Resource-oriented sanitation represents a fundamental departure from the linear model that has dominated sanitation engineering for more than a century. Instead of collecting wastewater in energy-intensive networks and transporting it over long distances to centralized plants, ROS seeks to recover water, nutrients, organic matter and energy at or near the source. Technologies range from source separation of urine and faeces to treatment wetlands, struvite precipitation, alkaline urine dehydration and anaerobic digestion for biogas production. The approach treats wastewater not as a disposal problem but as a circulating resource stream, one that can simultaneously reduce pollution, ease pressure on freshwater supplies and return plant-essential nutrients such as nitrogen and phosphorus to agricultural soils.

The timing of the analysis is significant. Urbanization, population growth and climate change are intensifying competition for water, energy and food resources, a tension captured by the water-energy-food-environment nexus framework. Within this nexus, decisions in one sector cascade through the others: irrigation choices affect energy demand, fertilizer production drives greenhouse gas emissions, and wastewater discharge degrades the ecosystems that underpin food production. The United Nations’ 2030 Agenda, with its 17 goals and 169 targets, was designed to reflect these interdependencies, yet most sustainability assessments still operate at the coarse level of entire goals, obscuring the concrete interactions that policymakers actually regulate.

To close this gap, the research team applied a structured scoring method originally developed by Nilsson and colleagues in 2016 and adapted within Austria’s UniNEtZ project, a collaborative initiative of Austrian universities aimed at translating the SDGs into actionable national policy. Under the seven-point Nilsson scale, interactions range from +3, meaning an intervention is indispensable for achieving a target, down to -3, meaning it makes achievement impossible. Groups of at least three senior experts per SDG scored each interaction independently, provided written justifications, and then resolved divergences through moderated consensus deliberation. Simple averaging was prohibited, ensuring that disagreements were argued through rather than diluted numerically.

The results are striking. Of the 123 SDG targets assessed beyond SDG 6, 41 showed non-neutral interactions with resource-oriented sanitation, and every single one was positive. Four targets earned the highest score of +3, marking ROS as indispensable: sustainable and resilient food production under SDG 2.4, improved water quality and wastewater treatment under SDG 6.3, resource efficiency and decoupling growth from environmental harm under SDG 8.4, and upgrading infrastructure and industries for sustainability under SDG 9.4. A further cluster of reinforcing interactions, scored +2, spanned agricultural productivity, communicable disease prevention, sustainability education, water-use efficiency, renewable energy, green jobs, industrial innovation, urban sustainability, climate resilience and marine ecosystem protection.

The food-system lens reveals why these connections run so deep. Food systems are not merely agricultural production; they encompass processing, distribution, consumption and waste, embedded within social, economic, health and governance dimensions. When sanitation is reframed as part of the food system, the circularity becomes tangible. One illustrative calculation cited in the study found that wastewater from just 4 percent of Vienna’s population could supply the nutrients needed for the city’s vegetable production, equivalent to roughly one-third of local vegetable consumption. Closing that loop reduces dependence on synthetic fertilizers, whose manufacture is energy-intensive and emissions-heavy, while building soil health and buffering farms against price shocks and supply disruptions.

Water is the other critical thread. In Austria, irrigation water demand is projected to rise by around 80 percent by 2050, placing mounting pressure on groundwater resources that also supply drinking water. Reclaimed wastewater can substitute freshwater for irrigation and fertigation, directly improving water-use efficiency and relieving stressed aquifers. Source separation adds a further layer of protection: by isolating nutrient-rich and contaminant-rich streams before they mix, ROS reduces the release of pharmaceuticals and micropollutants into rivers, limits combined sewer overflows, and ultimately cuts the land-based nutrient runoff that drives eutrophication and ocean acidification in downstream marine environments, including the Danube-Black Sea corridor.

The study’s Austrian setting is itself noteworthy. Research on resource-oriented sanitation has concentrated overwhelmingly on low- and middle-income countries, leaving high-income, infrastructure-rich contexts underexplored. Austria is an instructive case: it enjoys excellent conventional sanitation, yet the European Union’s Water Reuse Regulation of 2020 established minimum quality requirements for agricultural water reuse that Austria opted not to implement, citing liability concerns and potential costs for farmers while acknowledging the need for re-evaluation. The new target-level evidence base is intended precisely to inform such reassessments, showing how even mature sanitation systems hold untapped potential for circular resource management aligned with broader sustainability objectives.

