Spatial differences and temporal changes in illicit drug use in Europe quantified by wastewater analysis

Optimisation of analytical methods for tuberculosis drug detection in wastewater: A multinational study

Wastewater-based epidemiology (WBE) is a robust tool for disease surveillance and monitoring of pharmaceutical consumption. However, monitoring tuberculosis (TB) drug consumption faces challenges due to limited data availability. This study aimed to optimise methods for detecting TB drugs in treated and untreated wastewater from four African countries: South Africa, Nigeria, Kenya, and Cameroon. The limit of detection (LOD) for these drugs ranged from a minimum of 2.20 (±1.02) for rifampicin to a maximum of 2.95 (±0.79) for pyrazinamide. A parallel trend was observed concerning the limit of quantification (LOQ), with rifampicin reporting the lowest average LOQ of 7.33 (±3.44) and pyrazinamide showing the highest average LOQ of 9.81 (±2.64). The variance in LOD and LOQ values could be attributed to factors such as drug polarity. Erythromycin and rifampicin exhibited moderately polar LogP values (2.6 and 2.95), indicating higher lipid affinity and lower water affinity. Conversely, ethambutol, pyrazinamide, and isoniazid displayed polar LogP values (-0.059, -0.6, and -0.7), suggesting lower lipid affinity and greater water affinity. The study revealed that storing wastewater samples for up to 5 days did not result in significant drug concentration loss, with concentration reduction remaining below 1 log throughout the storage period. Application of the optimised method for drug detection and quantification in both treated and untreated wastewater unveiled varied results. Detection frequencies varied among drugs, with ethambutol consistently most detected, while pyrazinamide and isoniazid were least detected in wastewater from only two countries. Most untreated wastewater samples had undetectable drug concentrations, ranging from 1.21 ng/mL for erythromycin to 54.61 ng/mL for isoniazid. This variability may suggest differences in drug consumption within connected communities. In treated wastewater samples, detectable drug concentrations ranged from 1.27 ng/mL for isoniazid to 10.20 ng/mL for ethambutol. Wastewater treatment plants exhibited variable removal efficiencies for different drugs, emphasising the need for further optimisation. Detecting these drugs in treated wastewater suggests potential surface water contamination and subsequent risks of human exposure, underscoring continued research's importance.

Chemical cousins with contrasting behavioural profiles: MDMA users and methamphetamine users differ in social-cognitive functions and aggression

Methamphetamine (METH, "Crystal Meth") and 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") share structural-chemical similarities but have distinct psychotropic profiles due to specific neurochemical actions. Previous research has suggested that their impact on social cognitive functions and social behaviour may differ significantly, however, direct comparisons of METH and MDMA users regarding social cognition and interaction are lacking. Performances in cognitive and emotional empathy (Multifaceted Empathy Test) and emotion sensitivity (Face Morphing Task), as well as aggressive social behaviour (Competitive Reaction Time Task) were assessed in samples of n = 40 chronic METH users, n = 39 chronic MDMA users and n = 86 stimulant-naïve controls (total N = 165). Self-reports and hair samples were used to obtain subjective and objective estimates of substance use patterns. METH users displayed diminished cognitive and emotional empathy towards positive stimuli, elevated punitive social behaviour regardless of provocation, and self-reported heightened trait anger relative to controls. MDMA users diverged from the control group only by exhibiting a distinct rise in punitive behaviour when faced with provocation. Correlation analyses indicated that both higher hair concentrations of MDMA and METH may be associated with reduced cognitive empathy. Moreover, greater lifetime MDMA use correlated with increased punitive behaviour among MDMA users. Our findings confirm elevated aggression and empathy deficits in chronic METH users, while chronic MDMA users only displayed more impulsive aggression. Dose-response correlations indicate that some of these deficits might be a consequence of use. Specifically, the dopaminergic mechanism of METH might be responsible for social-cognitive deficits.

Influenza transmission dynamics quantified from RNA in wastewater in Switzerland

INTRODUCTION

Influenza infections are challenging to monitor at the population level due to many mild and asymptomatic cases and similar symptoms to other common circulating respiratory diseases, including COVID-19. Methods for tracking cases outside of typical reporting infrastructure could improve monitoring of influenza transmission dynamics. Influenza shedding into wastewater represents a promising source of information where quantification is unbiased by testing or treatment-seeking behaviours.

METHODS

We quantified influenza A and B virus loads from influent at Switzerland's three largest wastewater treatment plants, serving about 14% of the Swiss population (1.2 million individuals). We estimated trends in infection incidence and the effective reproductive number (Re) in these catchments during a 2021/22 epidemic and compared our estimates to typical influenza surveillance data.

RESULTS

Wastewater data captured the same overall trends in infection incidence as laboratory-confirmed case data at the catchment level. However, the wastewater data were more sensitive in capturing a transient peak in incidence in December 2021 than the case data. The Re estimated from the wastewater data was roughly at or below the epidemic threshold of 1 during work-from-home measures in December 2021 but increased to at or above the epidemic threshold in two of the three catchments after the relaxation of these measures. The third catchment yielded qualitatively the same results but with wider confidence intervals. The confirmed case data at the catchment level yielded comparatively less precise R_e estimates before and during the work-from-home period, with confidence intervals that included one before and during the work-from-home period.

DISCUSSION

Overall, we show that influenza RNA in wastewater can help monitor nationwide influenza transmission dynamics. Based on this research, we developed an online dashboard for ongoing wastewater-based influenza surveillance in Switzerland.

Characterization of urban sources of antibiotics and antibiotic-resistance genes in a Dutch sewer catchment

A one year study was conducted in the city of Nijmegen, The Netherlands, to characterize various urban sources of antibiotics and antibiotic resistant genes (ARGs) in wastewater within a single sewer catchment. Prevalence of ermB, tet(W), sul1, sul2, intl1, and 16S rRNA gene was determined at 10 locations within the city. Sampling locations included a nursing home, a student residence, a hospital and an industrial area, among others. Wastewater concentrations of 23 antibiotics were measured using passive sampling. Additionally, excreted loads of 22 antibiotics were estimated based on ambulatory prescription and clinical usage data. Genes sul1 and intl1 were most abundant across most locations. Ciprofloxacin and amoxicillin together contributed over 92 % of the total estimated antibiotic selective pressure at all sampling points. The present study highlights the prominent role that hospitals can have in the prevalence and proliferation of ARGs in urban wastewater. Furthermore, results suggest that even short-term changes in the therapeutic regimen prescribed in hospitals may translate into shifting ARG abundance patterns in hospital wastewater. The methods applied present an opportunity to identify emission hotspots and prioritize intervention options to limit ARG spread from urban wastewater to the environment.

Quantitative analysis of drugs of abuse and cognitive enhancers in influent wastewater by means of two chromatographic methods

Sewage-based epidemiology using influent wastewater is used to estimate the consumption trends of (illicit) drugs over a short or long period of time in a subpopulation. The current study aimed to develop two separate methods for the quantitative analysis of selected drugs of abuse (DOA) and cognitive enhancers in influent wastewater using reversed-phase (RP) or hydrophilic interaction liquid chromatography (HILIC) coupled to high-resolution tandem mass spectrometry (LC-HRMS/MS). The performance of RP and HILIC column was evaluated. A simple solid phase extraction was used for sample preparation. Short runtimes of 10 and 15 min on the RP and the HILIC column, respectively, allowed sufficient throughput. A six-point calibration was used for quantification with calibration ranges between 10 and 100 ng/L for all analytes except for benzoylecgonine (BZE, 30-300 ng/L). Method validation was performed according to ICH guideline M10. Analytes such as amphetamine (AMPH), BZE, cocaethylene (CE), cocaine (COC), ethyl sulfate, 4-hydroxy-3-methoxymethamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), methamphetamine, methylphenidate (MPH), and ritalinic acid (RA) were included in method development and validation. Two different column types were necessary for sufficient chromatographic resolution. The analytical setup allowed detection of all other analytes at concentration levels between 1 ng/L for methylphenidate to 10 ng/L for amphetamine. A method for the detection and quantification of DOA, cognitive enhancers, and their biomarkers in wastewater was successfully developed and validated. Moreover, six proof-of-concept samples were analyzed in which AMPH, BZE, COC, MDMA, MPH, and RA were identified and further quantified.

