Authors: Michelle Clark, Melissa Severn
This Horizon Scan summarizes the available information regarding wastewater epidemiology, or wastewater surveillance, for the detection of pathogens that cause communicable diseases.
Wastewater surveillance can detect the presence of pathogens or chemical substances within the wastewater system and allows for the monitoring of a broad population with a single sample.
Wastewater surveillance has been used for decades but has become more common since it was implemented around the world for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. In Canada, wastewater surveillance is currently used for the detection of SARS-CoV-2, influenza, and respiratory syncytial virus.
Studies conducted in Canada and internationally indicate that wastewater surveillance can be used as a reliable method for detecting pathogens at the population level.
Future uses of wastewater surveillance may include monitoring of antibiotic use and antibiotic resistance, detection of cancers in the population, or assessing the prevalence of other infections within communities.
The purpose of this report is to present health care stakeholders in Canada with an overview of information related to the use of wastewater epidemiology, or wastewater surveillance, for the detection of viral and bacterial pathogens. This report describes what wastewater surveillance is and how it works, summarizes the evidence regarding its use in Canada and internationally, and presents ethical considerations.
This report is not a systematic review and does not involve critical appraisal or include a detailed summary of study findings. It is not intended to provide recommendations for or against the use of the technology.
A limited literature search was conducted by an information specialist on key resources including MEDLINE, Embase, the Cochrane Database of Systematic Reviews. Grey literature was identified by searching relevant sections of the Grey Matters checklist. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts were wastewater surveillance and infectious diseases. No filters were applied to limit the retrieval by study type. Conference abstracts were removed from the search results. The search was completed on November 10, 2022, and limited to English-language documents published since January 1, 2019.
Regular alerts updated the search until project completion; only citations retrieved before December 13, 2022, were incorporated into the analysis.
One author screened the literature search results and reviewed the full text of all potentially relevant studies. Studies were considered for inclusion if the intervention was wastewater surveillance. Grey literature was included when it provided additional information to that available in the published studies.
Wastewater surveillance, also called sewer monitoring or wastewater-based epidemiology, is an aggregate and anonymous method of monitoring for population-level infection trends and the spread of viral variants by testing samples of communal wastewater. Viruses that are shed in feces or urine can be detected using wastewater testing.1 Testing wastewater for the presence of specific pathogens allows for the monitoring of a large population at the same time that can include subclinical, asymptomatic, and symptomatic cases, thus providing a more complete picture of population-level infection than clinical testing alone. This is particularly important when clinical confirmation of infection is difficult or resource intensive.1 Systematic and continuous monitoring of wastewater samples for communicable pathogens can be used for early warning alerts for the emergence of new variants during an ongoing outbreak or monitoring for future outbreaks.1 Surveillance of wastewater can also be used for other purposes, such as estimating drug or alcohol use in a community or monitoring for antibiotic resistance.
