Wastewater-based Disease Surveillance for Public Health Action (2023) / Chapter Skim
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1 Introduction
1 Introduction
Pages 7-20
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public health infrastructure, particularly the challenges to implementing widespread clinical testing, tracking asymptomatic infections, and anticipating community disease outbreaks. During the COVID-19 pandemic, wastewater surveillance1 gained traction as an additional epidemiological tool to monitor trends and anticipate disease incidence in communities.
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into the wastewater system through feces, urine, saliva, and other sources. Household wastewater is discharged into the sewer system and collected at the inflow to the wastewater treatment plant, where sampling occurs.
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Additional approaches can directly detect other pathogen components, such as proteins and lipids, which can be used as biomarkers. Although methods based on these alternative biomarkers are less commonly used due to their relative inability to detect low concentrations, they may be required for certain infectious diseases (e.g., prion diseases)
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wastewater surveillance efforts. As proof-of-concept was established for the feasibility and potential public health value of SARS-CoV-2 RNA detection and variant sequence identification, the 2 See https://www.cdc.gov/polio/what-is-polio/index.htm.
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The NWSS is the first national-level wastewater disease surveillance system in the United States, and it coordinates with state-, tribal-, local-, and territorial-level health departments to design and integrate wastewater surveillance data to inform public health decisions. The mission of the NWSS is to offer technical assistance to public health departments and wastewater utilities implementing wastewater surveillance; coordinate a centralized and standardized data portal for tracking of disease presence across the country; establish working groups for health departments, public health laboratories, and wastewater utilities for knowledge sharing; and strengthen epidemiological and laboratory capacity for wastewater surveillance at health departments (Kirby et al., 2021)
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FIGURE 1-3-1 Map of sewersheds and sub-sewersheds used for SARS-CoV-2 in Jefferson County, Kentucky. NOTE: Triangles are wastewater treatment plants.
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The city collects wastewater samples from the 39 wastewater treatment plants within the city, as well as at lift stations within the sewershed and individual facilities. The city uses the wastewater data, along with other data sources such as individual clinical Houston, Texas testing results and vaccination rates, to identify ZIP code-level "hot spots" for targeted public health intervention.
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A public health, commercial, or academic laboratory partner analyzes the samples, and the public health department interprets the data to identify trends regarding infection prevalence within a community, integrate the wastewater data with other surveillance data, and determine the appropriate public health response. The multidisciplinary nature of a national wastewater surveillance system requires extensive collaboration between and across health departments, testing laboratories, and wastewater utilities.
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Cooperative Agreement grants provided by CDC to eligible health departments (i.e., state health departments, territories, and some large cities and counties) .6 An additional $200 million in grants were made available from the ELC Enhancing Detection/Enhancing Detection Expansion program, supported by the Coronavirus Response and Relief Supplemental Appropriations Act of 2021.7 Finally, the NWSS was granted $384 million through the American Rescue Plan,8 starting in FY 2022 for use through 2025.
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In particular, state, tribal, local, and territorial public health professionals; public utilities; and CDC are reviewing the usefulness of wastewater surveillance to inform public health decisions for SARS-CoV-2 as well as potential applications to other infectious pathogens. The surveillance system is also at a point of transition from an ad hoc collection of willing state and local participants seeking all useful information for local emergency pandemic response to a forwardlooking national wastewater surveillance system that serves state, tribal, local, territorial, and 9 See https://www.cdc.gov/budget/fact-sheets/covid-19/funding/index.html.
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In addition, uncertainty remains around the use of wastewater surveillance to inform public health response, particularly how this form of disease monitoring can contribute to and complement traditional public health surveillance through clinical data and syndromic surveillance. FIGURE 1-3 National Wastewater Surveillance System Federal Partnering Framework.
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The first phase, which is the focus of this report, provides an assessment of the usefulness of current community-level wastewater surveillance in the United States and its potential value for infectious disease beyond COVID-19. As explained in the statement of task, in the context of this study, "community-level" wastewater surveillance includes "sampling at wastewater treatment plants" and does not include "local surveillance at neighborhood or institutional scales." However, in committee discussions with the sponsor, hyperlocal sampling at specifically designated sentinel sites, such as likely points of entry of infectious disease, was deemed to be within the scope of the study because the intent of these sites is to provide data of value to the nation (see also Chapter 3)
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For the purpose of this study, community-level wastewater-based disease surveillance implies sampling at wastewater treatment plants and does not include local surveillance at neighborhood or institutional scales. To inform the study, the committee will briefly review ongoing and planned U.S.
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Data reporting, data analysis, and data interpretation for detecting emerging threats to public health and estimating disease incidence and prevalence, including data integration with other surveillance data for improving predictive models.
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