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Parkins MD, Lee BE, Acosta N, Bautista M, Hubert CRJ, Hrudey SE, Frankowski K, Pang XL. Wastewater-based surveillance as a tool for public health action: SARS-CoV-2 and beyond. Clin Microbiol Rev 2024; 37:e0010322. [PMID: 38095438 PMCID: PMC10938902 DOI: 10.1128/cmr.00103-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024] Open
Abstract
Wastewater-based surveillance (WBS) has undergone dramatic advancement in the context of the coronavirus disease 2019 (COVID-19) pandemic. The power and potential of this platform technology were rapidly realized when it became evident that not only did WBS-measured SARS-CoV-2 RNA correlate strongly with COVID-19 clinical disease within monitored populations but also, in fact, it functioned as a leading indicator. Teams from across the globe rapidly innovated novel approaches by which wastewater could be collected from diverse sewersheds ranging from wastewater treatment plants (enabling community-level surveillance) to more granular locations including individual neighborhoods and high-risk buildings such as long-term care facilities (LTCF). Efficient processes enabled SARS-CoV-2 RNA extraction and concentration from the highly dilute wastewater matrix. Molecular and genomic tools to identify, quantify, and characterize SARS-CoV-2 and its various variants were adapted from clinical programs and applied to these mixed environmental systems. Novel data-sharing tools allowed this information to be mobilized and made immediately available to public health and government decision-makers and even the public, enabling evidence-informed decision-making based on local disease dynamics. WBS has since been recognized as a tool of transformative potential, providing near-real-time cost-effective, objective, comprehensive, and inclusive data on the changing prevalence of measured analytes across space and time in populations. However, as a consequence of rapid innovation from hundreds of teams simultaneously, tremendous heterogeneity currently exists in the SARS-CoV-2 WBS literature. This manuscript provides a state-of-the-art review of WBS as established with SARS-CoV-2 and details the current work underway expanding its scope to other infectious disease targets.
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Affiliation(s)
- Michael D. Parkins
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bonita E. Lee
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole Acosta
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maria Bautista
- Department of Biological Sciences, Faculty of Science, University of Calgary, Calgary, Alberta, Canada
| | - Casey R. J. Hubert
- Department of Biological Sciences, Faculty of Science, University of Calgary, Calgary, Alberta, Canada
| | - Steve E. Hrudey
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Frankowski
- Advancing Canadian Water Assets, University of Calgary, Calgary, Alberta, Canada
| | - Xiao-Li Pang
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Provincial Health Laboratory, Alberta Health Services, Calgary, Alberta, Canada
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Zammit I, Badia S, Mejías-Molina C, Rusiñol M, Bofill-Mas S, Borrego CM, Corominas L. Zooming in to the neighborhood level: A year-long wastewater-based epidemiology monitoring campaign for COVID-19 in small intraurban catchments. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 907:167811. [PMID: 37852481 DOI: 10.1016/j.scitotenv.2023.167811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/14/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023]
Abstract
In recent years, wastewater-based epidemiology (WBE) has emerged as a valuable and cost-effective tool for monitoring the prevalence of COVID-19. Large-scale monitoring efforts have been implemented in numerous countries, primarily focusing on sampling at the entrance of wastewater treatment plants (WWTPs) to cover a large population. However, sampling at a finer spatial scale, such as at the neighborhood level (NGBs), pose new challenges, including the absence of composite sampling infrastructure and increased uncertainty due to the dynamics of small catchments. This study aims to investigate the feasibility and accuracy of WBE when deployed at the neighborhood level (sampling in sewers) compared to the city level (sampling at the entrance of a WWTP). To achieve this, we deployed specific WBE sampling stations at the intraurban scale within three NGBs in Barcelona, Spain. The study period covers the 5th and the 6th waves of COVID-19 in Spain, spanning from March 2021 to March 2022, along with the WWTP downstream from the NGBs. The results showed a strong correlation between the dynamics of COVID-19 clinical cases and wastewater SARS-CoV-2 loads at both the NGB and city levels. Notably, during the 5th wave, which was dominated by the Delta SARS-CoV-2 variant, wastewater loads were higher than during the 6th wave (Omicron variant), despite a lower number of clinical cases recorded during the 5th wave. The correlations between wastewater loads and clinical cases at the NGB level were stronger than at the WWTP level. However, the early warning potential varied across neighborhoods and waves, with some cases showing a one-week early warning and others lacking any significant early warning signal. Interestingly, the prevalence of COVID-19 did not exhibit major differences among NGBs with different socioeconomic statuses.
