Cindy R. Friedman

Objectives: As SARS-CoV-2 testing has declined, estimating disease prevalence has become challenging. The Centers for Disease Control and Prevention’s Traveler-based Genomic Surveillance (TGS) program collects voluntary samples from arriving international travelers to detect SARS-CoV-2 variants. We assessed the correlation between SARS-CoV-2 positivity in travelers and community case data for their corresponding countries of origin. Methods: From December 6, 2021, through January 22, 2023, travelers (aged ≥18 y) arriving at selected US airports provided self-collected nasal swabs, which were pooled by country of origin and tested for SARS-CoV-2 using reverse transcription polymerase chain reaction. We compared weekly SARS-CoV-2 positivity rates from travelers who arrived from 6 countries (Brazil, France, Germany, India, South Africa, United Kingdom) with weekly community case rates for that same country. For the United Kingdom, we also compared traveler data with data from the UK Coronavirus (COVID-19) Infection Survey. We conducted correlation analyses by country and divided data into intervals to control for time-varying confounders. Using Spearman rank correlation, we assessed the correlations between traveler data and community or household data. Results: SARS-CoV-2 positivity in travelers and community case data frequently demonstrated concordance (66.7% of time intervals were significantly correlated, defined as P < .05). After June 12, 2022, when predeparture SARS-CoV-2 testing was no longer required of US-bound travelers, sample positivity among travelers arriving from the United Kingdom was significantly correlated with positivity estimates from the UK COVID-19 Infection Survey ( r _s = 0.76; P < .001). Conclusions: Data from travelers may reflect trends similar to country-level SARS-CoV-2 transmission. When community testing is limited, public health authorities could consider using TGS or similar systems to monitor transmission activity.

Early detection of outbreaks and emerging pathogens is critical for public health and global biosecurity. Airports, as major international travel hubs with dense, enclosed populations, are high-risk settings for disease transmission and potential pathogen introduction. The U.S. Centers for Disease Control and Prevention, in collaboration with Ginkgo Biosecurity and the University of Wisconsin–Madison, implemented air monitoring for pathogen surveillance in congregate areas at four U.S. international airports. From October 2023 to August 2024, SARS-CoV-2 was detected by PCR in 98.3% of air samples and influenza A in 17.2%. Influenza A positivity in air samples correlated with aviation wastewater (r = 0.48), traveler nasal swab positivity (r = 0.73), and national clinical surveillance (r = 0.86), whereas SARS-CoV-2 measurements did not correlate significantly across these modalities. Targeted amplicon sequencing of SARS-CoV-2 from air samples identified contemporaneous lineages also detected in wastewater collected from the same airports. Targeted enrichment sequencing detected 30 viral species and recovered high-quality genomes for SARS-CoV-2, influenza, bocavirus, and seasonal coronaviruses. Together, these findings demonstrate that air sampling can complement aviation wastewater surveillance at ports of entry, although performance and concordance vary by pathogen and sample type.

