key: cord-0695078-htkcg0m2 authors: Mao, Kang; Zhang, Kuankuan; Du, Wei; Ali, Waqar; Feng, Xinbing; Zhang, Hua title: The potential of wastewater-based epidemiology as surveillance and early warning of infectious disease outbreaks date: 2020-05-11 journal: Curr Opin Environ Sci Health DOI: 10.1016/j.coesh.2020.04.006 sha: af81b47cf0805ceeb123c49b647dc778e334c5c8 doc_id: 695078 cord_uid: htkcg0m2 Infectious diseases caused by pathogens have become one of the main threats to public health. Efficient monitoring of infectious disease transmission is critical to prevent and manage infectious disease epidemics. Wastewater-based epidemiology (WBE) is an efficient approach with great potential for early warning of infectious disease transmission and outbreaks. By analysing infectious disease biomarkers in wastewater taken from wastewater collection points, the transmission of infectious diseases in certain areas can be comprehensively monitored in near real time. This short review presents WBE as a surveillance and early warning system for infectious disease outbreaks regarding pathogens with pandemic potential. We also discuss the challenges and perspective of WBE in infectious disease surveillance and early warning. Recently, the novel pneumonia caused by the novel coronavirus 28 (SARS-CoV-2) has rapidly spread worldwide and become a pandemic, despite 29 city-wide quarantines and travel bans in many countries [1] . By April 15, 2020, Integral components of public health include strengthening the supervision of 36 infectious diseases, realizing early warning and preventing infectious disease 37 pandemics, especially emerging infectious diseases. There are many technologies to 38 surveil the spatial-temporal characteristics of infectious diseases, such as sentinel 39 surveillance, clinical-based surveillance, questionnaires or surveys, hospital admission 40 data, mortality and morbidity rates, which hold great significance for infectious 41 disease surveillance [4] . However, most of these approaches depend on acquired data 42 and information, such as incidence and mortality rates, prescription data and 43 hospitalization information, and herein, most of these systems are passive monitoring 44 forms. Therefore, these techniques are subject to bias, resource insensitivity, detection 45 blindness and high cost [5] . Taking countries with limited health services as an 46 example, the incidence rate may be higher than the assumed value due to a lack of 47 access to health services [6] . There are blind areas for epidemic monitoring using 48 traditional techniques. Because infectious disease testing is not available to everyone, 49 potential patients and asymptomatic patients cannot be effectively counted and 50 monitored, leading to an unknown extent of the spread. For example, it has been reported 51 that approximately 60% of asymptomatic or mild SARS-CoV-2 infections may lead to a 52 second outbreak [7] . Sometimes in serious epidemics, laboratory facilities are easily 53 overburdened, and many cases are not reported. In addition, with the acceleration of 54 global urbanization and the unprecedented growth in population, higher requirements 55 are proposed for rapid health monitoring and response, which undoubtedly poses a 56 challenge to the existing infectious disease monitoring and management system. 57 Therefore, novel monitoring and management approaches are needed for the 58 prevention and early warning of infectious diseases. These technologies should be 59 flexible, cost effective and scalable and should provide comprehensive and objective 60 data in real time. Meanwhile, they also need to monitor multiple diseases, even rare 61 diseases, in limited resource settings. Considering the current insufficient clinical and 62 laboratory information [8] , it is valuable to provide a novel surveillance and early 63 warning techniques to compensate for the shortcomings of traditional tools/methods 64 and to provide comprehensive and timely population exposure and disease results. Recently, wastewater-based epidemiology (WBE), which can provide objective and 66 comprehensive real-time assessments of public and environmental health status, has 67 developed rapidly. As an effective health assessment approach, WBE has great potential for the 69 prevention and early warning of infectious disease outbreaks for public health. Therefore, we first briefly introduce the principle of WBE and its wide application. to key aspects of infectious disease information. In addition, not only can the 122 spatial-temporal trends be determined but this information can also be monitored in In addition, the ultimate goal of WBE is to achieve on-site monitoring and provide 207 real-time data, which is also a guarantee of using WBE to provide early warning 208 timeliness of infectious disease outbreaks. Analytical tools are required for simple, 209 rapid, cost-effective, sensitive, selective and multi-target analysis. The latest 210 developments in sensor methods make field measurements possible so that the system 211 can provide real-time infectious disease and public health information (see Figure 2 ). 212 We also propose tracing COVID sources using an inexpensive and efficient 213 paper-based biosensor [43] . At present, the research in this area is relatively weak, and only a few scientists have performed related studies [21] . This is an important 215 challenge for WBE with a wide application of early warning of infectious diseases, 216 and many more scientists should focus on this technical limitation in the future. biomarker concentration must also be within a certain range to detect biomarkers in 226 wastewater downstream [44] . Another important feature is that biomarkers must be 227 stable, not only in wastewater systems but also during sampling and storage [45] . 228 Therefore, it is important to find suitable biomarkers for specific infectious diseases It is generally believed that an effective monitoring system is the key to quickly 2. 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Towards finding a 389 population biomarker for wastewater epidemiology studies 392 Critical review on the stability of illicit drugs in sewers and wastewater samples Sewage-based Epidemiology Requires a Truly 396 Transdisciplinary Approach Ammonium in Wastewater-Based Epidemiology: Application to Illicit Drug Monitoring Sewage epidemiology -A real-time approach to estimate the consumption of illicit drugs 402 in Brussels Sampling for Pharmaceuticals and Personal 408 Care Products (PPCPs) and Illicit Drugs in Wastewater Systems: Are Your Conclusions 409 Valid? A Critical Review This work is supported by STS of CAS (KFJ-STS-QYZD-185). The authors declare no competing financial interest.