The National Academies of Sciences, Engineering, and Medicine recommends selection of targets to expand wastewater surveillance beyond SARS-CoV-2 be based on 3 criteria: 1) public health significance, 2) analytical feasibility, and 3) usefulness of the wastewater surveillance data to inform public health action (4). The HHD, working with an existing advisory committee of local infectious disease doctors and public health specialists, conducted a hypothesis-generating study whereby infectious disease subject matter experts (SMEs) suggested a list of pathogens or diseases (hereafter referred to as targets) to be considered for surveillance with respect to criteria 1 and 3 above, considering feasibility for assessment outside the scope of the study (5).

The HHD received 47 unique and complete survey responses affiliated with 42 unique organizations (19 university or hospital systems, 21 public health departments, 2 others) from 21 different states, primarily in large cities or counties. Of the participants from public health departments, 19 worked at the city or county level and 2 worked at state-level agencies.

There was significant consistency across both categories. The suggested targets based on the 10 highest score values in either category were influenza A (novel or variant), measles (rubeola), hepatitis A, carbapenem-resistant Enterobacterales, monkeypox virus, Neisseria meningitidis (invasive [meningococcal disease]), Candida auris, West Nile virus, rabies (human), anthrax, legionellosis, pertussis, and cholera. Participants suggested several additional targets of concern to include in expanded wastewater monitoring, including norovirus, rotavirus, Marburg virus, and multidrug-resistant pathogens. Suggested target lists from academic, healthcare, and public health participants included measles, influenza A, hepatitis A, and Neisseria meningitidis, with an expected variance between lists relevant to each participant group’s healthcare focus.

The results of this study cannot be used to represent opinions regarding the prioritization of these suggested targets and cannot be generalized to a broader population, but they can be used to suggest a list of targets that could be considered for surveillance. As such, results from the study identified a list of 13 targets to be considered for expanded wastewater sampling based on public health importance and actionability. The results also can be used as the basis of a questionnaire for a future population-based study, with the intent of homing in on recommendations for target prioritization on a broader scale. Furthermore, supplementing these results with additional data based on local needs might favor the inclusion of different targets for a specific region.

A critical first step in expanding a wastewater surveillance program is to understand the pathogens that infectious disease SMEs consider to be the greatest threat to public health. A previous study ranked targets for wastewater surveillance prioritization by using binary and quantitative parameters based in empirical disease data (9). Other disease prioritization studies that incorporated feedback from SMEs were not focused specifically on rankings for wastewater surveillance and had narrower scopes focusing on specific events or types of targets (10,11). The methods used in this study complement those approaches by bringing in perspectives from infectious disease SMEs with a first-hand view of how these targets affect disease in the broader community, whose responses were provided with the express intent of translating the collective data to wastewater monitoring. We believe that these study results can be used to suggest an expanded target list for the National Wastewater Surveillance System and serve as pilot information for future studies.