Wastewater profiling of illicit drugs, an estimation of community consumption: A case study of eThekwini Metropolitan Municipality, South Africa

Estimation of community-wide consumption of illicit drugs through wastewater analysis is a new concept in Africa although widely applied in developed nations as wastewater-based epidemiology (WBE). It is an important tool that can be used in understanding supply and demand patterns of illicit drug use on a local, national, and international scale. Information on illicit drug use is currently limited in Africa, because of a lack of monitoring structures by governments and financial constraints. This study hopes to bridge that gap by contributing to Africa's baseline information on illicit drug use. This study provides the first application of wastewater analysis to quantitatively evaluate daily illicit drug use in the eThekwini Metropolitan Municipality of KwaZulu-Natal Province of South Africa by quantifying the major urinary excreted metabolites, called drug target residues (DTRs), in raw wastewater from four major wastewater treatment plants (WWTPs) sampled for a week. The results showed that cocaine was the dominant illicit drug consumed in the catchment followed by amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine and 3,4-methylenedioxyamphetamine, with a per capita use of 360-3000 mg day-1 1000 inh-1, 47-800 mg day-1 1000 inh-1, 19-120 mg day -1 1000 inh-1, not detected (ND) to 4.9 mg day-1 1000 inh-1, and ND to 410 g day-1 1000 inh-1 respectively. The weekly usage patterns between the four WWTPs differed probably due to the lifestyle of the populace serving the different WWTPs. These results provide useful data on illicit drug use in eThekwini that can be utilised by public health agencies to implement suitable response strategies.

Application of wastewater-based epidemiology to estimate the usage of beta-agonists in 31 cities in China

The illegal use of beta-agonists could cause severe problems to human health. In this study, the usage of beta-agonists in 31 cities across China was estimated using wastewater-based epidemiology (WBE). The proposed method is based on solid-phase extraction (SPE) and LC-MS/MS and was developed and validated to determine the concentration of seven beta-agonists in wastewater. A population model based on cotinine (COT), NH4-N and the flow volume was constructed to estimate the population equivalents for different wastewater treatment plants (WWTPs). Clenbuterol and ractopamine are banned in China for both animal husbandry and medical use, but were nevertheless detected in some wastewater samples at rates of 6.2 % and 4.7 %, respectively (n = 339). The WBE-based consumption of clenbuterol and ractopamine were compared with the acceptable daily intake (ADI) and the health risks were assessed by their hazard quotients (0.26-6.62 for clenbuterol and 9.27 × 10-4-0.05 for ractopamine). Salbutamol, clorprenaline and terbutaline were observed in practically all wastewater samples at concentrations of up to several ng/L, whereas the formoterol and bambuterol concentrations were below the detection limit in all samples. Salbutamol consumption (7.35 ± 4.14 mg/1000 inh/day) was highest among the examined beta-agonists and varied regionally. Beta-agonist consumption based on WBE was higher in some cities than that based on medical survey data, indicating potential illegal use. These results show that WBE can be a straightforward and supplementary method for monitoring beta-agonist usage at the population level and spatially.

Estimation of legal and illegal drugs consumption in Valencia City (Spain): 10 years of monitoring

Wastewater-based epidemiology (WBE) approach provides objective, quantitative, near real-time profiles of illicit drug consumption by monitoring the concentration of unchanged parent drugs or their metabolites entering the municipal sewage system. Valencia is the third most populous city in Spain (an important country for the use and transit of several of these drugs). Estimations of consumption over long periods of time will help get better understanding of spatial and temporal trends in the use of licit and illicit drugs. Accordingly, applying the "best practice" protocol, 16 drugs of abuse and metabolites were monitored in this study, and 8 were daily measured during one-two weeks between 2011 and 2020 at the inlet of three wastewater treatment plants of Valencia City. Analysis of the selected compounds was performed by liquid chromatography-triple quadrupole mass spectrometry, and the concentrations obtained were used to back-calculate the consumption data. Cannabis, tobacco, and cocaine were the most consumed drugs whereas opioids were less used. Cannabis and cocaine consumption are on average 2.7-23.4 and 1.1-2.3 g/day/1000inh, respectively, and their use tended to increase since 2018. Weekly profiles were characterized by higher consumption of cocaine, ecstasy, and heroin during weekends compared to weekdays. Similarly, during "Las Fallas" (main local festivity), increased use of cocaine and amphetamine-type stimulants, mainly MDMA, was measured. WBE proved to be an objective and useful methodology to get more insight on temporal drugs of abuse consumption, and the changes derived from local festivities.

High resolution mass spectrometry (HRMS) determination of drugs in wastewater and wastewater based epidemiology in Cadiz Bay (Spain)

Multi-residue methods for the determination of the myriad of compounds of emerging concern (CECs) entering in the environment are key elements for further assessment on their distribution and fate. Here, we have developed an analytical protocol for the simultaneous analysis of 195 prescription, over-the-counter, and illicit drugs by using a combination of solid phase extraction (SPE) and determination by liquid chromatography coupled to high resolution mass spectrometry (LC-HRMS). The method was applied to the analysis of influent sewage samples from 3 wastewater treatment plants (WWTPs) from Cadiz Bay (SW Spain), enabling the quantification of more than 100 pharmaceuticals, 19 of them at average concentrations higher than 1 μg L^-1, including caffeine (92 μg L^-1), paracetamol (72 μg L^-1), and ibuprofen (56 μg L^-1), as well as several illicit drugs (e.g., cocaine). Wastewater based epidemiology (WBE) was applied for 27 of the detected compounds to establish their consumption in the sampling area, which has been never attempted before. Caffeine, naproxen, and salicylic acid stood out because of their high consumption (638, 51, and 20 g d^-1·1000pop^-1, respectively). Regarding illicit drugs, cocaine showed the highest frequency of detection and we estimated an average consumption of 3683 mg d^-1·1000pop^-1 in Cadiz Bay. The combination of new HRMS methods, capable of discriminating thousands of chemicals, and WBE will allow for a more comprehensive characterization of chemical substances and their consumption in urban environments in the near future.

Wastewater-based epidemiology for comprehensive community health diagnostics in a national surveillance study: Mining biochemical markers in wastewater

This manuscript showcases results from a large scale and comprehensive wastewater-based epidemiology (WBE) study focussed on multi-biomarker suite analysis of both chemical and biological determinants in 10 cities and towns across England equating to a population of ∼7 million people. Multi-biomarker suite analysis, describing city metabolism, can provide a holistic understanding to encompass all of human, and human-derived, activities of a city in a single model: from lifestyle choices (e.g. caffeine intake, nicotine) through to health status (e.g. prevalence of pathogenic organisms, usage of pharmaceuticals as proxy for non-communicable disease, NCD, conditions or infectious disease status), and exposure to harmful chemicals due to environmental and industrial sources (e.g. pesticide intake via contaminated food and industrial exposure). Population normalised daily loads (PNDLs) of many chemical markers were found, to a large extent, driven by the size of population contributing to wastewater (especially NCDs). However, there are several exceptions providing insights into chemical intake that can inform either disease status in various communities or unintentional exposure to hazardous chemicals: e.g. very high PNDLs of ibuprofen in Hull resulting from its direct disposal (confirmed by ibuprofen/2-hydroxyibuprofen ratios) and bisphenol A (BPA) in Hull, Lancaster and Portsmouth likely related to industrial discharge. An importance for tracking endogenous health markers such as 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA, an oxidative stress marker) as a generic marker of health status in communities was observed due to increased levels of HNE-MA seen at Barnoldswick wastewater treatment plant that coincided with higher-than-average paracetamol usage and SARS-CoV-2 prevalence in this community. PNDLs of virus markers were found to be highly variable. Being very prevalent in communities nationwide during sampling, SARS-CoV-2 presence in wastewater was to a large extent community driven. The same applies to the fecal marker virus, crAssphage, which is very prevalent in urban communities. In contrast, norovirus and enterovirus showed much higher variability in prevalence across all sites investigated, with clear cases of localized outbreaks in some cities while maintaining low prevalence in other locations. In conclusion, this study clearly demonstrates the potential for WBE to provide an integrated assessment of community health which can help target and validate policy interventions aimed at improving public health and wellbeing.

