Age-dependent association between SARS-CoV-2 cases reported by passive surveillance and viral load in wastewater

The actual number of individuals infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is difficult to estimate using a case-reporting system (i.e., passive surveillance) alone because of asymptomatic infection. While wastewater-based epidemiology has been implemented as an alternative/additional monitoring tool to reduce reporting bias, the relationship between passive and wastewater surveillance data has not yet been explicitly examined. As there is strong age dependency in the symptomatic ratio of SARS-CoV-2 infections, here, we aimed to estimate i) an age-dependent association between the number of reported cases and viral load in wastewater and ii) the time lag between these time series. The viral load in wastewater was modeled as a combination of contributions from virus shedding by different age groups, incorporating the delay, and fitted with daily case count data collected from the Massachusetts Department of Public Health and SARS-CoV-2 RNA concentration in wastewater recorded by the Massachusetts Water Resources Authority. The estimated lag between the time series of viral loads in wastewater and of reported cases was 10.8 (95% confidence interval: 10.2-11.6) and 8.8 (8.4-9.1) days for the northern and southern areas of the wastewater treatment plant, respectively. The estimated contribution rate of a reported case to the viral load in wastewater in the 0-19 yr age group was 0.38 (0.35-0.41) and 0.40 (0.37-0.43) for the northern and southern areas, and that in the 80+ yr age group was 0.67 (0.65-0.69) and 0.51 (0.49-0.52) for the northern and southern areas, respectively. The estimated lag between these time series suggested the predictability of reported cases 10 days later using viral loads in wastewater. The contribution of a reported case in passive surveillance to the viral load in wastewater differed by age, suggesting a large variation in viral shedding kinetics among age groups.