Abstract Wastewater surveillance is increasingly used for antimicrobial resistance (AMR) monitoring in urban environments, but low-resource settings often lack a piped sewerage system. Instead, coprophagous flies—flies that ingest feces—may serve as composite samplers for monitoring fecal wastes present in terrestrial environments. We evaluated whether the class 1 integron-integrase gene intI1 was associated with genetic markers of AMR and fecal source tracking markers (FST) in coprophagous flies collected from latrine entrances and food preparation areas in low-income urban Maputo, Mozambique. We quantified intI1 , an enteric 16S rRNA target (for normalization), three FST markers, and 30 ARG targets using qPCR. We normalized concentrations of intI1 and each target to enteric 16S rRNA. We fit linear mixed models with a random intercept for housing compound to estimate within-fly associations between log 10 relative abundance of intI1 and log 10 relative abundance of each target with and without adjustment for fly taxonomic group, capture location, and standardized fly mass. We also modeled per-fly unique ARG count (i.e., number of ARG targets detected) using Poisson regression. Of 188 flies assayed, 176 passed internal controls; intI1 and enteric 16S rRNA were detected in 95% and 96% of flies, respectively. Higher relative abundance of intI1 was positively associated with ARG and FST targets, with the strongest associations observed for sulfonamide-( sul1 : β = 0.87; 95% CI: 0.81, 0.94; sul2 : β = 0.81; 95% CI: 0.73, 0.89), tetracycline- ( tetA : β = 0.78; 95% CI: 0.70, 0.85; tetB : β = 0.69; 95% CI: 0.60, 0.79), and trimethoprim-related ( dfrA17 : β = 0.78; 95% CI: 0.70, 0.86) genes. Associations with FST markers were weaker (i.e., human mtDNA: β = 0.46; 95% CI: 0.37, 0.55; human-associated Bacteroides : β = 0.34; 95% CI: 0.25, 0.43). Higher relative abundance of intI1 was also associated with a greater number of ARGs detected: each 10-fold increase in intI1 was associated with an 8% higher expected unique ARG count (aRR=1.08, 95% CI: 1.04–1.12). These findings support the need for further research across different settings exploring intI1 carried by coprophagous flies as a potential standardized screening target for AMR surveillance in unsewered terrestrial environments.

Wastewater surveillance has been widely adopted since the COVID-19 pandemic, but non-sewered (e.g., onsite) sanitation is a common form of sanitation in cities of low- and middle-income countries. Environmental surveillance in these settings requires alternatives to wastewater. We collected 81 soil samples adjacent to public waste bins inside the sewered and non-sewered areas of Maputo and a 150-meter-wide buffer zone between the two areas, as well as from subsistence farms near the wastewater treatment plant for comparison. We cultured Escherichia coli (E. coli) and determined the prevalence of 29 unique enteric pathogens via RT-qPCR. E. coli concentrations were significantly higher (p < .001) in soils adjacent to public waste bins (mean = 5.1x105 per gram) compared to soils from farms (mean = 8.7x101 per gram). The mean number of unique pathogens was higher in soils from the non-sewered area (mean = 7.9, n = 32 samples) and the 150-meter buffer area (mean = 11, n = 10) compared to the sewered area (mean = 4.6, n = 20) and soils from farms (mean = 3.8, n = 19). Findings demonstrate that the presence of enteric pathogens in soils adjacent to public waste bins were associated with neighborhood sanitation infrastructure. In high-burden settings with poor sanitation, direct examination of soils and other environmental matrices are potentially scalable means of environmental pathogen surveillance to consider beyond conventional matrices.