Wastewater surveillance began in the 1940s when scientists in the US used cell culture techniques to detect poliovirus and other viral pathogens via wastewater samples.2 Recently, wastewater surveillance has gained popularity as a tool to monitor and quantify the level of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, in the population at large.3 People infected with SARS-CoV-2 shed the virus and viral genetic material in their feces which ends up in the wastewater system. Testing the wastewater for the presence of SARS-CoV-2 allows for tracking and monitoring of population-level viral levels without having to rely on clinical testing (either formal or by self-report of at-home rapid test results) and confirmation of individual infections.3
Wastewater surveillance involves the collection of samples of wastewater that are representative of a population. These samples can be collected for a single building or an entire community depending on the location of the sampling site.4 Sampling sites can range from a single waste pipe from a building to a wastewater holding pond at a water treatment facility. Wastewater samples are collected for analysis through a variety of sampling methods, including grab sampling, composite sampling, and passive sampling.3 Grab sampling involves taking a single water sample from 1 location at a specific point in time. Composite sampling combines water samples from multiple time points or locations into a single sample for analysis. Passive sampling is done by leaving a sample collection device in 1 place within the wastewater system where it is in contact with the wastewater for an extended period of time. Comparisons have shown that passive sampling tends to provide better results for the detection of SARS-CoV-2 than grab sampling because of the extended time the sampling device spends in contact with the wastewater.3
A variety of factors influence the concentration of a virus in wastewater before sampling. These include the amount of virus shed in fecal matter or urine, population size, and in-sewer factors (e.g., the amount of solid particles, organic load, travel time, flow rate, wastewater pH, temperature).5 Note that high-risk populations, such as some older adults or hospitalized patients, may not contribute to the viral RNA load in the wastewater if catheters or other incontinence aids that collect urine or feces are not emptied into the toilet.5
Wastewater samples must go through several steps before the target can be detected. For the detection of SARS-CoV-2 RNA, the sample must go through primary and secondary concentration via filtration before the sample is run through assays to extract, amplify, detect, and quantify the target gene sequences of the virus.6 The assays used to detect SARS-CoV-2 include real-time (RT) quantitative polymerase chain reaction (qPCR) SYBR, RT-qPCR Taqman, other types of RT-qPCR, and digital droplet qPCR.6 Because SARS-CoV-2 is still a relatively new virus, standardized methods of detection and analysis from wastewater have not yet been established.7 Quantitative PCR assays are also used for the detection of other viruses (e.g., respiratory syncytial virus and influenza) in wastewater samples.
The costs involved in the wastewater surveillance process include costs related to the collection and analysis of the samples. There are labour costs for the sampling crew (e.g., travel to sampling locations and collection, packaging, and shipping of samples), laboratory staff, and project administration staff (e.g., data and project management).8 At the sampling stage, there are costs associated with the purchase of sampling equipment and supplies, such as personal protective equipment for staff, sample bottles and packaging, and ice and shipping costs for sample transport. At the analysis stage, there are costs associated with the equipment and assays required for PCR quantification or measurement of specific targets of concern.8 The total cost of surveillance will vary depending on how the samples are collected and analyzed and how many collection sites are included in the program.
Wastewater testing for infection surveillance of a population is considered to be a cost-effective method of estimating overall prevalence, particularly when compared with the costs of testing the individuals that make up the population.9
The use of wastewater surveillance to monitor infection at the population level could benefit most of the population. However, areas that rely on septic tanks for the removal of wastewater may not be included in surveillance due to the difficulty in collecting samples from singular sites and maintaining confidentiality of people’s health information when sampling from a single dwelling. The sooner an outbreak can be identified and quantified, the sooner mitigation can be put into place to prevent or slow the spread of the pathogen. Population-level surveillance also helps provide public health professionals with a picture of overall infection, particularly when individual-level testing is inaccessible or not feasible.
Wastewater surveillance capabilities are present in every province and territory in Canada. As of December 2022, these sites provided information on approximately 62% of the Canadian population across all surveillance networks.10 Coverage ranges from approximately 2% of the population in Yukon to 82% of the population in Alberta.10 Federal wastewater surveillance includes 65 sites and covers approximately 25% of the Canadian population.10
At the beginning of the 2022–2023 respiratory virus season, monitoring for influenza and respiratory syncytial virus (RSV) was added to wastewater surveillance in some Canadian jurisdictions. In August 2022, the Public Health Agency of Canada announced that Canada would begin to monitor wastewater for the Mpox virus and poliovirus; however, no further information was identified regarding this plan.11 Table 1 presents the state of wastewater surveillance in Canada as of December 2022.