Stability and WBE biomarkers possibility of 17 antiviral drugs in sewage and gravity sewers

Wastewater-based epidemiology (WBE) is a promising technique for monitoring the rapidly increasing use of antiviral drugs during the COVID-19 pandemic. It is essential to evaluate the in-sewer stability of antiviral drugs in order to determine appropriate biomarkers. This study developed an analytical method for quantification of 17 typical antiviral drugs, and investigated the stability of target compounds in sewer through 4 laboratory-scale gravity sewer reactors. Nine antiviral drugs (lamivudine, acyclovir, amantadine, favipiravir, nevirapine, oseltamivir, ganciclovir, emtricitabine and telbivudine) were observed to be stable and recommended as appropriate biomarkers for WBE. As for the other 8 unstable drugs (abacavir, arbidol, ribavirin, zidovudine, ritonavir, lopinavir, remdesivir and efavirenz), their attenuation was driven by adsorption, biodegradation and diffusion. Moreover, reaction kinetics revealed that the effects of sediments and biofilms were regarded to be independent in gravity sewers, and the rate constants of removal by biofilms was directly proportional to the ratio of surface area against wastewater volume. The study highlighted the potential importance of flow velocity for compound stability, since an increased flow velocity significantly accelerated the removal of unstable biomarkers. In addition, a framework for graded evaluation of biomarker stability was proposed to provide reference for researchers to select suitable WBE biomarkers. Compared with current classification method, this framework considered the influences of residence time and different removal mechanisms, which additionally screened four antiviral drugs as viable WBE biomarkers. This is the first study to report the stability of antiviral drugs in gravity sewers.

Application of the metal ions as potential population biomarkers for wastewater-based epidemiology: estimating tobacco consumption in Southern China

Wastewater-based epidemiology (WBE) is an objective approach for the estimation of population-level exposure to a wide range of substances, in which the use of a population biomarker (PB) could significantly reduce back-calculation errors. Although some endogenous or exogenous compounds such as cotinine and other hormones have been developed as PBs, more PBs still need to be identified and evaluated. This study aimed to propose a novel method to estimate population parameters from the mass load of metal ion biomarkers in wastewater, and estimate the consumption of tobacco in 24 cities in Southern China using the developed method. Daily wastewater samples were collected from 234 wastewater treatment plants (WWTPs) in 24 cities in Southern China. Atomic absorption spectroscopy (AAS) was applied to determine the concentrations of common health-related metal ions in wastewater, including sodium (Na), potassium (K), magnesium (Mg), calcium (Ca), iron (Fe), and zinc (Zn), and compared them with the daily mass load of cotinine corresponding to catchment populations. The concentrations of cotinine in wastewater samples were measured using liquid chromatography-tandem mass spectrometry. There were clear and strong correlations between the target metal ion equivalent population and census data. The correlation coefficients (R) were R_K = 0.78, R_Na = 0.66, R_Ca = 0.81, R_Mg = 0.77, and R_Fe = 0.69, at p < 0.01 and R² > 0.6. Subsequently, the combination of WBE and metal ion PBs was used to estimate tobacco consumption. Daily consumption of nicotine was estimated to be approximately 1.76 ± 1.19 mg/d/capita, equivalent to an average of 13.0 ± 8.75 cigarettes/d being consumed by smokers. The data on tobacco consumption in this study were consistent with those in traditional surveys in Southern China. The metal ion potassium is an appropriate PB for reflecting the real-time population and could be used to evaluate the tobacco consumption in WBE study.

Bioconcentrations, depuration, shift in metabolome and a behavioural response in the nymphs of the dragonfly Aeshna cyanea (Müller, 1764) to environmentally relevant concentrations of methamphetamine

Methamphetamine (MEA) is commonly detected in municipal wastewater. It causes imbalances in the system of neurotransmitters as well as several other adverse effects on human health. The aim of this study was to investigate bioconcentration and depuration rates at an environmentally relevant concentration of 1 µg·L^-1 in Aeshna cyanea nymphs exposed to MEA for six days followed by three days of depuration. The metabolomes of nymphs sampled during exposure and depuration were compared using non-targeted screening. Concurrently, a behavioural experiment was run to evaluate the effect of MEA on movement. Since most samples were below the limits of quantification (LOQs) - MEA was quantified in only four out of the 87 samples and only during the first 24 h of exposure at concentrations at LOQ level - we estimated maximal possible bioconcentration factor (BCF) on 0.63 using the LOQ. An MEA metabolite - amphetamine - was not detected in any sample at levels above their LOQs. From 247 up to 1458 significant down- and up-regulated metabolite signals (p ≤ 0.05) were detected by non-targeted screening during initial times of exposure and depuration. Numbers of significant down- and/or up-regulated signals in metabolomes (p ≤ 0.05) calculated for particular sampling times possibly correlated with the size of the effect on movement recorded at the same times. In the MEA treatment, movement was not significantly greater during exposure (p > 0.05) but was significantly lower during depuration (p < 0.05). This study shows how MEA acts on dragonfly nymphs, an ecologically important group of aquatic insects with a high trophic level.

Knowledge graph of wastewater-based epidemiology development: A data-driven analysis based on research topics and trends

Wastewater-based epidemiology (WBE) has contributed significantly to the monitoring of drug use and transmission of viruses that has been published in numerous research papers. In this paper, we used LitStraw, a self-developed text extraction tool, to extract, analyze, and construct knowledge graphs from nearly 900 related papers in PDF format collected in Web of Science from 2000 to 2021 to analyze the research hotspots and development trends of WBE. The results showed a growing number of WBE publications in multidisciplinary cross-collaboration, with more publications and close collaboration between the USA, Australia, China, and European countries. The keywords of illicit drugs and pharmaceuticals still maintain research hotness, but the specific research hotspots change significantly, among which the research hotspots of new psychoactive substances, biomarkers, and stability show an increasing trend. In addition, judging the spread of COVID-19 by the presence of SARS-CoV-2 RNA in sewage has become the focus since 2020. This work can show the development of WBE more clearly by constructing a knowledge graph and also provide new ideas for the paper mining analysis methods in different fields.

Occurrence of contaminants of emerging concern in the Eerste River, South Africa: Towards the optimisation of an urban water profiling approach for public- and ecological health risk characterisation

The study evaluated the presence and fate of various contaminants of emerging concern (CECs) from a South African wastewater treatment works (WWTW) and surface waters located around an urban setting. A total of 45 CECs were quantified from nine sampling locations over an 11-month period. Daily loads (g/day) of the target analytes in the WWTW showed persistence of some CECs, along with population-normalised daily loads (mg/day/1000inh) of pharmaceuticals and drugs of abuse (DOA) that were estimated for the first time in the study area. Multiple chemical markers were recorded in river water located upstream of the WWTW discharge throughout the study period, suggesting a high degree of diffuse pollution from urban communities in the study area that are not connected to sewage networks or where sanitation services are limited. The potential of using defined surface water locations to perform community-wide substance use profiling for non-sewered communities was also explored. Environmental risk characterisation for the WWTW effluent and surface waters throughout the study period provided multiple risk quotients (RQ) for the target list of CECs spanning over various sentinel trophic levels. High risk profiles (RQ > 1.0) with a frequency of exceedance (FoE) larger than 75 % were recorded for several CECs in both WWTW effluent and surface water locations that suggest potential long-term ecological health risk impacts of pollution hotspot areas in the river catchment situated around the urban area. We present challenges in surface water quality within the study area that is relatable, or may even present more challenging, in other low- or middle-income country (LMICs) settings. The study also highlighted some challenges and limitations associated with the much-needed application of wastewater-based epidemiology (WBE) intervention in non-sewered communities that can inform on public health and communal substance use profiles of the entire urban setting.

The burden of city's pain treatment - A longitudinal one year study of two cities via wastewater-based epidemiology

This paper explores Wastewater-Based Epidemiology (WBE) as a tool enabling understanding of city's pain treatment in an intercity longitudinal study. An intensive 13-month monitoring programme was undertaken in two adjacent urban areas in South-West England: a small commuter town Keynsham and the city of Bath (>180 samples collected). The study has shown a great potential of using triangulated WBE and National health Service (NHS) prescription data in understanding pain treatment in two contrasting communities with strong apparent seasonal patterns of short pain medications vs chronic pain treatment as well as the type of treatment used (e.g. oral vs topical). Community-wide usage of Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and paracetamol in the intercity study is population size and season driven with the highest usage recorded in winter months. This contrasts with other pain pharmaceuticals, especially those used for chronic pain, where no/limited seasonal usage was recorded. Unmetabolized NSAIDs are, to a large extent, directly disposed of into the sewerage system bypassing metabolism due to their topical application. This is particularly apparent in winter months with naproxen showing the highest seasonal variability. Pharma/met (ratio of pharmaceutical and its metabolite concentration) analysis allows for tracking topical (non-metabolic) application/down-the-drain disposal of pharmaceuticals with frequent instances of direct disposal of NSAIDs into the sewerage system observed. Normalisation of pharma markers to population size shows comparable estimates of pharma usage in the two cities confirming population as the main driver of pharma loads in wastewater. Variable application patterns of pain pharmaceuticals make back-calculation of intake more convoluted. Intake calculated using percentage excretion of parent NSAIDs will likely lead to overestimation, as it is assumed that NSAIDs are subject to extensive metabolism (this is not the case for topical applications). Intake calculated using percentage excretion of metabolites (or parent compound) as consumption markers leads to underestimation of NSAIDs usage due to contributions from topical application not being accounted for. Prescription data indicates cumulative internal and topical usage, but the data ignores large proportion of over-the-counter usage. Therefore, we have proposed a combined approach allowing for estimation of total usage including, and differentiating between, topical application and oral administration.