The authors are careful to delineate what the assessment does and does not show. The absence of negative scores does not mean trade-offs are impossible in practice; rather, it reflects that ROS, defined explicitly as promoting the safe reuse of water, nutrients, energy and materials in compliance with treatment standards, was judged not to systematically impede any SDG target in the Austrian context. Implementation barriers remain real and are not captured by the scoring framework: highly centralized infrastructure may limit the cost-effectiveness of decentralized solutions, regulatory uncertainty persists around recovered products, public acceptance hinges on risk perceptions, and low water tariffs and cheap synthetic fertilizers weaken the economic case. Emerging contaminants such as PFAS and microplastics add further technical and regulatory complexity to the safe reuse of recovered resources.

What emerges overall is a portrait of sanitation as a cross-sectoral enabler rather than a stand-alone service. The interaction patterns map onto every dimension of sustainable food systems: environmental benefits through pollution reduction and ecosystem protection, economic gains through reduced input dependency and new circular-economy jobs, social benefits through more equitable access to locally recovered resources, health gains through reduced pathogen exposure, and institutional benefits through the participatory governance that safe reuse demands. The UN-Water SDG 6 Synthesis Report 2026 identifies fragmentation between sectors as a key barrier to SDG progress, and this study offers a concrete methodological answer: by making target-level interactions explicit, expert-based assessments can give policymakers a structured, evidence-grounded basis for coordinating agriculture, energy, health, climate and water policy. If the toilet is to become a tool of the circular economy, the evidence now suggests the connections it forges may be among the most consequential in the entire 2030 Agenda.

Subject of Research: Target-level assessment of resource-oriented sanitation linkages with the Sustainable Development Goals in sustainable food systems

Article Title: Resource-oriented sanitation in sustainable food systems: Identification and analysis of linkages across the sustainable development goals

Article References: Vobruba, T., Delgado, C., Germann, V., Costa-Pereira, I., Wirth, M., Hartl, M., Huber-Humer, M., & Langergraber, G. (2026). Resource-oriented sanitation in sustainable food systems: Identification and analysis of linkages across the sustainable development goals. Environmental and Sustainability Indicators, 32, Article 101517. https://doi.org/10.1016/j.indic.2026.101517

Image Credits: AI Generated

DOI: 10.1016/j.indic.2026.101517

Keywords: resource-oriented sanitation, sustainable development goals, food systems, wastewater reuse, nutrient recovery, water-energy-food nexus, circular economy, SDG interactions, Austria, sustainable agriculture, water reuse regulation, climate resilience

The study’s foundation is a simple but powerful epidemiological logic. If SARS-CoV-2 were still exerting a serious toll on the population, the age groups most vulnerable to the virus, principally those aged 60 and older, should show mortality rates above their pre-pandemic baselines. The researchers therefore calculated mortality rate ratios for every combination of sex and ten-year age band, dividing the 2024 death rate by the average rate across 2017 to 2019. A ratio above 1.00 would signal excess mortality; a ratio below 1.00 would suggest that deaths have fallen relative to before the pandemic. Confidence intervals were derived using the delta method on the log scale, allowing the team to distinguish signal from statistical noise.

The results were unambiguous for older Austrians. Despite 1,212 officially reported COVID-19 deaths in 2024, all-cause mortality rates in every stratum aged 40 and over were equal to or lower than before the pandemic, and in the 60-plus groups, the very populations at risk from the virus, rates were equal or lower in 2024 compared with 2019. In many of these strata the ratios fell well below 1.00. The team stress-tested this finding against several counterfactuals. An optimistic sensitivity analysis assumed that mortality would have continued improving after 2019 at the pace seen between 2012 and 2014, yielding an expected ratio of 0.929; five of the twelve age-sex strata aged 40 and over beat even that demanding benchmark. A trend-of-trends model trained on Austrian data from 2003 to 2019 produced an expected ratio of 0.976, and ten of twelve strata performed better than that. A Lee-Carter mortality forecasting model, fitted to age- and sex-specific rates from 2003 to 2019 and projected to 2024 via ARIMA with bootstrapped confidence intervals, showed observed 2024 life expectancy to be numerically higher than predicted in every age-sex stratum, significantly so for females across all age groups.

