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 55-94
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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.
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From page 56... ...
. This critical infrastructure and expertise can provide the foundation of a national wastewater infectious disease surveillance system.
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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)
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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.
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From page 59... ...
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 60... ...
, 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 61... ...
Seamless integration is particularly important for consistent and effective public health messaging and risk communication, especially when many independent entities are contributing to the collection and interpretation of wastewater data. Actionable The ultimate goal of a surveillance system is to produce actionable data for public health agencies and policy makers.
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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.
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From page 63... ...
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 64... ...
64 FIGURE 3-1 Framework for identifying candidate pathogens for wastewater surveillance.
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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?
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From page 66... ...
in wastewater across a range of expected prevalence. Both rare and widespread pathogens pose unique challenges to detection and interpretation of surveillance data.
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From page 67... ...
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 68... ...
• To what extent can wastewater data expand the population repre sented by existing disease surveillance systems? Because wastewater surveillance data can be captured passively, without requiring indi viduals to seek care, participate in a study, or even exhibit symp toms, they may provide an opportunity to expand the population represented in existing data.
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From page 69... ...
, 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 reevaluated; 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 70... ...
Criterion 2: Analytical feasibility for wastewater surveillance. SARS-CoV-2 wastewater surveillance has been implemented broadly, with demonstrated analytical feasibility of threat detection.
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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)
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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.
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From page 73... ...
. Criterion 2: Analytical feasibility for wastewater surveillance.
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From page 74... ...
Furthermore, wastewater data might serve as a leading indicator of the emergence of new influenza strains in some settings. Antimicrobial Resistance Criterion 1: Public health significance of the threat.
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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)
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From page 76... ...
. Many clinically relevant antimicrobial resistance genes are carried on plasmids, which are pieces of DNA that replicate separately from the bacterial chromosome and may be transferred between related and sometimes unrelated organisms.
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From page 77... ...
Wastewater surveillance data on a ntimicrobial 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 78... ...
However, the high prevalence and range of antimicrobial resistance genes present in commensal organisms may make it difficult to identify relevant increases of antimicrobial resistance genes above the very high background rate that is detected. 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.
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From page 79... ...
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 80... ...
In summary, EV-D68 is a promising candidate for expanded and improved wastewater surveillance. Examples of Pathogens That Are Not Currently Applicable or Need More Data Applying the criteria outlined above, many microbial threats do not currently meet the level of public health significance, analytical feasibility of measurement, and adequate value above and beyond existing public health strategies required to be considered for broad implementation.
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From page 81... ...
Finally, because colonization can occur in the absence of infection, it is unclear whether wastewater data would be correlated with clinical outcomes, and no data exist to suggest that levels in wastewater relative to clinical outcomes would be consistent over time. That being said, as 2 See https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html.
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From page 82... ...
Thus, wastewater surveillance data, if accurate and quantitative, might be helpful. Furthermore, very little is known about community prevalence of the agent outside clinical settings.
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From page 83... ...
Due to the rare nature of the human disease and the poor transmissibility of the agent, most TSEs are unlikely to pose a broad and significant public health concern. However, chronic wasting disease in deer may pose a risk to hunters and others handling or consuming felled deer, and many states in the northern Midwest have surveillance for chronic wasting disease using neural tissue from killed deer.
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From page 84... ...
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 85... ...
Each of these sources of temporal variation will affect the sampling frequency needed to capture useful wastewater surveillance information for different pathogens. It is well known that influent flow rate and composition coming into wastewater treatment plants fluctuate owing to daily and weekly variations in contributions to the sewer system, which can affect pathogen measurements in wastewater (Wade et al., 2022)
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From page 86... ...
. factors may change over time, adding additional complexity to the choice of sampling frequency.
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From page 87... ...
. Spatial Variability Spatial factors can result in variability in wastewater surveillance data over regional and national scales.
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From page 88... ...
(2020) , Disease surveillance systems are established and designed for diverse pur poses, including to collect data for understanding variations in disease frequency across populations, space, and time, to monitor pathogen com position over time, to detect outbreaks and forecast epidemics, to assess the impact of interventions, and to determine risk factors associated with diseases.
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From page 89... ...
Consideration of equity of sampling with attention to environmental justice populations needs to be embedded in site selection. Equitable action to improve public health requires information from a disease surveillance system that represents and resolves patterns for a range of populations across sociodemographic groups, particularly those who may not be as well-reflected in traditional clinical surveillance methods that may be impacted by issues of access to and availability of care, issues of trust, and issues of cost.
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From page 90... ...
Sentinel Sites Wastewater-based surveillance for SARS-CoV-2 was initially set up and continues to be carried out in a range of settings, from highly localized efforts at universities or prisons to aggregated and more standardized surveillance spanning hundreds of wastewater treatment plants across the nation. Although this report focuses on the importance of a national wastewater surveillance system, hyperlocal surveillance at selected sentinel sites in certain circumstances would be an integral element of a true national system.
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From page 91... ...
. Because of the need for a variety of sentinel sites based on these targets, it would be advisable to include among these sentinel sites both major cities and small, rural wastewater treatment plants.
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From page 92... ...
Although the NWSS supports both local and national public health decision making, a sustainable national wastewater surveillance program may not serve every locality's objectives but should allow for locally funded initiatives, such as pilot surveillance of a pathogen of emerging regional concern. When evaluating potential targets for future wastewater surveillance, CDC should consider three criteria: (1)
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From page 93... ...
population resides in unsewered commu nities, wastewater surveillance in and of itself cannot be fully representa tive of the population but should be viewed as one key component of a national infectious disease surveillance system. CDC should take additional steps to bring the benefits of wastewater surveillance to critical areas not addressed by the NWSS.
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From page 94... ...
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. As part of a national wastewater surveillance system, strategic incorporation of sentinel sites is recommended as a mechanism for early detection.
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