Although wastewater surveillance for assessing community health and well-being is now mainstream, most cities in low- and middle-income countries lack conventional wastewater services. In these settings, environmental surveillance beyond conventional wastewater offers the potential to inform public health responses, design interventions intended to reduce exposures, and to evaluate infection control programs. To explore these potential use cases, we measured pathogens, source-tracking markers, and fecal indicator bacteria in wastewater treatment plant (WWTP) influent and effluent, wastewater surface discharges, impacted river water, impacted soils, open drains, stormwater, and fecal sludges from onsite sanitation in Maputo, Mozambique. We detected a wide range of pathogens by multi-parallel RT-qPCR across all matrices, revealing a nuanced picture of pathogen flows in the city and suggesting the potential for exposures beyond those typically included in studies of sanitation and health. We developed a regression model with multiple pathogens as the dependent variable and observed lower pathogen concentrations in direct wastewater discharges (mean difference -1.4 log10 per liter, 95% CI: -1.7, -1.1), WWTP effluent (-0.97 log10, 95% CI: -1.5, -0.47), water from open drains (-2.0 log10, 95% CI: -2.5, -1.6), impacted river water (-3.0 log10, 95% CI: -3.7, -2.4), and stormwater (-4.7 log10, 95% CI: -7.0, -3.3) compared to WWTP influent. We further observed that a one standard deviation increase in 7-day cumulative precipitation was associated with an increase in the pathogen concentration in all matrices (0.11 log10, [0.04, 0.19]). Despite lower concentrations of pathogens in matrices compared to WWTP influent, frequent detection of pathogens indicates clear potential to use environmental pathogen surveillance to inform public health responses in cities lacking universal conventional wastewater, with a wide range of promising applications.

The relationship between enteric pathogen exposure and long-term health effects like stunting and cognitive deficiencies may be mediated, in part, by environmental enteric dysfunction (EED). We aimed to assess whether access to a shared sanitation intervention affected the concentration of biomarkers of intestinal inflammation and permeability in the stool of young children living in Maputo, Mozambique. The Maputo Sanitation trial was a controlled before-and-after study of a shared onsite sanitation intervention in low-income, unplanned urban neighborhoods of Maputo, Mozambique. We collected data and stool specimens at baseline (pre-intervention) and 12- and 24-months post-intervention and measured the concentration of four biomarkers of EED: alpha-1-antitrypsin, neopterin, myeloperoxidase, and calprotectin. We assessed the effect of the intervention at 12- and 24-months post-intervention among all children, as well as among sub-groups of children with longitudinal data and children who were born into study sites post-intervention. After 12-months, the concentration of neopterin was higher among intervention children compared with controls (mean difference 0.39 log nmol/L, 95% CI: 0.15 - 0.62). Concentrations of calprotectin (mean difference 0.43 log ng/mL, 95% CI: 0.041 - 0.82) and neopterin (mean difference 0.38 nmol/L, 95% CI: 0.0079, 0.76), both measures of intestinal inflammation, were also higher among children born into intervention sites by the 24-month follow-up visit. The intervention did not a have statistically significant effect on the concentration of alpha-1-antitrypsin, the only marker of intestinal permeability.The intervention did not reduce the concentration of EED biomarkers after 12- and 24-months of exposure. The etiology and pathophysiologic mechanisms underlying EED have not been fully described, complicating its measurement. The lack of a formal case definition and of representative healthy reference concentrations for common EED biomarkers makes interpretation of effect estimates, including their potential clinical significance, complex. Our results highlight the importance of filling these evidence gaps so we may begin designing and implementing sanitation interventions that prevent, or at least delay, the onset of EED.

