Bridging wastewater and case surveillance reveals the hidden burden of the 2022 mpox outbreak dynamics

Bridging wastewater and case surveillance reveals the hidden burden of the 2022 mpox outbreak dynamics | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging wastewater and case surveillance reveals the hidden burden of the 2022 mpox outbreak dynamics Caroline N Mburu, Aidan M Nikiforuk, Ana C Marquez, Agatha N Jassem, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8929243/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract Transmission models of the 2022 global mpox outbreak relied on case data to infer transmission dynamics despite substantial underascertainment driven by barriers to testing and care. Wastewater-based surveillance (WBS) captures community viral shedding independent of healthcare access, yet how it can be integrated with case data to improve infection estimates remains unclear. We developed a compartmental model integrating case-notifications, wastewater viral-load, sexual network structure, and vaccination to evaluate how WBS complements case surveillance. Three model variants were fitted and validated using serological data: i) case-only, ii) wastewater-only and iii) combined. The case-only model reproduced incidence but not wastewater dynamics, whereas the wastewater-only model captured viral load trends but overestimated peak incidence. Joint calibration reconciled both data streams, yielding more precise estimates of infection burden, including a peak prevalence of 344 infections (95% CrI: 230-494) and a cumulative incidence of 1,132 (95% CrI: 943-1,349). Model-predicted seroprevalence aligned with that observed among sexual health clinic attendees, providing external validation. The wastewater-case model revealed infection underascertainment, time-varying contributions of sexual activity groups to wastewater signals and showed that wastewater lead-lag relationships depended on epidemiological and operational conditions. Together, these findings establish integrated wastewater-case modelling as a robust framework for epidemic reconstruction. Health sciences/Diseases Earth and environmental sciences/Environmental sciences Health sciences/Health care Physical sciences/Mathematics and computing Full Text Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.pdf Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8929243","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":605134859,"identity":"5fcf61cf-7dd8-407a-994b-d003b679b40d","order_by":0,"name":"Caroline N 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Wastewater-based surveillance (WBS) captures community viral shedding independent of healthcare access, yet how it can be integrated with case data to improve infection estimates remains unclear.\nWe developed a compartmental model integrating case-notifications, wastewater viral-load, sexual network structure, and vaccination to evaluate how WBS complements case surveillance. Three model variants were fitted and validated using serological data: i) case-only, ii) wastewater-only and iii) combined. The case-only model reproduced incidence but not wastewater dynamics, whereas the wastewater-only model captured viral load trends but overestimated peak incidence. Joint calibration reconciled both data streams, yielding more precise estimates of infection burden, including a peak prevalence of 344 infections (95\\% CrI: 230-494) and a cumulative incidence of 1,132 (95\\% CrI: 943-1,349). Model-predicted seroprevalence aligned with that observed among sexual health clinic attendees, providing external validation.\nThe wastewater-case model revealed infection underascertainment, time-varying contributions of sexual activity groups to wastewater signals and showed that wastewater lead-lag relationships depended on epidemiological and operational conditions. 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