More than seven million lives were lost to COVID-19 since SARS-CoV-2 was first detected in December 2019 (1). Despite the availability of highly advanced technologies for detection of pathogens of pandemic potentials, the most developed countries of the world could not protect their population from the devastating consequences of the pandemic. While the virus continues to spread in a less virulent form, the governments face the challenge of producing the best possible strategy to prevent the next outbreak of the so-called “Disease X” (2). One Health approach has been proposed to integrate many diverse levels of infectious disease surveillance for early detection and efficient management of threats posed by the emerging and re-emerging pathogens of pandemic potential (3–6). The role of an Intergovernmental Panel for One Health for strengthening pandemic preparedness has also been critically evaluated by health policy experts (7). This paper presents the findings of a proof-of-concept study carried out in Kuwait during the COVID-19 pandemic for detection of SARS-CoV-2 on the environmental surfaces and discusses the implications of this approach for surveillance of emerging and re-emerging viral outbreaks.

Coronaviruses are important human and animal pathogens that may have originated in bats (8, 9). The major symptoms of COVID-19 were dry cough, sore-throat, fever, and various degrees of respiratory difficulties (10). The alarming rate of the spread of COVID-19 across the globe prompted many governments to take stringent isolation strategies including complete lock down of affected regions with closure of schools and offices. Even curfews have been implemented in many countries including Kuwait to restrict the mobility of the people and limit person-to-person spread. Human-to-human transmission of SARS-CoV-2 has already been confirmed (11). The major route of transmission of the virus is thought to be via respiratory droplets of infected humans, while transmission from contaminated inanimate surfaces to humans has also been documented (12–15). The virus has been detected in throat swab, blood, urine, and stool of infected patients by reverse-transcriptase quantitative PCR (RT-qPCR), and the viral RNA was detectable up to 25 days after the onset of symptom (12). The possibility of asymptomatic healthy people carrying the virus raises concerns about transmission in the community although the significance of this mode of transmission is unknown. WHO recommends frequent hand washing with soap and water and the use of face mask and personal protective equipment (PPE) to protect individuals who have the risk of exposure.

Previous studies on the persistence of human and veterinary coronaviruses on inanimate surfaces revealed that human coronaviruses such as SARS coronavirus, MERS coronavirus or endemic human coronaviruses can persist on inanimate surfaces like metal, glass, or plastic for up to 9 days (14). A controlled experimental study showed that SARS-CoV-2 may survive in the air for < 4 h while it may remain viable for 2 days on plastic and 3 days on metallic surface (15). It is unknown how long the virus remains viable in the different environments that exist in different countries with diverse climatic conditions where the virus continues to spread. The present study was conducted to detect the virus in the environment of Kuwait when the disease activity was already established in the community.

In pooled samples analyzed by RT-qPCR (n^p = 83), the rate of positive test was highest with the freezer handles (50%) followed by the shopping carts (32.5%), the POS terminals (25%), ATMs (23%), and the elevators (16.66%) (Table 1, Figure 2). Tables 2–7 show the results of the RT-qPCR performed in the surface samples collected from all the cooperative societies. The samples were numbered according to the sequence of collection which was scheduled in coordination with the respective Cooperative Society Stores. Thus, the two stores of the same governorate were not always sampled in the same week as indicated by the differences in the sample numbers.

Kuwait has a population of 4.8 million people of which one-third are Kuwaiti citizens and the remaining are foreign nationals (20). According to the World Bank development indicators, 100 per cent of Kuwait's population have an urban life (21). Kuwait is divided into six governorates or provinces namely, Al-Asimah, Jahra, Hawalli, Farwaniya, Mubarak Al-Kabeer, and Al-Ahmadi. In Kuwait, there are around 60 Cooperative Society Stores, also known as Co-Ops, which are public entities distributed across the six governorates. The Co-ops are the grocery and convenience stores that account for most of the retail trade in Kuwait. In order to save lives, Kuwait Government took stringent measures including complete lockdown, curfews, and international travel bans during the COVID-19 pandemic. The Co-Ops, however, remained in service during the whole period of the pandemic but required online appointments for access. Since most of the institutions including offices, schools, and most shopping malls have been shut down during the pandemic, the Co-Ops were chosen for collection of swab samples from high-touch surfaces with all precautions recommended by the Ministry of Health of Kuwait.

