Wastewater Surveillance for Disease Epidemiology

Embracing the Chaos and the Uncertainties





Wastewater-based epidemiological surveillance (WBE) showed the potential to become a pivotal public health tool for measuring community disease burden during the COVID-19 pandemic. Many countries used WBE as part of their national disease surveillance to inform on the optimal deployment of public health measures. In India, civil society groups, research institutions, and private companies across various urban areas also demonstrated the utility of WBE in assessing community burden. While the European Union has recently begun to craft policies for the integration of WBE into a global surveillance network, many countries (including India) do not have a national policy to enable such integration. This paper argues for a national wastewater surveillance system for India, covering community-level assessment of various public health threats, along with integration of data from urban marginalised populations, to promote health equity and facilitate OneHealth-based thinking of disease emergence and spread. The paper outlines WBE efforts around the world, highlights its advantages as a cost-effective tool to supplement rather than supplant existing frameworks, and makes a case for its implementation in India, along with recommendations for next steps towards such implementation. The effective use of WBE should help India identify areas of emerging health threats, prepare for future infectious disease outbreaks, and allocate resources according to population requirements.


Wastewater surveillance, Public health, disease surveillance, IDSP


Download data is not yet available.

Authors Bio

Shambhavi Naik, Takshashila Institution

Shambhavi Naik, PhD, is the Head of Research at Takshashila and is the chairperson of the Advanced Biology programme.

Shyamala T, Takshashila Institution

Shyamala T is a research assistant at the Takshashila Institution

Varsha Shridhar, Molecular Solutions Care Health LLP

Varsha Shridhar is a molecular biologist and public health diagnostician


Ampuero Manuel, Martínez-Valdebenito Costanza, Ferrés Marcela, Soto-Rifo Ricardo, Gaggero Aldo. “Monkeypox Virus in Wastewater Samples from Santiago Metropolitan Region, Chile” Emerging Infectious Diseases. 2023;29(11):2358-2361. doi:10.3201/eid2911.230096.

Ansari, Nadia, Furqan Kabir, Waqasuddin Khan, Farah Khalid, Amyn A. Malik, Joshua L. Warren, Usma Mehmood, et al. “Environmental Surveillance for COVID-19 Using SARS-CoV-2 RNA Concentration in Wastewater – a Study in District East, Karachi, Pakistan.” The Lancet Regional Health - Europe, October 1, 2023, 100299. https://doi.org/10.1016/j.lansea.2023.100299.

Benschop Kimberley SM, van der Avoort Harrie G, Jusic Edin, Vennema Harry, van Binnendijk Rob, and Duizer Erwin. “Polio and Measles Down the Drain: Environmental Enterovirus Surveillance in the Netherlands, 2005 to 2015” Appl Environ Microbiol. 2017 Jun 16;83(13):e00558-17. doi: 10.1128/AEM.00558-17. PMID: 28432101; PMCID: PMC5478994.

Bloom, Henry H, Mack WN, Krueger Brian J, and Mallmann, WL “Identification of Enteroviruses in Sewage” The Journal of Infectious Diseases 105, no. 1 (July 1, 1959): 61–68. https://doi.org/10.1093/infdis/105.1.61.

Census of India, 2011.

Centazzo, Nicole, Bonnie-Marie Frederick, Alethea Jacox, Shu‐Yuan Cheng, and Marta Concheiro. “Wastewater Analysis for Nicotine, Cocaine, Amphetamines, Opioids and Cannabis in New York City.” Forensic Sciences Research 4, no. 2 (April 3, 2019): 152–67. https://doi.org/10.1080/20961790.2019.1609388.

Centers for Disease Control and Prevention. “National Wastewater Surveillance System,” March 14, 2023. https://www.cdc.gov/nwss/wastewater-surveillance.html#:~:text=In%20response%20to%20the%20COVID,samples%20collected%20across%20the%20country.

Environment and Climate Change. “Wastewater Surveillance for COVID-19 Virus - Environment and Climate Change.” Environment and Climate Change -, October 17, 2023. https://www.gov.nl.ca/ecc/waterres/wastewater-surveillance-for-covid-19-virus/.

