Translating pathogen knowledge to practice for sanitation decision-making Uncorrected Proof

Sanitation planners make complex decisions in the delivery of sanitation services to achieve health outcomes. We present ﬁ ndings from a stakeholder engagement workshop held in Kampala – Uganda to educate, interact with, and solicit feedback from participants on how the relevant scienti ﬁ c literature on pathogens can be made more accessible to practitioners to support decision-making. We targeted Water, Sanitation and Hygiene (WASH) practitioners involved in different levels of service delivery. Practitioners revealed that different sanitation planning tools are used to inform decision-making; however, most of these tools are not user-friendly or adapted to meet their needs. Most stakeholders (68%) expressed familiarity with pathogens, yet less than a half (46%) understood that fecal coliforms were bacteria and used as indicators for fecal pollution. A number of stakeholders were unaware that fecal indicator bacteria do not behave and persist the same as helminths, protozoa, or viruses, making fecal indicator bacteria inadequate for assessing pathogen reductions for all pathogen groups. This suggests a need for awareness and capacity development around pathogens found in excreta. The ﬁ ndings underscore the importance to engage stakeholders in the development of support tools for sanitation planning and highlighted broader opportunities to bridge science with practice in the WASH sector.


INTRODUCTION
In order to meet the Sustainable Development Goal 6 (SDG6) on universal access to safe water and sanitation, access to scientific data, such as on the occurrence, persistence, inactivation, and removal of pathogens in excreta and wastewater to support evidence-based sanitation decision-making, is needed (Rose & Jiménez-Cisneros ). Unsafely This paper outlines what knowledge and tools are currently available, and what is needed by sanitation planners to support improved evidence-based decision-making on safe sanitation. Specifically, it outlines the methods used to engage and solicit feedback from stakeholders, so that the scientific literature can be made more accessible to practitioners. The engagement of stakeholders, including engineers, managers, policymakers, and NGOs, in the development of tools that ease access, understanding, and use of scientific data for sanitation planning is critical for achieving safely managed sanitation and reducing exposure to excreta.
A study on integrated fecal sludge management (FSM) cities in Burkina Faso showed that the involvement of stakeholders in the selection of sanitation options ensured that the designs of fecal sludge treatment plants were adapted to local conditions (Bassan et al. ). In a study on the engagement of stakeholders in the development of a theory of change for handwashing and sanitation behavior change, authors point out that stakeholders are important in providing the context in which programs are implemented (De Buck et al. ). Additionally, stakeholder involvement is crucial for the planning and implementation of sanitation infrastructure and services as it helps to promote sustainability and improved operation and maintenance (Lüthi et al. ).
Unlike the Millennium Development Goals that focused only on access to improved water and basic sanitation, the SDG sanitation indicators provide a more holistic approach to the entire sanitation service chain (containment, emptying, transportation, treatment, and disposal/use) (WHO/ UNICEF ). However, to achieve 'safely managed' sanitation as defined in the SDG targets, it is crucial to identify pathogens present in excreta and wastewater, understand their persistence, and determine their removal or inactivation along the sanitation chain. This knowledge can provide defined targets which can be used to limit the population's exposure to the vast array of excreta-associated pathogens and ultimately achieve improved health outcomes (Murphy ; Schmitz et al. ). Achieving safely managed excreta along the full-service chain necessitates that sanitation planners have access to scientific data that support decision-making, policy development, project development, implementation and evaluation, and advocacy (Mitchell et  To bridge the gap between science and practice, the knowledge to practice (K2P) team is developing a safe sanitation decision support application (App) that contains two tools to support sanitation decision-making. These K2P tools will build off and supplement existing safe sanitation planning (SSP) approaches or frameworks such as the Eawag compendium on sanitation technologies (Tilley et al. ), the WHO sanitation safety planning manual (WHO ), and the shit flow diagrams (SFDs) (tools that help to visualize the flow and treatment of excreta and wastewater in an urban system) (Peal et al. ). Uganda is the first implementation country, and a coalition of national and local stakeholders is being assembled and engaged in the development of these analytical tools. The primary outcome of the K2P agenda is to improve accessibility to the existing body of evidence on pathogens in excreta and sewage through scientific tools that WASH professionals can use to apply an evidence-based approach to water and sanitation planning.
This paper shares findings from stakeholder engagement workshops in Uganda that aimed to provide answers to the following questions that are broadly applicable to global sanitation planning.  Following the overview presentation, participants were randomly assigned to groups to engage in small discussions with experts at three different stations. This approach refers to as a marketplace rotates through the stations.
Each station was equipped with illustrative posters and two facilitators to guide and engage stakeholders in detailed discussion. At each station (4-10 participants), a brief overview was provided along with key questions that the facilitators wanted to address with most of the station time devoted to stakeholder discussion and feedback.
The stations were broken up into three key themes: Station 1: Understanding and compiling existing tools and information for Ugandan sanitation planners and gaps in these tools.