Active surveillance of any infectious disease is traditionally conducted by collecting appropriate body fluids (blood, urine, stool, saliva, throat swab, etc.) from an adequate number of exposed people. Conducting active surveillance for SARS-CoV-2 in the community was extremely risky because of high virulence of the coronavirus. On the other hand, collection of swab samples from the high-touch surfaces in the Co-ops for detection of SARS-CoV-2 was a much safer approach as compared with collection of nasopharyngeal swabs from the exposed community dwellers. Although previous studies have confirmed the presence and viability of coronaviruses on some environmental surfaces in hospitals and elsewhere, the abundance and detectability of SARS-CoV-2 on environmental surfaces within the convenience stores were unknown. The unique distribution of the Co-ops across the whole country offered the study team the opportunity for collecting surface samples from these locations that were visited by many people daily even during the height of the pandemic.

The surface samples collected from the Co-Ops represented all the governorates of Kuwait. Almost every type of high touch surfaces tested in this study showed the presence of SARS-CoV-2 in variable proportions. While the handles of the shopping carts and the freezer handles showed high rate of positivity, the handles of the outside door were negative although they were used by many people visiting the same store. A possible explanation of this could be that the lower temperature inside the air-conditioned store had facilitated the prolonged viability of the virus on those surfaces whereas the outside high temperature reaching up to 125°F in June might have resulted in rapid degradation of the viral RNA on the entrance door handles. The longer contact time with the shopping carts as compared with the other objects tested could have accounted for the higher rate of viral detection in the former. The rate of detection of the virus on the keypads of the POS terminals was lower than that on the ATM machines probably because the former were frequently cleaned with disinfectants. Also, many clients made contactless payment using their cards without making any physical contact with the keypads with the keypads of the POS terminals. Thus, avoidance of physical contact with contaminated surfaces by the customers and frequent sanitization of the keypads could have resulted in lesser frequency of occurrence of virus particles on these surfaces.

Several research groups have examined the occurrence of SARS-CoV-2 on various types of touch surfaces during the COVID-19 outbreak (14–16, 22–27). A meta-analysis of 22 studies by Kampf et al. (14) revealed that human coronaviruses such as SARS coronavirus, MERS coronavirus, or endemic human coronaviruses can persist on inanimate surfaces like metal, glass, or plastic for up to 9 days, but can be efficiently inactivated by surface disinfection procedures. Also, a high frequency of occurrence of SARS-CoV-2 RNA was found on stainless steel and plastic surfaces (22). The results of the study we report here clearly show that high-touch surfaces are prone to accumulate viral particles that are detectable by RT-qPCR which has a 100% specificity for detection of the infection in humans. The application of environmental sampling in infectious disease epidemiology has a long history. Wastewater-based epidemiology (WBE) has been used by the WHO for poliovirus monitoring since 2003 (28). However, its application for tracking community-level infection trends gained widespread popularity during the COVID-19 pandemic. The worldwide interest in the use of WBE underscores the potential of environmental surveillance to complement traditional epidemiological methods (29). The detection of viral RNA in wastewater, regardless of viability of the virus, provided crucial information for health regulators to implement life-saving measures and mitigate the viral spread within the community. The surface sampling method employed in our study fundamentally shared the same objective as wastewater-based epidemiology (WBE)—to assess the presence and prevalence of SARS-CoV-2 in the environment. The relative ease of swab sample collection and testing offers a powerful tool for environmental surveillance of SARS-CoV-2. While the role of surface transmission remains uncertain, detecting the virus on surfaces can effectively monitor human cases and carriers within a community, allowing governments to optimize resource allocation and manage the situation effectively. Moreover, environmental surface testing provides a unique opportunity to detect potential SARS-CoV-2 resurgences, enhancing preparedness for future outbreaks or pandemics. We strongly advocate incorporating this approach into the arsenal of preventative measures against a future pandemic.