The journey toward effectively managing data and modernizing data systems is critical, yet complex, for state and territorial health departments. The intersection of ever-evolving public health crises and rapid technological advancements highlights an increasing need for data systems capable of keeping pace. However, health departments often face significant challenges in this process, which can stem from workforce limitations, outdated infrastructure, and difficulties in the practical application of data.
In the face of these challenges, it is crucial to realize that state and territorial health departments are not alone. Their peers’ shared experiences—in different jurisdictions or even in different industries—can serve as valuable lessons. These collective experiences offer insights into common challenges, provide examples of effective strategies, and, most importantly, inspire solutions. Data management and systems modernization should not be viewed merely as a technical upgrade but rather as a holistic transformation involving changes in workforce education, infrastructural enhancements, and operational adjustments to streamline data applications.
State and territorial health departments share common ground in their efforts to modernize data systems and improve data management practices. Their experiences and challenges often converge in areas such as workforce capacity, data infrastructure, and managing/applying data. Recognizing and understanding these shared challenges can lead to collaborative solutions that address gaps and strengthen the overall public health data landscape.
Common contributing factors to these challenges include:
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Workforce
- Insufficient IT and informatics skills: Health departments often grapple with a lack of staff members who possess the requisite knowledge, skills, and abilities in information technology and informatics.
- Limited contractor availability and understanding: IT contractors, often brought in to bolster in-house capacity, may have little time to fully comprehend and address the unique needs of health departments.
- Competition for IT talent: The compensation for in-house IT talent in public health often cannot compete with the private sector, making it difficult to attract and retain skilled professionals.
- Tech companies in the health space: The entrance of tech companies into the health and public health space has further intensified competition for IT talent.
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Data Infrastructure
- Outdated IT systems: Health departments often struggle with maintaining up-to-date IT software and hardware, with legacy systems posing significant challenges.
- Lack of interoperability: The existing data infrastructure may not be interoperable, creating obstacles to efficient data sharing and analysis.
- Procurement and funding challenges: Health departments may face procurement difficulties and inconsistent data standards. Short-term funding often limits strategic investment in data systems.
- Continued use of redundant reporting: Despite the push for modernization, some health departments continue to use paper-based and redundant reporting methods.
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Management/Application
- Inconsistent reporting requirements: Health departments must deal with inconsistent or redundant reporting requirements that complicate data management processes.
- Data sharing across jurisdictions: Sharing data across jurisdictions can be challenging, creating gaps in comprehensive public health surveillance.
- High data volume and rapid analysis expectations: The increasing volume of data to process and analyze and expectations for rapid analysis and reporting can significantly strain health departments.
Understanding these shared challenges can allow health departments to develop more robust and efficient data systems that meet their unique needs. It also paves the way for more effective collaborations and best practice sharing among state and territorial health departments.
This section highlights a successful and innovative solution your peers implemented to address challenges with training and resources. This story presents the factors that catalyzed the innovation, the existing policies or funding mechanisms that facilitated action, the potential barriers the agency faced, the collaborations and partnerships the agency leveraged, and tips for implementing and/or scaling the solution.
From Samples to Insights: Advancing Equity Through Data Modernization in Wastewater-Based Disease Surveillance
Introduction
In response to the COVID-19 pandemic, CDC launched its National Wastewater Surveillance System (NWSS) in September 2020. CDC established this initiative to enhance the nation's ability to detect and track the SARS-CoV-2 virus, providing a valuable supplement to traditional case surveillance. NWSS has also been a crucial testing ground for CDC’s Data Modernization Initiative, fostering collaborations between local, tribal, territorial, and state health departments, national laboratories, and local wastewater facilities.
These partnerships work toward generating real-time, population-level data, which is pivotal for informed public health decision-making and addressing vital equity considerations. Wastewater surveillance inherently offers an equitable and non-invasive method of monitoring health as it covers a large population, including those who may not have ready access to personal health care. This democratizes public health trend tracking and makes it more inclusive.
