Abstract
Objectives:
Wastewater surveillance (WWS) is a valuable public health tool for monitoring infectious diseases. Recent studies suggest its potential for monitoring opioids or other drugs. We evaluated WWS awareness and public acceptance of WWS for respiratory and vector-borne diseases and opioids in the US population.
Methods:
We conducted a nationwide cross-sectional survey in June 2024 among US adults aged ≥18 years. We used quantitative analysis (N = 2024) to assess associations between participants’ awareness of and attitudes toward WWS, including how those data should be used. We performed qualitative analysis to identify themes among participants who provided comments about opioids or other illicit drugs (n = 67).
Results:
Overall, more than half of participants expressed comfort with WWS for respiratory diseases (54.1%), mosquito-borne diseases (57.3%), and opioids or other drugs (51.1%). These percentages were significantly higher (P < .001) among people with awareness of WWS than among those who were unaware of WWS: 70.6% were comfortable with WWS for respiratory diseases and 71.6% were comfortable with WWS for mosquito-borne diseases, while slightly fewer participants were comfortable with WWS for opioids or other drugs (64.8%). Among those unaware of WWS, about half were comfortable with WWS for respiratory diseases (50.8%), mosquito-borne diseases (55.5%), or opioids or other drugs (49.2%). Qualitative analysis highlighted concerns about privacy, changes in law enforcement activity with opioid monitoring, and the possibility of negative community effects.
Conclusions:
Comfort with WWS activities was higher among those who were aware of WWS than among those who were not. Future efforts could focus on improving public awareness and knowledge of how wastewater data are collected and used to benefit public health.
Keywords
Introduction
The COVID-19 pandemic highlighted the importance of wastewater surveillance (WWS) as a noninvasive strategy to monitor community viral spread. 1 WWS provides near–real-time data, which state and local health officials have used to gain insights into community disease transmission levels, improve outbreak response, and allocate resources. As of December 2024, 50 states, 7 territories, and some tribal communities conducted WWS.2,3
Several public opinion surveys have found strong support for WWS for respiratory infectious diseases, environmental toxins, and terrorist threats.4-8 A 2024 nationwide survey found that 74.6% of participants supported WWS for infectious diseases conducted by public health departments. 4 Most participants (95.3%) indicated they would take protective actions if WWS data showed disease transmission in their area, and 57.8% wanted access to WWS data even in the absence of clear public health actions. 4 Similarly, a 2024 survey conducted in 5 US states found high (80.0%) support for WWS to detect viruses or bacteria, despite only 56.0% of participants reporting awareness of WWS and 65.0% reporting little to no knowledge about WWS. 8 However, in nationwide surveys conducted in 2022 and 2023, respondent support for WWS surveillance was strongest (85%) at larger geographic scales (ie, citywide vs smaller areas) to protect individual privacy.6,7
While WWS is primarily used for infectious disease surveillance, it has also been used to monitor opioids or other drugs.9-16 We evaluated WWS awareness and public acceptance of WWS for respiratory and vector-borne diseases and opioids in the US population.
Methods
Survey
We collected data using the PN View survey, a cross-sectional online survey conducted by Porter Novelli Public Services and Big Village. The sampling frame comprised opt-in panel members recruited from Cint’s Insight Exchange. The survey was administered June 19 to 23, 2024, to a nationwide sample of US adults aged ≥18 years selected using nonprobability quota sampling. Porter Novelli computed survey weights using its proprietary process to reflect the demographic composition of the US population in sex, age, region, race and ethnicity, and education based on Current Population Survey proportions. 17 Overall, 2024 people from 50 states and the District of Columbia completed the survey. This activity was reviewed by the Centers for Disease Control and Prevention (CDC), deemed not research, and conducted consistent with applicable federal law and CDC policy (eg, 45 CFR part 46, 21 CFR part 56; 42 USC Sect 241[d]; 5 USC Sect 552a; 44 USC Sect 3501 et seq).
