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RAPID EPIDEMIOLOGICAL MAPPING OF
ONCHOCERCTASTS (REMO) rN MALAWI
MISSION REPORT (UAY L6 - JUNE 1-5, 1997'
FOR
WORLD HEALTH ORGANTZATION AFRTCAN PROGRAUME FOR ONCHOCERCIASIS CONTROL (APOC)
BY
DR. B.E.B. NI{OKE (OVlrCP/cTDl 5O4lAPle7 I O40'
STATUS: WHO Temporary Adviser (U197 lOt4329l
Professor of Medical/Public Health Parasitology & Entomology
School of Biological Sciences Imo State University
PMB 2000 Owerri, Nigeria
Phoner (234)83-23 05 85 (Home) Fax: (2341A3-23 18 83
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JUNE 15, 1997
II
L. O onchocerciasis is Northern Districts of
Rurnphi, and NkhatabaY.
SUMMARY
Under the sponsorship of the African Programme .for Onchocerciasii Control (APOC), Rapid Epidemiological Mapping of onchocerciasis was conducted in Malawi
Uelireen 1,6th May and June l-6th L997. During the course of the exercise-, 4O5 villages were primarily selected to be examined for the prevalence of onchocercal nodules of which 48 ( 1f-. 85Ul were not sampled due - to inaccessibility. Pending the final Atlas GIS analysis of the data, the results showed that:
apparentty absent from all the 5 Uafawi: ChitiPa, Karonga, Mzimba, 2.O In the central Region, onchocerciasis is absent in 7 districts of Kasungu, Nkhotakota, salima, Mchinji,
Dowa, Ntchisi and Lilongwe out of the 9 Districts.
Ntcheu District has endemic communities on the western border with Mozambique as welI as with the southern border with the Mwanza/Neno area. There is also onchocerciasis at the east-central- part of Dedza district.
3. O The Southern Region is the onchocerciasis zone in Malawi. Onchocerciasis is endemic in Thyolo, south and Eastern Mulanje, Phalombe, Mwanza, Chiradzulu, and western and southern BIantyre. The Mwanza and Thyolo onchocerciasis foci spread into meso endemic foci in northern Chikwawa District.
Title page ""'l
Summary
List of contents " " 3
]-.0 INTRODUCTION ...4
2
2.O MATERIALS AND METHODS ....6
2.2 Training of National Teams... " " "9
2.3 Planning and Implementation ' ' 10 3. O RESULTS AND DISCUSSION . . ].]-
2.L StudY Area ""'6
4.0 REFERENCES... ...].3
6.0 ANNEXES ..].6
6.1 Trip Schedule ""'L6
5.0 ACKNOWLEDGEMENTS ...15
6.2 Population of Mal-awi(1"989).... " "t7
6.3 Map of Matawi showing the Present
onchocerciasis areas as determined by REMO..l-8 6.4 Summary of REMO results in Malawi May/June
L997 19
LIST OF CONTENTS
1.0 INTRODUCTION
Human onchocerciasis was first formally reported in Malawi by Gopsil (L939). Later Harvey (L967 ) made another report-. These early studies described cases only i" Thyolo District. The first systematic atternpt to present a nation-wide prevalence- 1t'd geographical
ai=t.iUrtion of onchocerciisis in Malawi was carried out by Ben-sira and his colleagues in L972. In this study a totaL of 3482? people from alt over the country were
randomly chosen ind skin snipped and most of these came from Th-yo]o district. This \^ras followed up subsequently
by othei epidemiological studies which include the work of Rampen -(1-976), eudaen (L979), Chirambo et AI (L986), gurnham (1-988 , ' 'L991) . AI1 these studies showed that
endemic onchocerciasis is far from being restricted to the Thyolo District as was previously thought.
nntomoroqical studies have also confirmed this, ds vector r-ri"= have been found breeding and biting in other areas outside Thyolo (Berner & carr, 1954;
Lewis, L96L; Davies, t985; TambaIa, 1-988; Roberts,
r-ee0).
