A Systematic Review of Gastrointestinal and Respiratory Pathogen Detection in Wastewater in Africa, with Focus on Rwanda: Implications for Early Warning and Public Health Surveillance.

In Africa, the disease burden of diarrheal and respiratory diseases is amplified by limited surveillance capacity, diagnostic limitations, and socioeconomic inequalities. In rapidly urbanizing settings such as Kigali (Rwanda), integrating wastewater-based epidemiology (WBE) into existing surveillance systems offers a promising strategy for generating real-time epidemiological intelligence, identifying community-level hotspots, and addressing gaps in traditional reporting systems. Gastrointestinal and respiratory infections remain major causes of morbidity and mortality globally, particularly in low- and middle-income countries (LMICs), where traditional clinical surveillance systems frequently underreport the true disease burden. This systematic review synthesizes current evidence on the detection of gastrointestinal and respiratory pathogens in wastewater and evaluates the utility of WBE for early warning and public health action. A narrative review approach was used to identify peer-reviewed literature, global health reports, and surveillance studies focusing on the wastewater detection of gastrointestinal and respiratory pathogens. Databases including PubMed, Scopus, and Google Scholar were searched for studies published between 2000 and 2026. The search yielded 1247 records, of which 312 duplicates were removed. After title/abstract screening, 228 full-text articles were retrieved and assessed for eligibility. After a detailed evaluation, 108 studies were excluded for the following reasons: absence of pathogen-specific wastewater data (