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Affiliation(s)
- Ian Zammit
- Catalan Institute for Water Research (ICRA-CERCA), Emili Grahit 101, 17003 Girona, Spain; University of Girona, Plaça de Sant Domènec 3, 17004 Girona, Spain
| | - Sergi Badia
- Catalan Institute for Water Research (ICRA-CERCA), Emili Grahit 101, 17003 Girona, Spain; University of Girona, Plaça de Sant Domènec 3, 17004 Girona, Spain
| | - Cristina Mejías-Molina
- Laboratory of Viruses Contaminants of Water and Food, Genetics, Microbiology & Statistics Dept., Universitat de Barcelona, Barcelona, Catalonia, Spain; The Water Research Institute (IdRA), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Marta Rusiñol
- Laboratory of Viruses Contaminants of Water and Food, Genetics, Microbiology & Statistics Dept., Universitat de Barcelona, Barcelona, Catalonia, Spain; The Water Research Institute (IdRA), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Sílvia Bofill-Mas
- Laboratory of Viruses Contaminants of Water and Food, Genetics, Microbiology & Statistics Dept., Universitat de Barcelona, Barcelona, Catalonia, Spain; The Water Research Institute (IdRA), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carles M Borrego
- Catalan Institute for Water Research (ICRA-CERCA), Emili Grahit 101, 17003 Girona, Spain; Group of Molecular Microbial Ecology, Institute of Aquatic Ecology, University of Girona, Girona, Catalonia, Spain
| | - Lluís Corominas
- Catalan Institute for Water Research (ICRA-CERCA), Emili Grahit 101, 17003 Girona, Spain; University of Girona, Plaça de Sant Domènec 3, 17004 Girona, Spain.
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3
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Baz Lomba JA, Pires J, Myrmel M, Arnø JK, Madslien EH, Langlete P, Amato E, Hyllestad S. Effectiveness of environmental surveillance of SARS-CoV-2 as an early-warning system: Update of a systematic review during the second year of the pandemic. JOURNAL OF WATER AND HEALTH 2024; 22:197-234. [PMID: 38295081 PMCID: wh_2023_279 DOI: 10.2166/wh.2023.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
The aim of this updated systematic review was to offer an overview of the effectiveness of environmental surveillance (ES) of SARS-CoV-2 as a potential early-warning system (EWS) for COVID-19 and new variants of concerns (VOCs) during the second year of the pandemic. An updated literature search was conducted to evaluate the added value of ES of SARS-CoV-2 for public health decisions. The search for studies published between June 2021 and July 2022 resulted in 1,588 publications, identifying 331 articles for full-text screening. A total of 151 publications met our inclusion criteria for the assessment of the effectiveness of ES as an EWS and early detection of SARS-CoV-2 variants. We identified a further 30 publications among the grey literature. ES confirms its usefulness as an EWS for detecting new waves of SARS-CoV-2 infection with an average lead time of 1-2 weeks for most of the publication. ES could function as an EWS for new VOCs in areas with no registered cases or limited clinical capacity. Challenges in data harmonization and variant detection require standardized approaches and innovations for improved public health decision-making. ES confirms its potential to support public health decision-making and resource allocation in future outbreaks.
