Wastewater-based epidemiology (WBE) has been widely implemented around the world as a complementary tool to conventional surveillance techniques to inform and improve public health responses. Currently, wastewater surveillance programs in the U.S. are evaluating integrated approaches to address public health challenges across multiple domains, including substance abuse. In this work, we demonstrated the potential of online solid-phase extraction coupled with liquid chromatography–high-resolution mass spectrometry to support targeted quantification and nontargeted analysis of psychoactive and lifestyle substances as a step toward understanding the operational feasibility of a statewide wastewater surveillance program for substance use assessment in New York. Target screening confirmed 39 substances in influent samples collected from 10 wastewater treatment plants with varying sewershed characteristics and is anticipated to meet the throughput demands as the statewide program scales up to full capacity. Nontarget screening prioritized additional compounds for identification at three confidence levels, including psychoactive substances, such as opioid analgesics, phenethylamines, and cathinone derivatives. Consumption rates of 12 target substances detected in over 80% of wastewater samples were similar to those reported by previous U.S.-based WBE studies despite the uncertainty associated with back-calculations. For selected substances, the relative bias in consumption estimates was sensitive to variations in monitoring frequency, and factors beyond human excretion (e.g., as indicated by the parent-to-metabolite ratios) might also contribute to their prevalence at the sewershed scale. Overall, our study marks the initial phase of refining analytical workflows and data interpretation in preparation for the incorporation of substance use assessment into the statewide wastewater surveillance program in New York.

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Wastewater surveillance provides a cost-effective and non-invasive way to gain an understanding of infectious disease transmission including for COVID-19. We analyzed wastewater samples from one school site in Jefferson County, New York during the 2021–2022 school year. We tested for SARS-CoV-2 RNA once weekly and compared those results with the clinical COVID-19 cases in the school. The amount of SARS-CoV-2 RNA correlated with the number of incident COVID-19 cases, with the best correlation being one day lead time between the wastewater sample and the number of COVID-19 cases. The sensitivity and positive predictive value of wastewater surveillance to correctly identify any COVID-19 cases up to 7 days after a wastewater sample collection ranged from 82–100% and 59–78% respectively, depending upon the amount of SARS-CoV-2 RNA in the sample. The specificity and negative predictive value of wastewater surveillance to correctly identify when the school was without a case of COVID-19 ranged from 67–78% and 70–80%, respectively, depending upon the amount of SARS-CoV-2 RNA in the sample. The lead time observed in this study suggests that transmission might occur within a school before SARS-CoV-2 is identified in wastewater. However, wastewater surveillance should still be considered as a potential means of understanding school-level COVID-19 trends and is a way to enable precision public health approaches tailored to the epidemiologic situation in an individual school.

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COVID-19 saw the expansion of public health tools to manage the pandemic. One tool that saw extensive use was the public health dashboard, web-based visualization tools that communicate information to users in easy-to-read graphics. Dashboards were widely used prior to the pandemic, but COVID-19 saw expanded use and development. To date, dashboards have become an important part of public health surveillance programs around the world helping decisionmakers use data to evaluate different public health metrics including caseloads, hospitalizations, and environmental surveillance results from testing wastewater. Wastewater surveillance provides community-based, spatially relevant data on disease trends within communities to assess the scale of infection in a region, which makes it an excellent candidate for dashboard development to improve public health. We developed a dashboard for New York State's wastewater surveillance program using open-source, reproducible web programming. The dashboard we developed has been used for the COVID-19 response in New York, and our methods can be adapted to other programs and pathogens. We provide:

• descriptions of how the dashboard was developed and maintained

• specific guidance for reproducing our dashboard in other areas and for other pathogens

• fully reproducible code with step-by-step instructions for researchers and professionals to make their own data dashboards

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Background: The public health response to COVID-19 has shifted to reducing deaths and hospitalizations to prevent overwhelming health systems. The amount of SARS-CoV-2 RNA fragments in wastewater are known to correlate with clinical data including cases and hospital admissions for COVID-19. We developed and tested a predictive model for incident COVID-19 hospital admissions in New York State using wastewater data.

