Wastewater Surveillance-"Messy" Science With Public Health Potential

Wastewater surveillance as a tool for understanding West Nile virus transmission and distribution in Oklahoma

West Nile Virus (WNV) is the most widespread and frequently reported mosquito-borne disease in the US, with a high risk of outbreaks. Accurate surveillance of WNV is complicated by many mild or asymptomatic infections, resulting in human cases being under-reported and disease distribution and transmission not being well understood. In this study, we investigated how wastewater surveillance can be used for monitoring WNV in Oklahoma. We analyzed samples collected from wastewater treatment facilities in 16 counties during July 1 to September 31, 2023, for the presence of WNV genetic material and compared the results to the distribution of notified WNV cases in humans and equines and WNV-positive mosquitoes. WNV was detected in wastewater from four locations in three counties. All positive wastewater samples were collected from counties with confirmed human cases and, in two counties, with positive mosquito pools. There was no geographical match between positive wastewater samples and equine cases. We did not detect WNV in wastewater samples from 13 counties, of which five did not report human cases and four had no reports of WNV-positive mosquitoes. Our study presents evidence that WNV genetic material can be detected in wastewater to which thousands of people have contributed. This highlights wastewater surveillance as a promising tool for understanding the distribution of emerging vector-borne diseases, particularly in areas where traditional surveillance approaches lack in representativeness and timeliness.

Surveillance via wastewater monitoring and nasal self-collection of specimens (The SWANSS Study): a CFIR-informed qualitative study with key carceral and healthcare stakeholders

BACKGROUND

Implementing public health interventions can be challenging in carceral settings. Jails are institutions with the shortest lengths of stay, resulting in frequent turnover and constantly shifting populations. Jails had particularly acute challenges during the early stages of the COVID-19 pandemic when incarcerated persons were highly susceptible to infection and severe disease. The purpose of this study was to identify barriers and facilitators to wastewater-based surveillance (WBS) and nasal self-testing (NST) as a combined strategy of COVID-19 surveillance in Fulton County Jail (FCJ), Atlanta, Georgia. Implications for efficient and effective infectious disease testing among this susceptible population are relevant for ongoing surveillance of current endemic pathogens and future epidemics.

METHODS

We utilized a multilevel, theory-informed qualitative approach to conduct semi-structured one-on-one and small group interviews with nine distinct jail stakeholder groups: jail custody leadership, administrators, officers, maintenance workers, Georgia Department of Health's COVID-19 testing contractor, jail health care leaders, nursing staff, laboratory leadership, and staff. Interview guides and analyses were informed by the Consolidated Framework for Implementation Research (CFIR). We used Applied Thematic Analysis to identify domains within CFIR reflecting barriers and facilitators to WBS combined with NST in large urban jail settings.

RESULTS

Twelve interviews were conducted with administrative, healthcare, maintenance, custody, and laboratory personnel from July 2022 to November 2022. Seven CFIR constructs were identified as barriers, sixteen as facilitators, and one as a neutral factor for the implementation of WBS combined with NST. Jail stakeholders underscored the relative advantage of self-testing, highlighted limited resources, and expressed concerns for the sustainability of WBS due to competing priorities. Many of the stakeholders within the jail setting that were interviewed had hierarchical organizational structures, which made decision-making processes regarding WBS and NST complex and challenging to implement.

CONCLUSIONS

Given the political, structural, and organizational factors in a jail setting, innovations such as NST and WBS require a rigorous implementation strategy supported by ongoing engagement and collaboration with a multitude of stakeholders.

COVID-19 Risk and Crisis Communication Challenges and Opportunities: Qualitative Insights from Rural Wastewater Surveillance Partners

OBJECTIVES

Understand perceptions of COVID-19 messages and information sources among rural wastewater treatment plant operators to inform context-specific communication strategies for implementing wastewater surveillance methodologies locally.

METHODS

Eight employees from 7 Eastern Kentucky facilities involved in SARS-CoV-2 wastewater surveillance participated in semi-structured interviews. Respondents shared perceptions of traditional and social media COVID-19 information channels in their communities, as well as factors influencing trustworthiness of sources. Using the U.S. Centers for Disease Control and Prevention's Crisis and Emergency Risk Communication (CERC) framework, 3 investigators conducted iterative, thematic coding of interview transcripts.

RESULTS

Respondents' statements most frequently related to "Be Credible," "Be Right," and "Promote Action" CERC constructs, while mixed messages, high volumes of information, and numerous sources undermined trust in COVID-19 information.

CONCLUSIONS

Understanding the relative importance of CERC constructs and their distractors may improve future risk communication to advance infectious disease surveillance strategies in rural contexts.

