COVID-19 and AMR Wastewater Surveillance: A matter of Urgency! 

Recent initiatives for COVID monitoring in urban wastewater demonstrate the need for a national action plan for both COVID and AMR surveillance.

The presence of SARS-CoV-2 in stools and wastewater raises key issues: 

Being able to predict the course of the epidemic ahead of time is key for state planning and hospital ICU preparedness! The demonstrated possibility of faecal-oral transmission of SARS-CoV-2 (as occurred in the first SARS epidemic) and that “Different routes from faeces to the mouth of a susceptible person exist” mean that water, surfaces and places with vectors can be transmission routes. 

With these considerations in mind, what is required is:
1 - Wastewater surveillance, as the quantity of coronavirus present is PREDICTIVE of outbreaks in the relevant community/ Below, we showcase a number of studies and initiatives from Australia, France, The Netherlands, Finland, Spain, Italy, and in USA where states and cities have confirmed virus detection. We also refer to an excellent article in the publication STAT which echoes our own convictions. Meanwhile, in the creation of the DUTCH antibiotic and water Consortium, we see the importance of wastewater surveillance as more effective than traditional GLASS surveillance on AMR.
2 - Water access/infrastructure needs prioritization as investments in wealthy nations and communities (typical neglect from New York to Flint, and from the UK to France), while ill-equipped countries need international massive investments
3 - Important information to the public, health care providers, home care and nursing care workers, and patients is required urgently, in wealthy and developing countries alike.
4 - Lastly, water NGOs should be part of the effort and get increased access to funding!
All the above measures will be of much use to control the spread of AMR infections and upgrade health services and the general health of populations.

Wastewater surveillance for COVID-19: case examples accross the world

Wastewater surveillance offers a cost-effective approach to track virus and antibiotics and provide early warnings.

In a remarkable article in the Boston based STAT, the authors propose that: "It’s time to begin a national (USA) wastewater testing program for COVID-19". This analysis, which we fully share, would also apply to the world as a whole. As a case in point, Massachusetts Water Resources Authority, for example, have been providing an excellent work in monitoring RNA signature in wastewater, and publish their results online. (source here)





The analysis clearly reveals that a 2nd wave of virus RNA is appearing in the sewage system on early august. The STAT authors wrote:
"As the COVID-19 pandemic marches across America, causing record-breaking numbers of cases, almost every solution for controlling the disease includes more testing, especially as cities and states try to reopen. But with states hitting their limits on testing, we need new tools for understanding COVID-19 transmission. A national wastewater surveillance program offers a cost-effective approach to track Covid-19 across the majority of the U.S. population and provides early warnings of resurgence."
"People infected with SARS-CoV-2 shed the virus in their stool even before they show symptoms of Covid-19. Analyzing sewage for the virus, using methods like the ones used for testing individuals, can predict the community level of infection one week to two weeks in advance of clinical diagnoses, and show increasing and decreasing levels of coronavirus infection and transmission. Testing the wastewater of a nursing home, prison, or dormitory could potentially give an early signal that one or more residents are infected and therefore prompt testing of each resident"
National wastewater surveillance would require at least weekly testing at wastewater treatment plants and in sewers. Although some states, such as Colorado, Ohio, and New York, have taken steps toward implementing wastewater surveillance efforts, the U.S. lacks a national COVID-19 program for it." (...)

The authors then cite some countries: Australia "the Collaboration on Sewage Surveillance of SARS-CoV-2 project. In Finland, the Finnish Institute for Health and Welfare is overseeing sampling at 28 wastewater treatment plants in a monitoring program that covers 60% of the Finnish population. The Netherlands has implemented weekly testing at 29 plants that cover about 25% of the Dutch population...
Pakistan has instituted a program that leverages the existing polio environmental surveillance network to monitor SARS-CoV-2 at 78 wastewater treatment plants across the country."
The STAT article authors then detail how to do planning for the undertaking overall. A must article to read. In yet another previous STAT article with a striking title "How the world can avoid screwing up the response to Covid-19 again", June 5th, authors Begley and Helen Branswell asked 11 experts (...) what best to do:  "One idea: wastewater surveillance" June 5, 2020


In France, Eau de Paris (the entity in charge of wastewater management for the city) has also advocated for wastewater surveillance and done scientific studies. Evaluation of lockdown impact on SARS-CoV-2 dynamics through viral genome quantification in Paris wastewaters” "In the present work we assumed that the quantification of SARS-CoV-2 genomes in wastewaters should correlate with the number of symptomatic or non-symptomatic carriers. To test this hypothesis, we performed a time-course quantitative analysis of SARS-CoV-2 by RT-qPCR in raw wastewater samples collected from several major wastewater treatment plants of the Parisian area. The study was conducted from March 5 to April 23 2020, therefore including the lockdown period in France (since March 17 2020). We confirmed that the increase of genome units in raw wastewaters accurately followed the increase of human COVID-19 cases observed at the regional level. Of note, the viral genomes could be detected before the beginning of the exponential growth of the epidemic. As importantly, a marked decrease in the quantities of genomes units was observed concomitantly with the reduction in the number of new COVID-19 cases which was an expected consequence of the lockdown. As a conclusion, this work suggests that a quantitative monitoring of SARS-CoV-2 genomes in wastewaters should bring important and additional information for an improved survey of SARS-CoV-2 circulation at the local or regional scale.