Methods: Using county-level COVID-19 hospital admissions and wastewater surveillance covering 13.8 million people across 56 counties, we fit a generalized linear mixed model predicting new hospital admissions from wastewater concentrations of SARS-CoV-2 RNA from April 29, 2020 to June 30, 2022. We included covariates such as COVID-19 vaccine coverage in the county, comorbidities, demographic variables, and holiday gatherings.

Findings: Wastewater concentrations of SARS-CoV-2 RNA correlated with new hospital admissions per 100,000 up to ten days prior to admission. Models that included wastewater had higher predictive power than models that included clinical cases only, increasing the accuracy of the model by 15%. Predicted hospital admissions correlated highly with observed admissions (r = 0.77) with an average difference of 0.013 hospitalizations per 100,000 (95% CI = [0.002, 0.025]).

Interpretation: Using wastewater to predict future hospital admissions from COVID-19 is accurate and effective with superior results to using case data alone. The lead time of ten days could alert the public to take precautions and improve resource allocation for seasonal surges.

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Context: The COVID-19 pandemic sparked efforts across the globe to implement wastewater surveillance for SARS-CoV-2.

Program: New York State (NYS) established the NYS Wastewater Surveillance Network to estimate the levels of COVID-19 community risk and to provide an early indication of SARS-CoV-2 transmission trends. The network is designed to provide a better understanding of public health burdens and to assist health departments to respond effectively to public health threats.

Implementation: Wastewater surveillance across NYS increased from sporadic and geographically spare in 2020 to routine and widespread in 2022, reaching all 62 counties in the state and covering 74% of New Yorkers. The network team focused on engaging local health departments and wastewater treatment plants to provide wastewater samples, which are then analyzed through a network-affiliated laboratory. Both participating local health departments and wastewater treatment plants receive weekly memos on current SARS-CoV-2 trends and levels. The data are also made publicly available at the state dashboard.

Evaluation: Using standard indicators to evaluate infectious disease surveillance systems, the NYS Wastewater Surveillance Network was assessed for accuracy, timeliness, and completeness during the first year of operations. We observed 96.5% sensitivity of wastewater to identify substantial/high COVID-19 transmission and 99% specificity to identify low COVID-19 transmission. In total, 80% of results were reported within 1 day of sample collection and were published on the public dashboard within 2 days of sample collection. Among participating wastewater treatment plants, 32.5% provided weekly samples with zero missing data, 31% missed 1 or 2 weeks, and 36.5% missed 3 or more weeks.

Discussion: The NYS Wastewater Surveillance Network continues to be a key component of the state and local health departments' pandemic response. The network fosters prompt public health actions through real-time data, enhancing the preparedness capability for both existing and emerging public health threats.

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Wastewater surveillance proved to be a successful early-warning, population level, trend detection system during the COVID-19 pandemic. Now, it is developing into a versatile tool for public health as laboratories start to use this testing to monitor for other pathogens of concern.

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Sewer systems provide many services to communities that have access to them beyond removal of waste and wastewater. Understanding of these systems’ geographic coverage is essential for wastewater-based epidemiology (WBE), which requires accurate estimates for the population contributing wastewater. Reliable estimates for the boundaries of a sewer service area or sewershed can be used to link upstream populations to wastewater samples taken at treatment plants or other locations within a sewer system. These geographic data are usually managed by public utilities, municipal offices, and some government agencies, however, there are no centralized databases for geographic information on sewer systems in New York State. We created a database for all municipal sewersheds in New York State for the purpose of supporting statewide wastewater surveillance efforts to support public health. We used a combination of public tax records with sewer access information, physical maps, and municipal records to organize and draw digital boundaries compatible with geographic information systems. The methods we employed to create these data will be useful to inform similar efforts in other jurisdictions and the data have many public health applications as well as being informative for water/environmental research and infrastructure projects.

