Water quality assessment and evaluation of human health risk of drinking water from source to point of use at Thulamela municipality, Limpopo Province

Water quality has been linked to health outcomes across the world. This study evaluated the physico-chemical and bacteriological quality of drinking water supplied by the municipality from source to the point of use at Thulamela municipality, Limpopo Province, South Africa; assessed the community practices regarding collection and storage of water and determined the human health risks associated with consumption of the water. Assessment of water quality was carried out on 114 samples. Questionnaires were used to determine the community’s practices of water transportation from source to the point-of-use and storage activities. Many of the households reported constant water supply interruptions and the majority (92.2%) do not treat their water before use. While E. coli and total coliform were not detected in the water samples at source (dam), most of the samples from the street taps and at the point of use (household storage containers) were found to be contaminated with high levels of E. coli and total coliform. The levels of E. coli and total coliform detected during the wet season were higher than the levels detected during the dry season. Trace metals’ levels in the drinking water samples were within permissible range of both the South African National Standards and World Health Organisation. The calculated non-carcinogenic effects using hazard quotient toxicity potential and cumulative hazard index of drinking water through ingestion and dermal pathways were less than unity, implying that consumption of the water could pose no significant non-carcinogenic health risk. Intermittent interruption in municipal water supply and certain water transportation and storage practices by community members increase the risk of water contamination. We recommend a more consistent supply of treated municipal water in Limpopo province and training of residents on hygienic practices of transportation and storage of drinking water from the source to the point of use.

Research design. This study adopted a quantitative design comprising of field survey and water analysis. Field survey. The survey was done to identify the selected households and their shared source of drinking water (street taps). The village was divided into 10 quadrants for sampling purposes. From each quadrant, 6 households were randomly selected where questionnaires were distributed and household water samples were also collected for analysis.
Quantitative data collection. A structured interviewer-administered questionnaire was employed for data collection in the selected households. The population of Lufule village residents aged 15-69 years is 1, 026 (Census, 2011). About 10% of the adult population (~ 103) was selected to complete the questionnaires to represent the entire population. However, a total of 120 questionnaires were distributed, to take care of those which might be lacking vital information and therefore would not qualify to be analysed. Adults between the ages of 18 and 69 years were randomly selected to complete the questionnaire which includes questions concerning demographic and socio-economic statuses of the respondents, water use practices, sanitation, hygiene practices as well as perception of water quality and health. The face validity of the instrument was ensured by experts in the Department of Public Health, University of Venda, who reviewed questionnaire and confirmed that the items measure the concepts of interest relevant to the study 24 . Respondents were given time to go through the questionnaire and the researcher was present to clear any misunderstanding that may arise. www.nature.com/scientificreports/ Water sampling. Permission to collect water samples from the reservoir tank at the Nandoni water treatment plant and households was obtained from the plant manager and the households' heads respectively. Two sampling sites were identified at the dam, from where a water sample each was collected during the dry and the wet season. Similarly, 8 sampling sites were identified from the street and household taps, while 60 sampling sites were targeted for the household storage containers. However, only 39 household sites were accessible for sample collection, due to unavailability of the residents at the times of the researcher's visit. Thus, water samples were collected from a total of 57 sites. Samples were collected from each of the sites during the dry (12th-20th April, 2019) and wet seasons (9th-12th December, 2019) between the hours of 08h00 and 14h30. A total of 114 samples were collected during the sampling period: 4 from the reservoir, 16 from street taps, 16 from household taps and 78 from households' storage systems. Water samples were collected in 500 mL sterile polyethylene bottles. After collection, the containers were transported to the laboratory on ice in a cooler box. Each of the samples was tested for physico-chemical parameters, microbial parameters and trace metals' concentration.
Physicochemical parameters' analysis. Onsite analysis of temperature, pH, Electrical conductivity (EC) and Total Dissolved Solids (TDS) were performed immediately after sampling using a multimeter (model HI "HANNA" instruments), following the standards protocols and methods of American Public Health Association (APHA) 25 . The instrument was calibrated in accordance with the manufacturer's guideline before taking the measurements. The value of each sample was taken after submerging the probe in the water and held for a couple of minutes to achieve a reliable reading. After measurement of each sample, the probe was rinsed with de-ionized water to avoid cross contamination among different samples.