The picture for young Austrians was markedly different, and more troubling. Mortality rate ratios were elevated in the 10-to-19, 20-to-29 and 30-to-39 age bands, significantly so among men aged 30 to 39. Crucially, these increases cannot be attributed to COVID-19 itself: only a single individual across these young strata was recorded as having died of the disease in 2024. When the researchers decomposed the excess by cause, they found moderate increases spread across multiple high-level categories, with consistent rises in mental and behavioural disorders, external causes and diseases of the nervous system, though only external causes in the 10-to-19 group reached statistical significance. The authors suggest these patterns may reflect adverse consequences of the pandemic and the pandemic response, noting that escalating violence, alcohol problems, drug overdoses and suicides among young people have been documented in several countries and may constitute a lasting legacy that requires tracking and intervention.

The second half of the study tackles a subtler problem: how to count a COVID-19 death. Death certificates record an underlying cause of death, the condition that initiates the chain leading to death, along with other contributing conditions. In practice, anyone who dies with a positive SARS-CoV-2 test may be coded as a COVID-19 death even when other conditions are more relevant, a distinction that matters enormously in elderly and chronically ill populations. To address this, the team applied a weighted multiple-cause methodology to the full text of Austrian death certificates. In their main analysis, the underlying cause received a weight of 50 percent and all other mentioned causes shared the remaining 50 percent; when no other cause was listed, the underlying cause carried full weight. Ill-defined and duplicate causes were excluded. From more than 538,000 death certificates spanning 2019 to 2024, containing over 2.5 million non-duplicate ICD code mentions, the researchers constructed age-standardised rates for both unweighted underlying-cause counts and weighted counts.

The comparison between the two measures is the study’s most technically revealing result. If a cause is genuinely driving deaths, it should appear disproportionately as the underlying cause, and its weighted rate should approach its unweighted rate. For COVID-19 in the 60-plus age groups, the ratio of weighted to unweighted rates sat between 0.51 and 0.58, both in 2020 and in 2024, meaning the virus was far more likely to be listed as the underlying cause than other conditions were, and that this preference barely changed even as absolute death counts collapsed. Sensitivity analyses using alternative weighting schemes, equal weighting of all causes or double weight for the underlying cause, produced even lower weighted estimates, for example 4.15 versus a main-analysis 7.12 for 2024, and more stringent data-cleaning criteria left the COVID-19 findings intact. Taken together, the authors argue, these patterns point to systematic overcounting of COVID-19 deaths, potentially throughout the entire pandemic rather than only in its aftermath.

Supporting evidence comes from how COVID-19 behaved within the broader cause-of-death landscape. Respiratory diseases traditionally show a weighted-to-unweighted ratio well above 1.00, around 1.47 in 2019, because they are typically recorded as contributing rather than underlying conditions. During the pandemic years 2020 to 2023, once COVID-19 was stripped out of the respiratory category, other respiratory diseases fell markedly, and the category’s ratio rose to 1.64, as if COVID-19 had absorbed deaths that would otherwise have been attributed to pneumonia and related conditions. The causes most frequently co-mentioned with COVID-19 in 2024 were pneumonia, residual infections, hypertensive disease, ischaemic heart disease and renal failure, and even in 2024 COVID-19 was still listed as the underlying cause in 68 to 85 percent of those co-occurrences, down from 88 to 98 percent in 2020. Meanwhile, the apparent decline in ischaemic heart disease between 2019 and 2024 was, in the authors’ view, too large to reflect genuine improvement and may partly represent recoding of deaths with multiple comorbidities.