Crucially, around 80 percent of U.S. households are served by municipal wastewater collection systems, implying a broad reach for this surveillance system across diverse communities. This expansive coverage helps minimize health inequities related to location and access to health care.
Moreover, CDC is committed to leveraging this system to advance health equity further. It aims to understand how wastewater surveillance can be expanded to detect and respond to various infectious diseases, including threats like antibiotic resistance and foodborne illnesses. By doing so, CDC strives to create a surveillance system that serves all communities, thereby ensuring health equity remains central in our public health response strategies.
Policies and Funding
Since 2020, CDC has allocated over $100 million through the annual Epidemiology and Laboratory Capacity funding opportunity to support wastewater surveillance and related operations across 46 states, five cities, and two territories. In August 2022, CDC granted an additional $64 million to enhance wastewater surveillance in 42 states and five cities. This financial support has played a crucial role in helping establish and expand NWSS, allowing health departments at various levels to access necessary resources. In line with this initiative, CDC has also funded two Centers of Excellence, located in Texas and Colorado, which work to foster partnerships with health departments, academic researchers, and wastewater treatment plants to implement more robust surveillance systems.
Challenges and Barriers
Implementing NWSS has posed several challenges. One key issue is the variable frequency of sample collection and data reporting across different locations, which can lead to gaps and inconsistencies in the data. Additionally, the data analysis process can be time-consuming and costly, presenting potential barriers, especially for under-resourced communities.
To address these challenges, CDC introduced the DCIPHER platform, a cloud-based solution that streamlines the data analysis process. This platform, accessible to all implementing partners, aims to offer a more efficient and equitable approach to disease surveillance. By making advanced data analysis tools and resources universally available, DCIPHER democratizes access to information and technology, ensuring that all communities can benefit from NWSS regardless of their resources. This platform feature helps agencies identify shifting disease trends up to a week before such trends become apparent in clinical case surveillance data.
However, it is also essential to recognize potential community resistance to implementing NWSS. Some of this resistance may stem from concerns about privacy, misunderstanding about the nature and purpose of wastewater surveillance, or skepticism about its benefits to the community. This resistance can be particularly strong in marginalized communities that have historically experienced a lack of trust in public health initiatives due to previous injustices and neglect.
To address these concerns, engaging in transparent, respectful, and culturally sensitive communication about NWSS’s purpose, benefits, and safety is critical. Health departments should actively involve community members in planning and implementing wastewater surveillance efforts and ensure their perspectives and needs are considered. This involvement can foster trust, increase understanding, and ultimately enhance NWSS’ acceptability and effectiveness, leading to a more equitable and inclusive public health response.
Collaborations and Partnerships
Successfully implementing NWSS was made possible through key collaborations and partnerships between various stakeholders, including:
- Academic and research institutions: These institutions contributed expertise and resources, collaborating with health departments and providing scientific guidance in areas such as sample collection methods, laboratory testing, data analysis, and interpretation. Their research capabilities also contributed to advancing knowledge and best practices in wastewater surveillance.
- Community interest groups: Community interest groups have played an important role in NWSS implementation by raising awareness, participating in sample collection initiatives, and providing feedback. Engaging with these groups helps build trust, improve participation rates, and foster community support for surveillance efforts. Input from community members is also crucial to addressing equity concerns.
- Wastewater treatment plants: Wastewater treatment plants have collaborated with health departments by providing access to their facilities, assisting with sample collection logistics, and supporting data sharing coordination. Their involvement is critical in ensuring the representativeness and reliability of the collected samples.
Tips for Implementing and Scaling
States, cities, or territories looking to establish their own NWSS program should consider the following recommendations:
- Build robust partnerships with diverse stakeholders: Strong collaborations with academic institutions, water utilities, and wastewater treatment facilities can provide invaluable expertise and resources. Local health departments, academic researchers, and community interest groups each bring a unique perspective and set of resources that can improve the surveillance program’s efficiency and reach.
