Science of the Total Environment 755 (2021) 142575

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Science of the Total Environment

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Possible transmission of viruses from contaminated human feces and

sewage: Implications for SARS-CoV-2
Mohamed Elsamadony a,b,⁎, Manabu Fujii a, Takayuki Miura c, Toru Watanabe d
a
Department of Civil and Environmental Engineering, Tokyo Institute of Technology, Meguro-ku, Tokyo 152-8552, Japan
b
Department of Public Works Engineering, Faculty of Engineering, Tanta University, 31521 Tanta City, Egypt
c
Department of Environmental Health, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama 351-0197, Japan
d
Faculty of Agriculture, Yamagata University, 1-23 Wakaba-machi, Tsuruoka, Yamagata 997-8555, Japan

H I G H L I G H T S G R A P H I C A L A B S T R A C T

• Hand hygiene protects from the trans-

mission of COVID-19 via fecal-Oral
route.
• Personal protection tools are essential
for workers at wastewater treatment
plant.
• Virus occurrence in wastewater enable
to estimate the spread of the infected
cases.
• Aerosols might infect workers if infec-
tious SARS-CoV-2 arrived to WWTP.

a r t i c l e i n f o a b s t r a c t

Article history: Humanity has experienced outbreaks by viruses such as severe acute respiratory syndrome coronavirus 1 (SARS-
Received 3 June 2020 CoV-1) in 2003, Eastern respiratory syndrome coronavirus (MERS-CoV) in 2012, Ebola virus in 2014 and nowa-
Received in revised form 15 September 2020 days SARS-CoV-2. While clinicians seek for a vaccine to reduce the epidemic outbreak, environmental engineers
Accepted 20 September 2020
need to understand consequence of virus entity in sewage given the reported persistency of viruses in human
Available online 29 September 2020
feces and sewage environments for more than days. Herein, we discuss about concerns associated with virus oc-
Editor: Thomas Kevin V currence in human feces and sewage, with attention to the possible SARS-CoV-2 transmission routes, based on
the review of recent studies on SARS-CoV-2 as well as the previous pandemic events. Given the reported environ-
Keywords: mental stability of coronavirus, the feces- and sewage-derived transmission routes may be of importance to pre-
SARS-CoV-2 vent unprecedented spread of coronavirus disease 2019 (COVID-19) particularly in developing countries.
Wastewater However, so far, limited number of studies detected infectious SARS-CoV-2 even in human feces, whereas a num-
Transmission routes ber of virus RNA copies were identified in both feces and sewage specimens. Therefore, uncertainty remains in
Developing countries the possibility of this transmission pathway, and further investigation is warranted in future studies, for example,
by increasing the number of specimens, examining the effectiveness of methods for viral viability test, consider-
ing the patient medical history, and so forth.
© 2020 Elsevier B.V. All rights reserved.

1. Introduction
⁎ Corresponding author at: Department of Civil and Environmental Engineering, Tokyo
Institute of Technology, Meguro-ku, Tokyo 152-8552, Japan.
E-mail addresses: [email protected] (M. Elsamadony),
Nowadays, there is an increasing global fear of viral pandemics in the
[email protected] (M. Fujii), [email protected] (T. Miura), hyperconnected world. In 1918, Spanish influenza H1N1 pandemic
[email protected] (T. Watanabe). caused deaths number exceeding 50 million people (Taubenberger

https://doi.org/10.1016/j.scitotenv.2020.142575
0048-9697/© 2020 Elsevier B.V. All rights reserved.
M. Elsamadony, M. Fujii, T. Miura et al. Science of the Total Environment 755 (2021) 142575