The Austrian findings align with a growing international literature based on clinical record audits. In Greece, only 64.9 percent of hospital deaths listed as COVID-19 were judged attributable or related to the virus upon audit. In Sweden, auditors found that 24 percent of certificate-listed COVID-19 deaths had absolutely no relationship to the infection, and that in most of the remainder COVID-19 was contributing rather than underlying; death certificates counted 799 underlying-cause COVID-19 deaths where clinical audit supported only 213. In Ireland, clinicians considered COVID-19 the primary cause in only 72.7 percent of audited deaths during the winter of 2021 to 2022, and Danish surveillance documented increasing overcounting with the Omicron variants. Notably, the feared undercounting in lower-income settings appears smaller than assumed: a Colombian audit found only 6 percent undercounting in 2021, although an Iranian audit of 339 certificates found major errors in 58 percent. The overall pattern suggests overcounting, not undercounting, has been the dominant error in well-resourced countries.

The study has limitations the authors acknowledge candidly. Without comorbidity data, the results cannot be generalised to specific high-risk populations such as immunocompromised patients or nursing home residents, among whom COVID-19 mortality may remain meaningful. Death certificate reporting itself is imperfect, with empirical studies suggesting major errors exceed 50 percent even in pre-pandemic years, and Austria’s automated IRIS coding algorithms may have favoured selecting COVID-19 as the underlying cause. There is also genuine uncertainty about the right counterfactual: whether mortality should have continued declining after 2019 at all, given that life expectancy gains in Austria and other high-income countries had already slowed dramatically in the decade before the pandemic, adding just 0.41 years between 2014 and 2019 compared with more than a year in each of the three preceding five-year periods. Some of the lower mortality among the very old in 2024 may reflect mortality displacement, the premature deaths during the pandemic of people who would otherwise have died a few years later.

Even so, the implications for policy are concrete. Accurate post-pandemic burden estimates directly shape vaccination recommendations, which currently diverge widely across Europe, from yearly boosters offered from age 12 in Austria to age 65 and older in Denmark. The authors’ earlier work estimated that, assuming correct COVID-19 death counts, the only Austrian group with a mortality rate implying a number needed to vaccinate below 1,000, residents of nursing homes aged 85 and over, had average life expectancies below one year. With an estimated 2.8 million SARS-CoV-2 infections in Austria in 2024, the reported 1,212 deaths already imply an infection fatality rate of just 0.043 percent, and the weighted analysis suggests even that figure is too high. The study’s most urgent message, however, may be the one about the young: a post-pandemic rise in mortality driven by mental health, external and neurological causes demands confirmation, explanation and intervention, long after the virus itself has faded from the mortality statistics.

Subject of Research: Post-pandemic all-cause mortality patterns and estimation of the residual COVID-19 death burden using weighted multiple-cause-of-death analysis in Austria

Article Title: Post-pandemic mortality patterns and COVID-19 burden considering multiple death causes

Article References: Riedmann, U., Levitt, M., Pilz, S., & Ioannidis, J. P. (2026). Post-pandemic mortality patterns and COVID-19 burden considering multiple death causes. European Journal of Epidemiology. https://doi.org/10.1007/s10654-026-01462-7

Image Credits: AI Generated

DOI: 10.1007/s10654-026-01462-7

Keywords: COVID-19, mortality, Austria, death certificates, multiple causes of death, excess mortality, epidemiology, vaccination policy, life expectancy, infection fatality rate, public health, youth mortality

Enterococci are gram-positive bacteria that normally colonize the intestinal tracts of humans and animals, where they usually live as harmless commensals. Yet two species in particular, Enterococcus faecalis and Enterococcus faecium, are among the most important causes of opportunistic and healthcare-associated infections. Enterococcus faecium is notorious for its capacity to acquire resistance to penicillins and, increasingly, to glycopeptides such as vancomycin, an antibiotic class introduced in 1955 that kills bacteria by binding to peptidoglycan precursors and blocking cell wall synthesis. Vancomycin-resistant enterococci were first described more than two decades after the drug’s introduction, and among resistant E. faecium isolates the vanB genotype has become the most prevalent in several European countries. VanB-type resistance is known for phenotypic variability, meaning that laboratory phenotype does not always reliably reflect the underlying resistance genes, a property that has now proven consequential in a dramatic way.

