Wastewater concentrations of rotavirus RNA are associated with infection and vaccination metrics in the USA – Nature

Report on Rotavirus Surveillance via Wastewater Analysis and its Alignment with Sustainable Development Goals

Executive Summary

This report summarizes a one-year surveillance study of rotavirus RNA in wastewater solids collected from 185 wastewater treatment plants across the United States. The study’s findings demonstrate a strong correlation between wastewater data and clinical infection metrics, identify clear spatiotemporal patterns of rotavirus circulation, and establish a link between markers of vaccination coverage and the duration of viral presence in communities. This surveillance method directly supports several United Nations Sustainable Development Goals (SDGs). Primarily, it advances SDG 3 (Good Health and Well-being) by providing a robust tool to monitor and control a vaccine-preventable disease. Furthermore, it leverages infrastructure central to SDG 6 (Clean Water and Sanitation) and provides critical data to address health disparities, thereby contributing to SDG 10 (Reduced Inequalities). The report concludes that wastewater monitoring is a valuable tool for targeting vaccination campaigns and strengthening public health systems.

Introduction: Public Health Surveillance and the Sustainable Development Agenda

The surveillance of infectious diseases is a cornerstone of public health, directly contributing to the achievement of Sustainable Development Goal 3 (SDG 3): Good Health and Well-being. Rotavirus, a leading cause of diarrheal deaths, poses a significant threat to this goal, particularly for vulnerable populations such as children. Despite the availability of effective vaccines, coverage gaps persist, necessitating innovative surveillance methods to guide public health interventions. This report details a study utilizing wastewater-based epidemiology—a method that leverages sanitation infrastructure (SDG 6: Clean Water and Sanitation)—to monitor rotavirus infections across the United States. The objective was to assess spatiotemporal patterns of the virus and correlate them with vaccination coverage markers, thereby providing a tool to identify health inequalities (SDG 10: Reduced Inequalities) and target vaccination campaigns more effectively.

Methodology

Data Collection and Analysis

1. Sample Collection: Wastewater solids were collected multiple times per week over approximately one year from 185 wastewater treatment plants (WWTPs) across 40 states and the District of Columbia.
2. Laboratory Analysis: Rotavirus RNA concentrations were measured using droplet digital reverse transcription-polymerase chain reaction (ddRT-PCR). Pepper mild mottle virus (PMMoV) RNA was measured and used as a fecal strength normalizer to ensure data comparability.
3. Data Comparison: Wastewater data were systematically compared against:
   • Clinical metrics from the National Respiratory and Enteric Virus Surveillance System (NREVSS) and the Epic Cosmos electronic health record dataset.
   • State and county-level rotavirus vaccination coverage estimates.
   • Sociodemographic characteristics associated with vaccination uptake to identify markers of health disparity.
4. Prevalence Estimation: A mass balance model was employed to estimate the fraction of the population shedding rotavirus, providing an indication of infection prevalence.

Key Findings

Spatiotemporal Occurrence of Rotavirus

• A distinct national winter-spring peak in rotavirus RNA concentrations was observed, aligning with known seasonality and supporting SDG 3 by enhancing epidemic preparedness and forecasting capabilities.
• The seasonal onset of elevated concentrations began in the South and progressed geographically, providing critical data for issuing timely public health alerts in different regions.

Correlation with Clinical and Vaccination Metrics

• Wastewater measurements of rotavirus RNA were significantly correlated with national clinical metrics of infection, validating wastewater as a reliable and comprehensive surveillance tool for tracking community health trends in line with SDG 3.
• WWTP service areas characterized by markers of high vaccination coverage generally experienced a shorter duration of elevated rotavirus concentrations. This finding directly links wastewater data to vaccination efficacy, offering a novel method for identifying communities at risk and advancing SDG 10 by highlighting areas that may require targeted health interventions.

