The COVID-19 pandemic highlighted an urgent need for innovative, scalable, and non-invasive tools to monitor public health and track disease spread. Wastewater-based Epidemiology (WBE) emerged as a valuable method during the pandemic, serving as an early warning system for tracking viral trends. Having had the opportunity to work on COVID-19 wastewater surveillance in Pune with CSIR-NCL, IISER and Pune Knowledge Cluster; I observed the effectiveness of this approach firsthand. The potential of WBE, however, extends far beyond COVID-19. With applications across multiple infectious diseases, WBE offers a cost-effective, proactive solution for public health surveillance that could have transformative benefits for India’s metro cities.
Surveillance of Critical Diseases Using WBE
Countries around the world have demonstrated the versatility of WBE to monitor other critical diseases. Examples include:
Poliovirus Surveillance in Israel: WBE has been used in several countries to monitor poliovirus and hepatitis E, especially in regions where clinical testing coverage is sparse thereby helping authorities contain outbreaks before they spread. In 2013, Israel identified traces of poliovirus in wastewater, enabling pre-emptive action and avoiding an outbreak.
Influenza Monitoring in the Netherlands: Tracking influenza variants through wastewater can offer timely insights, potentially months in advance of clinical reports, helping prevent seasonal flu outbreaks. Dutch researchers have used WBE to monitor influenza trends, providing real-time data that is crucial for guiding public health responses, especially during flu season.
Antibiotic Resistance Tracking in Sweden: As antibiotic resistance grows into a major global health threat, WBE could be used to monitor resistance patterns, helping guide public health interventions and antibiotic stewardship efforts. The technique is non-intrusive, cost-effective, and scalable—qualities that make it particularly suited for long-term public health surveillance. Sweden has pioneered using WBE to identify hotspots of antibiotic-resistant bacteria, offering insights into resistance patterns and allowing for targeted interventions to manage antibiotic resistance.
These global examples showcase how WBE can monitor a range of pathogens, from viruses to bacteria, positioning it as a powerful tool for comprehensive health monitoring.
Why India’s Metro Cities Should Invest in WBE
India’s high-density urban centres face unique challenges in disease surveillance. Clinical testing infrastructure often struggles to cover vast populations effectively, particularly in metro cities with dense communities and diverse health needs. WBE offers a solution: it provides early insights into community health trends without requiring individual testing. For resource-limited settings, WBE offers the dual advantages of cost savings and population-wide reach, enabling health authorities to detect outbreaks early, guide targeted interventions, and allocate healthcare resources efficiently.
Adopting WBE across India’s metros would empower health authorities to track disease trends in real-time, guide targeted interventions, and allocate healthcare resources more effectively. For India, with its diverse urban landscape and dense population, WBE represents a scalable, inclusive approach to safeguarding public health.
The Future of WBE in India: Partnership and Implementation
The future of WBE lies in its potential to become an integral part of India’s public health infrastructure. By establishing wastewater testing as a routine part of our health surveillance system, India can be better prepared to face future pandemics and health crises. The expansion of WBE requires strong partnerships among utility operators, research laboratories, and academic institutions.
Utility Operators: Municipal water and wastewater utilities play a vital role in sample collection. They can facilitate a comprehensive surveillance network across metro cities by ensuring that wastewater samples are consistently collected from a range of urban areas.
Research Laboratories: Laboratories provide the analytical capabilities needed to interpret wastewater samples accurately. They offer real-time data analysis, which can be used to monitor health trends and provide actionable insights for public health authorities.
Academic Institutions: Universities and research institutions can drive the innovation required to improve WBE technology. By enhancing detection sensitivity and refining data interpretation techniques, academia plays a crucial role in advancing WBE’s effectiveness.
Each stakeholder stands to benefit uniquely from this collaboration. Utility operators enhance public health outcomes in communities, research laboratories contribute crucial data, and academic institutions engage in impactful, societally beneficial research. Together, they form the backbone of a sustainable, citywide health monitoring system. The significant co benefit here which tends to be easily looked over is that the students from different discipline can get to work upon impact research while working in the industry with the industry experts. This not only helps them to realize the true potential of the education they receive during their academic endeavour but also brings them closer to develop passion for professional career.
Economic Benefits: Cost Savings in Public Health
Investing in WBE offers long-term economic benefits. When an epidemic strikes, the costs to national economies are immense, including lost productivity, treatment expenses, and the social burden of disease measured in Disability-Adjusted Life Years (DALY).
A study in PLOS One (2018) suggested that the economic cost of seasonal influenza (direct and indirect costs) in India could be in the range of US$ 1.5 to 2 billion annually. This includes lost working days, healthcare costs, and the cost of treating complications associated with influenza, such as pneumonia.
A study published in The Lancet Infectious Diseases (2020) estimated that influenza contributes to a significant number of DALYs in India. Seasonal influenza results in an estimated 10 to 20 million DALYs annually in India. This encompasses both the burden from direct illness (e.g., hospitalizations and deaths) and the broader social and economic impact of lost productivity and increased healthcare utilization.
WBE can detect early signs of a viral outbreak before clinical cases are reported, enabling health authorities to mobilize resources and prevent widespread infection. The cost of WBE infrastructure is significantly lower than the cost of managing an unchecked epidemic. With WBE-driven early warning capabilities, India’s metros can avoid the spiralling economic burdens associated with late intervention, including extensive healthcare costs, workforce productivity loss, and prolonged disease impact on communities.
A Shield Against Future Pandemics
Surveillance data collected within a city does not reach its full potential unless it is shared with other cities at national and global level. Global collaboration on wastewater surveillance can transform WBE into an international defence mechanism against pandemics. By sharing WBE data, countries can identify transnational disease spread patterns and act faster on potential outbreaks. As COVID-19 illustrated, infectious diseases know no borders. An interconnected global WBE network would provide the early warning signals necessary to contain diseases before they reach pandemic proportions. Transparent data sharing for the benefit of humanity could prevent millions of lives lost, protect economies, and ensure a healthier future.
Conclusion: A Path Forward for India
In a developing country like India, WBE represents a forward-thinking approach to public health—one that is proactive, cost-effective, and adaptable. As India’s metros continue to grow, public health surveillance must evolve to match the complexities of urban life. Wastewater-based epidemiology offers a solution that addresses these challenges, providing early warnings, economic savings, and a collaborative framework among utilities, research labs, and academia.
India’s investment in WBE would position its cities at the forefront of global health surveillance, helping detect and mitigate health crises early, minimizing economic impact, and contributing to a healthier future. By adopting WBE as a permanent part of its health infrastructure, India will not only strengthen its own public health system but also participates in a global effort to prevent the next pandemic.
Author: Dhawal Patil