ICP-OES and ICP-MS analyses of major and trace elements.
An inductively coupled plasma optical emission spectrophotometer (ICP-OES) was used to analyse the major metals (Calcium (Ca), Sodium (Na), Potassium (K) and Magnesium (Mg)) in the water samples while inductively coupled plasma mass spectrophotometer (ICP-MS) was used to analyze the trace metals. The instrument was standardized with a multi-element calibration standard IV for ICP for Copper (Cu), Manganese (Mn), Iron (Fe), Chromium (Cr), Cadmium (Cd), Arsenic (As), Nickel (Ni), Zinc (Zn), Lead (Pb) and Cobalt (Co) and analytical precision was checked by frequently analysing the standards as well as blanks. ICP multi Standard solution of 1000 ppm for K, Ca, Mg and Na was prepared with NH 4 OAC for analysis to verify the accuracy of the calibration of the instrument and quantification of selected metals before sample analysis, as well as throughout the analysis to monitor drift.
Microbiological water quality analysis. Analysis of microbial parameters was conducted within 6 h of collection as recommended by APHA 25  where RfD ing is ingestion toxicity reference dose (mg/kg/day). An HQ under 1 is assumed to be safe and taken as significant non-carcinogenic, but HQ value above 1 may indicate a major potential health concern associated with over-exposure of humans to the contaminants 28 . The total non-carcinogenic risk is represented by hazard index (HI). HI < 1 means the non-carcinogenic risk is acceptable, while HI > 1 indicates the risk is beyond the acceptable level 29 . The HI of a given pollutant through multiple pathways can be calculated by summing the hazard quotients by Eq. (4) below.
(1) www.nature.com/scientificreports/ Carcinogenic risks for ingestion pathway is calculated by Eq. (5). For the selected metals in the study, carcinogenic risk (CR ing ) can be defined as the probability that an individual will develop cancer during his lifetime due to exposure under specific scenarios 30 .
where CRing is carcinogenic risk via ingestion route and SF ing is the carcinogenic slope factor. Data analysis. Data obtained from the survey were analysed using Microsoft Excel and presented as descriptive statistics in the form of tables and graphs. The experimental data obtained was compared with the South African National Standards (SANS) 31 and Department of Water Affairs and Forestry (DWAF) 32 guidelines for domestic water use.
Ethics approval and consent to participate. The ethical clearance for this study was granted by the University of Venda Health, Safety and Research Ethics' Committee (SHS/19/PH/14/1104). Permission to conduct the study was obtained from the Department of Water affairs, Limpopo province, Vhembe district Municipality and the selected households. Respondents were duly informed about the study and informed consent was obtained from all of them. The basic ethical principles of voluntary participation, informed consent, anonymity and confidentiality of respondents were duly complied with during data collection, analysis and reporting.

Results
Socio-demographic characteristics of respondents. A total of 120 questionnaires were distributed but only 115 were completed, making a good response rate of 95%. The socio-demographic characteristics of the respondents are presented in Table 1.
Household water supply. Many households (68.7%) had their primary water source from the municipality piped into their yards, but only 5.2% have the water flowing within their houses. The others have to fetch water at their neighbours' yards or use the public taps on the streets. When the primary water supply is interrupted (i.e. when there is no water flowing through the pipes within the houses, yards or the public taps due to water rationing activities by the municipality, leakage of water distribution pipes, vandalization of pipes during road maintenance, etc.), the interruption usually lasts between a week or two, during which the respondents resort to other alternative sources. A return trip to the secondary source of water usually takes between 10 and 30 min for more than half of the respondents (53.0%) ( www.nature.com/scientificreports/ Water storage and treatment practices at the household. Household water was most frequently stored in plastic buckets (n = 78, 67.8%), but ceramic vessels, metal buckets and other containers are also used for water storage (Fig. 2). Most households reported that their drinking water containers were covered (n = 111, 96.5%). More than half (53.9%) of the respondents used cups with handles to collect water from the storage containers whereas 37.4% used cups with no handles. Only 7.8% households reported that they treat their water before use mainly by boiling. Approximately 82.6% of respondent are of the opinion that one cannot get sick from drinking water and only 17.4% knew the risks that come with untreated water, and cited diarrhoea, schistosomiasis, cholera, fever, vomiting, ear infections, malnutrition, rash, flu and malaria as specific illnesses associ- www.nature.com/scientificreports/ ated with water. Despite these perceptions, the majority (76.5%) were satisfied with their current water source. The few (23.5%) who were not satisfied cited poor quality, uncleanness, cloudiness, bad odour and taste in the water as reasons for their dissatisfaction (Table 3).

