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Pages 45-76

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From page 45...
... 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.
From page 46...
... . 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.
From page 47...
... Ad campaigns were developed closely with community partners, using trends in wastewater surveillance data to increase vaccination. More than 2,500 people interacted with the ads, which reflects a click-through rate of 0.15 percent, compared to an industry-wide rate of 0.06 percent.
From page 48...
... 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.
From page 49...
... 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
From page 50...
... INNOVATION IN RESPONSE TO IMPLEMENTATION CHALLENGES The rapid spread of SARS-CoV-2, globally and across the nation, initiated an emergency response to surveillance, including the early implementation of wastewater surveillance. The early voluntary nature of the response initiative, the need for rapid implementation without existing guidance, strained laboratory capacity, and a lack of validated methods and sampling designs were major challenges in developing coordinated surveillance.
From page 51...
... 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
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.
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.
From page 55...
... 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.
From page 56...
... BOX 3-1 Potential High-Priority Use Cases for Wastewater Data Detecting a new emerging pathogen and associated variants. Here, the goal of wastewater surveillance is to monitor for introduction of the pathogen into a new population.
From page 57...
... For example, in the COVID-19 pandemic, wastewater surveillance has been valuable in providing a more consistent mea sure of transmission levels when case data become less reliable due to increased reliance on at-home testing and subsequent decreased reporting within the public health system. Wastewater data provide lead time in advance of hospitalizations and/or deaths without requiring active testing of individuals (see Chapter 2)
From page 58...
... KEY CHARACTERISTICS OF A NATIONAL WASTEWATER SURVEILLANCE SYSTEM The committee's vision for a robust surveillance system includes five key characteristics: flexible, equitable, sustainable, integrated, and actionable. Flexible The system should have the flexibility to monitor multiple pathogens at the same time and pivot as needed to new pathogens of public health importance.
From page 59...
... Dialogue may also reveal ethical, social, political, or legal worries that could be assuaged by learning from the experiences of existing wastewater surveillance programs. A robust national wastewater surveillance system should include strategies by which data can be usefully extrapolated through statistical techniques to communities not covered by the system, including unsewered areas (e.g., based on mobility data and laborshed information on com­ muting and work patterns)
From page 60...
... Implementing partners, including local utilities, wastewater treatment plants, academic research centers, and public health departments, that have been strained to provide wastewater surveillance services during a time of emergency cannot be expected to do so indefinitely without attention to the burdens that participation involves. In addition to scaling up financial support, there may be a need to consider ways to scale down operational aspects of wastewater surveillance relative to the pandemic period while maintaining institutional capacity.
From page 61...
... For early warning potential of wastewater surveillance to be realized, sample collection, analysis, and interpretation of data by public health decision makers must operate on a timescale that allows for informed and timely interventions. Timeliness is related to sustainability in that expeditious collection, analysis, and interpretation of wastewater data are unlikely to occur in the absence of sufficient human and financial resources.
From page 62...
... 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.
From page 63...
... analytical feasibility for wastewater surveillance, and 3. usefulness of community-level wastewater surveillance data to inform public health action.
From page 64...
... 64 FIGURE 3-1  Framework for identifying candidate pathogens for wastewater surveillance.
From page 65...
... . Drawing on work by these organizations, key parameters to evaluate whether a candidate pathogen for wastewater surveillance meets the criteria for public health significance include the following: • What is the current or potential severity of disease in people?
From page 66...
... Other contributing sources of the agent in wastewater, such as animals or environmen tal sources, could reduce the usefulness of wastewater surveillance for public health decision making.
From page 67...
... than sources that rely on potentially changing behaviors around care-seeking and testing. If only syndromic data are available, wastewater surveillance data may be able to distin guish between different pathogens that lead to the same symptoms.
From page 68...
... Lead time from reporting wastewater surveillance data to observed health outcomes (e.g., positive cases as measured in the same com munity, clinical disease in local healthcare settings, and local hospi talizations) will be relevant benchmarks for comparing wastewater surveillance data to other data sources for use in informing public health action.
From page 69...
... Regardless, these criteria and questions can guide how and when wastewater surveillance data may fill a gap or complement other forms of disease monitoring and public health data. ILLUSTRATIVE APPLICATIONS OF CRITERIA Putting the criteria outlined above into action requires careful consideration of the public health significance of the threat, the analytical feasibility of measuring the agent in wastewater, and understanding how this type of information might complement existing public health strategies to monitor the threat and inform decision making.
From page 70...
... Criterion 2: Analytical feasibility for wastewater surveillance. SARS-CoV-2 wastewater surveillance has been implemented broadly, with demonstrated analytical feasibility of threat detection.
From page 71...
... 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)
From page 72...
... Wastewater surveillance data continue to be used for public health decision making, staging of resources, and planning and thus are clearly actionable. However, if severity continues to drop as the virus becomes endemic, the actionability of wastewater trend data correlated to case data may diminish.
From page 73...
... . Criterion 2: Analytical feasibility for wastewater surveillance.
From page 74...
... Thus, new strains of influenza may first be detected through wastewater surveillance instead of clinical typing; furthermore, once a new strain of influenza is found to be circulating in a population, wastewater surveillance could supplement clinical and syndromic surveillance to provide early warning of spread of the virus to new regions. Even tracking of seasonal flu within populations using wastewater surveillance has the potential to inform public health decisions on communication to the public and distribution and staging of resources (i.e., vaccine clinics, hospital staffing)
From page 75...
... The wastewater resistome will reflect the predominant resistance genes in the community microbiome, predominantly the human gastro­intestinal microbiome -- although human non-intestinal 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)
From page 76...
... Thus, neither approach is amenable to routine wastewater surveillance but may be useful if triggered by specific hospital or community disease outbreaks (see Box 3-2)


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