The survey asked whether participants had heard of WWS to monitor respiratory and mosquito-borne diseases and elicited their opinions toward WWS for infectious diseases and opioids or other drugs as well as potential uses of those data (eMethods in the Supplement). We captured data on comfort with WWS for 3 testing targets on a 5-point Likert scale, ranging from 1 = very uncomfortable to 5 = very comfortable. We used a similar scale to assess participants’ agreement that WWS data on opioids or other drugs are informative and actionable, and trust that public health officials would use it only to improve public health (range: 1 = strongly disagree to 5 = strongly agree). Participants also rated their perceptions of WWS data accuracy on community levels of COVID-19, mosquito-borne viruses, and opioids or other drugs (1 = not at all accurate; 2 = a little accurate; 3 = mostly accurate; 4 = completely accurate; and 5 = not sure). Finally, we captured participants’ concerns about WWS using an open-ended question, “Do you have any concerns about wastewater monitoring in your community? Why or why not?”
Quantitative Analysis
We weighted all analyses using the survey weights provided with the data and conducted analyses using Stata version 18.0 (StataCorp LLC). We described participant characteristics and opinions toward WWS overall and by WWS awareness, defined as an affirmative response to the following question: When you use the toilet, wash your hands, or wash your clothes, wastewater goes into the sewage system. Public health agencies test wastewater in communities to track the spread of public health threats. Have you heard of each of the following wastewater activities? A. Wastewater being used to monitor for COVID-19.
We determined significant differences in comfort with WWS, agreement with the potential uses of WWS data to monitor opioids or other drugs, and perceived accuracy of WWS data by WWS awareness using the Pearson χ2 test corrected for survey design, with α = .05 considered significant. We calculated the Cronbach α coefficients for each construct to assess internal consistency across the items.
Qualitative Analysis
Preliminary analysis revealed lower levels of trust and comfort with WWS for drug monitoring than for respiratory infectious and mosquito-borne diseases. To better understand perceptions of WWS for drug monitoring, we analyzed responses to the question, “Do you have any concerns about WWS in your community? Why or why not?” First, 4 analysts (E.N., H.T., K.T., and D.V.) searched all 2024 responses for references to drugs (eg, “medication[s],” “narcotic[s],” “opioid[s]”) and specific drug names to identify responses to include in the analysis. The search yielded 67 relevant responses. The analysts met to collaboratively review and code these responses using Microsoft Excel. The analysts developed the codebook iteratively using an inductive approach. They identified 4 themes: public health value, trust in authorities and intentions, effectiveness and accuracy, and community impact. During the meeting, the analysts discussed the theme(s) that aligned with the content of each response and resolved disagreements through further discussion until they reached consensus.
Results
Participant Characteristics
Of the 2024 survey participants, 1002 (50.9%) were female, 598 (30.2%) were aged ≥60 years, and 1056 (50.8%) were married or in a union (Table 1). Most participants were White (61.3%) and had at least some college education (61.9%). Participant characteristics were generally similar by WWS awareness, with some exceptions. For example, 51.7% of those who were aware of WWS had a bachelor’s degree or higher compared with those who were not aware of (32.1%) or unsure of (27.0%) WWS (P < .001).
Characteristics of survey participants overall and by awareness of wastewater surveillance for COVID-19, Porter Novelli View Survey, United States, June 2024
Unweighted counts and weighted percentages.
Statistical significance of differences in responses was determined at α = .05 using the Pearson χ2 test, corrected for survey design.
People of Hispanic or Latino (Hispanic) origin might be of any race but are categorized as Hispanic; all racial group tabulation is limited to those reporting being non-Hispanic.
Includes Middle Eastern or North African people, people identifying as another race not listed in the survey, and people identifying as >1 race.
Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming.
Self-reported experience of ≥1 of the following conditions: deafness or serious difficulty hearing; blindness or serious difficulty seeing; serious difficulty in concentrating, remembering, or making decisions; difficulty walking or climbing stairs; difficulty dressing or bathing; and difficulty doing errands alone.