The public health stakes are considerable. The World Health Organization’s 2024 Bacterial Priority Pathogens List classifies vancomycin-resistant E. faecium as a high-priority pathogen, and according to the European Centre for Disease Prevention and Control the mean vancomycin resistance rate among European E. faecium isolates stands at roughly 20 percent. Austria had long reported comparatively low figures, with the national action program on antibiotic resistance documenting a resistance rate of just 3 percent among invasive isolates in 2023. That picture changed abruptly. After years without any invasive vancomycin-resistant E. faecium infections, the diagnostic laboratory serving Graz and the wider region observed the resistance rate among E. faecium-positive blood cultures climb to 6 percent in 2024 and then to 20 percent in the first half of 2025. By June 2025, thirty-one resistant isolates had been collected, and virtually all could be attributed to a single previously unreported lineage, ST117/CT7799.

The outbreak’s first signal appeared in February 2024, when automated VITEK2 susceptibility testing flagged vancomycin resistance in a clinical E. faecium isolate even though disk diffusion, gradient testing, and broth microdilution all failed to confirm it under routine conditions. When the laboratory reorganized its workflow to route all enterococcal isolates through automated testing and systematically re-examined results, five further isolates with the same distinctive phenotype emerged within months. All came from specimens obtained for genuine infection diagnostics rather than screening, and every case was confirmed as vanB-type resistance by molecular PCR. Retrospective review of raw instrument data found no evidence of this phenotype in the laboratory’s records before 2024, strongly suggesting a genuinely new arrival. Early cases clustered around invasive procedures performed at a single hospital, and a second transmission chain later surfaced among urology patients who had undergone double-J catheterization in an operating room shared with surgeons. Notably, environmental surface sampling by the hospital infection control team failed to locate the organism, and nearly all affected patients had either been hospitalized for at least four days or had recent inpatient care history with the same provider.

To characterize the outbreak, the team subjected twenty non-duplicate isolates to whole genome sequencing using both Illumina short-read and Oxford Nanopore long-read platforms, achieving highly concordant results between technologies. Core genome multilocus sequence typing based on 1,423 loci revealed a strikingly homogeneous cluster: even isolates sampled sixteen months apart differed by no more than six alleles, far below the cluster threshold of three alleles used for assignment once the clonal relationship was established. The nearest local control strain, isolated at the same site during the same period, differed by 159 alleles, and the closest reference strain from the Robert Koch Institute collection differed by 142 alleles. Searches of the cross-national surveillance platform MiGenomeSurv showed the next closest relative still 76 alleles away, confirming that CT7799 represents an entirely novel lineage. The clone was provisionally named VREfmstyr, after Styria, the Austrian federal state where it was first isolated.

Genomic analysis also illuminated the genetic architecture of resistance. All outbreak isolates carried a complete copy of the transposon Tn1549, the mobile element responsible for vanB-mediated vancomycin resistance, inserted into the chromosome. Long-read assemblies proved essential: short-read assemblies fragmented the transposon across three contigs, obscuring its structure, whereas long reads revealed three matching blocks separated by two intervening regions of 1,494 and 1,417 base pairs containing insertion sequence elements, including an ISL3-like transposase of the ISEfa11 family and an IS3-like ISEnfa3-family transposase alongside a helix-turn-helix domain protein. An additional IS91 transposase was found inserted in a YodL domain protein upstream of the vanB gene cluster. All seven vancomycin resistance genes, vanB, vanY-B, vanW-B, vanH-B, vanX-B, vanR-B, and vanS-B, were identical across every outbreak isolate, underscoring the clone’s remarkable genetic stability despite months of circulation. Based on the classification scheme of the Norwegian VRE study group, the vanB cassette appears to be a hybrid between variants typically associated with different sequence types, hinting at a recombination event in the strain’s recent history.

The true significance of the study, however, lies in its systematic evaluation of diagnostic methods, and the results are sobering. Broth microdilution, the reference standard for antimicrobial susceptibility testing, correctly identified only 16 of 31 isolates, or 52 percent, as vancomycin resistant when read after the standard 24 hours of incubation, even though all control strains behaved as expected. Extending incubation to 48 hours eventually pushed minimum inhibitory concentrations above the susceptibility breakpoint for all isolates, but the growth around concentrations of 2 milligrams per liter and above was so sparse that even trained personnel could easily overlook it. Gradient testing from two different manufacturers failed to detect resistance in every single case at 24 hours, and disk diffusion was equally deceptive: all isolates produced inhibition zone diameters clearly wider than the 12-millimeter resistance threshold, and the zone edges lacked the fuzzy appearance that typically signals vancomycin resistance. Only VITEK2 automated testing, which correctly flagged all 31 isolates under routine settings, proved reliable, a finding that diverges from earlier studies reporting only 81 percent sensitivity for low-MIC resistant strains and possibly reflecting improvements in newer test cards and software.

