Spain Mpox

Case Study #3 - “Spanish wastewater reveals the current spread of Monkeypox virus”

The aim of the study was to trace the community circulation of the MPXV from potentially symptomatic, asymptomatic, or presymptomatic individuals using the previous established Spanish National SARS-CoV-2 Wastewater Surveillance Network (VATar COVID-19).

Surveillance Strategy/System Design:

  • Sampling location: 20 sampling locations throughout Spain
  • Sampling site: sewage (untreated wastewater) from wastewater treatment plants
  • Sampling frequency: weekly sample collection from 20 sites
  • Sample collection method: active; grab sampling
  • Reason for sampling method(s): The grab sample method, combined with the aluminum adsorption-precipitation method to concentrate the viral particles, was previously validated when Spain did WBE for SARS-Cov-2.
  • Integration with ongoing surveillance efforts: Built upon existing COVID-19 wastewater monitoring, and enables comparison of wastewater data and clinical trends from the National Epidemiological Surveillance Network (RENACE) in Spain.
  • Detection & sequencing approach: qPCR testing only (MPXV generic and Clade II-specific), no sequencing.
  • How data will be used: Quantification of MPXV DNA in samples from different regions and comparison to clinical case counts

Ethical/Legal Considerations and Approvals:

Core ethical considerations:

  • Beneficience and non-maleficence: Approach aims to enable earlier MPXV detection, including in asymptomatic individuals, potentially preventing ongoing transmission. Positives and trend information is resolved at the level of “Autonomous Community” regional level (comparable to a state or province), and does not have the potential to lead to stigmatizing of individuals or communities beyond what is already known clinically.
  • Distributive Justice: Approach is focused on large scale WWTPs, and does not bias towards particular areas or communities. It is, however, focused on urban areas, and does not directly monitor rural populations.
  • Privacy and Autonomy: Although explicit consent is not possible at this scale, the program is coordinated by the Institute of Agrochemistry and Food Technology, IATA-CSIC, a national public health research center run by the Spanish government. Catchment sizes are large, and all data collection is just qPCR-based quantification, with no sequencing performed.
  • Data ownership and usage: Data is owned by IATA, maintained by researchers, and not made available to the public, outside of specific government reports. Data is “available on request”, but not publicly available, with limited transparency and ease of access. Data is virus quantification based, and no sequencing data is generated.

Core legal considerations:

  • Legal authorization:Study is funded and overseen by the Spanish government, with direct interaction with the Spanish Ministry of Health, which has an explicit mandate for pathogen surveillance, including via sewage. The study is coordinated by leading public health institutions and universities, that are accountable and are deploying a proportional response that is clearly necessary to understand possible undetected Mpox spread.
  • Mandatory Reporting Requirements: No reporting mandate specific to MPXV, but results were transparent and reported regularly through Ministry of Health public health surveillance reports.
  • Data Protection and Privacy: All data is de-identified and results are aggregated at the regional level for reporting, and samples are collected from large wastewater treatment plants. No personal identifiers needed, since the project is purely focused on wastewater.
  • Public Health Integration: Wastewater analyses were directly incorporated into tracking and reporting for the MPXV outbreak, and disseminated through regular reporting from the Ministry of Health.
  • Community and Indigenous Rights: Data is robustly anonymized (by nature of wastewater sampling) and in line with European Union wastewater treatment directives, and sampling does not specifically target any group or sub-population. No specific engagement with community leaders was reported, but research produced actionable information that was broadly shared to community members.

Data Analysis Approach:
The study analyzed trends and regional differences in MPXV DNA prevalence in wastewater by region, using qPCR based virus abundance quantification. Trends were directly compared to numbers of confirmed clinical cases from the Spanish Ministry of Health. No bioinformatic analyses were used since sequencing was not performed.

Data Sharing Strategy: Unfortunately, data is not publicly available, but may be available upon request to the corresponding authors.