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Affiliation(s)
- Jose Antonio Baz Lomba
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway E-mail:
| | - João Pires
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway; ECDC fellowship Programme, Public Health Microbiology path (EUPHEM), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Mette Myrmel
- Faculty of Veterinary Medicine, Virology Unit, Norwegian University of Life Science (NMBU), Oslo, Norway
| | - Jorunn Karterud Arnø
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Elisabeth Henie Madslien
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Petter Langlete
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Ettore Amato
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Susanne Hyllestad
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
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4
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Trigo-Tasende N, Vallejo JA, Rumbo-Feal S, Conde-Pérez K, Vaamonde M, López-Oriona Á, Barbeito I, Nasser-Ali M, Reif R, Rodiño-Janeiro BK, Fernández-Álvarez E, Iglesias-Corrás I, Freire B, Tarrío-Saavedra J, Tomás L, Gallego-García P, Posada D, Bou G, López-de-Ullibarri I, Cao R, Ladra S, Poza M. Wastewater early warning system for SARS-CoV-2 outbreaks and variants in a Coruña, Spain. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023:10.1007/s11356-023-27877-3. [PMID: 37286834 DOI: 10.1007/s11356-023-27877-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023]
Abstract
Wastewater-based epidemiology has been widely used as a cost-effective method for tracking the COVID-19 pandemic at the community level. Here we describe COVIDBENS, a wastewater surveillance program running from June 2020 to March 2022 in the wastewater treatment plant of Bens in A Coruña (Spain). The main goal of this work was to provide an effective early warning tool based in wastewater epidemiology to help in decision-making at both the social and public health levels. RT-qPCR procedures and Illumina sequencing were used to weekly monitor the viral load and to detect SARS-CoV-2 mutations in wastewater, respectively. In addition, own statistical models were applied to estimate the real number of infected people and the frequency of each emerging variant circulating in the community, which considerable improved the surveillance strategy. Our analysis detected 6 viral load waves in A Coruña with concentrations between 103 and 106 SARS-CoV-2 RNA copies/L. Our system was able to anticipate community outbreaks during the pandemic with 8-36 days in advance with respect to clinical reports and, to detect the emergence of new SARS-CoV-2 variants in A Coruña such as Alpha (B.1.1.7), Delta (B.1.617.2), and Omicron (B.1.1.529 and BA.2) in wastewater with 42, 30, and 27 days, respectively, before the health system did. Data generated here helped local authorities and health managers to give a faster and more efficient response to the pandemic situation, and also allowed important industrial companies to adapt their production to each situation. The wastewater-based epidemiology program developed in our metropolitan area of A Coruña (Spain) during the SARS-CoV-2 pandemic served as a powerful early warning system combining statistical models with mutations and viral load monitoring in wastewater over time.
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Affiliation(s)
- Noelia Trigo-Tasende
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain
| | - Juan A Vallejo
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain
| | - Soraya Rumbo-Feal
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain
| | - Kelly Conde-Pérez
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain
| | - Manuel Vaamonde
- Research Group MODES, Research Center for Information and Communication Technologies (CITIC), University of A Coruña (UDC), Campus de Elviña, 15071 , A Coruña, Spain
| | - Ángel López-Oriona
- Research Group MODES, Research Center for Information and Communication Technologies (CITIC), University of A Coruña (UDC), Campus de Elviña, 15071 , A Coruña, Spain
| | - Inés Barbeito
- Research Group MODES, Research Center for Information and Communication Technologies (CITIC), University of A Coruña (UDC), Campus de Elviña, 15071 , A Coruña, Spain
| | - Mohammed Nasser-Ali
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain
| | - Rubén Reif
- Center for Research in Biological Chemistry and Molecular Materials (CiQUS), University of Santiago de Compostela (USC), 15782, Santiago de Compostela, Spain
| | - Bruno K Rodiño-Janeiro
- BFlow, University of Santiago de Compostela (USC) and Health Research Institute of Santiago de Compostela (IDIS), Campus Vida, 15706, Santiago de Compostela, A Coruña, Spain
| | - Elisa Fernández-Álvarez
- University of A Coruña (UDC), Research Center for Information and Communication Technologies (CITIC), Database Laboratory, Campus de Elviña, 15071, A Coruña, Spain
| | - Iago Iglesias-Corrás
- University of A Coruña (UDC), Research Center for Information and Communication Technologies (CITIC), Database Laboratory, Campus de Elviña, 15071, A Coruña, Spain
| | - Borja Freire
- University of A Coruña (UDC), Research Center for Information and Communication Technologies (CITIC), Database Laboratory, Campus de Elviña, 15071, A Coruña, Spain
| | - Javier Tarrío-Saavedra
- Research Group MODES, Research Center for Information and Communication Technologies (CITIC), University of A Coruña (UDC), Campus de Elviña, 15071 , A Coruña, Spain
| | - Laura Tomás
- CINBIO, Universidade de Vigo, 36310, Vigo, Spain
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312, Vigo, Spain
| | - Pilar Gallego-García
- CINBIO, Universidade de Vigo, 36310, Vigo, Spain
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312, Vigo, Spain
| | - David Posada
- CINBIO, Universidade de Vigo, 36310, Vigo, Spain
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312, Vigo, Spain
- Department of Biochemistry, Genetics, and Immunology, Universidade de Vigo, 36310, Vigo, Spain
| | - Germán Bou
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain
| | - Ignacio López-de-Ullibarri
- Research Group MODES, Research Center for Information and Communication Technologies (CITIC), University of A Coruña (UDC), Campus de Elviña, 15071 , A Coruña, Spain
| | - Ricardo Cao
- Research Group MODES, Research Center for Information and Communication Technologies (CITIC), University of A Coruña (UDC), Campus de Elviña, 15071 , A Coruña, Spain
| | - Susana Ladra
- University of A Coruña (UDC), Research Center for Information and Communication Technologies (CITIC), Database Laboratory, Campus de Elviña, 15071, A Coruña, Spain
| | - Margarita Poza
- University of A Coruña (UDC) - Microbiome and Health group (meiGAbiome), Institute of Biomedical Research (INIBIC) - University Hospital of A Coruña (CHUAC) - Interdisciplinary Center for Chemistry and Biology (CICA) - Spanish Network for Infectious Diseases (CIBERINFEC-ISCIII), Campus da Zapateira, 15008, A Coruña, Spain.
