Wastewater surveillance suggests unreported Mpox cases in a low-prevalence area

Wastewater surveillance has emerged as a valuable tool for monitoring infectious disease agents including SARS-CoV-2 and Mpox virus. However, detecting the Mpox virus in wastewater is particularly challenging due to its relatively low prevalence in the community. In this study, we detected Mpox virus in wastewater from a US-Mexico border city with a low prevalence of Mpox disease during February and March 2023 using real-time PCR assays targeting the C22L, F3L, and F8L genes. An increasing trend of viral concentration was observed 1~2 weeks earlier than when the Mpox case was reported. Further sequencing and epidemiological analysis provided supporting evidence for unreported Mpox infections in the city. This study showcases a combined approach with multiple molecular assays for efficient detection of the Mpox virus in wastewater in a low-prevalence area. The findings emphasize the value of wastewater surveillance as a timely identification tool for infectious diseases in low-prevalence areas, and the need for heightened vigilance to control the spread of infectious diseases in such settings. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work is supported by Faculty Startup funding from the Center of Infectious Diseases at UTHealth, the UT system Rising STARs award, and the Texas Epidemic Public Health Institute (TEPHI). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.