Monitoring Alcohol Consumption in Slovak Cities during the COVID-19 Lockdown by Wastewater-Based Epidemiology

The consumption of alcohol in a population is usually monitored through individual questionnaires, forensics, and toxicological data. However, consumption estimates have some biases, mainly due to the accumulation of alcohol stocks. This study's objective was to assess alcohol consumption in Slovakia during the COVID-19 pandemic-related lockdown using wastewater-based epidemiology (WBE). Samples of municipal wastewater were collected from three Slovak cities during the lockdown and during a successive period with lifted restrictions in 2020. The study included about 14% of the Slovak population. The urinary alcohol biomarker, ethyl sulfate (EtS), was analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). EtS concentrations were used to estimate the per capita alcohol consumption in each city. The average alcohol consumption in the selected cities in 2020 ranged between 2.1 and 327 L/day/1000 inhabitants and increased during days with weaker restrictions. WBE can provide timely information on alcohol consumption at the community level, complementing epidemiology-based monitoring techniques (e.g., population surveys and sales statistics).

Occurrence of Z-drugs, benzodiazepines, and ketamine in wastewater in the United States and Mexico during the Covid-19 pandemic

Z-drugs, benzodiazepines and ketamine are classes of psychotropic drugs prescribed for treating anxiety, sleep disorders and depression with known side effects including an elevated risk of addiction and substance misuse. These drugs have a strong potential for misuse, which has escalated over the years and was hypothesized here to have been exacerbated during the COVID-19 pandemic. Wastewater-based epidemiology (WBE) constitutes a fast, easy, and relatively inexpensive approach to epidemiological surveys for understanding the incidence and frequency of uses of these drugs. In this study, we analyzed wastewater (n = 376) from 50 cities across the United States and Mexico from July to October 2020 to estimate drug use rates during a pandemic event. Both time and flow proportional composite and grab samples of untreated municipal wastewater were analyzed using solid-phase extraction followed by liquid chromatography-tandem mass spectrometry to determine loadings of alprazolam, clonazepam, diazepam, ketamine, lorazepam, nordiazepam, temazepam, zolpidem, and zaleplon in raw wastewater. Simultaneously, prescription data of the aforementioned drugs were extracted from the Medicaid database from 2019 to 2021. Results showed high detection frequencies of ketamine (90 %), lorazepam (87 %), clonazepam (76 %) and temazepam (73 %) across both Mexico and United States and comparatively lower detection frequencies for zaleplon (22 %), zolpidem (9 %), nordiazepam (<1 %), diazepam (<1 %), and alprazolam (<1 %) during the pandemic. Average mass consumption rates, estimated using WBE and reported in units of mg/day/1000 persons, ranged between 62 (temazepam) and 1100 (clonazepam) in the United States. Results obtained from the Medicaid database also showed a significant change (p < 0.05) in the prescription volume between the first quarter of 2019 (before the pandemic) and the first quarter of 2021 (pandemic event) for alprazolam, clonazepam and lorazepam. Study results include the first detections of zaleplon and zolpidem in wastewater from North America.

Not a waste: Wastewater surveillance to enhance public health

Domestic wastewater, when collected and evaluated appropriately, can provide valuable health-related information for a community. As a relatively unbiased and non-invasive approach, wastewater surveillance may complement current practices towards mitigating risks and protecting population health. Spurred by the COVID-19 pandemic, wastewater programs are now widely implemented to monitor viral infection trends in sewersheds and inform public health decision-making. This review summarizes recent developments in wastewater-based epidemiology for detecting and monitoring communicable infectious diseases, dissemination of antimicrobial resistance, and illicit drug consumption. Wastewater surveillance, a quickly advancing Frontier in environmental science, is becoming a new tool to enhance public health, improve disease prevention, and respond to future epidemics and pandemics.

Wastewater pandemic preparedness: Toward an end-to-end pathogen monitoring program

Molecular analysis of public wastewater has great potential as a harbinger for community health and health threats. Long-used to monitor the presence of enteric viruses, in particular polio, recent successes of wastewater as a reliable lead indicator for trends in SARS-CoV-2 levels and hospital admissions has generated optimism and emerging evidence that similar science can be applied to other pathogens of pandemic potential (PPPs), especially respiratory viruses and their variants of concern (VOC). However, there are substantial challenges associated with implementation of this ideal, namely that multiple and distinct fields of inquiry must be bridged and coordinated. These include engineering, molecular sciences, temporal-geospatial analytics, epidemiology and medical, and governmental and public health messaging, all of which present their own caveats. Here, we outline a framework for an integrated, state-wide, end-to-end human pathogen monitoring program using wastewater to track viral PPPs.

Wastewater-based monitoring of illicit drugs in Cyprus by UPLC-MS/MS: The impact of the COVID-19 pandemic

The outbreak and spread of COVID-19 impacted through various ways the lives of millions of humans globally. In this work, wastewater-based epidemiology (WBE) was applied to investigate the effect of the actions taken by the Republic of Cyprus to confine COVID-19 on the use of illicit stimulant drugs. Daily influent samples were collected from the six main wastewater treatment plants (WWTPs) of the country i) before lockdown (3-9 April 2019), ii) during lockdown (21-27 April 2020), iii) during the post-lockdown period (14-20 July 2020), and, iv) during each season of the following year (20-26 April 2021, 19-25 July 2021, 11-17 October 2021, 25 December 2021-2 January 2022), and analyzed for amphetamine, methamphetamine, MDMA and cocaine. In most areas, amphetamine and methamphetamine use was not affected during the confinement period, but as availability of the substances decreased with time, a drop in their use was observed when most restriction measures were eased (up to 9- and 22-fold decrease, respectively). The limitations on social interactions and events during the quarantine period seem to have led to the reduction of MDMA and cocaine and driven a sharp decrease of their use in most areas studied (up to 11 and 6 times lower, respectively). However, the re-opening of activities led to a pronounced consumption increase, reaching maximum daily values of 800 and 2691 mg/1000 inhabitants/day, respectively. In 2021, drug use was re-established to lower levels. The examination of weekly patterns during this year revealed higher weekend use of methamphetamine, MDMA and cocaine. Our results suggest that both the implementation and the easing of COVID-19 related measures affected the availability and the use of drugs. This study also provides the first insight on the consumption of illicit drugs in the Republic of Cyprus during pre-, post- and pandemic times and demonstrates the importance of WBE.

Illicit drugs and their metabolites in urban wastewater: Analysis, occurrence and consumption in Xinjiang, China

The use of illicit drugs has increased considerably across the world. Wastewater-based epidemiology (WBE) of illicit drugs might help determine the types and quantity of illicit drugs consumed in a region. In this study, WBE was applied to analyze illicit drugs in five representative urban wastewater treatment plants (WWTPs) in Xinjiang, China. The collected samples were pretreated under optimized solid-phase extraction conditions and then analyzed using high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). The results revealed the presence of 9 of the 11 evaluated drugs; among them, the concentrations of these substances ranged as follows: METH (2.60-10.02 ng/L), MDMA (0.49-6.87 ng/L), MOR (4.53-44.75 ng/L), COD (2.24-8.30 ng/L), MTD (1.36-3.75 ng/L), COC (0.48 ng/L), THC (5.98-18.89 ng/L), BE (1.12-2.45 ng/L) and KET (1.50 ng/L). And an estimate of the per capita consumption revealed morphine (10.2 mg/d/1000inhabitants), cannabis (3.9 mg/d/1000inhabitants), 3,4-methylenedioxymethamphetamine (3.9 mg/d/1000 inhabitants), and methamphetamine (2.2 mg/d/1000 inhabitants) as the main substances of abuse in Xinjiang, China. The results of this study might be taken as a reference for future studies on the continuous monitoring of such drugs.