Background knowledge of participants
During the first session of the workshop, participants anonymously responded to questions regarding pathogens and indicator organisms to gage their knowledge. Four groups of pathogens (bacteria, e.g. Vibrio cholera; helminths, e.g. Ascaris; protozoa, e.g. Giardia; and viruses, e.g. rotavirus) and indicator organisms were introduced to participants and their important differences concerning size, persistence, potency, and resistance to treatment (see Figure 1 for illustrations used). Table 2 shows that most stakeholders (68%, n ¼ 17 and 71%, n ¼ 20) were familiar with the terms pathogens and fecal indicator microorganisms, respectively. Yet, fewer than half understood that fecal coliforms were bacteria and used as indicators of fecal pollution (46%, n ¼ 13), while a third (32.2%, n ¼ 9) reported that they were only indicator microorganisms and did not know that they are also a part of the bacteria group (Table 1) (Table 1).
Marketplace station 1: stakeholder engagement to understand current tools used for sanitation safety planning Table 2 shows a range of documents used by stakeholders to make sanitation decisions. These range from crosscutting tools used by many organizations to organization-specific documents.
Stakeholder responses (Table 2) indicated that most of the sources of information they use are not necessarily tools but generic documents, frameworks, or approaches that may not be user-friendly enough to support decisionmaking. Limitations with existing information sources (Table 3)  Surprisingly, no reference was made to more quantitative and design-related tools, such as the Eawag compendium on sanitation technologies (Tilley et al. ) or the WHO guidelines for the safe use of wastewater, excreta, and graywater in agriculture (WHO ). The tools cited by the participants were largely frameworks and did not seem to support their needs in terms of sanitation technology selection and resource prioritization  Additionally, participants expressed the need for capacity building regarding the microbial risks and hazards associated with inadequate management of wastewater and excreta, access to data, and user-friendly tools for using Government: WHO sanitation safety plans, Public Health Act, sector performance reports, district implementation plans, financing strategy for improved sanitation and hygiene promotion, town sanitation plans, and manuals (such as implementation manual for water and sanitation development facilities, design manual for water supply, population data, MoWE sanitation manualunder development, and manuals for water quality indicators and standards). Other sources of information mentioned include internet, books, documents on handwashing and waste disposal, bacteriological test certificates from laboratories on the quality of water sources, regulations on sanitation and water quality standards, the construction of lined pit latrines, and FSM.
University: National water and sanitation policies, GIS maps, sector performance reports, community-led total sanitation (CLTS), health risk awareness for schools, questionnaires on perceptions and trends, ArcGIS for mapping survey areas, and population data.
Water and sewerage utility: Wastewater loads produced, information on area population, topography and cost of establishment, conversion and non-conversion technologies, effluent discharge standards manual, standard operating laboratory procedures, and academic training in treatment plant operations.
City authorities: WHO sanitation safety plans, FSM toolbox, SFD, World Bank sanitation toolbox, CLTS, child hygiene and sanitation training (CHAST), and participatory hygiene and sanitation transformation (PHAST). Authority specific documents include the ordinance for sewage and FSM, minimum standards for sanitation technology specifications for the containment of waste in communities and institutions, inspection tools for the assessment of fecal sludge transporters, monitoring and evaluation data, health inspection checklists, onsite sanitation guidelines, drainage sanitation legislations, and solid waste management ordinance.