Perceptions of WWS
Overall, participant comfort with WWS was moderate. Slightly more than half of participants were very or somewhat comfortable with WWS for respiratory diseases (54.1%) and mosquito-borne diseases (57.3%), with a slightly lower percentage for opioids or other drugs (51.1%) (Table 2). Reliability analysis showed good internal consistency across the 3 categories of testing targets (Cronbach α = .87; N = 2024), indicating that participants who were very or somewhat comfortable with WWS to monitor respiratory diseases were also very or somewhat comfortable with WWS for mosquito-borne diseases and opioids or other drugs. Similarly, marginally higher percentages of participants believed that WWS data mostly or completely accurately reflected community levels of infectious diseases (46.5% for COVID-19 and 51.1% for mosquito-borne viruses) than opioids or other drugs (41.5%) (3 items; Cronbach α = .77; N = 2024). Finally, 52.3% of participants strongly or somewhat agreed that WWS could help understand community levels of opioid use, while 56.7% believed that WWS data on opioids should be used to guide public health actions. Similar levels of participants trusted that public health officials would use WWS data only to improve public health (53.3%) (3 items; Cronbach α = .74; N = 2024).
Perceptions of wastewater surveillance overall and by awareness of wastewater surveillance for COVID-19, Porter Novelli View Survey, United States, June 2024
Unweighted counts and weighted percentages.
Statistical significance of differences in responses was determined at α = .05 using the Pearson χ2 test, corrected for survey design.
Disaggregation by WWS awareness revealed differences across all items (Table 2). Compared with participants who were unaware of WWS, those who were aware of WWS expressed significantly greater comfort with WWS activities for respiratory diseases (70.6% vs 50.8%; P < .001), mosquito-borne diseases (71.6% vs 55.5%; P < .001), and opioids or other drugs (64.8% vs 49.2%; P < .001). Furthermore, those with WWS awareness more frequently expressed trust in WWS data accuracy for COVID-19 (64.8% vs 38.9%; P < .001), mosquito-borne viruses (65.7% vs 46.5% P < .001), and opioids or other drugs (55.1% vs 37.3%; P < .001) than those who were not aware of WWS. Finally, participants who were aware of WWS more frequently agreed that WWS data should help guide public health actions (69.9% vs 54.8%; P < .001) and trusted that the data would be used only to improve public health (64.3% vs 50.3%; P < .001) compared with those who were unaware of WWS. Participant opinions toward WWS differed by education (eTable in the Supplement). Favorable opinions were generally higher among those who had any postsecondary education than among those with lower levels of educational attainment, regardless of WWS awareness.
Perceptions About Using WWS for Opioids or Other Drugs
We identified 4 themes based on 67 responses: public health value (n = 25), trust in authorities and intentions (n = 23), effectiveness and accuracy of WWS data as an indicator of drug use (n = 18), and community impact (n = 11) (Table 3). Overall, 42 of 67 participants (63%) expressed drug monitoring concerns.
Participant perceptions of wastewater surveillance (WWS) for opioids or other drugs (n = 67), Porter Novelli View Survey, United States, June 2024
Theme 1: public health value
“I think it can prove beneficial to the community for prevention of diseases or drug epidemics,” wrote 1 participant. Other participants said, “I am not worried about opioids being present, but knowing if [COVID-19] is increasing would be useful,” and “If they can monitor the progress of diseases and drugs before it becomes a major problem and can somewhat get a heads-up, that would be good.” How the findings are used was also important. One participant noted, “If it helps identify disease outbreaks AND something positive gets done about said outbreak, then great.”
Theme 2: trust in authorities and intentions
Some participants drew a distinction based on the testing target. One participant noted, “Providing public health information on infectious disease is one thing, monitoring for drug use is entirely different.” Another participant said, “I see why it’s being done in relation to diseases, but looking for drug use seems an invasion of privacy.” One participant wrote, “I support it in monitoring diseases and illnesses, but I feel using it to monitor drug use could be done nefariously.” Another participant said, “[I] agree [that WWS] could be beneficial for disease and virus spreading. But used to determine if opioid [is used] in a community, if incorrect could create a negative impact on that community.” Other participants thought it was “invasive to drug screen wastewater as well as a waste of tax dollars,” and noted, “It sounds like big brother trying to guess which areas are possibly using opioids.”
