Lisbon ADDICTIONS  Conference 2015 – Lisbon, 23‐25 September 2015

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

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 sewage treatment plants sewage treatment plants

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

Amount of  target residues Amount of  target residues entering a  sewage treatment plant per day (g/day)

Daily flow rate

AmountsAmounts

of each parent substance  parent substance   consumed by the population served by  the plant

Human metabolism

Collection of rawraw

wastewater wastewater  samples

Composite 24 h samples

Ability to provide: 

Objective Objective estimates of use

Rapid reporting on changes in the use on changes in the use at the population level

RealReal‐‐time  time  estimates –

updatedupdated

information

Identification of the use of novel substancesthe use of novel substances

A pre‐

and post‐measure for intervention studiesmeasure for intervention studies

Potentials of the WBE Approach

Spatial and temporal Spatial and temporal trends at different geographical scales

WBE approach was proposed as a complementary complementary indicator indicator of drug use

Objectives

Sewage analysis CORE group (SCORE) Activities

2010 8 European Research Institutes joinedand a European Collaboration started

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

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 protocol Guidelines

addressing sampling, storage and chemical analyses

Identification of gaps and uncertainty

Minimize or control uncertaintiesSuggestions

for each step of WBE 

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

Europe-wide monitoring –

Regional differences

Thomas et al., STOTEN, 2012

Results from Europe-wide monitoringLOADS mg/day/1000 people

Integrate WBE results with epidemiological data

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

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 collaborationCollaboration with epidemiologistsepidemiologists

is essential 

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

Identify the use of new synthetic recreational drugssynthetic cannabinoids, cathinones (NPS)

Wastewater-Based EpidemiologyCurrent applications

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 habitsItaly 2013

(Castiglioni et al., Tobacco Control, 2015)

0.0

0.5

1.0

1.5

2.0

2.5

Nicotine Cotinine trans‐3'‐hydroxycotinine

Loads(g/day/100

0 inhabitants)

North ITALY Centre ITALY South  ITALY

***

******

**

****

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%

Back‐calculation using  cotinine +

trans‐3’‐

hydroxycotinine

Novel synthetic stimulantsDrug 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 substances 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 protocol

Several attempts were a done to integrate data – WBE and epidemiological indicators WBE and epidemiological indicators 

Interdisciplinary collaboration Interdisciplinary collaboration is essential to  improve the methodologies and their integration

Thanks

Thanks for your attention!Thanks for your attention!

SCORE GroupSCORE GroupSara Castiglioni

Lubertus Bijlsma, Adrian Covaci,

Erik EmkeFélix Hernández,

Malcolm Reid, Christoph Ort,

Kevin V Thomas, Alexander LN van Nuijs,

Pim de Voogt, Ettore Zuccato

EMCDDAEMCDDAPaul Griffith,

Jane Mounteney, Danica Thanki, Liesbeth Vandam

COST Action ES1307

Compare WBE with epidemiological data

Wastewater-Based Epidemiology: a large urine testThe route of the drugs: from the consumer to the STP

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)  

Illicit DrugsIllicit Drugs

‐cocaine

‐cannabis 

‐heroin

‐amphetamines

CONSUMER

Excretes residues of 

the drugs with urine 

after the intake

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