Wastewater-based epidemiology: current uses and future opportunities as a public health surveillance tool

Wastewater-based epidemiology (WBE) seeks to use biological or chemical indicators in sewage to provide information on the overall health of a community. This paper provides an overview of the range of applications of WBE over the past two decades, how it has been used to inform public health responses, and considerations for more integrated approaches to WBE based on a review of the literature. The review finds that WBE has been used extensively around the world for the estimation of consumption patterns of illicit drugs and other substances, but a range of novel applications also exist. As a result of the COVID-19 pandemic, many communities used WBE for the first time as a complementary public health surveillance tool, monitoring trends in SARS-CoV-2 prevalence in large cities, and for micro-surveillance on a more targeted level. WBE may continue to be a useful public health surveillance tool in the future; however, several limitations and challenges exist. Consideration of how information obtained through WBE can be used to inform public health responses is essential to understanding the potential costs and benefits compared with conventional public health surveillance techniques.