There is still no definite source of the current cholera outbreak, according to health minister Dr Joe Phaahla during a media briefing about the department’s efforts and interventions in response to the current cholera outbreak. 

The two laboratory-confirmed cases of cholera in February 2023 can be traced to two women who travelled back from Malawi in January, said Phaahla. They tested positive for cholera on 5 February. Cholera is endemic to Malawi, and nine more cases were confirmed in Johannesburg and Ekurhuleni after the initial report. These cases, referred to as imported cases, did not spread further and were limited to close household contact, he said. 

The situation in Free State 

The next cholera outbreak occurred in Fezile Dabi District Municipality in Free State. “We received notification from the province that there was a rise in cases of gastroenteritis, that’s a disease of diarrhoea and vomiting, especially affecting the towns of Vredefort and Parys,” Phaahla said.

In early May, there was a total of 174 cases of diarrhoea were reported and attended to at various clinics and hospitals, mainly in Parys District Hospital and Boitumelo District Hospital. 

“Unfortunately, because many of the patients presented to primary care facilities, where there were no proper conditions where specimens could be obtained, many of the patients did not have swabs taken,” he said. Six of the patients passed away without a diagnosis. Of the patients that were tested, one person who passed away and eight who were hospitalised were found to have cholera in Fezile Dabi District, bringing the total to nine cases. 

Free State province also tested four water sources, but these tests were deemed “inconclusive”. This is because the water had been treated with too much chlorine at the time and had high levels of nitrate, he said. 

The last positive case of cholera in the Free State was on 23 May. “There have not been any further cases of cholera in the Free State, so in a way, we believe it has been brought under control and managed through the measures we have undertaken,” Phaahla commented. These measures include educating people about water safety, handling food, and hand hygiene. 

Agrineth Baloyi holds up a picture of her mother Gladys in her bedroom in Hammanskraal on 24 May 2023. Her mother died of cholera on Monday in Jubilee Hospital. See article here (Photo: Yeshiel Panchia)

The current epicentre

Tshwane is the epicentre of cholera in Gauteng, said Phaahla. The first reported case in the area was a 56-year-old male, originally from Limpopo but residing in Musina. The patient is a police officer who had enrolled for a three-week course at Hammanskraal SAPS College and arrived on 7 May.  On 12 May, he complained of abdominal pain, diarrhoea and vomiting, and was subsequently taken to hospital, where he tested positive for cholera on 15 May. The patient is still in hospital but is in stable condition.  A total of 33 more students from Hammanskraal SAPS reported having gastrointestinal symptoms, eight of whom were admitted to the hospital. All the admissions are in stable condition. 

Gauteng and National Department of Health outbreak response teams were called to Jubilee Hospital on 19 May and were informed that a significant number of patients were arriving with gastrointestinal symptoms. By 19 May, 52 patients with gastrointestinal symptoms were seen at the hospital, with six patients passing away.  From 17 to 24 May, 162 patients presented to Jubilee Hospital with diarrhoea and vomiting, with 17 patients passing away during this period. 

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A downward trend 

“There was a rapid rise from that period, starting from the 17 May on Wednesday to the next Wednesday. There were 162 patients who presented to Jubilee with diarrhoea and vomiting, and 17 patients passing away,” said Phaala. 

A number of interventions were made in the following seven days, which decreased the number of patients drastically. “From 24 May to 30 May, there were 30 patients reporting having diarrhoea and vomiting, with 2 patients passing away,” Phaala confirmed. 

Interventions included the creation of special cholera wards and the deployment of a gastrointestinal specialist at Jubilee Hospital, a field clinic with additional staff at Kanana Village in Hammanskraal, and the National Health Laboratory Service prioritising specimens from Hammanskraal to speed up cholera diagnosis. 

Phaala said the interventions were helping, citing a definite decline in diarrhoea cases, seriously ill patients, and reported deaths. Currently, the total number of confirmed cholera cases in Tshwane is 99. In the last 24 hours, seven new cases were confirmed. 

“At this stage, the outbreak of cholera can be defined as being limited to very specific areas in the country,” he said. 

“Weare noticing a promising steep downward trend and we are optimistic that sooner rather than later the situation will be contained.” 

What’s the source?

Phaala said they are still tracing the source of the current outbreak. 

“The only definite source which we could locate is the earlier outbreak of Johannesburg which was traced to travelling to the endemic country which is Malawi,” said Phaala. At this stage, the source of the outbreak in Fezile Dabi District has not been found. The source could either be an individual who travelled, similar to the earlier outbreak in Johannesburg, or an environment, with inadequate sewage treatment, but more investigations need to be conducted. “We don’t as of yet have a clear pattern, we need to drill deeper,” he said. 

Phaahla added that the recent outbreak in Hammanskraal cannot yet be linked to years of poor water quality in the area, and it still needs to be established if it wasn’t imported, from mass gatherings or contaminated food.  “It is very easy for us to take the easy route and say the source is in the water, but the investigation could reveal a different source,” he said. 

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Phaahla also said while it is desirable, it is not always realistic to identify the cause. 

“It is not always the case that you will drill down and find the initial cause in a community. It is good if you can do that, but because of various factors, you don’t always depend on that, you take precautions, irrespective of if you have found the original cause or not,” he said. 

‘Harsh reminder of continued neglect’

Meanwhile, on Wednesday, South Africa’s Auditor-General Tsakani Maluleke was presenting her findings on the 2021/2022 local government audit outcomes to Parliament. Maluleke said that local government institutions have “continued to deteriorate”. South Africans see the impact of this in the delivery of services, decaying infrastructure and the continued inability to put projects on the ground. 

Empty basins at the Rooiwal Waste Water Works. (Photo:Felix Dlangamandla)

Maluleke said the deaths from the cholera outbreak in Hammanskraal were a “harsh reminder” of the impact of “continued neglect” at a local government level.

“The financial position of 70 of the 241 municipalities where we completed our audits was so dire that they had to disclose significant doubt about their ability to fully operate in future. These municipalities included City of Tshwane and Mangaung metros in Gauteng and the Free State, respectively, which together were responsible for 10% of the total local government budget and for service delivery to 9% of the households in the country,” said Maluleke, adding. “Incidentally, in that particular instance, we had actually issued a material irregularity on that Rooiwal wastewater treatment plant,” said Maluleke.DM

Additional reporting by Victoria O’Regan