“Encyclopaedia Cloacae”—Mapping Wastewaters from Pathogen A to Z

Background During the past decades, the growth of knowledge to prevent disease on the one hand and the growth of public acceptance to prevent disease on the other hand led to form public health systems. Soon after, health was no longer considered as an individual responsibility only, and more effective interventions against health threats and communicable diseases were developed. As a result, public agencies and authorities were established to implement newly discovered interventions against health threats and to prevent non-communicable diseases. Though, the orientation of public health agencies and authorities shifted from prevention of disease to promotion of health in almost all countries, their public health systems are developed widely differently. While some countries look back to traditionally established public health systems, others are pursuing different approaches to achieve Health in All Policies through policy and legislation in Wales or are now evaluating their public health policies after a ten-years-strategy, like Sweden and still others have only recently (2015) introduced a new Preventive Health Care Act and follow a bottom up approach called “Future Forum Public Health”, like Germany. Objectives This workshop aims at presenting the very different perspectives on the achievement of public health and different systems around Europe. Both, the disparity of the approaches and their different forms, and different stages of their development will be addressed by each presentation. Despite differences of the public health systems in each context, the workshop will focus on identifying shared features and common challenges of the countries with the goal of identifying inspiring examples and discussing criteria of transferability. During the discussion that will follow, different possibilities of cooperation and exchange will be assessed and debated. In particular, the workshop will encompass a presentation from Wales on “the future generation’s act” and will include information on the requirements to turn the legislation into practice. The Swedish input will focus on the Swedish national public health policy and its achievements after ten years. France will give an overview of the structural developments during the last ten years. The presentation from Germany will consist of contrasting a top-down and a bottom-up approach, namely the act to strengthen health promotion and prevention in Germany on the one hand and the future forum public health on the other hand. And last but not least, we will hear about the particular success of the Slovenian example with a newly shaped and largely developed public health system. Key messages Acquiring insight into different approaches to achieve improvements in public health based on alternative systems is important to identify inspiring examples, shared features and common challenges. Identification of criteria of transferability of public health strategies, legislation and policies between countries, and requirements for implementation are crucial for learning from best practice.

Health Systems Need to Transform Data Collection to Advance Health Equity.

A National Research Agenda for Public Health Services and Systems

Wastewater based epidemiology (WBE) is an important tool to fight against COVID-19 as it provides insights into the health status of the targeted population from a small single house to a large municipality in a cost-effective, rapid, and non-invasive way. The implementation of wastewater based surveillance (WBS) could reduce the burden on the public health system, management of pandemics, help to make informed decisions, and protect public health. In this study, a house with COVID-19 patients was targeted for monitoring the prevalence of SARS-CoV-2 genetic markers in wastewater samples (WS) with clinical specimens (CS) for a period of 30 days. RT-qPCR technique was employed to target nonstructural (ORF1ab) and structural-nucleocapsid (N) protein genes of SARS-CoV-2, according to a validated experimental protocol. Physiological, environmental, and biological parameters were also measured following the American Public Health Association (APHA) standard protocols. SARS-CoV-2 viral shedding in wastewater peaked when the highest number of COVID-19 cases were clinically diagnosed. Throughout the study period, 7450 to 23,000 gene copies/1000 mL were detected, where we identified 47 % (57/120) positive samples from WS and 35 % (128/360) from CS. When the COVID-19 patient number was the lowest (2), the highest CT value (39.4; i.e., lowest copy number) was identified from WS. On the other hand, when the COVID-19 patients were the highest (6), the lowest CT value (25.2 i.e., highest copy numbers) was obtained from WS. An advance signal of increased SARS-CoV-2 viral load from the COVID-19 patient was found in WS earlier than in the CS. Using customized primer sets in a traditional PCR approach, we confirmed that all SARS-CoV-2 variants identified in both CS and WS were Delta variants (B.1.617.2). To our knowledge, this is the first follow-up study to determine a temporal relationship between COVID-19 patients and their discharge of SARS-CoV-2 RNA genetic markers in wastewater from a single house including all family members for clinical sampling from a developing country (Bangladesh), where a proper sewage system is lacking. The salient findings of the study indicate that monitoring the genetic markers of the SARS-CoV-2 virus in wastewater could identify COVID-19 cases, which reduces the burden on the public health system during COVID-19 pandemics.

In an era of diminished resources, public health agencies are being asked to do more with less. Evidence suggests that while revenues at the state and local levels have been flat or increased slightly since 2010, a large number of governmental public health agencies in the United States have been forced to cut programs and/or staff to compensate for the relative paucity of funds at their disposal. At the same time, these agencies have been challenged to effectively deploy diminished resources to develop and implement multi-level interventions in their communities and to address the many determinants of complex chronic diseases, such as diabetes mellitus and heart disease. Infectious diseases like influenza still pose significant threats to public health, placing an additional strain on departmental resources. One way many health departments are addressing the challenge posed by diminished resources is through collaborating with other partners in the public health system to protect community health.

Public Health Finance

By providing affordable healthcare to many Americans for the first time, the Affordable Care Act increases demand for public mental health services. It is, however, unclear if states’ provision standards for supply of mental health services will be able to accommodate this demand increase. Both the demand and supply of public mental health services vary within states; it is necessary to measure both locally. In this paper, we estimate the prevalence of mental illness within 30 geographical regions in the state of Virginia, a representative example of how many states organize their public mental health systems and how mental illness prevalence can be measured locally. Our methodology extends the analysis in Stern (Health Serv. Outcomes Res. Methods 14:109–155, 2014) by covering an entire state and accounting for peoples’ insurance status. The latter allows us to compare estimates of demand for public mental health services among those 30 geographical regions. We find that over 66,000 uninsured and Medicaid-insured individuals in Virginia are not provided with public mental health services. The deficit varies locally, with several regions having no deficit and others having 5000 or more untreated people. We also estimate that a large portion of the unserved people with mental illness are uninsured but would be insured for mental health services through Medicaid if Virginia were to accept the Medicaid expansion associated with the Affordable Care Act. These results provide evidence that there is significant variation in the demand for and public health systems’ ability to supply mental health services within states. This implies states can better serve populations relying on mental health care by allocating scarce public mental health dollars to localities reflecting their need.