Multiclass target analysis of contaminants of emerging concern including transformation products, soil bioavailability assessment and retrospective screening as tools to evaluate risks associated with reclaimed water reuse

The occurrence of 200 multiclass contaminants of emerging concern (CECs) encompassing 168 medicinal products and transformation products (TPs), 5 artificial sweeteners, 12 industrial chemicals, and 15 other compounds was investigated in influent and effluent wastewater samples collected during 7 consecutive days from 5 wastewater treatment plants (WWTPs) located in Cyprus. The methodology included a generic solid-phase extraction protocol using mixed-bed cartridges followed by Ultra-High Performance Liquid Chromatography coupled with Quadrupole-Time of Flight Mass Spectrometry (UHPLC-QTOF-MS) analysis. A total of 63 CECs were detected at least in one sample, with 52 and 55 out of the 200 compounds detected in influents and effluents, respectively. Ten (10) out of the 24 families of parent compounds and associated TPs were found in the wastewater samples (influent or effluent). 1-H-benzotriazole, carbamazepine, citalopram, lamotrigine, sucralose, tramadol, and venlafaxine (>80 % frequency of appearance in effluents) were assessed with respect to their bioavailability in soil as part of different scenarios of irrigation with reclaimed water following a qualitative approach. A high score of 12 (high probability) was predicted for 2 scenarios, a low score of 3 (rare occasions) for 2 scenarios, while the rest 28 scenarios had scores 5-8 (unlikely or limited possibility) and 9-11 (possibly). Retrospective screening was performed with the use of a target database of 2466 compounds and led to the detection of 158 additional compounds (medicinal products (65), medicinal products TPs (15), illicit drugs (7), illicit drugs TPs (3), industrial chemicals (11), plant protection products (25), plant protection products TPs (10), and various other compounds (22). This work aspires to showcase how the presence of CECs in wastewater could be investigated and assessed at WWTP level, including an expert-based methodology for assessing the soil bioavailability of CECs, with the aim to develop sustainable practices and enhance reclaimed water reuse.

Monitoring of changes in illicit drugs, alcohol, and nicotine consumption during Ramadan via wastewater analysis

Illicit drug use is a global problem imposing social, economic, and health burdens on society. Wastewater-based epidemiology is an approach based on calculating the consumption of substances in the target population by analyzing the concentrations of human metabolic excretion products of licit and illicit substances in wastewater. This study estimated the changes in illicit drugs (cocaine, amphetamine, methamphetamine, ecstasy (3,4-Methylenedioxymethamphetamine), heroin, and marijuana (THC)), alcohol, and nicotine consumption in Adana Province during Ramadan compared to normal periods using wastewater-based epidemiology. An overall decrease was observed during the Ramadan Period, most strongly for ecstasy (29%) followed by heroin (19%). For cocaine, the variation was the slightest (8.6%). The differences were statistically significant for ecstasy, heroin, nicotine, and alcohol but not for cocaine, amphetamine, methamphetamine, and marijuana. This study is the first to show changes in the use of illicit drugs, alcohol, and nicotine under the influence of religious beliefs. In addition, there is limited data about illicit drugs, alcohol and nicotine abusers/users in Ramadan. This study provides information on the literature on this subject.

Comparative Analysis of RNA-Extraction Approaches and Associated Influences on RT-qPCR of the SARS-CoV-2 RNA in a University Residence Hall and Quarantine Location

Wastewater-based epidemiology (WBE) provides an early warning and trend analysis approach for determining the presence of COVID-19 in a community and complements clinical testing in assessing the population level, even as viral loads fluctuate. Here, we evaluate combinations of two wastewater concentration methods (i.e., ultrafiltration and composite supernatant-solid), four pre-RNA extraction modifications, and three nucleic acid extraction kits using two different wastewater sampling locations. These consisted of a quarantine facility containing clinically confirmed COVID-19-positive inhabitants and a university residence hall. Of the combinations examined, composite supernatant-solid with pre-RNA extraction consisting of water concentration and RNA/DNA shield performed the best in terms of speed and sensitivity. Further, of the three nucleic acid extraction kits examined, the most variability was associated with the Qiagen kit. Focusing on the quarantine facility, viral concentrations measured in wastewater were generally significantly related to positive clinical cases, with the relationship dependent on method, modification, kit, target, and normalization, although results were variable-dependent on individual time points (Kendall's Tau-b (τ) = 0.17 to 0.6) or cumulatively (Kendall's Tau-b (τ) = -0.048 to 1). These observations can support laboratories establishing protocols to perform wastewater surveillance and monitoring efforts for COVID-19.

The role of the sewer system in estimating urban emissions of chemicals of emerging concern

The use of chemicals by society has resulted in calls for more effective control of their emissions. Many of these chemicals are poorly characterized because of lacking data on their use, environmental fate and toxicity, as well as lacking detection techniques. These compounds are sometimes referred to as contaminants of emerging concern (CECs). Urban areas are an important source of CECs, where these are typically first collected in sewer systems and then discharged into the environment after being treated in a wastewater treatment plant. A combination of emission estimation techniques and environmental fate models can support the early identification and management of CEC-related environmental problems. However, scientific insight in the processes driving the fate of CECs in sewer systems is limited and scattered. Biotransformation, sorption and ion-trapping can decrease CEC loads, whereas enzymatic deconjugation of conjugated metabolites can increase CEC loads as metabolites are back-transformed into their parent respective compounds. These fate processes need to be considered when estimating CEC emissions. This literature review collates the fragmented knowledge and data on in-sewer fate of CECs to develop practical guidelines for water managers on how to deal with in-sewer fate of CECs and highlights future research needs. It was assessed to what extent empirical data is in-line with text-book knowledge and integrated sewer modelling approaches. Experimental half-lives (n = 277) of 96 organic CECs were collected from literature. The findings of this literature review can be used to support environmental modelling efforts and to optimize monitoring campaigns, including field studies in the context of wastewater-based epidemiology.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11157-022-09638-9.

Refining the estimation of amphetamine consumption by wastewater-based epidemiology

Consumption of amphetamine and methamphetamine, two common illicit drugs, has been monitored by wastewater-based epidemiology (WBE) in many countries over the past decade. There is potential for the estimated amount of amphetamine used to be skewed at locations where methamphetamine is also consumed, because amphetamine is also excreted to wastewater following methamphetamine consumption. The present study aims to review the available data in the literature to identify an average ratio of amphetamine/methamphetamine (AMP/METH) that is excreted to wastewater after methamphetamine consumption. This ratio could then be used to refine the estimation of amphetamine consumption in catchments where there is both amphetamine and methamphetamine use. Using data from more than 6000 wastewater samples from Australia where methamphetamine is the dominant illicit amphetamine-type substance on the market, we were able to subtract the contribution of legal sources of amphetamine contribution and obtain the median AMP/METH ratio in wastewater of 0.09. Using this value, the amphetamine derived from methamphetamine consumption can be calculated and subtracted from the total amphetamine mass loads in wastewater samples. Without considering the contribution of amphetamine from methamphetamine use, selected European catchments with comparable consumption of amphetamine and methamphetamine showed up to 83% overestimation of amphetamine use. For catchments with AMP/METH ratio greater than 1.00, the impact of amphetamine from methamphetamine would be negligible; for catchments with AMP/METH ratio in the range of 0.04-0.19, it will be difficult to accurately estimate amphetamine consumption.

Illicit drug consumption estimated using wastewater analysis and compared by settlement size in New Zealand

Estimation of consumption of illicit drugs by wastewater-based epidemiology provides estimates of community drug-use patterns. This study describes monitoring data of three illicit drugs in New Zealand using wastewater-based epidemiology. Wastewater samples were collected at monthly intervals for larger (population ~ 50,000+) cities or in smaller towns where more data was required by authorities. In other smaller towns, samples were collected every 2 months. Samples were extracted and analysed for parent compounds and metabolites of methamphetamine, MDMA, cocaine, heroin and fentanyl consumption using solid-phase extraction followed by liquid chromatography coupled with tandem-mass spectrometry (LC-MS/MS) detection. Back calculations were performed to estimate the consumption of each drug in each catchment area. Methamphetamine was the drug measured with the highest estimated mean consumption rates (724 mg/1000 people per day) in New Zealand. North Island small urban settlements had the highest estimated mean methamphetamine consumption rates (1259 mg/1000 people/day). Cocaine had the lowest estimated consumption rates (9.4 mg/1000 people/day). The highest estimated mean cocaine consumption rate was in North Island major urban settlements (24.4 mg/1000 people/day). Major urban settlements had the highest estimated mean MDMA (420 mg/1000 people/day) and cocaine consumption rates (18.8 mg/1000 people/day). South Island medium urban settlements had unexpectedly high estimated mean consumption rates of MDMA (533 mg/1000 people/day) and cocaine (17.0 mg/1000 people/day). The higher-than-expected estimated cocaine consumption was from one medium urban settlement that is also a popular tourist destination in the South Island. Heroin biomarkers were not detected at any locations, and fentanyl was detected around or below the limit of reporting. This research provides information for appropriate responses for improved social and health investment to support social services associated with illicit drug consumption.