Fergus, A. “On the Sanitary Aspect of the Sewage Question; with Remarks on a Little-Noticed Cause of Typhoid Fever, and Other Zymotics” Edinb Med J. 1872 Feb;17(8):717-733. PMID: 29639974

Gawlik Bernd M, Tavazzi Simona, Mariani Giulio, Skejo Helle, Sponar Michel, Higgins Trudy, Medema Gertjan, Wintgens Thomas. “SARS-CoV-2 Surveillance employing Sewers Towards a Sentinel System, Feasibility assessment of an EU approach” EUR 30684 EN, Publications Office of the European Union, Luxembourg, 2021, ISBN 978-92-76-36888-5, doi:10.2760/300580, JRC125065.

Girón-Guzmán, Inés, Azahara Díaz-Reolid, Pilar Truchado, Albert Carcereny, David García-Pedemonte, Bruno Hernáez, Albert Bosch, et al. “Spanish Wastewater Reveals the Current Spread of Monkeypox Virus.” Water Research 231 (March 1, 2023): 119621. https://doi.org/10.1016/j.watres.2023.119621.

Global Wastewater Conference, Maarten de Jong, GGD, Using passive samplers in sewage to monitor a Hepatitis A outbreak at an Amsterdam school, poster presentation at the Global Wastewater Conference, 2023

Hawksley, T. “Proposal for the Drainage of London” Sanit Rev J Public Health. 1857 Apr;3(9):28-36. PMID: 30378959; PMCID: PMC5981566.

Hemalatha, M., Kiran Uday, Kuncha Santosh Kumar, Kopperi Harishankar Gokulan, CG, S. Venkata Mohan, and Mishra Rakesh. “Surveillance of SARS-CoV-2 Spread Using Wastewater-Based Epidemiology: Comprehensive Study.” Science of the Total Environment 768 (May 1, 2021): 144704. https://doi.org/10.1016/j.scitotenv.2020.144704.

Hendriksen, René S., Patrick Munk, Patrick Murigu Kamau Njage, Bram a. D. Van Bunnik, Luke McNally, Oksana Lukjancenko, Timo Röder, et al. “Global Monitoring of Antimicrobial Resistance Based on Metagenomics Analyses of Urban Sewage.” Nature Communications 10, no. 1 (March 8, 2019). https://doi.org/10.1038/s41467-019-08853-3.

Huang, Yue, Nan Zhou, Shihan Zhang, Youqin Yi, Ying Han, Minqi Liu, Han Yue-Hong, et al. “Norovirus Detection in Wastewater and Its Correlation with Human Gastroenteritis: A Systematic Review and Meta-Analysis.” Environmental Science and Pollution Research 29, no. 16 (January 19, 2022): 22829–42. https://doi.org/10.1007/s11356-021-18202-x.

IA.PHP Indian Alliance for Public Health Preparedness, n.d. http://www.esallianceforpublichealth.org/ last accessed 02, Dec, 2023.

Ishtiaq, Farah. “India Must Scale up Wastewater Analysis for Health Surveillance.” Nature, December 15, 2022. https://doi.org/10.1038/d44151-022-00130-5.

Keshaviah, Aparna, Megan B. Diamond, Matthew J. Wade, Samuel V. Scarpino, Warish Ahmed, Fabian Amman, Olusola Aruna, et al. “Wastewater Monitoring Can Anchor Global Disease Surveillance Systems.” The Lancet Global Health 11, no. 6 (June 1, 2023): e976–81. https://doi.org/10.1016/s2214-109x(23)00170-5.

Kumar, Manish, Arbind Kumar Patel, Ankit Shah, Janvi Raval, Neha Rajpara, Madhvi Joshi, and Chaitanya Joshi. “First Proof of the Capability of Wastewater Surveillance for COVID-19 in India through Detection of Genetic Material of SARS-CoV-2.” Science of the Total Environment 746 (December 1, 2020): 141326. https://doi.org/10.1016/j.scitotenv.2020.141326.

Link‐Gelles, Ruth, Emily Lutterloh, Patricia Schnabel Ruppert, P. Bryon Backenson, Kirsten St George, Eli S. Rosenberg, Bridget J. Anderson, et al. “Public Health Response to a Case of Paralytic Poliomyelitis in an Unvaccinated Person and Detection of Poliovirus in Wastewater — New York, June–August 2022.” Morbidity and Mortality Weekly Report 71, no. 33 (August 19, 2022): 1065–68. https://doi.org/10.15585/mmwr.mm7133e2.