and Morens, 2008). Since then, we have experienced viral pandemics et al., 2019). The presence of coronaviruses in the gastrointestinal
such as SARS, MERS, and Ebola virus disease with 774, 456 and 10,353 tract was previously confirmed. Their resistance against digestive en-
fatalities, respectively (ECDC, 2015; Ge et al., 2013; WHO, 2020a). zymes as well as lower pH environment is most likely due to the strong
Some respiratory viruses such as SARS-CoV-1 and MERS-CoV affiliated interaction between mucins and S protein (Holmes, 2001; van
to Coronaviridae family are known as zoonotic virus which can cause in- Doremalen et al., 2013). Indeed, 76 and 25% of patients infected by
fection in both animal (e.g., bats) and human as virus host (Woolhouse SARS-CoV-1 and MERS-CoV, respectively, experienced the gastrointesti-
and Gaunt, 2007). Emergence of mutation further causes high risk of nal symptoms (i.e., diarrhea) during their illness period (Assiri et al.,
transmission from person to person in the absence of immunity against 2013; Kwan et al., 2005), and infectious SARS-CoV-1 was isolated
novel strain (Wigginton et al., 2015). In addition, the global travel from the intestinal tissue (Lee et al., 2003). Similarly, MERS virus was re-
expanding, growing demand for food (especially animal market), and il- ported to reproduce in the human intestinal enteroids and enterically
legal trade of endangered species, may facilitate virus spreading and transmitted to transgenic mice (hDPP4) (which is similar to human tis-
evolution (Naidoo and Fisher, 2020). These facts combined with the sues; e.g., kidney and lung) (Zhou et al., 2017).
strong contagious nature as well as the environmental persistency can SARS-CoV-2 has been reported to recognize angiotensin-converting
be, at least partially, related to the unprecedented pandemic of the enzyme 2 (ACE2) as its viral receptor in human gastrointestinal tract
novel SARS-CoV-2 (posing the coronavirus disease 2019, namely, (Arslan et al., 2020). Xiao et al. (2020a, 2020b) discovered that ACE2
COVID-19), which has infected about 19.5 million people and caused protein is plentifully expressed in the glandular cells of gastric, duode-
722,285 deaths at minimum (according to World Health Organization nal, and rectal epithelia, though it is rarely seen in esophageal mucosa.
[WHO] situation report accessed on 10 August 2020) (WHO, 2020a). Additionally, Zang et al. (2020) explained that co-expression of Trans-
The SARS-CoV-2 infection has also been spreading in developing membrane Serine Protease (TMPRSS2 and TMPRSS4) with ACE2 facili-
countries including African countries. For example, increasing number tated the entry of SARS-CoV-2 into host cells in the human small
of infection cases are confirmed in South Africa (553,188 cases), Egypt intestine. Such enteric infection can be accompanied by symptoms of
(95,314), Nigeria (46,140), Ghana (40,533), Algeria (34,693) and nausea or vomiting (10.2% of total infected cases) and diarrhea
Morocco (32,007) (accessed on 10 August 2020). The number of infection (12.5%) (Cheung et al., 2020; Guan et al., 2020; Hindson, 2020). The ex-
cases are also growing in the other African countries (WHO, 2020a). Con- crement from virus-infected human has virus loads ranging from 105 to
sequently, particular concerns should be given to developing countries for 1013 copies per gram of feces in case for viruses listed in Table 1 (with
mitigating the spread of SARS-CoV-2 especially in low-income and daily human sheds approximately 100 g feces/person) (Fechner et al.,
densely populated area that suffer from limited healthcare facilities, as 2013; Timm et al., 2013). In case of SARS-CoV-2, the PCR-positive
well as limited access to safe water and sufficient hygiene (Brauer et al., feces' specimens in France had the virus load of 106.8–108.1 copies/g
2020). Nearly 60% of Sub-Saharan Africa population subsist in slum condi- (note that the positives were 2 out of 5 patients investigated) (Lescure
tions with lack of basic sanitation such as sewer collection networks. Nai- et al., 2020). Urine samples were free of SARS-CoV-2 in the same
robi and Uganda, for example, use mainly latrines, small-bore sewers and study, though the study in China suggested possible occurrence of the
natural wetlands for the sewage treatment. The coverage of centralized virus in urine in case of severe infection (Zhang et al., 2020b). In any