Before the last two decades or so, simulium neavei complex was the predominant vector of human or"iro"".ciasis in MaIawi, especially on the Thyolo Highlands, the main onchocerciasis foci in the country ao" MeiIIon , 1-930; Lewis ,Lg6L) - with the rapid population growth and movement of people in the l-960s i"'a L97os i; the country (Coleman, L974), and resultant widespread deforestation as welI as other environmental
modifications Simulium damnosum complex displaced the less aggressive S.nearrei complex as the main disease vector. Burnham (1991-) noted that the prevalence of Simulium has increased steadily since the 1950s when Berner & Carr (1954) observed that S.damnosum was hardly noticeable. This increase of S.damnosum was to the extent that in Lg85-87, over 99.92 of the l-00,000 Simulium flies caught biting man in the country were
S.damnosum s.7. (Roberts, 1990).
From the already known bionomics of s.damnosum.s.7.,
especially the ffignt range and vectorial capacity as welt as Lfre continued movement of inhabitants in the country, the extent to which onchocerciasis is endemic has rernained undefined. This has created Some fundamental questions and difficulty to health planners i-nvolved in onchocerciasis control to operationally define endemic Districts/areas. The definition of people at risk of infection in Malawi is especially important now that wHo executed African Programme for Onchocerciasis Control (APOC) is determined to control
this debilitating disease in Africa to such a level that it will no longei be a public health problem or obstacle to socioecoromi" development in the continent. The
APOC main strategy for tnis control effort is Community Oirectea Oistrif-uifion (CDD) of ivermectin to endemic areas. For obvious operational reasons, and successful i*pi"*""iation of the cDD strategy, there - is, therefore, need for a nation-wide baseline epidemiological information gathering based on uiriformTstindard procedure to define areas where cDD should be applied, where it is possible and where the disease is not endemic. This information is not readily avaitable or comprehensive in most endemic African countries including Malawi.
In Malawi and elsewhere r^lhere onchocerciasis is endemic,
and where mass ivermectin distribution has been adopted, the hitherto acceptable conventional diagnostic procedure f or identifying _communi-ti-es e1igibIe f or treatment is the skin lnip method to determine community Microfilarial Rate tcMRl. The advantage of this method is that it is - a specific diagnostic procedure very useful in small scale survey, in irospitals and laboratories, and very reliable. when efficiency of intervention programmes needs to be assessed. However, skin snip method has a lot of technical and Iogistic Iimitations: it is invasive and time consumi-ng, ?equires expensive equipment/materials and cornmunities show poor cooperation. This method is also likely to increale the risk of infection of HIV, infective hepatitis etc (wHo, L9g2). In Malawi in particular, tne skin snip method is complicated by the ieculiar length and the tough topography of the _Great ifift Valley -system as weII as the scattered settlement pattern. arl these make national-wide coverage aifficuft if not impossible by this method'
AII these shortcomings taken into consideration, TDR/WHO has developed and adopted an alternative epidemiological assessment method for rapid mapping of human onchocerciasis in endemic countries in Africa. This current method is Rapid Epidemiological Mapping of onchocerciasis (REMO). REMO exercise is based on the prevalence of palpable onchocercal nodules lonchocercomata) in the community. T-ni= has a very good ierationship with community Microfilariar Rate (Taylor et AI, Lggz; wHo , :-gg7). REMO has been used severally in the field in the last 2-3 years and has proven to be
simple and non-invasive, rapid and cheap, appllcable and pratticable over wide range of ecological conditions. rt i= also reliable and sensitive regardless of the severity and duration of infection. ft is non-technical acceptable and tolerable in terms of sociocultural and relilious considerations as weII as absence of risk of
complications or infections (Nwoke, 1993;L9941 Nwoke et aI l-9931 Ngoumou & Walsh l-993).
