Capturing the SARS-CoV-2 infection pyramid within the municipality of Rotterdam using longitudinal sewage surveillance

Miranda de Graaf*, Jeroen Langeveld, Johan Post, Christian Carrizosa, Eelco Franz, Ray W. Izquierdo-Lara, Goffe Elsinga, Leo Heijnen, Frederic Been, Janko van Beek, Remy Schilperoort, Rianne Vriend, Ewout Fanoy, Evelien I.T. de Schepper, Marion P.G. Koopmans, Gertjan Medema

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Despite high vaccination rates in the Netherlands, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to circulate. Longitudinal sewage surveillance was implemented along with the notification of cases as two parts of the surveillance pyramid to validate the use of sewage for surveillance, as an early warning tool, and to measure the effect of interventions. Sewage samples were collected from nine neighborhoods between September 2020 and November 2021. Comparative analysis and modeling were performed to understand the correlation between wastewater and case trends. Using high resolution sampling, normalization of wastewater SARS-CoV-2 concentrations, and ‘normalization’ of reported positive tests for testing delay and intensity, the incidence of reported positive tests could be modeled based on sewage data, and trends in both surveillance systems coincided. The high collinearity implied that high levels of viral shedding around the onset of disease largely determined SARS-CoV-2 levels in wastewater, and that the observed relationship was independent of variants of concern and vaccination levels. Sewage surveillance alongside a large-scale testing effort where 58 % of a municipality was tested, indicated a five-fold difference in the number of SARS-CoV-2-positive individuals and reported cases through standard testing. Where trends in reported positive cases were biased due to testing delay and testing behavior, wastewater surveillance can objectively display SARS-CoV-2 dynamics for both small and large locations and is sensitive enough to measure small variations in the number of infected individuals within or between neighborhoods. With the transition to a post-acute phase of the pandemic, sewage surveillance can help to keep track of re-emergence, but continued validation studies are needed to assess the predictive value of sewage surveillance with new variants. Our findings and model aid in interpreting SARS-CoV-2 surveillance data for public health decision-making and show its potential as one of the pillars of future surveillance of (re)emerging viruses.

Original languageEnglish
Article number163599
Number of pages10
JournalScience of the Total Environment
Early online date25 Apr 2023
Publication statusPublished - Jul 2023

Bibliographical note

Funding Information:
This study was financed by STOWA, TKI Watertechnology , Erasmus Foundation, Adessium Foundation, European Union's Horizon H2020 grant VEO (grant no. 874735 ), 2018 NWO Stevin Award Koopmans, Ministry of Health, Welfare and Sport , H2020 and Waterboards Waterschap Hollandse Delta , Hoogheemraadschap van Delfland and Hoogheemraadschap Schieland en Krimpenerwaard .

Publisher Copyright:
© 2023


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