Biobanking: Possibilities for Wastewater-Based Epidemiology.

Wastewater-based epidemiology (WBE) is the analysis of wastewater to detect pathogen levels or activity for public health awareness or action. Pioneered in the 1940s, WBE underwent a resurgence during the COVID-19 pandemic, providing important information about number of cases, outbreaks, and seasonal impact. With advancements in detection technologies and growing interest in environmental surveillance, WBE is poised to become a standard practice in public health monitoring. Here, we provide an overview of the current state of the art of pathogen WBE, including methods of molecular detection, analysis of wastewater data, real-world applications and programs, public health interventions, and benefits and challenges for the field.

Introducing public health ethics poses two special challenges. First, it is a relatively new field that combines public health and practical ethics. Its unfamiliarity requires considerable explanation, yet its scope and emergent qualities make delineation difficult. Moreover, while the early development of public health ethics occurred in a western context, its reach, like public health itself, has become global. A second challenge, then, is to articulate an approach specific enough to provide clear guidance yet sufficiently flexible and encompassing to adapt to global contexts. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in accordance with accepted values and standards of right and wrong. In these ways, public health ethics builds on its parent disciplines of public health and ethics. This dual inheritance plays out in the definition the U.S. Centers for Disease Control and Prevention (CDC) offers of public health ethics: “A systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (CDC 2011). Public health ethics shares with other fields of practical and professional ethics both the general theories of ethics and a common store of ethical principles, values, and beliefs. It differs from these other fields largely in the nature of challenges that public health officials typically encounter and in the ethical frameworks it employs to address these challenges. Frameworks provide methodical approaches or procedures that tailor general ethical theories, principles, values, and beliefs to the specific ethical challenges that arise in a particular field. Although no framework is definitive, many are useful, and some are especially effective in particular contexts. This chapter will conclude by setting forth a straightforward, stepwise ethics framework that provides a tool for analyzing the cases in this volume and, more importantly, one that public health practitioners have found useful in a range of contexts. For a public health practitioner, knowing how to employ an ethics framework to address a range of ethical challenges in public health—a know-how that depends on practice—is the ultimate take-home message.

Alcohol consumption in Vietnam increased significantly over past decade alongside its economic development. However, in recent years, several alcohol control measures including a new drink-driving law and taxes as well as the COVID-19 pandemic have affected the consumption levels. This study aimed to monitor alcohol use trends in Hanoi over six consecutive years. We conducted a time series analysis of wastewater-based epidemiology (WBE) for alcohol consumption from 2018 to 2023. Ethyl sulfate, a biomarker for alcohol consumption, was measured in wastewater samples collected consecutively for at least 30 days each year from a catchment of approximately 400,000 people. The findings revealed a clear downward trend in alcohol consumption, with an average annual decline of 7.51%. Consumption remained stable across all days of the week, including during the COVID-19 pandemic. The most pronounced reduction occurred during 2020-2021, coinciding with COVID-19 restrictions. From 2022 onwards, signs of a rebound in alcohol consumption were observed, consistent with the national sales trends. Additionally, a marked shift was noted from on-trade (e.g., bars/restaurants) to off-trade (home-based), likely reflecting both pandemic-related restrictions and the enforcement of the strict drink-driving law. Alcohol consumption trends and shifts in drinking settings in Hanoi during the study period were likely influenced by a combination of public health measures and policy interventions, including the COVID-19 pandemic and the strict drink-driving law. This study successfully used WBE for relatively low-cost longitudinal monitoring of alcohol use in resource-limited settings, providing necessary evidence for public health policy formulation.

During the COVID-19 pandemic, wastewater-based epidemiology (WBE) has been engaged to complement medical surveillance and in some cases to also act as an early diagnosis indicator of viral spreading in the community. Most efforts worldwide by the scientific community and commercial companies focus on the formulation of protocols for SARS-CoV-2 analysis in wastewater and approaches addressing the quantitative relationship between WBE and medical surveillance are lacking. In the present study, a mathematical model is developed which uses as input the number of daily positive medical tests together with the highly non-linear shedding rate curve of individuals to estimate the evolution of global virus shedding rate in wastewater along calendar days. A comprehensive parametric study by the model using as input actual medical surveillance and WBE data for the city of Thessaloniki (~700,000 inhabitants, North Greece) during the outbreak of November 2020 reveals the conditions under which WBE can be used as an early warning tool for predicting pandemic outbreaks. It is shown that early warning capacity is different along the days of an outbreak and depends strongly on the number of days apart between the day of maximum shedding rate of infected individuals in their disease cycle and the day of their medical testing. The present data indicate for Thessaloniki an average early warning capacity of around 2 days. Moreover, the data imply that there exists a proportion between unreported cases (asymptomatic persons with mild symptoms that do not seek medical advice) and reported cases. The proportion increases with the number of reported cases. The early detection capacity of WBE improves substantially in the presence of an increasing number of unreported cases. For Thessaloniki at the peak of the pandemic in mid-November 2020, the number of unreported cases reached a maximum around 4 times the number of reported cases.