Table 1: Wastewater Surveillance in Canadian Jurisdictions as of December 2022
Jurisdiction | Region | SARS-CoV-2 | Influenza | RSV |
|---|---|---|---|---|
PHAC12 | Pan-Canadian | Yes | No | No |
Alberta13 | Province-wide data | Yes | Yes | Yes |
British Columba14 | Vancouver | Yes | No | No |
Manitoba12 | Brandon and Winnipeg | Yes | No | No |
New Brunswick12 | Moncton | Yes | No | No |
Newfoundland and Labrador15 | Province-wide data | Yes | No | No |
Northwest Territories16 | Province-wide data | Yes | Yes | Yes |
Nova Scotia12 | Halifax | Yes | No | No |
Nunavut10 | Territory-wide data | Yes | No | No |
Ontario | Ottawa17 | Yes | Yes | Yes |
Toronto18 | Yes | No | No | |
Province-wide data19 | Yes | No | No | |
Prince Edward Island20 | Province-wide data | Yes | No | No |
Quebec21 | Montreal and Quebec City | Yes | No | No |
Saskatchewan22 | North Battleford, Prince Albert, and Saskatoon | Yes | Yes | Yes |
Yukon12 | Haines Junction | Yes | No | No |
PHAC = Public Health Agency of Canada; RSV = respiratory syncytial virus, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
Wastewater surveillance is used internationally for a variety of monitoring purposes. The main focus around the world continues to be the monitoring of SARS-CoV-2 and COVID-19. COVIDPoops19 is a dashboard that displays international wastewater surveillance sites and includes data from 70 countries, more than 150 dashboards, and close to 3,900 monitoring sites (as of January 3, 2023).23 The dashboard was assembled using data from a literature review, direct submissions, and daily social media keyword searches.24 A review of the dashboard showed that 65% of sites were located in high-income countries. 24 The data from these monitoring sites are not publicly available for analysis or to inform global public health action.24
Wastewater surveillance has been used for decades to identify poliovirus, which continues to be monitored internationally. In 2022, cases of polio were discovered in the UK. After a confirmed case of polio was detected in New York State in late 2022, wastewater surveillance revealed community transmission of poliovirus in the surrounding counties.25 Wastewater surveillance has also been used to detect the presence of rotavirus,26 norovirus,27 and Mpox.28
Table 2 summarizes the results of studies conducted in Canada that examined the use of wastewater surveillance for SARS-CoV-2 during the COVID-19 pandemic.
The Public Health Agency of Canada monitors wastewater samples from 5 Canadian cities and uses those results as input for mathematical modelling to track and monitor SARS-CoV-2 in Canada.7 Li et al. (2022)29 conducted a study in Alberta to determine the minimum number of cases of COVID-19 required in a population to allow for the detection of SARS-CoV-2 RNA in the wastewater. To detect SARS-CoV-2 at a 99% probability required 38 cases per 100,000 people.29 Masri et al. (2022)30 also assessed the testing sensitivity and specificity of wastewater-based epidemiology for detecting SARS-CoV-2. For different genetic markers, the cut points were 19 cases per 100,000 per week for the N1 gene and 16.3 cases per 100,000 per week for N2.30
Wastewater surveillance can be difficult in remote areas where samples need to be sent to labs outside of the community for analysis. The travel time and shipping conditions can result in degradation of the sample and add to the cost of the procedure. In an effort to enable sample analysis closer to the source, Daigle and colleagues assessed the clinical validation of GeneXpert, a rapid, portable detection system, to analyze wastewater samples for the presence of SARS-CoV-2 RNA in a remote community in the Northwest Territories.31 Using samples from across Canada during a peak of infection, they determined that the GeneXpert testing showed high overall agreement with standard lab analysis (97.8%). When GeneXpert was used in Yellowknife, the test was able to detect SARS-CoV-2 in the wastewater samples, which coincided with a confirmed travel-related case of COVID-19 in the area. Contact tracing detected 6 more cases of COVID-19.31
