Impact case study database

The research breakthroughs at UoB have helped protect some of the most vulnerable human populations globally, by supporting a ‘multiple barrier approach’ to disease control, particularly in low-resource and emergency settings. By collaborating with NGOs, policymakers and communities, UoB research has protected human health through evidence-led interventions into global-health policy (WHO/UNICEF) and on-site treatment practice to reduce risk to families, communities and those working to support the most vulnerable to virus and infection.

4.1 Protocols for the safe handling and disposal of human excreta

UoB scientists were mobilised initially to help MSF with the humanitarian response in Haiti following the 2010 earthquake and cholera outbreak, via the development and application of low-cost lime-based methods to protect communities located downstream of three CTCs from infection. Following subsequent USAID funding, the intervention extended to encompass the containment of Ebolavirus in response to the 2013 – 2016 outbreak. This work revealed critical knowledge gaps relating to the water, sanitation and hygiene (WASH) activities of international NGOs. In particular, the absence of information on the survival of the Ebolavirus within human excreta prompted the WHO/UNICEF to invite an international panel of experts (including Taylor for his microbial ecology expertise) to review critically existing WASH practices.

In October 2014, with direct input from Taylor, the WHO/UNICEF panel revised their guidance due to concerns about the potential dangers of using excreta chlorination protocols prescribed in 2004 MSF Guidelines [5.1a]. The revised guidance now recommends the lime-based procedures developed at the UoB to counter these concerns. WHO/UNICEF WASH guidelines on Ebola virus disease also now include protocols for managing excreta from ETC patients to accelerate ‘ the inactivation of the Ebola Virus using lime’ [5.2]; these guidelines are recommended by WHO/UNICEF as best operating practice for all international NGOs working in Ebola-affected areas of West Africa (including UNICEF, OXFAM, Save the Children and MSF). Subsequent collaboration with Tufts University (2015 – 16), during which the UoB team compared the efficacy of emerging lime and existing chlorine approaches, resulted in further improvements in treatment efficacy (by refining the dosage, including a mixing step for lime and identifying the optimum duration of contact). UoB research is also referenced in the WHO’s 2018 Guidelines on sanitation and health to demonstrate the suitability of phage and lime-based approaches for detecting and preventing faecal contamination in emergency settings [5.3].

In 2017, UoB’s optimised lime-based protocols were adopted as part of revised Standard Operating Procedures (SOP) for MSF’s CTC facilities [5.1]. In 2018, MSF treated 63,722 people for cholera in 16 outbreaks affecting 6 countries (Cameroon, DR Congo, Haiti, Niger, Nigeria, South Sudan) using UoB protocols for excreta management. This figure rose further in 2019 as MSF responded to outbreaks in Yemen and Mozambique in the wake of cyclones Idai and Kenneth; in Beira (Mozambique), MSF had 446 staff assisting with WASH activities at three purpose-built CTCs treating 4,330 patients [5.4]. UoB researchers continue to work closely with ‘on-the-ground’ MSF staff on refinements to the SOP and through the provision of real-time advice on the safe handling of cholera-laden waste. In March 2020, MSF released a revised SOP (Comprehensive Method) for use at all its on-site treatment Centres [5.1b].

4.2 Improved approaches for the surveillance of potential disease transmission routes

In 2017, UoB scientists were sub-contracted by Emory University to provide MST expertise to a Gates Foundation-funded collaboration with NICED, India. The initiative aimed to protect slum-dwellers from typhoid fever (an important cause of avoidable morbidity and mortality) in Kolkata’s slums, home to over 1.5 million people. The UoB contribution to the SaniPath typhoid project has, for the first time, made it possible for NICED staff to separate the human faecal pollution pathways (along which S. typhi and/or Paratyphi A travels) from the pervasive ‘background noise’ of non-human faecal contamination in such settings [5.5].

The new capability within the SaniPath Exposure Assessment Tool (not available before 2017) allows users, including staff at NICED, to gain valuable understanding of the relative importance of human faecal contamination pathways and to identify high risk practices and situations [5.5, 5.6]. Our ability to pin-point human faecal transmission within domestic and environmental settings is providing local communities in three districts of Kolkata (home to >100,000 people) with the knowledge necessary to avoid hazardous activities such as eating unwashed raw produce or the use of unhygienic food preparation areas. UoB findings have demonstrated to NICED and the SaniPath international scientific advisory committee why previous WASH interventions targeting alternative transmission routes (eg drinking water supplies) were not accompanied by declines in typhoid incidence [5.5, 5.6].

Phage-based monitoring has been utilised by KEMRI to improve the protection of 1,170 inhabitants (234 households) in rural Kenya, where 29% of households rely on unprotected surface waters for drinking water supply and where childhood diarrhoea from livestock affects 20% of children under five. UoB methods in Kenya work by quantifying faecal contamination arising from animal sources and the risk of encountering ‘zoonotic’ pathogens. Regional water quality testing capacity has been strengthened by the training of 16 laboratory researchers, academics, and technicians from institutions across the region in rapid, low-cost, phage-based approaches in 2019. The MRC-funded project has facilitated more effective management of rural water supplies in Kenya by indicating which interventions stakeholders and householders need to invest in and builds on other laboratory training events staged by UoB researchers in Brazil (44 participants, 2015) and India (22 participants, 2017) [5.7].

In April 2015, the US Environmental Protection Agency (EPA) conducted a high-level review [5.8] into alternative water quality indicators, as evidence emerged that bacterial indicators (used for the last 100 years) do not adequately indicate risk from viral pathogens, a leading cause of recreational waterborne illness [5.9]. This review and the subsequent EPA Experts Workshop [5.9] held in March 2016 used evidence from 9 UoB publications on phage-based recreational water quality indicators, eg their removal by wastewater treatment, relationship with viral pathogens ( norovirus, Adenovirus) and their densities in faecally-impacted waters from the US, EU and UK. As such, UoB research has made it possible for the EPA to develop criteria for water quality that reflect accurately the ‘latest scientific knowledge’ (as required in the US Clean Water Act) and effectively protect the health of 331 million US citizens.

Most recently, in response to the COVID-19 pandemic, WHO/UNICEF have produced interim guidance entitled Water, sanitation, hygiene and waste management for the COVID-19 virus to aid global efforts to control the disease. UoB’s phage and lime-based research are used in this guidance, which highlights that ‘ chlorine is ineffective for disinfecting media containing large amounts of solid and dissolved organic matter’ and that ‘ where there is no off-site treatment, in-situ treatment can be done using lime’). This early policy development to contain, control and remove a virulent new virus from human waste serves to demonstrate the flexibility of solutions developed at UoB to protect human health in low-resource settings [5.10].