Sanitation practices at the household level.
More than half of the respondents (67%) use pit toilets, whereas only 26.1% use the flush to septic tank system, most of the toilets (93.9%) have a concrete floor. About 76.5% of households do not have designated place to wash their hands, however, all respondents indicated that they always wash their hands with soap or any of its other alternatives before preparing meals and after using the toilet (Table 4).
Water samples analysis. The water samples analyses comprise of microbial analysis, physico-chemical analysis and trace metals' parameters.
Microbial analysis. The samples from the reservoir during dry and wet season had 0 MPN/100 mL of total coliform and E. coli and were within the recommended limits of WHO and SANS for drinking water. During the wet season, seven out of the eight water samples collected from the street taps were contaminated with total coliform, while four of the samples taken from the same source were contaminated with total coliform during the dry season. Water samples from street taps 3 and 7 (ST 3 and ST7) were contaminated with total coliform during both seasons, however, the total coliform counts during the wet season were more than the counts during the dry season. None of the samples was contaminated with E. coli during the dry season, however, 2 samples from the street taps (ST3 & ST6) were found to be contaminated with E. coli during the wet season. Samples from household taps showed a similar trend with the street taps-with all samples being contaminated with total coliform during the wet season. Though 7 of the 8 samples taken from the household taps were contaminated with total coliform during the dry season, the samples from the same sources showed a higher level of total coliform in the wet season, with almost all the samples showing contamination at maximum detection levels of more than 2000 MPN/100 mL, except one sample (HT8) which showed a higher level of contamination with total coliform during the dry compared with the wet season. Only one sample (HT4) was found to be contaminated with E. coli during both dry and wet season. This shows that total coliform contamination levels are higher during the wet season than the dry season (Table 5). Water samples from household storage containers (HSC) showed a higher level of total coliform during the wet season than the dry season and more samples were contaminated with E. coli during the wet season also ( Table 6). A higher level of contamination was recorded for the HSCs compared to the street and household taps. www.nature.com/scientificreports/   www.nature.com/scientificreports/ Physico-chemical analysis. In the reservoir samples, the pH value ranged from 8.37 to 8.45, EC ranged between 183 and 259 µS/cm whereas TDS varied between 118 and 168 mg/L. Similarly, in the street tap samples, pH value ranged from 7.28 and 9.33, EC ranged between 26 and 867 µS/cm whereas TDS varied between 16 and 562 mg/L (Fig. 3).

Analysis of cations and trace metals in water.
To detect the cations' and trace metals' concentrations in the water samples, representative samples from each of the sources were selected for analysis. The concentra- www.nature.com/scientificreports/ tion of Calcium ranged between 2.14 and 31.65 mg/L, Potassium concentration ranged from 0.14 to 1.85 mg/L, Magnesium concentration varied from 1.32 to 16.59 mg/L, Sodium ranged from 0.18 to 12.96 mg/L (Table 7).
Trace metals' analysis. The minimum and maximum concentrations of trace metals (Al, Mn, Fe, Co, Ni, Cu, Zn, As and Pb) present in water samples from selected street taps, household taps and household storage containers are presented in Table 8.    www.nature.com/scientificreports/ Hazard quotient (HQ) and carcinogenic risk assessment. Table 9 presents the exposure dosage and hazard quotient (HQ) for ingestion and dermal pathway for metals. The HQ ing and HQ derm for all analyzed trace metals in both children and adults were less than one unit, indicating that there are no potential noncarcinogenic health risks associated with consumption of the water. Table 10 presents the total Hazard Quotient and Health risk index (HI) for trace metals in the water samples, showing that residents of the study area are not susceptible to non-cancer risks due to exposure to trace metals in drinking water. Table 11 presents the cancer risk associated with the levels of Ni, As and Pb in the drinking water samples. The table shows that only the maximum levels of lead had the highest chance of cancer risks for both adults and children.

