The role of wastewater-based epidemiology for SARS-CoV-2 in developing countries: Cumulative evidence from South Africa supports sentinel site surveillance to guide public health decision-making

The uptake of wastewater-based epidemiology (WBE) for SARS-CoV-2 as a complementary tool for monitoring population-level epidemiological features of the COVID-19 pandemic in low-and-middle-income countries (LMICs) is low. We report on the findings from the South African SARS-CoV-2 WBE surveillance network and make recommendations regarding the implementation of WBE in LMICs. Eight laboratories quantified influent wastewater collected from 87 wastewater treatment plants in all nine South African provinces from 01 June 2021 to 31 May 2022 inclusive, during the 3rd and 4th waves of COVID-19. Correlation and regression analyses between wastewater levels of SARS-CoV-2 and district laboratory-confirmed caseloads were conducted. The sensitivity and specificity of novel 'rules' based on WBE data to predict an epidemic wave were determined. Amongst 2158 wastewater samples, 543/648 (85 %) samples taken during a wave tested positive for SARS-CoV-2 compared with 842 positive tests from 1512 (55 %) samples taken during the interwave period. Overall, the regression-co-efficient was 0,66 (95 % confidence interval = 0,6-0,72, R2 = 0.59), ranging from 0.14 to 0.87 by testing laboratory. Early warning of the 4th wave of SARS-CoV-2 in Gauteng Province in November-December 2021 was demonstrated. A 50 % increase in log copies of SARS-CoV-2 compared with a rolling mean over the previous five weeks was the most sensitive predictive rule (58 %) to predict a new wave. Our findings support investment in WBE for SARS-CoV-2 surveillance in LMICs as an early warning tool. Standardising test methodology is necessary due to varying correlation strengths across laboratories and redundancy across testing plants. A sentinel site model can be used for surveillance networks without affecting WBE finding for decision-making. Further research is needed to identify optimal test frequency and the need for normalisation to population size to identify predictive and interpretive rules to support early warning and public health action.

South African Institute of Drug-Free Sport Position Statement on CBD (Cannabidiol) and THC (Tetrahydrocannabinol)

Cannabidiol (CBD) and Tetrahydrocannabinol (THC) have become easily available to athletes over the years. Using these substances may inadvertently expose an athlete to the possibility of an adverse analytical finding (a "positive" test) and a sanction. Athletes need to understand the risk of an anti-doping rule violation or adverse analytical finding should these products be used, especially if no therapeutic use exemption exists. This position statement attempts to clarify the use of CBD and THC and their associated risks with Anti-Doping Rule Violations (ADRV) in the athletic population. The South African Sports Medicine Association supports this position statement.

Sport during the COVID-19 bio-bubble: Wellness and opinions in South African elite football

Background

COVID-19 imposed challenges on professional sport, with restrictions leading to the delay in the completion of the South African Premier Soccer League (PSL). Creating a biologically safe environment (BSE) provided a solution enabling the 2019/2020 season to be completed.

Objectives

Evaluating the impact that the BSE had on player wellness and what coping mechanisms were used in the BSE.

Methods

A questionnaire was distributed to PSL teams on the final weekend in the BSE. It consisted of three validated psychology questionnaires. An additional section focused on the impact and coping strategies during the PSL's BSE.

Results

A total of 37 completed questionnaires were analysed. General anxiety (4.7±4.2) and depression levels (4.8±3.9) were at an overall low. The health of the players, as well as separation from and concerns about family, were the greatest contributors to anxiety. Electronic communication with family and friends, social interactions with others in the BSE and time spent on self-reflection were important coping mechanisms for players. As time progressed, they adapted to the BSE.

Conclusion

The BSE did not have a negative impact on the anxiety and depression levels of the respondents, with a variety of coping mechanisms key helping them adapt in the BSE.

The congested International Match Calendar in football: views of 1055 professional male players

Background

The International Match Calendar congestion affects players recovery. The views of a worldwide cohort of professional football players is shared in this communication.

Methods

A cross-sectional observational study recruited players through Fédération Internationale des Associations de Footballeurs Professionnel’s national members. An electronic survey was shared in English, French, Italian and Spanish with 1055 players consenting and completing it anonymously in November 2021.

Results

A total of 42% of respondents believe back-to-back matches should be limited to three. Most respondents (69%) felt off or in season breaks are infringed by clubs or national teams and 83% believe regulations should protect them. A total of 55% of players believed they sustained one or more injuries due to the overload and it has affected 52% of respondents’ mental state.