Constructed wetlands for the removal of pharmaceuticals and personal care products (PPCPs) from wastewater: origin, impacts, treatment methods, and SWOT analysis

The continuous exposure to pharmaceuticals and personal care products can lead to a series of individual antagonistic and synergistic effects and long-lasting toxicity to humans and aquatic lives. This may also lead to developing antibiotic resistance, teratogenic, carcinogenic, and endocrine-disrupting effects. However, several PPCPs are also considered biologically active for non-target aquatic organisms, such as mosquito fish, goldfish, and the algae Pseudokirchneriella subcapitata. Various physicochemical methods such as ozonation, photolysis, and membrane separation are recognized for the effective removal of PPCPs. However, the high operation and maintenance costs and associated ecological impacts have limited their further use. Constructed wetlands are considered eco-friendly and sustainable for the removal of pharmaceuticals and personal care products together with antibiotic resistance genes. Several mechanisms such as sorption, biodegradation, oxidation, photodegradation, volatilization, and hydrolysis are occurring during the phytoremediation of PPCPs. During these processes, more than 50% of PPCPs can be eliminated through constructed wetlands. They also offer several additional benefits as obtained macrophytic biomass may be used as raw material in pulp and paper industries and a source for second-generation biofuel production. In this study, we have discussed the origin and impacts of PPCPs together with their treatment methods. We have also investigated the strengths, weaknesses, opportunities, and threats associated with constructed wetlands during the treatment of wastewater laden with pharmaceutical and personal care products.

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

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 epidemiology (WBE) for SARS-CoV-2 - A review focussing on the significance of the sewer network using a Dublin city catchment case study

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.

Occurrence, hazard, and risk of psychopharmaceuticals and illicit drugs in European surface waters

This study aimed to provide insights into the risk posed by psychopharmaceuticals and illicit drugs in European surface waters, and to identify current knowledge gaps hampering this risk assessment. First, the availability and quality of data on the concentrations of psychopharmaceuticals and illicit drugs in surface waters (occurrence) and on the toxicity to aquatic organisms (hazard) were reviewed. If both occurrence and ecotoxicity data were available, risk quotients (risk) were calculated. Where abundant ecotoxicity data were available, a species sensitivity distribution (SSD) was constructed, from which the hazardous concentration for 5% of the species (HC₅) was derived, allowing to derive integrated multi-species risks. A total of 702 compounds were categorised as psychopharmaceuticals and illicit drugs based on a combination of all 502 anatomical therapeutic class (ATC) 'N' pharmaceuticals and a list of illicit drugs according to the Dutch Opium Act. Of these, 343 (49%) returned occurrence data, while only 105 (15%) returned ecotoxicity data. Moreover, many ecotoxicity tests used irrelevant endpoints for neurologically active compounds, such as mortality, which may underestimate the hazard of psychopharmaceuticals. Due to data limitations, risks could only be assessed for 87 (12%) compounds, with 23 (3.3%) compounds indicating a potential risk, and several highly prescribed drugs returned neither occurrence nor ecotoxicity data. Primary bottlenecks in risk calculation included the lack of ecotoxicity data, a lack of diversity of test species and ecotoxicological end points, and large disparities between well studied and understudied compounds for both occurrence and toxicity data. This study identified which compounds merit concern, as well as the many compounds that lack the data for any calculation of risk, driving research priorities. Despite the large knowledge gaps, we concluded that the presence of a substantial part (26%) of data-rich psychopharmaceuticals in surface waters present an ecological risk for aquatic non-target organisms.

Wastewater Sequencing-An Innovative Method for Variant Monitoring of SARS-CoV-2 in Populations

The SARS-CoV-2 outbreak has already affected more than 555 million people, and 6.3 million people have died. Due to its high infectivity, it is crucial to track SARS-CoV-2 outbreaks early to prevent the spread of infection. Wastewater monitoring appears to be a powerful and effective tool for managing epidemiological situations. Due to emerging mutations of SARS-CoV-2, there is a need to monitor mutations in order to control the pandemic. Since the sequencing of randomly chosen individuals is time-consuming and expensive, sequencing of wastewater plays an important role in revealing the dynamics of infection in a population. The sampling method used is a crucial factor and significantly impacts the results. Wastewater can be collected as a grab sample or as a 24 h composite sample. Another essential factor is the sample volume, as is the method of transport used. This review discusses different pretreatment procedures and RNA extraction, which may be performed using various methods, such as column-based extraction, TRIzol, or magnetic extraction. Each of the methods has its advantages and disadvantages, which are described accordingly. RT-qPCR is a procedure that confirms the presence of SARS-CoV-2 genes before sequencing. This review provides an overview of currently used methods for preparing wastewater samples, from sampling to sequencing.

Back-estimation of norovirus infections through wastewater-based epidemiology: A systematic review and parameter sensitivity

The amount of norovirus RNA (Ribonucleic Acid) in raw wastewater, collected from a wastewater treatment plant (WWTP), can provide an indication of disease prevalence within the sampled catchment. However, an accurate back-estimation might be impeded by the uncertainties from in-sewer/in-sample degradation of viral RNA, variable shedding magnitude, and difficulties in measurement within raw wastewater. The current study reviewed the published literature regarding the factors of norovirus shedding, viral RNA decay in wastewater, and the occurrence of norovirus RNA in raw wastewater based on molecular detection. Sensitivity analysis for WBE back-estimation was conducted using the reported data of the factors mentioned above considering different viral loads in wastewater samples. It was found that the back-estimation is more sensitive to analytical detection uncertainty than shedding variability for norovirus. Although seasonal temperature change can lead to variation of decay rates and may influence the sensitivity of this pathogen-specific parameter, decay rates of norovirus RNA contribute negligibly to the variance in estimating disease prevalence, based on the available data from decay experiments in bulk wastewater under different temperatures. However, the effects of in-sewer transportation on viral RNA decay and retardation by sewer biofilms on pipe surfaces are largely unknown. Given the highest uncertainty from analytical measurement by molecular methods and complexity of in-sewer processes that norovirus experienced during the transportation to WWTP, future investigations are encouraged to improve the accuracy of viral RNA detection in wastewater and delineate viral retardation/interactions with wastewater biofilms in real sewers.

Human population as a key driver of biochemical burden in an inter-city system: Implications for One Health concept

This paper tests the hypothesis that human population and city function are key drivers of biochemical burden in an inter-city system, which can be used to inform One Health actions as it enables a holistic understanding of city's metabolism encompassing all of the activities of a city in a single model: from lifestyle choices, through to health status and exposure to harmful chemicals as well as effectiveness of implemented management strategies. Chemical mining of wastewater for biophysico-chemical indicators (BCIs) was undertaken to understand speciation of BCIs in the context of geographical as well as community-wide socioeconomic factors. Spatiotemporal variabilities in chemical and biological target groups in the studied inter-city system were observed. A linear relationship (R² > 0.99) and a strong positive correlation between most BCIs and population size (r > 0.998, p < 0.001) were observed which provides a strong evidence for the population size as a driver of BCI burden. BCI groups that are strongly correlated with population size and are intrinsic to humans' function include mostly high usage pharmaceuticals that are linked with long term non-communicable conditions (NSAIDs, analgesics, cardiovascular, mental health and antiepileptics) and lifestyle chemicals. These BCIs can be used as population size markers. BCIs groups that are produced as a result of a specific city's function (e.g. industry presence and occupational exposure or agriculture) and as such are not correlated with population size include: pesticides, PCPs and industrial chemicals. These BCIs can be used to assess city's function, such as occupational exposure, environmental or food exposure, and as a proxy of community-wide health. This study confirmed a strong positive correlation between antibiotics (ABs), population size and antibiotic resistance genes (ARGs). This confirms the population size and AB usage as the main driver of AB and ARG levels and provides an opportunity for interventions aimed at the reduction of AB usage to reduce AMR. Holistic evaluation of biophysicochemical fingerprints (BCI burden) of the environment and data triangulation with socioeconomic fingerprints (indices) of tested communities are required to fully embrace One Health concept.