Discussion
This study provides information about the quality of drinking water in a selected rural community of Thulamela municipality of Limpopo province, South Africa, taking into consideration the physicochemical, microbiological and trace metals' parameters of the treated water supplied to the village by the government, through the municipality. Many participants in the study have their primary source of water piped into their yards, while very few have water in their houses. This implies that getting water for household use would involve collecting the water from the yard and then into the storage containers. Those who do not have the taps in their yards have to collect water from the neighbours' yards or the street taps. This observation is not restricted to the study area, as a similar situation has been observed in other rural communities of Limpopo Province 21 . This need to pass water through multiple containers before the point of use increases the risk of contamination.  www.nature.com/scientificreports/ Residents of the study area, just like residents of other settlements in Thulamela Municipality 21 , store their drinking water in plastic buckets, ceramic vessels, jerry cans and other containers. Almost all the respondents (96.5%) claim that their water storage vessels are covered and that their drinking water usually stays for less than a week in the storage containers (87.8%). Covering of water storage containers reduces the risk of water contamination from dust or other airborne particles. However, intermittent interruption of municipal water supply lasting for a week or more in the study area and the consequent use of alternative sources of water predispose the residents to various health risks as intermittent interruption in water supply has been linked to higher chances of contamination in the distribution systems, compared with continuous supply; in addition, the alternative sources of water may not be of a good quality as the treated municipal water 33,34 , yet, more than half of the respondents in this study (53%) use water directly from source without any form of treatment. This is because many residents in rural communities of Limpopo province believe that the water they drink is of good quality and thus do not need any further treatment 21 . The few who treat their water before drinking mostly use the boiling method. While boiling and other home-based interventions like solar disinfection of water have been reported to improve the quality of drinking water; drinking vessels, like cups, have also been implicated in water re-contamination of treated water at the point of use 16 and most respondents (91.3%) in this study admittedly use cups to collect water from the storage containers. The risk of contamination is even increased when cups without handles are used, where there is a higher chance that the water collector would touch the water in the container with his/her fingers. The Centres for Disease Control and Prevention (CDC) recommends that containers for drinking water should be fitted with a small opening with a cover or a spigot, through which water can be collected while the container remains closed, without dipping any potentially contaminated object into the container 35 . However, it is noteworthy that all the respondents claim to always wash their hands with soap (or its equivalents) and water after using the toilets, a constant practice of hand washing after using the toilet has been associated with a reduced risk of water contamination with E. coli 19 .
Treated water from the dam tested negative for both total coliform and E. coli hence complied with regulatory standards of SANS 31 and WHO 8 . The results could probably be due to the use of chlorine as a disinfectant in the treatment plant. Using disinfectants, pathogenic bacteria from the water can be killed and water made safe for the user. Similar studies have also reported that treated water in urban water treatment plants contains no total coliforms and E. coli 36 . In contrast, treated water sources in rural areas have been reported to have considerable levels of total coliform and E. coli 37 . The reason alluded to this include lack of disinfectant, no residual chlorine in the treated water, high prevalence of open defecation and unhygienic practices in proximity to water sources 38 .
From the water samples collected from the street taps, 62.5% were found to be contaminated with total coliform during the dry season, while the percentage rose to 87.5% during the wet season. The street tap which is about 13 km from the reservoir recorded high levels of total coliform ranging from 1.0 -2000 MPN/100 mL with most of the sites exceeding the WHO guidelines of 10 MPN/100 mL 8 . In both seasons, all the samples tested negative for E. coli, this complies with the WHO guideline of 0 MPN/100 mL. While the water leaving the treatment plant met bacteriological standards, the detection of coliform bacteria in the distribution lines suggest that the water is contaminated in the distribution networks. This could be due to the adherence of bacteria onto biofilms or accidental point source contamination by broken pipes, installation and repair works 39 . Furthermore, the water samples from households' storage containers were contaminated by total coliform (73% and 85%) and E. coli (10.4% and 13.2%) during the dry and wet season, respectively. Microbiological contamination of household water stored in containers could be due to unhygienic practices occurring between the collection point and the point-of-use 40,41 .