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5
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van Boven M, Hetebrij WA, Swart A, Nagelkerke E, van der Beek RF, Stouten S, Hoogeveen RT, Miura F, Kloosterman A, van der Drift AMR, Welling A, Lodder WJ, de Roda Husman AM. Patterns of SARS-CoV-2 circulation revealed by a nationwide sewage surveillance programme, the Netherlands, August 2020 to February 2022. Euro Surveill 2023; 28:2200700. [PMID: 37347416 PMCID: PMC10288829 DOI: 10.2807/1560-7917.es.2023.28.25.2200700] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 03/16/2023] [Indexed: 06/23/2023] Open
Abstract
BackgroundSurveillance of SARS-CoV-2 in wastewater offers a near real-time tool to track circulation of SARS-CoV-2 at a local scale. However, individual measurements of SARS-CoV-2 in sewage are noisy, inherently variable and can be left-censored.AimWe aimed to infer latent virus loads in a comprehensive sewage surveillance programme that includes all sewage treatment plants (STPs) in the Netherlands and covers 99.6% of the Dutch population.MethodsWe applied a multilevel Bayesian penalised spline model to estimate time- and STP-specific virus loads based on water flow-adjusted SARS-CoV-2 qRT-PCR data for one to four sewage samples per week for each of the more than 300 STPs.ResultsThe model captured the epidemic upsurges and downturns in the Netherlands, despite substantial day-to-day variation in the measurements. Estimated STP virus loads varied by more than two orders of magnitude, from ca 1012 virus particles per 100,000 persons per day in the epidemic trough in August 2020 to almost 1015 per 100,000 in many STPs in January 2022. The timing of epidemics at the local level was slightly shifted between STPs and municipalities, which resulted in less pronounced peaks and troughs at the national level.ConclusionAlthough substantial day-to-day variation is observed in virus load measurements, wastewater-based surveillance of SARS-CoV-2 that is performed at high sampling frequency can track long-term progression of an epidemic at a local scale in near real time.
