Wastewater-based Disease Surveillance for Public Health Action (2023) / Chapter Skim
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2 Wastewater Surveillance for COVID-19
2 Wastewater Surveillance for COVID-19
Pages 25-54
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epidemiological surveillance has incorporated a number of conventional data sources to track COVID-19 burdens and trends, including clinical test results and case information, COVID-19 hospitalizations (compiled through the HHS [U.S. Department of Health and Human Services]
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In other words, could wastewater data be a leading indicator of the traditional surveillance data time series and provide an early warning of clinical trends? If so, could they help direct more timely public health decisions?
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Numerous local dashboards have been developed to date, although some have stopped posting data as of summer 2022.3 Some local dashboards present the wastewater data only (see Figure 2-1) , whereas others present wastewater data alongside standard surveillance data (see Figure 2-2)
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. NOTE: Data are normalized against concentrations of the pepper mild mottle virus (PMMoV)
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/person/day) in wastewater compared to polymerase chain reaction positive case count in Milwaukee Municipal Sanitation District South Shore, Wisconsin.
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Vaccination status, for example, may change the shedding levels and dynamics with infection, which would ultimately change the viral trends observed in a sewershed's wastewater. There is an interest in using wastewater to estimate the overall COVID-19 disease burden in communities rather than simply using cor relations to predict incidence or hospitalization trends (McMahan et al., 2021; Soller et al., 2022)
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From page 31... ...
Second, there may be shorter time delays for wastewater analysis and communication of results to reach public health officials than for analysis and communication of results for clinical tests and reporting of hospitalization data. W astewater data represent a single measurement per day for a whole sewershed, whereas case data represent many measurements, with samples collected in different clinics and analysis performed in different laboratories with different tests.
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The different conclusions regarding lead times reported between studies could stem from numerous factors, including • the phase of the pandemic, with different phases having different testing availability and potentially changing viral shedding charac teristics associated with different variants and shifting natural and vaccine-induced immunities (Wu et al., 2022b) ; • different amounts of time required for sample transport, analysis, and data reporting; • different wastewater sampling frequencies; • the sewershed structure and population; and • the specifics of the conventional surveillance data to which the wastewater data are compared (e.g., date of specimen collection, date of symptom onset, and date of data reporting)
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. The value of wastewater surveillance data as a leading indicator of conventional surveillance data can be enhanced at times when there are significant testing delays and case/hospitalization/ death number reporting delays and when wastewater data do not have a significant reporting delay.
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The COVID-19 case data are typically aggregated for the entire county on public health dashboards. Wastewater data from the two communities, which are analyzed with the same methods in the same laboratory, have provided higher spatial resolution compared to the aggregated county case data.
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In this case, the community-scale wastewater data provide higher spatial resolution than that provided by aggregated county surveillance data and have identified differences in trends and burdens between the two communities. NOTE: PMMoV = pepper mild mottle virus.
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. that are "often underrepresented in clinical testing, such as low-income neighborhoods and communities of color." Comparative analysis of SARS-CoV-2 RNA levels in wastewater across communities is complicated by several factors.
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Variants Mutations in the SARS-CoV-2 genome have led to new variants throughout the course of the COVID-19 pandemic, and some variants have caused increased transmissibility, increased disease severity, and increased ability to escape immunity induced by either vaccination or prior infection, and, as a result, decreased effectiveness of public health measures. Wastewater variant tracking has been used to complement clinical testing for early detection and understanding of the spread of known and emerging variants.
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As an example, wastewater from all 14 wastewater treatment plants in New York City has been sequenced twice per month for the presence of novel variants, whereas PCR-based wastewater testing has been conducted weekly since June 2020 (Smyth et al., 2022)
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(2022) demonstrated that variants of concern could be identified in wastewater via high-resolution genome sequencing up to 2 weeks prior to their detection in clinical samples.4 USE IN INFORMING PUBLIC HEALTH ACTIONS In this section, the committee discusses the usefulness of wastewater surveillance data to inform public health decision making and to enhance public awareness of COVID-19 disease transmission, thereby informing public health–related actions.
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. When compared with other sources of information about disease burden, wastewater data can help inform decision making across a wide range of geographical scales (e.g., countries, states, cities, neighborhoods, institutions)
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. Clinical testing of dorm residents based on the wastewater results enabled early diagnosis of 85 percent of COVID-19 cases (Karthikeyan et al., 2021)
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Confirming Trends through Comparison with Other Public Health Surveillance Data When analyzed in comparison with other disease surveillance information, wastewater surveillance data are particularly useful in informing public health responses. By using multiple metrics in support of decision making, other sources of data are available to investigate anomalous results and increase confidence in observed trends.
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From page 43... ...
Informing Public Health Resource Allocation Numerous examples show the value of wastewater surveillance data to inform decisions on the allocation of public health resources, such as testing sites, contact tracing, vaccination centers, and public notification efforts: • In Ohio, a 10-fold increase in SARS-CoV-2 RNA levels within the state's wastewater surveillance system triggered an email warning to state and local health departments, utilities, and community leaders. The notifications were used to inform actions and allocate resources (Kirby et al., 2021)
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. • The City of Davis, California, used wastewater surveillance data to determine where to send geotargeted public health communications (e.g., door hangers, texts, phone calls, emails)
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WASTEWATER SURVEILLANCE FOR COVID-19 45 FIGURE 2-11 Door hanger delivered in response to a spike of SARS-CoV-2 RNA in wastewater in the area. SOURCE: https://healthydavistogether.org/the-new-pandemic-landscape-and-thevalue-of-wastewater-monitoring.
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. Challenges Affecting the Use of Wastewater Surveillance Data There are multiple challenges that prevent local governments from fully adopting wastewater surveillance or fully putting the data to use.
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. Early information and anecdotal accounts suggest that mentions of wastewater data by public health officials likely increase public awareness.
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Although this undoubtedly increased public knowledge on the topic, little is known about how media attention has affected public understanding, perception, and use of wastewater data or how wastewater surveillance has attracted readers compared to other COVID-19 surveillance reporting.
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The same study found that 85 percent of those surveyed were supportive of wastewater surveillance. Those who were aware that SARS-CoV-2 could be measured in wastewater were more likely to be supportive of the activ
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Innovation, across utilities, analytical laboratories, and health departments, was essential in the rapid scaling and continuous process improvement of SARS-CoV-2 detection. Early in the COVID-19 pandemic, efforts to collect and analyze wastewater data began with proof-of-concept work that was concentrated in university laboratories familiar with environmental monitoring due to available expertise and laboratory equipment.
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The committee's Phase 2 report will review sampling approaches, analytical methods, data analysis, and data visualization and research needs in light of experience gained during the first 2 years of the pandemic. CONCLUSIONS The experience with wastewater surveillance during COVID-19, demonstrates that these data are useful for informing public health action and that wastewater surveillance is worthy of further development and
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From page 52... ...
Although wastewater surveillance is not currently being used as a standalone method to reliably estimate the number of community infections, SARS-CoV-2 wastewater data have correlated with case data and other conventional public health surveillance data. Depending on a number of factors, including wastewater sampling frequency, the time required for sample transport and analysis, and the time required for data reporting, wastewater SARS-CoV-2 viral trends have the potential to be reported more quickly or along a more consistent time frame than conventional disease surveillance reporting.
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From page 53... ...
To date, sites within the NWSS have been based primarily on wastewater utility and public health jurisdiction willingness to participate, including volunteering time and resources, and thus do not comprise a representative national system. Importantly, participating sites have successfully built new partnerships across professional communities with limited prior interactions, spurring innovation and increased efficiency.
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