NWSS CoE Publications

Explore the latest contributions from our team as we advance our mission to expand the knowledge base in wastewater surveillance.

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Featured Publication

Framework for Addressing Ethical Considerations in Infectious Diseases Public Health Wastewater Surveillance

Colorado NWSS CoE Contributors:

  • Allison Wheeler, MSPH, Colorado NWSS CoE Co-Director
  • Corinne Lengsfeld, PhD, Colorado NWSS CoE Co-Director

Published in ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS, Reports. (2025, March 10)

Executive Summary:

Wastewater surveillance (WWS), which measures pathogen levels in wastewater, is vital to evaluate community-level trends and can be used to complement traditional surveillance and interventions. During the COVID-19 pandemic, CDC launched the National Wastewater Surveillance System to coordinate state, tribal, local, and territorial (STLT) public health departments’ WWS programs. Until this point, WWS was not being coordinated at the national level. In 2021, 43 public health departments were using funds from CDC to support WWS activities, with a majority of them reporting data to the National Wastewater Surveillance System. As a result of the COVID-19 pandemic response, the use and visibility of wastewater surveillance for infectious disease expanded, illuminating and clarifying the ethical dimensions of WWS in the process. 

“Ethics” is sometimes seen as an abstract, difficult, or intimidating topic. By developing this framework, ASTHO aims to bolster public health practitioners’ ability to engage in ethical analysis. This report focuses on five ethical values: trust and trustworthiness; reciprocity; justice, equity, and fairness; common good; and privacy. Ethical issues arise when values such as these are challenged or are in tension with each other. This framework outlines questions practitioners can use to analyze a program or decision under consideration. 

ASTHO, in consultation with public health ethics and wastewater surveillance subject matter experts from academic institutions and CDC, developed this framework to support STLT health departments; federal public health institutions; and implementing partners, including water utilities, in addressing ethical issues in WWS. ASTHO developed this framework in direct response to recommendations from CDC’s Public Health Ethics Committee to address the ethical concerns of privacy, stigma, and data stewardship in WWS. This framework is also responsive to reports from a committee of the National Academies of Sciences, Engineering, and Medicine, convened at CDC’s request, to review WWS for uses beyond COVID-19. In its reports the committee noted the importance of addressing ethical dimensions of WWS. 

This project included facilitating a discussion with the National Wastewater Surveillance System Centers of Excellence, convening a workgroup, hosting an in-person workshop, and facilitating focus group discussions to center the framework around perspectives and insights from the field. This framework is intended to be one component of a larger ethics strategy that supports WWS ethics preparedness, and includes tools for ethical analysis, case studies, and recommendations about strengthening public health ethics infrastructure. 

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Integrating wastewater analysis and targeted clinical testing for early disease outbreak detection and an enhanced public health response

Colorado NWSS CoE Contributors:

  • Vicente Contreras, MS, Molecular Diagnostics Technical Leader, University of Denver
  • Vander Georgeff, Lead Molecular Diagnostics Student Intern, University of Denver
  • Gabriela Iglesias-Mendoza, Colorado NWSS CoE Coordinator, Colorado Department of Public Health and Environment
  • Tara Nicklay, Program Manager, University of Denver
  • Corinne Lengsfeld, Co-Director, Colorado NWSS CoE
  • Phillip Danielson,  Scientific Advisor, Colorado NWSS CoE

Published in Environ. Sci.: Water Res. Technol., 2025,11, 317-327

Abstract:

The COVID-19 pandemic provided an unprecedented opportunity to assess the value of wastewater based epidemiology (WBE) as a tool to complement clinical testing in efforts to monitor and mitigate disease outbreaks. This study presents a retrospective assessment of a WBE approach that integrated WBE from congregate living facilities with high-frequency, rapid-turnaround clinical testing within a university setting. By focusing on communal living spaces, such as dormitories, this approach made it possible to rapidly identify and counter the spread of SARS-CoV-2 as well as to monitor the efficacy of campus-focused public health measures throughout the pandemic. Beginning in 2020, the University of Denver (DU) implemented a campus-wide, dual-prong COVID-19 response that combined WBE with frequent high-sensitivity testing (FHST) of individuals by RT-qPCR. Wastewater monitoring at the building level was employed in an effort to facilitate the early detection of SARS-CoV-2 spread and thereby make it possible to more confidently and precisely allocate limited clinical testing resources to identify and isolate infected individuals. This data-driven approach to WBE-informed targeting of FHST resources contributed to markedly and consistently lower SARS-CoV-2 positivity rates on campus compared to the surrounding metropolitan area. Analyses of data from multiple dormitories, and spanning several early-stage disease outbreaks, have highlighted the potential of WBE to optimize limited clinical resources for detecting, containing, and resolving the spread of communicable diseases. The information gained from DU's COVID-19 response can help to guide the development of future public health strategies in other communities confronting similar challenges.