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Affiliation(s)
- Michiel van Boven
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wouter A Hetebrij
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Arno Swart
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Erwin Nagelkerke
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Rudolf Fhj van der Beek
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Sjors Stouten
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Rudolf T Hoogeveen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Fuminari Miura
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Center for Marine Environmental Studies (CMES), Ehime University, Ehime, Japan
| | - Astrid Kloosterman
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Centre for Environmental Safety and Security, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Anne-Merel R van der Drift
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Anne Welling
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Willemijn J Lodder
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Ana Maria de Roda Husman
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Institute for Risk Assessment Science (IRAS), Utrecht University, Utrecht, the Netherlands
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6
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Tamáš M, Potocarova A, Konecna B, Klucar Ľ, Mackulak T. Wastewater Sequencing-An Innovative Method for Variant Monitoring of SARS-CoV-2 in Populations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9749. [PMID: 35955106 PMCID: PMC9367975 DOI: 10.3390/ijerph19159749] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 05/14/2023]
Abstract
The SARS-CoV-2 outbreak has already affected more than 555 million people, and 6.3 million people have died. Due to its high infectivity, it is crucial to track SARS-CoV-2 outbreaks early to prevent the spread of infection. Wastewater monitoring appears to be a powerful and effective tool for managing epidemiological situations. Due to emerging mutations of SARS-CoV-2, there is a need to monitor mutations in order to control the pandemic. Since the sequencing of randomly chosen individuals is time-consuming and expensive, sequencing of wastewater plays an important role in revealing the dynamics of infection in a population. The sampling method used is a crucial factor and significantly impacts the results. Wastewater can be collected as a grab sample or as a 24 h composite sample. Another essential factor is the sample volume, as is the method of transport used. This review discusses different pretreatment procedures and RNA extraction, which may be performed using various methods, such as column-based extraction, TRIzol, or magnetic extraction. Each of the methods has its advantages and disadvantages, which are described accordingly. RT-qPCR is a procedure that confirms the presence of SARS-CoV-2 genes before sequencing. This review provides an overview of currently used methods for preparing wastewater samples, from sampling to sequencing.
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Affiliation(s)
- Michal Tamáš
- Department of Environmental Engineering, Institute of Chemical and Environmental Engineering, Faculty of Chemical and Food Technology, Slovak University of Technology, Radinského 9, 81237 Bratislava, Slovakia
- Institute of Physiology, Faculty of Medicine, Comenius University in Bratislava, 81372 Bratislava, Slovakia
| | - Alena Potocarova
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Sasinkova 4, 81108 Bratislava, Slovakia
| | - Barbora Konecna
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, Sasinkova 4, 81108 Bratislava, Slovakia
| | - Ľubos Klucar
- Institute of Molecular Biology, Slovak Academy of Sciences, Dúbravská Cesta 21, 84551 Bratislava, Slovakia
| | - Tomas Mackulak
- Department of Environmental Engineering, Institute of Chemical and Environmental Engineering, Faculty of Chemical and Food Technology, Slovak University of Technology, Radinského 9, 81237 Bratislava, Slovakia
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7
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Acosta N, Bautista MA, Waddell BJ, McCalder J, Beaudet AB, Man L, Pradhan P, Sedaghat N, Papparis C, Bacanu A, Hollman J, Krusina A, Southern DA, Williamson T, Li C, Bhatnagar S, Murphy S, Chen J, Kuzma D, Clark R, Meddings J, Hu J, Cabaj JL, Conly JM, Dai X, Lu X, Chekouo T, Ruecker NJ, Achari G, Ryan MC, Frankowski K, Hubert CRJ, Parkins MD. Longitudinal SARS-CoV-2 RNA wastewater monitoring across a range of scales correlates with total and regional COVID-19 burden in a well-defined urban population. WATER RESEARCH 2022; 220:118611. [PMID: 35661506 PMCID: PMC9107283 DOI: 10.1016/j.watres.2022.118611] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/13/2022] [Accepted: 05/13/2022] [Indexed: 05/03/2023]
Abstract
Wastewater-based epidemiology (WBE) is an emerging surveillance tool that has been used to monitor the ongoing COVID-19 pandemic by tracking SARS-CoV-2 RNA shed into wastewater. WBE was performed to monitor the occurrence and spread of SARS-CoV-2 from three wastewater treatment plants (WWTP) and six neighborhoods in the city of Calgary, Canada (population 1.44 million). A total of 222 WWTP and 192 neighborhood samples were collected from June 2020 to May 2021, encompassing the end of the first-wave (June 2020), the second-wave (November end to December 2020) and the third-wave of the COVID-19 pandemic (mid-April to May 2021). Flow-weighted 24-hour composite samples were processed to extract RNA that was then analyzed for two SARS-CoV-2-specific regions of the nucleocapsid gene, N1 and N2, using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Using this approach SARS-CoV-2 RNA was detected in 98.06% (406/414) of wastewater samples. SARS-CoV-2 RNA abundance was compared to clinically diagnosed COVID-19 cases organized by the three-digit postal code of affected individuals' primary residences, enabling correlation analysis at neighborhood, WWTP and city-wide scales. Strong correlations were observed between N1 & N2 gene signals in wastewater and new daily cases for WWTPs and neighborhoods. Similarly, when flow rates at Calgary's three WWTPs were used to normalize observed concentrations of SARS-CoV-2 RNA and combine them into a city-wide signal, this was strongly correlated with regionally diagnosed COVID-19 cases and clinical test percent positivity rate. Linked census data demonstrated disproportionate SARS-CoV-2 in wastewater from areas of the city with lower socioeconomic status and more racialized communities. WBE across a range of urban scales was demonstrated to be an effective mechanism of COVID-19 surveillance.
