Effectiveness of environmental surveillance of SARS-CoV-2 as an early warning system during the first year of the COVID-19 pandemic: a systematic review

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Drinking water and public health: Prevention, detection and response to waterborne outbreaks in Norway

Access to safe drinking water is highly important for public health. In Norway, most people have access to reliable sources of drinking water and high-standard water supply and sanitation services. Despite precautionary actions, however, every year events implying a health risk occur in Norway, in addition to large waterborne outbreaks such as the Campylobacter-outbreak in Askøy in 2019. This outbreak is a strong reminder of the vulnerability of water supply systems. In this thesis, a multidisciplinary approach is used to meet the overall objective of preventing waterborne outbreaks by examining the risks in the water supply system, the early detection of waterborne outbreaks and public compliance with boil water advisories. A specific concern can arguably be linked to an aging and vulnerable distribution system prone for contamination. In addition, changing climate parameters serve as stressors and induce critical events. In case of a contamination event evolving into a waterborne outbreak, there is no clear evidence that syndromic surveillance may serve as early detection, at least not for smaller and local waterborne outbreaks with an acute onset of illness. Public compliance with boil water advisories is affected by awareness and the perception of the severity of the situation; compliance is lower if the risk of illness is perceived as low. The findings demonstrate that preventive long-term precautionary actions and conducting risk-based surveillance of drinking water supplies are essential to limit societal consequences. Effective communication of health advice is also imperative to ensure high compliance. The findings adds to the knowledge of preventing, detecting and response to waterborne outbreaks in Norway, and contribute to putting emerging risks in the drinking water supply on the agenda

Human development in a post-conflict setting. Water governance and human principles in South Sudan

South Sudan finally reached the status of being an independent country after having been in almost constant conflict with northern Sudan for the last half century. On the other hand, due to the protracted war, South Sudan is one of the least developed countries in the world. The challenges are daunting as the state of the country in all areas is destroyed and people remain one of the poorest in the world. Water is a basic human right and water management is crucial towards achieving human development and eradicating poverty. In this thesis, I have explored and analysed issues of water governance in this newly independent country in order to highlight and understand the challenges of water resources and relations between the different actors in the light of a human rights-based approach. This is relevant for gaining an understanding – especially with the government of South Sudan as a new actor with a mandate – of the challenges, aspects and factors in water governance as one of the essential mechanisms of achieving access to water for people in South Sudan

Kartlegging av praksis ved bruk av kokeråd for drikkevann blant kommuner i Norge i 2018

Utsendelse av kokeråd er et anbefalt tiltak ved påvist eller mistanke om mikrobielt kontaminert drikkevann. Det er imidlertid lite kunnskap om hvordan og i hvilken grad kokeråd praktiseres i Norge. I denne studien kartlegges bruken av kokeråd i norske kommuner. Data om praksis, rutiner og holdninger til kokeråd ble innhentet ved en web-basert spørreundersøkelse rettet til kommunene i Norge, samt ved intervjuer av nøkkelpersoner innen vannforsyning i noen av kommunene som besvarte undersøkelsen. Av 417 inviterte kommuner, svarte 139 (33 %). Disse sendte til sammen ut 396 kokeråd. 6 % av kommunene som svarte endte ut mer enn fire kokeråd i 2018, 29 % sendte 1-4 kokeråd og 65 % sendte ingen. Respondentene viste ulik forståelse av føre-var-begrepet, og varierende syn på når abonnenter skulle varsles om helsemessig utrygt vann. Det er diskrepans mellom oppgitte kriterier, holdninger og eksisterende praksis for utsendelse av kokeråd blant kommunene. Innsikten fra kartleggingen kan danne grunnlag for nasjonal rådgivning, og mer treffsikre avgjørelser om kokeråd lokalt

Kartlegging av praksis ved bruk av kokeråd for drikkevann blant kommuner i Norge i 2018