In Italy,  the Italian Higher Institute of Health (Istituto Superiore di Sanita; ISS) reports that sewage water from Milan and Turin already contained COVID viral RNA sequences on 18 Dec 2019 [over 2 weeks before China reported its 1st cases and 6 weeks before the 1st Italian cases were detected on 31 Jan 2020. - PNP]. (reported in the Italian paper: The Local)
In Spain, SARS-CoV-2 RNA in wastewater anticipated COVID-19 occurrence in a low prevalence area Faecal shedding of SARS-CoV-2 RNA from COVID-19 patients has extensively been reported. Therefore, we investigated the occurrence of SARS-CoV-2 RNA in six wastewater treatment plants serving the major municipalities within the Region of Murcia (Spain), the area with the lowest COVID-19 prevalence within the Iberian Peninsula. (...) This environmental surveillance data were compared to declared COVID-19 cases at the municipality level, revealing that members of the community were shedding SARS-CoV-2 RNA in their stool even before the first cases were reported by local or national authorities in many of the cities where wastewaters have been sampled. The detection of SARS-CoV-2 in wastewater in early stages of the spread of COVID-19 highlights the relevance of this strategy as an early indicator of the infection within a specific population. (source: Gloria Sanchez et all. Institute of Agrochemistry and Food Technology,  and IATA-CSIC)

Interestingly, the above studies from Italy and Spain have led to speculations that the SARS-CoV-2 may have existed worldwide BEFORE its emergence in Wuhan, China, and it is a UK conservative paper The Telegraph which highlights the story: "Exclusive: COVID-19 may not have originated in China", Oxford University expert believes: Senior CEBM (Centre for Evidence-Based Medicine, Oxford) tutor Dr Tom Jefferson believes many viruses lie dormant throughout the globe and emerge when conditions are favorable (...).
In Australia, Collaboration on Sewage Surveillance of SARS-CoV-2 Project WaterRA is leading an innovative, and collaborative Australia-wide investigation that aims to integrate reliable results of sewage testing for the SARS-CoV-2 virus with health data for COVID-19 on a national basis. The ColoSSoS Project – Collaboration on Sewage Surveillance of SARS-COV-2 — will track and monitor the presence of the virus that causes COVID-19 and its persistence in the Australian sewerage network, thus providing information on where it is present in the population. 
In the USA, New York City Considers Testing Sewage for Coronavirus Analysis of wastewater could serve as an early detection system and get ahead of outbreaks. In Cleveland, Testing poop at wastewater treatment plants could help predict coronavirus outbreaks, research says.  Colorado sewage treatment plants are examining poop for coronavirus clues. Humans begin to shed coronavirus in their feces within three days of infection, which could provide a heads up on outbreaks. SARS-CoV-2 RNA concentrations in primary municipal sewage sludge as a leading indicator of COVID-19 outbreak dynamics (USA metropolitan area- editor's note). "We report a time course of SARS-CoV-2 RNA concentrations in primary sewage sludge during the Spring COVID-19 outbreak in a northeastern U.S. metropolitan area. SARS-CoV-2 RNA was detected in all environmental samples, and when adjusted for the time lag, the virus RNA concentrations tracked the COVID-19 epidemiological curve"

In the Netherlands, The Dutch Association Innovative Medicines (VIG), the Dutch Generic and Biosimilar Medicines Association (BOGIN), the European Water Stewardship (EWS) and AMR Insights have taken the initiative to establish a Dutch Public-Private Consortium with the aim to support technological solutions and innovation capacity to reduce emissions from antibiotic waste streams. The Consortium targets hospitals, wastewater treatment plants, and manufacturing plants within and outside the European Union including countries such as China, India, and other LMIC’s.
In the short term, the action-oriented Consortium will access and provide existing technologies. In the long term, the Consortium will make available highly innovative, more affordable solutions resulting from current and newly initiated research and development work.
The Consortium will connect to and embed in existing, leading global structures. The objective of the Consortium is to reduce the antibiotic emissions with the overarching aim of adding to the global curbing of Antimicrobial resistance (AMR).

In Finland, The Finnish Institute for Health and Welfare; Coronavirus found in wastewater in Helsinki and Turku but not at other sites monitored weekly. The collection of samples began in April at a total of 28 sewage treatment plants. For the time being, samples are collected weekly at treatment plants in Helsinki, Turku, Tampere, Kuopio, and Oulu. In addition, samples will be collected on a monthly basis in (listing of 20 localities)...The sample collection has got off to a good start, and the treatment plants have welcomed the study.

Our ongoing work

This autumn the AMR Think-Do-Tank will produce a dossier with the world's leading experts on the theme "AMR & the ENVIRONMENT, a Global Health Security Issue”, a project launched at EDAR2019 in Hong Kong and which was premonitory since we had included the theme of GHS issue long before the SARS-CoV-2 virus appeared. So, naturally, we will include COVID-19 in wastewater in the topics covered.

Last but not least, a 6 year old girl also sent us her last work on AMR and we are pleased to share it:

boston COVID.png

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Written by the editorial team of The Brief.

Garance F. Upham

Arno Germond