Non-Government Organizations: Community-led urban environmental sanitation planning approach (CLUES), CLTS, water quality analysis, PHAST, area-specific data, data on costs, SFDs, Uganda National Bureau of Standards (UNBS), WHO guidelines, joint monitoring program (JMP) for drinking water and sanitation standards, FSM toolbox, community sanitation maps, national sanitation data collection tools, latrine and water coverage data for community entries, human-centered designs, nudging/behavioral guide, WHO sanitation safety plans, bylaws, and minimum onsite sanitation standards Notes: Common tools used for decision-making mentioned more than once are indicated in bold font. Others are specific to the organization. In this station, stakeholders were presented with preliminary concepts for a tool (Figure 2) that would determine pathogen flows throughout the sanitation service chain, using information about the design, management, and performance of the different components of the sanitation system with respect to pathogen containment and reduction.
The design of the tool builds off the SFD approach regarding the proportion of unsafely managed excreta in a given context. The main difference is that instead of mapping the flow of excreta, the tool maps the flow of pathogens throughout the sanitation chain. The tool will complement design standards as it will be able to help sanitation planners and engineers select technologies based on anticipated pathogen reductions achievable for onsite sanitation and centralized sanitation technologies used in their particular context.
The tool will predict the log reduction of pathogens throughout the sanitation service chain (using data from the GWPP) as the fecal sludge moves through several treatment barriers ( Figure 2). The tool will output an overall log reduction achieved and will show the variability and uncertainty in the data using prediction intervals. The probability of achieving a target overall log reduction value that is established at the beginning by the user is then calculated based on the local context, priorities, and health targets. The results will be shown as the percentage probability of achieving versus not achieving the target. The K2P team hypothesizes that this form of communicating uncertainty (i.e., showing a binary output based on the comparison between a prediction interval and a user-selected target value) will (1) be more intuitive for practitioners (rather than simply showing the predicted value with its respective prediction interval) and (2) empower practitioners by allowing them to view predictions within the context of their own targets and goals. This approach resonated with stakeholders as some users mentioned that the output was 'easy to interpret.' The stakeholders also shared feedback on the utility of the tool and its application that have contributed to improve the current version of the tool. Some stakeholder suggestions were specific to Uganda, while others centered on several key themes (Table 4). First, stakeholders suggested that the tool should be explicit in providing additional treatment barriers that could be added into the system to increase overall pathogen reductions. This has been addressed by predicting pathogen flows in both liquid and solid fractions of onsite and centralized sanitation system components. We are also developing short factsheets that highlight the ability of onsite and centralized sanitation technologies to inactivate and remove pathogens from waste streams.  Lastly, to justify the need and advocate for improved treatment efficiency within certain communities or areas, it was suggested that the tool incorporates the use of scenarios to demonstrate anticipated changes in surface or ground water quality in the absence or presence of a How to establish a meaningful log reduction value Stakeholders liked the per cent or probability safe versus unsafe as it was easy to interpret. However, they requested guidance on how to establish meaningful target log reduction for their particular system. Some sanitation systems might be considered safe if they achieve an overall 3-log reduction of pathogens, while for others, this log reduction value might still be considered 'unsafe.' They suggested improvement strategies, such as the provision of additional barriers to demonstrate to users how to achieve an appropriate log reduction value for their particular context.