Analysis of ancient desiccated feces - termed paleofeces or coprolites - can unlock insights into the lives of ancient people. We collected desiccated feces from caves in the Rio Zape Valley in Mexico (725-920 CE). First, we extracted DNA with methods previously optimized for paleofeces. Then, we applied highly sensitive modern molecular tools (i.e., PCR pre-amplification followed by multi-parallel qPCR) to assess the presence of 30 enteric pathogens. We detected ≥1 pathogen associated gene in each of the ten samples and a mean of 3.9 pathogens per sample. The targets detected included Blastocystis spp. (n=7), atypical enteropathogenic E. coli (n=7), Enterobius vermicularis (n=6), Entamoeba spp. (n=5), enterotoxigenic E. coli (n=5), Shigella spp./enteroinvasive E. coli (n=3), Giardia spp. (n=2), and E. coli O157:H7 (n=1). The protozoan pathogens we detected (i.e., Giardia spp. and Entamoeba spp.) have been previously detected in paleofeces via enzyme-linked immunoassay (ELISA), but have not via PCR. This work represents the first detection of Blastocystis spp. atypical enteropathogenic E. coli, enterotoxigenic E. coli, Shigella spp./enteroinvasive E. coli, and E. coli O157:H7 in paleofeces. These results suggest that sensitive modern molecular tools, such as PCR, can be used to evaluate ancient materials for genes of interest.

DNA analysis of ancient, desiccated feces - termed paleofeces - can unlock insights into the lives of ancient peoples, including through examination of the gut microbiome and identification of specific pathogens and parasites. We collected desiccated feces from the Cave of the Dead Children (La Cueva de Los Muertos Chiquitos) in the Rio Zape Valley in Mexico dated to 725-920 CE, for targeted pathogen analysis. First, we extracted DNA with methods previously optimized for paleofeces. Then, we applied highly sensitive modern molecular tools (i.e., PCR pre-amplification followed by multi-parallel qPCR) to assess the presence of 30 enteric pathogens and gut microbes. We detected ≥1 pathogen or gut microbe associated gene in each of the ten samples and a mean of 3.9 targets per sample. The targets detected included Blastocystis spp. (n = 7), atypical enteropathogenic E. coli (n = 7), Enterobius vermicularis (n = 6), Entamoeba spp. (n = 5), enterotoxigenic E. coli (n = 5), Shigella spp./enteroinvasive E. coli (n = 3), Giardia spp. (n = 2), and E. coli O157:H7 (n = 1). The protozoan pathogens we detected (i.e., Giardia spp. and Entamoeba spp.) have been previously detected in paleofeces via enzyme-linked immunoassay (ELISA), but not via PCR. This work represents the first detection of Blastocystis spp. atypical enteropathogenic E. coli, enterotoxigenic E. coli, Shigella spp./enteroinvasive E. coli, and E. coli O157:H7 in paleofeces. These results suggest that enteric infection may have been common among the Loma San Gabriel people, who lived in the Rio Zape Valley in Mexico during this period.

BACKGROUND:Wastewater monitoring data can be used to estimate disease trends to inform public health responses. One commonly estimated metric is the rate of change in pathogen quantity, which typically correlates with clinical surveillance in retrospective analyses. However, the accuracy of rate of change estimation approaches has not previously been evaluated. OBJECTIVES:We assessed the performance of approaches for estimating rates of change in wastewater pathogen loads by generating synthetic wastewater time series data for which rates of change were known. Each approach was also evaluated on real-world data. METHODS:Smooth trends and their first derivatives were jointly sampled from Gaussian processes (GP) and independent errors were added to generate synthetic viral load measurements; the range hyperparameter and error variance were varied to produce nine simulation scenarios representing different potential disease patterns. The directions and magnitudes of the rate of change estimates from four estimation approaches (two established and two developed in this work) were compared to the GP first derivative to evaluate classification and quantitative accuracy. Each approach was also implemented for public SARS-CoV-2 wastewater monitoring data collected January 2021-May 2023 at 25 sites in North Carolina, USA. RESULTS:All four approaches inconsistently identified the correct direction of the trend given by the sign of the GP first derivative. Across all nine simulated disease patterns, between a quarter and a half of all estimates indicated the wrong trend direction, regardless of estimation approach. The proportion of trends classified as plateaus (statistically indistinguishable from zero) for the North Carolina SARS-CoV-2 data varied considerably by estimation method but not by site. DISCUSSION:Our results suggest that wastewater measurements alone might not provide sufficient data to reliably track disease trends in real-time. Instead, wastewater viral loads could be combined with additional public health surveillance data to improve predictions of other outcomes.