Medema, Gertjan, Leo Heijnen, Goffe Elsinga, Ronald Italiaander, and Anke Brouwer. “Presence of SARS-Coronavirus-2 RNA in Sewage and Correlation with Reported COVID-19 Prevalence in the Early Stage of the Epidemic in The Netherlands.” Environmental Science and Technology Letters 7, no. 7 (May 20, 2020): 511–16. https://doi.org/10.1021/acs.estlett.0c00357.

Musehold, P. "Uber die Widerstand flahigkeit der mit dem Lungenauswurf - herausbeforderten Tuberkelbazillen im Abwassern, im Flusswasser und im Kultiverten Boden.'' Arb. Kaiserl. Gesundh., 1900, 17, 56

Naughton, Colleen C, Holm, Rochelle H, Lin, Nancy J, James, Brooklyn P, and Smith, Ted, "Online dashboards for SARS-CoV-2 wastewater data need standard best practices: An environmental health communication agenda" J Water Health. 2023 May;21(5):615-624. doi: 10.2166/wh.2023.312. PMID: 37254909.

Ndiaye, AK, Diop PAM, Diop OM, “Environmental surveillance of poliovirus and non-polio enterovirus in urban sewage in Dakar, Senegal (2007-2013)” Pan Afr. Med. J., 19 (2014), p. 243, 10.11604/pamj.2014.19.243.3538

Newton, Ryan J., Sandra L. McLellan, Deborah K. Dila, Joseph H. Vineis, Hilary G. Morrison, A. Murat Eren, and Mitchell L. Sogin. “Sewage Reflects the Microbiomes of Human Populations.” MBio 6, no. 2 (May 1, 2015). https://doi.org/10.1128/mbio.02574-14.

Phalkey, R.K., Shukla, S., Shardul, S. et al. Assessment of the core and support functions of the Integrated Disease Surveillance system in Maharashtra, India. BMC Public Health 13, 575 (2013). https://doi.org/10.1186/1471-2458-13-575

Playter, E. “Our Inland Lakes and Rivers, the Disposal of Sewage, and the Spread of Infectious Diseases.” Public Health Pap Rep. 1886;12:123-32. PMID: 19600265; PMCID: PMC2266144

Prasad, R. “Wastewater Study Detects a Large, Silent Wave in Bengaluru.” The Hindu, May 6, 2023. https://www.thehindu.com/sci-tech/wastewater-study-detects-a-large-silent-wave-in-bengaluru/article66816590.ece.

Priyadarshini, Subhra. “India’s Sewage Surveillance for SARS-CoV-2 Going down the Drain.” Nature India, May 21, 2021. https://doi.org/10.1038/nindia.2021.75.

Rajput, Vinay, Rinka Pramanik, Vinita Malik, Rakeshkumar Yadav, Rachel Samson, Pradnya Kadam, Unnati Bhalerao, et al. “Genomic Surveillance Reveals Early Detection and Transition of Delta to Omicron Lineages of SARS-CoV-2 Variants in Wastewater Treatment Plants of Pune, India.” Environmental Science and Pollution Research, November 3, 2023. https://doi.org/10.1007/s11356-023-30709-z.

Riordan, J T. “The 1961 Middletown Oral Poliovirus Vaccine Program. IX. Isolation of enteroviruses from sewage before and after vaccine administration.” The Yale journal of biology and medicine vol. 34,5 (1962): 512-21

SAMRC. “SARS-COV-2 Wastewater Surveillance Dashboard,” n.d. https://www.samrc.ac.za/wbe/.

Takuissu, Guy Roussel, Sébastien Kenmoe, Lucy Ndip, Jean Thierry Ebogo‐Belobo, C Kengne-Ndé, Donatien Serge Mbaga, Arnol Bowo‐Ngandji, et al. “Hepatitis E Virus in Water Environments: A Systematic Review and Meta-Analysis.” Food and Environmental Virology 14, no. 3 (August 29, 2022): 223–35. https://doi.org/10.1007/s12560-022-09530-

Sutton, Robert I., and Huggy Rao. Scaling Up Excellence: Getting to More Without Settling for Less. National Geographic Books, 2014.

Tandukar, Sarmila, Niva Sthapit, Ocean Thakali, Bikash Malla, Samendra P. Sherchan, Bijay Man Shakya, Laxman Shrestha, et al. “Detection of SARS-CoV-2 RNA in Wastewater, River Water, and Hospital Wastewater of Nepal.” Science of the Total Environment 824 (June 1, 2022): 153816. https://doi.org/10.1016/j.scitotenv.2022.153816.

