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Therefore, viruses causing gastroenteritis may be detected in wastewater, even if only a few persons are infected. In this study, the presence of eight pathogenic viruses (norovirus, astrovirus, rotavirus, adenovirus, Aichi virus, parechovirus, hepatitis A virus [HAV], and hepatitis E virus) was investigated in sewage to explore whether their identification could be used as an early warning of outbreaks. Samples of the untreated sewage were collected in proportion to flow at Ryaverket, Gothenburg, Sweden. Daily samples collected during every second week between January and May 2013 were pooled and analyzed for detection of viruses by concentration through adsorption to milk proteins and PCR. The largest amount of noroviruses was detected in sewage 2 to 3 weeks before most patients were diagnosed with this infection in Gothenburg. The other viruses were detected at lower levels. HAV was detected between weeks 5 and 13, and partial sequencing of the structural VP1protein identified three different strains. Two strains were involved in an ongoing outbreak in Scandinavia and were also identified in samples from patients with acute hepatitis A in Gothenburg during spring of 2013. The third strain was unique and was not detected in any patient sample. The method used may thus be a tool to detect incipient outbreaks of these viruses and provide early warning before the causative pathogens have been recognized in health care.<\/jats:p>","DOI":"10.1128\/aem.01981-14","type":"journal-article","created":{"date-parts":[[2014,8,29]],"date-time":"2014-08-29T21:52:15Z","timestamp":1409349135000},"page":"6771-6781","update-policy":"https:\/\/doi.org\/10.1128\/asmj-crossmark-policy-page","source":"Crossref","is-referenced-by-count":477,"title":["Detection of Pathogenic Viruses in Sewage Provided Early Warnings of Hepatitis A Virus and Norovirus Outbreaks"],"prefix":"10.1128","volume":"80","author":[{"given":"Maria","family":"Hellm\u00e9r","sequence":"first","affiliation":[{"name":"Department of Clinical Microbiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicklas","family":"Pax\u00e9us","sequence":"additional","affiliation":[{"name":"Gryaab AB, Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lars","family":"Magnius","sequence":"additional","affiliation":[{"name":"MTC, Karolinska Institutet, Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucica","family":"Enache","sequence":"additional","affiliation":[{"name":"Gryaab AB, Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Birgitta","family":"Arnholm","sequence":"additional","affiliation":[{"name":"Department of Communicable Disease Control, V\u00e4stra G\u00f6taland Region, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annette","family":"Johansson","sequence":"additional","affiliation":[{"name":"Gryaab AB, Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tomas","family":"Bergstr\u00f6m","sequence":"additional","affiliation":[{"name":"Department of Clinical Microbiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hel\u00e9ne","family":"Norder","sequence":"additional","affiliation":[{"name":"Department of Clinical Microbiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden"},{"name":"MTC, Karolinska Institutet, Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"235","reference":[{"key":"e_1_3_2_2_2","doi-asserted-by":"publisher","DOI":"10.1021\/es3032105"},{"key":"e_1_3_2_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.coviro.2013.12.003"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.1128\/AEM.02477-07"},{"key":"e_1_3_2_5_2","doi-asserted-by":"publisher","DOI":"10.3201\/eid1101.040606"},{"key":"e_1_3_2_6_2","doi-asserted-by":"publisher","DOI":"10.3201\/eid1811.111570"},{"key":"e_1_3_2_7_2","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1099-1654(200001\/02)10:1<57::AID-RMV266>3.0.CO;2-H"},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.meegid.2013.10.023"},{"key":"e_1_3_2_9_2","doi-asserted-by":"publisher","DOI":"10.1038\/nrgastro.2012.187"},{"key":"e_1_3_2_10_2","doi-asserted-by":"publisher","DOI":"10.1099\/vir.0.059238-0"},{"key":"e_1_3_2_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.meegid.2011.07.024"},{"key":"e_1_3_2_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/B978-0-12-249951-7.50003-1"},{"key":"e_1_3_2_13_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0072788"},{"key":"e_1_3_2_14_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.f7204"},{"key":"e_1_3_2_15_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.meegid.2011.04.031"},{"key":"e_1_3_2_16_2","doi-asserted-by":"publisher","DOI":"10.1038\/srep01812"},{"key":"e_1_3_2_17_2","doi-asserted-by":"publisher","DOI":"10.1128\/genomeA.00068-12"},{"key":"e_1_3_2_18_2","doi-asserted-by":"publisher","DOI":"10.3945\/jn.112.170118"},{"key":"e_1_3_2_19_2","doi-asserted-by":"publisher","DOI":"10.1186\/1475-2891-12-101"},{"key":"e_1_3_2_20_2","first-page":"191","article-title":"Human enteric viruses in the water environment: a minireview","volume":"1","author":"Bosch A","year":"1998","unstructured":"BoschA. 1998. 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