PONE-D-24-16609Equity in wastewater monitoring: Differences in the demographics and social vulnerability of sewered and unsewered populations across North CarolinaPLOS ONE

Dear Dr. Reckling,

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PLOS ONE

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Additional Editor Comments:

Dear Dr. Stacie Reckling,

Thank you for submitting your manuscript to PLOS ONE. 

Reviewers' comments on your paper entitled "Equity in wastewater monitoring: Differences in the demographics and social vulnerability of sewered and unsewered populations across North Carolina" have now been received. You will see that they are advising revision of the manuscript. I suggest to consider these comments in your revised version of manuscript.

If you decide to revise the work, please submit a list of changes or a rebuttal against each point which is being raised when you submit the revised manuscript. After manuscript resubmission, it will be reviewed again.

Best regards,

Handling Editor

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have presented quite a comprehensive, descriptive and informative set of information on the manuscript entitled ‘Equity in wastewater monitoring: Differences in the demographics and social vulnerability of sewered and unsewered populations across North Carolina’.

The authors may address the following queries:-

Introduction section can be revised and include a discussion addressing the following points-

• What were the main challenges to accessing clinical testing during the early COVID-19 pandemic, and how did these challenges align with existing structural disparities?

• What were the main challenges to accessing clinical testing during the early COVID-19 pandemic, and how did these challenges align with existing structural disparities?

• What are the potential limitations and equity concerns associated with wastewater monitoring, particularly in low- and middle-income countries (LMICs)?

Methodology Section:-

• In what ways could the methodology used in this study be improved or expanded to provide a more comprehensive understanding of the representativeness and equity of wastewater monitoring across different regions?

In the results and discussion section, the following points can be explained with relevant citations:-

• How reliable is wastewater monitoring as a public health tool in representing the health markers and disease burden of an entire community, especially given the variations in sewershed populations?

• What are the implications of finding that sewered populations are more vulnerable than unsewered populations on the overall effectiveness of wastewater monitoring in reflecting the true state of public health?

• How do the demographic and social vulnerability differences between sewered and unsewered populations affect the accuracy and equity of health data derived from wastewater monitoring?

• What measures can be taken to ensure that wastewater monitoring includes a representative sample of the entire population, especially in areas with significant differences between sewered and unsewered residents?

A section of future perspective can be included in the manuscript and following points can be highlighted:-

What are the potential limitations of relying on wastewater monitoring for public health surveillance, and how can these limitations be mitigated to improve the accuracy and inclusivity of the data?

How might the differences between individual sewershed and county populations impact the interpretation of wastewater monitoring data for public health decision-making at the county and state levels?

How can the findings of this study inform the development of policies and practices to enhance the use of wastewater monitoring as a tool for equitable public health surveillance and intervention?

What role do socio-economic and infrastructural factors play in the observed differences between sewered and unsewered populations, and how can these factors be accounted for in future wastewater monitoring studies?

Reviewer #2: This manuscript looks at differences in the demographics of sewered and unsewered populations across North Carolina. From the wastewater-surveillance and wastewater-based epidemiology aspect, I'm really unsure what the purpose is because of course the samples only represent those who contributed to them. There are other publications that have used census data and wastewater analysis to identify correlates of demographics which may have otherwise remained unknown which is what I was hoping this study would contribute to - but these seem to have been overlooked. As such I don't really see how this adds valuable information to the literature - but it is something that obviously should be considered when interpreting data in. It is written well though and the methodology used to determine catchment demographics is correct. BUT it also ignores that catchments are dynamic and that changes occur both in terms of short term and longer term - which is also important consideration for monitoring.

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Reviewer #1: Yes: Devlina Das Pramanik

Reviewer #2: No

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PONE-D-24-16609R1Equity in wastewater monitoring: Differences in the demographics and social vulnerability of sewered and unsewered populations across North CarolinaPLOS ONE

Dear Dr. Reckling,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 20 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Renjith VishnuRadhan, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #3: Equity in wastewater monitoring: Differences in the demographics and social vulnerability of sewered and unsewered populations across North Carolina

The authors have developed a framework that can be used for assessing the demographic and social vulnerability of sewered and unsewered populations for diseases with the help of wastewater monitoring data. Through geospatial analysis, the authors have shown that the wastewater monitoring data can be representative at the state or county level using demographic details from the US census. The authors have appropriately responded to the Editors and reviewers’ comments during the first revision and adequately revised the manuscript. The work carried out by the authors is unique and can be considered for publication with minor revisions. I have some questions or suggestions to improve the quality of the manuscript.

1. One of the outcome of the study is that the sewered population is vulnerable than unsewered population. Is that because for the unsewered population, water quality is not monitored? Is it monitored? How is it monitored? Can that add to the data gap?

2. In the case of COVID-19, even at the household level, if not all the members were infected, then how can wastewater monitoring be helpful than clinical assessment, which would provide individual-level assessment to take precautions? Although wastewater monitoring would be helpful in identifying county or state-level severity of the spread of disease; at the local or individual level, clinical assessment would be important. Then what is the contribution of this study? For whom the information obtained through this assessment would be beneficial?

3. The results from the study can be briefly justified based on the authors’ experience or understanding

a. For example-

Line 260-263 - Educational attainment was lower in the sewered population than the unsewered population in seven counties (all but Forsyth County and Pitt County), ranging from a -7.0 to -0.2 pp difference. This difference was also statistically significant for Durham and Chatham counties (Table S4).

What is the reason for this? How is this expression related to the aim of the study? The authors can explain the results after stating them with the reason as per their experience or understanding.

4. The discussion section explains more about the result, limitations and future work; however, a generalized discussion about integrating the findings of the study to provide a comprehensive picture and its importance in the context of existing literature needs to be added apart from just one the statement in line number 319-320 “Furthermore, given these disparities, wastewater monitoring data should be interpreted alongside other surveillance data to gain a more complete picture of the ‘true’ state of public health”

5. Conclusion, is a stand-alone section that should also include the limitation and future scope. In the conclusion section, the authors have precisely stated the outcomes of the study. However, the authors also need to summarize the limitations and future scope to make it a distinct section for effective readership.

6. Minor corrections:

a. At some places % or pp is written, be consistent about its use throughout the manuscript

b. Supplementary sheet – Include the title, authors and affiliation at the top of the supplementary sheet so that the file doesn't get lost when a reader downloads it.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Devlina Das Pramanik

Reviewer #3: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Equity in wastewater monitoring: Differences in the demographics and social vulnerability of sewered and unsewered populations across North Carolina

PONE-D-24-16609R2

Dear Dr. Reckling,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Renjith VishnuRadhan, PhD

Academic Editor

PLOS ONE