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Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (C. Adams, L. Horter, J.N. Ricaldi, S. Louis, S. Santibañez); Goldbelt Professional Services, Chesapeake, Virginia, USA (L. Horter); University of Iowa, Iowa City, Iowa, USA (S.E. Beekmann, P.M. Polgreen)

Although clinical reporting is critical to infectious disease surveillance, it is limited to the interaction of individual patients with the healthcare system. Wastewater surveillance (WWS) has a history of detecting disease early, independent of healthcare-seeking behavior or access to healthcare and testing (1). WWS data often correlate with transmission levels found in case-based surveillance and can strengthen efforts to prevent disease transmission (1). To enhance the capacity to detect SARS-CoV-2 and additional microbial and chemical targets in wastewater, the US Centers for Disease Control and Prevention (CDC; Atlanta, GA, USA) established the National Wastewater Surveillance System (https://www.cdc.gov/nwss/wastewater-surveillance.html) during the COVID-19 pandemic (2). As of April 2024, a total of 1,690 NWSS sites in all 50 states and several cities and tribal communities have been monitoring wastewater for infectious diseases. Data on SARS-CoV-2 and monkeypox virus are publicly available (3–6).

Often, the first to diagnose and report infectious diseases are physicians (7). However, before physicians’ initial interactions with case-patients, public health and clinical awareness of infections can be enhanced by WWS. To describe the knowledge and practices of US infectious disease physicians regarding WWS, we surveyed the Emerging Infections Network (EIN), a provider-based network supported by CDC and the Infectious Diseases Society of America (8). The activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy (e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.).

During February–March 2024, we distributed a 9-question cross-sectional survey to EIN members (Appendix). We described the survey responses received from 448 (25%) of 1,809 US-based infectious disease physician members and summarized them by respondent characteristics. We identified example quotations that summarized themes identified most frequently from the open-ended question.

Although 64% of respondents knew of WWS in their county or state of work, 36% reported uncertainty or no WWS occurrence (Tables 1, 2). Respondents in the midwestern and western United States were more aware of WWS than those in the northeastern and southern United States (Appendix Table 1). A total of 22% respondents reviewed WWS data regularly, 56% did not review regularly, and 22% were not aware of those data (Table 3). For data sources, 43% of respondents used CDC websites (3–6) and 28% used non-CDC websites. Among the 108 respondents who listed non-CDC websites, most reported state health department websites (58%), followed by local health department and private/academic institution websites (25% each). Targets considered most useful for WWS included influenza A (67%), influenza B (57%), respiratory syncytial virus (55%), norovirus (55%), and measles (55%). Providers with <15 years of experience were more likely to consider measles a useful target than were providers with ≥15 years of experience (Appendix Table 2). Facility-level reporting was most often considered very useful for hospitals (60%) and long-term care facilities (54%). Compared with providers of adult healthcare, providers of pediatric healthcare were less likely to consider reporting for long-term care facilities very useful and were more likely to consider reporting for kindergarten–12th grade schools very useful (Appendix Table 3).

In 192 free-text responses, 178 (40%) of the 448 respondents reported how WWS has affected or could affect their clinical practice and 14 respondents reported that WWS does not affect their clinical practice (Table 3). The most common (47%) response was improving situational awareness, including advanced warning of surges and outbreaks to guide patient counseling. For example, a respondent noted, “If we see measles suddenly popping up in a community, we know we have to act.” Respondents reported using WWS to guide healthcare infection prevention and control decisions (24%) and diagnostic testing and differential diagnoses (15%). When prompted for additional comments regarding WWS, 47 respondents replied. Providers described the utility of WWS (n = 10), how WWS is not useful (n = 5), and the need to better understand correlations with clinical disease (n = 4).

Results from our survey may not be generalizable to all US infectious disease physicians; respondents may have a greater interest in public health surveillance than nonparticipating physicians. However, respondents’ practice characteristics were comparable to those of all EIN members (Appendix Figure). It is unknown how nonrespondents would have answered. If nonresponse resulted from lack of awareness or review of wastewater data, our findings underestimate the need for increased communication with physicians regarding WWS.

Among our findings, many respondents reported examples of how wastewater data affected or could affect their clinical practice, but few reviewed wastewater data regularly. Many respondents were not aware of WWS in their county or state; however, WWS is currently conducted in all 50 states. Increased messaging about the public availability of WWS data is needed. In addition, endemic respiratory viruses, including influenza A, were most commonly reported as useful pathogens for WWS. That finding is consistent with another national survey of infectious disease subject matter experts (9). Last, local WWS data were reported as most useful. Currently, CDC reports wastewater data publicly at the sampling site, state, and national levels. Our survey revealed that increased communication between public health professionals and physicians regarding WWS, along with more local reporting, could increase WWS utility.

Dr. Adams is an epidemiologist at CDC in Atlanta. Her research interests include infectious disease transmission dynamics in healthcare facilities and wastewater surveillance for SARS-CoV-2 and other infectious diseases.

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