Experts are advising healthcare workers to treat all diarrhoea cases as suspected Cholera until proven otherwise.
This is while government is working tirelessly to contain the spread of the disease that has already claimed 15 lives in Hammanskraal, north of Pretoria.
Head of the Centre for Enteric Diseases at the National Institute for Communicable Diseases (NICD), Dr Juno Thomas, said the hallmark of cholera is acute watery diarrhoea.
"This is defined as diarrhoea lasting less than seven days, which is typically watery, non-bloody liquid stools that may contain a bit of mucous," she explained, adding that diarrhoea is three or more stools within 24 hours.
Speaking during a webinar on Tuesday, she said 20% of those infected with cholera - caused by the bacteria Vibrio cholerae - develop acute watery diarrhoea and most patients may vomit, while fever is mostly absent.
"The classical appearance of stool in severe cases is described as rice water."
However, according to Thomas, in many cases with mild to moderate cholera, stool is watery but coloured.
"Therefore, any acute watery stool, regardless of colour, must be regarded as suspected cholera."
According to the latest data, Gauteng and Free State are the hardest hit, while another case of cholera has been detected in another province yet to be confirmed.
South Africa reported its first cholera death in February after the virus arrived in the country from Malawi.
"Locally acquired cases are of great concern because it often means there are many infections that have not been identified."
Ideally, Thomas said, clinicians should alert the lab before submitting a specimen from a suspected cholera case.
"Patient management must never wait for a laboratory diagnosis. The laboratory diagnosis is for public health action and not to guide individual patient management," she stressed.
Meanwhile, Wits University's infectious diseases specialist, Dr Jeremy Nel, said it was uncommon for adults to have severe dehydration from diarrhoea.
"So, always think of cholera," Nel stressed.
"If you get the fluids right in cholera, you're almost fine ... Remember that fluid hydration is 90% of the management of cholera. If you get this right, even if you don't have antibiotics and forget about other components, you're almost certain you'll be saving their lives."
Therefore, he said it was important for clinicians not to delay rehydrating the patient.
"The oral volume of fluid for moderate cases can be excessive, so intravenous administration of some or all of the fluid is often necessary."
Meanwhile, the Department of Health's Aneliswa Cele, said as of 21 May 2023, cholera has been reported in at least 24 countries, of which 15 are in Africa.
"Given the ongoing cholera outbreaks in the South African region, there is a high possibility of continued importation of cases to South Africa."
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Cele urged clinicians to maintain a "high index" of suspension for cholera in patients who present acute watery diarrhoea.
"Surveillance measures should be strengthened to enable early detection of cases. That is why in Free State, for instance, we have a national team on the ground to support the provincial team."
In the meantime, Water and Sanitation Minister Senzo Mchunu has sent technical teams to work with the City of Tshwane and the Department of Health in response to the cholera outbreak.
He has since directed the City of Tshwane to stop supplying water from the Temba Water Treatment plant after the tests found that the drinking water quality does not meet the minimum drinking water quality.
