Municipal water in the Western Cape has tested clean for the bacteria that cause enteric fever (better known as typhoid fever), spokesperson for the provincial health department Mark van den Heever said.

“The number of laboratory-confirmed enteric fever cases detected in Western Cape Province during 2021/22 is higher than in previous years, with City of Cape Town Metro, Cape Winelands and Garden Route districts reporting more cases than expected,” said Van den Heever.

“Whole-genome sequencing of enteric fever isolates has identified specific strains responsible for separate clusters in these districts, confirming that in those districts cases are linked and there is ongoing local transmission.”

Teams still haven’t found the origins of these outbreaks, though municipal water sources have been ruled out.

“District municipality environmental health services officials are part of the response teams to address sanitation and water safety-related issues,” said Van den Heever. “They are responsible for the routine monitoring of municipal water supply to communities, which involves routine sampling for indicator organisms. In areas where water samples were collected (municipal sources and untreated water) and tested at specific laboratories as part of the investigations, typhoid fever bacteria could not be isolated.  District and sub-district services also conduct health promotion activities (as part of the diarrhoeal season) that includes general hygiene and handwashing,” he said.

“All recent single cases and clusters are currently under investigation by the districts, sub-districts and local authorities. The response teams had been activated with guidance for further public health and surveillance activities received from the National Institute for Communicable Disease, Enteric Unit. Healthcare professionals are encouraged to be alert for possible cases and have a low threshold for collecting blood cultures when investigating cases of acute febrile illness (fever with an unknown cause).

“The identification and investigation of enteric fever cases and clusters involves ongoing surveillance … thorough case management, contact tracing and environmental investigations (food, water and sanitation), and health promotion activities,” Van den Heever said.

“The symptoms of enteric fever are non-specific and can resemble many other infections. The most characteristic symptom is a high fever, which is usually prolonged, and other symptoms include fatigue, headache, nausea, abdominal pain, and constipation or diarrhoea. Severe disease may occur, and can lead to severe complications which can be fatal,” the NICD stated in an alert.

The diagnosis is usually made by isolating the bacteria from a blood sample (blood culture); there is no reliable rapid test.

There are currently three outbreaks in Western Cape and one in North West province, around Klerksdorp, that is being linked to illegal mining activities in the area. Nineteen cases have been linked to this outbreak, with one person being hospitalised at Welmark Private Hospital and another 18 at Klerksdorp Hospital.

In an alert sent out by the National Institute for Communicable Diseases, experts warn that the biggest problem in containing typhoid fever is that, even when a person’s symptoms have resolved and they have completed treatment, they may still carry bacteria that will continue to be shed in their faeces.

“These persons are called carriers. About 10% of persons who have had an episode of enteric fever intermittently shed bacteria in their faeces for several weeks after infection while up to 4% of those infected become chronic carriers who shed bacteria in their faeces for more than a year. All carriers can spread infection to others when their faeces contaminate food or water. Carriers cause ongoing transmission in their communities.

“Enteric fever is readily treatable with antibiotics, and most patients recover without complications. However, the fatality rate for patients with severe disease who develop serious complications can be up to 30%,” the NICD alert stated.

The number of reported enteric fever cases in South Africa has declined over the past few decades, and larger outbreaks have become less common. The most recent large outbreak occurred in Delmas in 2005, with more than 2,900 cases.

After the Delmas outbreak, the number of enteric fever cases in South Africa has remained stable with less than 150 cases a year with an average of 97 cases a year.

The most recent cases of enteric fever were reported in the Cape Town metropolitan area in January 2022 and in December 2021 in George. The Cape Winelands cases, now linked through genetic sequencing, were reported in the middle of 2021.

The NICD’s Professor Juno Thomas said results of more genetic sequencing in cases picked up in Western Cape and North West provinces in January 2022 were still pending.

But, Thomas cautioned last week, it is also the time of the year when there usually is an increase in gastrointestinal disease.

“Some gastrointestinal infections have seasonality, with an annual increase in cases during specific seasonal periods. In South Africa, we typically do see an increase in some infections (for example, nontyphoidal Salmonella, Shigella and norovirus) during the summer months.

“There are often informal reports during summer about increased ‘gastro’ cases, but without recording the actual number of diarrhoea cases, or testing their stool samples, it is impossible to say what infection(s) are causing these, and if they can be attributed to the usual seasonal increase or are actually part of an outbreak due to contaminated water or food, for example,” she added.

Typhoid symptoms include a sustained fever (one that doesn’t come and go) that can be as high as 39-40°C.

• Other symptoms of typhoid fever include
• Weakness
• Stomach pain
• Headache
• Diarrhoea or constipation
• Cough
• Loss of appetite

Some people with typhoid fever develop a rash of flat, rose-coloured spots. DM/MC