wastewater treatment technologies (e.g., activated sludge, trickling filters, cases, however, the feces samples frequently hold the viral RNA
stabilizing lagoons and oxidation ditch) are limited in Africa (Wang et al., (e.g., 10 out of 12 feces samples with average concentration of 5623
2014). According to the recent report of United Nation (UN), Egypt and copies/mL in case of the study in China) for a long period
Tunisia sustain 51 to 75% of safely treated wastewater, while Morocco (e.g., extending 22 days of disease, and interestingly, the virus remained
has 26 to 50% of achievement with the rest of African countries having ei- in fecal even 26 days after the patient recovery) (Zhang et al., 2020b).
ther less than 25% or insufficient data (WHO, 2018). Kingsbury et al. (2020) hypothesized that nasal passage mucus in-
While SARS-CoV-2 is transmitted mainly from person to person via gestion is the reason behind the occurrence of high RNA copies of
respiratory droplet and contagious routes (thus community behavior SARS-CoV-2 in the gastrointestinal tract, though this is unlikely the
is a key in the pandemic trajectory) (Naddeo and Liu, 2020; La Rosa case. For example, it is reported that those who became negative with
et al., 2020a), this respiratory virus is also confirmed to be excreted in nasopharyngeal RT-PCR test persistently showed positive in the rectal
human waste (Chen et al., 2020a). Thus, fecal-oral contamination swabs test (Chen et al., 2020a; Hindson, 2020; Zhang et al., 2020b). Fur-
route may be one of concerns in developing countries holding insuffi- ther, Wu et al. (2020) demonstrated that viral load shed from the diges-
cient sanitation system (Lodder and de Roda Husman, 2020). Further, tive tract was usually higher than that for the respiratory tract.
even in the countries with safe sanitation systems such as wastewater Therefore, the continuous positive detection of viral RNA from feces
treatment plants (WWTPs), sewage-associated virus transmission suggests that the infectious viruses are secreted from the virus infected
routes are still reported to exist for some viruses (e.g., via inhalation of gastrointestinal cells (Xiao et al., 2020b).
virus-loaded sewage aerosols) (Brinkman et al., 2017; Drossinos and To date, some studies reported that infectious SARS-CoV-2 was de-
Stilianakis, 2020), despite the fact that current technologies used in tected from the PCR-positive stool specimens mainly using the method
sewer system can be effective in safe transport of sewage and removal of Vero cells, as listed in Table 2 (Jeong et al., 2020; Wang et al., 2020;
of some pathogens (Qiao et al., 2018; Ye et al., 2018). Accordingly, we Xiao et al., 2020b, 2020a; Zhang et al., 2020a). Among these studies,
herein discuss concerns on the occurrence of viruses in human feces the study by Wang et al. (2020) detected infectious virus in stool spec-
and sewage with attention given to the possible SARS-CoV-2 transmis- imens of patients even with no symptoms of diarrhea. In contrast, infec-
sion via fecal-oral route and sewage-derived aerosol routes, which is of tious virus was undetectable from the treatments of urine and stool
particular concern in the developing countries. We also discuss the chal- specimens using the Vero cells in the study by Jeong et al. (2020),
lenges in future study and summarize precautions for the possible fecal- though viral RNA loads were higher than 20 copies/ml. Interestingly,
and sewage-derived transmission. ferrets intranasally inoculated with the same stool and urine specimens
witnessed the increased body temperature and rhinorrhea, suggesting
2. Fecal-oral transmission the occurrence of infectious virus undetectable by the Vero cells.
Zang et al. (2020) simulated the reactions taken place in gastrointes-
To obtain viable and infectious virus particles in feces, virus must tinal tract using gastric fluid [FaSSGF at pH 1.6], small intestinal fluid
survive after experiencing variety of chemically harsh environments. [FaSSIF-V2 at pH 6.5] and colonic fluid [FaSSCoF at pH 7.8] (purchased
In the gastrointestinal tract, virus structure will be in contact with the from Biorelevant.com Ltd) to mimic the human gastrointestinal condi-
stomach and bile acids. Furthermore, virus needs to keep infectious tions. The authors found that the low pH of gastric fluids significantly re-
after released to the environment to infect a new host (Bushman duced the infectious ability of virus after 10 min of exposure. In addition,

