Analysis and interpretation of specific ethanol metabolites, ethyl sulfate, and ethyl glucuronide in sewage effluent for the quantitative measurement of regional alcohol consumption

Community infectious disease treatment with antimicrobial agents - A longitudinal one year study of antimicrobials in two cities via wastewater-based epidemiology

Antimicrobial resistance (AMR) is one of the most significant global health threats. Inappropriate and over-usage of antimicrobial agents (AAs) is a major driver for AMR. Wastewater-based epidemiology (WBE) is a promising tool for monitoring AA usage in communities which is, for the first time, explored in this large scale, longitudinal study. Two contrasting urban catchment areas have been investigated: one city and one small town in the Southwest of the UK over a 13-month period in 2018-2019. Per capita daily intake of 17 AAs and metabolites has been estimated and obtained estimates were triangulated with catchment specific AA prescription data to understand AA usage patterns (both seasons driven prescription and AA prescription compliance). Results have demonstrated positive correlations for all quantifiable parent AAs and metabolites in wastewater, and spatial variability in AA usage was observed even in neighbouring urban areas. WBE and catchment specific prescription data showed similar seasonal trends but with low correlation in intake. The reasons might be variable prescribing patterns, prescription/intake outside the studied catchment, and/or lack of patient compliance. WBE proved useful in differentiating between consumption vs topical usage and/or direct disposal of unused AA. WBE is considered superior to prescription data as it provides information on AAs prescribed outside of the monitoring catchment, e.g. HIV antivirals and TB drugs. However, data triangulation, of both prescription data and wastewater data, provides the most comprehensive approach to understanding AA usage in communities.

Biomarker selection strategies based on compound stability in wastewater-based epidemiology

The specific compositions of human excreta in sewage can be used as biomarkers to indicate the disease prevalence, health status, and lifestyle of the population living in the investigated catchment. It is important for guiding and evaluating public health policies as well as promoting human health development. Among several parameters of wastewater-based epidemiology (WBE), the decay of biomarkers during transportation in sewer and storage plays a crucial role in the back-calculation of population consumption. In this paper, we summarized the stability data of common biomarkers in storage at different temperatures and in-sewer transportation. Among them, cardiovascular drugs and antidiabetic drugs are very stable which can be used as biomarkers; most of the illicit drugs are stable except for cocaine, heroin, and tetrahydrocannabinol which could be substituted by their metabolites as biomarkers. There are some losses for part of antibiotics and antidepressants even in frozen storage. Rapid detection of contagious viruses is a new challenge for infectious disease control. With the deeper and broader study of biomarkers, it is expected that the reliable application of the WBE will be a useful addition to epidemiological studies.

A Framework for Public Health Authorities to Evaluate Health Determinants for Wastewater-Based Epidemiology

BACKGROUND

Wastewater-based epidemiology (WBE) is rapidly developing as a powerful public health tool. It can provide information about a wide range of health determinants (HDs), including community exposure to environmental hazards, trends in consumption of licit and illicit substances, spread of infectious diseases, and general community health. As such, the list of possible candidate HDs for WBE is almost limitless. Consequently, a means to evaluate and prioritize suitable candidates for WBE is useful, particularly for public health authorities, who often face resource constraints.

OBJECTIVES

We have developed a framework to assist public health authorities to decide what HDs may be appropriate for WBE and what biomarkers could be used. This commentary reflects the experience of the authors, who work at the interface of research and public health implementation.

DISCUSSION

To be suitable for WBE, a candidate HD should address a public health or scientific issue that would benefit from better understanding at the population level. For HDs where information on individual exposures or stratification by population subgroups is required, WBE is less suitable. Where other methodologies are already used to monitor the candidate HD, consideration must be given to whether WBE could provide better or complementary information to the current approach. An essential requirement of WBE is a biomarker specific for the candidate HD. A biomarker in this context refers to any human-excreted chemical or biological that could act as an indicator of consumption or exposure to an environmental hazard or of the human health state. Suitable biomarkers should meet several criteria outlined in this commentary, which requires background knowledge for both the biomarker and the HD. An evaluation tree summarizing key considerations for public health authorities when assessing the suitability of candidate HDs for WBE and an example evaluation are presented. https://doi.org/10.1289/EHP11115.