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Assessment of Public Health Agency and Utility Training Needs for CDC National Wastewater Surveillance System Jurisdictions in the United States

Colorado NWSS CoE Contributors:

  • Allison Wheeler, MSPH, Colorado NWSS CoE Co-Director
  • Corinne Lengsfeld, PhD, Colorado NWSS CoE Co-Director
  • Kirsten Weisbeck, MPH, Colorado NWSS CoE Wastewater Data Analytics Supervisor

Published in Health Promotion Practice. 2024;0(0)

Abstract:

Since the start of the COVID-19 pandemic, wastewater surveillance has emerged as a critical tool for tracking the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and other pathogens in communities throughout the United States. In 2020, the Centers for Disease Control and Prevention (CDC) launched the National Wastewater Surveillance System (NWSS), which partners with state, local, tribal, and territorial health departments to develop and implement wastewater collection and analysis systems and to share data. In 2022, the CDC established the first two NWSS Centers of Excellence to lead its implementation and coordination efforts—one in Colorado (Colorado CoE) and one in Houston (Houston CoE). As the NWSS expands, it is becoming more important to support the training needs of jurisdictions at different stages of developing their wastewater surveillance infrastructure. To evaluate these needs, the Colorado CoE and Houston CoE conducted a needs assessment study of NWSS-funded public health agencies and public utilities departments located in the United States using surveys developed by the Colorado CoE. The results of the surveys showed that although some training needs were universal, it will be most beneficial to develop training modules tailored to the needs of entities that operate wastewater surveillance programs of various sizes, workforce experience levels, and at different stages in the infrastructure development process.

Wastewater Surveillance for Influenza A Virus and H5 Subtype Concurrent with the Highly Pathogenic Avian Influenza A(H5N1) Virus Outbreak in Cattle and Poultry and Associated Human Cases

Colorado NWSS CoE Contributors:

  • Allison Wheeler, MSPH, Colorado NWSS CoE Co-Director
  • Shannon Matzinger, PhD, Colorado NWSS CoE Genomic Surveillance Program Manager

Published in MMWR Morb Mortal Wkly Rep 2024;73

Abstract:

As part of the response to the highly pathogenic avian influenza A(H5N1) virus outbreak in U.S. cattle and poultry and the associated human cases, CDC and partners are monitoring influenza A virus levels and detection of the H5 subtype in wastewater. Among 48 states and the District of Columbia that performed influenza A testing of wastewater during May 12–July 13, 2024, a weekly average of 309 sites in 38 states had sufficient data for analysis, and 11 sites in four states reported high levels of influenza A virus. H5 subtype testing was conducted at 203 sites in 41 states, with H5 detections at 24 sites in nine states. For each detection or high level, CDC and state and local health departments evaluated data from other influenza surveillance systems and partnered with wastewater utilities and agriculture departments to investigate potential sources. Among the four states with high influenza A virus levels detected in wastewater, three states had corresponding evidence of human influenza activity from other influenza surveillance systems. Among the 24 sites with H5 detections, 15 identified animal sources within the sewershed or adjacent county, including eight milk-processing inputs. Data from these early investigations can help health officials optimize the use of wastewater surveillance during the upcoming respiratory illness season.

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Multimodal Surveillance Model for Enterovirus D68 Respiratory Disease and Acute Flaccid Myelitis among Children in Colorado, USA, 2022

Colorado NWSS CoE Contributors:

  • Allison Wheeler, MSPH, Colorado NWSS CoE Co-Director
  • Kirsten Weisbeck, MPH, Colorado NWSS CoE Wastewater Analytics Supervisor

Published in Emerging Infectious Diseases. 2024;30(3)

Abstract:

Surveillance for emerging pathogens is critical for developing early warning systems to guide preparedness efforts for future outbreaks of associated disease. To better define the epidemiology and burden of associated respiratory disease and acute flaccid myelitis (AFM), as well as to provide actionable data for public health interventions, we developed a multimodal surveillance program in Colorado, USA, for enterovirus D68 (EV-D68). Timely local, state, and national public health outreach was possible because prospective syndromic surveillance for AFM and asthma-like respiratory illness, prospective clinical laboratory surveillance for EV-D68 among children hospitalized with respiratory illness, and retrospective wastewater surveillance led to early detection of the 2022 outbreak of EV-D68 among Colorado children. The lessons learned from developing the individual layers of this multimodal surveillance program and how they complemented and informed the other layers of surveillance for EV-D68 and AFM could be applied to other emerging pathogens and their associated diseases.

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Considerations for Implementing Wastewater Surveillance in Rural Communities

Colorado NWSS CoE Contributors:

  • Allison Wheeler, MSPH, Colorado NWSS CoE Co-Director

Published in APHL Lab Matters. 2023; Winter

Summary:

Implementing effective wastewater surveillance for SARS-CoV-2 in rural communities requires additional  considerations such as ensuring privacy while sampling in smaller populations, limited laboratory and utility capacity due to fewer personnel and resources, access to representative clinical data for interpretation, and transparent, timely and targeted communications. However, when these factors are considered and addressed, wastewater surveillance can aid in decreasing health inequities in rural communities and serve as a valuable public health tool by providing beneficial information about community health trends. 

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The National Wastewater Surveillance System’s Centers of Excellence Contributions to Public Health Action During the Respiratory Virus Season — Four U.S. Jurisdictions, 2022–23

Colorado NWSS CoE Contributors:

  • Allison Wheeler, MSPH, Colorado NWSS CoE Co-Director
  • Shannon Matzinger, PhD, Colorado NWSS CoE Genomic Surveillance Program Manager
  • Alexander Yu, MD, Colorado NWSS CoE Advisory Board Member

Published in MMWR Morb Mortal Wkly Rep 2023;72

Summary:

Wastewater surveillance (WWS), the systematic detection of infectious agents in wastewater, provided a valuable tool for monitoring SARS-CoV-2 circulation during the COVID-19 pandemic; surveillance has expanded from 20 to 53 jurisdictions across the United States, with increasing capacity to test for more respiratory pathogens (1,2). This report highlights the use of wastewater data by the four National Wastewater Surveillance System’s (NWSS) Centers of Excellence (California; Colorado; Houston, Texas; and Wisconsin) to guide public health action during the 2022–23 respiratory disease season. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.*

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