Generally, higher levels of contamination were recorded in the wet season than in the dry season. The wet season in Thulamela Municipality is often characterized with increased temperature which could lead to favourable condition for microbial growth. Also, the treatment plant usually makes use of the same amount of chlorine for water purification during both seasons, even though influent water would be of a higher turbidity during the wet season, hence reducing the levels of residual chlorine 42 .
The pH of the analyzed samples from the study area ranged from 7.15 to 9.92. Most of the samples were within the values recommended by SANS (5 to 9.7) and comparable to results from previous similar studies 31,43 . Also, the electrical conductivity of all water samples from this study ranged from 28 µS/cm to 903 µS/cm which Table 11. Cancer risk associated with the levels of Ni, As and Pb in the drinking water. www.nature.com/scientificreports/ complied with the recommended value of SANS: < 1700 µS/cm 31 . The presence of dissolved solids such as calcium, chloride, and magnesium in water samples is responsible for its electrical conductivity 44 . Total dissolved solids are the inorganic salts and small amounts of organic substance, which are present as solution in water 45 . Water has the ability to dissolve a wide range of inorganic and some organic minerals or salts such as potassium, calcium, sodium, bicarbonates, chlorides, magnesium, sulphates, etc. These minerals produced unwanted taste and colour in water 46 . A high TDS value indicates that water is highly mineralised. The recommended TDS value set for drinking water quality is ≤ 1200 mg/L 31 . In this study, the TDS values ranged from 18 mg/L to 572 mg/L. Hence, the TDS of all the household's storage samples complied with the guidelines and consistent with previous studies 47 .
The analysis of magnesium (1.32 to 16.59 mg/L) and calcium (2.14 to 31.65 mg/L) concentrations showed that they were within the permissible range recommended for drinking water by SANS 31 and WHO 8 . All living organisms depend on magnesium in all types of cells, body tissues and organs for variety of functions while calcium is very important for human cell physiology and bones. Similar studies in Ethiopia and Turkey also showed acceptable levels of these metals in drinking water 46,48 . Likewise, the levels of potassium (0.14 to 1.85 mg/L) and sodium (0.18 to 12.96 mg/L) were within the permissible limit of WHO and SANS and may not cause health related problems. Sodium is essential in humans for the regulation of body fluid and electrolytes, and for proper functioning of the nerves and muscles, however, excessive sodium in the body can increase the risk of developing a high blood pressure, cardiovascular diseases and kidney damage 49,50 . Potassium is very important for protein synthesis and carbohydrate metabolism, thus, it is very important for normal growth and body building in humans, but, excessive quantity of potassium in the body (hyperkalemia) is characterized with irritability, decreased urine production and cardiac arrest 51 .
Metals like copper (Cu), cobalt (Co) and zinc (Zn) are essential requirements for normal body growth and functions of living organisms, however, in high concentrations, they are considered highly toxic for human and aquatic life 42 . Elevated trace metal(loids) concentrations could deteriorate water quality and pose significant health risks to the public due to their toxicity, persistence, and bio accumulative nature 52 . In this study, the concentrations of Manganese, Cobalt, Nickel and Copper all complied with the recommended concentration by SANS for domestic water use.
Aluminum concentration in the drinking water samples ranged from 1.25-13.46 µg/L. All analysed samples complied with the recommended concentration of ≤ 300 µg/L for domestic water use 31 . The recorded levels of Al in water from this study should not pose any health risk. At a high concentration, aluminium affects the nervous system, and it is linked to several diseases, such as Parkinson's and Alzheimer's diseases 53 . Iron (Fe) is an essential element for human health, required for the production of protein haemoglobin, which carries oxygen from our lungs to the other parts of the body. Insufficient or excess levels of iron can have negative effect on body functions 54 . The recommended concentration of iron in drinking water is ≤ 2000 µg/L 31 . In this study, the concentration of iron in the samples ranged from 0.96 to 73.53 µg/L. Similar results were reported by Jamshaid et al. in Khyber Pakhtunkhwa province 55 . A high concentration of Fe in water can give water a metallic taste, even though it is still safe to drink 56 .
