Barriers must be erected against the transmission of cholera
analysis
Lindy Morrison and Richard Holden
Facing the threat of cholera in South Africa requires a multifaceted, multi-stakeholder, coordinated effort. Life shows us that when faced with any problem it is best to treat both the symptoms and the cause. The problem, unfortunately, with many cholera interventions is that only part of the cause is addressed that is, the quality of the external source of water. In truth, the spread of cholera has many causes, including hand-to-hand, hand-to-mouth, hand-to-food-to-mouth transmission and contaminated drinking water containers.
This is particularly relevant to the current epidemic in the rural areas around Ladysmith in KwaZulu-Natal. When addressing this particular outbreak it is important to consider the differences between it and other incidences in the country and not to simply apply a standard approach.
Firstly, as part of the government’s standard response, all sources of water in the Ladysmith area are regularly tested. To date, although fairly high levels of E.coli have been found, there is no conclusive evidence of cholera contamination. Also, the pattern of infection is not typical of a contaminated source. Frequently a single family in a community is infected whereas adjacent families, using the same water source, are left untouched.
The organism, vibrio cholerae, is distributed by any faecal-oral route contamination. It results in nausea, vomiting, profuse diarrhoea and stomach cramps. If left untreated, death can result through kidney failure due to the loss of fluids and dehydration.
Contamination occurs when caring for people with cholera in an environment where there is not sufficient water for personal hygiene. Clothing and bedding become soiled, people come into contact with faecal matter and, due to the shortage of water, it is difficult to maintain hygiene.
The government standard for the provision of water is a standpipe within 200m of the home, so even where water is available its consumption is limited to an average of three to four cubic metres a month by the fact that it needs to be carried back to the home. Transporting water from a tanker, a further distance away, further limits consumption.
To treat cholera, it is essential that people have adequate supplies of good quality water for drinking and personal hygiene, and sufficient water for washing. The Department of Health is doing the correct thing by removing infected people from the community to rehydration centres where the above are available. This is the best short-term, emergency response, but it remains reactive. We need to be more proactive so that outbreaks of cholera do not occur in the first place.
The Mvula Trust believes this is possible by getting the household to establish as many barriers as possible to the transmission of the disease, with the limited resources they have. These include:
Purification of potable water, which can be done within the household. By getting the household to treat the drinking water an effective barrier to disease can be created. Home treatment can be done by bleaching or by solar disinfectant (that is, leaving a two-litre bottle in the sun for a day and the combination of ultraviolet light and temperature then sterilises the water).
Depositing faeces in a hole and preventing contact with animals and humans. With the current government allocations to sanitation it will be at least 10 years before 100% coverage is achieved. However, effective containment can be achieved with a far lower subsidy than is currently offered. (In Ladysmith it is planned to achieve effective containment by fast-tracking toilet construction and building a rudimentary hessian structure for privacy, which can be upgraded to a better standard later.)
The provision of hand-washing facilities. The Mvula Trust has developed a hand-washing container, which is easy to use, costs less than R5 and only uses the actual water required. A second self-closing device, which fits on a two-litre soft-drink bottle, has been devised but requires funding to develop the mould for manufacturing.
Local education. To get people to change habits requires constant reinforcing. This is best done through community health workers or nompilo, as they are known in KwaZulu-Natal. These people are at the frontline of preventative medicine and more resources need to be made available to them.
By working with the resources available, the Mvula Trust believes that barriers to the transmission of the disease can be significantly increased. This message needs to be promoted rather than a message that scares people unnecessarily about water sources that are not contaminated.
The multifaceted, multi-stakeholder effort in the Ladysmith area is, as per provincial policy, squarely the responsibility of the uThukela District Council to coordinate. The Mvula Trust will be assisting the council in the development of a strategy that includes establishing the causes of transmission; disseminating correct information; removing patients from households to centres with facilities for oral rehydration and hygiene; the provision of adequate quantities of water and quality management (at source and household level); the provision of sanitation facilities; ongoing testing of water sources and the continual re-evaluation of strategies accordingly.
Lindy Morrison and Richard Holden are officials of the Mvula Trust, a water and sanitation NGO working in rural and peri-urban communities
ENDS