This chapter discusses the future prospects for “pandemic preparedness” in terms of digital tooling, stakeholders and the further possibilities.
Standardisation for monitoring outbreaks around the globe
The method of testing wastewater is a very effective way of monitoring various kinds of data (drug use, SARS-COV-2 etc.), but it requires a structured and constant (read large) set of information to be provided to be able to start implementing any methodology. This means that metrics and measuring targets e.g. CrAssphage would need to be defined and measured over a long period of time at specific locations with high frequency to provide a baseline for the information, and this would need to continue for an analytic model to continue to function. There are many aspects to these decisions that would need to be considered such as population demographics, transport availability (e.g. airport, trains), commuting schedule etc.
As such, it is clear from the challenges experienced in this work that data standardisation is vital for data processing. This process needs to be better defined, incorporating several variables, whilst still allowing room for flexibility, especially in emergency situations. Additional data sets, i.e. water ingress, flow rates and area rainfall were not included in the scope of this project, but are important considerations towards standardisation. Being able to move out of the development phase swiftly is key in getting ahead of any future pandemic.
That said, urgency does allow for simplicity and innovation. Using categorised Ct values appeared to be the best method to allow the comparison of data from different laboratories, making use of different extraction and identification procedures for the viral RNA, across geographical areas. This will enable the COVID-19 incidence to be observed over time, while regional, national and/ or global comparisons can occur as well.
Stakeholder key outcomes
Science-based evidence and political decisions experienced major gaps in the first half of the pandemic. The regulations and reasons fluctuated tremendously, aggravating not only the average citizen, but also stifling research. Joint forces within the scientific community across the globe allowed for swift development and progress. As the SACCESS network had shown, organisations that are more open to collaboration will fare better in the future to mitigate the effects of another outbreak.
The future of WBE
It is important to understand that without ongoing WBE research we would have not come this far, this quickly. Years of WBE research for poliovirus and drug tracking allowed us to learn substantially for the COVID-19 pandemic. WBE helped get the buy-in needed from researchers and other stakeholders. We therefore recommend continued WWTP sampling and WBE research in a strategized and structured way. Ideally, health data with regards to infections continues as well, however some national budgets may not allow for both, and contamination of data with other viruses and illnesses remains a challenge. This again highlights that, currently, only WWTP data allows for a consistent comparison of viral infections. It must also be added that the work done within the non-sewered regions of South Africa has brought invaluable insight to warning and identification of sub-clinical infections, and has simultaneously collected knowledge for improving sampling standardisation for the majority of the world’s population living in non-sewered areas. This makes the case for continued WBE research to monitor outbreaks in sewered and non-sewered regions even stronger. As such, we will be able to respond even faster to the next pandemic, with all the accumulated knowledge from the past 2,5 years.
Regarding future monitoring of wastewater, there are several pathogens that are of relevance, especially in the developing world:
Viruses: norovirus, rotavirus, and the different hepatitis viruses are all relevant in addition to polio, which is already monitored as part of the global surveillance programme.
Bacteria: salmonella, campylobacter, helicobacter, cholera and shigella
Parasites: crypto and giardia, as well as the different worms. In the Western Cape helminth infections result in lower IQ scores and nutritional status, with as much as 80% of some population groups having worms. Examples include ascaris, hookworm, whipworm, and pinworm to name a few.
The ambition is to continue to look at the broader picture of (waste)water surveillance for not only for community health and outbreak monitoring, but also for:
Drug use tracking
Emerging contaminants tracking
Monitoring of irrigation water quality and the use of pesticides
In this way we can utilise the plethora of information wastewater surveillance has to offer to benefit the world as a whole.
Finally, funding is pivotal to acquiring continued and consistent data. With this data, the analysis and machine-learning tools will verify their added value and in turn, a visualisation tool will be instrumental in supporting decision-makers to create better policies. If this pandemic, and the incredible work within WBE research has taught us anything, it is that there is immense value in being prepared. The economic damages of the interventions to mitigate the spreading of the virus have been enormous. Who is willing to invest in preventing this reoccurrence?
Furthermore, public investments are needed to unlock the full potential of WBE. An accumulation of vast data and a future dashboard are only possible if stakeholders, essentially all of us, are aware of the benefit, forcing our politicians to prioritise “preparedness” for future pandemics. The incentive is our safety and our health, including mental well-being. Is this enough to maintain the sense of urgency we experienced two years ago?