Utsendelse av kokeråd er et anbefalt tiltak ved påvist eller mistanke om mikrobielt kontaminert drikkevann. Det er imidlertid lite kunnskap om hvordan og i hvilken grad kokeråd praktiseres i Norge. I denne studien kartlegges bruken av kokeråd i norske kommuner. Data om praksis, rutiner og holdninger til kokeråd ble innhentet ved en web-basert spørreundersøkelse rettet til kommunene i Norge, samt ved intervjuer av nøkkelpersoner innen vannforsyning i noen av kommunene som besvarte undersøkelsen. Av 417 inviterte kommuner, svarte 139 (33 %). Disse sendte til sammen ut 396 kokeråd. 6 % av kommunene som svarte endte ut mer enn fire kokeråd i 2018, 29 % sendte 1-4 kokeråd og 65 % sendte ingen. Respondentene viste ulik forståelse av føre-var-begrepet, og varierende syn på når abonnenter skulle varsles om helsemessig utrygt vann. Det er diskrepans mellom oppgitte kriterier, holdninger og eksisterende praksis for utsendelse av kokeråd blant kommunene. Innsikten fra kartleggingen kan danne grunnlag for nasjonal rådgivning, og mer treffsikre avgjørelser om kokeråd lokalt

Identifying challenges in drinking water supplies: Assessment of boil water advisories in Norway (2008-2019)

The issuing of boil water advisories (BWAs) is a widely used response to microbiological contamination events in drinking water supply systems, and may therefore serve as an indicator for the access to safe drinking water. To supplement data source on the overall status of water supply systems (WSSs) in Norway, we analysed public media reports published in Norway to assess trends, causes, geographical and seasonal distribution of BWAs issued during the period 2008–2019. We identified 1,108 BWA events increasingly reported over the study period but characterised by a decreasing trend in time with respect to duration. The two main frequent causes for BWA were detection of faecal indicator bacteria (42.6%) and risk of contaminants intrusion in the distribution system (21%). We observed higher reporting rates in summer and autumn compared with winter, and higher reporting rates in Northern and Eastern Norwegian regions compared with the Central region. The results of this study could serve as supplementary information to better understand the overall status among WSSs in Norway, particularly in case of recurrent BWA's events, as well as suggest the relevance of BWAs' monitoring in identifying risk factors and planning targeted interventions. HIGHLIGHTS Trends of boil water advisories.; Assessment of risks in drinking water supplies.; Media reports as data source for drinking water status.

The effectiveness of syndromic surveillance for the early detection of waterborne outbreaks: a systematic review

Background Waterborne outbreaks are still a risk in high-income countries, and their early detection is crucial to limit their societal consequences. Although syndromic surveillance is widely used for the purpose of detecting outbreaks days earlier than traditional surveillance systems, evidence of the effectiveness of such systems is lacking. Thus, our objective was to conduct a systematic review of the effectiveness of syndromic surveillance to detect waterborne outbreaks. Method We searched the Cochrane Library, Medline/PubMed, EMBASE, Scopus, and Web of Science for relevant published articles using a combination of the keywords ‘drinking water’, ‘surveillance’, and ‘waterborne disease’ for the period of 1990 to 2018. The references lists of the identified articles for full-text record assessment were screened, and searches in Google Scholar using the same key words were conducted. We assessed the risk of bias in the included articles using the ROBINS-I tool and PRECEPT for the cumulative body of evidence. Results From the 1959 articles identified, we reviewed 52 articles, of which 18 met the eligibility criteria. Twelve were descriptive/analytical studies, whereas six were simulation studies. There is no clear evidence for syndromic surveillance in terms of the ability to detect waterborne outbreaks (low sensitivity and high specificity). However, one simulation study implied that multiple sources of signals combined with spatial information may increase the timeliness in detecting a waterborne outbreak and reduce false alarms. Conclusion This review demonstrates that there is no conclusive evidence on the effectiveness of syndromic surveillance for the detection of waterborne outbreaks, thus suggesting the need to focus on primary prevention measures to reduce the risk of waterborne outbreaks. Future studies should investigate methods for combining health and environmental data with an assessment of needed financial and human resources for implementing such surveillance systems. In addition, a more critical thematic narrative synthesis on the most promising sources of data, and an assessment of the basis for arguments that joint analysis of different data or dimensions of data (e.g. spatial and temporal) might perform better, should be carried out. Trial registration PROSPERO: International prospective register of systematic reviews. 2019. CRD42019122332