Throughout the COVID19 pandemic in the U.S., persons in jails have borne a share of disease 3-fold or greater than that seen in the general population. While many cases have been imported from surrounding communities, crowding in these congregate settings has led to rapid in-house transmission, especially since testing in jails has been sparse. Vaccine hesitancy among staff and those detained mean the population is ill prepared for new waves of infection, perhaps from virus variants. Better surveillance could warn systems earlier, and allow jails to stem the tide of a new outbreak. At least half, if not more, of infected persons shed coronavirus in their stool. Monitoring wastewater is a promising practice that only a few jails have adopted. Our overarching goal is to introduce or refine Wastewater Based Surveillance (WBS) as an evidence-based strategy for SARS-CoV-2 surveillance in the jails of Atlanta, Chicago, suburban Boston and Washington DC. We will adapt it to the needs of jail settings and evaluate the implementation with the Consolidated Framework for Implementation Research. Implementation teams will be formed of both correctional staff and formerly incarcerated individuals. Our aims: (1) To assess the barriers to and facilitators of implementing WBS for SARS-CoV-2 detection in 4 jail demonstration sites. Guided by CFIR, we hold an informational webinar, then conduct focus groups. Four will be with leaders at each of the jails; these will discuss the site-specific context in which WBS will be introduced or refined. A fifth, cross-site focus group of jail workers, and a sixth, cross-site group of persons with lived jail experience, will reflect on characteristics of WBS approaches and implementation strategies in jail settings. (2) To measure implementation outcomes associated with WBS and use these outcomes to inform key stakeholders, using a knowledge to action framework. We will study uptake, acceptability, appropriateness and feasibility of WBS as a sensitive early warning system and a way of quantifying SARS-CoV-2 levels to monitor trends in COVID19 prevalence. Feasibility, the suitability of how WBS data are acted upon, will be of utmost importance. We will use the Knowledge to Action process model, leveraging implementation outcomes to further engage stakeholders and characterize the adaptions needed to successfully implement WBS in jails. (3, Pilot) To study the process and the perceived effectiveness of incorporating diverse stakeholders, including the formerly incarcerated, on the WBS implementation team. We will use the Research Engagement Survey Tool (REST), to survey early in the implementation process and eight months later, individuals on the implementation team who have lived experience in jail; all other consenting implementation team members will be surveyed once early in the implementation process. Successfully completing the aims will determine factors that promote WBS implementation to improve disease monitoring in jails. By including persons recently released from jail on the implementation teams, we hope to inform researchers and policy makers about the ethics and process of collaboration in implementation.

Project Narrative The U.S. response to the COVID-19 pandemic underscores that structural racism and discrimination affect the health of Americans; disproportional minority confinement is one of the most overt structural processes that have blocked access to infectious disease testing for vulnerable individuals. Wastewater-based coronavirus surveillance in jails can provide a method of monitoring for new SARS-CoV-2 outbreaks that will address structural impediments blocking equitable access to testing. We hypothesize that including persons with lived experience in jail on an implementation team to roll out this new technology will help ensure that the data it produces are used, and in ways which improve the health of those meant to benefit from it.