Race-based disparities in access to surgical palliation for hypoplastic left heart syndrome

BACKGROUND

Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome.

METHODS

The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center.

RESULTS

Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization.

CONCLUSION

We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome.

Prevalence of illicit drug consumption in a population of Hanoi: an estimation using wastewater-based epidemiology

Illicit drug use is a serious issue in Vietnam, but information about their prevalence is scarce, mainly based on seizure data. Wastewater-based epidemiology (WBE) is an alternative tool for obtaining such information, especially when stigma related to drug use can hinder survey approaches. The study aimed to apply WBE to assess the prevalence of use of a range of illicit drugs in an urban population of Vietnam. A total of 184 wastewater samples were collected at two different sites along a sewage canal, receiving sewage from over 400,000 people in Hanoi, Vietnam, in three different periods between 2018 and 2020. Illicit drugs and their metabolites were measured by direct injection using liquid chromatography-tandem mass spectrometry. The results were back-estimated, normalised to per capita daily consumption for assessement of consumption patterns and trends. Most drugs were detected in all the samples except cocaine, benzoylecgonine, amphetamine indicating a low prevalence of cocaine and amphetamine use. The estimated consumption level of methamphetamine was varied from 119.5 to 553.5 mg/d/1000 pp. The market of illicit drugs in Vietnam has changed from opiates to amphetamine-type simulants, and methamphetamine has replaced heroin as the No.1 drug, its use can be as much as 3 times more than heroin use. Moreover, we observed the considerable and potentially increasing level of ketamine consumption in Hanoi. No statistical difference was found in daily consumption per capita among days of the week for any drugs, both legal (codeine, methadone) and illegal (methamphetamine, MDMA, ketamine and heroin), suggesting the drugs were consumed mainly by regular users. This study provides important information related the illicit drug consumption in Vietnam, which will help to formulate appropriate drug control policies in this country.

Wastewater-based epidemiology in hazard forecasting and early-warning systems for global health risks

With the advent of the SARS-CoV-2 pandemic, Wastewater-Based Epidemiology (WBE) has been applied to track community infection in cities worldwide and has proven succesful as an early warning system for identification of hotspots and changingprevalence of infections (both symptomatic and asymptomatic) at a city or sub-city level. Wastewater is only one of environmental compartments that requires consideration. In this manuscript, we have critically evaluated the knowledge-base and preparedness for building early warning systems in a rapidly urbanising world, with particular attention to Africa, which experiences rapid population growth and urbanisation. We have proposed a Digital Urban Environment Fingerprinting Platform (DUEF) - a new approach in hazard forecasting and early-warning systems for global health risks and an extension to the existing concept of smart cities. The urban environment (especially wastewater) contains a complex mixture of substances including toxic chemicals, infectious biological agents and human excretion products. DUEF assumes that these specific endo- and exogenous residues, anonymously pooled by communities' wastewater, are indicative of community-wide exposure and the resulting effects. DUEF postulates that the measurement of the substances continuously and anonymously pooled by the receiving environment (sewage, surface water, soils and air), can provide near real-time dynamic information about the quantity and type of physical, biological or chemical stressors to which the surveyed systems are exposed, and can create a risk profile on the potential effects of these exposures. Successful development and utilisation of a DUEF globally requires a tiered approach including: Stage I: network building, capacity building, stakeholder engagement as well as a conceptual model, followed by Stage II: DUEF development, Stage III: implementation, and Stage IV: management and utilization. We have identified four key pillars required for the establishment of a DUEF framework: (1) Environmental fingerprints, (2) Socioeconomic fingerprints, (3) Statistics and modelling and (4) Information systems. This manuscript critically evaluates the current knowledge base within each pillar and provides recommendations for further developments with an aim of laying grounds for successful development of global DUEF platforms.

In-Sewer Stability Assessment of Anabolic Steroids and Selective Androgen Receptor Modulators

Wastewater-based epidemiology is a potential complementary technique for monitoring the use of performance- and image-enhancing drugs (PIEDs), such as anabolic steroids and selective androgen receptor modulators (SARMs), within the general population. Assessing in-sewer transformation and degradation is critical for understanding uncertainties associated with wastewater analysis. An electrospray ionization liquid chromatography mass spectrometry method for the quantification of 59 anabolic agents in wastewater influent was developed. Limits of detection and limits of quantification ranged from 0.004 to 1.56 μg/L and 0.01 to 4.75 μg/L, respectively. Method performance was acceptable for linearity (R² > 0.995, few exceptions), accuracy (68-119%), and precision (1-21%RSD), and applicability was successfully demonstrated. To assess the stability of the selected biomarkers in wastewater, we used laboratory-scale sewer reactors to subject the anabolic agents to simulated realistic sewer environments for 12 h. Anabolic agents, including parent compounds and metabolites, were spiked into freshly collected wastewater that was then fed into three sewer reactor types: control sewer (no biofilm), gravity sewer (aerobic conditions), and rising main sewer (anaerobic conditions). Our results revealed that while most glucuronide conjugates were completely transformed following 12 h in the sewer reactors, 50% of the investigated biomarkers had half-lives longer than 4 h (mean residence time) under gravity sewer conditions. Most anabolic agents were likely subject to biofilm sorption and desorption. These novel results lay the groundwork for any future wastewater-based epidemiology research involving anabolic steroids and SARMs.

Illicit drug use in Reykjavik by wastewater-based epidemiology

Estimation of illicit drug use on a community level by wastewater-based epidemiology (WBE) is both an objective and reliable way to establish near real-time results. Wastewater samples were collected at eleven timepoints in Reykjavik from 2017 to 2020. The use of commonly abused illicit drugs in Iceland (amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), cocaine, and cannabis) was estimated. Solid phase extraction and ultra-high performance liquid chromatography coupled to tandem mass spectrometry was used for analysis. Estimated amphetamine and methamphetamine use showed signs of an increase from 2017 to 2020 with amphetamine being the dominant stimulant on the market. MDMA use remained stable from 2017 to 2020. Results showed a large increase in cocaine use from 2017 to 2019 but interestingly, a marked decrease in 2020 during the COVID-19 pandemic. Cannabis use was stable from 2017 to 2019 but showed signs of an increase during the pandemic in 2020. Results by WBE corresponded with data based on two other indicators of drug use, seizure data and driving under the influence cases. Both temporal and spatial trends in illicit drug use were successfully estimated by using WBE, complimenting other indicators which provided a comprehensive picture of drug abuse in Reykjavik.

Wastewater-based epidemiology for illicit drugs: A critical review on global data

Illicit drug use is complex, hidden and often highly stigmatized behaviour, which brings a vast challenge for drug surveillance systems. Drug consumption can be estimated by measuring human excretion products in untreated wastewater, known as wastewater-based epidemiology (WBE). Over the last decade, the application of wastewater-based epidemiology to monitor illicit drug loads increased and WBE is currently applied on a global scale. Studies from over the globe are evaluated with regard to their sampling method, analytical accuracy and consumption calculation, aiming to further reduce relevant uncertainties in order to make reliable comparisons on a global level. Only a limited number is identified as high-quality studies, so further standardization of the WBE approach for illicit drugs is desired especially with regard to the sampling methodology. Only a fraction of the reviewed papers explicitly reports uncertainty ranges for their consumption data. Studies which had the highest reliability are recently published, indicating an improvement in reporting WBE data. Until now, WBE has not been used in large parts of Africa, nor in the Middle East and Russia. An overview of consumption data across the continents on commonly studied drugs (cocaine, MDMA, amphetamine and methamphetamine) is provided. Overall, high consumption rates are confirmed in the US, especially for cocaine and methamphetamine, while relatively low illicit drug consumption is reported in Asia.

Identification of biomarkers in wastewater-based epidemiology: Main approaches and analytical methods

Wastewater-based epidemiology (WBE) has become popular to estimate the use of drugs of abuse and recently to establish the incidence of CoVID 19 in large cities. However, its possibilities have been expanded recently as a technique that allows to establish a fingerprint of the characteristics of a city, such as state of health/disease, healthy/unhealthy living habits, exposure to different types of contaminants, etc. with respect to other cities. This has been thanks to the identification of human biomarkers as well as to the fingerprinting and profiling of the characteristics of the wastewater catchment that determine these circumstances. The purpose of this review is to analyze the different methodological schemes that have been developed to perform this biomarker identification as well as the most characteristic analytical techniques in each scheme, their advantages and disadvantages and the knowledge gaps identified. We also discussed the future scope for development.

