Temporal Alignment of Wastewater Signals with Clinical Indicators of Respiratory Illness Postpandemic, Texas, USA.

In the COVID-19 postpandemic era, declining clinical testing for SARS-CoV-2 has led to the exploration of complementary early detection methods. We evaluated metagenomic wastewater-based epidemiology (WBE) in Texas, USA, by comparing viral signals with the National Syndromic Surveillance Program tracked emergency department visits and Texas All-Payer Claims Database insurance claims across several Texas counties during 2022-2024. By analyzing SARS-CoV-2, influenza, and respiratory syncytial virus, we found moderate-to-strong temporal correlations between wastewater and clinical indicators. Influenza showed the most stable associations (r<0.98), whereas SARS-CoV-2 signals generally preceded clinical metrics. Respiratory syncytial virus exhibited higher geographic and temporal heterogeneity, reflecting differences in clinical data capture. Despite sampling frequency and geographic alignment challenges, metagenomic WBE consistently tracked community trends. Our findings suggest WBE can offer valuable situational awareness and a resilient complement to clinical surveillance, supporting public health preparedness in an evolving respiratory disease landscape.