Brain-eating amoeba: the whole truth

By
F. H. Mughal
Twelve persons have so far died, during this year, due to the fatal brain infection called primary amoebic
meningoencephalitis (PAM) caused by Naegleria fowleri. The oldest victim was 57-year old person and
the youngest victim was a 9-month old baby girl. In 2013, three persons lost their lives, while in 2012,
ten people died due to the infection.
The latest victim, Humaira Bano, was a young woman of 25 years and, she lived in Malir. The health
director said, it was unclear how Ms Bano came into contact with the deadly amoeba. She mostly stayed
at home and like other previous cases had no history of swimming. So far none of the 12 victims, who
died this year, had a history of swimming. So, what is wrong in Karachi?
According to the Atlanta-based US Centers for Disease Control and Prevention, Naegleria fowleri is a
heat-loving amoeba, commonly found in warm freshwaters. The amoeba is able to grow and survive at
temperatures up to 46C. Naegleria fowleri lives in freshwater habitats by feeding on bacteria. The
amoeba can infect humans by entering the nose during water-related activities. Once in the nose, the
amoeba travels to the brain and causes fatal PAM.
The fact that Naegleria fowleri, a climate-sensitive, thermophilic ameba, enters the nose, typically during
swimming, and migrates to the brain via the olfactory nerve, causing death, is correct. But, in the
context of Karachi, this is only half of the truth. The whole truth is as follows:
Naegleria fowleri can grow in the pipes of water supply distribution system, and water reservoirs,
maintained by the Karachi water agency. Aging water pipelines are vulnerable to the development of
biofilms inside the pipes. Biofilms possess the properties of bioaccumulation and bioadsoprtion. All kinds
of organisms and microorganisms, like bacteria, viruses, protozoa (Naegleria fowleri), fungi, algae and
invertebrates attach themselves to the biofilms.
The raw water sources of Karachi are the unprotected lakes and river. Naegleria fowleri can enter the
water treatment plants through these unprotected sources. Inadequate water filtration and chlorination
at the treatment plants allow Naegleria fowleri to pass through. Once in the pipelines, it can easily
proliferate due to (a) inadequate chlorine residual; (b) intermittent water supply, causing negative
pressure in pipes, dislodging the organisms from the biofilms and entering the water, when the supply is
resumed; and (c) frequent leaks in water supply and sewer lines, causing inflow of wastewater into the
water supply lines.
The only trusted defence against Naegleria fowleri, in the context of Karachi, is maintaining a chlorine
residual level of 0.5 mg/l (milligrams per liter) in the water distribution system, up to the point of
maximum residence time in the distribution system (farthest end). There should be a minimum of 30
minutes of contact time of chlorine with water at 20C, at pH level of 5.5 to 7, for effective disinfection.
pH, a measure of the degree of the acidity or the alkalinity of a solution, is defined as the negative
logarithm of the hydrogen ion concentration. The effectiveness of chlorine disinfection reduces with
increasing pH. At pH values of 8, 9 and above 9, the free chlorine residual level should be 0.6, 0.8 and
1.0 mg/l, respectively. Likewise, if the water temperature drops to 10C, the contact time should be 1
hour.
For effective chlorination, the turbidity of water must be less than 1 ntu (nephelometric turbidity units).
Chlorination will not be effective if the turbidity is greater than 5 ntu, because the microorganisms hide
themselves within the suspended particles to escape disinfection.
Free chlorine in the water distribution system is consumed by the various substances in the water,
biofilms, and by the pipe walls. The concentration of chlorine, therefore, decreases as it travels through
the distribution system, an aspect known as chlorine decay.
Maintaining a chlorine residual of 0.5 mg/l at the point of maximum residence time in the distribution
system, does not mean that Karachi water agency should go for excessive chlorination at the water
treatment plants, as the people living near the treatment plants will get excessive levels of chlorine in
the water. High chlorine levels (greater than 2 mg/l) will cause taste and odour problems, corrosion of
pipelines, and, more importantly, would lead to the formation of trihalomethanes, which are strong

carcinogens. The rational approach, in case of Karachi, would be to setup booster stations along the
water distribution network, to maintain chlorine residual of 0.5 mg/l.
The World Health Organizations Drinking-Water Guidelines says: For effective disinfection, there should
be a residual concentration of free chlorine of equal to, or greater than 0.5 mg/l after at least 30 min
contact time at pH less than 8.0. Chlorine residual should be maintained throughout the distribution
system (WHO, 2011).
The Australian Drinking Water Guidelines, version 2.0, updated Dec 2013 says: Free chlorine or
chloramines at 0.5 mg/l or higher will control N. fowleri, provided that the disinfectant persists
throughout the water supply system.
In conclusion, it is again emphasized that only a free chlorine residual of 0.5 mg/l, at all points in the
Karachis water distribution system, would be required to inactivate Naegleria fowleri. Chief Minister,
Sindh, must issue an emergency rule, requiring maintaining a minimum level of 0.5 mg/l of free chlorine
residual in Karachi.