Research needs for optimising wastewater-based epidemiology monitoring for public health protection

Abstract

Wastewater-based epidemiology (WBE) is an unobtrusive method used to observe patterns in illicit drug use, poliovirus, and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The pandemic and need for surveillance measures have led to the rapid acceleration of WBE research and development globally. With the infrastructure available to monitor SARS-CoV-2 from wastewater in 58 countries globally, there is potential to expand targets and applications for public health protection, such as other viral pathogens, antimicrobial resistance (AMR), pharmaceutical consumption, or exposure to chemical pollutants. Some applications have been explored in academic research but are not used to inform public health decision-making. We reflect on the current knowledge of WBE for these applications and identify barriers and opportunities for expanding beyond SARS-CoV-2. This paper critically reviews the applications of WBE for public health and identifies the important research gaps for WBE to be a useful tool in public health. It considers possible uses for pathogenic viruses, AMR, and chemicals. It summarises the current evidence on the following: (1) the presence of markers in stool and urine; (2) environmental factors influencing persistence of markers in wastewater; (3) methods for sample collection and storage; (4) prospective methods for detection and quantification; (5) reducing uncertainties; and (6) further considerations for public health use.

Wastewater-Based Surveillance of Respiratory Syncytial Virus Epidemic at the National Level in Finland

“…In contrast to clinical surveillance, which only detects cases that seek treatment, WBS could reveal the community-level disease prevalence, including subclinical infections. 13 For example, based on wastewater data, the spread of COVID-19 has been shown to be much higher than it was according to clinical data. 14 Respiratory viruses, such as RSV, may cause mild symptoms, and these cases have not been clinically tested.…”

“…Thus, the virus may enter wastewater from both symptomatic and asymptomatic individuals, and wastewater-based surveillance (WBS) could provide a new way of monitoring RSV infections in the population. In contrast to clinical surveillance, which only detects cases that seek treatment, WBS could reveal the community-level disease prevalence, including subclinical infections . For example, based on wastewater data, the spread of COVID-19 has been shown to be much higher than it was according to clinical data .…”

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

“…In developing countries, structural challenges such as low number of wastewater treatment facilities, low service levels or non-functionality of plants and absent or limited testing resources stand in the way of WBE implementation [10]. Challenges shared with developed countries such as uncertainty regarding how to integrate WBE findings into existing surveillance programmes [11] and how to interpret WBE results with regard to actionable thresholds [12], have most likely contributed to reluctance to invest in WBE surveillance programmes. maximise coverage across metros and sentinel sites in provinces with smaller populations.…”

Wastewater-based surveillance of respiratory syncytial virus epidemic at the national level in Finland

“…Thus, wastewater-based surveillance (WBS) could be used to monitor RSV infections in the population. In contrast to clinical surveillance, which only detects cases that seek treatment, WBS could reveal the community-level disease prevalence, including subclinical infections (Robins et al, 2022). For example, based on wastewater data, the spread of COVID-19 has been shown to be much higher than it was according to clinical data (Wu et al, 2020).…”