Biosensors for the detection of disease outbreaks through wastewater-based epidemiology

Wastewater-Based Epidemiology (WBE) is a novel community-wide monitoring tool that provides comprehensive real-time data of the public and environmental health status and can contribute to public health interventions, including those related to infectious disease outbreaks (e.g., the ongoing COVID-19 pandemic). Nonetheless, municipalities without centralized laboratories are likely still not able to process WBE samples. Biosensors are a potentially cost-effective solution to monitor the development of diseases through WBE to prevent local outbreaks. This review discusses the economic and technical feasibility of eighteen recently developed biosensors for the detection and monitoring of infectious disease agents in wastewater, prospecting the prevention of future pandemics.

A wastewater-based assessment of the impact of a minimum unit price (MUP) on population alcohol consumption in the Northern Territory, Australia

AIM

To test if there was a reduction in alcohol consumption in wastewater samples in the Northern Territory of Australia after the implementation of a minimum unit alcohol price policy (MUP) in October 2018.

DESIGN, SETTING, CASES

Between August 2016 and February 2020, wastewater samples were collected across 66 sites in the Northern Territory and all other states and territories in Australia. Samples were collected every 2 months in capital cities and every 4 months in regional places during this period. Overall, 4917 samples were taken (2816 before MUP and 2101 after).

MEASUREMENTS

The number of standard drinks per 1000 people per day in the respective catchment areas was estimated based on the concentration of an alcohol-specific metabolite, ethyl sulphate in the samples (using the excretion factor of ethyl sulphate, the flow of wastewater entering the wastewater treatment plants and the population of each wastewater catchment).

FINDINGS

Results from a linear mixed model showed that there was a large drop in alcohol consumption immediately after the MUP in Northern Territory [estimated drop = 1231, 99% confidence interval (CI) = 830, 1633; 38.75%]. There was no significant drop in all other states/territories except for Queensland, which showed a significant but much smaller drop (estimated drop: 310; 99% CI = 114, 550). One year after the MUP, the drop narrowed to 520 (99% CI = 189, 851) and was no longer statistically significant in February 2020 (15 months after MUP; estimated drop = 283, 99% CI = -114, 681).

CONCLUSIONS

Per-capita consumption of alcohol appears to have decreased substantially in the Northern Territory of Australia immediately after the implementation of a minimum unit price but consumption steadily recovered and almost returned to the pre-MUP consumption level after 15 months.

Estimating population-level of alcohol, tobacco and morphine use in a small Russian region using wastewater-based epidemiology

INTRODUCTION

Alcohol, tobacco and illicit drug use combined are the largest modifiable health risk factors. Wastewater-based epidemiology (WBE) is a complementary approach for monitoring substance use in the population. In this study we applied WBE technique to a community in the Moscow region to estimate population-level consumption of alcohol, tobacco and morphine.

METHODS

Wastewater sampling was carried out over 47 days, in 2018 and 2019, including the New Year period. Analysis of the samples for consumption biomarkers (ethyl sulphate, cotinine and morphine) were undertaken using liquid chromatography tandem mass spectrometry (LC-MS/MS). Daily consumption estimates were then compared with sales/production/prescription data and between different days of the week using Mann-Whitney U test.

RESULTS

Alcohol consumption was significantly higher on Sundays and during the New Year and Russian Christmas period compared to weekdays and Saturdays. Tobacco consumption estimates were largely consistent throughout the week. Morphine was detected by WBE during the monitoring period but was inconsistent with prescription record data.

DISCUSSION AND CONCLUSIONS

This study provides evidence for the feasibility of conducting WBE in Russia. Estimates of alcohol consumption derived from WBE were higher than average alcohol sales data for the country. The estimated consumption of nicotine is generally consistent with the production data, with estimates higher than in most other countries. Our results also suggest potential illegal use of opioids (morphine-based) in the population. Given the considerable health and economic costs of substance use in Russia, more extensive WBE testing is recommended to inform and evaluate public health policies.