Background: Quantifying contributions of environmental faecal contamination to child diarrhoea and growth faltering can illuminate causal mechanisms behind modest health benefits in recent water, sanitation, and hygiene (WASH) trials. We aimed to assess associations between environmental detection of enteropathogens and human or animal microbial source tracking markers (MSTM) and subsequent child health outcomes. Methods: In this individual participant data meta-analysis we searched we searched PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus for WASH intervention studies with a prospective design and concurrent control that measured enteropathogens or MSTM in environmental samples, or both, and subsequently measured enteric infections, diarrhoea, or height-for-age Z-scores (HAZ) in children younger than 5 years. We excluded studies that only measured faecal indicator bacteria. The initial search was done on Jan 19, 2021, and updated on March 22, 2023. One reviewer (AM) screened abstracts, and two independent reviewers (AM and RT) examined the full texts of short-listed articles. All included studies include at least one author that also contributed as an author to the present Article. Our primary outcomes were the 7-day prevalence of caregiver-reported diarrhoea and HAZ in children. For specific enteropathogens in the environment, primary outcomes also included subsequent child infection with the same pathogen ascertained by stool testing. We estimated associations using covariate-adjusted regressions and pooled estimates across studies. Findings: Data from nine published reports from five interventions studies, which included 8603 children (4302 girls and 4301 boys), were included in the meta-analysis. Environmental pathogen detection was associated with increased infection prevalence with the same pathogen and lower HAZ (Delta HAZ -009 [95% CI -017 to -001]) but not diarrhoea (prevalence ratio 122 [95% CI 095 to 158]), except during wet seasons. Detection of MSTM was not associated with diarrhoea (no pooled estimate) or HAZ (Delta HAZ -001 [-013 to 011] for human markers and Delta HAZ -002 [-024 to 021] for animal markers). Soil, children's hands, and stored drinking water were major transmission pathways. Interpretation: Our findings support a causal chain from pathogens in the environment to infection to growth faltering, indicating that the lack of WASH intervention effects on child growth might stem from insufficient reductions in environmental pathogen prevalence. Studies measuring enteropathogens in the environment should subsequently measure the same pathogens in stool to further examine theories of change between WASH, faecal contamination, and health. Given that environmental pathogen detection was predictive of infection, programmes targeting specific pathogens (eg, vaccinations and elimination efforts) can environmentally monitor the pathogens of interest for population-level surveillance instead of collecting individual biospecimens.

ABSTRACT Wastewater-based epidemiology has expanded as a tool for collecting COVID-19 surveillance data, but there is limited information on the feasibility of this form of surveillance within decentralized wastewater systems (e.g., septic systems). This study assessed SARS-CoV-2 RNA concentrations in wastewater samples from a septic system servicing a mobile home park (66 households) and from two pumping stations serving a similarly sized (71 households) and a larger (1,000 households) neighborhood within a nearby sewershed over 35 weeks in 2020. Also, raw wastewater from a hospital in the same sewershed was sampled. The mobile home park samples had the highest detection frequency (39/39 days) and mean concentration of SARS-CoV-2 RNA (2.7 × 107 gene copies/person/day for the N1) among the four sampling sites. N1 gene and N2 gene copies were highly correlated across mobile home park samples (Pearson's r = 0.93, p < 0.0001). In the larger neighborhood, new COVID-19 cases were reported every week during the sampling period; however, we detected SARS-CoV-2 RNA in 12% of the corresponding wastewater samples. The results of this study suggest that sampling from decentralized wastewater infrastructure can be used for continuous monitoring of SARS-CoV-2 infections.