Wastewater-based monitoring of SARS-CoV-2 RNA also correlated well with clinically diagnosed cases across the city of Calgary.32 The authors of a study conducted in the city in 2022 concluded that monitoring at a smaller scale, such as at the neighbourhood level, could provide the most useful information for future disease monitoring; however, more work is required to make this level of monitoring specific enough to provide adequate information.32 Another study conducted in Alberta tracked the spread of the Omicron variant of SARS-CoV-2 throughout the province between November 2021 and January 2022.33 The authors found that the Omicron variant spread more quickly in urban centres than in rural areas. Small but busy areas, such as Banff and Fort McMurray, were the exception. The authors concluded that wastewater monitoring in Alberta offered early and reliable indicators of population-level results.33
In Saskatchewan, researchers compared the viral load present in wastewater between small and large cities and determined that wastewater surveillance data from larger cities can typically be used to indicate what is also happening in regions with smaller populations.34
Researchers in Ottawa observed an increase in SARS-CoV-2 viral RNA in wastewater 48 hours before clinical test numbers increased and 96 hours before an increase in hospitalizations.35 Wastewater surveillance at a temporary housing shelter in Toronto was used to alert staff to the presence of active SARS-CoV-2 infection among the residents before confirmation with a clinical test.36 Early detection of the infection allowed the staff at the shelter to introduce cleaning and testing protocols and symptom screening among residents before the virus was able to spread to a larger number of people.36
Table 2: Summary of SARS-CoV-2 Wastewater Studies Conducted in Canada
Author (year) | Type of study | Setting and sampling | Findings |
|---|---|---|---|
Acosta et al. (2022)32 | Prospective observational study June 2020 to May 2021 | Calgary, Alberta
|
|
Akingbola et al. (2022)36 | Prospective observational study January 2021 to September 2021 | Toronto, Ontario
|
|
Daigle et al. (2022)31 | Clinical validation of a rapid, portable detection system (GeneXpert) for wastewater testing and a prospective evaluation of the system to detect SARS-CoV-2 in wastewater in a remote community March 2021 to April 2021 | Yellowknife, Northwest Territories • 2 major lift stations including > 85% of the population |
|
Hubert et al. (2022)33 | Prospective observational study tracking the emergence and spread of the Omicron variant by wastewater surveillance November 2021 to January 2022 | Alberta
|
|
Joung et al. (2022)7 | Review of the framework of the national wastewater-based surveillance conducted at PHAC to present methods used in Canada to track and monitor SARS-CoV-2 September 2020 to 2022 | Canada
|
|
Li et al. (2022)29 | Sensitivity assessment to determine the number of COVID-19 cases required in a population to detect SARS-CoV-2 RNA May 2020 to June 2021 | Alberta
|
|
Masri et al. (2022)30 | Testing sensitivity and specificity of wastewater-based epidemiology for detecting SARS-CoV-2 January 2021 to July 2021 | Vancouver Island, British Columbia |
|
Oloye et al. (2022)34 | Prospective observational study August 2021 to January 2022 | Saskatchewan
|
|
D’Aoust et al. (2021)35 | Prospective observational study | Ottawa, Ontario
|
|
NML = National Microbiology Laboratory; PHAC = Public Health Agency of Canada; qPCR = quantitative polymerase chain reaction; RT = real time; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; VOC = variant of concern; WWTP = wastewater treatment plant.