Impact of COVID-19 Controls on the Use of Illicit Drugs and Alcohol in Australia

Methamphetamine, MDMA, cocaine, cannabis, and alcohol in samples from 20 wastewater treatment plants servicing the eight state or territory capitals of Australia were analyzed, with equivalent coverage of >45% of the national population. Trends in drug consumption were calculated and assessed from samples collected from 2016 to 2020, with a focus on pre-COVID-19 (August 2016 to December 2019), versus February to June 2020, when Australia observed a nationwide lockdown. Results showed delayed but significant decreases in methamphetamine, >50% in Western Australia. In contrast, significant increases in cannabis in most jurisdictions were observed. This suggests changes in consumption may be somewhat linked to reduced supply of imported substances, with increased use of locally produced drugs. Initial decreases in cocaine and MDMA consumption were evident in many parts of the country, but pre-COVID trends were re-established after April 2020. Interestingly, weekend-weekday differences were narrowed for cocaine, MDMA, and alcohol during lockdown, which might be expected due to bars being closed and social gathering not allowed. With this study providing insight into the first four months of COVID-19 restrictions in Australia, it remains to be seen what the longer-term effect of the pandemic will be.

Changes in alcohol consumption associated with social distancing and self-isolation policies triggered by COVID-19 in South Australia: a wastewater analysis study

AIM

To assess the effects of social distancing and social isolation policies triggered by COVID-19 on alcohol consumption using wastewater analysis in Adelaide, South Australia.

DESIGN

Longitudinal quantitative analysis of influent wastewater data for alcohol concentration.

SETTING

Adelaide, South Australia.

PARTICIPANTS

Wastewater catchment area representative of 1.1 million inhabitants.

MEASUREMENTS

Twenty-four hour composite influent wastewater samples were collected from four wastewater treatment plants in Adelaide, South Australia for 7 consecutive days (Wednesday-Tuesday) every 2 months from April 2016-April 2020. The alcohol metabolite ethyl sulfate was measured in samples using chromatography-tandem mass spectrometry. Data were population-weighted adjusted with consumption expressed as standard drinks/day/1000 people. Weekly consumption and weekend to mid-week consumption ratios were analysed to identify changes in weekday alcohol use pattern.

FINDINGS

Estimated weekend alcohol consumption was significantly lower (698 standard drinks/day/1000 people) after self-isolation measures were enforced in April 2020 compared with the preceding sampling period in February 2020 (1047 standard drinks/day/1000 people), P < 0.05. Weekend to midweek consumption ratio was 12% lower than the average ratio compared with all previous sampling periods. April 2020 recorded the lowest alcohol consumption relative to April in previous years, dating back to 2016.

CONCLUSIONS

Wastewater analysis suggests that introduction of social distancing and isolation policies triggered by COVID-19 in Adelaide, South Australia, was associated with a decrease in population-level weekend alcohol consumption.

A review of the presence of SARS-CoV-2 RNA in wastewater and airborne particulates and its use for virus spreading surveillance

According to the WHO, on October 16, 2020, the spreading of the SARS-CoV-2, responsible for the COVID-19 pandemic, reached 235 countries and territories, and resulting in more than 39 million confirmed cases and 1.09 million deaths globally. Monitoring of the virus outbreak is one of the main activities pursued to limiting the number of infected people and decreasing the number of deaths that have caused high pressure on the health care, social, and economic systems of different countries. Wastewater based epidemiology (WBE), already adopted for the surveillance of life style and health conditions of communities, shows interesting features for the monitoring of the COVID-19 diffusion. Together with wastewater, the analysis of airborne particles has been recently suggested as another useful tool for detecting the presence of SARS-CoV-2 in given areas. The present review reports the status of research currently performed concerning the monitoring of SARS-CoV-2 spreading by WBE and airborne particles. The former have been more investigated, whereas the latter is still at a very early stage, with a limited number of very recent studies. Nevertheless, the main results highlights in both cases necessitate more research activity for better understating and defining the biomarkers and the related sampling and analysis procedures to be used for this important aim.

Quantifying nicotine and alcohol consumption in New Zealand using wastewater-based epidemiology timed to coincide with census

INTRODUCTION

Accurate and timely information about nicotine and alcohol consumption is needed to inform effective policy. Wastewater-based epidemiology provides an opportunity to quantify consumption, which can complement traditional data collection methods.

METHODS

Wastewater samples were collected from seven wastewater treatment plants on seven consecutive days in three regions of New Zealand during the same week as the national census (6 March 2018). Samples were analysed for nicotine and alcohol metabolites using liquid chromatography-tandem mass spectrometry. Detailed catchment maps were developed and per capita consumption calculated.

