Consensus Study Report
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This activity was supported by contracts between the National Academy of Sciences and the U.S. Centers for Disease Control and Prevention through the National Association of County and City Officials (Contract No. 2021-100601). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-69551-0
International Standard Book Number-10: 0-309-69551-1
Digital Object Identifier: https://doi.org/10.17226/26767
Library of Congress Control Number: 2023934388
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. https://doi.org/10.17226/26767.
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COMMITTEE ON COMMUNITY WASTEWATER-BASED INFECTIOUS DISEASE SURVEILLANCE
GUY H. PALMER (NAM), Chair, Washington State University, Spokane
AMI S. BHATT, Stanford University, Palo Alto, CA
MARISA C. EISENBERG, University of Michigan, Ann Arbor
RAUL A. GONZALEZ, Hampton Roads Sanitation District, Virginia Beach, VA
CHARLES N. HAAS (NAE), Drexel University, Philadelphia, PA
LOREN P. HOPKINS, Houston Health Department and Rice University, Houston, TX
NA’TAKI OSBORNE JELKS, Spelman College, Atlanta, GA
CHRISTINE K. JOHNSON (NAM), University of California, Davis
ROB KNIGHT, University of California, San Diego
SANDRA L. McLELLAN, University of Wisconsin–Milwaukee
MICHELLE M. MELLO (NAM), Stanford University, Palo Alto, CA
JOHN SCOTT MESCHKE, University of Washington, Seattle
REKHA SINGH, Virginia Department of Health, Charlottesville
NEERAJ SOOD, University of Southern California, Los Angeles
KRISTA WIGGINTON, University of Michigan, Ann Arbor
STEPHANIE E. JOHNSON, Study Director, Water Science and Technology Board
KATALYN VOSS (until June 2022), Associate Program Officer, Water Science and Technology Board
ALEXIS WOJTOWICZ (starting July 2022), Associate Program Officer, Board on Population Health and Public Health Practice
CALLA ROSENFELD (until May 2022), Senior Program Assistant, Water Science and Technology Board
PADRAIGH HARDIN (starting May 2022), Program Assistant, Water Science and Technology Board
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This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although these reviewers provided many constructive comments and suggestions, they were not asked to endorse the conclusions and recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Georges C. Benjamin (NAM), American Public Health Association, and Joan B. Rose (NAE), Michigan State University. Appointed by the National Academies, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments received full consideration. Responsibility for the final content of this report rests entirely with the authoring committee and the National Academies.
The emergence and rapid global spread of SARS-CoV-2 and the ensuing COVID-19 pandemic impacted lives and livelihoods across the world. The loss of millions of lives and the chronic sequelae of infection known as “long COVID” are the most tragic and direct disease impacts. Added to this pandemic burden are the lost years of education, the impact on families (especially those who had to take on additional childcare responsibilities), lost employment, the physical and mental exhaustion of healthcare professionals, and numerous other consequences. The world now understands “pandemic” in a real sense that no textbook could convey.
The pandemic also catalyzed innovation: rapid development, testing, and deployment of diagnostic assays, vaccines, and medications. As SARSCoV-2 spread throughout the nation, public health agencies, universities, and municipalities began to detect and track the virus in wastewater. Although wastewater had previously been used to detect viruses and other microbial pathogens, detecting and tracking SARS-CoV-2 required developing and validating quantitative assays, triangulating wastewater levels with clinical laboratory data, and reporting results both within public health agencies and more broadly to communities. The need for emergency response led to multiple approaches from different municipalities and agencies to determine what worked best in general and for specific communities. The spirit of innovation and collective sharing of the acquired expertise reflects the “can do” character of our communities. Countless individuals donated their time and expertise to bring wastewater surveillance online as a critical tool in public health response to the pandemic.
The challenge now is to solidify this emergency response to the COVID-19 pandemic into a national system that not only continues to track the presence and spread of SARS-CoV-2 and its emergent variants but also provides near real-time data on endemic and newly emergent microbial threats for public health action. The full development and deployment of a national wastewater surveillance system can provide critical, ongoing data for public health decisions. The current report addresses the lessons learned from the COVID-19 pandemic; assesses targets and approaches for a diversity of microbial threats; and outlines a vision for a sustainable, flexible, and equitable wastewater surveillance system.
The complexity of a national system that achieves these goals requires multidisciplinary and interdisciplinary expertise. The National Academies of Sciences, Engineering, and Medicine brought together a committee with expertise in public health, epidemiology, wastewater, analytical methods, environmental engineering and microbiology, data science, and medical ethics. The committee has endeavored to examine the full range of approaches used by different municipalities and public health agencies. The responsiveness of the multiple wastewater facilities, state and local public health jurisdictions, and the U.S. Centers for Disease Control and Prevention was deeply appreciated.
