WastewaterWastewater--based epidemiology as a novel based epidemiology as a novel
tool to evaluate illicit drugs, alcohol and tool to evaluate illicit drugs, alcohol and
Sara Castiglioni Sara Castiglioni Mario Negri InstituteMario Negri Institute
Department of Environmental Health Sciences Department of Environmental Health Sciences
Unity of Environmental BiomarkersUnity of Environmental Biomarkers
tool to evaluate illicit drugs, alcohol and tool to evaluate illicit drugs, alcohol and
tobacco use in a populationtobacco use in a population
Lisbon ADDICTIONS Conference 2015 – Lisbon, 23-25 September 2015
Rational of the approach
� Almost all substances substances we consume consume
are excretedare excreted unchanged or as a
mixture of metabolites in urine in urine
and/faeces and/faeces
� Excreted substances end up in sewer sewer networknetwork
�Enter sewagesewage treatment treatment plantsplants
Raw wastewater Raw wastewater represents anonymous urine
samples of thousands of people containing
traces of excretion products
Raw wastewater Raw wastewater contains multiple information
on human habitshuman habits in a defined population
Wastewater - Based Epidemiology ApproachA Large Urine Test
Mass spectrometric analyses Mass spectrometric analyses
Concentrations of Target
Residues
Daily flow
rate
Collection of rawraw wastewater wastewater
samplesComposite 24 h samples
Residues
Amount of target residues Amount of target residues entering a
sewage treatment plant per day (g/day)
rate
AmountsAmounts of each parent substance parent substance
consumed by the population served by
the plant
Human
metabolism
Wastewater-Based Epidemiology: a large urine testThe route of the drugs: from the consumer to the STP
Illicit DrugsIllicit Drugs
-cocaine
-cannabis
-heroin
-amphetamines
CONSUMER
Excretes residues of
the drugs with urine
after the intake
TREATMENT PLANT
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)
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
Ability to provide:
�� Objective Objective estimates of consumption
�� Rapid reporting on changes in illicit drug use on changes in illicit drug use at the population level
�� RealReal--time time estimates
Potentials of the WBE Approach
�� Spatial and temporal Spatial and temporal trends at different geographical scales
� Identification of the use of novel substancesthe use of novel substances
�� A pre- and post-measure for intervention studiesmeasure for intervention studies
�� Spatial and temporal Spatial and temporal trends at different geographical scales
WBE approach was proposed as a complementary complementary
indicator indicator of drug use
Sewage analysis CORE group (SCORE) Activities
2010 8 European Research Institutes joined
and a European Collaboration started
Objectives
�� Organize the first Organize the first EuropeEurope--wide monitoringwide monitoring
�� Establish a Establish a common protocolcommon protocol
�� Check the Check the performance of analysisperformance of analysis through an through an
interlaboratory studyinterlaboratory study
Sewage analysis CORE group (SCORE) Activities
EuropeEurope--wide monitoring (2011wide monitoring (2011--2015)2015)Results available at:
http://www.emcdda.europa.eu/topics/pods/waste-water-analysis
Interlaboratory test (2011Interlaboratory test (2011--2015) to check the quality of results2015) to check the quality of results
Each laboratory is required to analyze standards and samples analyze standards and samples spiked
at known levels and distributed by one lab – paper in preparation
European study – Regional differences
Thomas et al., STOTEN, 2012
Results from Europe-wide monitoring
LOADS mg/day/1000 people
1. How to improve data comparability data comparability ?
2. How results from WBE can be used to
integrate integrate epidemiological data?
Sewage analysis CORE group (SCORE) Activities
Best practice protocolGuidelines addressing sampling,
storage and chemical analyses
Identification of gaps
and uncertaintyMinimize or control uncertainties
Suggestions for each step of WBE
Integrate WBE results with epidemiological data
WBE: Amount of drug used Surveys: Prevalence of drug used
Population surveys compared with wastewater analysis for monitoring illicit drug consumption in Italy in 2010-2014
Ettore Zuccato, Sara Castiglioni, et al. Submitted DAD
Multidisciplinary collaborationMultidisciplinary collaboration
Collaboration with epidemiologistsepidemiologists is essential
New Insight publication New Insight publication on WBE will be presented next month by EMCDDA
20072007--8: 8: European Monitoring Centre for Drugs and Drug
Addiction (EMCDDA) EMCDDA Publications, Demonstration
Projects and international conferences
http://www.emcdda.europa.eu/wastewater-analysis
� Estimation of illicit drugs consumptioncocaine, amphetamines, ecstasy, cannabis, heroin
� Monitoring drinking habitsethyl sulphate and ethyl glucuronide
� Monitoring smoking habitscotinine and trans-3’-hydroxycotinine
Wastewater-Based EpidemiologyCurrent applications
cotinine and trans-3’-hydroxycotinine
� Identify the use of new synthetic recreational drugssynthetic cannabinoids, cathinones (NPS)
� Other potential applications related to lifestyle, health and
diet and environment (Thomas and Reid, ES&T, 2011, 45:7611)
Monitoring of drinking habitsOslo September 2009 (Reid et al., Alcohol Clin. Exp. Res. 2011)
Monitoring of smoking habitsCastiglioni et al., Tobacco Control, 2015
0.5
1.0
1.5
2.0
2.5
Loa
ds
(g/d
ay
/10
00
inh
ab
ita
nts
)
North ITALY Centre ITALY South ITALY
***
******
**
****
Back-calculation using
cotinine + trans-3’-0.0
Nicotine Cotinine trans-3'-hydroxycotinine
Loa
ds
Number of cigarettes smoked
Wastewater analysis Epidemiological survey data Difference (%)Difference (%)
Northern Italy 1695538 1701190 +0.3+0.3
Central Italy 2987243 3114850 +4+4
Southern Italy 1207092 1112987 --8%8%
cotinine + trans-3’-
hydroxycotinine
Novel synthetic stimulants
Drug Use in Adelaide, Australia (Chen et al., Forensic Science International, 2013)
Conclusions
� Wastewater Wastewater -- based epidemiology based epidemiology is a promising novel
indicator to measure drug use in a population
� The approach gives objective and updated information objective and updated information
� The approach has been refined by developing a
best practice protocolbest practice protocolbest practice protocolbest practice protocol
� Several attempts were a done to compare data –
WBE versus epidemiological data WBE versus epidemiological data
� Interdisciplinary collaboration Interdisciplinary collaboration is essential to improve
the methodologies and their comparison
ThanksSCORE GroupSCORE GroupSara Castiglioni
Lubertus Bijlsma, Adrian Covaci,
Erik EmkeFélix Hernández,
Malcolm Reid, Christoph Ort,
EMCDDAEMCDDAPaul Griffith,
Jane Mounteney, Danica Thanki, Liesbeth Vandam
COST Action ES1307
Thanks for your attention!Thanks for your attention!
Christoph Ort, Kevin V Thomas,
Alexander LN van Nuijs, Pim de Voogt, Ettore Zuccato
Compare WBE with epidemiological data