Monitoring geographical differences in illicit drugs, alcohol, and tobacco consumption via wastewater-based epidemiology: Six major cities in Turkey

A national wastewater-based epidemiology (WBE) monitoring campaign has been initiated to determine the trends in drug consumption in Turkey since 2019. This study aimed to present the wastewater monitoring results for four periods in 2019 for six major cities with 17 wastewater treatment plants. The study investigated heroin (HER), amphetamine (AMP), methamphetamine (METH), cocaine (COC), 3,4-methylenedioxymethamphetamine (MDMA), cannabis, alcohol, and tobacco to understand the temporal and geographical drug consumption trends. The results indicated a trend of regular cannabis use in all the cities. Considering geographical variations, the drug usage trends were not homogeneous within the country for any of the investigated drugs, except cannabis. HER consumption was predominant in Denizli (1042.48 mg/1000 inh/day), while İzmir and Antalya (154.10 and 79.56 mg/1000 inh/day, respectively) topped for COC consumption. Aydın had the highest consumption levels of AMP (90.03 mg/1000 inh/day) and METH (358.13 mg/1000 inh/day), while MDMA consumption was the highest in Samsun (157.64 mg/1000 inh/day). Tobacco consumption was high in Aydın (8791.69 mg/1000 inh/day) and Antalya (5375.17 mg/1000 inh/day), whereas alcohol consumption was higher in Bursa than in the other cities (53434.61 mL/1000 inh/day). There were no statistically significant differences in the weekend consumption levels of the investigated drugs among these six cities. Although this study included the results of 1 year of consumption monitoring, the data confirms internationally published information on the drug trafficking routes of conventional drugs in this region, especially the Heroin-Balkan route. Results from further sampling will enable accurate evaluation of global drug consumption and trafficking, in addition to alcohol and tobacco use.

Source identification of amphetamine-like stimulants in Spanish wastewater through enantiomeric profiling

Amphetamine (AMP), methamphetamine (MAMP) and 3,4-methylenedioxymethamphetamine (MDMA) occur in wastewater not only as a result of illicit consumption, but also, in some cases, from prescription drug use or by direct drug disposal into the sewage system. Enantiomeric profiling of these chiral drugs could give more insight into the origin of their occurrence. In this manuscript, a new analytical methodology for the enantiomeric analysis of amphetamine-like substances in wastewater has been developed. The method consists of a solid-phase extraction (SPE) followed by liquid chromatography-triple quadrupole-tandem mass spectrometry (LC-MS/MS), which showed low quantification limits in the 2.4-5.5 ng L^-1 range. The LC-MS/MS method was first applied to characterize a total of 38 solid street drug samples anonymously provided by consumers. The results of these analysis showed that AMP and MDMA trafficked into Spain are synthesized as racemate, while MAMP is exclusively produced as the S(+)-enantiomer. Then, the analytical method was employed to analyse urban wastewater samples collected from the wastewater treatment plants (WWTPs) of five different cities in 2018 and 2019. Consumption estimated through normalized population loads in wastewater showed an increased pattern of AMP use in the Basque Country. Furthermore, the enantiomeric profiling of wastewater samples was contrasted to lisdexamfetamine (LIS) and selegiline (SEL) prescription figures, two pharmaceuticals which metabolize to S(+)-AMP, and to R(-)-AMP and R(-)-MAMP, respectively. From this analysis, and considering uncertainties derived from metabolism and adherence to treatment, it was concluded that LIS is a relevant source of AMP in those cases with low wastewater loads, i.e. up to a maximum of 60% of AMP detected in wastewater in some samples could originate from LIS prescription, while SEL does not represent a significant source of AMP nor MAMP. Finally, removal efficiencies could be evaluated for the WWTP (serving ca. 860,000 inhabitants) with higher AMP influent concentrations. The removal of AMP was satisfactory with rates higher than 99%, whereas MDMA showed an average removal of approximately 60%, accompanied by an enrichment of R(-)-MDMA.

Fish self-awareness: limits of current knowledge and theoretical expectations

Animal self-awareness is divided into three levels: bodily, social, and introspective self-awareness. Research has focused mainly on the introspection of so-called higher organisms such as mammals. Herein, we turn our attention to fish and provide opinions on their self-awareness based on a review of the scientific literature. Our specific aims are to discuss whether fish (A) could have a neural substrate supporting self-awareness and whether they display signs of (B) social and (C) introspective self-awareness. The present knowledge does not exclude the possibility that fish could have a simple neocortex or other structures that support certain higher cognitive processes, as the function of the primate cerebral cortex can be replaced by other neurological structures. Fish are known to display winner, loser, and audience effects, which could be interpreted as signs of social self-awareness. The audience effect may be explained not only by ethological cost and benefit theory but also by the concept of public self-awareness, which comes from human studies. The behavioural and neural manifestations of depression may be induced in fish under social subordination and may be viewed as certain awareness of a social status. The current findings on fish introspective self-awareness have been debated in the scientific community and, therefore, demand replication to provide more evidence. Further research is needed to verify the outlined ideas; however, the current knowledge indicates that fish are capable of certain higher cognitive processes, which raises questions and implications regarding ethics and welfare in fish-related research and husbandry.

Performance- and image-enhancing drug use in the community: use prevalence, user demographics and the potential role of wastewater-based epidemiology

Performance- and image-enhancing drug (PIED) misuse is a significant public health issue. Currently, seizure data, surveys, anti-doping testing, and needle service provider data are used to estimate PIED use in populations. These methods are time consuming, single point-in-time measurements that often consist of small sample sizes and do not truly capture PIED prevalence. Wastewater-based epidemiology (WBE) has been used globally to assess and monitor licit and illicit drug consumption within the general community. This method can objectively cover large populations as well as specific subpopulations (gyms, music festivals, prisons), and has potential as a complementary monitoring method for PIED use. Information obtained through WBE could be used to aid public health authorities in developing targeted prevention and education programmes. Research on PIED analysis in wastewater is limited and presents a significant gap in the literature. The focus is on anabolic steroids, and one steroid alternative currently growing in popularity; selective androgenic receptor modulators. This encompasses medical uses, addiction, prevalence, user typology, and associated public health implications. An overview of WBE is described including its benefits, limitations and potential as a monitoring method for PIED use. A summary of previous work in this field is presented. Finally, we summarise gaps in the literature, future perspectives, and recommendations for monitoring PIEDs in wastewater.

Sub-Part-Per-Billion Level Sensing of Fentanyl Residues from Wastewater Using Portable Surface-Enhanced Raman Scattering Sensing

Detection of illicit drug residues from wastewater provides a new route toward community-level assessment of drug abuse that is critical to public health. However, traditional chemistry analytical tools such as high-performance liquid chromatography in tandem with mass spectrometry (HPLC-MS) cannot meet the large-scale testing requirement in terms of cost, promptness, and convenience of use. In this article, we demonstrated ultra-sensitive and portable surface-enhanced Raman scattering sensing (SERS) of fentanyl, a synthetic opioid, from sewage water and achieved quantitative analysis through principal component analysis and partial least-squares regression. The SERS substrates adopted in this application were synthesized by in situ growth of silver nanoparticles on diatomaceous earth films, which show ultra-high sensitivity down to 10 parts per trillion in artificially contaminated tap water in the lab using a commercial portable Raman spectrometer. Based on training data from artificially contaminated tap water, we predicted the fentanyl concentration in the sewage water from a wastewater treatment plant to be 0.8 parts per billion (ppb). As a comparison, the HPLC-MS confirmed the fentanyl concentration was below 1 ppb but failed to provide a specific value of the concentration since the concentration was too low. In addition, we further proved the validity of our SERS sensing technique by comparing SERS results from multiple sewage water treatment plants, and the results are consistent with the public health data from our local health authority. Such SERS sensing technique with ultra-high sensitivity down to sub-ppb level proved its feasibility for point-of-care detection of illicit drugs from sewage water, which is crucial to assess public health.

Preparing for COVID-2x: Urban Planning Needs to Regard Urological Wastewater as an Invaluable Communal Public Health Asset and Not as a Burden

Prior to the COVID-19 pandemic, the analysis of urological wastewater had been a matter of academic curiosity and community-wide big-picture studies looking at drug use or the presence of select viruses such as Hepatitis. The COVID-19 pandemic saw systematic testing of urological wastewater emerge as a significant early detection tool for the presence of SARS-CoV-2 in a community. Even though the pandemic still rages in all continents, it is time to consider the post-pandemic world. This paper posits that urban planners should treat urological wastewater as a communal public health asset and that future sewer design should allow for stratified multi-order sampling.