Background: In September 2021, the U.S. Centers for Disease Control and Prevention (CDC) implemented the Traveler-based Genomic Surveillance (TGS) program, a surveillance system that leverages genomic sequencing of samples from international air travelers and aviation wastewater for early detection of infectious threats. Methods: During September 2021–August 2024, nasal samples were collected anonymously from volunteer international travelers arriving at eight U.S. airports. During February 2023– August 2024, aviation wastewater samples were collected from arriving flights. Nasal samples were pooled and sent to a laboratory for RT-PCR testing. Genomic sequencing was conducted for SARS-CoV-2 and respiratory, gastrointestinal (wastewater), and other pathogens of public health importance. Findings: Nasal samples from 694,798 travelers were grouped into 67,308 pools and tested; 13,990 (20.8%) were positive for SARS-CoV-2. Over 80% (400/495) of airplane and 96·6% (422/437) triturator (a wastewater collection point from multiple airplanes) samples were positive for SARS-CoV-2. Sequence results were made publicly available a median of 11 days (IQR 10– 13 days) after sample collection. Predominant SARS-CoV-2 variants changed over time. Positive tests for influenza virus and respiratory syncytial virus were high in December/January, and gastrointestinal viruses were detected in wastewater during all months. Monitoring was scaled in response to reported outbreaks of COVID-19 and Mycoplasma pneumoniae in China and clade 1 monkeypox virus in central Africa. Interpretation: Traveler nasal and aviation wastewater sampling can provide critical early detection of infectious pathogens before widespread U.S. community transmission. The TGS program provides a model for integrated traveler-based genomic surveillance. Funding: CDC Research in Context: Evidence before this project: We searched PubMed for relevant studies published during December 1, 2020–August 31, 2024, using the terms “traveler surveillance”, “wastewater monitoring”, “SARS-CoV-2 genomics”, and “airport-based surveillance”, without language restrictions. Previous reports have shown the feasibility of using travelers as sentinel populations for disease surveillance. Modeling studies have proposed integrating genomic data into international travel surveillance systems to enhance early pathogen detection, and evidence from Australia, Canada, and the UK suggests such programs could be scalable and effective. Early pandemic-era wastewater surveillance, particularly aviation wastewater, demonstrated that air travel hubs can be used to monitor pathogen importation. Prior efforts largely focused on SARS-CoV-2, with limited integration of multi-pathogen surveillance or side-by-side comparisons of nasal and wastewater surveillance modalities. A limited number of public health reviews have examined the broader implications of airport-based surveillance, including novel methods like airplane wastewater testing. However, empirical data on sustained, large-scale implementation of these models especially outside of regulatory or mandatory testing frameworks have been sparse. Added value of this project: This is the first real-world implementation and scale-up of an anonymized, multi-pathogen traveler-based surveillance system across multiple U.S. international airports. We developed a scalable framework that integrated nasal swab testing, airplane and airport wastewater sampling, with genomic sequencing into a unified pathogen surveillance platform. Unlike prior efforts which primarily focused on SARS-CoV-2, this program captured respiratory and gastrointestinal viruses simultaneously and tracked genomic variation in near-real time. The program transitioned from a pilot to a multi-modality national surveillance system in under four years, engaging nearly 700,000 international travelers, and nearly 1000 aviation wastewater samples. Our findings demonstrate the feasibility of rapidly adapting this infrastructure for emerging threats and underscores the importance of sentinel surveillance in addressing global sequencing blind spots. Implications of all the available evidence: The successful scale-up and real-time application of the TGS program illustrates that traveler-based surveillance can serve as a critical global early warning tool. Data generated from this program have filled gaps in global pathogen tracking, informed public health responses to outbreaks, and demonstrated that surveillance of international travelers can be achieved without mandatory testing. The scalability, speed, and adaptability of the program offer a viable model for global replication, especially as routine surveillance capacities decline. Our findings suggest that integration of multi-modal, voluntary traveler surveillance including sequencing and wastewater-based epidemiology should be considered a core component of pandemic preparedness and response frameworks worldwide.

We present findings from the first known pilot study of transatlantic airplane wastewater monitoring, conducted over six months at two connected international airports in the United States and the United Kingdom. This study demonstrates the feasibility of implementing bilateral wastewater-based pathogen surveillance at international travel hubs. We outline the operational and analytical methodologies employed, highlight key challenges encountered in transnational coordination, and provide recommendations for the design and implementation of future surveillance programs at points of entry.