Phenotypic Antibiotic Resistance Patterns of Escherichia coli Isolates from Clinical UTI Samples and Municipal Wastewater in a Grenadian Community

Antimicrobial resistance (AMR) is a growing global health threat. This study investigated antibiotic resistance in E. coli isolates from municipal wastewater (86 isolates) and clinical urinary tract infection (UTI) cases (34 isolates) in a Grenadian community, using data from January 2022 to October 2023. Antibiogram data, assessed per WHO guidelines for Critically Important antimicrobials (CIA), showed the highest resistance levels in both clinical and wastewater samples for ampicillin, followed by amoxicillin/clavulanic acid and nalidixic acid, all classified as Critically Important. Similar resistance was observed for sulfamethoxazole-trimethoprim (highly important) in both groups, with nitrofurantoin showing resistance in the important category. According to the WHO AWaRe classification, ampicillin (ACCESS group) had the highest resistance, while nitrofurantoin had the lowest across all samples. The WATCH group antibiotics, cefuroxime and cefoxitin, showed comparable resistance levels, whereas aztreonam from the RESERVE group (tested only in wastewater) was 100% sensitive. Multiple Antibiotic Resistance (MAR) index analysis revealed that 7% of wastewater and 38.2% of clinical samples had MAR values over 0.2, indicating prior antibiotic exposure in clinical isolates. These parallel patterns in wastewater and clinical samples highlight wastewater monitoring as a valuable tool for AMR surveillance, supporting antibiotic stewardship through ongoing environmental and clinical assessment.

Wastewater Surveillance for Xylazine in Kentucky

Introduction

In the U.S., xylazine, the veterinary non-opioid sedative, has emerged as a major threat to people who use illicitly manufactured fentanyl and other drugs. The aim of this study was to compare wastewater detection of xylazine with other public health and safety surveillance data from 2019 to 2023 in Kentucky.

Methods

Wastewater samples from 5 rest areas, 2 truck weigh stations, and 4 wastewater treatment plants were tested for xylazine. Wastewater xylazine positivity rates were compared with xylazine-positive submission rates from the National Forensic Laboratory Information System and Kentucky's fatal overdoses in 6-month periods (Period 1=January-June; Period 2=July-December).

Results

Xylazine was detected in 61.6% (424 of 688) of daily wastewater samples from roadway sites/wastewater treatment plants. For roadways, detection increased from 55% (Period 1, 2021) to 94% (Period 1, 2023), and wastewater treatment plants had an overall detection of 25.8% (n=66 samples, Periods 1 and 2, 2022). Increasing roadway positivity corresponded to trends in National Forensic Laboratory Information System xylazine-positive submission rates: from 0.19 per 1,000 submissions (Period 1, 2019) to 2.9 per 1,000 (Period 2, 2022, latest available). No deaths from xylazine were reported publicly in Kentucky, although this study's authors identified 1-4 deaths (true count suppressed) in the overdose surveillance system, which, in back-of-the-envelope comparisons with other states, is far fewer than expected.

Conclusions

Wastewater signals indicate broad geographic exposure to xylazine in Kentucky, yet health outcomes data suggest otherwise. These findings may inform regional, national, and international efforts to incorporate wastewater-based drug surveillance. Harm-reduction activities along roadways and other suitable locations may be needed.

Core components of an anti-racist approach among health professions educators: an integrative review

Objectives

This integrative literature review aimed to identify the core elements of an anti-racist approach among health professions educators.

Methods

We searched five databases CINAHL (EBSCOhost), ERIC (ProQuest Dissertations & Thesis Global), EMBASE (Ovid), MEDLINE (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded) in March 2021. The search strategy combined concepts related to anti-racist pedagogies in the context of health professions education by educators in any capacity. From 1,755 results, we selected 249 manuscripts published in English or French between 2008 and 2021 based on titles and abstracts. After reviewing the full texts, we selected the 48 most relevant sources. We extracted data regarding knowledge, skills, and attitudes in reference to anti-racist approaches or surrogate terms. Within each category, we grouped similar data using a conceptual map.

Results

Analysis of the selected sources revealed that, for health professions educators, engaging in an anti-racist pedagogical approach requires more than incorporating racialized perspectives and content into the classroom. It rather rests on three interrelated components: developing a critical understanding of power relationships, moving toward a critical consciousness, and taking action at individual and organizational levels.

Conclusions

This review sheds light on knowledge, attitudes and skills that educators must deploy to adopt an anti-racist approach competently. This approach is a learned, intentional, and strategic effort in which health professions educators incorporate anti-racism into their teaching and apply anti-racist values to their various spheres of influence. This ongoing process strives for institutional and structural changes and requires whole-system actions.