The main outcomes from the interviews for use in a dashboard have been listed below:

i. Basic requirements

The main needs of the stakeholders were as follows:

  • The results in the dashboard need to be up-to-date and as recent as possible

Sending of the samples to labs for analyses adds extra lag time between the actual measurements and the results. The analysis turnaround time has decreased significantly since the outbreak started, since measuring of COVID-19 infections and SARS-CoV-2 has been established internationally, however an internationally recognised standard has not yet been set-up.

  • The dashboard needs to be simplified so that crucial role players (e.g. government) can make informed decisions as quickly as possible.

Many public dashboards remain complex to interpret. Also, outliers (unexplained spikes) in data or inconsistency with clinical tests have led and continue to lead to extreme confusion across the board.

  • Government/organisations must make use of the data/dashboard, otherwise it is perceived by the stakeholder as “useless”.

ii. Displaying viral loads

As mentioned previously, the stakeholder analysis in South Africa commenced soon after the news regarding the outbreak of the Omnicron variant in South Africa. This was considered by WHO as a variant of concern (VoC), making the focus on viral particles alone, according to the University researchers, less relevant and the change in viral loads more interesting, e.g. shedding per person. Furthermore, the changes in the viral load within the wastewater over time, i.e. via degradation was also deemed relevant.

Key questions requiring insight from the dashboard:

  • Do the different variants affect the viral load shed?

  • Is there a way to determine why different people shed different loads? What influences that? When does degradation of the viral load within wastewater begin? By answering the last question, it would be valuable to know whether sampling should happen closer to the source and more frequently instead of, as is the case with the Netherlands, predominantly at WWTPs.

Hurdles: For this work, the collection of data and standardisation remained a focal point, because the quality of the incoming data remains the biggest influencer on the outcome of any dashboard. Therefore, viral loads form the baseline of the dashboard, however there are many gaps in the data and a lack of standardisation with regards to either sampling or measuring of said data. Load shed per person is still difficult to ascertain.

Stakeholders further elaborated on the need of the following:

iii. Normalising the data (loads, dilutions, flows):

Various companies e.g. Luminultra, Promega, Innovaprep are using other methodologies for virus extraction and Orvion B.V. or Kando have equipment available for on-site monitoring system (see evaluation in Work Package 1). These technologies can help with further normalisation of data. When coupled to a dashboard this type of data collection could allow for an immediate feedback loop and quicker intervention.

iv. Comparing methodologies

Researchers mentioned the challenges surrounding the various methodologies used to measure the viral loads: ddPCR vs qPCR vs other testing methodologies. The testing of CrAssphage via kits was also implemented at a later stage and stored samples measured retroactively.

In a country as big as South Africa and with funds being distributed differently throughout the country, plus the added pressure for real-time results, the simplest and most efficient method may work to the country’s advantage.

The need for a more standardised data protocol is necessary, as mentioned in Chapter 3, but results from simple techniques were still found to match up to hi-tech methodologies. Finding a comparative “scale” is probably more important in the short-term especially during the outbreak of a pandemic. See Chapter 4 for comparison between KWR and Waterlab data.

More elaboration on data standardisation can be found in the Chapter about Collection of Covid-19 health & wastewater surveillance data and associated open data.

v. Inclusion of variants and subsequent effects

With the emergence of new SARS-CoV-2 variants, many stakeholders requested the need for showing the breakdown of these variants in tested samples. This, since a preliminary conclusion drawn by many countries around the world initially indicated that the Delta variant may lead to a higher rate of hospitalisations, while the Omnicron variant was said to be more transmissible, but less severe. We are cautious to confirm this conclusion, however we do believe that retrieving sequencing data from all samples (retroactive testing is possible up to a certain point) and adding it to the dashboard could eventually confirm or eradicate some of these hypotheses, allowing policymakers to make more informed decisions and healthcare institutions to be able to prepare.

An overview of the currently circulating SARS-CoV-2 VoCs.[1]

Our stakeholders working within air pollution quality expressed the need for linking COVID-19-related deaths to each variant and subsequently the demand on, not only healthcare, but also crematoriums, who struggled with lack of capacity, i.e. due to the increase in deaths, during the surges.

