/ 5 April 2023

Cholera: Sewage infrastructure failure worsens disease spread

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The Jukskei River flows through the City of Johannesburg, including areas that are poorly serviced. Photos: Odd Andersen/Getty Images & Bafana Mahlangu/Gallo Images

When Ferrial Adam heard last week that Gauteng’s cholera outbreak had been linked to baptisms in the Jukskei and Klip rivers, she wasn’t surprised.

“Given the amount of sewage, raw sewage, that we’ve seen flowing into rivers, I’m surprised that there haven’t been many more [cases],” said Adam, the executive manager of WaterCAN, an initiative of the Organisation Undoing Tax Abuse (Outa). “The thing with cholera is that people can be infected but sometimes don’t get hospitalised, so the case numbers might be higher.” 

With the state of the country’s rivers and streams, it is likely that many cases go undiagnosed or untreated, she added, calling on the government to test water sources regularly. 

There are now 11 confirmed cholera cases, including one death of the bacterial disease in Gauteng, which have been reported since 5 February. Eight are in the City of Johannesburg in Diepsloot and three are in the Ekurhuleni district, said Foster Mohale, spokesperson for the department of health. For the most recent cases, the suspected source of transmission is water from the Jukskei and Klip rivers, he said.

The National Institute for Communicable Diseases (NICD) told the Mail & Guardian this week that the cholera outbreak strain in Gauteng has not been detected in any samples taken from the two rivers. 

“Exposure to, or consumption of, untreated water from the Jukskei and Klip rivers was identified as possible sources of infection for several recent cases,” Juno Thomas, the head of the Centre for Enteric Diseases at the NICD, said. 

“Water samples from both rivers were collected by environmental health officials and submitted for testing. To date, the cholera outbreak strain has not been detected in any samples.”

In its most recent communique last week, the NICD said all cases are in Gauteng and no confirmed cases have been reported in other provinces. The first three cases in the cholera outbreak were imported or import-related cases after people travelled to Malawi. All subsequent cases acquired infection locally and are classified as indigenous cases. 

The indigenous cases are from the City of Johannesburg and Ekurhuleni. 

“While there is an ongoing risk for imported cases following travel from other African countries currently experiencing cholera outbreaks (especially Malawi, Mozambique, Zambia and Zimbabwe), the increasing number of locally acquired indigenous cases is very concerning,” the NICD said. 

Cholera is an acute diarrhoeal infection caused by ingestion of water or food contaminated with the bacterium Vibrio cholerae, according to the World Health Organisation. 

“Most people infected with V cholerae do not develop any symptoms, although the bacteria are present in their faeces for one to 10 days after infection and are shed back into the environment, potentially infecting other people,” it said. 

Among people who develop symptoms, most have mild or moderate symptoms, while a minority develop acute watery diarrhoea with severe dehydration. This can lead to death if untreated.

It is critical that healthcare and laboratory workers consider and test for cholera in people with acute watery diarrhoea, even in the absence of a travel history or a link to known cases, the NICD said.

“While this is especially important in Gauteng, where local transmission of cholera has been established in at least two districts, the other provinces remain at risk for imported cases and subsequent local transmission and must remain vigilant.”

On Tuesday, Mohale said that until the health department received the analysis of samples collected from the Klip and Jukskei, the rivers are a “suspected source of local cholera infections, especially for those who tested positive after baptising in and drinking water from the rivers”.

Last week, the health department, in confirming four new laboratory-confirmed cholera cases, said a couple from Diepsloot were admitted at Helen Joseph Hospital on 21 March with acute watery diarrhoea and severe dehydration. “During the investigation, both the wife and husband mentioned being baptised in the Jukskei River with six others on 18 March. They experienced health complications a few days later.” 

On 19 March, a 10-year-old girl from Katlehong in Ekurhuleni presented with diarrhoea, nausea and vomiting at Botshelong Empilweni Private Hospital in Vosloorus. She was admitted and her test results confirmed positive status. It was established during the investigation that her mother was admitted at Thelle Mogoerane Regional Hospital in Vosloorus on 17 March and was treated for different health conditions, but died the next day. 

“Cholera was not suspected by the clinicians [and] as a result, no stool samples were taken for processing. It was also established that the girl and her mother were baptised with other church members at the Klip River a week earlier,” the department said. 

A 50-year-old woman in Diepsloot, the pastor who baptised the couple who tested positive from Diepsloot at the Jukskei River, drank the same water from the river. “She was detected by the health response team during contact tracing and field investigation, having diarrhoea and vomiting. Although she was not admitted to hospital, her stool was taken for laboratory testing and the results came back positive.” 

Sewage pollution poses a serious risk to human health because it contains waterborne pathogens such as cholera, salmonella, typhoid and hepatitis. 

Jo Barnes, a former lecturer at Stellenbosch University’s Faculty of Medicine and Health Sciences’ division of community health, said: “Even though we can’t prove that these extra cholera cases are from there [Klip and Jukskei rivers], what I can say without a shadow of doubt is that these cholera organisms that the patients are excreting are hitting the sewer system. 

“If they live in low-income areas, those areas are really poorly served with sewer systems. The systems that are there are collapsing and leaking and the sewage is disposing into the environment. The moment that happens, it’s going to hit our rivers,” she said. “When there are more cases [of cholera], it’s going to end up there because the sewage runs every which way.”

To control the cholera outbreak, authorities need to ensure that sewage is not spilt in the environment and distributed among people.

Barnes fears it’s too late. “How do they now suddenly upgrade all their sewer systems that are leaking and cracking within a week or two?”

Decent sanitation systems are a basic requirement for safe living but South Africa is “driving its sewer system on the knife edge”, she said, citing how there are a large number of sewage treatment works countrywide that are virtually dysfunctional.

“In other words, what comes in, goes out. We’re just everywhere, sitting and waiting for somebody with an infection to come in and the sewer system is going to help spread it. Now it’s cholera. Next time, it’s another waterborne disease. It’s going to come thick and fast if they don’t get their act together and start repairing infrastructure.”

The state of the country’s rivers and streams is unacceptable, WaterCAN’s Adam said. The organisation conducted tests at the Klein Jukskei, which feeds into the Jukskei River, and confirmed the water is highly polluted. The levels for E coli were greater than 100 000 colony-forming units per 100ml. It said a safe range is a count between 0 and 130.“If people are using the rivers for drinking, swimming or baptisms, this level should be zero. Such high levels of E coli demand that there should be no human contact with the water … we must act now to prevent further outbreaks and protect the health of our citizens.”