Conclusion

The congested International Match Calendar poses a risk to professional footballers physical and mental health. Poor recovery between matches may affect player availability and performance. Players should be represented by active players when International Match Calendar scheduling decisions are made. Administrators should seek medical guidance regarding the effects of overload on performance prior to making decisions. This study allows the opportunity for a larger national team player sample to be studied.

Effect of selected wastewater characteristics on estimation of SARS-CoV-2 viral load in wastewater

Wastewater-based epidemiology has been used as a tool for surveillance of COVID-19 infections. This approach is dependent on the detection and quantification of SARS-CoV-2 RNA in untreated/raw wastewater. However, the quantification of the viral RNA could be influenced by the physico-chemical properties of the wastewater. This study presents the first use of Adaptive Neuro-Fuzzy Inference System (ANFIS) to determine the potential impact of physico-chemical characteristics of wastewater on the detection and concentration of SARS-CoV-2 RNA in wastewater. Raw wastewater samples from four wastewater treatment plants were investigated over four months. The physico-chemical characteristics of the raw wastewater was recorded, and the SARS-CoV-2 RNA concentration determined via amplification with droplet digital polymerase chain reaction. The wastewater characteristics considered were chemical oxygen demand, flow rate, ammonia, pH, permanganate value, and total solids. The mean SARS-CoV-2 RNA concentrations ranged from 648.1(±514.6) copies/mL to 1441.0(±1977.8) copies/mL. Among the parameters assessed using the ANFIS model, ammonia and pH showed significant association with the concentration of SARS-CoV-2 RNA measured. Increasing ammonia concentration was associated with increasing viral RNA concentration and pH between 7.1 and 7.4 were associated with the highest SARS-CoV-2 concentration. Other parameters, such as total solids, were also observed to influence the viral RNA concentration, however, this observation was not consistent across all the wastewater treatment plants. The results from this study indicate the importance of incorporating wastewater characteristic assessment into wastewater-based epidemiology for a robust and accurate COVID-19 surveillance.

RT-LAMP: A Cheaper, Simpler and Faster Alternative for the Detection of SARS-CoV-2 in Wastewater

Reverse transcription loop-mediated isothermal amplification (RT-LAMP) has the potential to become a cheaper and faster option for monitoring COVID-19 infections through wastewater-based epidemiology. However, its application in COVID-19 surveillance has been limited to clinical testing only. We present in this paper two optimized RT-LAMP protocols based on colour change and fluorescence detection and application of these protocols for wastewater monitoring from four wastewater treatment plants over 4 weeks. The optimized RT-LAMP protocols have a limit of detection of 10 copies/25 µl reaction with positive amplification within 35 minutes. Over the 4 weeks of monitoring, the colorimetric protocol detected a prevalence of 12.5%, when 1 µl of extracted RNA with 92.7(± 28.2) ng/µl concentration was analysed. When the RNA template was increased by fivefold, the prevalence increased to 44%. The fluorescent RT-LAMP had a prevalence of 31% and 47% for starting templates of 92.7(± 28.2) ng/µl and 480(± 134.5) ng/µl of the extracted RNA, respectively. All samples were positive for SARS-CoV-2 when analysed with droplet digital PCR, with viral loads ranging from 18.1 to 195.6 gc/ml of wastewater. The RT-ddPCR, therefore, confirms the presence of the viral RNA in the wastewater samples, albeit at low concentrations. Additionally, the RT-LAMP protocols positively detected SARS-CoV-2 in wastewater samples with copies as low as 20.7 gc/ml. The results obtained in our study show the potential application of RT-LAMP for the detection of SARS-CoV-2 in wastewater, which could provide a cheaper and faster alternative to RT-qPCR or RT-ddPCR for wastewater-based epidemiological monitoring of COVID-19 and other viral infections.

Monitoring changes in COVID-19 infection using wastewater-based epidemiology: A South African perspective

Monitoring of COVID-19 infections within communities via wastewater-based epidemiology could provide a cost-effective alternative to clinical testing. This approach, however, still requires improvement for its efficient application. In this paper, we present the use of wastewater-based epidemiology in monitoring COVID-19 infection dynamics in the KwaZulu-Natal province of South Africa, focusing on four wastewater treatment plants for 14 weeks. The SARS-CoV-2 viral load in influent wastewater was determined using droplet digital PCR, and the number of people infected was estimated using published models as well as using a modified model to improve efficiency. On average, viral loads ranged between 0 and 2.73 × 10⁵ copies/100 ml, 0-1.52 × 10⁵ copies/100 ml, 3 × 10⁴-7.32 × 10⁵ copies/100 ml and 1.55 × 10⁴-4.12 × 10⁵ copies/100 ml in the four wastewater treatment plants studied. The peak in viral load corresponded to the reported COVID-19 infections within the districts where these catchments are located. In addition, we also observed that easing of lockdown restrictions by authorities corresponded with an increase in viral load in the untreated wastewater. Estimation of infection numbers based on the viral load showed that a higher number of people could potentially be infected, compared to the number of cases reported based on clinical testing. The findings reported in this paper contribute to the field of wastewater-based epidemiology for COVID-19 surveillance, whilst highlighting some of the challenges associated with this approach, especially in developing countries.