Wastewater surveillance emerged during the COVID-19 pandemic as a novel strategy for tracking the burden of illness in communities. Previous work has shown that trends in wastewater SARS-CoV-2 viral loads correlate well with reported COVID-19 case trends over longer time periods (i.e., months). We used detrending time series to reveal shorter sub-trend patterns (i.e., weeks) to identify leads or lags in the temporal alignment of the wastewater/case relationship. Daily incident COVID-19 cases and twice-weekly wastewater SARS-CoV-2 viral loads measured at 20 North Carolina sewersheds in 2021 were detrended using smoothing ranges of ∞, 16, 8, 4 and 2 weeks, to produce detrended cases and wastewater viral loads at progressively finer time scales. For each sewershed and smoothing range, we calculated the Spearman correlation between the cases and the wastewater viral loads with offsets of -7 to +7 days. We identified a conclusive lead/lag relationship at 15 of 20 sewersheds, with detrended wastewater loads temporally leading detrended COVID-19 cases at 11 of these sites. For the 11 leading sites, the correlation between wastewater loads and cases was greatest for wastewater loads sampled at a median lead time of 6 days before the cases were reported. Distinct lead/lag relationships were the most pronounced after detrending with smoothing ranges of 4–8 weeks, suggesting that SARS-CoV-2 wastewater viral loads can track fluctuations in COVID-19 case incidence rates at fine time scales and may serve as a leading indicator in many settings. These results could help public health officials identify, and deploy timely responses in, areas where cases are increasing faster than the overall pandemic trend.

Uncontained fecal wastes in cities may present exposure risks to the public. We collected discarded feces from public spaces in San Francisco, CA for analysis by RT-qPCR for a range of enteric pathogens. Out of 59 samples, we found 12 (20%) were of human origin and 47 (80%) were non-human; 30 of 59 stools were positive for ≥1 of the 35 pathogens assessed, including pathogenic E. coli, Shigella, norovirus, Cryptosporidium, and Trichuris. Using quantitative enteric pathogen estimates and data on observed fecal waste from a public reporting system, we modeled pathogens removed from the environment attributable to a recently implemented program of public toilet construction. We estimated that each new public toilet reduced the annual number of enteric pathogens released into the immediate environment (within 500 m walking distance), including 6.3 x 1012 enteropathogenic E. coli (95% CI: 4.0 x 1012–7.9 x 1012), 3.2 x 1011 enteroaggregative E. coli (95% CI: 1.3 x 1011–6.3 x 1011), and 3.2 x 108 Shigella (6.3 x 107–2.5 x 109). Improving access to public sanitation can reduce enteric pathogen hazards in cities. Interventions must also consider the hygienic disposal of animal waste to reduce microbial hazards with zoonotic infection potential.

INTRODUCTION:We previously assessed the effect of an onsite sanitation intervention in informal neighbourhoods of urban Maputo, Mozambique on enteric pathogen detection in children after 2 years of follow-up (Maputo Sanitation (MapSan) trial, ClinicalTrials.gov: NCT02362932). We found significant reductions in Shigella and Trichuris prevalence but only among children born after the intervention was delivered. In this study, we assess the health impacts of the sanitation intervention after 5 years among children born into study households postintervention. METHODS AND ANALYSIS:We are conducting a cross-sectional household study of enteric pathogen detection in child stool and the environment at compounds (household clusters sharing sanitation and outdoor living space) that received the pour-flush toilet and septic tank intervention at least 5 years prior or meet the original criteria for trial control sites. We are enrolling at least 400 children (ages 29 days to 60 months) in each treatment arm. Our primary outcome is the prevalence of 22 bacterial, protozoan, and soil transmitted helminth enteric pathogens in child stool using the pooled prevalence ratio across the outcome set to assess the overall intervention effect. Secondary outcomes include the individual pathogen detection prevalence and gene copy density of 27 enteric pathogens (including viruses); mean height-for-age, weight-for-age, and weight-for-height z-scores; prevalence of stunting, underweight, and wasting; and the 7-day period prevalence of caregiver-reported diarrhoea. All analyses are adjusted for prespecified covariates and examined for effect measure modification by age. Environmental samples from study households and the public domain are assessed for pathogens and faecal indicators to explore environmental exposures and monitor disease transmission. ETHICS AND DISSEMINATION:Study protocols have been reviewed and approved by human subjects review boards at the Ministry of Health, Republic of Mozambique and the University of North Carolina at Chapel Hill. Deidentified study data will be deposited at https://osf.io/e7pvk/. TRIAL REGISTRATION NUMBER:ISRCTN86084138.