In low-income and middle-income countries, such as those in sub-Saharan Africa and Latin America, the COVID-19 pandemic has had substantial implications for women's wellbeing. Policy responses to the COVID-19 pandemic have highlighted the gendered aspect of pandemics; however, addressing the gendered implications of the COVID-19 pandemic comprehensively and effectively requires a planetary health perspective that embraces systems thinking to inequalities. This Viewpoint is based on collective reflections from research done by the authors on COVID-19 responses by international and regional organisations, and national governments, in Latin America and sub-Saharan Africa between June, 2020, and June, 2021. A range of international and regional actors have made important policy recommendations to address the gendered implications of the COVID-19 pandemic on women's health and wellbeing since the start of the pandemic. However, national-level policy responses to the COVID-19 pandemic have been partial and inconsistent with regards to gender in both sub-Saharan Africa and Latin America, largely failing to recognise the multiple drivers of gendered health inequalities. This Viewpoint proposes that addressing the effects of the COVID-19 pandemic on women in low-income and middle-income countries should adopt a systems thinking approach and be informed by the question of who is affected as opposed to who is infected. In adopting the systems thinking approach, responses will be more able to recognise and address the direct gendered effects of the pandemic and those that emerge indirectly through a combination of long-standing structural inequalities and gendered responses to the pandemic.

Chapter 15 - Health Technology, Quality, Law, and Ethics

Two years after SARS-COV-2 was declared a public health emergency, global estimates of excess deaths from the Institute for Health Metrics and Evaluation indicate that 18·2 million people died due to the pandemic by Dec 31, 2021—three times higher than official records suggest. 100 million people have been plunged into extreme poverty by the pandemic, according to World Bank estimates. While the true burden of COVID-19 is being unravelled, is a mental health crisis being unmasked? The pandemic has exposed long-standing gaps and a global underinvestment in mental health care and prevention, disproportionately affecting young people and women.

Increased alcohol consumption, especially among young people, is a major concern in Turkey as it is around the world due to negative effects on public health and safety. Regarding this, it is pivotal to monitor and therefore control alcohol use in public. In this case, wastewater-based epidemiology (WBE), which is the in-depth analysis of wastewater and a relatively new method, can deliver complementary information concerning the abuse of different substances. The proven potential of the WBE approach offers new promises in the process of monitoring alcohol use, namely the monitoring of the levels of ethyl sulfate (EtS) as a urinary biomarker of alcohol consumption, and it is a powerful mean to estimate alcohol use at the community level. In this study, raw 24-h composite wastewater samples were collected from Seyhan and Yüregir wastewater treatment plants (WWTPs) in Adana Province for one week per season (October 2016-August 2017). The fast and validated analytical method was performed by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) and therefore applied to the analysis of ethyl sulfate (EtS). Obtained concentration values were back-calculated, and regional and temporal social usage rates were determined. Higher values were calculated for both WWTPs on Sunday. Alcohol consumption in the region served by Seyhan WWTP was higher than Yüregir WWTP. The results showed that the levels of alcohol consumption during given periods in Adana ranged from 659.8 to 8998.7 mL/day/1000 per person with an average value of 4983.9 and 3924.2 mL/day/1000 inhabitant in Seyhan WWTP and Yüregir WWTP, respectively. This study shows that weekly and annual trends in alcohol consumption can be detected quickly from wastewater analysis.

Wastewater-based epidemiology (WBE) has been employed by many countries globally since the beginning of the COVID-19 pandemic in order to assess the benefits of this surveillance tool in the context of informing public health measures. WBE has been successfully employed to detect SARS-CoV-2 at wastewater treatment plants for community-wide surveillance, as well as in smaller catchments and institutions for targeted surveillance of COVID-19. In addition, WBE has been successfully used to detect new variants, identify areas of high infection levels, as well as to detect new infection outbreaks. However, due to to the large number of inherent uncertainties in the WBE process, including the inherent intricacies of the sewer network, decay of the virus en route to a monitoring point, levels of recovery from sampling and quantification methods, levels of faecal shedding among the infected population, as well as population normalisation methods, the usefulness of wastewater samples as a means of accurately quantifying SARS-CoV-2 infection levels among a population remains less clear. The current WBE programmes in place globally will help to identify new areas of research aimed at reducing the levels of uncertainty in the WBE process, thus improving WBE as a public health monitoring tool for future pandemics. In the meantime, such programmes can provide valuable comparisons to clinical testing data and other public health metrics, as well being an effective early warning tool for new variants and new infection outbreaks. This review includes a case study of sampled wastewater from the sewer network in Dublin, Ireland, during a peak infection period of COVID-19 in the city, which evaluates the different uncertainties in the WBE process.