With the APOC interest to support endemic African countries including Malawi to control human
onchocerciasis, and the absence of a comprehensive
national-wide epidemiological data on the disease as
werr as the urgent need to determine endemic areas where community Directed Distribution of ivermectin should be
implemented and at the same time ensure adequate
coverage, the objectives of my mission as WHO Temporary
Adviser were:
To assist the NOTF of Malawi
REMO survey teams and with the training of The planning and
throughout Malawi.
1
i-mplementation of REMO surveys
2.0
MATERIALS AND METHODS2.I
STT]DY AREAThe study area for this mission was Marawi, a randrocked
southeast African country of dramatic highrands and
extensive lakes. The Repubric of Marawi with a current estimated population of 1,2 miltion occupies a narrow,
curvinq strip of rand along the East African Great Rift Valley stretching about 837km from north to south, it has a width varying from 8km to t-60km. rt is bordered
by Tanzania to the north, Mozambique to the east and
south, and south west, and Zambia to the west. Its total area of l-18,484 sq.km includes some 24,ZOg sq.km.
of inland water areas of Lake Malombe, Chilwa, Cniuta and Lake Ma1awi (Green, l_983).
While Malawi's landscape is highly varied, there are
four basic physicat regions: viz. the East African or Great Rift Valley, the centrar prains, the highrands and
the isolated prateau or mountaineous areas. The Great
Rift Valley by far the dominant feature of the country i9 a gigantic trough like depressj-on runnin|
throughout the country from north to south and
containing Lake Marawi and shire River valrey. The
Lakers littorar situated along the western and southern
shores and ranging from 8km to 24km in width, covers
about 8z of the total rand area and is spotted with
swamps and Lagoons. The shire River valrey stretches
some 4o0km from the southern end of the Lake Marawi at
Mangochi to Nsanje at the Mozambique border and contains Lake Malombe at its northern end. The central region prains rise to an artitude of between 760 and tillo
2
metres (2500 4500ft) and lies beyond the littoral to the west. The plains cover about three quarters of the total land area. The highland areas are mainly
isolated tracts that rise to as much as 24OO metres
(8000 ft) above sea 1evel. They comprise the Nyika,
Viphya and Dowa highlands, and Dedza kirk Mountain
range in the north and west and the Shire Highlands in the South. The high plateau areas are mostly isolated massifs of Mulanje at 3OOO metres (1O,OOOft) and Zomba at 2,LOO metres (7000 ft) and represent the fourth physical region.
The major drainage system is that of Lake Ma1awi. ft is fed by various rivers including North and South Rukuru, Dwangwa, Lilongwe and Bua Rivers. The Shire River, the Lakers only outlet flows through adjacent Lake Malombe
and receives several tributaries before joining the Zambezi River in Mozambique. A second drainage system
is that of Lake Chilwa, the rivers of which flow from
the Lake Chilwa- Phalombe plains and the adjacent highlands.
There are two main seasons in Malawi: the dry season
(May October) and wet season (November April).
Altitude has an important effect upon temperature.
Nsanje, ln the Shire River plain, has a mean JuIy temperature of degrees Celsius (69 degrees F) and an
October mean of 29 degrees C (84 degrees F) while Dedza,
which Iies at an altitude of more than L5OO metre
(5000ft), has a July mean of L4 degrees C (degrees) and
an October mean of 2L degrees C (59 degrees F). On the
Nyika plateau, and on the upper levels of the Mulanje massif, frosts are not uncommon in Juty.
AnnuaI rainfall is highest over most parts of the
northern highlands and on the Sapitwa peak of Mulanje
Mountain, where it is about 2,3O0 mm (90 inches) .