Tlhagale, Mamohloding, Stanley Liphadzi, Jay Bhagwan, V. Naidoo, Jonas Korlach, Lani Van Vuuren, Gertjan Medema, et al. “Establishment of Local Wastewater-Based Surveillance Programmes in Response to the Spread and Infection of COVID-19 – Case Studies from South Africa, the Netherlands, Turkey and England.” Journal of Water and Health 20, no. 2 (February 1, 2022): 287–99. https://doi.org/10.2166/wh.2022.185.

Tiwari, Satya Brat, Pallavi Gahlot, Vinay Kumar Tyagi, Liang Zhang, Yan Zhou, A.A. Kazmi, and Manish Kumar. “Surveillance of Wastewater for Early Epidemic Prediction (SWEEP): Environmental and Health Security Perspectives in the Post COVID-19 Anthropocene.” Environmental Research 195 (April 1, 2021): 110831. https://doi.org/10.1016/j.envres.2021.110831.

Tran HN, Le GT, Nguyen DT, Juang RS, Rinklebe J, Bhatnagar A, Lima EC, Iqbal HMN, Sarmah AK, Chao HP. SARS-CoV-2 coronavirus in water and wastewater: A critical review about presence and concern. Environ Res. 2021 Feb;193:110265. doi: 10.1016/j.envres.2020.110265. Epub 2020 Oct 1. PMID: 33011225; PMCID: PMC7528884.

UK Government. “EMHP Wastewater Monitoring of SARS-CoV-2 in England: 1 June 2021 to 7 March 2022,” March 31, 2022. https://www.gov.uk/government/publications/monitoring-of-sars-cov-2-rna-in-england-wastewater-monthly-statistics-1-june-2021-to-7-march-2022/emhp-wastewater-monitoring-of-sars-cov-2-in-england-1-june-2021-to-7-march-2022#:~:text=The%20EMHP%20team%20coordinates%20with,see%20figures%201%20to%209.

“Virus Particles in Wastewater | Coronavirus Dashboard | Government.Nl,” December 8, 2022. https://coronadashboard.government.nl/landelijk/rioolwater.

Wannigama, Dhammika Leshan, Mohan Amarasiri, Phatthranit Phattharapornjaroen, Cameron Hurst, Charin Modchang, Sudarat Chadsuthi, Suparinthon Anupong, et al. “Tracing the New SARS-CoV-2 Variant BA.2.86 in the Community through Wastewater Surveillance in Bangkok, Thailand.” Lancet Infectious Diseases, October 1, 2023. https://doi.org/10.1016/s1473-3099(23)00620-5.

WastewaterSCAN. “Home - Wastewater Talks. We Listen.,” October 24, 2023. https://www.wastewaterscan.org/en?gclid=Cj0KCQiAjMKqBhCgARIsAPDgWlwC3H1BeQr9vYGBFE021s6ltPpEzzp0aPWUMjhz6c4xMzGfY5jdMsEaAsbUEALw_wcB&utm_medium=search&utm_content=adgroup2&utm_source=google&utm_campaign=wastewaterscan.3.

WHO, n.d. https://www.afro.who.int/news/how-wastewater-surveillance-helping-covid-19-fight

Wilson, W J. “Isolation of Enteric Bacilli from sewage and water and its bearing on epidemiology” British medical journal vol. 2,3794 (1933): 560-2. doi:10.1136/bmj.2.3794.560

Yoo, Byung-Kwang, Ryo Iwamoto, Ung‐il Chung, Tomoko Sasaki, and Masaaki Kitajima. “Economic Evaluation of Wastewater Surveillance Combined with Clinical COVID-19 Screening Tests, Japan.” Emerging Infectious Diseases 29, no. 8 (August 1, 2023). https://doi.org/10.3201/eid2908.221775.

Zhang, Ying, Kongquan Zhu, Weixin Huang, Ziyue Guo, Senhua Jiang, Cao Zheng, and Yang Yu. “Can Wastewater Surveillance Assist China to Cost-Effectively Prevent the Nationwide Outbreak of COVID-19?” Science of the Total Environment 829 (July 1, 2022): 154719. https://doi.org/10.1016/j.scitotenv.2022.154719.