Monitoring drug consumption is crucial for public health systems to address ongoing crises and anticipate future surges. Considering that drug overdoses generally go unreported, wastewater-based epidemiology (WBE) can be an effective tool for assessing drug use. The presence of a drug metabolite in wastewater can predict parent drug use within a population. This study investigates the use of WBE to monitor drug consumption patterns in seven Canadian cities by focusing on the detection of drug residues (parent compounds and metabolites) in wastewater and analyzing the potential link between drugs categorized by Statistics Canada as prescribed and unprescribed and cocaine detection. A model and research hypotheses were developed based on extensive literature and theoretical reviews on prescribed and unprescribed drug consumption to affirm the nature of the hypotheses for the study. Our analysis used datasets from Statistics Canada (Drug metabolites in wastewater in select Canadian cities, by month. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310082001/ , 2024), which categorized drugs into prescribed and unprescribed groups. These categories reflect regulatory and pharmacological status and do not allow us to distinguish between medically prescribed use, diverted prescription use, or illicit/recreational use at the individual level. The data collected were analyzed using structural equation modelling (SEM) and Artificial Neural Network (ANN) techniques to affirm the study hypotheses. The findings revealed a higher concentration of unprescribed drugs in the wastewater compared to prescribed drugs in six of the seven cities, with Prince Albert, Edmonton and Vancouver showing the highest detection. Halifax was the only city in which drugs categorized as prescribed had a higher total detection than those categorized as unprescribed. Within the three cities with the highest total detection, cocaine had the highest concentration (measured as mean concentration in mg/1000 people/day), followed by methamphetamine, amphetamine and ecstasy. Correlation analysis indicated significant positive associations between certain drugs, with the strongest observed between the prescribed drugs cannabis and morphine. Predictive modelling was performed to further examine the probability of detecting cocaine alongside drugs classified as prescribed. The probability of cocaine detection was found to be the highest when cannabis and methadone were detected separately in wastewater. The results demonstrate associations, rather than causality, between residues of selected prescribed-type and unprescribed-type drugs and cocaine residues in wastewater. WBE provides valuable population-level indicators of drug consumption patterns and co-detection trends that can inform public health and harm reduction strategies.

Prevalence and emergence of steroidal and non-steroidal anabolic agents in the Australian community measured through wastewater analysis

Waterborne diseases are a major global problem, resulting in high morbidity and mortality, and massive economic costs. The ability to rapidly and reliably detect and monitor the spread of waterborne diseases is vital for early intervention and preventing more widespread disease outbreaks. Pathogens are, however, difficult to detect in water and are not practicably detectable at acceptable concentrations that need to be achieved in treated drinking water (which are of the order one per million litre). Furthermore, current clinical-based surveillance methods have many limitations such as the invasive nature of the testing and the challenges in testing large numbers of people. Wastewater-based epidemiology (WBE), which is based on the analysis of wastewater to monitor the emergence and spread of infectious disease at a population level, has received renewed attention in light of the current coronavirus disease 2019 (COVID-19) pandemic. The present review will focus on the application of WBE for the detection and surveillance of pathogens with a focus on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the waterborne protozoan parasites Cryptosporidium and Giardia. The review highlights the benefits and challenges of WBE and the future of this tool for community-wide infectious disease surveillance.

