As the National Institute of Communicable Diseases (NICD) warns that more cholera cases are likely, Amnesty International has condemned the outbreak that has killed 15 people and left scores in hospital or sick, saying that people dying of a preventable and easily treatable disease was unacceptable and appalling.
Infections appear to be spreading, reports BusinessLIVE, putting hundreds of thousands of lives at risk and shining a spotlight on the country’s dysfunctional sewerage networks, with the NICD saying “there is potential for larger localised cholera outbreaks because of unsafe water supply countrywide”.
The institute’s head of enteric diseases, Dr Juno Thomas, said the issues of poor sanitation that lead to cholera haven’t changed for decades, reports EWN.
“The focus on water and sanitation cannot be underestimated. Wherever there is a breakdown in water supply or unsafe sanitation you have the potential for cholera introduction into communities.”
According to the 2022 Green Drop report by the Department of Water & Sanitation, one-third of SA’s 1 186 water supply networks are at high to critical risk of failure. The report also found that only 40% of systems met the microbiological standards and 23% met the chemical standards for water quality.
Health Deputy Minister Sibongiseni Dhlomo said there had been 41 reported cases of cholera in SA: one in Limpopo, six in the Free State and 34 in Tshwane, Gauteng, and by Monday, Gauteng Health Department spokesperson Motalatale Modiba said 107 patients had been attended to in hospitals.
Of these, 29 tested positive for cholera, while 46 were admitted at the Jubilee District Hospital, and 18 transferred to Dr George Mukhari Academic Hospital and Steve Biko Academic Hospital.
Hardest hit by the outbreak is Hammanskraal, a town north of Pretoria, where residents have protested and demanded clean water for years. In 2019, the SA Human Rights Commission (SAHRC) deemed the water at Hammanskraal unfit for human consumption.
The water crisis in the area has been ongoing since 2005, when the Rooiwal water treatment plant started malfunctioning due to receiving volumes greater than it could handle.
The plant has been discharging untreated or partially treated sewage into the Apies River, which in turn flows into the Leeukraal Dam – the main source of water for the town of about 20 000 people.
Acting spokesperson for the Department of Water & Sanitation (DWS) Andile Tshona said the Hammanskraal community has been suffering from unreliable and poor quality potable water supply for an extended period, despite the upgrade of Temba water treatment plant to a capacity of 120 megalitres a day.
He added that the department was pursuing legal action against the Tshwane metro in an effort to force it to use its grant allocations to rehabilitate and upgrade the Rooiwal plant.
In 2021, the SAHRC produced the “Gauteng provincial inquiry into the Sewage Pollution of the City of Tshwane’s Rivers and the Roodeplaat Dam” report, recommending, among other things, that the national government take over the city’s water and sanitation functions.
The department engaged with the National Treasury for funding for the intervention recommended by the SAHRC, but the Treasury said the city had already been provided with funding for the rehabilitation and upgrading of the Rooiwal plant.
“Consequently, the department is pursuing legal action for a court order to force the city to use its USDG allocations to rehabilitate and upgrade the Rooiwal wastewater treatment works,” the department said.
Over the years, it added, it had instituted a series of enforcement directives against the city for it to address the pollution from the Rooiwal plant into the Apies River and Leeukraal Dam.
“After the city failed to respond to the directives, a legal process was instituted, with the aim of obtaining a court order to force the city to address the failure of the Rooiwal wastewater treatment works. This legal process is now under way. To date, the city has opposed the legal action.”
The DWS said its technical team would assist water quality investigations and identifying the causes of the outbreak, and that it had continuously been testing water quality at the Temba water treatment works and water distribution points in Hammanskraal.
However, the latest tests “indicate the quality does not meet minimum standards… water supplied by Magalies and Rand Water meets the drinking water quality standards, therefore the challenges are in central Hammanskraal, which is supplied by the city”, it emphasised.
TimesLIVE reports that the department said it had directed the city to stop supplying water from the Temba plant to Hammanskraal residents.
“The city is providing potable water to affected communities, initially supplied by the Temba plant, (via) tankers.”
Tshwane metro spokesperson Selby Bokaba said the capital city had received the results from samples taken from multiple sites around Temba and Hammanskraal to trace the cholera outbreak.
These included reservoirs, fire hydrants, primary schools, clinics and other locations that received water from the Temba plant.
“All of these tests have conclusively indicated no microbiological contaminants that point to E. coli or faecal coliforms that can be linked to the cholera outbreak,” he said.
“This means there is no cholera present in the water being distributed via the city’s bulk water distribution network in the area.”
Water & Sanitation Minister Senzo Mchunu has committed to meeting Tshwane mayor Cilliers Brink before Friday, with the aim of agreeing on a plan with timeframes for the city to rehabilitate and upgrade the Rooiwal wastewater treatment works.
The department said a joint task team between the department and the city would be established to oversee the work.
Anthony Turton, a water expert at the University of Free State, told BusinessLIVE the cause of the cholera outbreak was not difficult to pin down: “It’s the 5bn litres of untreated or partially treated sewage we allow to go to our rivers every day.”
“We cannot expect a good outcome until the general population holds elected officials accountable,” he said.
And in the Free State, News24 reports, provincial spokesperson Mondli Mvambi said 76 people with diarrhoeal infections had been seen at clinics and hospitals in the area, with six confirmed cholera cases.
