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Wastewater surveillance enables tracking infectious disease dynamics and community prevalence quantification for public health. However, the testing requirement of centralized laboratories and well-trained staff challenges underserved areas and low-resource settings. The development of new rapid and low-cost sensors enables in-field testing of wastewater from the community to the individual building levels for early warning of pandemics.

Wastewater-based epidemiology WBE has shown to be an innovative and promising tool for the estimation of community-wide health such as drugs, alcohol, and tobacco use in the past couple of decades since it was proposed in the beginning of 21 centuries. Since the first report from the Netherland in March 2020 on the presence of viral RNA fragment of SARS-CoV-2 in wastewater, WBE, also namely, wastewater surveillance, has been rapidly emerged as a new public health tool for the monitoring of pathogens to establish the early warning for the pandemic, which can provide the complementary data sets for the clinical testing. For example, viral RNA of SARS-CoV-2 can be monitored in the community at the early stage, effective measures can be taken as early as possible to minimize the pathogen spread.

Public health is attracting increasing attention due to the current global pandemic, and wastewater-based epidemiology (WBE) has emerged as a powerful tool for monitoring of public health by analysis of a variety of biomarkers (e.g., chemicals and pathogens) in wastewater. Rapid development of WBE requires rapid and on-site analytical tools for monitoring of sewage biomarkers to provide immediate decision and intervention. Biosensors have been demonstrated to be highly sensitive and selective tools for the analysis of sewage biomarkers due to their fast response, ease-to-use, low cost and the potential for field-testing. This paper presents biosensors as effective tools for wastewater analysis of potential biomarkers and monitoring of public health via WBE. In particular, we discuss the use of sewage sensors for rapid detection of a range of targets, including rapid monitoring of community-wide illicit drug consumption and pathogens for early warning of infectious diseases outbreaks. Finally, we provide a perspective on the future use of the biosensor technology for WBE to enable rapid on-site monitoring of sewage, which will provide nearly real-time data for public health assessment and effective intervention.

Wastewater-based epidemiology (WBE) was applied for the first time in seven cities across Europe with the aim of estimating quinolones consumption via the analysis of human urinary metabolites in wastewater. This report is also the first pan-European study focussed on the enantiomeric profiling of chiral quinolones in wastewater. By considering loads of (fluoro)quinolones in wastewater within the context of human stereoselective metabolism, we identified cities in Southern Europe characterised by both high usage and direct disposal of unused ofloxacin. In Northern European cities, S-(-)-ofloxacin loads were predominant with respect to R-(+)-ofloxacin. Much more potent, enantiomerically pure S-(-)-ofloxacin was detected in wastewaters from Southern European cities, reflecting consumption of the enantiomerically pure antibiotic. Nalidixic acid, norfloxacin and lomefloxacin were detected in wastewater even though they were not prescribed according to official prescription data. S,S-(-)-moxifloxacin and S,S-(-)-moxifloxacin-N-sulphate were detected in wastewater due to metabolism of moxifloxacin. For the first time, average population-normalised ulifloxacin loads of 22.3 and 1.5 mg day−1 1000 people−1 were reported for Milan and Castellón as a result of prulifloxacin metabolism. Enrichment of flumequine with first-eluting enantiomer in all the samples indicated animal metabolism rather than its direct disposal. Fluoroquinolone loads were compared with qnrS gene encoding quinolone resistance to correlate usage of fluoroquinolone and prevalence of resistance. The highest daily loads of the qnrS gene in Milan corresponded with the highest total quinolone load in Milan proving the hypothesis that higher usage of quinolones is linked with higher prevalence of quinolone resistance genes. Utrecht, with the lowest quinolones usage (low daily loads) had also one of the lowest daily loads of the qnrS gene. However, a similar trend was not observed in Oslo nor Bristol where higher qnrS gene loads were observed despite low quinolone usage.

The information obtained from the chemical analysis of specific human excretion products (biomarkers) in urban wastewater can be used to estimate the exposure or consumption of the population under investigation to a defined substance. A proper biomarker can provide relevant information about lifestyle habits, health and wellbeing, but its selection is not an easy task as it should fulfil several specific requirements in order to be successfully employed. This paper aims to summarize the current knowledge related to the most relevant biomarkers used so far. In addition, some potential wastewater biomarkers that could be used for future applications were evaluated. For this purpose, representative chemical classes have been chosen and grouped in four main categories: (i) those that provide estimates of lifestyle factors and substance use, (ii) those used to estimate the exposure to toxicants present in the environment and food, (iii) those that have the potential to provide information about public health and illness and (iv) those used to estimate the population size. To facilitate the evaluation of the eligibility of a compound as a biomarker, information, when available, on stability in urine and wastewater and pharmacokinetic data (i.e. metabolism and urinary excretion profile) has been reviewed. Finally, several needs and recommendations for future research are proposed. This work was supported by the COST Action ES1307 “SCORE – Sewage biomarker analysis for community health assessment”. Emma Gracia-Lor is very grateful to Generalitat Valenciana, Conselleria d'Educació, Investigació, Cultura i Esport (APOSTD/2015, Programa VALi + d) for her post-doctoral contract. Lubertus Bijlsma acknowledges NPS-Euronet (HOME/2014/JDRUG/AG/DRUG/7086), co-funded by the European Union, for his post-doctoral fellowship. Erika Castrignanò, Richard Bade, Juliet Kinyua, Pedram Ramin, Nikolaos I. Rousis, Yeonsuk Ryu would like to thank the SEWPROF MC ITN project, ‘A new paradigm in drug use and human health risk assessment: Sewage profiling at the community level’ [grant agreement 317205] supported by the European Union's Seventh Framework Programme for research, technological development and demonstration for the financial support. Iria González-Mariño extends her gratitude to the Galician Council of Culture, Education and Universities for her postdoctoral contract (Plan Galego de Investigación, Innovación e Crecemento 2011–2015). Foon Yin Lai acknowledges her postdoctoral fellowship from the University of Antwerp. Luigi Lopardo, Axel Rydevik and Barbara Kasprzyk-Hordern would like to acknowledge Leverhulme Trust for funding ‘TOX-EDC, Wastewater profiling for community-wide human exposure assessment from environmental endocrine disrupting chemicals in personal care and consumer products’ (Project No: RPG-2013-297). Frederic Been would like to thank the Swiss National Science Foundation (SNF, P2LAP2_164892) for his post-doctoral grant. This publication reflects the views only of the authors, and the European Commission cannot be held responsible for any use which may be made of the information contained therein.

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.

Caffeine metabolites in wastewater were investigated as potential biomarkers for assessing caffeine intake in a population. The main human urinary metabolites of caffeine were measured in the urban wastewater of ten European cities and the metabolic profiles in wastewater were compared with the human urinary excretion profile. A good match was found for 1,7-dimethyluric acid, an exclusive caffeine metabolite, suggesting that might be a suitable biomarker in wastewater for assessing population-level caffeine consumption. A correction factor was developed considering the percentage of excretion of this metabolite in humans, according to published pharmacokinetic studies. Daily caffeine intake estimated from wastewater analysis was compared with the average daily intake calculated from the average amount of coffee consumed by country per capita. Good agreement was found in some cities but further information is needed to standardize this approach. Wastewater analysis proved useful to providing additional local information on caffeine use. (C) 2017 Elsevier B.V. All rights reserved.