Wastewater-based Disease Surveillance for Public Health Action (2023) / Chapter Skim
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3 Vision for National Wastewater Surveillance
3 Vision for National Wastewater Surveillance
Pages 45-76
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From page 45... ...
Finally, the committee reviews spatial and temporal sampling approaches consistent with this national strategy for surveillance. BENEFITS OF SUSTAINED NATIONAL WASTEWATER SURVEILLANCE Investment in a robust national wastewater disease surveillance system is important to increase national preparedness for emerging infectious diseases and to monitor resurgences of known agents.
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From page 46... ...
For example, early detection of influenza can provide critical data for healthcare systems and public health messaging in communities. Several illustrative, highpriority use cases that demonstrate the value of a national wastewater disease surveillance system are given in Box 3-1.
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From page 47... ...
. Reliably inferring community disease burden from wastewater data requires calibration with alternative robust sources of data.
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From page 48... ...
The use of multiple disease surveillance data sources can also help ensure equity of surveillance efforts with respect to unsewered households and communities, and regional public health agencies should take these data gaps into consideration when investing resources. Sustainable The COVID-19 pandemic highlighted the need for the U.S.
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From page 49... ...
, and (2) the analysis of data from different disease surveillance systems to ensure comprehensive understanding in supporting public health action.
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From page 50... ...
Finally, wastewater surveillance data should be interpretable in a public health context. The analysis methods and interpretation guidance should link the data with population patterns of disease so that public health officials and the public understand what the wastewater data imply for public health.
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From page 51... ...
analytical feasibility for wastewater surveillance, and 3. usefulness of community-level wastewater surveillance data to inform public health action.
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From page 52... ...
Similarly, it is important to consider how much uncertainty exists in our knowledge of the distribution of the disease; for example, diseases that are mostly asymptomatic but cause severe outcomes in a PREPUBLICATION COPY
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From page 53... ...
Both rare and widespread pathogens pose unique challenges to detection and interpretation of surveillance data. Rare pathogens may fall below the level of detection at the community wastewater scale, while widespread pathogens require quantification rather than simple presence/absence for interpretation.
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From page 54... ...
The extent to which other sources of data are readily available, cost-effective, and capable of informing public health actions should be weighed relative to the potential contributions of wastewater data. For many targets, samples and data could be available at clinics, hospitals, and other healthcare facilities through routine, syndromic-based, or targeted surveillance efforts.
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From page 55... ...
, including assessments of implementation costs relative to the value added beyond other available disease surveillance data. As the state of the science and infectious disease risk evolves, candidate pathogens will need to be re-evaluated; pathogens that may not be good candidates for surveillance now might be well suited for wastewater surveillance in the future.
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From page 56... ...
In other cases, such as antimicrobial resistance, improvements in features such as analytical feasibility will be important to actualize a useful surveillance scheme. Longer-Term Dynamics of COVID-19 and SARS-CoV-2 Variants Criterion 1: Public health significance of the threat.
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From page 57... ...
Criterion 3: Usefulness of community-level wastewater surveillance data to inform public health action. SARS-CoV-2 wastewater surveillance is increasing in usefulness for informing public health action as SARS-CoV-2 begins to follow more of an endemic transmission pattern, with reduced clinical testing and at-home testing becoming much more common (see Chapter 2)
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From page 58... ...
However, this is no greater problem than delineating different variants of SARS-CoV-2 and may be overcome with next-generation sequencing approaches. One potentially complicating factor is the wide availability of a live attenuated influenza PREPUBLICATION COPY
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From page 59... ...
Criterion 3: Usefulness of community-level wastewater surveillance data to inform public health action. Influenza infections are prevalent, and because only a small subset of infected individuals present for clinical care and are captured by public health surveillance systems, wastewater surveillance data are expected to be of high use in informing public health action.
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From page 60... ...
The wastewater resistome will reflect the predominant resistance genes in the community microbiome, predominantly the human gastrointestinal microbiome -- although human nonintestinal microbiomes and animal microbiomes may also contribute to detectable levels depending on the community. One challenge to using wastewater surveillance for the presence, absence, and abundance of antimicrobial resistance genes is that it reflects genes that are present in both pathogens and commensal organisms (which are carried without causing disease in most individuals)
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From page 61... ...
Wastewater surveillance data on antimicrobial resistance are likely to be useful to inform public health action, though the exact ways in which they complement existing data sources and result in specific actions have yet to be defined. Thus, while promising, wastewater surveillance of antimicrobial resistance may not yet be ready to put into use at this time.
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From page 62... ...
Antimicrobial resistance is of high public health significance, and if analytical advances allow more rapid and cost-effective mapping of resistance to specific pathogens, surveillance in wastewater would be of even higher value. Furthermore, as antimicrobial resistance frequently emerges in "hot spots" outside the United States and then spreads globally, wastewater surveillance at sentinel sites such as airports may serve as an early warning signal for additional screening of newly emergent antimicrobialresistant pathogens.
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From page 63... ...
Wastewater surveillance data about EV-D68 are expected to be highly complementary to the limited existing public health data on this pathogen and are expected to inform public health action. Because EV-D68 infection often is asymptomatic or minimally symptomatic and severe respiratory disease or AFM as a consequence of EV-D68 is not reportable from a public health perspective, little is known about the prevalence and seasonality of this virus in the community.
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From page 65... ...
That being said, as colonization rates increase, wastewater data may correlate with increased exposure for susceptible hosts and thus increased infections. Criterion 3: Usefulness of community-level wastewater surveillance data to inform public health action.
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From page 66... ...
If present in sewage, they would be expected to persist. Criterion 3: Usefulness of community-level wastewater surveillance data to inform public health action.
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From page 67... ...
They observed a greater likelihood of detection during periods of peak diurnal flow (under dry weather conditions) and recommended PREPUBLICATION COPY
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From page 68... ...
For example, an outbreak could proceed rapidly through a highly susceptible, dense population but move much more slowly through a population with lower PREPUBLICATION COPY
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From page 69... ...
. Spatial Variability Spatial factors can result in variability in wastewater surveillance data over regional and national scales.
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From page 70... ...
On the other hand, for SARS-CoV-2 and other pathogens that tend to show broad-scale community spread or where population contact/mobility is high, it may be sufficient to have fewer, potentially larger sewersheds that are monitored and provide information about overall population trends in an actionable way (although analysis of CDC's National Wastewater Surveillance System [NWSS] data would be needed to determine the optimal sampling plan)
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From page 71... ...
An aggregate disease surveillance program can achieve equity, even if any single component, such as wastewater surveillance, may not cover all components. Design of the best complementary tools for the unsewered population is important but beyond the scope of this study.
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From page 72... ...
A sentinel site here refers to a location where enhanced or specific surveillance should take place because it represents the "front line" of entry to a larger community. Wastewater infectious disease surveillance information gathered as close as possible to where targets of interest enter a community may have a differentiated value from that obtained from a non-selective community wastewater surveillance system.
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From page 73... ...
Infectious diseases, whether endemic, seasonal, newly emergent, or re-emergent, are dynamic and never fully predictable. The high likelihood that SARS-CoV-2 variants will continue to emerge and circulate is alone a strong rationale to maintain and strengthen a national wastewater surveillance system.
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From page 74... ...
, CDC should assess whether tools can be used to extrapolate data from monitored regions to estimate disease burden in areas without wastewater surveillance. CDC and local health departments should also maintain robust infectious disease surveillance programs using other sources of data on disease trends and provide public education about how to interpret wastewater data alongside other indicators.
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