Screening carried a similar message of failure. When seven representative isolates were plated on kanamycin-vancomycin agar and four commercially available chromogenic VRE screening media, three of the four commercial agars yielded no growth at all after 24 hours, and the sole medium showing some activity was only weakly positive for four isolates and negative for the remaining three. Prolonging incubation to 48 and even 72 hours improved results only marginally and inconsistently across manufacturers, while the outbreak strain failed entirely to grow on kanamycin-vancomycin agar. These findings matter because VRE often constitutes only a small fraction of the intestinal enterococcal population, making selective screening media indispensable for controlling transmission, and because prior research has already shown that sensitivity drops sharply for strains with vancomycin minimum inhibitory concentrations below 16 milligrams per liter. Only CHROMagar VRE proved dependable after standard incubation, and even that required confirming results under the study’s specific conditions.

Intriguingly, when a representative isolate was exposed to vancomycin on a gradient strip for more than 100 hours, single colonies eventually grew within the inhibition zone, and after two passages the derivative consistently displayed a minimum inhibitory concentration of at least 32 milligrams per liter. Sequencing revealed that this resistant derivative carried a single nucleotide substitution in the vanS-B gene, the sensor kinase that regulates the vancomycin resistance operon, causing an amino acid change from serine to arginine at position 243. This observation suggests that the outbreak clone’s occult phenotype stems from a regulatory mutation or arrangement that dampens resistance expression, and that vancomycin pressure can select for compensatory variants restoring full resistance. The authors caution, however, that whether the insertion elements or the specific allele differences in vanR-B, vanY-B, and vanW-B are causally responsible for the difficult-to-detect phenotype remains an open question demanding further investigation.

The implications reach well beyond Styria. Because many diagnostic laboratories worldwide rely on 24-hour disk diffusion zone readings to determine vancomycin susceptibility, a strain with this phenotype could spread through hospitals without triggering any alarm, quietly colonizing patients and contaminating environments while appearing fully susceptible on paper. The research team recommends that laboratories verify the adequacy of their screening media and incubation times, and adapt their susceptibility testing protocols by prolonging incubation, adding molecular vanB PCR testing, or employing automated VITEK2 analysis. Given the clone’s demonstrated epidemic potential, its absence from all prior surveillance databases, and the growing proportion of invasive infections it now accounts for in the region, surveillance studies will be essential to determine whether ST117/CT7799 remains a local phenomenon or whether laboratories across Europe and beyond must urgently reassess whether their diagnostic procedures can catch a superbug designed, by evolutionary accident, to stay invisible.

Subject of Research: Emergence and diagnostic challenges of a novel vancomycin-resistant Enterococcus faecium clone (ST117/CT7799) in Austria

Article Title: Emergence of a Novel, Phenotypically Difficult‐to‐Detect Vancomycin‐Resistant Enterococcus faecium Clone (ST117/CT7799)

Article References: Forstner, P., Uitz, C., Dabernig‐Heinz, J., Wagner, G. E., Bender, J., Fischer, M., Siebenhofer, D., Werner, G., Busche, T., Klages, L. J., Rückert‐Reed, C., Steinmetz, I., & Dichtl, K. (2026). Emergence of a Novel, Phenotypically Difficult‐to‐Detect Vancomycin‐Resistant Enterococcus faecium Clone (ST117/CT7799). MicrobiologyOpen, 15(5), Article e70393. https://doi.org/10.1002/mbo3.70393

Image Credits: AI Generated

DOI: 10.1002/mbo3.70393

Keywords: vancomycin-resistant Enterococcus faecium, VRE, ST117/CT7799, hospital outbreak, antimicrobial resistance, vanB operon, Tn1549 transposon, whole genome sequencing, diagnostics, Austria, infection control, cgMLST