FEATURE
An Environmental View
Wastewater-based surveillance is an important focus in Africa as well , part of the
Global Fund ’ s project STELLAR to scale up testing for long-term strengthening of laboratory systems . Environmental surveillance offers a powerful opportunity to span disease pillars , said Toni Whistler , PhD , a US CDC detailee to the Global Fund . Up to now , she noted , most programs have had a singular focus : HIV , for example , or tuberculosis , or malaria .
“ One thing this pandemic has shown us over and over and over again is that , from a laboratory systems point of view , that really doesn ’ t work when you want preparedness .”
Environmental surveillance programs are already used to monitor polio and other agents in parts of Africa . “ Wastewater is a valuable , complex sample that has a host of molecular and NGS applications , including polio , monkeypox , antimicrobial resistance markers , pan-respiratory disease agents and emerging infectious diseases ,” said Noah Hull , PhD , MPH , APHL laboratory technical manager for Global Health . “ It is also independent of healthcareseeking behaviors . This is really where NGS and wastewater-based surveillance can intersect and provide valuable — and actionable — public health intelligence .”
Newer initiatives in South Africa and Botswana ( as well as in the US ) have shown the utility of wastewater for COVID-19 monitoring as well .
“ Through use of [ waste ] water-based surveillance systems , countries or public health institutions were able to identify potential new hotspots for COVID-19 before actual cases were realized ,” said Osborn Otieno , STELLAR project manager and advisor for the Global Fund ’ s Integrated Laboratory Systems Strengthening and Health Security team . That makes the approach “ a very critical tool as an early warning indicator before an outbreak or a spike can be reported within any community setting .”
Earlier this year , thanks to support from the Global Fund , APHL started wastewater-based surveillance pilots for SARS-CoV-2 in Kenya , Uganda ,
Ethiopia and Mozambique . The APHL team has conducted in-country needs assessments and is providing technical assistance to develop detailed protocols for implementation , drawing on protocols that have been used successfully in the US and working with the Ministries of Health and National Institutes of Health to adapt them to local contexts . Sampling and molecular analysis were scheduled to roll out in late summer , alongside efforts to develop local dashboards that would allow national public health institutes to access data in real time .
The project partners work with each country to model the implementation through a bottom-up process . It takes time , Otieno said , “ but the beauty of it is that the countries have been able to come up with a scientific protocol that is country-owned and jointly developed through stakeholder participation at the country level .”
That ownership is key for the sustainability of these projects . It is also critical when thinking about data management , because considerations and sensitivities around data and information vary from country to country .
“ Some countries are open , while others have a lot of rules and regulations on how to manage public health information ,” Otieno said . In Kenya , with input from stakeholders across multiple ministries , they have been able to develop a laboratory information system interface to automate data collection and transmit it to a national repository to guide decision making , while ensuring data integrity and de-identification .
Importantly , these “ environmental surveillance pilots are being implemented at a time where there ’ s a massive decline in testing ,” Whistler said . In this context , environmental surveillance for enteric pathogens provides a critical window into the course of the pandemic , including tracking the emergence of new variants .
“ It ’ s the first time , really , that we ’ ve had tools available to us that would allow low-middle income countries or countries with lesser surveillance capacity to … have a very useful tool at their fingertips for surveillance ,” she said .
You cannot spend much time building your capacity during wartime . During war , you go with whatever tools that you have . We need to do a lot of investment during normal time .”
Yenew Kebede Tebeje , MD , MPH , MSc
A Laboratory Ecosystem
To be truly successful , such laboratory strengthening efforts need to occur within the framework of a broader laboratory ecosystem that can streamline disease-agnostic financing , procurement , workforce development and , ultimately , delivery of services .
“ The last mile , as we say , is extremely difficult ,” Cognat said . “ If you have done all the steps from research , development , delivery [ and ] regulations , but then your diagnostics are in laboratories that are not available for most of the population ”— due to geographic , financial or information barriers , for example —“ the efforts and investments made upstream are totally useless .”
Currently , various aspects of that ecosystem fall under purview of a wide range of agencies , ministries and departments . In this fragmented environment , laboratory systems need to have strong leaders who can convey the importance and value of laboratory services to non-experts , including policymakers , Cognat said . Too often , “ laboratories are seen as a cost , not as an investment ,” he noted .
“ We need to change this mindset . We need to be able to articulate a new vision , we need to be able to convince decision makers .”