Detection of SARS-CoV-2 RNA on contact surfaces within shared sanitation facilities

Contamination of contact surfaces with SARS-CoV-2 has been reported as a potential route for the transmission of COVID-19. This could be a major issue in developing countries where access to basic sanitation is poor, leading to the sharing of toilet facilities. In this study, we report SARS-CoV-2 contamination of key contact surfaces in shared toilets and the probabilistic risks of COVID-19 infections based on detection and quantification of the nucleic acid on the surfaces. We observed that 54-69% of the contact surfaces were contaminated, with SARS-CoV-2 loads ranging from 28.1 to 132.7 gene copies per cm². Toilet seats had the highest contamination, which could be attributed to shedding of the virus in feces and urine. We observed a significant reduction in viral loads on the contaminated surfaces after cleaning, showing the potential of effective cleaning on the reduction of contamination. The pattern of contamination indicates that the most contaminated surfaces are those that are either commonly touched by users of the shared toilets or easily contaminated with feces and urine. These surfaces were the toilet seats, cistern handles and tap handles. The likelihood (probability) of infection with COVID-19 on these surfaces was highest on the toilet seat (1.76 × 10^-4(1.58 × 10^-6)) for one time use of the toilet. These findings highlight the potential risks for COVID-19 infections in the event that intact infectious viral particles are deposited on these contact surfaces. Therefore, this study shows that shared toilet facilities in densely populated areas could lead to an increase in risks of COVID-19 infections. This calls for the implementation of risk reduction measures, such as regular washing of hands with soap, strict adherence to wearing face masks, and effective and regular cleaning of shared facilities.

Development and validation of a single HPLC method for the determination of thirteen pharmaceuticals in bulk and tablet dosage form

The aim of this study was to develop and validate a high performance liquid chromatography (HPLC) method for the determination of thirteen selected pharmaceutical compounds (metformin, amoxicillin, chloroquine, theophylline, trimethoprim, caffeine, norfloxacin, ciprofloxacin, acetylsalicylic acid, doxycycline hyclate, metronidazole, albendazole and cloxacillin) in bulk and tablet dosage form. Chromatographic separation using a Kromasil C18 column, gradient elution with aqueous formic acid (0.1%), methanol and acetonitrile, a UV absorption wavelength of 250 nm and a mobile phase flow rate of 1 mL/min over a 22 min run time was optimized for complete separation of the selected target compounds. The method was validated and results for: linearity, precision, sensitivity, accuracy, specificity, suitability and method robustness were obtained and met the ICH guidelines. Calibration curve correlation coefficients ranged from 0.9985-0.9998 and the percentage relative standard deviations for repeated analysis was below 5%, indicating acceptable method precision. The limits of detection (LODs) and quantification (LOQs) ranged from 0.020-0.27 µg/L and 0.080-0.91 µg/L, respectively. The accuracy study yielded recoveries in the ranges 86.0-102% for pure compounds and 90.9-106% for compounds in tablet dosage form. The method is robust for small or deliberate changes to the chromatographic parameters and found to be appropriate for analysis of tablets for the determination of the thirteen pharmaceuticals.                     KEY WORDS: Pharmaceuticals, Bulk determination, Tablet dosage, High performance liquid chromatography, Method development, ICH guidelines   Bull. Chem. Soc. Ethiop. 2021, 35(1), 17-31. DOI: https://dx.doi.org/10.4314/bcse.v35i1.2

Microplastics in the environment: Interactions with microbes and chemical contaminants

Microplastics (MPs) are contaminants of emerging concern that have gained considerable attention during the last few decades due to their adverse impact on living organisms and the environment. Recent studies have shown their ubiquitous presence in the environment including the atmosphere, soil, and water. Though several reviews have focused on the occurrence of microplastics in different habitats, little attention has been paid to their interaction with biological and chemical pollutants in the environment. This review therefore presents the state of knowledge on the interaction of MPs with chemicals and microbes in different environments. The distribution of MPs, the association of toxic chemicals with MPs, microbial association with MPs and the microbial-induced fate of MPs in the environment are discussed. The biodegradation and bioaccumulation of MPs by and in microbes and its potential impact on the food chain are also reviewed. The mechanisms driving these interactions and how these, in turn, affect living organisms however are not yet fully understood and require further attention.