The results of systematic reviews that examined the use of wastewater surveillance for SARS-CoV-2 are summarized in Table 3. The correlation between the SARS-CoV-2 RNA concentration in wastewater and new cases of COVID-19 was stronger than that of active cases and cumulative cases.37 Qualitative synthesis indicated that environmental surveillance may serve as an early warning system of 1 to 2 weeks for SARS-CoV-2 infection.38 The effectiveness of wastewater surveillance is influenced by the use of different sampling methods, data normalization, and estimation of viral load.38 Wastewater sample positivity was often reported before the detection of cases in the community.39 The authors suggested that wastewater surveillance cannot replace large-scale diagnostic testing but it can serve as a complement to clinical surveillance.39 Standardized protocols are needed to ensure reproducibility and comparability of outcomes.40
Table 3: Summary of Systematic Reviews Examining Surveillance of SARS-CoV-2
Author (year) | Objective | Findings |
|---|---|---|
Li et al. (2023)37 | To examine the correlation between the concentration of SARS-CoV-2 RNA in wastewater and cases in the community |
|
Hyllestad et al. (2022)38 | To identify and synthesize evidence on the environmental surveillance of SARS-CoV-2 as an early warning system to evaluate the added value for public health |
|
Shah et al. (2022)39 | To assess the performance of wastewater surveillance as an early warning system of COVID-19 community transmission |
|
Amereh et al. (2021)40 | To summarize existing methods of sampling procedures, detecting, and quantifying SARS-CoV-2 in sewage samples and provide direction for future research to improve the current scientific knowledge |
|
SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
In 2021, a Canadian group released a document outlining ethics guidance for environmental scientists about wastewater surveillance of SARS-CoV-2.41 The authors pointed out that environmental scientists in particular may not be as familiar with the ethical requirements associated with collecting and sharing human health outcomes data as researchers who regularly work in health research fields.41 Generally, the ethical concerns related to data collected through wastewater surveillance become greater when the population contributing to the collected samples is smaller.41 This may occur when samples come from a single institution, such as a prison or a dormitory, or from a wastewater plant in a small community. The authors based their recommendations on a 2017 evidence-based guidance document from WHO regarding ethical issues in public health surveillance.41
The authors suggested that surveillance only be undertaken when there is a clear and legitimate public health purpose and there is a plan for data collection, analysis, and dissemination based on public health priorities. Countries undertaking wastewater surveillance have an ethical obligation to ensure the data collected are of sufficient quality to meet public health goals and values while taking into account the concerns of the communities involved.41 Monitoring for harm related to the surveillance should be ongoing and include actions to mitigate any harm, if identified. Data collected through surveillance must be shared.41
Wastewater surveillance can be used to monitor the presence of a range of pathogens and chemicals. The Canadian Wastewater Survey has been estimating levels of various licit and illicit drugs in the wastewater of 5 Canadian cities since 2019.9 Wastewater surveillance is or has been used around the world to:
measure the level of psychiatric drugs, alcohol, and stimulants used during the COVID-19 pandemic and associated lockdowns42,43
measure the level of environmental contaminants, such as pesticides and plasticizers, present in wastewater4
estimate community-level prevalence of cardiovascular disease or cancer by the detecting specific urinary protein biomarkers to monitor trends44
test hospital sewage for antibiotic resistance and antibiotic use in the community7
assess the prevalence of sexually transmitted infections in the community7
monitor specific settings, such as cruise ships and airplanes,45 university campuses, or hospitals, to provide a snapshot of viruses that may be present and spreading among the population.
As mentioned previously, although wastewater surveillance capabilities exist in every Canadian province and territory, data from portions of the population are not included in these surveillance activities. Rural and remote areas often rely on septic tanks for the removal of wastewater and do not have municipal wastewater systems or wastewater treatment plants to serve as locations for sample collection for testing and surveillance.7
There are several known and suspected sources of uncertainty associated with wastewater surveillance, which are outlined in Table 4.
Table 4: Sources of Uncertainty in Wastewater Surveillance
Domain | Uncertainties |
|---|---|
Population | • Proportion of population previously vaccinated or infected with the target pathogen • Shedding rate, duration, and viral profile • Population mobility |
Wastewater network | • Leakage from the network • Temperature- and time-driven decay • Chemical status of the water • Contribution from industrial effluent • Rainfall inflow and groundwater • Variation between sites |
Sampling | • Method, time, duration, and frequency of sample collection • Sampling location in the network • Sample volume, preservation, and storage |
Analysis | • Limits of levels of quantification and detection • Number of technical and biological replicates • Sample transportation time |
As the spread of communicable diseases continues around the world, wastewater surveillance may become an even more important method to monitor the spread of existing pathogens and the emergence of new ones. Monitoring the spread of communicable disease is not a new idea but the emergence of the COVID-19 pandemic and subsequent outbreaks of polio, RSV, and influenza around the world have brought more awareness to the need for reliable ways to track infections and their spread in larger populations. The need for monitoring as an element of public health management must be balanced with the need for individual and group privacy. When done appropriately, wastewater surveillance can provide a cost-effective and reliable method for the surveillance of some communicable diseases. However, wastewater monitoring should not be the only surveillance method used; it is most effective when combined with clinical testing and diagnosis.
