“One life lost is just too many. And the risk from all other indications from the study indicates there is even more than meets the eye,” Dr Jennifer Molwantwa, CEO of the Water Research Commission (WRC), told a media briefing hosted by the National Press Club on Wednesday as she provided an update on the WRC’s independent analysis of the recent cholera outbreak in Hammanskraal.

The WRC was commissioned by the Department of Water and Sanitation to do an independent investigation on 31 May 2023. At that stage, 20 people had already died, but a total of 32 deaths were eventually recorded. 

Cholera is a diarrhoeal disease caused by ingesting water or food contaminated with faecal matter containing the bacterium Vibrio cholerae.

A water tanker delivers to residents of Hammanskraal during the cholera outbreak in May 2023. (Photo: Felix Dlangamandla)

While cholera is not endemic to South Africa, several countries in southeastern Africa – particularly Malawi, which is currently experiencing the largest active cholera outbreak on the continent, and Mozambique – experienced outbreaks in March 2023, which spread regionally to Tanzania, Zambia, Zimbabwe and South Africa.

Source unknown

The WRC, which worked with Cubic M Africa, Virtual Consulting Engineers and the University of Pretoria on the assessment, said that it is still not known whether water was a source of the cholera outbreak. 

However, it noted that, at the time of the outbreak, cholera was circulating in the environment and the conditions from a water, sanitation and hygiene perspective enabled its quick spread.

Sounding the alarm on a much bigger issue

Jac Wilsenach, from Virtual Consulting Engineers, said: “Although the recent cholera outbreak could not be directly linked to wastewater treatment plants, it remains incidental to poor maintenance and is not an isolated event.

“Instead, it represents the ears of the hippopotamus, of acute and chronic diseases caused by viruses, bacteria, fungi and parasites, as well as chemical compounds. E. Coli remains the best indicator organism, well correlated with all health risks.”

Wilsenach explained to Daily Maverick that E. coli is an indicator organism, because if E. coli levels are detected, it means water has been contaminated by sewage – or that the sewerage works are not doing their job.

So, while cholera was not detected upstream of the Rooiwal Wastewater Treatment Works, which affects water supplied to Hammanskraal, and was only detected once in the first sample downstream of Hammanskraal, there were extremely high concentrations of E. coli, as well as the presence of other bacteria, including salmonella and shigella, in the Apies River, which is where the Rooiwal effluent is discharged into.

“What’s important is that we can conclude that if you find E. coli at very high levels, everything else we measure is already there,” said Wilsenach.

E. coli, salmonella and shigella are enteric bacteria, meaning they can affect the intestines and cause diseases.

Results from the assessment showed that both Rooiwal Wastewater Treatment Works and Temba Drinking Water Treatment Works are dysfunctional and that both the final treated wastewater and final treated drinking water were found not to be compliant with the regulated water quality standards, highlighting the community’s susceptibility to health risks.

Empty basins at the Rooiwal Waste Water Treatment Works in Tshwane. It is set for a R4bn upgrade. (Photo:Felix Dlangamandla)

Along with inadequate sanitation and hygiene infrastructure – particularly in the informal and rural settlements – the independent assessment also found that there was illegal dumping and poor solid waste management, and that a general lack of awareness of the issues poses risks and serves as a potential pathway for future waterborne disease outbreaks.

Dr Erika du Plessis, a senior researcher in food safety in the plant pathology laboratories at the University of Pretoria, said the take-home message with regard to water and food safety is that cholera contamination in our water sources impacts on the food chain and market access negatively and that other studies have shown that V. cholerae (the bacterium that causes cholera) can survive on crops and that waterborne pathogens (including V. cholerae) can be transferred to crops. 

The WRC’s research team (right) and advisory panel at the media briefing on the commission’s independent analysis of the recent cholera outbreak in Pretoria, 26 July 2023. (Photo: Frans Sello saga Machate / National Press club)

Recommendations

The WRC shared its assessment and recommendations with the City of Tshwane, and the Department of Water and Sanitation.

Key recommendations include improving access to clean drinking water and sanitation facilities and promoting safe household water treatment, storage and handling as well as safe hygiene practices, which is vitally important in preventing the spread of cholera and other waterborne diseases. 

“Generally, the poor water services situation in Hammanskraal poses a high risk to public health,” the WRC said.

“Most importantly, the Rooiwal Wastewater Treatment Plant must be upgraded to increase capacity. Design capacity for the nutrient removal plant is around 3×40 million litres per day [the plant has three sections], but flow rates could be up to 200 million litres per day. Parts of the plant must be overhauled too, because it is dysfunctional.”

Daily Maverick previously reported that the Rooiwal Wastewater Treatment Plant was not built to support such a big population. As well as not having the capacity to meet the demands of an expanding population (which has led to sewage spills), the plant is not maintained properly, which can also cause the water to be contaminated.

“The situation can only be turned around if the existing process units were repaired, reconfigured and upgraded to reclaim drinking water directly as a venture with commercial incentive with professional oversight,” Wilsenach said.

He said that in the short term, possibly within a year, if the pumps, mixers, clarifiers and diffusers were fixed there would be month-by-month improvements to the plant.

“There’s a lot that can be fixed in the short term to get the plant to some sort of operation … because right now only a third is working, if that,” Wilsenach said.

“But then you need to step back and do a full master plan for the whole works, because it’s beyond capacity; it receives much more than it can treat.”

Raw sewage flows into a stream, close to a day-care centre in Hammanskraal, Gauteng. (Photo: Mia Lindeque)

Such long-term interventions could last five years.

The WRC also recommended quick responses to outbreaks, saying: “At the onset of an outbreak (one case confirmed), early detection, surveillance, treatment and case management are critical in managing the spread of cholera.”

Other recommendations include integrating water and wastewater quality surveillance into early warning systems for cholera outbreaks and considering the impacts of climate change – as drought, rainfall and certain temperature conditions make it favourable for V. cholerae to survive. 

Finally, as a combination of poor wastewater from both Rooiwal and Temba and contaminated surface run-off from land (which enters natural water bodies) is then used by the community for cultural, religious, recreational purposes, irrigation and for the production of drinking water, it’s important that safe water reuse practices are implemented in Hammanskraal.

“It is imperative that best practices and standards for water reuse quality and safety for various uses (cultural, religious, recreational, irrigation, drinking, etc) are followed to safeguard public health,” the WRC said. DM