Wastewater-based Disease Surveillance for Public Health Action (2023) / Chapter Skim
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Pages 77-98
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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... ...
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 antimicrobial-resistant pathogens. In summary, antimicrobial resistance is a promising candidate for future wastewater surveillance system development, though some challenges and exact applications have to be further investigated and defined.
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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... ...
states and more than 30 countries. Criterion 2: Analytical feasibility for wastewater surveillance.
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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... ...
Criterion 2: Analytical feasibility for wastewater surveillance. There are substantial challenges to the analytical feasibility and robust and reliable detection of this agent in wastewater.
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From page 84... ...
Prion measurement in wastewater is not currently analytically feasible, although biochemical methods exist that could enable method development, and the data are currently expected to be of limited value for public health management of prion diseases. VISION FOR AN EFFECTIVE FRAMEWORK FOR DETERMINING TEMPORAL AND SPATIAL RESOLUTION When developing a vision for a national wastewater surveillance program, a key consideration is its spatial and temporal resolution -- that is, how frequently and from which locations samples should be collected to provide optimal cost-effectiveness and usefulness of the data.
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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... ...
The allocation of wastewater surveillance sampling effort over time and space can also be viewed as an optimization question. Two other questions then arise in the design of a sampling program that has the objective of discerning prevalence and trends: 1.
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From page 89... ...
Importantly, there is also an ethical trade-off relating to the spatial scale at which wastewater surveillance is conducted: sampling at the larger community level helps avoid stigmatization of particular neighborhoods and minimize threats to individuals' privacy, but examining smaller sewersheds could help target resources and useful public health efforts to the areas that need them most (see Chapter 4 for additional discussions of ethics and privacy)
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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... ...
Sentinel sites could serve to screen for a wide range of potential pathogens or diseases of concern in other countries, including emerging pathogens. Initial pathogen detection at one or more sentinel sites could trigger expanded wastewater surveillance at communities or broad-scale national surveillance, as appropriate for the pathogen detected.
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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... ...
Finally, it is critical that the value of wastewater surveillance information for a given pathogen be considered in the context of the broader universe of surveillance approaches so as to maximize the use of resources to inform public health action (e.g., allocation of clinical or public health resources)
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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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From page 95... ...
has the important task of prioritizing among candidate pathogens or pathogenic markers to include in the National Wastewater Surveillance System (NWSS)
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From page 96... ...
Community wastewater surveillance targets may also be identified from concerns identified in other countries or pathogen outbreaks in highly localized settings, like hospitals. CDC should develop and implement an open and transparent process by which potential targets for wastewater surveillance are evaluated according to key selection criteria.
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From page 97... ...
Similar to the development process for the CCL, CDC could solicit public comment on potential candidates for wastewater surveillance, making targeted outreach to the global academic community and experts from public health, industry, and utilities. To update the candidate list, this solicitation could be repeated at regular intervals (e.g., biannually, or more often during periods of disease outbreaks of public health significance)
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From page 98... ...
Thus, the committee envisions a process that is methodical with opportunities for public and expert input while also having the flexibility to move quickly when the need arises. PUBLIC ACCEPTANCE: LEGAL AND ETHICAL CONSIDERATIONS The success of a national wastewater surveillance program relies on building public trust in the system (Hrudey et al., 2021)
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