Publication date: May 22, 2025

During the COVID-19 pandemic, several US jurisdictions began to regularly report levels of SARS-CoV-2 in wastewater as a proxy for SARS-CoV-2 incidence. Despite the promise of this approach for improving COVID-19 situational awareness, the degree to which wastewater surveillance data agree with other data has varied, and better evidence is needed to understand the situations in which wastewater surveillance data track closely with traditional surveillance data. In this study, we quantified the statistical relationship between wastewater data and traditional case-based surveillance data for multiple jurisdictions. We collated data on wastewater SARS-CoV-2 RNA levels and COVID-19 case reports from July 2020 to March 2023 for 107 counties representing a range in terms of geographic location, population size, and urbanicity. For these counties, we used Bayesian hierarchical regression modeling to estimate the statistical relationship between wastewater data and reported cases, allowing for variation in this relationship across counties. We compared different model structural approaches and assessed how the strength of the estimated relationships varied between settings and over time. Our analyses revealed a strong positive relationship between wastewater data and COVID-19 cases for the majority of locations, with a median correlation coefficient between observed and predicted cases of 0. 904 (IQR 0. 823-0. 943). In total, 23/107 counties (21. 5%) had correlation coefficients below 0. 8, and 3/107 (2. 8%) had values below 0. 6. Across locations, the COVID-19 case rate associated with a given level of wastewater SARS-CoV-2 RNA concentration declined over the study period. Counties with greater population size (P

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Semantics