A PRIMARY CARE PHYSICIAN SITS IN HER OFFICE WITH her patient, an overweight 57-year-old man with diabetes and hypertension. She knows that in addition to treating his chronic medical conditions, she also should encourage him to quit smoking, modify his diet, and increase his level of activity to reduce the risk of developing disabling or fatal heart disease or stroke. At the same time, a public health officer in another part of town focuses on overcoming the challenges presented by lack of access to healthy foods and open space for exercise and by the easy availability of cigarettes in the community in which this patient lives—all of which likely have contributed to the development of the patient’s chronic medical conditions. Both the primary care physician and the public health officer are aware of and encouraged by the Million Hearts Initiative recently launched by the Department of Health and Human Services to prevent 1 million myocardial infarctions and strokes in the next 5 years through clinic and community interventions. Although they strive for the same goal—improved health for those whom they serve— the primary care physician and public health officer work in silos, independent of one another. They may wonder how to bridge the worlds of the clinic and community to more effectively serve this patient and those like him. Would the primary care physician be able to do a better job of preventing and treating cardiovascular disease if her local public health department shared information with her about affordable community resources that could help her patients exercise or gain access to healthy foods or if the public health department collaborated with local primary care practices to offer educational programs aimed at improving self-management of blood pressure or diabetes? Would the public health officer be better able to target community interventions if he had information on the adequacy of blood pressure control in different neighborhoods and among specific populations of underserved minorities or on the frequency of emergency department visits for cardiovascular conditions? The Institute of Medicine (IOM) recently issued a report, “Primary Care and Public Health: Exploring Integration to Improve Population Health,” that addresses these questions. The authors of this Viewpoint were members of the IOM committee that produced this report on strategies to promote the integration of public health and primary care. The report is not the first to explore how these 2 sectors might align and coordinate efforts to improve population health. Integration of primary care and public health has always been logical. Both sectors share an emphasis on prevention and population health that requires understanding individuals in the context of their communities and environment. However, many factors have stymied repeated calls in the United States during the past several decades for integration of these sectors. Not the least of these factors is a cultural and organizational separation between primary care and public health that dates back to the early 20th century and the advent of public health schools distinct from medical schools. Both sectors tend to view themselves as underappreciated and underresourced. Payment systems reward primary care physicians for delivering office visits rather than improving population health. Models such as communityoriented primary care that integrate primary care and public health have proved to be impractical to implement broadly in the absence of payment models that support these activities. The United States has not made the same investment in public health infrastructure that it has in biomedical research. Even the calls in the last decade for strengthening the US public health system have focused more on bioterrorism preparedness than on health promotion. Could things be different this time? There are several reasons why there is potential for meaningful progress on in-

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.

Estimating antimicrobial resistance burden in Europe—what are the next steps?

This brochure explores wastewater-based epidemiology (WBE) as an innovative tool for disease surveillance. By detecting pathogen markers in wastewater, WBE enables early identification of infection trends and complements conventional monitoring. The Asian Development Bank, with support from the Government of Austria, piloted WBE in Nepal and the Philippines to help strengthen sanitation and public health systems. The project developed protocols, built capacity, and conducted pilot surveillance to demonstrate WBE’s potential. The brochure highlights key lessons and opportunities for scaling WBE across Asia and the Pacific to enhance resilience against future outbreaks.

The aptness of a bacterium to combat the repercussions of an antimicrobial agent, including antibacterial agents, antifungal agents, potentially poisonous metals (PTMs), and disinfectants, is known as antimicrobial resistance (AMR). Due to their ineffectiveness in humans and animals, AMR causes increased illness and death; hence, it is a fast-escalating worldwide problem. Essential data for reducing the transmission of AMR can come from environmental monitoring; this includes assessing antibiotic resistance genes (ARGs) found in human populations, identifying important hotspots for the evolution and spread of resistance, improving epidemiological and human health risk assessment models, and quantifying removal efficiencies of home wastewater systems. Generating appropriate information required to address these questions will depend on standardized approaches for tracking antibiotic resistance in aquatic ecosystems. Using wastewater analysis, wastewater-based epidemiology is a useful tool for monitoring several AMR targets in different areas. This chapter attempts to clarify the hazards and sources of ARGs and ARB in wastewater and the mechanisms of AMR dissemination in wastewater systems. It summarizes the worldwide influence of the AMR problem on public health, together with methods and systems to stop ARB and ARG dissemination. Although current water treatment techniques reduce ARB and ARGs in water sources, they do not completely eradicate them, therefore sustaining the AMR issue and enabling their spread to species of relevance. This chapter underlines the vital need to monitor the AMR in wastewater. Together with the development of improved monitoring methods and efficient treatment, removal, or decomposition processes, the drop in antibiotic residue discharge into the environment, especially aquatic ecosystems, may greatly lessen the threat of AMR.

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.

Social Media Posts and Search Engine Queries as the Canary in the Coal Mine for Public Health Surveillance

Heterogeneity and Interoperability in Local Public Health Information Systems.