Robust early warning of emerging viruses requires sampling populations that drive spread coupled with assays capable of detecting new viral variants or species. Untargeted viral metagenomic sequencing can, in principle, detect any virus, including completely novel ones. Composite airplane wastewater enables monitoring long-distance travelers from central collection points; however, the performance of untargeted viral metagenomic sequencing in this sample type remains unknown. In municipal wastewater, abundant sewer-associated microbes and ribosomal RNA depress viral relative abundance, limiting metagenomic sensitivity. We compared untargeted viral metagenomic sequencing of composite airplane wastewater with time-matched municipal wastewater from the Greater Boston area. Human viruses and other human-associated taxa had consistently higher relative abundance in airplane samples than municipal samples, while most sewer-associated taxa had lower relative abundance. An increased relative abundance of human viruses lowers the sequencing depth required to detect emerging pathogens, suggesting that metagenomic sequencing of composite airplane wastewater is a cost-effective method for pathogen-agnostic surveillance. Importance: Long-distance air travelers spread viral pathogens globally, making them an ideal sentinel population for pandemic surveillance systems. Testing composite airplane wastewater offers a practical, noninvasive approach to monitoring the traveler population. However, current surveillance systems rely on tests targeting specific known pathogens, missing novel threats. Untargeted metagenomic sequencing can detect viruses known or novel, but remains expensive to implement at scale; in municipal wastewater, sewer-derived microbes tend to overwhelm human viruses in sequencing data. We investigated whether a hypothesized reduced sewer microbial load in airplane wastewater would lower the sequencing effort required for viral detection. Understanding the performance of metagenomic sequencing in this context informs the design of cost-effective early-warning systems for emerging pandemics.

Early detection of outbreaks and emerging pathogens is critical for public health and global biosecurity. Airports, as major international travel hubs with dense, enclosed populations, are high-risk settings for disease transmission and potential pathogen introduction. The U.S. Centers for Disease Control and Prevention, in collaboration with Ginkgo Biosecurity and the University of Wisconsin–Madison, implemented air monitoring for pathogen surveillance in congregate areas at four U.S. international airports. From October 2023 to August 2024, SARS-CoV-2 was detected by PCR in 98.3% of air samples and influenza A in 17.2%. These results correlated with positivity trends from other sample modalities, including aviation wastewater, traveler nasal swabs, and national clinical surveillance data. Targeted amplicon sequencing of SARS-CoV-2 from air samples correlated with contemporaneous lineages in wastewater collected and sequenced from the same airports. Metagenomic enrichment sequencing detected 30 viral species and recovered high-quality genomes for SARS-CoV-2, influenza, bocavirus, and seasonal coronaviruses. Together, these findings demonstrate that air sampling is a complementary surveillance modality to aviation wastewater for early pathogen detection at ports of entry.

Airport-Based Pathogen Monitoring Program

Colistin is a last-resort antibiotic used to treat infections caused by multidrug-resistant Gram-negative bacteria. People with a history of travel to the Dominican Republic have become sick with pathogenic bacteria carrying the mobile colistin resistance gene, mcr-1, during and after traveling. This investigation aimed to identify mcr genes in Enterobacteriaceae isolated from food animal sources in the Dominican Republic. Three hundred and eleven samples were tested, from which 1354 bacterial isolates were obtained. Real-time PCR tests showed that 70.7% (220 out of 311) of the samples and 3.2% (44 out of 1354) of the isolates tested positive for the mcr gene. All RT-PCR presumptive mcr-positive isolates (n = 44) and a subset (n = 133) of RT-PCR presumptive mcr-negative isolates were subjected to whole-genome sequencing. WGS analysis showed that 39 isolates carried the mcr gene, with 37 confirmed as positive through RT-PCR and two as negative. Further, all of the mcr-positive genomes were identified as Escherichia coli and all contained a IncX4 plasmid replicon. Resistant determinants for other antibiotics important for human health were found in almost all isolates carrying mcr genes.

We enrolled arriving international air travelers in a severe acute respiratory syndrome coronavirus 2 genomic surveillance program. We used molecular testing of pooled nasal swabs and sequenced positive samples for sublineage. Traveler-based surveillance provided early-warning variant detection, reporting the first US Omicron BA.2 and BA.3 in North America.