Wastewater monitoring can anchor global disease surveillance systems

To inform the development of global wastewater monitoring systems, we surveyed programmes in 43 countries. Most
programmes monitored predominantly urban populations. In high-income countries (HICs), composite sampling at
centralised treatment plants was most common, whereas grab sampling from surface waters, open drains, and pit
latrines was more typical in low-income and middle-income countries (LMICs). Almost all programmes analysed
samples in-country, with an average processing time of 2·3 days in HICs and 4·5 days in LMICs. Whereas 59% of
HICs regularly monitored wastewater for SARS-CoV-2 variants, only 13% of LMICs did so. Most programmes share
their wastewater data internally, with partnering organisations, but not publicly. Our findings show the richness of
the existing wastewater monitoring ecosystem. With additional leadership, funding, and implementation frameworks,
thousands of individual wastewater initiatives can coalesce into an integrated, sustainable network for disease
surveillance—one that minimises the risk of overlooking future global health threats.