Infection Prevalence and Model Sensitivity

• Estimates of infection prevalence derived from wastewater data were found to be highly uncertain and sensitive to fecal shedding parameters used in the model.
• This highlights a key area for future research to refine quantitative models and improve the precision of wastewater-based epidemiology for public health applications.

Discussion: Implications for Sustainable Development Goals

Advancing Good Health and Well-being (SDG 3)

This study demonstrates that wastewater monitoring is a powerful, non-invasive tool for the surveillance of vaccine-preventable diseases. By providing comprehensive, near real-time data on rotavirus circulation, it strengthens the capacity of public health systems for early warning and response, a key target of SDG 3. It effectively complements traditional clinical surveillance, which is often limited by testing biases, access to healthcare, and reporting delays.

Leveraging Water and Sanitation Infrastructure (SDG 6)

The methodology repurposes existing wastewater treatment infrastructure for public health intelligence. This innovative use of sanitation systems adds significant value beyond environmental protection, showcasing how investments in SDG 6 can yield direct benefits for public health monitoring and disease prevention. This creates a synergistic relationship where progress in one goal directly supports another.

Reducing Health Inequalities (SDG 10)

A critical implication of this research is the ability of wastewater surveillance to help identify and address gaps in vaccination coverage. By correlating longer rotavirus wastewater events with sociodemographic markers of low vaccination, this approach can pinpoint communities that may be underserved by public health programs. This allows for the equitable and targeted deployment of resources, such as mobile vaccination clinics and educational campaigns, directly addressing the SDG 10 target of reducing inequalities in health outcomes.

Building Sustainable and Resilient Communities (SDG 11)

Integrating wastewater surveillance into routine public health practice enhances community resilience to infectious disease outbreaks. This proactive monitoring system provides cities and communities with the data needed to protect their populations, contributing to the creation of safe, healthy, and sustainable living environments as envisioned in SDG 11.

Conclusion and Recommendations

Wastewater monitoring of rotavirus offers a valuable and scalable method for public health surveillance that aligns with and advances multiple Sustainable Development Goals. It provides an unbiased overview of community-level infection dynamics and can effectively identify areas with potential vaccination coverage gaps, thereby informing targeted public health action.

Recommendations:

1. Integrate wastewater surveillance for vaccine-preventable diseases into national public health monitoring frameworks to support the targets of SDG 3.
2. Invest in research to refine models that estimate disease prevalence from wastewater data, improving their accuracy and utility for quantitative risk assessment.
3. Utilize wastewater findings to guide targeted vaccination campaigns and public health outreach in underserved communities, thereby advancing health equity as outlined in SDG 10.
4. Promote the dual use of sanitation infrastructure for both environmental protection and public health surveillance, particularly in low- and middle-income countries, to maximize the impact of investments in SDG 6.

Analysis of Sustainable Development Goals (SDGs) in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article on rotavirus surveillance using wastewater connects to several Sustainable Development Goals (SDGs) by addressing public health, disease prevention, sanitation infrastructure, and health equity.

• SDG 3: Good Health and Well-being

  This is the most central SDG addressed. The entire study focuses on monitoring and understanding the epidemiology of rotavirus, a vaccine-preventable disease that is a “leading cause of diarrheal deaths worldwide, particularly affecting individuals under 5.” The research aims to improve public health surveillance to better target vaccination campaigns and reduce the disease burden.

• SDG 6: Clean Water and Sanitation

  The methodology of the study is fundamentally linked to this goal. The research leverages existing sanitation infrastructure, specifically 185 wastewater treatment plants (WWTPs), as a tool for public health surveillance. This demonstrates an advanced and innovative use of sanitation systems for managing community health, which aligns with the broader objective of safely managed sanitation services.

• SDG 10: Reduced Inequalities

  The article directly addresses health inequalities by investigating how rotavirus occurrence and vaccination coverage vary across different populations. It analyzes how wastewater data correlates with “geographic, sociodemographic, and healthcare characteristics” to identify “populations inadequately covered by vaccines.” This focus on identifying and understanding disparities is a core component of reducing inequalities in health outcomes.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the article’s focus, several specific SDG targets can be identified:

1. SDG 3: Good Health and Well-being

   • Target 3.2: End preventable deaths of newborns and children under 5 years of age.