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M. Elsamadony, M. Fujii, T. Miura et al. Science of the Total Environment 755 (2021) 142575

Table 1
Previous studies on virus occurrence in human feces, sewage and sewage-associated aerosols.

Virus Structure and diameter of Disease and viral load at human feces Virus concentration in wastewater Virus concentration in aerosols released
the virus from wastewater

The survival of SARS-COV-2 in

wastewater was confirmed by some
Recent study found the virus in toilets'
The virus causes respiratory and enteric studies (Lodder and de Roda Husman,
Enveloped (+) ssRNA aerosols with concentration of 19
symptoms (Yeo et al., 2020). It was found in 2020; Wurtzer et al., 2020). A French
virus with copies/m3. High viral loaded aerosols
SARS-CoV-2 fecal samples with different concentration study found that virus concentration in
diameter ~ 50–200 nm was associated with the aerodynamic
range from 105.6 to 108.1 copies/g (Lescure wastewater was directly proportional to
(Chen et al., 2020b). diameter in the range 0.25–0.5 μm (Liu
et al., 2020; Zhang et al., 2020b). number of fatal cases in range from 105
et al., 2020).
to 106.5 copies/L (Wurtzer et al., 2020).
The lifetime is not determined.
Average concentration of SARS-CoV-1
SARS-CoV-1 was found in wastewater
was determined to be 144
Enveloped (+) ssRNA The virus causes respiratory and enteric aerosols during Hong Kong outbreak in
plaque-forming units (PFU)/mL in
virus with symptoms and its viral load at human feces 2003. The airborne aerosols were
SARS-CoV-1 wastewater (Wang et al., 2005). The life
diameter ~ 60–220 nm was found to be around 107 copies/g (Hung generated from leaked pipe, resulting in
time of SARS-CoV-1 in wastewater was
(Gundy et al., 2009) et al., 2009). the infection of 319 cases (Naddeo and
2–3 days with log10 reduction ranging
Liu, 2020; Wigginton et al., 2015).
from 2.0 to 3.4 (Gundy et al., 2009)
Among tested, 9 out of 16 wastewater
aerosol samples were positive with
highest virus concentration of 3.2 × 102
copies/m3. Samples were collected from
grit chamber and aeration tank of
activated sludge with sampling place
80 cm higher than the wastewater
Nonenveloped (+) ssRNA The virus causes gastroenteritis (with surface (Matsubara and Katayama,
The reported virus concentration at
virus with symptom of vomiting and diarrhea). Viral 2019)
Norovirus WWTPs is ≤109 copies/L (Wigginton
diameter ~ 23–40 nm load at human fecal sample is 109 copies/g
et al., 2015).
(Hasegawa et al., 2017) (Lee et al., 2007). Aerosol samples were collected from
two sites near the rack of grit removal
chamber and aeration tank, and 3 out of
123 samples were found to be positive
(though concentrations were under
detection limit). Sampling place was
1.5 m above the basin's surface
(Masclaux et al., 2014).
Aerosol samples were collected from
Respiratory and gastrointestinal diseases are 1.5 m above of grit removal chamber
Nonenveloped dsDNA
caused by infection with this virus. Infected The reported virus concentration in and aeration tank water surface. Positive
virus with
Adenovirus human stool has adenovirus load in the range wastewater is ≤108 copies/L (Wigginton samples were 123 out of 123 and
diameter ~ 80–90 nm
from 105 to 1013 copies/g (Elmahdy et al., et al., 2015). maximum virus concentration was
(Delmdahl, 2006)
2019). 2.27 × 106 copies/m3 (Masclaux et al.,
2014)
Air samples were collected from four
Nonenveloped dsRNA Rotavirus causes gastroenteritis with diarrhea WWTPs, where 6 out of 10 samples were
Virus concentration in wastewater
virus with and was found at high concentrations up to positive, and maximum and minimum
Rotavirus 10 ranges ≤107 copies/L (Wigginton et al.,
diameter ~ 75 nm (Yates, 10 copies in gram of feces (Ruggeri et al., virus concentrations were 2.2 × 105 and
2015).
2014) 2015). 1.7 × 104 copies/m3, respectively
(Brisebois et al., 2018)
Concentration of Ebola model viruses (MS2
and Phi) in aerosols was investigated,
Enveloped (−) ssRNA indicating that virus was not loaded at
Ebolavirus can survive for 1 day in
virus with Ebola disease causes severe diarrhea and virus aerosols released from the toilet, while
7 wastewater and ~ 94% remains in the
Ebolavirus diameter ~ 80 nm and its human feces was found at around 10 virus was detected in the aerosols released
mobile liquid phase (Lin and Marr,
length is around 1 μm copies/mL (Lin and Marr, 2017). from aeration chamber at concentrations
2017).
(Vingolo et al., 2015). of 20 and 0.1 plaque-forming units (PFU)/L
for MS2 and Phi, respectively (Lin and
Marr, 2017).