AnnuaI rainfall is lowest in the lower Shire VaIley, where it ranges from 650 to gOOmm (25-35 inches). It is
important to note here that in the recent past as a result of global climatic/environmental changes, Malawi has experienced low and erratic annual rainfalI. During
the L99L-94 period the country had a severe drought
disaster that sar,,r the drying up of three quarters of its river systems. An international appeal for assistance was also launched. In the current L996/97 rainfall cycIe, some parts of Karonga District aTe experiencing drought. The effect of these on the epidemiology of water-associated diseases like human onchocerciasis is not yet understood.
The natural- vegetation pattern refrects diversities in altitude, soils, and climate. Savanna (grassy parkland) occurs in the dry lowland areas. Open woodland with
bark cloth trees or regumious trees unsuitabre for timber, is widespread on the fertite plateaus and
escarpments. woodrands, with species of acacia tree cover isolated, fertire prateau sites and river margins.
Muranje and Zomba massif and other highrands are covered
by grassrand and evergreen forests. swamp vegetation is, however, being greatly artered by human settrement.
Much of the original woodland has been cleared and at the same time, forests of softwoods are being pranted in the highrand areas. There are a rot of toresl reserves
in the country estimated at 6400 sq. km. These forest reserves together with several nationar park create favourabre environment for the diversity of game animars . antelopes, buffalo, elephants, Ieopards, 1ions,
rhinocercoses, and zebra. HippopotamuseJ live in Lake
MaIawi.
A rurar virlage in Malawi is usuatry smalr predominantry
rnade up of farmers, curtivating maize, toba-co, peanutsl cassava, rice, tea, sugar cane, coffee etc. The virlages are limited by the amount of water and arable rand
availabre in the vicinity. on the prateaus, which
support the burk of the population, the most common
village sites are at the margins of rivers or streams
characterized by woodrand, grassrand and fertire arluvial soils. rn the highland areas, scattered vilrages are located near perenniar mountain streams and
pockets of thin but arabre rand. However, improvement
in road network and the sinking of bore-hores in semi-
arid areas as we]1 as irrigation projects have
perrnitted the establishments of new settrement in previously un-inhabited areas.
Health facilities in Marawi include central Hospitars, Generar Hospitars, mentar hospital, leprosaria and
District Hospitars as welr as numerous comm-unity clinics and hearth centres. The current emphasis ok hearth services in Malawi is primary Health cire (pHC). There
are 25 administrative Districts in the country. Each
district has a functionar hospital and the pHc iystem is strongry supported at this lever. with adequate
logistic support (Four-wheel vehicles, motorcycres and
bicycres) by Government and international aono? agencies
and effective communication network, the District hospitar staff have adequate coverage of the communi-ties
in the District. To strengthen this, pHc in Matawi has
for sometime now, estabrished a health cadre carred the Health surveirrance Assistants (HSA) attached to the
vilrages/communities. supported by ; bicycle, the HSA
lives in the village and has a catchment population of 2900 villagers to mobilize, assist and rLptrt to the
District office of any disease epidemics or hearth rerated.emergencies. This has continued to herp in the
timely intervention and success of the pHc system and
),) strategy in this country.
TRAINING OF ST]RVEY TEAMS
For this study three different groups were trained: the Nationar and District teams as wert as the Health
surveil-rance Assistants (HSA). The detailed REMO training was given to the Nationat team who in turn trained and red the District teams and HSAs to the serected communities for the REMO exercise. At each revel of the training there were theoreticar and
practical aspects.
Members of the Nationar team red by the Nocp National coordinator are experienced and ha-ve been working at different levers of onchocerciasis contror in the
country. This fact notwithstanding, there was need for this tra.in.ing since is signif icant that globar REMO is a n"r hi.gnostic toot standard-s in proceaure and beit maintained for obvious epidemiorogical reasons. The
team was, therefore, exposed to ; 3 _ day detailed theoreticar training which covered arr the aspects of wHo-REMo documents (Ngoumour & walsh essentiar, 1,gg3,
wHo, 1-995). rn addition, other aipects covered incruded thg b.iorogy and contror of the di=ea=e and vector in
Ma rawi , cr inicopathologicar- manifestations, socioeconomic impact of the disease in endemic areas, and the need and
the current strategy for contror with emphasis on the community Directed oistribution of Mectizai. rn course
of the training, team members were given opportunities
f or personar contributions and discutsior',=.' ' rt ,u= a
rewarding training.