     The article explicitly states that rotavirus infection is a primary cause of diarrheal deaths in children under five. The study’s goal of improving surveillance to enhance vaccination efforts directly contributes to preventing these deaths.

   • Target 3.3: End the epidemics of… water-borne diseases and other communicable diseases.

     Rotavirus is a communicable, water-borne (via the fecal-oral route) disease. The research provides a novel method for the “continued surveillance of infections” to understand its epidemiology and control its spread, which is essential for ending epidemics.

   • Target 3.8: Achieve universal health coverage, including… access to… essential… vaccines for all.

     The article highlights that rotavirus “vaccines are underutilized in the USA,” with coverage (75.1%) falling “below the Healthy People 2020 target of 80%.” By identifying areas with low vaccination coverage, the study aims to inform targeted campaigns to improve vaccine access and uptake, moving closer to universal coverage.

   • Target 3.d: Strengthen the capacity of all countries… for early warning, risk reduction and management of national and global health risks.

     The study’s core proposal is that “wastewater monitoring of vaccine-preventable diseases is valuable for informing where vaccination campaigns should be targeted.” This establishes wastewater surveillance as a powerful tool for early warning and managing the health risks associated with rotavirus outbreaks.

2. SDG 6: Clean Water and Sanitation

   • Target 6.3: Improve water quality by… halving the proportion of untreated wastewater.

     The study’s methodology relies on the collection of samples from 185 WWTPs across the United States. The existence and operation of this extensive wastewater treatment infrastructure, which is necessary for the surveillance, is a direct reflection of progress towards this target.

3. SDG 10: Reduced Inequalities

   • Target 10.2: Empower and promote the social, economic and political inclusion of all, irrespective of… economic or other status.

     The research identifies that longer “wastewater event durations” are associated with markers of lower vaccination coverage, which are in turn linked to sociodemographic factors. The article notes a “moderate effect size for Black or African American children, uninsured children, and children born to younger mothers.” By providing a tool to pinpoint these health disparities, the study supports efforts to create more equitable public health interventions.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article mentions or implies several quantitative and qualitative indicators that can measure progress:

• Indicators for SDG 3

  • Incidence of Rotavirus: The article uses several metrics as proxies for disease incidence, including “clinical metrics of infection,” “rotavirus test positivity rate,” and the “proportion of patients with a rotaviral enteritis encounter diagnosis.” The concentration of rotavirus RNA in wastewater is itself proposed as a new, less-biased indicator of community-level disease occurrence.
  • Vaccination Coverage Rate: This is a direct indicator mentioned in the article. It cites the “estimated rotavirus vaccination coverage was 75.1% in the 2020–2021 birth cohort,” which can be tracked over time to measure progress towards universal health coverage (Target 3.8).
  • Duration of Disease Outbreaks: The study introduces the “rotavirus wastewater event duration” as a key metric. The finding that this duration is “shorter in sewersheds with markers of high rotavirus vaccination coverage” suggests that a reduction in this duration can serve as an indicator of effective public health interventions.

• Indicators for SDG 6

  • Wastewater Treatment Capacity: The study’s network of “185 WWTPs across 40 states and the District of Columbia” serves as an implicit indicator of the proportion of wastewater being collected and treated, which is fundamental to Target 6.3.

• Indicators for SDG 10

  • Health Disparities by Sociodemographic Group: The article measures and compares wastewater event durations across tertiles of various population characteristics, such as “publicly insured children,” “children below poverty,” and racial groups (“Black or African American children”). These comparisons serve as indicators of health inequality, and reducing the differences between these groups would indicate progress.

4. Table of SDGs, Targets, and Indicators

Source: nature.com