Solid waste addition to onsite sanitation systems
Stakeholders mentioned that households use onsite systems such as pit latrines as dumping sites for solid waste. During the pit emptying process, solid waste needs to be separated from human excreta before conveyance to the treatment facility. This practice can result in a potential flow of pathogens back into the environment and thus needs to incorporate it in the tool.
End use or disposal Burying sludge at the treatment facility and reusing treated biosolids in agriculture were highlighted as two potential end users of the solid products from a sanitation system. Stakeholders requested that the tool clarifies the appropriate log reductions needed under different end-use scenarios. The application of fecal sludge on farms is of great importance to users and requires adding the exposure risk into the models. Essentially, the users requested that the tool incorporates exposure into the hazard assessment to enable the use of risk assessment methods.

Cost of different treatment technologies
Many individuals are involved in the design and construction of onsite sanitation systems, e.g. pit latrines and septic tanks, but normally provide different quotes. The App should have a feature to estimate the cost of materials used in relation to various sizes (dimensions) of onsite sanitation systems. The design life of a facility in this case should also be included.

Retention time
The log reduction or percentage removal of pathogens achieved when waste stabilization ponds are used for wastewater and fecal sludge treatment depends on flow rates, volume, depth of ponds, and total retention time. The greater the retention time, the more pathogen reduction/ inactivation obtained. Key factors, such as the number of sunshine hours (UV radiation) or the number of sunshine days received for the total retention time, should be included to improve the predictability or accuracy of results produced by the App.

Treatment facility or no treatment facility
The tool should have scenarios that indicate the impact or change in surface or ground water quality in the presence or absence of a wastewater/fecal sludge treatment facility with existing or proposed additional barriers. This is important in the planning and advocacy process to justify the need for a treatment facility in a given community/area. particular set of sanitation barriers. Future versions of the tool will allow users to select additional treatment barriers to achieve suggested pathogen reduction values if the current configuration is not achieving the desired goals. These modifications will allow users to track improvements in the performance of the sanitation systems with respect to planned expansions or upgrades to facilities.
From the clicker survey feedback on the PFT, the majority of the stakeholders (94.2%, N ¼ 35) either agreed (25.7%, n ¼ 9) or strongly agreed (68.5%, n ¼ 24) that they wanted to learn more about the tool moving forward  (Table S1). for both scenarios (Okaali & Hofstra ). In Scenario 1, everyone in Uganda was given a sewer connection, but the  Stakeholders were also critical about the omission of pit latrines and septic tanks in the model, and they emphasized that the scenarios were not realistic. Additionally, stakeholders suggested including socio-demographic inputs like population growth, as well as data on sanitation technologies and seasonal variations. Suggested outputs included health impacts and disease burden. While the latter outputs would be an asset, they are not currently a part of the project and will need to be integrated in future. Moreover, stakeholders will get the opportunity to develop their own scenarios that could, for example, include socio-economic development, climate change, and management interventions.
From the clicker survey feedback, the majority of the stakeholders (90.7%, N ¼ 29) either agreed (31.3%, n ¼ 10) or strongly agreed (59.4%, n ¼ 19) that they wanted to learn more about the pathogens emission mapping tool ( Figure 5).
Similarly, they also either agreed (38.2%, n ¼ 13) or strongly agreed (41.2%, n ¼ 14) that the mapping tool would be useful for sanitation decision-making or planning (see Table S1).  (Table S2). In addition, during the small group discussions, participants were challenged to reflect on the value of using pathogen data in sanitation planning.
In these discussions, stakeholders mentioned that the K2P tools were good for targeting and allocating resources to priority areas, technology selection, designing of treatment facilities, the selection of appropriate technologies, advocacythrough mobilization and lobbying for funds, and providing direction for planning, implementation, and evaluation of sanitation projects (Table S2) These studies highlight the importance of stakeholder input for the success in any tool development, uptake, and use in practice.

CONCLUSIONS
Uganda, like other UN member states, is committed to the 2030 SDGs agenda, among which is the aim to achieve 100% access to safe water and sanitation. Achieving this target calls for more consolidated, evidence-based, and readily accessible information on the treatment performance and appropriateness of sanitation technologies to inform decision-making. Often, the data present in the academic literature have not been translated to a form that is usable and accessible to practitioners. In order to move to a science and risk-based framework, the first step is to translate scientific knowledge to practitioners. The K2P agenda with assistance from stakeholders seeks to fill this gap by providing accessible tools, so that sanitation practitioners can use scientific evidence to move up the ladder from 'basic' to 'safely managed' excreta when planning and implementing sanitation projects. The findings presented in this paper underscore the need for evidence-based support tools for sanitation planning and the potential for communicating scientific data through digital Apps and visualization tools to bridge science with practice.