Wastewater surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be useful for monitoring population-wide coronavirus disease 2019 (COVID-19) infections, especially given asymptomatic infections and limitations in diagnostic testing. We aimed to detect SARS-CoV-2 RNA in wastewater and compare viral concentrations to COVID-19 case numbers in the respective counties and sewersheds. Influent 24-hour composite wastewater samples were collected from July to December 2020 from two municipal wastewater treatment plants serving different population sizes in Orange and Chatham Counties in North Carolina. After a concentration step via HA filtration, SARS-CoV-2 RNA was detected and quantified by reverse transcription droplet digital polymerase chain reaction (RT-ddPCR) and quantitative PCR (RT-qPCR), targeting the N1 and N2 nucleocapsid genes. SARS-CoV-2 RNA was detected by RT-ddPCR in 100 % (24/24) and 79 % (19/24) of influent wastewater samples from the larger and smaller plants, respectively. In comparison, viral RNA was detected by RT-qPCR in 41.7 % (10/24) and 8.3 % (2/24) of samples from the larger and smaller plants, respectively. Positivity rates and method agreement further increased for the RT-qPCR assay when samples with positive signals below the limit of detection were counted as positive. The wastewater data from the larger plant generally correlated (⍴ ~0.5, p < 0.05) with, and even anticipated, the trends in reported COVID-19 cases, with a notable spike in measured viral RNA preceding a spike in cases when students returned to a college campus in the Orange County sewershed. Correlations were generally higher when using estimates of sewershed-level case data rather than county-level data. This work supports use of wastewater surveillance for tracking COVID-19 disease trends, especially in identifying spikes in cases. Wastewater-based epidemiology can be a valuable resource for tracking disease trends, allocating resources, and evaluating policy in the fight against current and future pandemics.

Background Water, sanitation, and hygiene (WASH) improvements are promoted to reduce diarrhoea in low-income countries. However, trials from the past 5 years have found mixed effects of household-level and community-level WASH interventions on child health. Measuring pathogens and host-specific faecal markers in the environment can help investigate causal pathways between WASH and health by quantifying whether and by how much interventions reduce environmental exposure to enteric pathogens and faecal contamination from human and different animal sources. We aimed to assess the effects of WASH interventions on enteropathogens and microbial source tracking (MST) markers in environmental samples. Methods We did a systematic review and individual participant data meta-analysis, which included searches from Jan 1, 2000, to Jan 5, 2023, from PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus, of prospective studies with water, sanitation, or hygiene interventions and concurrent control group that measured pathogens or MST markers in environmental samples and measured child anthropometry, diarrhoea, or pathogen-specific infections. We used covariate-adjusted regression models with robust standard errors to estimate study-specific intervention effects and pooled effect estimates across studies using random-effects models. Findings Few trials have measured the effect of sanitation interventions on pathogens and MST markers in the environment and they mostly focused on onsite sanitation. We extracted individual participant data on nine environmental assessments from five eligible trials. Environmental sampling included drinking water, hand rinses, soil, and flies. Interventions were consistently associated with reduced pathogen detection in the environment but effect estimates in most individual studies could not be distinguished from chance. Pooled across studies, we found a small reduction in the prevalence of any pathogen in any sample type (pooled prevalence ratio [PR] 0 center dot 94 [95% CI 0 center dot 90-0 center dot 99]). Interventions had no effect on the prevalence of MST markers from humans (pooled PR 1 center dot 00 [95% CI 0 center dot 88-1 center dot 13]) or animals (pooled PR 1 center dot 00 [95% CI 0 center dot 97-1 center dot 03]). Interpretation The small effect of these sanitation interventions on pathogen detection and absence of effects on human or animal faecal markers are consistent with the small or null health effects previously reported in these trials. Our findings suggest that the basic sanitation interventions implemented in these studies did not contain human waste and did not adequately reduce exposure to enteropathogens in the environment.