although synthetic small intestinal and colonic fluids have neutral pH of Chan et al. (2020) tested virus stability in different environmen-
6.5 and 7.8, the infective titers of SARS-CoV-2 significantly decreased tal conditions by releasing the infectious virus to external environ-
(only small number of infectious SARS-CoV-2 was detected after 24 h) ment via fecal shedding. The results indicated that SARS-CoV-2
due most likely to the bile and digestive enzymes in small intestine, as remained viable for 7 days in solution at room temperature (25 °C),
well as the dehydration and exposure to multiple bacterial byproducts while the virus lost its infectious ability within 1 day at warmer tem-
synthesized in the colon. Despite the findings by Zang et al. (2020), perature of (37 °C). Further, the authors demonstrated that SARS-
some studies detected infectious SARS-CoV-2 in stool samples CoV-2 was unable to survive at pH 2 and 3, whereas the virus
(Table 2). The reason behind can be that Zang et al. (2020) utilized remained viable for 1 day in conditions of pH 4 and 11. Further, in
the fixed pH for gastrointestinal fluids, while the fluid pH can be variable pH range from 5 to 9, SARS-CoV-2 lost its infectivity by 2.9 and 5.3
from person to person, for example, due to the atrophic gastritis or uti- logs after 6 days. The authors also found that the virus remained vi-
lization of proton pump inhibitor medications (ELetters-Science Immu- able for 1–2 days in watery stool specimen at room temperature
nology, 2020). (25 °C) with loss of infectivity by 5 logs.

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M. Elsamadony, M. Fujii, T. Miura et al. Science of the Total Environment 755 (2021) 142575

Table 2
Studies that detected infectious SARS-CoV-2 in human excreta.

Specimen Genetically positive result relative to all Occurrence of infectious viruses Methods References
types samples

Stool 44 of 153 (29%) Not quantified Detection and quantification of RNA were
2 of 6 (33%) performed using reverse
Stool 6 of 20 (30%) transcription-polymerase chain reaction (Wang
Note: Patients did not have diarrhea. (RT-PCR) and real-time RT-PCR (RT-PCR). et al.,
Virus isolation in Vero cells and subsequent 2020)
Urine Not detected Not detected electron microscopy observation was performed
to detect live virus
39 of 73(53%)

Note: Positive stool results spanned from 1 to RNA was detected via RT-PCR tools. (Xiao
Stool 12 days after commencement of illness. In Infectious SARS-CoV-2 detected (not quantified) Viral nucleocapsid staining was performed using et al.,
addition, 17 (23%) patients remained to have laser scanning confocal microscopy 2020b)
positive results in stool after showing negative
results in respiratory samples.
12 of 28 (42.8%)

Detection and quantification of SARS-CoV-2 RNA (Xiao

Note: Viral load was higher in feces than in
Stool 2 of 3 (66.67%) were performed via RT-PCR tools. et al.,
respiratory specimens collected at multiple
Vero cells were used for virus isolation. 2020a)
time sampling (i.e., 17–28 days after symptom
onset)
(Zhang
Virus was isolated using Vero cells, and then
Stool 1 of 1 (100%) 1 of 1 (100%) et al.,
detected using electron microscopy
2020a)
5 of 5 (100%)
Occurrence of SARS-CoV-2 was not detected in Detection and quantification of SARS-CoV-2 RNA
Stool urine and stool samples via Vero cells though the were performed via RT-PCR devices. Vero cells
Note: Virus loads were 1.17 ± 0.32 log10
specimens had high viral loads. However, were used for virus isolation. Cells were (Jeong
copies/ml
intranasally inoculated ferrets with urine and monitored daily for 4 days to examine the et al.,
5 of 5 (100%)
stool specimens witnessed increase in body cytopathic effects. Infection of ferrets with 2020)
Urine temperature and rhinorrhea, showing the clinical specimens' method was used to assess
Note: Virus loads were 1.08 ± 0.16–2.09
occurrence of infectious virus. the occurrence of infectious virus.
± 0.85 log10 copies/ml

