Conflict, Enteric Disease Burden, Infrastructure, and Policy to Guide Targeted Deployment of Wastewater Surveillance in Low- and Middle-Income Countries

Abstract

Objective: Enteric diseases are a leading cause of death in low- and middle-income countries (LMICs), and wastewater surveillance is a novel approach to understanding their spread in communities. This study identifies LMICs that could benefit from the implementation of wastewater surveillance, offering field researchers, health organizations, and policymakers data-driven guidance for prioritization. Materials and Methods: We used principal component analysis (PCA) across country-level self-reported policy capabilities, estimated enteric disease prevalence, the impact of conflicts, and the status of water and sanitation infrastructure for LMICs to model clusters of highly similar countries. Each PCA cluster grouped countries with greater similarity to one another than to other clusters, allowing for targeted surveillance interventions. Results: We modeled 7 clusters. We based recommendations ranging from actively increasing internal investment to promoting wastewater surveillance or deferring current wastewater surveillance implementation on the balance of attributes found for each cluster. Practice Implications: This country-clustering framework offers several policy and investment profiles without overwhelming complexity. Within this framework, the targeted deployment of wastewater surveillance may provide data to reduce enteric disease morbidity and mortality in LMICs.