There is an increasing trend of developing various low-cost biogenic sorbents for the efficient and economical removal of noxious metals . Curry leaf powder (CLP), a promising non-toxic biosorbent containing several bioactive compounds was prepared by the pulverization of the dried leaves for the effective removal of Lead (Pb) and Cadmium (Cd). Various batch sorption experiments were carried out under constant temperature (25 °C), different pH (4.5–10.5), initial concentrations (50–200 mg L−1), adsorbent dosages (0.10–0.40 g) and contact times (0–60 min) to understand the optimum experimental conditions and simultaneously evaluate the adsorption isotherms and removal kinetics of CLP. Adsorption equilibrium was established in less than an hour interval (50 min). The pseudo-equilibrium process was best described by the pseudo-second-order kinetic (R2 ≥ 0.99), Freundlich and Langmuir isotherm model (R2 ≥ 0.94). The removal rate of Pb and Cd gradually increased (15.7 and 12.7 mg g−1 for Pb and Cd) at 100 mg L−1 of initial concentration till 60 min of contact period in a single contaminant system, the effect was non-significant for multiple adsorbent dosage systems (p > 0.05; t-test) though. The regeneration potential of the exhausted biosorbent was excellent upto 5 cycles with the better efficiency observed for Pb. The obtained results explicitly validated the probable utilization of CLP as a promising green adsorbent for metal removal . Future study may highlight the decontamination aspects of emerging contaminants with such green bio sorbents in large scale as well as mimicing the stomach conditions.

With 9 million hogs, North Carolina (NC) is the second leading hog producer in the United States. Most hogs are housed at concentrated animal feeding operations (CAFOs), where millions of tons of hog waste can pollute air and water with fecal pathogens that can cause diarrhea, vomiting, and/or nausea (known as acute gastrointestinal illness (AGI)). We used NC's ZIP code-level emergency department (ED) data to calculate rates of AGI ED visits (2016-2019) and swine permit data to estimate hog exposure. Case exposure was estimated as the inverse distances from each hog CAFO to census block centroids, weighting with Gaussian decay and by manure amount per CAFO, then aggregated to ZIP code using population weights. We compared ZIP codes in the upper quartile of hog exposure ("high hog exposed") to those without hog exposure. Using inverse probability of treatment weighting, we created a control with similar demographics to the high hog exposed population and calculated rate ratios using quasi-Poisson models. We examined effect measure modification of rurality and race using adjusted models. In high hog exposed areas compared to areas without hog exposure, we observed a 11% increase (95% CI: 1.06, 1.17) in AGI rate and 21% increase specifically in rural areas (95% CI: 0.98, 1.43). When restricted to rural areas, we found an increased AGI rate among American Indian (RR = 4.29, 95% CI: 3.69, 4.88) and Black (RR = 1.45, 95% CI: 0.98, 1.91) residents. The association was stronger during the week after heavy rain (RR = 1.41, 95% CI: 1.19, 1.62) and in areas with both poultry and swine CAFOs (RR = 1.52, 95% CI: 1.48, 1.57). Residing near CAFOs may increase rates of AGI ED visits. Hog CAFOs are disproportionally built near rural Black and American Indian communities in NC and are associated with increased AGI most strongly in these populations.