ARCHIVES
VOL. 8, ISSUE 3 (2026)
Wastewater-based epidemiology as a sentinel surveillance tool for antimicrobial resistance in low- and middle-income countries: A critical narrative review of methodological advances, implementation barriers, and equity considerations (2019–2026)
Authors
Vica Hilda Amelia, Muhammad Hamza Mubarak, Yaltafit Abror Jeem
Abstract
Antimicrobial resistance (AMR) is projected to
remain one of the defining public health threats of this century, yet clinical
surveillance in low- and middle-income countries (LMICs) continues to capture
only a fraction of the true resistance burden. Wastewater-based epidemiology
(WBE), long associated with poliovirus and SARS-CoV-2 tracking, has re-emerged
as a population-level complement to clinical AMR surveillance because it is
culture-independent, requires no individual consent for sample collection, and
can capture asymptomatic carriage and community-level transmission dynamics
that clinical sampling frames tend to miss. This narrative review synthesizes
evidence published largely between 2019 and 2026 on the methodological
maturation of wastewater-based AMR surveillance, its uneven geographic
deployment, and the structural barriers that continue to limit its scale-up in
resource-constrained settings. Methodologically, the field has moved from
culture-based indicator organisms toward quantitative PCR gene panels, shotgun
and long-read metagenomics, and, more recently, machine-learning-assisted
signal interpretation, each carrying distinct trade-offs in sensitivity, cost,
and infrastructure demand. Evidence from LMIC catchments in sub-Saharan Africa,
South Asia, and the Middle East demonstrates technical feasibility even under constrained
conditions, yet these programmes remain donor-dependent, methodologically
heterogeneous, and rarely linked to national AMR action plans. Four
interlocking barriers are identified: inadequate sanitation and sewer
infrastructure, limited laboratory and bioinformatics capacity, fragile and
non-recurrent financing, and weak governance mandates for translating signals
into policy response. The review also examines unresolved ethical tensions
around community-level data, stigma, and consent, and considers how
justice-oriented governance frameworks might be adapted to environmental AMR
surveillance. It concludes that wastewater-based AMR surveillance holds genuine
promise for closing LMIC-specific gaps in the Global Antimicrobial Resistance
and Use Surveillance System, but only if methodological harmonization,
sustainable financing, and community-centred governance are pursued as a
single, coordinated agenda rather than as separate technical, financial, and
ethical projects.
Download
Pages:43-56
How to cite this article:
Vica Hilda Amelia, Muhammad Hamza Mubarak, Yaltafit Abror Jeem "Wastewater-based epidemiology as a sentinel surveillance tool for antimicrobial resistance in low- and middle-income countries: A critical narrative review of methodological advances, implementation barriers, and equity considerations (2019–2026)". International Journal of Medical Science and Clinical Research, Vol 8, Issue 3, 2026, Pages 43-56
Download Author Certificate
Please enter the email address corresponding to this article submission to download your certificate.