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Affiliation(s)
- Nicole Acosta
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - María A Bautista
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Barbara J Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Janine McCalder
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Alexander Buchner Beaudet
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Lawrence Man
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Puja Pradhan
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Navid Sedaghat
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Chloe Papparis
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Andra Bacanu
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Jordan Hollman
- Department of Civil Engineering, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada; Department of Geosciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Alexander Krusina
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Danielle A Southern
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Carmen Li
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Srijak Bhatnagar
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Sean Murphy
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Jianwei Chen
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Darina Kuzma
- Advancing Canadian Water Assets, University of Calgary, 3131 210 Ave SE, Calgary, Alberta, T0L 0×0, Canada
| | - Rhonda Clark
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada; Advancing Canadian Water Assets, University of Calgary, 3131 210 Ave SE, Calgary, Alberta, T0L 0×0, Canada
| | - Jon Meddings
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Jia Hu
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada; Provincial Population & Public Health, Alberta Health Services, 3030 Hospital Drive NW, Calgary, Alberta, T2N 4W4, Canada
| | - Jason L Cabaj
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada; Provincial Population & Public Health, Alberta Health Services, 3030 Hospital Drive NW, Calgary, Alberta, T2N 4W4, Canada
| | - John M Conly
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada; Infection Prevention and Control, Alberta Health Services, 1403 29th Street NW, Calgary, Alberta, T2N 2T9, Canada; Department of Pathology and Laboratory Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada; Snyder Institute for Chronic Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Xiaotian Dai
- Department of Mathematics and Statistics, University of Calgary, 2500 Hospital Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Xuewen Lu
- Department of Mathematics and Statistics, University of Calgary, 2500 Hospital Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Thierry Chekouo
- Department of Mathematics and Statistics, University of Calgary, 2500 Hospital Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Norma J Ruecker
- Water Quality Services, City of Calgary, 625 25 Ave SE, Calgary, Alberta, T2G 4k8, Canada
| | - Gopal Achari
- Department of Civil Engineering, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - M Cathryn Ryan
- Department of Geosciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Kevin Frankowski
- Advancing Canadian Water Assets, University of Calgary, 3131 210 Ave SE, Calgary, Alberta, T0L 0×0, Canada
| | - Casey R J Hubert
- Geomicrobiology Group, Department of Biological Sciences, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| | - Michael D Parkins
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada; Snyder Institute for Chronic Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.
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8
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Community Wastewater-Based Surveillance Can Be a Cost-Effective Approach to Track COVID-19 Outbreak in Low-Resource Settings: Feasibility Assessment for Ethiopia Context. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148515. [PMID: 35886369 PMCID: PMC9319732 DOI: 10.3390/ijerph19148515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/02/2022] [Accepted: 07/08/2022] [Indexed: 11/19/2022]
Abstract
Wastewater surveillance systems have become an important component of COVID-19 outbreak monitoring in high-income settings. However, its use in most low-income settings has not been well-studied. This study assessed the feasibility and utility of wastewater surveillance system to monitor SARS-CoV-2 RNA in Addis Ababa, Ethiopia. The study was conducted at nine Membrane Bio-reactor (MBR) wastewater processing plants. The samples were collected in two separate time series. Wastewater samples and known leftover RT-PCR tested nasopharyngeal swabs were processed using two extraction protocols with different sample conditions. SARS-CoV-2 wastewater RT-PCR testing was conducted using RIDA GENE SARS-CoV-2 RUO protocol for wastewater SARS-CoV-2 RNA testing. Wastewater SARS-CoV-2 RNA RT-PCR protocol adaptation, optimization, and detection were conducted in an Addis Ababa, Ethiopia context. Samples collected during the first time series, when the national COVID-19 case load was low, were all negative. Conversely, samples collected during the second time series were all positive, coinciding with the highest daily reported new cases of COVID-19 in Ethiopia. The wastewater-based SARS-CoV-2 surveillance approach is feasible for Addis Ababa. The COVID-19 wastewater based epidemiological approach can potentially fill the evidence gap in distribution and dynamics of COVID-19 in Ethiopia and other low-income settings.
