Equities and Inequities Inherent in Wastewater Surveillance Systems for Public Health: New York State, 2020-2024.

Abstract

<b>Objectives.</b> To evaluate equity in wastewater-based infectious disease surveillance, including equity of inclusion, outbreak detection, and disease forecasting. <b>Methods.</b> We assessed New York State's wastewater surveillance network using census tract-level data to compare social vulnerability and environmental burden across included, sewered but excluded, and unsewered communities during the scale-up of the network (2020-2024) and under changing coverage scenarios. We modeled outbreak detection equity by estimating outbreak sizes required for 95% confidence in the detection of hypothetical pathogens and assessed forecasting equity using county-level COVID-19 hospitalization predictions in relation to population size, coverage, and vulnerability. <b>Results.</b> We found similar vulnerability distributions between included and sewered but excluded communities. The 25% most vulnerable communities required median outbreak sizes 3.45 times larger for detection than did the 25% least vulnerable. At medium sensitivity, more than 80% of individuals living in poverty and minoritized populations lived in areas where outbreaks exceeded 10 infections before detection. Forecasting accuracy was lower in smaller (< 20%) than in larger urban (> 60%) counties and increased with population size and network coverage (P < .001). <b>Conclusions.</b> Wastewater surveillance was equitable in population coverage but not in outbreak detection and forecasting performance. <b>Public Health Implications.</b> Strategies such as upstream sampling, expanded wastewater treatment plant participation in smaller communities, and improved modeling for low-population areas may reduce inequities and enhance the utility of wastewater surveillance. (<i>Am J Public Health</i>. Published online ahead of print May 21, 2026:e1-e9. https://doi.org/10.2105/AJPH.2026.308472).