1.Donia A, Hassan SU, Zhang X, Al-Madboly L, Bokhari H. Covid-19 crisis creates opportunity towards global monitoring & surveillance. Pathogens. 2021;10(3):1-28. PubMed
2.Schmidt C. Watcher in the wastewater. Nat biotechnol. 2020;38:917-920. https://www.nature.com/articles/s41587-020-0620-2. Accessed 24 Jan 2023. PubMed
3.Bivins A, Kaya D, Ahmed W, et al. Passive sampling to scale wastewater surveillance of infectious disease: Lessons learned from COVID-19. Science of the Total Environment. 2022;835:155347. PubMed
4.Nelson B. What poo tells us: wastewater surveillance comes of age amid covid, monkeypox, and polio. BMJ. 2022;378:o1869. PubMed
5.Bertels X, Demeyer P, Van den Bogaert S, et al. Factors influencing SARS-CoV-2 RNA concentrations in wastewater up to the sampling stage: A systematic review. Science of the Total Environment. 2022;820:153290. PubMed
6.Water Research Foundation. Wastewater Surveillance of the COVID-19 Genetic Signal in Sewersheds Recommendations from Global Experts. 2020: https://www.waterrf.org/sites/default/files/file/2020-06/COVID-19_SummitHandout-v3b.pdf. Accessed 21 Dec 2022.
7.Joung MJ, Mangat CS, Mejia E, et al. Coupling Wastewater-Based Epidemiological Surveillance and Modelling of SARS-COV-2/COVID-19: Practical Applications at the Public Health Agency of Canada [preprint]. medRxiv. 2022;27.
8.Wastewater surveillance utility cost calculator. Network of Wastewater-Based Epidemiology: https://nwbe.org/?page_id=180. Accessed 04 Jan 2023.
9.Canadian Wastewater Survey, December 2021 to January 2022. Ottawa: Government of Canada; 2022: https://www150.statcan.gc.ca/n1/daily-quotidien/220218/dq220218d-eng.htm. Accessed 04 Jan 2023.
10.National Collaborating Centre for Infectious Diseases. Update on Federal Efforts to Address Antibicrobial Resistance (AMR). 2022: https://nccid.ca/wp-content/uploads/sites/2/2022/11/WWS_Map_November2022.pdf. Accessed 03 Jan 2023.
11.Plans underway to monitor Canadian sewage for monkeypox, polio traces: Tam. Global News; 2022 Aug 12: https://globalnews.ca/news/9056740/canada-wastewater-surveillance-theresa-tam/. Accessed 21 Jan 2023.
12.Government of Canada. COVID-19 wastewater surveillance dashboard. 2022: https://health-infobase.canada.ca/covid-19/wastewater/. Accessed 22 Nov 2022.
13.University of Calgary. The COVID-19 response Alberta Wastewater. 2022: https://covid-tracker.chi-csm.ca/. Accessed 22 Nov 2022.
14.Metro Vancouver. Testing for the COVID-19 Virus in Wastewater 2022: http://www.metrovancouver.org/services/liquid-waste/environmental-management/covid-19-wastewater/Pages/default.aspx. Accessed 22 Nov 2022.
15.Government of Newfoundland and Labrador. Wastewater Surveillance for Covid-19 Virus. 2022: https://www.gov.nl.ca/ecc/waterres/wastewater-surveillance-for-covid-19-virus/. Accessed 22 Nov 2022.
16.Government of Northwest Territories. Wastewater Monitoring. 2022: https://www.hss.gov.nt.ca/en/services/wastewater-monitoring. Accessed 22 Nov 2022.