RESULTS

Observed nicotine consumption (mean 1528 ± 412 cigarettes/day/1000 people) was similar to national sales data. Observed alcohol consumption (mean 1155 ± 764 standard drinks/day/1000 people) was lower than estimated using alcohol availability data. Consumption of nicotine and alcohol was generally higher in the Bay of Plenty and Canterbury compared to Auckland, mirroring trends in the New Zealand Health Survey. Intra-regional differences were observed and the patterns could not be attributed to urbanisation alone. Nicotine consumption was consistent throughout the week whereas alcohol consumption often peaked at the weekend. Nicotine consumption was correlated with neighbourhood-deprivation. There was little correlation for alcohol.

DISCUSSION AND CONCLUSIONS

Wastewater-based epidemiology provides a quantitative dataset that complements traditional methods of investigating nicotine and alcohol consumption. Timing data collection to coincide with the census helps to account for the influence of population mobility when normalising consumption.

Estimating alcohol consumption by using wastewater-based epidemiology in Adana Province, Turkey

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

Longitudinal wastewater sampling in buildings reveals temporal dynamics of metabolites

Direct sampling of building wastewater has the potential to enable "precision public health" observations and interventions. Temporal sampling offers additional dynamic information that can be used to increase the informational content of individual metabolic "features", but few studies have focused on high-resolution sampling. Here, we sampled three spatially close buildings, revealing individual metabolomics features, retention time (rt) and mass-to-charge ratio (mz) pairs, that often possess similar stationary statistical properties, as expected from aggregate sampling. However, the temporal profiles of features-providing orthogonal information to physicochemical properties-illustrate that many possess different feature temporal dynamics (fTDs) across buildings, with large and unpredictable single day deviations from the mean. Internal to a building, numerous and seemingly unrelated features, with mz and rt differences up to hundreds of Daltons and seconds, display highly correlated fTDs, suggesting non-obvious feature relationships. Data-driven building classification achieves high sensitivity and specificity, and extracts building-identifying features found to possess unique dynamics. Analysis of fTDs from many short-duration samples allows for tailored community monitoring with applicability in public health studies.

Future perspectives of wastewater-based epidemiology: Monitoring infectious disease spread and resistance to the community level

Infectious diseases are acknowledged as one of the most critical threats to global public health today. Climate change, unprecedented population growth with accelerated rates of antimicrobial resistance, have resulted in both the emergence of novel pathogenic organisms and the re-emergence of infections that were once controlled. The consequences have led to an increased vulnerability to infectious diseases globally. The ability to rapidly monitor the spread of diseases is key for prevention, intervention and control, however several limitations exist for current surveillance systems and the capacity to cope with the rapid population growth and environmental changes. Wastewater-Based Epidemiology (WBE) is a new epidemiology tool that has potential to act as a complementary approach for current infectious disease surveillance systems and an early warning system for disease outbreaks. WBE postulates that through the analysis of population pooled wastewater, infectious disease and resistance spread, the emergence of new disease outbreak to the community level can be monitored comprehensively and in real-time. This manuscript provides critical overview of current infectious disease surveillance status, as well as it introduces WBE and its recent advancements. It also provides recommendations for further development required for WBE application as an effective tool for infectious disease surveillance.

An ultra-high-performance liquid chromatography tandem mass spectrometry method for oxidative stress biomarker analysis in wastewater

Reported herein is the development of an analytical method for the detection of four oxidative stress biomarkers in wastewater using ultra-high-performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/MS) and solid phase extraction (SPE). The following four biomarkers of oxidative stress and lipid peroxidation have been investigated: hydroxynonenal-mercapturic acid (HNE-MA), 8-iso-prostglandin F2beta (8-iso-PGF_2β), 8-nitroguanine (8-NO₂Gua) and 8-hydroxy-2-deoxyguanosine (8-OHdG). The method showed very good performance: accuracy (> 87%), precision (> 90%), method quantification limits (1.3-3.0 ng L^-1) and biomarker stability in wastewater in the case of HNE-MA, 8-OHdG and 8-iso-PGF_2β. In contrast, 8-NO₂Gua was found to be less stable in wastewater, which affected its method performance: accuracy (> 63%), precision (> 91%) and method quantification limits (85.3 ng L^-1). Application of the developed method resulted in, for the first time, HNE-MA being successfully observed and quantified within wastewater over a study period of a week (displayed average daily loads per capita of 48.9 ± 4.1 mg/1000/people/day). 8-iso-PGF_2β was detected with good intensity but could not be quantified due to co-elution with other isomers. 8-OHdG was detected, albeit at < MQL. This study demonstrates the potential for expanding on the possible endogenous biomarkers of health used in urban water fingerprinting to aid in measuring health in near-real time on a community-wide scale.