The committee members brought their expertise and, importantly, their commitment to provide the evidence base for a national wastewater surveillance system. All have sacrificed their time, including evenings, weekends, and holidays, without financial compensation in this commitment. Although the ongoing pandemic impacted our ability to consistently meet in person, the committee, individually and collectively, brought their expertise, experience, and knowledge to the task. I cannot thank them enough.
On behalf of the committee, I would like to express our thanks and appreciation to the National Academies staff: Alexis Wojtowicz, associate program officer with the Board on Population Health and Public Health Practice (Health and Medicine Division); and Katalyn Voss, associate program officer, Padraigh Hardin, program assistant, and Calla Rosenfeld, senior program assistant, with the Water Science and Technology Board (Division on Earth and Life Studies). We extend a special thank you and deep appreciation to the study director Stephanie Johnson, who provided exceptional leadership throughout the study. Without her leadership and the work of the staff in planning, organizing, and editing, this report would not have been possible.
The history of public health funding in the United States, and specifically for disease surveillance, is one of emergency response to disease epidemics followed by a precipitous decline once the immediate threat has passed—only to be rebuilt with the next infectious disease event. The impacts of the COVID-19 pandemic, which touched everyone, has, hope-
fully, forever changed this approach. Having built on the innovation and expertise of all those who brought the wastewater surveillance system to the point where a true national system is within reach, it is a pivotal moment to ensure that it achieves its promise.
Guy Hughes Palmer, Chair
Committee on Community Wastewater-based
Infectious Disease Surveillance
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|AFM||acute flaccid myelitis|
|CARES||Coronavirus Aid, Relief, and Economic Security Act|
|CCL||contaminant candidate list|
|CDC||U.S. Centers for Disease Control and Prevention|
|DCIPHER||Data Collation and Integration for Public Health Event Response|
|DUC||data use committee|
|ELC||Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases|
|ELISA||enzyme-linked immunosorbent assay|
|EPA||U.S. Environmental Protection Agency|
|GLASS||Global Antimicrobial Resistance and Use Surveillance System|
|HHS||U.S. Department of Health and Human Services|
|HPAI||high pathogenicity avian influenza|
|ITS||internal transcribed spacer|
|NACCHO||National Association of County and City Health Officials|
|NASEM||National Academies of Sciences, Engineering, and Medicine|
|NIH||National Institutes of Health|
|NIST||National Institute of Standards and Technology|
|NSF||National Science Foundation|
|NSSIL||National Sewage Surveillance Interagency Leadership|
|NWSS||National Wastewater Surveillance System|
|PCR||polymerase chain reaction|
|PMMoV||pepper mild mottle virus|
|rRNA||ribosomal ribonucleic acid|
|RSV||respiratory syncytial virus|
|RT-PCR||reverse transcription polymerase chain reaction|
|RT-qPCR||reverse transcription-quantitative polymerase chain reaction|
|SCAN||Sewer Coronavirus Alert Network|
|TRACE||Team-based Rapid Assessment of community-level Coronavirus Epidemics|
|TSE||transmissible spongiform encephalopathy|
|USDA||U.S. Department of Agriculture|
|USGS||U.S. Geological Survey|
|VADOC||Virginia Department of Corrections|
|VP1||viral envelope protein 1|
|WEF||Water Environment Federation|
|WHO||World Health Organization|
Development of the National Wastewater Surveillance System
2 WASTEWATER SURVEILLANCE FOR COVID-19
Value for Understanding COVID-19 in Communities
Use in Informing Public Health Actions
Innovation in Response to Implementation Challenges
3 VISION FOR NATIONAL WASTEWATER SURVEILLANCE
Benefits of Sustained National Wastewater Surveillance
Key Characteristics of a National Wastewater Surveillance System
A Framework for Identifying Candidate Pathogens for Wastewater Surveillance
Illustrative Applications of Criteria
Vision for an Effective Framework for Determining Temporal and Spatial Resolution
4 STRATEGIES FOR ACHIEVING THE VISION AND INCREASING THE PUBLIC HEALTH IMPACT OF NATIONAL WASTEWATER SURVEILLANCE
A Systematic and Dynamic Process for Evaluating Targets for Wastewater Surveillance
Public Acceptance: Legal and Ethical Considerations
Assuring Data Quality and Actionability
Building Broad and Sustainable Capacity
Achieving Integration and Collaboration
Conclusions and Recommendations
A COMMITTEE MEMBER AND STAFF BIOGRAPHICAL SKETCHES