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Wastewater surveillance of SARS-CoV-2 has been shown to be a valuable source of information regarding SARS-CoV-2 transmission and COVID-19 cases. Though the method has been used for several decades to track other infectious diseases, there has not been a comprehensive review outlining all of the pathogens that have been surveilled through wastewater. Herein we identify what infectious diseases have been previously studied via wastewater surveillance prior to the COVID-19 pandemic. Infectious diseases and pathogens were identified in 100 studies of wastewater surveillance across 38 countries, as well as themes of how wastewater surveillance and other measures of disease transmission were linked. Twenty-five separate pathogen families were identified in the included studies, with the majority of studies examining pathogens from the family Picornaviridae, including polio and non-polio enteroviruses. Most studies of wastewater surveillance did not link what was found in the wastewater to other measures of disease transmission. Among those studies that did, the value reported varied by study. Wastewater surveillance should be considered as a potential tool for many infectious diseases. Wastewater surveillance studies can be improved by incorporating other measures of disease transmission at the population-level including disease incidence and hospitalizations.

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What is already known about this topic?

In July 2022, a case of paralytic poliomyelitis was confirmed in an unvaccinated adult Rockland County, New York resident; environmental sampling found evidence of poliovirus transmission.

What is added by this report?

Wastewater testing has identified circulating polioviruses genetically related to virus isolated from the Rockland County patient in at least five New York counties.

What are the implications for public health practice?

Public health efforts to prevent polio should focus on improving coverage with inactivated polio vaccine. Although most persons in the United States are sufficiently immunized, unvaccinated or undervaccinated persons living or working in Kings, Orange, Queens, Rockland, or Sullivan counties, New York should complete the polio vaccination series to prevent additional paralytic cases and curtail transmission.

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What is already known about this topic?

Sustained poliovirus transmission has been eliminated from the United States for approximately 40 years; vaccines are highly effective in preventing paralysis after exposure.

What is added by this report?

In June 2022, poliovirus was confirmed in an unvaccinated immunocompetent adult resident of New York hospitalized with flaccid lower limb weakness. Vaccine-derived poliovirus type 2 was isolated from the patient and identified from wastewater samples in two neighboring New York counties.

What are the implications for public health practice?

Unvaccinated persons in the United States remain at risk for paralytic poliomyelitis if they are exposed to either wild or vaccine-derived poliovirus; all persons in the United States should stay up to date on recommended poliovirus vaccination.

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Infectious disease surveillance is vitally important to maintaining health security, but these efforts are challenged by the pace at which new pathogens emerge. Wastewater surveillance can rapidly obtain population-level estimates of disease transmission, and we leverage freedom from disease principles to make use of nondetection of SARS-CoV-2 in wastewater to estimate the probability that a community is free from SARS-CoV-2 transmission. From wastewater surveillance of 24 treatment plants across upstate New York from May through December of 2020, trends in the intensity of SARS-CoV-2 in wastewater correlate with trends in COVID-19 incidence and test positivity (⍴ > 0.5), with the greatest correlation observed for active cases and a 3-day lead time between wastewater sample date and clinical test date. No COVID-19 cases were reported 35% of the time the week of a nondetection of SARS-CoV-2 in wastewater. Compared to the United States Centers for Disease Control and Prevention levels of transmission risk, transmission risk was low (no community spared) 50% of the time following nondetection, and transmission risk was moderate or lower (low community spread) 92% of the time following nondetection. Wastewater surveillance can demonstrate the geographic extent of the transmission of emerging pathogens, confirming that transmission risk is either absent or low and alerting of an increase in transmission. If a statewide wastewater surveillance platform had been in place prior to the onset of the COVID-19 pandemic, policymakers would have been able to complement the representative nature of wastewater samples to individual testing, likely resulting in more precise public health interventions and policies.

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