Research Area: Wastewater-Based Epidemiology (WBE)

Enterovirus-68: Why is it a public health risk? How can wastewater-based epidemiology identify outbreaks?

Posted on by Stephanie Leisso

What is Enterovirus D68?

EV-D68 is a non-polio enterovirus that often leads to very mild symptoms such as runny nose, sneezing, and mild coughing (Hixon et al, 2019; Non-Polio Enterovirus, CDC). Children, particularly those with asthma or other respiratory conditions, are at higher risk for complications.

In 2014, EV-D68 gained national attention due to its association with accute flacid myelitis (AFM). This neurological condition is rare and leads to weakness in limbs, as well as the loss of muscle tone and reflexes.  Most AFM cases occur in children, and there is no vaccine available against EV-D68.

Wastewater surveillance as a public health tool in the fight against EV-D68

EV-D68 outbreaks tend to follow a biennial pattern, with spikes observed in 2014, 2016, 2018, and again in 2022 and 2024 (Nguyen-Tran et al. 2025). These outbreaks have coincided with increases in AFM cases, prompting the CDC to initiate active surveillance programs. As such, 2026 may be another year with a spike in EV-D68 cases.

Key advantages of WBE for EV-D68:

  • Early Detection: Viral RNA from EV-D68 can be detected in wastewater before clinical cases are reported, allowing for proactive public health responses.
  • Community-Level Monitoring: WBE captures data from symptomatic and asymptomatic individuals, offering a more comprehensive view of virus circulation (Mangeri et al, 2025).
  • Cost-Effective Surveillance: Compared to individual testing, wastewater sampling is scalable and efficient.

In California, researchers tracked EV-D68 RNA in wastewater solids over 26 months. They found that viral concentrations spiked between July and December 2022, aligning with confirmed clinical cases and AFM diagnoses. Similar studies in Israel and Colorado have demonstrated strong correlations between wastewater data and clinical surveillance, reinforcing the value of multimodal monitoring. [wwwnc.cdc.gov] [mdpi.com], [wwwnc.cdc.gov]

Looking ahead: Strengthening public health preparedness

As EV-D68 continues to circulate and evolve, integrating wastewater surveillance into routine public health monitoring can enhance outbreak preparedness. These data can offer health authorities a better understanding of transmission dynamics and emerging strains and ultimately allow them to allocate resources effectively.

At GT Molecular, we are committed to advancing molecular tools that support wastewater surveillance and pathogen detection. Our technologies empower communities to stay ahead of outbreaks and protect vulnerable populations.

Hepatitis A (HAV) in wastewater: A vaccine preventable disease

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Why monitor Hepatitis A in wastewater?

Broad community‐level surveillance

  • HAV is excreted in feces of infected individuals, and thus viral particles (or viral RNA) can be present in wastewater influent. This makes WBE (Wastewater-Based Epidemiology) a feasible method for population-level monitoring. For example, one study found HAV RNA in raw sewage over an 8-month period in southern Italy (Morace, et al.).

Early warning and outbreak detection

  • Because wastewater aggregates signal from many individuals, possibly including asymptomatic infections, detection of HAV in wastewater could precede or at least complement clinical case detection, offering earlier insight into rising circulation.
    For instance:

    • A study during a hepatitis outbreak in Detroit found that HAV concentrations in wastewater correlated with reported case counts one week later (McCall et al.).
    • A longitudinal study examining wastewater in an urban city in Argentina found that HAV concentrations in the collected samples correlated with reported clinical trends for Hepatitis A. Genetic characterization of these samples found that the Hepatitis A lineages in wastewater were the same as those found in clinical cases at given time points (Fantilli et al.)

Monitoring equality and vulnerability

  • The association of wastewater HAV detection with socioeconomic vulnerability suggests the method can highlight disparities in disease burden. For example, the U.S. national study found that states with above-average rates of homelessness had ~48 % higher likelihood of HAV detection in wastewater (Zulli, et al.).

Complement to clinical surveillance

  • Traditional surveillance for hepatitis A relies on reported laboratory confirmed cases (anti-HAV IgM or HAV RNA), and on providers reporting to public-health bodies (Hepatitis A Surveillance Guidance, CDC).
  • Many mild or asymptomatic infections may go undetected, and people in vulnerable settings may have limited access to care and testing. Therefore, wastewater surveillance offers a complementary data stream which provides a non-biased, population-level signal, improving situational awareness.

Public health implications

  • Wastewater surveillance for HAV can help identify hidden or underreported transmission, especially in populations underserved or outside routine clinical surveillance (e.g., homeless shelters, food service workers).
  • Early detection via wastewater can enable timely public health interventions, such as targeted vaccination campaigns, improving hygiene/sanitation in high-risk settings, or food-safety inspections.
  • By linking wastewater HAV signals to socioeconomic vulnerability data, health authorities can drive equity-focused responses (e.g., prioritizing vaccination in communities with high homelessness or overdose-death rates).
  • As part of One Health/environmental health thinking, wastewater monitoring underscores that liver-infecting viruses transmitted by the fecal oral route (like HAV) leave detectable community-level signatures beyond clinical case numbers.

At GT Molecular, we translate wastewater surveillance into actionable insights, giving users the tools to detect pathogens early and respond before outbreaks escalate. Our HepA digital PCR kit helps public health teams monitor transmission proactively and protect vulnerable populations.