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4 Strategies for Achieving the Vision and Increasing the Public Health Impact of National Wastewater Surveillance
Pages 95-122

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From page 95...
... Second, legal and ethical issues arising from wastewater surveillance are discussed. Although these concerns are not weighty enough to militate against the expansion of wastewater surveillance at the community level, the committee discusses the benefits of creating an ethics governance structure to consider the potential impacts of expanding the scope of data collection or data sharing.
From page 96...
... Several groups already have strong infrastructures for identifying candidate pathogens, including but not limited to CDC; the National Academies of Sciences, Engineering, and Medicine's Forum on Microbial Threats;1 local and state health agencies that issue reports about new infectious agents; and the World Health Organization's Global Antimicrobial Resistance and Use Surveillance System (GLASS) .2 Additionally, public health significance may be assessed by looking at clinical case and hospitalization data, treatment costs, availability and uptake of vaccines, and lists of antimicrobial resistance genes reported in clinical cases.
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)
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)
From page 99...
... Even if courts did recognize a privacy interest in wastewater, they would still be unlikely to find that wastewater surveillance for infectious disease violates the Fourth Amendment. Provided that the wastewater data 4  Riverdale Mills Corp.
From page 100...
... Ethical Concerns Arising from Community-Level Wastewater Surveillance Although legal concerns are minimal, two ethical issues arising from community-level wastewater surveillance merit close analysis: ensuring privacy and appropriate use of data. Privacy Considering whether wastewater surveillance unduly intrudes on people's privacy is ethically important because the ordinary moral and legal presumption in the United States is that individuals are entitled to control access to information about their health (Gable et al., 2020)
From page 101...
... a court ruling that wastewater data can be subpoenaed or are admissible in criminal or civil proceedings unrelated to public health interventions -- for example, drug-related prosecutions; (2) any report of wastewater data sharing with law enforcement agencies, or use of wastewater surveillance infrastructure by law enforcement; (3)
From page 102...
... A second dimension of the obligation to ensure appropriate use of data is preventing "function creep," or expansion of the purposes for which wastewater data are used. To maintain public trust in the wastewaterbased infectious disease surveillance system, firewalls must be maintained that prevent transmission of data to aid in law enforcement efforts (Joh, 2021; Ram et al., 2022; Scassa et al., 2022)
From page 103...
... Fostering public acceptance necessitates that concerns about data sharing and potential expansions of the scope of wastewater surveillance are addressed and requires good governance, accountability, and transparency (WHO, 2017)
From page 104...
... could undertake is the development of a carefully crafted, standard data use agreement for academic and industry partners who wish to analyze wastewater data. By specifying ground rules for data users, such agreements can minimize the risk that data sharing will result in reidentification or unauthorized analyses.
From page 105...
... Some level of methodological flexibility within the national wastewater surveillance system can be afforded as long as expectations for cross-validation with specific samples or standards are established and the data can be transformed by statistical methods into a comparable national-scale data set. Ongoing quality assurance and quality control will be important to provide the data required to correct for specific technical biases introduced by particular methods.
From page 106...
... In summary, a national wastewater surveillance system can accommodate some degree of diversity in sampling and analytical approaches but only if additional investments are made in developing methods for standardizing data for purposes of comparison across geographic areas. Advancing Data Interpretation and Actionability In addition to generating reliable and comparable data, a national wastewater surveillance system needs to support timely interpretation of those data to support public health actions.
From page 107...
... Wastewater infectious disease surveillance is a relatively new public health strategy in the United States, necessitating continued capacity development and efforts to increase awareness of its benefits. Creating and Maintaining Operational Capacity for Sampling and Analysis As the NWSS continues, potentially expanding in geographic and pathogen coverage and settling into long-term processes, attention is needed to ensure that the operational capacity within laboratories and wastewater utilities -- both staffing and equipment -- is appropriately developed and maintained to support the system moving forward.
From page 108...
... Utilities can contribute valuable insights about system characteristics, such as flow and industrial inputs, to support better data analysis and interpretation, and involving wastewater utilities in the design and refinement of surveillance sampling is also important to gain long-term buy-in. Strong relationships between public health agencies and wastewater utilities will help ensure that these partners remain engaged and prepared if increased surveillance activities are triggered.
From page 109...
... State, tribal, local, and territorial health departments; public health l­aboratories; and local wastewater utilities can join one of three respective Communities of Practice dedicated to developing COVID-19 wastewater surveillance with the National Wastewater Surveillance System (NWSS)
From page 110...
