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Wastewater-based epidemiology (WBE):
a new approach to monitor drug use and
emerging trends
EMCDDA Conference – 20 years of monitoring and communicating evidence on drugs
Lisbon, 21-22 September 2015
Sara Castiglioni Mario Negri Institute
Department of Environmental Health Sciences
Unity of Environmental Biomarkers
Rational of the approach
� Almost all substances we consume
are excreted unchanged or as a
mixture of metabolites in urine
and/faeces
� Excreted substances end up in sewer network
�Enter sewage treatment plants
Raw wastewater is containing all the metabolic
residues of substances consumed by a defined
population
Raw wastewater contains multiple information
on human habits in a defined population
Wastewater-Based Epidemiology: Illicit Drugs
The route of the drugs: from the consumer to the STP
CONSUMPTION ESTIMATE
Amounts of the residues
(g/day) are used to back-
calculate drug consumption in
the population served by the
STP (g/day of the parent drug)
Illicit Drugs
-cocaine
-cannabis
-heroin
-amphetamines
CONSUMER
Excretes residues of
the drugs with urine
after the intake
TREATMENT PLANT
The residues of the drugs
are transported to the STP
with the wastewater
DRUG RESIDUES
QUANTIFICATION
Wastewater is sampled and
the residues of the drugs at
the STP are quantified
Wastewater-Based Epidemiology Approach
Mass spectrometric analyses
Concentrations of Target
Residues
Amount of target residues entering a
sewage treatment plant per day (g/day)
Daily flow
rate
Amounts of each parent substance
consumed by the population served by
the plant
Human
metabolism
Collection of raw wastewater
samplesComposite 24 h samples
Ability to provide:
� Objective estimates
� Qualitative and quantitative evaluation
� Real-time estimates
� Updated information on substance use
� Possibility to identify changing habits and new substances
Novelty of the WBE Approach
WBE approach was proposed as a complementary
indicator of drug use
Objectives
Sewage analysis CORE group (SCORE) Activities
2010 8 European Research Institutes joined
and a European Collaboration started
� Organize the first Europe-wide monitoring
� Establish a common protocol
� Check the performance of analysis through an
interlaboratory study
Sewage analysis CORE group (SCORE) Activities
Europe-wide monitoring (2011-2015)Results available at:
http://www.emcdda.europa.eu/topics/pods/waste-water-analysis
Interlaboratory test (2011-2015) to check the quality of results
Each laboratory is required to analyze standards and samples spiked
at known levels and distributed by one lab – paper in preparation
Results from Europe-wide monitoring
LOADS mg/day/1000 people
1. How to improve data comparability ?
2. How results from WBE can be used to
integrate epidemiological data?
Sewage analysis CORE group (SCORE) Activities
Best practice protocol Guidelines addressing sampling,
storage and chemical analyses
Identification of gaps
and uncertainty
Minimize or control uncertainties
Suggestions for each step of WBE
New Insight publication on WBE by EMCDDA
Compare WBE with epidemiological data
Compare WBE with epidemiological data
Comparison among:
1. GPS survey
2. Wastewater analysis
3. Survey among drivers
Comparing consumption estimates
Data were compared as absolute quantities – total amount consumed
WBE Estimate of ConsumptionGPS data: number of users x
frequency of use
60-91 kg/year 70-165 kg/year
Comparing prevalence estimates
Data from WBE were transformed for comparison
WBE Estimates: Consumption/ per user consumption figure
GPS data
1.9% (1-4 %) 2.9% (2.6-3.2 %)
Reid et al., BMJ open, 2012
Compare WBE with epidemiological data
Population surveys compared with wastewater analysis for monitoring illicit drug consumption in Italy in 2010-2014
Ettore Zuccato, Sara Castiglioni, Ivan Senta, Andrea Borsotti,
Bruno Genetti, Alessandra Andreotti, Giovanni Pieretti,
Giovanni Serpelloni
Temporal trend of cocaine use in Milan
Spatial distribution of cocaine use in Italy
Prevalence data ( about 55% drop)
Last Month: 2.6% in 2007 - 1.2% in 2010
Last Year: 5% in 2007 - 2.1% in 2010(Source: Local Health Agency 2011)
Last Year: 2.1% in 2008 – 0.9% in 2010(GPS survey, Source: Department of Anti-Drug Policies, 2010)
45% drop
Temporal Trends in Milan - WBE approach Spatial distribution in Italy - WBE approach
Consumption measured in October 2011
Prevalence measured in January 2012
(last month prevalence)(GPS survey, Source: Department of Anti-Drug Policies, 2012)
Compare WBE with epidemiological data
Challenges and research needs:
�Comparison of similar estimates (collection of additional data)
� Size of sample populations
�Temporal inconsistencies
�Spatial inconsistencies :
- population is mobile
- lack of geographical correspondence between wastewater
catchment and surveyed areas
�Sampling strategy in WBE to produce reliable figures at different
geographical scales
WBE can’t act alone but provide supporting information
Collaboration with epidemiologists is essential
Wastewater-Based Epidemiology: Potential Uses
This method can provide
• Evidence-based and real-time estimates of drug collective consumption
It can be successfully employed to:
1. Estimate spatial differences at different scales (local, national, international)
2. Monitor temporal trends (daily, weekly, yearly)
3. Monitor consumption changes in specific sites (rural vs urban) or during special events (holidays or music events)
4. Assess drug use in specific populations (prisons, schools, sub-populations in a city)
5. Identify new substances (new psychoactive substances)
Temporal trends – Novel synthetic stimulants
Drug Use in Adelaide, Australia (Chen et al., Forensic Science International, 2013)
Monitoring of new synthetic recreational drugs
Ketamine is a
dissociative
anaesthetic drug...
...with documented
increase in its use
as a recreational drug
Increased use in Milan from 2008 to 2013
4-5 weeks investigated per year
Profile of KETAMINE use in Milan in a six-year study
Conclusions
� Wastewater - based epidemiology is a promising novel
indicator to measure drug use in a population
� The approach gives objective and updated information
� The approach has been refined by developing a
best practice protocol
� Several attempts were a done to compare data –
WBE versus epidemiological data
� Interdisciplinary collaboration is essential to improve
the methodologies and their comparison
Thanks
Thanks for your attention!
SCORE GroupSara Castiglioni
Lubertus Bijlsma, Adrian Covaci,
Erik EmkeFélix Hernández,
Malcolm Reid, Christoph Ort,
Kevin V Thomas, Alexander LN van Nuijs,
Pim de Voogt, Ettore Zuccato
EMCDDAPaul Griffith,
Jane Mounteney, Danica Thanki, Liesbeth Vandam
COST Action ES1307