Systematic sampling and analysis of wastewater is an increasingly used tool tocomplement more traditional techniques for assessing consumption of licit and illicitchemical substances in the population. The use of wastewater sampling andanalysis contributes to a broader field that is referred to as wastewater-basedepidemiology (WBE). Both spatial and temporal analysis can be conductedquantitatively, quickly and cost effectively using the WBE approach.In brief, per capita exposure to a given chemical within a population is estimated bymeasuring the concentration of that chemical or a metabolite in a representativewastewater sample multiplied by the volume of wastewater represented by thesample, divided by the population size from which the sample originates andcorrecting by factors such as the excretion factor of the metabolite or chemical,molecular weight change and potential stability of the chemical within the sewer. Ithas previously been determined that the population size is the largest uncertainty forWBE estimates.The aim of this thesis it to therefore identify useful markers that allow populationestimation for a given wastewater sample and apply this technique including toassess per capita exposure/release of a group of chemicals that have not beenexamined in previous WBE studies.The approach for this thesis was to systematically collect samples on a day when thepopulation is well defined. For this we collected samples on the 2011 Census Day inAustralia from 10 wastewater catchments ranging in size from approximately 1,500to 500,000 people. By providing catchment maps to the Australian Bureau ofStatistics, the accurate population size for each catchment was determined.The most obvious choice of a potentially useful population markers are endogenouschemicals such as creatinine. Therefore, in Chapter 2, creatinine was assessed as apopulation marker. It was found that there was no correlation between the mass loadof creatinine in wastewater and the population. Using laboratory-scale sewerreactors with conditions representative of both gravity sewers and rising mains, itwas found that creatinine, while stable in collected samples, is unstable under sewerconditions. We therefore conclude that creatinine is not suitable for predictingdifferences in population size particularly when different sewer systems arecompared.In Chapter 3, a method was developed to quantify 96 chemicals in wastewaterinfluent and applied to the census wastewater samples to identify potentialpopulation size markers. Thirteen chemicals including acesulfame, caffeine, andpharmaceuticals and personal care products were detected in all samples and foundto have a good correlation (R2 > 0.8) between mass load and population size. ABayesian inference model was developed which incorporated these potentialpopulation size markers to provide a population size estimate. The model wasvalidated using a leave-one-out approach for all sites and comparing the populationsize estimate from the model with the accurate census population data. It was shownthat for small catchments, the uncertainty of the estimate as measured by the widthof the posterior was 1.1 to 2.4 times narrower than the width of the posterior usingonly the WWTP operator population size estimates. For large WWTP catchments,the width of the posterior using the population size model was between 5 and 40times narrower than the WWTP operator population size estimates. Additionally, itwas found that the posterior width of the model was improved with addition of morechemicals in the model.In Chapter 4, using laboratory-scale sewer reactors, the impact of in-sewerdegradation of the population markers identified in Chapter 3 was evaluated. It wasfound that five of the fourteen markers were stable under all conditions over the 12hour study period. Those which were unstable ranged from little degradation over thestudy period and only under certain conditions to rapid degradation regardless ofsewer conditions. Additionally we assessed whether or not the degradation of thesechemicals impacted the population size estimation model by excluding the unstablecompounds from the model. We found that the uncertainty of the estimate did notdecrease through exclusion of the unstable chemicals.In Chapter 5 we assessed whether WBE can be expanded to chemicals other thanthose previously assessed (i.e. illicit drugs, alcohol and tobacco). For this a methodwas developed to analyse organophosphorous flame retardants (PFRs) inwastewater influent. Using the samples collected during census, it was estimatedthat 2.1 mg person-1 day-1 enter Australian wastewater. In addition we found a goodcorrelation (r2 ≥ 0.87) between the population size and mass load for each of the fourmain contributors (TBOEP, TCIPP, TDCIPP and TCEP).Overall, this thesis demonstrates that the uncertainty of WBE estimates can beimproved through identifying population markers, and developing and calibrating apopulation model. Additionally, we found that WBE is not limited to assessingexposure/consumption of the chemicals previously assessed (i.e. alcohol, illicit drugsand tobacco) and can be expanded to other chemical groups.

Impact of COVID-19 on maternal and child health

Public protest continued to represent a prominent form of social activism in democratic societies during the COVID-19 pandemic. In Australia, a lack of specific legislation articulating protest rights has meant that, in the context of pandemic restrictions, such events have been treated as illegal mass gatherings. Numerous large protests in major cities have, indeed, stirred significant public debate regarding rights of assembly during COVID-19 outbreaks. The ethics of infringing on protest rights continues to be controversial, with opinion divided as to whether public health goals or human rights should take precedence. This paper applies public health ethical theory to an in-depth analysis of arguments on both sides of the debate. Using the Nuffield Council on Bioethics framework as a backdrop, proportionality and necessity of restrictions are understood as key concepts that are common to both public health and human rights perspectives. The analysis presented here finds a middle-ground between the prevailing arguments on opposing sides and is further able to rationalize the use of protest itself as an important element of a mature public health ethics response to restrictive policy. Thus, this paper aims to influence public health policy and legislation regarding protest rights during public health emergencies.