At the to. Muranje/phalombe end of the training, the National District for the fierd team practi-um.traverred This was designed to ensure that the REMO tecinique had
been correctry learned. rn doing this the telrn was
first of arr given the opportunity to inaepenalntry mobilize and train the oistfict neaftn personner This is because this lever of staff are very importani in the successfuL imprementation of the REMO. At the end of this, r was satisfied with the rever of performance of the team.
For the fina] practicum, the Nationar team was divided llt" three groups: one red by the Nationar coordinator, the other led by the Deputy coordinator whilst another group was led by a senior fierd officer involved in rEF
distribution of Mectizan in Thyolo oi=tri"t. in"=.
groups were no\^/ assisted by the District mernbers and atl were taken to
. lro High -ni=x
and *" secondary rine virlages systematicarly in and the oistrict. effectivery demonstrate This hras done toto each team
member nodure palpation and how to differentiate
onchocercar nodures from the common lymph nodes, ripoma, sebaceous cysts, gangrion and other-rumps in'the'skin which are not of of less- significant to onchocercal REMO, !h"y origin. were r; addition, arso taught howbut
to identify Leopard skin - and acute/chronic onchodermatitis. Every member of the team was allowed to independentry examine the same villagers, using the community REMO forms to take a1r the records. These
results were pulred together, validated and discussed
after each virrage exercise' - to make sure that variations are embark on independent survey. reduced before the teams At the end, were arl-owed theto percentage agreement of my vLridation of their REMo
practical exercise in the 3 satisfactory (98u r.oo?). endemic rhis ri"ra communities -p.-a"ticarwas
training was very significant in irr" success of this exercise and therefore lasted for three days 23) - rt was so designed that at the end of it alr', (May the2L- members of th? three groups were adequately informed and prepared to lead successfurry an and HSA i-naepenaent District
REMO team to serecttd
"o*rnr.,itie= io -pr"a"""
standard and acceptable results.
were most
REMO
District and HSA members
the National teams, with the field in course of the
fn each Region, onchocerciasis population such as
parks, games and kept aside. fn attention was given
mobilized and trained of the trainings done
exercise.
byin
2.3 PLANNING AND IMPLEMENTATION
During the pranning and imprementation stage, efforts were made to-. put together and review aIr avairabre reports, studies and surveys on onchocerciasis and vectors in the country. into different ecologicar Attempts zone were to divide th;--ountrynot feasibre as the
Great Rift Varrey which dominates the features and
determines the
. bioecorogicar zone runs throughout the country. so the administrative division irito - trrr""
fegions (North, centrar and south) ,"." adopted and each
District in each Region constituted a sub unit.
However, the main focus was the river systems in the
Regions. By .this arrangement a group of the national team was assigned a negion for trris exercise. Each member was assigned a catchment District in th; negion.
This \^/as a,n.uj9I strategy to enable us complete this exercise within the time ii.me.
areas which are likely to be
free without significant human
^1akes, highlands, mountains, national forest reserves were identified .rra the planning and implementation,
to areas which appear t; be suitable
for onchocerciasis but with few or no avairabl_e data and
areas bordering arready known foci. Arso attention was
given to areas where onchocerciasis has been suspected such as the s.ongwe River system in chitipa and Kar6nga ,
thg Nyika highrands of Rumphi, chitifa and uortirern Mzimba Districts as well aJ i; Dedza. REMO in the suspected areas. mainly in the Northern Region was
personarry carried out by me working jointry ,itn the
National coordinator. areas were and handred by the The southern Deputy National ana-centrit prioritycooldinator finally varidated by me according to wHo (r-995).