Hurdles: With regards to new variants some of the researchers reported that the viral load shed per variant may differ as well. They elaborated saying that some variants may have a high viral load, while others may have a lower load, which makes detection and predictions more difficult. They would ideally like the dashboard tool to account for this kind of information.

The ultimate question is: When will the next variant / outbreak surface?

vi. Localised vs regional sampling and privacy regulations

For more accurate insights and to understand the spread of the virus better, the need for “sampling at source” e.g. at street-level was mentioned often within the South African context. Dutch Stakeholders were wary about this as privacy laws in the Netherlands and in the EU are more stringent and so, were content with sampling via the WWTPs only.

Another point in terms of privacy within the South African context is the differentiation within the cause of death. Fatalities cannot yet be distinguished between COVID-19 deaths or other, based on "HIV" privacy. The Constitution of South Africa protects people’s right to privacy and confidentiality around HIV. Even after death, the HIV status of the deceased person may not be disclosed to anybody without the consent of the family, except when required by law.

Monitoring of waterbodies or WWTPs along major transport routes were also suggested between cities / provinces / countries e.g. COVID-19 was found to have moved along the N1 highway in South Africa from the Eastern Cape (EC) to the Western Cape (WC) before it reached WC. The peaks measured at these WWTPs around the N1 also lasted longer. The reason for this was unknown, but it is plausible that people may have been returning to their original destinations.

Because most of the world lives in non-sewered areas, the work done in South Africa’s non-sewered regions has been invaluable to monitoring these communities, allowing for warning and identification of sub-clinical infections.

vii. Politics

The global bans on South Africa not only impacted the country’s economy, but also really hurt research, as transportation of goods, i.e. lab supplies were not being allowed into the country. University researchers mentioned importing e.g. their equipment from Germany and having to wait 6 months for these to arrive.

Internal politics within the countries was also a limitation throughout the pandemic and was more apparent in South Africa, due to lack of ownership and accountability. Joining forces allows for swift development as SACCESS has shown. Organisations that are more open to sharing data, information and resources will fare better in the future to mitigate such outbreaks.

viii. Funds

This section ties well with internal politics.

In South Africa some organisations started sampling from the same sites to ensure ownership over their data. Whether the investors were aware of “double-dipping”, i.e. multiple samplings by different parties at one site, or not, these funds could have been allocated elsewhere.

Funding and urgency would increase with the arrival of a new variant or new surge. But who should be accountable? Ownership in South Africa remained a big challenge as explained earlier.

ix. Potential owners / end-users

Due to a delay in the start of the project, by the time a draft of this dashboard was presented, many facilities all over the world had already started developing their own dashboards. Stakeholders generally believed that there was no need for yet another dashboard, however they did agree that the use of digital tools e.g. machine-learning and AI could certainly enhance and upgrade current dashboards, making early warning an even more interesting feature. For example, the National research institutes were already in conversation with local software developers to implement AI into their current dashboards. In general, most of the stakeholders were very transparent and forthcoming as to their dashboard needs, however they were also hesitant to commit to anything further.

Many stakeholders expressed the need for the dashboard to be practical and applicable for policymakers, but also for employers (and individuals) to protect their employees e.g. to determine “work from home” policy. Such dashboards would also empower the individual to make more informative decisions. Dutch stakeholders believe that different dashboards or different ways of displaying the information, may be more apt for each end-user.

Furthermore, the difficulty with defining an end-user or ownership lies between the users and the source owners, i.e.:

  • Source owners: e.g. water authorities

  • Data providers: e.g. laboratories

  • Main beneficiaries: e.g. public health authorities; insurance companies

It’s currently, government vs municipalities or public heath vs. water authorities. Who benefits the most?

For this reason, such pandemic disaster management requires a more intersectoral approach to ensure interest and equal benefits for all stakeholders.

  • 1 REVIEW article: Front. Immunol., 03 January 2022 | https://doi.org/10.3389/fimmu.2021.809244