2 outbreaks.

The announcement was made on Thursday by the World Health Organization’s (WHO) Africa region, which had deployed teams from the Independent Outbreak Response Assessment (OBRA) to review the five countries’ disease surveillance, laboratory and epidemiological data. 

“These outbreak closures demonstrate what can be achieved through strong national leadership, dedicated health workers and close collaboration between governments, communities and partners,” said Dr Mohamed Janabi, WHO Regional Director for Africa. 

“While this is an important milestone, it is not the end of the journey. Continued vigilance, strong surveillance and high immunisation coverage remain essential to protect children and prevent future outbreaks.” 

The WHO warned that there is still a risk of the poliovirus being reimported, as demonstrated by the recent poliovirus detection in Madagascar, following its previous outbreak closure.

This underscores the need to sustain high-quality surveillance and strong population immunity”, WHO Africa stressed. 

Image Credits: Josephine Chinele.