Wastewater surveillance expands to include multiple pathogens, including measles virus – American Public Health Association

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Wastewater monitoring to jump-start prevention of infectious outbreaks has expanded in the U.S. in recent years. At a Tuesday session, “Wastewater-based Epidemiology: Advances and Future Direction in Wastewater Surveillance,” experts discussed how the practice has grown into a surveillance juggernaut, in which scientists test for multiple pathogens, including the measles virus, to prompt timely public health action.
U.S. surveillance increased during the COVID-19 pandemic as wastewater testing ramped up for SARS-CoV-2. These days, public health officials are testing locally for a long list of viruses to prevent or mitigate outbreaks. Among them are RSV, influenza, norovirus, mpox, foodborne illnesses and even antimicrobial resistance pathogens.
As of Nov. 1, over 4,800 cases of measles have been reported in the U.S. this year, and more states are monitoring wastewater for the measles virus. California, which this year has had 59 measles cases, tests wastewater for the pathogen at 89 sites in 39 counties. Officials have found a correlation between positive tests and measles cases. 
“Wastewater surveillance may be effective in identifying presence of measles, complementing case surveillance and guiding public health response,” said Mariah Otstot of the California Department of Public Health.
North Carolina monitors wastewater for five pathogens at 36 sites in 29 counties. The state added measles testing in June 2025. It has had four wastewater measles detections, along with 24 documented measles cases in 10 counties, according to data at the North Carolina Department of Health. A correlation in test sites and measles infections has been found. 
Department workers have created extensive communication messaging programs in infected areas. Three-quarters of wastewater detections occurred within four days of the symptom onset in communities. A detection without a reported case prompted the opening of a community vaccination clinic.
Because North Carolina is mostly rural, only about half the population is on sewer systems. The rest use private septic tanks as their primary household wastewater treatment. That impedes pathogen detection in wastewater because there is no current way to monitor private septic tanks for pathogens, said Nicole Snyder, an epidemiologist at the North Carolina Department of Health and Human Services.
Snyder was not confident things would change in the conservative state. “Different people are more receptive or less receptive to” a government employee surveilling homeowner septic tanks, Snyder said.
Antimicrobial resistance — when bacteria and viruses adapt effective shields against antibiotics and antivirals — is an urgent public health threat. Nearly 51,000 people die in the U.S. each year because of resistance, according ot the Centers for Disease Control and Prevention. A chief culprit are resistant microbes in livestock finding their way into humans through the food supply. 
Colorado has begun a pilot program that monitors wastewater at nine sites for resistant pathogens. Beginning in 2025, the Colorado Department of Public Health and Environment tested about 2,000 wastewater samples, finding significant correlation between wastewater detections and prevalence of antimicrobial resistance in a region. 
A second correlation involved finding specific resistant pathogens in regions where the relevant livestock is raised. For example, OXA-48-like enzymes, which have been connected to antimicrobial resistance and found in hogs, were detected in regions where hog farming is common.
“OXA-48-like had the greatest proportion of samples, increasing in eight regions,” said Eve Curran, a health professional at the department. 
The pilot program is planning to generate additional community monitoring and hospital wastewater sampling, Curran said.
Photo by Onuma Inthapong, courtesy iStockphoto.
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