To successfurry implement this programme, a time-tabIe for the survey and rerated a-ctiviti"s in each
Region/District was drawn-indicating the order in which
each activity witr be undertaken. Long before the commencement of the exercise. The National coordinator had of the exercise written retters to arr the districts informing irr"*and the need for their effective sipport 3ld p.urticipation . with the time-table in prace, ^ arr Districts were finarly informed in advance of the dates
of the REMO and the serected communities in the oisiiict and the need for the virlage mobirizaton by HSAs and
need for Logistic support. successful because arl- the Districts in ttre country This approach was havevery
a functionar telephone line /system which enables us to plan well ahead of time.
fn addition the availability of motorcycles at the Districts and HSAs in these villages facilitated case of lack of petrol/gasoline in or motorcycles, the team had
responsibility to facilitate them.
strong vehicles and
the bicycles with the
our exercise. In any
the District vehicles to take up this
3.0
After-putting every plan in pIace, arr the and arrowances for the teams were colrected and materiars,every
team moved into the fierd to implement the REMO exercise. in case of The teams anv_ difficurty were in constant that cannot be handred, communication andthe
fnternati-onar Eye Foundation at Brantyre was informed
fo5.lecessary action. As the exercisi continued, the validation was also made. Notwithstanding the inherent difficulties survey, this arrangement achieved associated with such extensive fierdgreat success.
RESULTS AND DTSCUSSION
Th" summary of the REMO exercise in Marawi (May r_6
June 76, L997) is shown on Tabre l_. A total of 4o5
villages were serected for the (88. t-52) were examined whire the remaining 48 REMO exercise but i1r-. eszl357
were not sampled mainly due to inaccessibliiy
The resurts showed that of the 25 Districts in Marawi,
only 9 of them have endemic onchocerciasis foci.
onchocerciasis was found to be apparently absent in arr th? five (s) northern DistrictJ- of cnitipa, xaionga, Mzimba, conduct the Rumphi REMO and exercise in 7 of the Nkhata Bay. r had to High nisi personarlyvj_rrages
on the songwe River in chitipa and xaronga Districts
because of its boundary with tanzania. r arso had to participate in REMO of 6 High Risk communities on the Nyika Highrands of Rumphi and Northern Mzimba. A1r these
efforts showed that onchocerciasis is apparently absent
the whore of Northern Malawi. rt rnay be we-lr that
g.damnosum suspected to be breeding i., this region (Roberts, L990) is the ketaketa torir which have been
observed by v^a ji.me (1,997 ) to be non man uiting in other areas of the country; or that the flies ,;1, be
biting, but no parasite in-the population to transmit.
rn the central Region, of the nine (9) Districts, onry
two Districts: Ntcheu and Dedza are endemic. The other Districts: Kasungu, Nkhotakota, Salima, Mchinji, Dowa,
Ntchisi and Lirongwe are apparentry riee from
onchocerciasis. Most of the ri',rer systems in the centrar region are sruggish and most of these communities are on the priin, which someti_mes become
flooded. Arr these areas are unfavourabre to the
breeding of the vector fries. The presence of onchocerciasis in Ntcheu and Dedza is no€ unexpected because these foci are within the same Kirk Range
mountains in the Southern Region on the Mozambican of the border country.from Mwanza District rn the southern District, these are onchocerciasis foci 3I" in Thyolo, Mulan j e, Northern Chikwawa, Irlrurru, Blantyre and chj-radzuru as werr as southern Zomba. This shows that apart f rom the eastern side of trrulin j e
mountain, onchocerciasi-s is a major problem along the
Thyolo chikwawa escarpment from uuolra to Nkura. on
the west of the shire River the di.sease is enaemic from
northern chikwawa to Mwanza arong the Kirk Range
mountains. However, a furr picture oi this =i"av srroura be cLearer when the resurti are f inarly put ir., the
Altas GfS.
rt may be important to point out here that there is urgent need to know what is the onchocerciasis situation
i_n- Mozambique in view of the disease endemicity in -trre Muranje/Thyolo eastern border and the Mwania/Ntcheu western border. The significance of this in our current control strategy need not be over-emphasj_ze.
r wish to observe that the pHc system especialry the
District arrangement and the pre="n"" of the Health
surveirlance Assisstants is a qood frame-work for the
4.0
CDD strategy in onchocerciasis control.