Theme 3: effectiveness and accuracy of WWS data as an indicator of drug use
Participants expressed skepticism about the ability to distinguish the source of a positive detection. One participant said, “I am concerned when they are monitoring for opioids and have no way to differentiate between prescription and illegal use.” Another participant said, “I have flushed medications before not knowing that you aren’t supposed to do that, that would significantly affect the results.” Others described how “people in my area have a habit of flushing tons of things down the toilet even if they aren’t being used,” and “some people dump their old medications in the toilet.” A survey participant noted, I am very scared that further demonization of opioids through testing in wastewater will lead to harm to the chronic pain community. The current actions for the ‘opioid crisis’ have caused irreparable, and not infrequently lethal repercussions to patients whose reliance on their appropriate pain management was taken away without question.
The usefulness of findings was also a concern. One participant said, “I’m not sure what monitoring for opioids would trigger. More PSAs?” and another said, “I think it [would] depend on what was done with the info.” Another participant wrote, “I want to know how they are going to help communities that [are] heavily affected by drug use such as drug treatment facilities or programs to help my community and other communities get better in life.” Another participant asked, “How are they going to properly invest in local communities that deal with high drug use?”
Theme 4: community impact
People expressed concerns about “property values being affected by the knowledge of opioids in the community’s wastewater” and feared findings “can cause unnecessary drops in area worth.” One participant said, “I don’t like that they are ‘drug testing’ communities. I think it’s just to police poor people and used as an excuse to spend more money.” Authorities could “misuse the data in order to scare people into passing invasive laws,” which may lead to “decisions that will not take into account prophylactic pain management,” and “be used to target innocent people who live in a bad area,” another participant noted. One participant said, “I feel like in the wrong hands the information can be very dangerous. I also feel that it could be used against people by government or law enforcement surreptitiously.” Another participant wrote, “I hadn’t heard of it being used for opioids, but that does concern me a bit because it seems like this kind of tracking is always used for criminal activity instead of public health.”
Discussion
WWS can help health officials gain insights into community disease transmission levels, improve outbreak response, and distribute resources.3,18 Our findings suggest that greater awareness of WWS could lead to greater acceptability.
Slightly more than half of participants were comfortable with WWS, with similar levels for respiratory diseases, mosquito-borne diseases, and opioid testing. This percentage was lower than previous nationwide surveys conducted in 2022 and 2023, in which 92% and 93% of participants, respectively, supported WWS to monitor deadly diseases, and 2 surveys conducted in 2024, where 74.6% and 80.0% of participants supported WWS for infectious diseases.4,7,8 Disaggregation by awareness revealed higher support for WWS among those with WWS awareness than among those without awareness across all 3 targets.
Our findings confirm previously reported privacy concerns while providing greater detail on opinions toward WWS for drug monitoring than previous studies. Qualitative analysis of open-text responses identified apprehension about privacy and possible changes in law enforcement activity resulting from WWS for drug monitoring as well as data accuracy and specificity, which could negatively impact their community, alluding to the need for clear and transparent communication about the purpose and use of WWS. Our results reaffirm findings from previous surveys of concerns about privacy, exposure, and possible data misuse.6-8 Specifically, LaJoie et al found support for monitoring diseases and environmental toxins, but concerns about individual or household identification through wastewater data underscore the need for public debate on privacy as WWS becomes more common. 6 Kreuter et al similarly found high support for WWS coupled with concerns about household identification and the potential for misuse. 8 In a follow-up study, Holm et al noted individuals’ inability to opt out of surveillance and reasserted the need for clear communication about data collection and use. 7
Many of these concerns have been addressed in the Ethics Framework for Addressing Ethical Considerations in Infectious Diseases Public Health Wastewater Surveillance produced by the Association of State and Territorial Health Officials (ASTHO).19,20 Although the framework focuses on infectious disease monitoring, the core public health ethics principles of engaging and empowering communities involved in WWS apply to all testing targets, including opioids or other drugs.