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9
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Barbé L, Schaeffer J, Besnard A, Jousse S, Wurtzer S, Moulin L, Le Guyader FS, Desdouits M. SARS-CoV-2 Whole-Genome Sequencing Using Oxford Nanopore Technology for Variant Monitoring in Wastewaters. Front Microbiol 2022; 13:889811. [PMID: 35756003 PMCID: PMC9218694 DOI: 10.3389/fmicb.2022.889811] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/29/2022] [Indexed: 01/21/2023] Open
Abstract
Since the beginning of the Coronavirus Disease-19 (COVID-19) pandemic, multiple Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) mutations have been reported and led to the emergence of variants of concern (VOC) with increased transmissibility, virulence or immune escape. In parallel, the observation of viral fecal shedding led to the quantification of SARS-CoV-2 genomes in wastewater, providing information about the dynamics of SARS-CoV-2 infections within a population including symptomatic and asymptomatic individuals. Here, we aimed to adapt a sequencing technique initially designed for clinical samples to apply it to the challenging and mixed wastewater matrix, and hence identify the circulation of VOC at the community level. Composite raw sewage sampled over 24 h in two wastewater-treatment plants (WWTPs) from a city in western France were collected weekly and SARS-CoV-2 quantified by RT-PCR. Samples collected between October 2020 and May 2021 were submitted to whole-genome sequencing (WGS) using the primers and protocol published by the ARTIC Network and a MinION Mk1C sequencer (Oxford Nanopore Technologies, Oxford, United Kingdom). The protocol was adapted to allow near-full genome coverage from sewage samples, starting from ∼5% to reach ∼90% at depth 30. This enabled us to detect multiple single-nucleotide variant (SNV) and assess the circulation of the SARS-CoV-2 VOC Alpha, Beta, Gamma, and Delta. Retrospective analysis of sewage samples shed light on the emergence of the Alpha VOC with detection of first co-occurring signature mutations in mid-November 2020 to reach predominance of this variant in early February 2021. In parallel, a mutation-specific qRT-PCR assay confirmed the spread of the Alpha VOC but detected it later than WGS. Altogether, these data show that SARS-CoV-2 sequencing in sewage can be used for early detection of an emerging VOC in a population and confirm its ability to track shifts in variant predominance.
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Affiliation(s)
- Laure Barbé
- Laboratoire de Microbiologie (LSEM, Unité MASAE), IFREMER, Nantes, France
| | - Julien Schaeffer
- Laboratoire de Microbiologie (LSEM, Unité MASAE), IFREMER, Nantes, France
| | - Alban Besnard
- Laboratoire de Microbiologie (LSEM, Unité MASAE), IFREMER, Nantes, France
| | - Sarah Jousse
- Laboratoire de Microbiologie (LSEM, Unité MASAE), IFREMER, Nantes, France
| | | | - Laurent Moulin
- R&D Laboratory, DRDQE, Eau de Paris, Ivry-sur-Seine, France
| | | | | | - Marion Desdouits
- Laboratoire de Microbiologie (LSEM, Unité MASAE), IFREMER, Nantes, France
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10
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Extensive Wastewater-Based Epidemiology as a Resourceful Tool for SARS-CoV-2 Surveillance in a Low-to-Middle-Income Country through a Successful Collaborative Quest: WBE, Mobility, and Clinical Tests. WATER 2022. [DOI: 10.3390/w14121842] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The COVID-19 pandemic has challenged healthcare systems worldwide. Efforts in low-to-middle-income countries (LMICs) cannot keep stride with infection rates, especially during peaks. A strong international collaboration between Arizona State University (ASU), Tec de Monterrey (TEC), and Servicios de Agua y Drenaje de Monterrey (Local Water Utilities) is acting to integrate wastewater-based epidemiology (WBE) of SARS-CoV-2 in the region as a complementary approach to aid the healthcare system. Wastewater was collected from four sewer catchments in the Monterrey Metropolitan area in Mexico (pop. 4,643,232) from mid-April 2020 to February 2021 (44 weeks, n = 644). Raw wastewater was filtered and filter-concentrated, the RNA was extracted using columns, and the Charité/Berlin protocol was used for the RT-qPCR. The viral loads obtained between the first (June 2020) and second waves (February 2021) of the pandemic were similar; in contrast, the clinical cases were fewer during the first wave, indicating poor coverage. During the second wave of the pandemic, the SARS-CoV-2 quantification in wastewater increased 14 days earlier than the COVID-19 clinical cases reported. This is the first long-term WBE study in Mexico and demonstrates its value in pandemic management.