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ofin
(REMo)
WHO, (7992). Methods for community diagnosis onchocerciasis to guide ivermectin bised Control Africa. TDR/TDE/ONCHO/92.2. WHO Geneva.
!H9r (199s). Supplementary guide-Iine for Rapid
Epidemiotogicar Mapping of onchocercia-sis
TDR/TDF/ONCHO/95. 1. WHO Geneva.
5.0 ACKNOWLEDGEMENT
r am grateful to wHo-African programme for onchocerciasis control (Apoc) for the opporluniiy given
to me to serve in this capacity, and L; wR r,afos- and
Lilongwe offices for ar-r tnlir &'rorts to facililate my
mission. r am indebted to the Nocp Malawi Nationar -coordinator, Mr Tambara and arL the members of the
National REMO. team; Sitima,. Katambo, Nkhoma, Makina, Mpeni and Mizati for ttrlir suppJrt and goodrirr throughout the survey and to ubewe and oanlwe who
maintained courage ind cheerfulness i; dE;i"; us
through all the tough terrain to reach the ,peopie at the end of the road'i. r wish to speciar_ry acknowledge
with thanks !h" support, encouragement and hospitality given to me by or -witte, tnternitionar Eye Foundation country Director,. Blantyre and her correigues in the
course of this mission. The success of ttiis exercise wa: and commitment made. comparativery of arr the oistritt Health officiars easier by the numerous supportand
Health surveil]ance Assistants. To arl that helped in this exercise f say thank you.
6.0
ANNEXES6.I
TRIP SCHEDULE May 1l_May L2-L3 May 14
May l_5
May l-5
May l_6-t-9
May 20
May 2t-23
May May
24
25-June 7
Owerri - Lagos (Road)
Lagos
Lagos - Addis Ababa (Air) Addis Ababa Lilongwe (Air) Lilongwe Blantyre (Air) Blantyre NOCP He
Blantyre - Thyolo - Mulanje Mulanje (FieId
Practicum, REMO,
& Validation) Mulanje Blantyre
Blantyre Northern Central
Districts
Dedza - Ntcheu - Blantyre Blantyre - Mwanza
Mwanza - Thyolo ThyoIo Blantyre Blantyre
Blantyre Lilongwe (Air) Lilongwe Addis Ababa (Air) Addis Ababa Lagos (Air) Lagos Owerri
&
June June June June June June June June June
8 9
L0
l_0
10-16
L7
t_8
19 27
6.2
POPULATTON OF MALAWT (1989)1 2 3 4 5
6.
7.
8.9.
10.
11.
chitipa
Karonga Nkhata Bay Rumphi Mzirnba Kasungu
Nkhotakota
Ntchisi
Dowa
SaIima Lilongwe Mchinj i
Dedza Ntcheu Mangochi Machinga
Zomba
Chiradzulu Blantyre
Mwanza
Thyolo Mulanje
Chikwawa Nsanj e
LOt r 879 155, 458 L42, L24 101r 738 449 ,059
L2.
13.L4.
15.
15.
L7.
18.
19.20.
2L.22.
23.24.
332 ,595
L7 L, 427 L27 ,623
337 rLO6
2OO, LO6
1r 045 ,672 267 r942
434 r277 389r 390 539r805
552 , t48 455r080
2L7 ,4L9 626, L6g L32 r78L
453 r 986
67tr3OL 348 r284 223, L77
Source: Statistics Unit MoH Ma1awi
shrrt^)in., the pre_.ent Onchrlce.:-cjas.
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