Monitoring Genetic Population Biomarkers for Wastewater-Based Epidemiology

We report a rapid "sample-to-answer" platform that can be used for the quantitative monitoring of genetic biomarkers within communities through the analysis of wastewater. The assay is based on the loop-mediated isothermal amplification (LAMP) of nucleic acid biomarkers and shows for the first time the ability to rapidly quantify human-specific mitochondrial DNA (mtDNA) from raw untreated wastewater samples. mtDNA provides a model population biomarker associated with carcinogenesis including breast, renal and gastric cancers. To enable a sample-to-answer, field-based technology, we integrated a filter to remove solid impurities and perform DNA extraction and enrichment into a low cost lateral flow-based test. We demonstrated mtDNA detection over seven consecutive days, achieving a limit of detection of 40 copies of human genomic DNA per reaction volume. The assay can be performed at the site of sample collection, with minimal user intervention, yielding results within 45 min and providing a method to monitor public health from wastewater.

Increased levels of the oxidative stress biomarker 8-iso-prostaglandin F2α in wastewater associated with tobacco use

Wastewater analysis has been demonstrated to be a complementary approach for assessing the overall patterns of drug use by a population while the full potential of wastewater-based epidemiology has yet to be explored. F₂-isoprostanes are a prototype wastewater biomarker to study the cumulative oxidative stress at a community level. In this work, 8-iso-prostaglandin F_2α (8-iso-PGF_2α) was analysed in raw 24 h-composite wastewater samples collected from 4 Norwegian and 7 other European cities in 2014 and 2015. Using the same samples, biomarkers of alcohol (ethyl sulfate) and tobacco (trans-3′-hydroxycotinine) use were also analysed to investigate any possible correlation between 8-iso-PGF_2α and the consumption of the two drugs. The estimated per capita daily loads of 8-iso-PGF_2α in the 11 cities ranged between 2.5 and 9.9 mg/day/1000 inhabitants with a population-weighted mean of 4.8 mg/day/1000 inhabitants. There were no temporal trends observed in the levels of 8-iso-PGF_2α, however, spatial differences were found at the inter-city level correlating to the degree of urbanisation. The 8-iso-PGF_2α mass load was found to be strongly associated with that of trans-3′-hydroxycotinine while it showed no correlation with ethyl sulfate. The present study shows the potential for 8-iso-PGF_2α as a wastewater biomarker for the assessment of community public health.

Comparison of pharmaceutical, illicit drug, alcohol, nicotine and caffeine levels in wastewater with sale, seizure and consumption data for 8 European cities

BACKGROUND

Monitoring the scale of pharmaceuticals, illicit and licit drugs consumption is important to assess the needs of law enforcement and public health, and provides more information about the different trends within different countries. Community drug use patterns are usually described by national surveys, sales and seizure data. Wastewater-based epidemiology (WBE) has been shown to be a reliable approach complementing such surveys.

METHOD

This study aims to compare and correlate the consumption estimates of pharmaceuticals, illicit drugs, alcohol, nicotine and caffeine from wastewater analysis and other sources of information. Wastewater samples were collected in 2015 from 8 different European cities over a one week period, representing a population of approximately 5 million people. Published pharmaceutical sale, illicit drug seizure and alcohol, tobacco and caffeine use data were used for the comparison.

RESULTS

High agreement was found between wastewater and other data sources for pharmaceuticals and cocaine, whereas amphetamines, alcohol and caffeine showed a moderate correlation. methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA) and nicotine did not correlate with other sources of data. Most of the poor correlations were explained as part of the uncertainties related with the use estimates and were improved with other complementary sources of data.

CONCLUSIONS

This work confirms the promising future of WBE as a complementary approach to obtain a more accurate picture of substance use situation within different communities. Our findings suggest further improvements to reduce the uncertainties associated with both sources of information in order to make the data more comparable.