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11
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Brnić D, Lojkić I, Škoko I, Krešić N, Šimić I, Keros T, Ganjto M, Štefanac D, Viduka B, Karšaj D, Štiler D, Habrun B, Jemeršić L. SARS-CoV-2 circulation in Croatian wastewaters and the absence of SARS-CoV-2 in bivalve molluscan shellfish. ENVIRONMENTAL RESEARCH 2022; 207:112638. [PMID: 34990611 PMCID: PMC8721915 DOI: 10.1016/j.envres.2021.112638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/25/2021] [Accepted: 12/26/2021] [Indexed: 05/07/2023]
Abstract
The circulation of SARS-CoV-2 in the environment has been confirmed numerous times, whilst research on the bioaccumulation in bivalve molluscan shellfish (BMS) has been rather scarce. The present study aimed to fulfil the knowledge gap on SARS-CoV-2 circulation in wastewaters and surface waters in this region and to extend the current knowledge on potential presence of SARS-CoV-2 contamination in BMS. The study included 13 archive wastewater and surface water samples from the start of epidemic and 17 influents and effluents from nine wastewater treatment plants (WWTP) of different capacity and treatment stage, sampled during the second epidemic wave. From that period are the most of 77 collected BMS samples, represented by mussels, oysters and warty venus clams harvested along the Dalmatian coast. All samples were processed according to EN ISO 15216-1 2017 using Mengovirus as a whole process control. SARS-CoV-2 detection was performed by real-time and conventional RT-PCR assays targeting E, N and nsp14 protein genes complemented with nsp14 partial sequencing. Rotavirus A (RVA) real-time RT-PCR assay was implemented as an additional evaluation criterion of virus concentration techniques. The results revealed the circulation of SARS-CoV-2 in nine influents and two secondary treatment effluents from eight WWTPs, while all samples from the start of epidemic (wastewaters, surface waters) were negative which was influenced by sampling strategy. All tertiary effluents and BMS were SARS-CoV-2 negative. The results of RVA amplification were beneficial in evaluating virus concentration techniques and provided insights into RVA dynamics within the environment and community. In conclusion, the results of the present study confirm SARS-CoV-2 circulation in Croatian wastewaters during the second epidemic wave while extending the knowledge on wastewater treatment potential in SARS-CoV-2 removal. Our findings represent a significant contribution to the current state of knowledge that considers BMS of a very low food safety risk regarding SARS-CoV-2.
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Affiliation(s)
- Dragan Brnić
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia.
| | - Ivana Lojkić
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia
| | - Ines Škoko
- Croatian Veterinary Institute, Veterinary Department Split, Poljička cesta 33, 21000, Split, Croatia
| | - Nina Krešić
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia
| | - Ivana Šimić
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia; Ruđer Bošković Institute, Bijenička cesta 54, 10000, Zagreb, Croatia
| | - Tomislav Keros
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia
| | - Marin Ganjto
- Zagreb Wastewater Ltd., Čulinečka cesta 287, 10040, Zagreb, Croatia
| | - Dario Štefanac
- Vodovod i kanalizacija d.o.o., Gažanski trg 8, 47000, Karlovac, Croatia
| | - Branka Viduka
- Odvodnja d.o.o., Hrvatskog sabora 2D, 23000, Zadar, Croatia
| | - Dario Karšaj
- Vodovod d.o.o., Nikole Zrinskog 25, 35000, Slavonski brod, Croatia
| | - Darko Štiler
- Vinkovački vodovod i kanalizacija d.o.o., Ulica Dragutina Žanića Karle 47a, 32100, Vinkovci, Croatia
| | - Boris Habrun
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia
| | - Lorena Jemeršić
- Croatian Veterinary Institute, Savska cesta 143, 10000, Zagreb, Croatia.
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