In summary, the possibility of fecal-oral infection remains in debate. In addition to the sewage pipes, other household sanitation facilities
Thus, further research is needed to examine possible occurrence of such as pressure-assisted toilets are considered as possible sources of
fecal-oral transmission. Particularly, the patient medical history should COVID-19 infection. A study at two different Wuhan hospitals investi-
be recorded, since the credibility of the result can be affected by patient gated the airborne SARS-CoV-2, showing high viral load (19 copies/
health condition and associated prescription (e.g., drugs to facilitate di- m3) in aerosols at the toilets zone and the continual use of disinfection
gestion, reduce the acidity of stomach, or to treat the colon). Moreover, was forced to inactivate the virus in aerosols (Liu et al., 2020). The
studies on oral transmission of coronaviruses (i.e., foodborne or water- same study recommended to flush the toilet with the lid down where
borne ingestion) are still insufficient and further research is necessary available and minimize the usage of public bathrooms until this pan-
(Hoseinzadeh et al., 2020; Olaimat et al., 2020). Therefore, the occur- demic pass away (Liu et al., 2020; WHO, 2020). Li et al. (2020) also sim-
rence of fecal-oral transmission route should be warranted in further ulated the trajectories of aerosol particles during flushing the toilet, and
detailed studies for SARS-CoV-2, even though there are no reports on found that 40%–60% of particles reach above the toilet seat (107 cm
the presence of fecal-oral transmission. from the ground), potentially leading to the large-scale dispersion of
Another concern is the inhalation or aspiration of fecal particles, as virus in atmosphere. More recent study by Feng et al. (2020) investi-
well as its direct contact with skin and eyes (Hoseinzadeh et al., gated virus occurrence in aerosols from healthcare facilities found that
2020). During the SARS-CoV-1 outbreak in Hong Kong, 2003, the leak- SARS-CoV-2 RNA was positive for 2 (out of 6) samples with concentra-
age in household sewage pipe was likely associated with 319 infection tions of 4 and 2 copies/cm2 after defecation and toilet flushing, respec-
cases due to the spread of aerosolized fecal particles (Naddeo and Liu, tively. In addition, the virus RNA was detected for 1 (out of 6) sample
2020; Wigginton et al., 2015). Dense interconnected sewage pipes via with concentration of 2 copies/cm2 at floor of drainage system.
tees, ferrules and other fitting devices may have high opportunities to Least develop countries (LDCs) that suffer from the lack of basic san-
be busted and leaked, causing the spread of contaminated sewage. itation infrastructure can be more susceptible to the spread of the antic-
Thus, some precautionary measures to prevent clogging of plumbing ipated fecal-oral or fecal-inhalation transmission routes especially for
system such as use of U-bend pipes at bathrooms and kitchen has the countries where COVID-19 has been already or started spreading
been highly recommended in such cases. Controlled sealing of all pipe (Ober, 2020). The risk of exposure to the contaminated wastewater
connection should be also periodically checked (Gormley et al., 2020). aerosols can be increased in shared sanitation practice for crowded in-
Due to the insufficient compliance with aforementioned precautionary formal settlements in developing countries (Gwenzi, 2020). LDCs con-
measures, the COVID-19 group infection occurred in a high-rise building sist of 47 countries, and 33 of them are in the middle Africa. In most of
located in Guangzhou, China, where nine infected patients were identi- these African countries, less than 25% of people can access to safely
fied in three families living in three vertically aligned flats connected by managed sanitation, and there are totally two billion people worldwide
drainage pipes in the master bathrooms. The PCR-positive environmen- lack with basic sanitation (WHO, 2018). Regardless of the debates on
tal samples generally suggest the vertical spread of virus-laden aerosols occurrence of fecal-oral transmission, caution needs to be taken to re-
(Conticini et al., 2020). Further, Fears et al. (2020) demonstrated that duce the risk of virus outbreak via this route particular for developing
SARS-CoV-2 remained infectious for 16 h in the aerosol based on the countries with low healthcare facilities and poor sanitation as well as
laboratory experiment. lack of awareness about potential risk (Crocker et al., 2016a; Miesler

