Strengthening Public Health Response to Infectious Diseases Through Wastewater Surveillance

May 06, 2026 | Alyssa Boyea, Erin Laird

Background

Wastewater surveillance (WWS) uses samples of wastewater to detect disease pathogens circulating within a community. In 2020, CDC launched the National Wastewater Surveillance System, establishing a robust system to monitor infectious diseases using wastewater nationwide. The expansion of WWS for SARS-COV-2 has also been integral in supporting early detections of other infectious disease pathogens (e.g., influenza, RSV, and measles), maintaining situational awareness of disease infection trends, and supporting appropriate resource allocation for timely public health responses. When used in conjunction with complementary data and information systems, WWS can enhance public health decision-making and actions to help protect the health of a community.

In 2024, ASTHO partnered with CDC and ethics subject matter experts to identify current knowledge, capabilities, gaps, and ethical considerations related to WWS for infectious diseases. Building on this work, in early 2026, ASTHO conducted training workshops on ethical analysis for infectious disease WWS with four states. These workshops brought together state health agencies and their WWS partners (e.g., wastewater operators, local health departments, academic partners, health care coalitions, etc.) to strengthen knowledge and understanding of the ethical analysis process, and foster shared awareness of ethical issues relevant to their WWS programs. This brief summarizes key challenges and considerations, and highlights relevant resources shared during the workshops.

Key Challenges

Pathogen Selection

Agencies need to consider several variables when determining which infectious disease pathogens to monitor, including:

• Available epidemiological and clinical information.
• Public health impact and value.
• Site selection and lab capacity.
• Availability of necessary equipment and supplies for emerging pathogens. Resource and staffing allocations.
• Seasonality of some infectious disease pathogens.

Meanwhile, ethical considerations include public perception of certain infectious diseases, perceived privacy issues, and stigma concerns.

Sampling Sites and Surveillance Scale

WWS is a non-invasive form of surveillance with samples pooled at the community level. On some occasions, there may be a need to sample at a smaller scale (e.g., facility level). Availability of test sites, resource allocation, and staffing levels may impact decisions around the population scale appropriate for sampling. Rural communities raise unique challenges due to smaller population sizes, prevalence of unsewered communities, and advanced resource constraints, which can necessitate further evaluation related to privacy and access to the benefits of surveillance.

Data

WWS is often used as a complimentary surveillance system, filling in gaps in clinical surveillance and providing early trends, sometimes functioning as an “early warning system.” Establishing thresholds for public health action and integrating WWS data with other clinical or syndromic surveillance data are necessary to translate WWS data to public health action. Additional ethical considerations include data stewardship, transparency, and privacy concerns.

Communication

Several variables can impact effective communication about WWS, including:

• Interpretation and translation of data into clear and actionable information.
• Transparency of available information as science evolves.
• Communication mechanisms used to disseminate information to various audiences.
• Public trust and understanding.

Key Considerations

Partnership

In collaboration with partners, create action plans (e.g., Texas’s “Wastewater-Based Disease Surveillance for Local Public Health Action”) or response frameworks (e.g., Houston’s novel framework) for coordinated, efficient response efforts — considering clinical and epidemiological evidence for infectious disease pathogens, public health value and community impact, available resources, staff capacity, and effective communication pathways. It can also be helpful to proactively draft communication tools for describing WWS findings, including how WWS works and how to interpret findings. Partner with other internal teams or divisions as appropriate.

In addition, establish regular touchpoints with wastewater partners (e.g., wastewater operators, wastewater treatment facilities, laboratories, academia, health care systems, community partners, etc.). Create engagement opportunities to provide updates, discuss challenges, and identify opportunities to further enhance jurisdictional WWS efforts together. Consider having partners present on their role in WWS to ensure a shared understanding across all partners. Finally, share findings back with your partners, including wastewater treatment facilities. Ensuring they have access to and know how to interpret the information can help build buy-in. You may also consider informing them of any health alerts shared with providers.

Ongoing Training and Education

Keep up to date on peer-reviewed literature and promising practices from the field. Consider joining a WWS professional community to stay connected with subject matter experts and share resources with peers. Plus, explore training and educational resources to support public health and wastewater partners in key areas, such as data analysis and visualization, communication, and partnerships

Optimization Opportunities

Continue to explore opportunities to improve WWS in your jurisdiction:

• Assess and strengthen current data and surveillance systems. Implementing data modernization activities or initiatives can enhance resiliency and sustainability of data for public health decision making and response.
• Establish clear policies and protocols for the management, use, and sharing of wastewater data through mechanisms such as memorandums of understanding or data agreements.
• Develop a multiprong approach for education and communication with wastewater partners and the public. Utilize various communication strategies and mechanisms for sharing information. Messaging should be clear and concise with a focus on health literacy, audience interests, and accessibility.

Reviewed by Meredith Allen, DrPH, MS, Vice President, Health Security; Kate Petersen, MPH, Senior Director, Infectious Disease Infrastructure & Policy.