Addressing the challenges of establishing quality wastewater or non-sewered sanitation-based surveillance, including laboratory and epidemiological considerations, in Malawi

Learning from clinical laboratories, wastewater or environmental (including non-sewered sanitation) environmental microbiology laboratories can be established in resource-limited settings that focus on pathogen detection and pandemic prevention. Transparent discussions on the laboratory challenges and adaptations required for this can help meet the future requirements of health research and surveillance. This report aims to describe the challenges encountered when setting up a wastewater or environmental laboratory for multipathogen surveillance in Malawi, a resource-limited setting, as well as the lessons learnt. We identified nine unifying themes: what to monitor, human resource capacity, indicators of data quality, equipment availability, supply of consumable goods, ongoing operation and maintenance of the laboratory, application of localised guidelines for laboratory operations, lack of real-time clinical correlation for calibration and localised ethical considerations. Over our 6-month timeline, only Salmonella typhi, Vibrio cholerae and severe acute respiratory syndrome coronavirus 2 analyses were set-up. However, we were unable to set-up measles and tuberculosis analyses owing largely to supply delays. By establishing this system at a public higher education academic laboratory in Malawi, we have ensured that ongoing capacity building and piloting of public health work is conducted in the country, rather than relying on non-governmental organisations or reference laboratory support beyond national borders. This work is not intended to replace clinical testing but rather demonstrates the potential for adapting higher education academic laboratory infrastructure to add wastewater or environmental (including non-sewered sanitation) samples, where appropriate, as additive epidemiological data for better pandemic preparedness.