17.Ottawa COVID-19. Ottawa COVID-19 wastewater surveillance. 2022: https://613covid.ca/wastewater/. Accessed 22 Nov 2022.
18.City of Toronto. COVID-19: Wastewater Surveillance. 2022: https://www.toronto.ca/home/covid-19/covid-19-pandemic-data/covid-19-wastewater-surveillance/. Accessed 22 Nov 2022.
19.Public Health Ontario. COVID-19 Wastewater Surveillance in Ontario. 2022: https://www.publichealthontario.ca/en/Data-and-Analysis/Infectious-Disease/COVID-19-Data-Surveillance/Wastewater. Accessed 22 Nov 2022.
20.Government of Prince Edward Island. Wastewater Surveillance for COVID-19. 2022: https://www.princeedwardisland.ca/en/information/health-and-wellness/wastewater-surveillance-for-covid-19. Accessed 22 Nov 2022.
21.CentrEau. The CentrEau-COVID pilot project: Monitoring of sars-cov-2 virus in wastewater. 2022: https://centreau.org/en/covid/. Accessed 22 Nov 2022.
22.University of Saskatchewan. COVID-19 Early Indicators Wastewater Surveillance for SARS-COV-2 Virus Particles. 2022: https://water.usask.ca/covid-19/#SaskatoonWastewaterData. Accessed 22 Nov 2022.
23.University of California Merced. COVIDPoops19. 2023; https://www.arcgis.com/apps/dashboards/c778145ea5bb4daeb58d31afee389082. Accessed 03 Jan 2023.
24.Naughton CC, Roman FA, Alvarado AGF, et al. Show us the data: Global COVID-19 Wastewater monitoring efforts, equity, and gaps [preprint]. medRxiv. 2021;17.
25.Ryerson AB, Lang D, Alazawi MA, et al. Wastewater Testing and Detection of Poliovirus Type 2 Genetically Linked to Virus Isolated from a Paralytic Polio Case - New York, March 9-October 11, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(44):1418-1424. PubMed
26.Kittigul L, Pombubpa K. Rotavirus Surveillance in Tap Water, Recycled Water, and Sewage Sludge in Thailand: A Longitudinal Study, 2007-2018. Food environ. 2021;13(1):53-63.
27.Huang Y, Zhou N, Zhang S, et al. Norovirus detection in wastewater and its correlation with human gastroenteritis: a systematic review and meta-analysis. Environ Sci Pollut Res Int. 2022;29(16):22829-22842. PubMed
28.Tiwari A, Adhikari S, Kaya D, et al. Monkeypox outbreak: Wastewater and environmental surveillance perspective. Sci Total Environ. 2023;856(Pt 2):159166. PubMed
29.Li Q, Lee BE, Gao T, et al. Number of COVID-19 cases required in a population to detect SARS-CoV-2 RNA in wastewater in the province of Alberta, Canada: Sensitivity assessment. J Environ Sci (China). 2023;125:843-850. PubMed
30.Masri NZ, Card KG, Caws EA, et al. Testing specificity and sensitivity of wastewater-based epidemiology for detecting SARS-CoV-2 in four communities on Vancouver Island, Canada. Environ Adv. 2022;9:100310. PubMed
31.Daigle J, Racher K, Hazenberg J, et al. A Sensitive and Rapid Wastewater Test for SARS-COV-2 and Its Use for the Early Detection of a Cluster of Cases in a Remote Community. Appl Environ Microbiol. 2022;88(5):e0174021. PubMed
32.Acosta N, Bautista MA, Waddell BJ, et al. Longitudinal SARS-CoV-2 RNA wastewater monitoring across a range of scales correlates with total and regional COVID-19 burden in a well-defined urban population. Water Research. 2022;220:118611. PubMed
33.Hubert CRJ, Acosta N, Waddell BJM, et al. Tracking Emergence and Spread of SARS-CoV-2 Omicron Variant in Large and Small Communities by Wastewater Monitoring in Alberta, Canada. Emerg Infect Dis. 2022;28(9):1770-1776. PubMed
34.Oloye FF, Xie Y, Asadi M, et al. Rapid transition between SARS-CoV-2 variants of concern Delta and Omicron detected by monitoring municipal wastewater from three Canadian cities. Science of the Total Environment. 2022;841:156741. PubMed
