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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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Consensus Study Report

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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.

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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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 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

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

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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:

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
×

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 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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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-

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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Acronyms

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
DNA deoxyribonucleic acid
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
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
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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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
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2023. Wastewater-based Disease Surveillance for Public Health Action. Washington, DC: The National Academies Press. doi: 10.17226/26767.
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The COVID-19 pandemic spurred a rapid expansion of wastewater-based infectious disease surveillance systems to monitor and anticipate disease trends in communities.The Centers for Disease Control and Prevention (CDC) launched the National Wastewater Surveillance System in September 2020 to help coordinate and build upon those efforts. Produced at the request of CDC, this report reviews the usefulness of community-level wastewater surveillance during the pandemic and assesses its potential value for control and prevention of infectious diseases beyond COVID-19.

Wastewater-based Disease Surveillance for Public Health Action concludes that wastewater surveillance is and will continue to be a valuable component of infectious disease management. This report presents a vision for a national wastewater surveillance system that would track multiple pathogens simultaneously and pivot quickly to detect emerging pathogens, and it offers recommendations to ensure that the system is flexible, equitable, and economically sustainable for informing public health actions. The report also recommends approaches to address ethical and privacy concerns and develop a more representative wastewater surveillance system. Predictable and sustained federal funding as well as ongoing coordination and collaboration among many partners will be critical to the effectiveness of efforts moving forward.

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