- Invest in data infrastructure and analytical capabilities: The backbone of an effective NWSS program is a robust data management system. Investing in hardware, software, and training can ensure your team has the resources to interpret and utilize surveillance data accurately. Developing in-house analytics capabilities can lead to more rapid responses to changing data trends.
- Prioritize community engagement and communication: Engaging with community members is crucial for fostering trust and encouraging participation in the surveillance program. Transparent communication about the program's goals, processes, and findings can help alleviate concerns and misconceptions. Additionally, active dialogue with community members can ensure that their voices and perspectives are included in the decision-making process, promoting health equity.
- Establish clear protocols for data collection and reporting: To ensure consistency and comparability of data, you should establish clear protocols for sample collection, laboratory testing, data analysis, and reporting from the start. Providing training and technical support to all involved parties can help ensure these protocols are followed.
- Foster a culture of continuous learning and improvement: Given the novel nature of wastewater surveillance, it is important to stay adaptable and continually learn from the data and experiences. Encourage an environment where feedback is welcomed and used for system improvement.
- Address equity considerations: Pay particular attention to how your program can address health disparities and inequities. This could mean focusing more resources on underserved areas or those disproportionately affected by health crises. Ensuring that your data collection and analysis processes are designed with equity in mind can help your program contribute to more just health outcomes.
- Secure sustainable funding: Since establishing and operating a surveillance program requires considerable resources, it is essential to secure sustainable funding. This may involve identifying various funding opportunities, from government grants to partnerships with academic institutions or private organizations.
APPLYING THIS KNOWLEDGE TO INFECTIOUS DISEASE
NWSS’ implications for infectious disease practice in state and territorial health departments include:
- Leveraging wastewater surveillance for broad coverage: NWSS allows health departments to detect and track various diseases in a non-invasive and comprehensive manner, providing coverage for around 80% of U.S. households. This has significant implications for health departments looking to implement equitable surveillance strategies that can reach a large portion of their populations, including communities without ready access to personal health care.
- Allocating funding for wastewater surveillance: CDC’s significant investment in NWSS indicates the value and importance of wastewater surveillance. Health departments can use this funding to support and expand their disease surveillance efforts, enhancing their ability to track and respond to infectious diseases.
- Navigating challenges and barriers: Health departments must be prepared for potential challenges in implementing wastewater surveillance, such as variable frequency of sample collection, difficulty with data reporting, and time-consuming data analysis. Tools like CDC's DCIPHER platform can help streamline the data analysis process and ensure equitable access to advanced data analysis resources.
- Building collaborations and partnerships: NWSS has been successful due to collaborations between health departments, national laboratories, and local wastewater facilities. State and territorial health departments can learn from this model to establish their own partnerships, helping to foster robust surveillance systems that incorporate the strengths and expertise of various community stakeholders.
- Implementing and scaling wastewater surveillance: Health departments should consider strategies for successfully implementing and scaling wastewater surveillance. This includes building robust partnerships, investing in data infrastructure, prioritizing community engagement, establishing clear protocols, fostering continuous learning, addressing equity considerations, and securing sustainable funding.
- Enhancing community trust and participation: Implementing NWSS has underscored the importance of transparent, respectful, and culturally sensitive communication with the community, particularly to address potential resistance or skepticism. Health departments should ensure that community engagement is central to their infectious disease practices to foster trust, increase understanding, and enhance the effectiveness of their surveillance systems.
- Addressing health equity: Wastewater surveillance offers an opportunity to advance health equity by detecting and responding to a variety of infectious diseases across diverse communities. Health departments should actively involve community members in planning and implementing their surveillance efforts and should focus resources on areas that are underserved or disproportionately affected by health crises.
This section encompasses a collection of pertinent tools and resources curated from ASTHO's Public Health Innovations Catalog and various other sources to help you navigate and comprehend the intricacies of this subject area. Garner insights and experiences from your peers, enabling you to start building solutions tailored to your health department.
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