Cyclone Freddy hit the southern African nation for a second time in a month, after bringing downpours and havoc to other African nations including Madagascar and Mozambique.

“The situation is very dire” said Guilherme Botelho, Médecins Sans Frontières (MSF) emergency project coordinator in Blantyre, Malawi’s centre of finance and commerce. “There are many casualties — either wounded, missing, or dead — and the numbers will only increase in the coming days.”

The Blantyre district has recorded the highest number of deaths, with the Queen Elizabeth Central Hospital reporting 220 people having died. That included 42 adults and 43 children who were pronounced dead on arrival, MSF, or Doctors Without Borders, said in a statement on Tuesday.

Cholera spreads rapidly through contaminated water and efforts to contain the disease have also been hampered by a global lack of vaccines. Africa was facing an exponential rise in cases, with infections in the single month of January at a third of the level reached in the whole of 2022, according to the World Health Organization.

President Lazarus Chakwera declared a state of disaster in Malawi’s southern region, helping the government to accelerate its response to the storm. The country remains the most cholera-affected nation in Africa.

Freddy, which appears to have become the longest-lasting tropical cyclone ever, was first named on February 6.