ORIGINAL RESEARCH article
Front. Public Health
Sec. Infectious Diseases: Epidemiology and Prevention
This article is part of the Research TopicSARS-CoV-2: Virology, Epidemiology, Diagnosis, Pathogenesis and Control, Volume IIView all 17 articles
Association between SARS-CoV-2 in Wastewater and COVID-19 Hospitalizations in Three Countries, 2022-2024
Provisionally accepted
Mustapha Mustapha*
Laura E ChoiTobias Bergroth
Hannah R VolkmanKate Devlin
Jingyan YangAlon Yehoshua
Farid KhanJohn M MclaughlinJennifer L Nguyen- Pfizer, New York, United States
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Importance: As fewer jurisdictions report national COVID-19 hospitalization rates and testing of mild and asymptomatic cases is reduced, there is a need to better understand the relationship between COVID-19 hospitalizations and alternative measures of COVID-19 circulation, such as wastewater surveillance. Objective: We described the association between levels of SARS-CoV-2 in wastewater and COVID-19 hospitalization rates at the national level during and after the pandemic and explored whether wastewater virus level can predict COVID-19 hospitalization rates. Design, Setting, and Participants: Retrospective analysis of public health reports of national wastewater surveillance and COVID-19 hospitalizations from Denmark, the Netherlands, and the United States from 2022-2024. Main Outcomes and Measures: For each country, we calculated Pearson correlation coefficients and hospitalization multipliers (defined as the hospitalization rate for a given scaled wastewater virus level), for the overall study period and by Omicron subvariant predominance. Additionally, we developed linear regression models using scaled wastewater virus levels to predict concurrent and projected (1-4 weeks) COVID-19 hospitalization rates. Results: There was a strong correlation between national SARS-CoV-2 wastewater virus levels and weekly new COVID-19 hospitalization rates per million (0.86 [95% CI, 0.82 to 0.90], 0.80 [ 95% CI, 0.72 to 0.85], and 0.89 [95% CI, 0.85 to 0.92] in Denmark, the Netherlands, and the United States, respectively). Correlations were consistently strong across all subvariant predominance periods in all three countries (range, 0.72 to 1.0). Results from linear regression
Keywords: COVID, Hospitalization, Vaccine (COVID-19), wastewater, SARS-CoV-2 infection (COVID-19)
Received: 04 Aug 2025; Accepted: 30 Nov 2025.
Copyright: © 2025 Mustapha, Choi, Bergroth, Volkman, Devlin, Yang, Yehoshua, Khan, Mclaughlin and Nguyen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Mustapha Mustapha
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