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M. Elsamadony, M. Fujii, T. Miura et al. Science of the Total Environment 755 (2021) 142575

et al., 2020; Tilley et al., 2014). Table S1 summaries some of general les- causal relation between aerosol sizes and infection symptoms, in
sons obtained from previous studies in developing countries to mitigate which aerosols with aerodynamic diameters ranging from 5 μm to
the health risk from fecal contamination. Briefly, human hands (partic- 10 μm were found to be able to adhere the nose and oral cavity causing
ularly on children's hand) can be highlighted as a major vector in the disease (i.e., rhinitis), in case that aerosols carry viruses capable of in-
fecal-oral transmission route for most developing countries owing to fecting the entourage (Tellier et al., 2019). The aerosol with diameter
some specific habits such as open defecation (Clasen et al., 2012). Per- less than 5 μm can reach the alveoli and smaller particles less 3.3 μm
sonal hygiene is also commonly considered as the major protective have been identified as respirable fraction with higher infectious risk
shield against virus infection via fecal transmission route (Crocker to the lower respiratory tract (Han et al., 2020; Tellier et al., 2019).
et al., 2016b; Rah et al., 2015). Consequently, governments of develop- Mechanisms of aerosol generation at WWTPs were well investigated
ing countries should provide adequate amount of soap and increase in previous studies, though little studies were addressed in context of
the awareness of keeping the hand clean towards citizen. Other impor- the virus occurrence (note that virus occurrence in sewage-derived
tant vectors include contamination of water storage devices with sew- aerosol is described below). In the aeration process, a large assortment
age as consequence of improper sanitation practice. For example, of aerosols is potentially formed. For example, when a bubble with di-
household water treatments (HWT) such as boiling and chlorination ameter ~ 600 μm is injected from the bottom of the reactors, it ruptures
are recommended in rural areas, though the selected methods should at the water surface to approximately five small droplets (diame-
fit to the user adherence to grantee its effective use (Lantagne and ter ~ 60 μm) forming aerosols that may travel up to ~8 cm above the
Clasen, 2012; McGuinness et al., 2020). water surface (Piqueras et al., 2016). However, the aerosols generation
Further, WHO currently supports LDCs' governments with providing can be affected by operational parameters such as aeration rate and dif-
adequate number of instruments for SARS-CoV-2 detection as well as fuser type, as well as, weather conditions (i.e., temperature and humid-
increasing the capacity of health-care professionals to improve their ity) (Noh et al., 2019). Further, Bauer et al. (2002) indicated emission of
surveillance ability (Payne, 2020). More effort, however, should be airborne aerosols is reactor type dependent, where the aeration reactor
made from the governments in terms of spreading health awareness of activated sludge showed higher aerosols emission compared to the
and emphasizing on the personal hygiene between the communities biological fixed oxygen reactor (e.g., fixed biofilm reactor type with
to suppress the probability of COVID-19 spread via multiple routes. open-air water surface). In addition to the aeration reactor for activated
sludge treatment, aerosol release was also observed from coarse screen,
3. Sewage-derived transmission aerated grit chamber, primary settling tank and reactors with mixing
devices such as sludge dewatering devices, (Han et al., 2018; Yang
The occurrence of infectious SARS-CoV-2 in human excreta et al., 2019).
(i.e., feces and urine in severe cases) indicates the potential of virus sur- Regarding the mitigation of aerosols formation at WWTPs, Bauer
vival in our sewage systems (Collivignarelli et al., 2020). The viability of et al. (2002) advised to reduce the surface area of the reactor where pos-
enveloped viruses in wastewater was previously investigated. For ex- sible, which potentially prevents the spread of infection via inhalation,
ample, Ye et al. (2016) found that enveloped viruses (murine hepatitis skin-contact, and ingestion. Additionally, micro-bubbles aerators are ca-
virus and Pseudomonas phage Φ6 as models) retained their infectious pable of reducing the wastewater aerosol generation compared to
ability for a day in wastewater, where 26% of the two enveloped viruses macro-bubbles type (Temesgen et al., 2017). The micro-type also has
were adsorbed to the solid fraction. In case of Ebola virus (another the benefits of oxygen content enrichment and higher oxygen transfer
