Abstract
BACKGROUND: The prolonged viral shedding from the gastrointestinal tract is well documented for numerous pathogens, including SARS-CoV-2. However, the impact of prolonged viral shedding on epidemiological inferences using wastewater data is not yet fully understood. METHODS: To gain a better understanding of this phenomenon at the population level, we extended a wastewater-based modeling framework that integrates viral shedding dynamics, viral load data in wastewater, case report data, and an epidemic model. RESULTS: Our results indicate that as an outbreak progresses, the viral load from recovered individuals gradually becomes predominant, surpassing that from the infectious population. This phenomenon leads to a dynamic relationship between model-inferred and reported daily incidence over the course of an outbreak. Sensitivity analyses on the duration and rate of viral shedding for recovered individuals reveal that accounting for this phenomenon can considerably advance prediction of transmission peak timing. Furthermore, extensive viral shedding from the recovered population toward the conclusion of an epidemic wave may overshadow viral signals from newly infected cases carrying emerging variants, which can delay the rapid recognition of emerging variants based on viral load. CONCLUSIONS: These findings highlight the necessity of integrating post-recovery viral shedding to enhance the accuracy and utility of wastewater-based epidemiological analysis.