The ASTHO Ethics Framework emphasizes safeguarding WWS data to maintain anonymity and protect individuals’ and communities’ privacy. Because WWS data are pooled, they typically will not identify an individual. However, equally important are responsibilities to collect, analyze, and store WWS data in a way that safeguards the interests of individuals and communities. 21 Health information is often sensitive, and its disclosure (or concerns about its disclosure) can have negative economic, social, or psychological consequences. Policies governing health information aim to balance privacy interests with the broader social benefits of collecting health data, such as tracking disease and reducing illness and death. Institutions that collect health information have a duty to protect it. Public surveys of attitudes about WWS suggest people are willing to give up some privacy to promote community health if they trust that government officials will uphold data confidentiality. 6 Group privacy is highly relevant to WWS, as pooled data may still reveal information about groups of people based on their location, especially if certain pathogens or substances are detected and associated with a particular group or community. 19 WWS conducted at larger geographic scales minimizes these risks by reducing the likelihood of identification. 21 Nationwide survey data indicate a higher level of public support for WWS at a larger scale, where anonymity can be preserved, than for smaller areas, where concerns about privacy and stigmatization emerge.6,7
Some hesitancy toward WWS may stem from limited public familiarity. In our study, greater acceptance of WWS across all measures was associated with participants’ knowledge and prior engagement with wastewater data, specifically, awareness of wastewater monitoring for COVID-19. This finding highlights the need to increase public awareness of WWS as a resource to help individuals make informed health decisions. Some of the ways increasing public awareness could be accomplished include making WWS results publicly available, easy to access, and accompanied by information presented in plain language, including protective health actions. 8 To build public trust, it is important for outreach efforts to explain how WWS works, address privacy concerns, clarify the public benefits of WWS, and outline safeguards to protect individual and community privacy.6,8 Increased communication between public health professionals and physicians regarding WWS may aid in advising about vaccination and other public health measures. 22 Future research could use qualitative methods (eg, focus groups, in-depth interviews) to gain insight into how well members of the public understand WWS data, their perceptions and concerns, and effective strategies to increase WWS literacy among the general public.
Limitations
This study had several limitations. First, the use of an online survey may have prevented people with limited internet access or technological proficiency from participating. Furthermore, the use of quota sampling, rather than a probability-based sampling method, may have reduced overall generalizability, as each participant’s selection probability is unknown. Second, bivariate analyses do not account for factors that confound, mediate, or modify the relationships observed in this study. Future studies could consider multivariable logistic regression modeling to obtain more refined measures of association. Third, because participants were not required to answer all questions, the open-ended responses may not have captured the full range of concerns about WWS. Finally, because the survey was administered in English only, these data do not include the perspectives of people with limited English proficiency.
Conclusions
Acceptance of WWS activities was higher among those with WWS awareness for all survey items than among those without WWS awareness. In the absence of clear public health benefits, participants expressed distrust with using WWS to monitor opioids or other drugs due to a combination of concerns about privacy, monitoring intention, potential data misuse, and data accuracy. Acceptance may improve with greater community engagement, participant awareness and knowledge of how wastewater data are measured, and assurance that findings are being used in an ethical manner for public health purposes with input from and benefit to communities.
Supplemental Material
sj-docx-1-phr-10.1177_00333549261457426 – Supplemental material for Public Awareness and Acceptance of Wastewater Surveillance in the United States, June 2024
Supplemental material, sj-docx-1-phr-10.1177_00333549261457426 for Public Awareness and Acceptance of Wastewater Surveillance in the United States, June 2024 by Rieza H. Soelaeman, Diana Valencia, Libby Horter, Hannah Turner, Rajesh Yadav, Kathleen M. Tatti, Emily Nelson, Manpreet Kaur, Deanna Amarosa, B. Casey Lyons, Michael Welton, Souci Louis, Jena Losch and Scott Santibañez in Public Health Reports®
Footnotes
Acknowledgements
The authors acknowledge the following Centers for Disease Control and Prevention staff for the review and feedback they provided for this article: Danielle Kleven, MPH; Nicole Fehrenbach, MPP; and Angela Blackwell, DrPH. The authors also thank the survey participants for their time.
ORCID iDs
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Scott Santibañez serves as a member of the Editorial Committee of Public Health Reports.
Disclaimer
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Supplemental Material
Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.
References
Supplementary Material
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