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SARS-CoV-2 has been detected in wastewater and its abundance correlated with community COVID-19 cases, hospitalizations and deaths. We sought to use wastewater-based detection of SARS-CoV-2 to assess the epidemiology of SARS-CoV-2 in hospitals. Between August and December 2020, twice-weekly wastewater samples from three tertiary-care hospitals (totaling >2100 dedicated inpatient beds) were collected. Hospital-1 and Hospital-2 could be captured with a single sampling point whereas Hospital-3 required three separate monitoring sites. Wastewater samples were concentrated and cleaned using the 4S-silica column method and assessed for SARS-CoV-2 gene-targets (N1, N2 and E) and controls using RT-qPCR. Wastewater SARS-CoV-2 as measured by quantification cycle (Cq), genome copies and genomes normalized to the fecal biomarker PMMoV were compared to the total daily number of patients hospitalized with active COVID-19, confirmed cases of hospital-acquired infection, and the occurrence of unit-specific outbreaks. Of 165 wastewater samples collected, 159 (96%) were assayable. The N1-gene from SARS-CoV-2 was detected in 64.1% of samples, N2 in 49.7% and E in 10%. N1 and N2 in wastewater increased over time both in terms of the amount of detectable virus and the proportion of samples that were positive, consistent with increasing hospitalizations at those sites with single monitoring points (Pearson's r=0.679, P<0.0001, Pearson's r=0.799, P<0.0001, respectively). Despite increasing hospitalizations through the study period, nosocomial-acquired cases of COVID-19 (Pearson's r =0.389, P<0.001) and unit-specific outbreaks were discernable with significant increases in detectable SARS-CoV-2 N1-RNA (median 112 copies/ml) versus outbreak-free periods (0 copies/ml; P<0.0001). Wastewater-based monitoring of SARS-CoV-2 represents a promising tool for SARS-CoV-2 passive surveillance and case identification, containment, and mitigation in acute- care medical facilities.

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A ranking system for contaminated sites based on comparative risk methodology using fuzzy Preference Ranking Organization METHod for Enrichment Evaluation (PROMETHEE) was developed in this article. It combines the concepts of fuzzy sets to represent uncertain site information with the PROMETHEE, a subgroup of Multi-Criteria Decision Making (MCDM) methods. Criteria are identified based on a combination of the attributes (toxicity, exposure, and receptors) associated with the potential human health and ecological risks posed by contaminated sites, chemical properties, site geology and hydrogeology and contaminant transport phenomena. Original site data are directly used avoiding the subjective assignment of scores to site attributes. When the input data are numeric and crisp the PROMETHEE method can be used. The Fuzzy PROMETHEE method is preferred when substantial uncertainties and subjectivities exist in site information. The PROMETHEE and fuzzy PROMETHEE methods are both used in this research to compare the sites. The case study shows that this methodology provides reasonable results.

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