Implications of COVID-19 for resumption of sport in South Africa: A South African Sports Medicine Association (SASMA) position statement - Part 2

The lockdown regulations due to the coronavirus pandemic (COVID-19) that broke out towards the end of 2019 and continued to spread throughout most countries in the world had a negative effect on the sporting community. The South African government eased the lockdown rules to Level 1 from 21 September 2020. In Part 2 of this Position Statement of the South African Sports Medicine Association (SASMA), the authors address the position regarding the safe return to sports for athletes who were infected by the virus. An update on clinical manifestations and multi-organ involvement, testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), prolonged positive real time polymerase chain reaction (RT-PCR) and the role of quantitative real time polymerase chain reaction (RT-qPCR) in informing return to sports, grading of disease severity, individualised management of infected athletes and graduated return to play guidelines (GRTP) is provided. The authors also share thoughts on athletes with disabilities, immunisation, the using of masks during exercise and utilising biologically safe environments (BSE). Finally the SASMA Guidelines for Safe RTP in Level 1 lockdown during SARS-Cov-2 are introduced.

Year of the face mask: do's and don'ts during exercise

The COVID-19 pandemic causes widespread anxiety and uncertainty regarding disease transmission. In many countries people are obliged to wear a face mask in public spaces. Individuals involved in sports participation at any level need to make informed decisions on wearing a face mask during exercise. Currently there is no scientific evidence on what to advise regarding the safety of wearing a face mask during exercise, or what type of mask to use. This short report aims to answer these questions in a structured and practical way.

Implications of COVID-19 for resumption of sport in South Africa: A South African Sports Medicine Association (SASMA) position statement - Part 1

The significant impact of the coronavirus disease 2019 (COVID-19) pandemic has extended to sport with the cessation of nearly all professional and non-professional events globally. Recreational parks and fitness centres have also closed. A challenge remains to get athletes back to participation in the safest way, balancing the protection of their health while curbing the societal transmission of the virus. With this Position Statement, the South African Sports Medicine Association (SASMA) aims to guide return-to-sport as safely as possible, in an evidence-based manner, given that COVID-19 is a new illness and new information from experts in various fields continues to emerge. Clinical considerations are briefly described, focusing on a return-to-sport strategy, including education, preparation of the environment, risk stratification of sports and participants, and the practical implementation of these guidelines. The management of the potentially exposed or infected athlete is further highlighted. It is important that persons charged with managing athletes' return-to-sport in any environment must be up-to-date with local and international trends, transmission rates, regulations and sport-specific rule changes that might develop as sport resumes. Additionally, such information should be applied in a sports-specific manner, considering individual athlete's and team needs and be consistent with national legislation.

Assessment of physicochemical parameters and prevalence of virulent and multiple-antibiotic-resistant Escherichia coli in treated effluent of two wastewater treatment plants and receiving aquatic milieu in Durban, South Africa

The poor operational status of some wastewater treatment plants often result in the discharge of inadequately treated effluent into receiving surface waters. This is of significant public health concern as there are many informal settlement dwellers (ISDs) that rely on these surface waters for their domestic use. This study investigated the treatment efficiency of two independent wastewater treatment plants (WWTPs) in Durban, South Africa and determined the impact of treated effluent discharge on the physicochemical and microbial quality of the receiving water bodies over a 6-month period. Presumptive Escherichia coli isolates were identified using biochemical tests and detection of the mdh gene via PCR. Six major virulence genes namely eae, hly, fliC, stx1, stx2, and rfbE were also detected via PCR while antibiotic resistance profiles of the isolates were determined using Kirby-Bauer disc diffusion assay. The physicochemical parameters of the wastewater samples ranged variously between 9 and 313.33 mg/L, 1.52 and 76.43 NTUs, and 6.30 and 7.87 for COD, turbidity, and pH respectively, while the E. coli counts ranged between 0 and 31.2 × 10(3) CFU/ml. Of the 200 selected E. coli isolates, the hly gene was found in 28 %, fliC in 20 %, stx2 in 17 %, eae in 14 %, with stx1 and rfbE in only 4 % of the isolates. Notable resistance was observed toward trimethoprim (97 %), tetracycline (56 %), and ampicillin (52.5 %). These results further highlight the poor operational status of these WWTPs and outline the need for improved water quality monitoring and enforcement of stringent guidelines.