The levels of Pb, As and Zn were in the range of 0.02-0.57 µg/L, 0.02-0.17 µg/L, and 2. .96 µg/L, respectively whereas Cr was not detected in the samples collected. The levels recorded complied with the SANS 31 and WHO 8 guidelines for drinking water. Similar results were reported by Mohod and Dhote 57 . Lead is not desirable in drinking water because it is carcinogenic and can cause growth impairment in children 41 . Inorganic arsenic is a confirmed carcinogen and is the most significant chemical contaminant in drinking-water globally 44 . Zinc deficiency can cause loss of appetite, decreased sense of taste and smell, slow wound healing and skin sores 58 . Cr is desirable at low concentration but can be harmful if present in elevated levels.
The hazard quotient (HQ) takes into consideration the oral toxicity reference dose for a trace metal that humans can be exposed to 59 . Health related risk associated with the exposure through ingestion depends on the weight, age and volume of water consumed by an individual. HQ ing and HQ derm for all analyzed trace metals in both children and adults were less than one unit (Table 9), indicating that there are no potential non-carcinogenic health risks associated with the consumption of the water from the study area either by children or adults. The calculated average cumulative health risk index (HI) for children and adult was 3.88E-02 and 1.78E-02, respectively. HQ across metals serve as a conservative assessment tool to estimate high-end risk rather than low endrisk in order to protect the public. This served as a screen value to determine whether there is major significant health risk 60 . The results in this study signifies that the population of the investigated area are not susceptible to non-cancer risks due to exposure to trace metals in drinking water. Similar observation has been reported by Bamuwamye et al. after investigating human health risk assessment of trace metals in Kampala (Uganda) drinking water 61 . It should be noted that the hazard index values for children were higher than that of adult, suggesting that children were more susceptible to non-carcinogenic risk from the trace metals.
Drinking water with trace metals such as Pb, As, Cr and Cd could potentially enhance the risk of cancer in human beings 62,63 . Long term exposure to low amounts of toxic metals might, consequently, result in many types of cancers. Using As, Ni and Pb carcinogens, the total exposure risks of the residents in Table 11. For trace metals, an acceptable carcinogenic risk value of less than 1 × 10 −6 is considered as insignificant and the cancer risk can be neglected; while an acceptable carcinogenic risk value of above 1 × 10 -4 is considered as harmful and the cancer risk is worrisome. Amongst the studied trace metals, only the maximum levels of lead for both adults and children had the highest chance of cancer risks (1.93E−03 and 4.46E−03) while Arsenic and Nickel have no chance of cancer risk with values of 3.34E−06; 7.72E−06 and 2.24E−05; 5.18E−05, in both adults and children respectively. The only cancer risk to residents of the studied area could be from the cumulative ingestion of lead in their drinking water. The levels of Pb recorded in this study complied to the SANS guideline value for safe drinking water. While the levels of Pb from the dam and the street pipes were relatively low, higher levels where recorded at household taps and storage containers and this may be due to the kind of storage containers and pipes www.nature.com/scientificreports/ used in those households. Generally, the water supply is of low Pb levels which should not pose any health risk to the consumers. However, the residents in rural areas should be properly educated on the kind of materials to be used for safe storage of water which should not pose an additional health burden. The likelihood of cancer risk was only associated with the consumption of the highest levels of Pb reported for a life time for adults (set at 70 years) and 6 years for children. Consistent consumption of water from the same source throughout an adult's lifetime is unlikely as residents in those communities may change their locations at some points, hence reducing the possible risk associated with consistent exposure to the same levels of Pb.

Conclusions
The study shows that as distance increases from the treatment reservoir to distribution points, the cross-contamination rate also increases, therefore, good hygienic practices is required while transporting, storing and using water. Unhygienic handling practices at any point between collection and use contribute to the deterioration of drinking water quality. The physicochemical, bacteriological quality and trace metals' concentration of water samples from treated source, street taps and household storage containers were majorly within the permissible range of both WHO and SANS drinking water standards. HQ for both children and adults were less than unity, showing that the drinking water poses less significance health threat to both children and adults. Amongst the studied trace metals, only the maximum level of lead for both adults and children has the highest chance of cancer risks.
We recommend that appropriate measures should be taken to maintain residual free chlorine at the distribution points, supply of municipal treated water should be more consistent in all the rural communities of Thulamela municipality, Limpopo province and residents should be trained on hygienic practices of transportation and storage of drinking water from the source to the point of use.