35.D'Aoust PM, Graber TE, Mercier E, et al. Catching a resurgence: Increase in SARS-CoV-2 viral RNA identified in wastewater 48 h before COVID-19 clinical tests and 96 h before hospitalizations. Science of the Total Environment. 2021;770:145319. PubMed
36.Akingbola S, Fernandes R, Borden S, et al. Early identification of a COVID-19 outbreak detected by wastewater surveillance at a large homeless shelter in Toronto, Ontario. Can J Public Health. 2022;26:26. PubMed
37.Li X, Zhang S, Sherchan S, et al. Correlation between SARS-CoV-2 RNA concentration in wastewater and COVID-19 cases in community: A systematic review and meta-analysis. Journal of Hazardous Materials. 2023;441:129848. PubMed
38.Hyllestad S, Myrmel M, Baz Lomba JA, Jordhoy F, Schipper SK, Amato E. 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. Journal of Water and Health. 2022;20(8):1223-1242. PubMed
39.Shah S, Gwee SXW, Ng JQX, Lau N, Koh J, Pang J. Wastewater surveillance to infer COVID-19 transmission: A systematic review. Science of the Total Environment. 2022;804:150060. PubMed
40.Amereh F, Negahban-Azar M, Isazadeh S, et al. Sewage Systems Surveillance for SARS-CoV-2: Identification of Knowledge Gaps, Emerging Threats, and Future Research Needs. Pathogens. 2021;10(8):28. PubMed
41.Hrudey SE, Silva DS, Shelley J, et al. Ethics Guidance for Environmental Scientists Engaged in Surveillance of Wastewater for SARS-CoV-2. Environ Sci Technol. 2021;55(13):8484-8491. PubMed
42.Boogaerts T, Quireyns M, De Prins M, et al. Temporal monitoring of stimulants during the COVID-19 pandemic in Belgium through the analysis of influent wastewater. Int J Drug Policy. 2022;104:103679. PubMed
43.Boogaerts T, Bertels X, Pussig B, et al. Evaluating the impact of COVID-19 countermeasures on alcohol consumption through wastewater-based epidemiology: A case study in Belgium. Environment International. 2022;170:107559. PubMed
44.Amin V, Bowes DA, Halden RU. Systematic scoping review evaluating the potential of wastewater-based epidemiology for monitoring cardiovascular disease and cancer. Sci Total Environ. 2023;858(Pt 3):160103. PubMed
45.Ahmed W, Bertsch PM, Angel N, et al. Detection of SARS-CoV-2 RNA in commercial passenger aircraft and cruise ship wastewater: a surveillance tool for assessing the presence of COVID-19 infected travellers. Journal of Travel Medicine. 2020;27(5):20. PubMed
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Subject to the aforementioned limitations, the views expressed herein are those of CADTH and do not necessarily represent the views of Canada’s federal, provincial, or territorial governments or any third-party supplier of information.
This document is prepared and intended for use in the context of the Canadian health care system. The use of this document outside of Canada is done so at the user’s own risk.
This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada.
The copyright and other intellectual property rights in this document are owned by CADTH and its licensors. These rights are protected by the Canadian Copyright Act and other national and international laws and agreements. Users are permitted to make copies of this document for non-commercial purposes only, provided it is not modified when reproduced and appropriate credit is given to CADTH and its licensors.
About CADTH: CADTH is an independent, not-for-profit organization responsible for providing Canada’s health care decision-makers with objective evidence to help make informed decisions about the optimal use of drugs, medical devices, diagnostics, and procedures in our health care system.
Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
Questions or requests for information about this report can be directed to Requests@CADTH.ca