Sewer systems: epidemiological imaging of populations

Three examples will be presented to demonstrate the capacity of sewage analyses to provide a unique understanding of the presence and spread of pathogens in the community, and to furnish data for planning intervention and measuring its success. 1. Geographical distribution of pathogens with multi drug resistant genes: Sewage analysis demonstrated their presence in the general population as well as in sewage catchment areas of inpatient institutes. 2. Correlation of the geographical distribution of Hepatitis A virus (HAV) in sewage with distribution of HAV clinical cases: HAV, presumed to have been brought under control in Israel through an intensive routine vaccination program, caused a small outbreak in 2012–2013. HAV was found in sewage samples collected from areas with and without reported clinical cases indicating a large area in which there were sub-clinical HAV infections. 3. The use of environmental surveillance for routine monitoring of poliovirus infections in populations: Israel has been polio-free since 1989. Routine environmental surveillance revealed introduction and subsequent sustained transmission of wild type one poliovirus (WPV1) in Israel in 2013 in the absence of poliomyelitis cases. Rapid expansion and modification of the program enabled the Ministry of Health (MOH) to obtain information regarding both the extent of penetration and the geographical spread of the WPV1 and to evaluate the efficacy of supplementary immunization activities (SIA)