Wastewater-based Disease Surveillance for Public Health Action (2023)

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Wastewater-based Disease Surveillance for Public Health Action Committee on Community Wastewater-based Infectious Disease Surveillance Water Science and Technology Board Division on Earth and Life Studies Board on Population Health and Public Health Practice Health and Medicine Division Consensus Study Report Prepublication Copy 

NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 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-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26767 This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2023 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved. Printed in the United States of America. 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/26767. PREPUBLICATION COPY 

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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY 

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 Study Staff 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 PREPUBLICATION COPY v 

Reviewers 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: Kyle Bibby, University of Notre Dame Thomas Burke, Johns Hopkins University Michael D. Lairmore (NAM), University of California, Davis Daniel C. Lang, New York State Department of Health David Larsen, Syracuse University Anna Mehrotra, Water Environment Federation Kara Nelson, University of California, Berkeley Natalie Ram, University of Maryland Steven Rhode, Massachusetts Water Resources Authority Helena Solo-Gabriele, University of Miami Renee Street, South African Medical Research Council James M. Tiedje (NAS), Michigan State University Lance Waller, Emory University 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. PREPUBLICATION COPY vi 

Preface 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 SARS-CoV-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 PREPUBLICATION COPY vii 

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, hopefully, 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 PREPUBLICATION COPY viii 

Acronyms AFM acute flaccid myelitis AMR Antimicrobial Resistance 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 DNA deoxyribonucleic acid DUCs data use committees ELC Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases ELISA enzyme-linked immunosorbent assay EPA U.S. Environmental Protection Agency EV-D68 enterovirus D68 FY fiscal year 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 RNA ribonucleic acid 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 PREPUBLICATION COPY ix 

Contents SUMMARY ....................................................................................................................................1 1 INTRODUCTION....................................................................................................................7 Development of the National Wastewater Surveillance System, 10 Motivation for the Study, 18 Report Structure, 18 2 WASTEWATER SURVEILLANCE FOR COVID-19 ......................................................21 Value for Understanding COVID-19 in Communities, 21 Use in Informing Public Health Actions, 34 Innovation in Response to Implementation Challenges, 42 Conclusions, 43 3 VISION FOR NATIONAL WASTEWATER SURVEILLANCE ....................................45 Benefits of Sustained National Wastewater Surveillance, 45 Key Characteristics of a National Wastewater Surveillance System, 46 A Framework for Identifying Candidate Pathogens for Wastewater Surveillance, 51 Illustrative Applications of Criteria, 55 Vision for an Effective Framework for Determining Temporal and Spatial Resolution, 67 Conclusions and Recommendations, 73 4 STRATEGIES FOR ACHIEVING THE VISION AND INCREASING THE PUBLIC HEALTH IMPACT OF NATIONAL WASTEWATER SURVEILLANCE ..................77 A Systematic and Dynamic Process for Evaluating Targets for Wastewater Surveillance, 77 Public Acceptance: Legal and Ethical Considerations, 79 Assuring Data Quality and Actionability, 84 Building Broad and Sustainable Capacity, 86 Achieving Integration and Collaboration, 92 Conclusions and Recommendations, 96 REFERENCES .............................................................................................................................99 APPENDIXES A BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS AND STAFF ...........115 B BOARD ROSTERS ............................................................................................................123 PREPUBLICATION COPY xi