enveloped virus), 90% inactivation was observed after 2 days' residence rate in the liquid phase (Terasaka et al., 2011). There are various type
in domestic wastewater. This significant reduction is likely due to the of micro-bubbles generators (i.e., spiral liquid flow, venturi, ejector
adsorption of viral particles to wastewater particles (Bibby et al., and pressurized dissolution types) that can sustain oxygen bubbles
2015). On the other hand, the period when 90% inactivation was with diameter in the range of 10–50 μm (Parmar and Majumder, 2013).
achieved for phage Φ6 (enveloped virus model) varied from 24 min to While different environmental stability of enveloped virus
117 days depending on the temperature and composition of aqueous (e.g., coronaviruses and Ebola virus) from non-enveloped virus
media employed (Aquino De Carvalho et al., 2017). Regarding the first (e.g., norovirus, adenovirus, and rotavirus) should be carefully consid-
SARS pandemic, SARS-CoV-1 RNA was detected in the sewage of hospi- ered, non-enveloped viruses are often detected in sewage aerosols
tals treating the infected patients. The inactivation of SARS-CoV-1 was (Table 1). For example, adenovirus was earlier detected in airborne
assessed under different conditions. For example, SARS-CoV-1 was aerosols collected from 31 WWTPs in Switzerland especially from
found to retain its viability at hospital sewage for 2 weeks at 4 °C, and screening site and aeration tank (Masclaux et al., 2014). In many of
2 days at 20 °C (Wang et al., 2005). Further, lifetime of SARS-CoV-1 countries (particularly developing countries), WWTPs generally consist
(~3-log reduction) was determined to be 2–3 days in sewage and up of basic primary and secondary treatment stages, where most of such
to 10 days in tap water at 23 °C (Gundy et al., 2009). Regarding SARS- reactors (or tanks) are not covered: thus higher emission of sewage-
CoV-2 (which shares 82% genetic similarity with SARS-CoV-1 (Arslan derived aerosol is expected (Awad et al., 2019). A previous study in
et al., 2020)), this virus is reported to have the environmental stability Japanese WWTPs (equipped with grit chamber, closed aeration [acti-
comparable to SARS-CoV-1 (Taylor et al., 2020). vated sludge] reactor and settling tank) indicated that the virus-
Apart from its viability, occurrence of SARS-CoV-2 RNA in wastewa- contaminated aerosols (i.e., noroviruses and adenoviruses) were highly
ter has been reported in a number of recent studies. In Amsterdam, for released from grit chamber, whereas the closed aeration reactor sub-
example, SARS-CoV-2 RNA was detected in wastewater by using RT- stantially reduced virus-loaded aerosol formation showing the impor-
PCR in 4 days after the emergence of first COVID-19 case (Lodder and tant role of closed system in mitigating contaminated aerosol
de Roda Husman, 2020). Similarly, the quantitative measurement of formation (Matsubara and Katayama, 2019). On the other hand, the
SARS-CoV-2 RNA at three major WWTPs in Paris witnessed the increase study by Haas et al. (2017) on Ebola virus as enveloped virus suggests
of viral gene abundance, which corresponded to the reported number of the higher risk of Ebola virus infection via inhalation of sewage aerosols
fatal cases in upstream cities (Wurtzer et al., 2020). Therefore, increas- holding the virus.
ing interest and attention have been given to the wastewater surveil- Practitioners in WWTPs were previously infected with non-
lance for epidemic warning (Ahmed et al., 2020; Hata and Honda, enveloped virus via inhalation of wastewater aerosols. For example, at
2020; Kitajima et al., 2020; Noise, 2020; La Rosa et al., 2020b). the secondary treatment zone in Canadian WWTP, three workers
Other important concerns include virus infection via inhalation of were infected by hepatitis A virus owing to high abundance of contam-
sewage aerosols that may occur if inhaled aerosols retain the sufficient inated aerosols (De Serres and Laliberté, 1997). Moreover, 37% of the
concentration of infectious virus (LeChevallier et al., 2020). There is a workers in Danish WWTP suffered from gastrointestinal symptoms,

5
M. Elsamadony, M. Fujii, T. Miura et al. Science of the Total Environment 755 (2021) 142575

which was likely caused by the inhalation of sewage aerosols loaded Appendix A. Supplementary data
with noroviruses. Indeed, 1.4 × 103 copies of noroviruses were collected
from the aerosols using dust filter, which was orders of magnitudes Supplementary data to this article can be found online at https://doi.
higher than the infectious dose (e.g., 18 viral copies) (Uhrbrand et al., org/10.1016/j.scitotenv.2020.142575.
2011).
Until now there are no reports showing infected cases by enveloped References
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