Wastewater-based epidemiology has emerged as a promising technology for
population-level surveillance of COVID-19. In this study, we present results of a large
nationwide SARS-CoV-2 wastewater monitoring system in the United States. We profile 55
locations with at least six months of sampling from April 2020 to May 2021. These
locations represent more than 12 million individuals across 19 states. Samples were
collected approximately weekly by wastewater treatment utilities as part of a regular
wastewater surveillance service and analyzed for SARS-CoV-2 RNA concentrations.
SARS-CoV-2 RNA concentrations were normalized to pepper mild mottle virus, an indicator
of fecal matter in wastewater. We show that wastewater data reflect temporal and
geographic trends in clinical COVID-19 cases and investigate the impact of normalization
on correlations with case data within and across locations. We also provide key lessons
learned from our broad-scale implementation of wastewater-based epidemiology, which can
be used to inform wastewater-based epidemiology approaches for future emerging diseases.
This work demonstrates that wastewater surveillance is a feasible approach for
nationwide population-level monitoring of COVID-19 disease. With an evolving epidemic
and effective vaccines against SARS-CoV-2, wastewater-based epidemiology can serve as a
passive surveillance approach for detecting changing dynamics or resurgences of the
virus.