... Guidance and training on the analysis and interpretation of wastewater data would help build understanding and confidence in evaluating wastewater data patterns and using that information for public health decisions. Looking forward toward an expanded NWSS, public health guidance and training will need to include the following: • How to interpret the implications of wastewater surveillance data for disease epidemiology across a range of pathogens.
From page 111...
... In summary, training public health practitioners and improving access to those with experience with wastewater surveillance implementation, analysis, and data interpretation is expected to increase the use of wastewater surveillance data for public health action. Expanding the Talent Pipeline Training within university programs in biomedical informatics, biostatistics, environmental engineering, epidemiology, microbiology, or other related fields is necessary to develop and maintain a workforce with the BOX 4-2 COVID-19 Wastewater Surveillance Centers of Excellence In August 2022, the Centers for Disease Control and Prevention (CDC)
From page 112...
... Robust health informatics support that can set up and maintain complex systems is needed for automating and disseminating wastewater data efficiently. A wide range of health informatics is involved in wastewater surveillance that, ideally, would be integrated with other data streams within the public health system.
From page 113...
... ACHIEVING INTEGRATION AND COLLABORATION Achieving the vision of an integrated, actionable wastewater surveillance program requires coordination and collaboration across many par Capacity Building • Transition NWSS from an emergency  pandemic response to a sustained program • Support and train staff at utilities,  laboratories, public health departments,  NWSS data management • Assist workforce development • Provide state‐of‐the‐art equipment and tools  Predictable and  and access to commercial laboratory support A Robust National  Sustained  Wastewater  Funding Surveillance System Advances in Science and Technology • Improve analytical approaches and reduce  cost • Method validation criteria • New method development • Strategies to correlate and compare data • New algorithms for data analysis FIGURE 4-1  Areas for sustained investment to support the National Wastewater Surveillance System (NWSS)
From page 114...
... will be necessary. Typically, the primary public health agency7 overseeing the wastewater surveillance program provides data interpretations and ensures that the wastewater data are integrated with other data sources (e.g., clinical testing, syndromic data)
From page 115...
... The public health agency's wastewater surveillance group collaborates with wastewater utilities and laboratories, which play a critical role in providing samples, data, and expertise, and also leads internal coordination with infectious disease/epidemiology teams to integrate wastewater data into public health actions. The public health agency typically represents the primary organization receiving ELC funding (e.g., states, large cities/counties)
From page 116...
... To maximize actionability, local health departments need to be engaged, because they can provide input on community characteristics and ensure local buy-in. State public health systems that lead wastewater surveillance efforts are excellent points of contact for local and county public health officials and will be most familiar with the state's specific needs, b ­ arriers, and vulnerable populations.
From page 117...
... National utility member associations, like the WEF, have utility Communities of Practice that can forge and maintain public health/utility partnerships, and facilitate communication among other Communities of Practice and health agencies. Wastewater utilities ideally should interact with both the laboratory and the wastewater surveillance group within the public health agency because their expertise would be important to accurate interpretation of the data.
From page 118...
... , which provide valuable information sharing within individual communities for laboratories, public health practitioners, and wastewater utilities. These communities will be important to achieve the vision of a national wastewater surveillance system as it expands to new areas and new pathogens.
From page 119...
... . These workforce needs will include the full spectrum of wastewater surveillance from sampling methods and design to laboratory analysis, data analysis, data interpretation, and communication.
From page 120...
... Furthermore, if the prospects for identifying individuals in wastewater data strengthen over time, or if any agency or private-sector organization expresses interest in using wastewater data for purposes other than infectious disease surveillance, this body should re-evaluate the balance of health benefits versus risks associated with data sharing and any proposed expansions in data collection and data linkage. There should be a strong firewall maintained that precludes use of data by law enforcement.
From page 121...
... CDC's Communities of Practice for wastewater utilities, laboratory personnel, and public health practitioners provide valuable support for coordination within each of these fields, and CDC can work with these communities to establish expectations for coordination and collaboration with other agencies. State, tribal, local, and territorial public health agencies should also work to strengthen relationships across these partners -- for example, by encouraging biweekly meetings with staff from the public health agency, the analytical laboratory department, and the wastewater utility, as appropriate, in support of data interpretation.
From page 122...
... 122 WASTEWATER-BASED DISEASE SURVEILLANCE as the CDC Broad Agency Announcements. Academic and other research laboratories could provide needed training, and an NWSS workforce needs study would help ensure that a trained workforce can meet current and future needs.


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