The six patients with cholera were treated at Parys Hospital and Boitumelo Hospital in Kroonstad.
Mvambi said the first laboratory-confirmed case in the Free State was on 17 May. The province, district, and local area outbreak response teams were activated and supported by the World Health Organisation and the NICD.
“The teams working in Vredefort and Ngwathe are continuously monitoring the water quality for all sources supplying water to the community. Environmental risk assessment is also ongoing,” said Mvambi.
The outbreak in the Free State began two weeks ago.
“There have been cases of diarrhoea reported in Parys (and) Vredefort. We had several meetings with the district and the province. At the time, there were no confirmations of cholera," said Mayor Victoria De Beer-Mthombeni.
“Understandably, our people think that our water could cause diarrhoea. However, I can confirm that we have chemicals required to purify the water to supply to our communities.”
Some residents have complained that water sourced from communal water tanks was dirty, she added.
“But we have done tests that showed that the outbreak could not be based on our Jojo tanks. The same chemicals we use to clean the water in Parys are the same ones we use in Vredefort and Koppies. We haven’t had complaints of diarrhoea in Koppies.”
She said the municipality had not ruled out that its proximity to Gauteng and North West could have led to the outbreak.
Slamming the outbreaks in the country, Amnesty International organisation’s executive director Shenilla Mohamed said the deaths of the 15 people in Hammanskraal were deeply troubling, and that authorities needed to act urgently to prevent further loss of lives.
“The provision of safe water and sanitation is critical in preventing and controlling the transmission of cholera. Despite the Gauteng Health Department’s warning to residents not to drink tap water, and confirmation that further samples are being tested, now is the time for the DWS to work with municipalities, like the City of Tshwane, and across the country, to act in the short and long term and invest in and manage basic water and sanitation infrastructure.
“The outbreak must be brought under control immediately, and the spread of and possible future outbreaks must be prevented.”
She said the right to access safe, sufficient and reliable water was enshrined in the constitution, and would continue to be threatened, and lives risked, unless the government prioritised investment in infrastructure and tackled corruption and the mismanagement of public funds.
“Lives are at stake and access to water is a human right, not a privilege.”
Meanwhile, as a wave of cholera outbreaks spreads around the world, Gavi, the Vaccine Alliance, said it expected the global shortage of oral cholera vaccines to continue until the end of 2025 according to a Health Policy Watch report.
Supply of oral cholera vaccines for preventative use could catch up to demand by 2026, but "urgent action is needed," according to a vaccine production roadmap published by Gavi, the WHO and other global health partners on Monday.
There are currently still enough vaccine supplies to respond to emergencies, Gavi said.
"The good news is we have doses to meet all emergency demand despite the rise in outbreaks, and that is expected to continue," said Dr Derrick Sim, head of vaccine markets and health security at Gavi, adding that the global resurgence of cholera "underscores the need to prevent outbreaks before they occur."
The past 10 years have seen a steady increase in the availability of oral cholera vaccines. Global production rose from 4m doses in 2012 to 35m by 2022, with a similar number of vaccines expected to be produced this year.
But the recent spike in cholera outbreaks driven by climate shocks, war and humanitarian crises have caused a surge in demand for the vaccines for emergency response, limiting the availability of supplies for preventative use.
Between 2021 and 2022, 48m oral cholera vaccines were needed for emergency response, 10m more than in the entire previous decade.
"The outlook is bleak," WHO incident manager for the global cholera response Henry Gray said at a press briefing on Friday. "We're not able to provide enough vaccines." Only 8m of 18m doses requested by WHO have been made available so far in 2023, Gray added.
The WHO has warned that climate change is a major threat to global health, and that cholera is one of the diseases that is most likely to be affected. Extreme weather events, such as floods and droughts, increase the risk of cholera outbreaks by contaminating water supplies with sewage, waste and bacteria. People displaced by climate shocks are also less likely to have access to clean water and sanitation, increasing their risk of infection.
In response to a shortage of oral cholera vaccines last year, WHO advised countries to ration supplies during outbreaks by giving just one of the two-dose vaccine to patients. The WHO still ran out of vaccines by the end of the year.
AfriForum, meanwhile, said it was not surprised by the rising cholera cases. Writing in PoliticsWeb, Lambert de Klerk, manager: environmental affairs, AfriForum, said that for several years, the organisation has been busy with various court applications and strategies regarding the country’s water quality and the defective sewage system contributing to it.
AfriForum has filed several court applications in Parys because the water is unfit for human consumption, he said, adding that the DWS and the municipality “have therefore been aware of this issue for the past three years but are not prepared to solve it”.
He said AfriForum had already provided a workable plan in 2020 to get the water works back up to standard.
The Democratic Nursing Organisation of SA has called for an urgent inquiry into the water crisis at Hammanskraal, saying it would point out exactly “where the crisis began”. The Cosatu-affiliated union wants those responsible to be held accountable for the disaster.
Green Drop Report
BusinessLIVE article – Cholera stalks SA as death toll rises to 15 (Restricted access)
Health Policy Watch – cholera-vaccine-shortage-to-continue-through-2025
IOL article – Don’t drink tap water: Tshwane appeals to residents amid cholera outbreak (IOL)
News24 article – Diarrhoea in Parys and Vredefort: Teams on high alert (Restricted access)
EWN article – nicd: potential for larger cholera outbreaks due to unsafe water supply (Open access)
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