Performance of a Norfentanyl Immunoassay in Specimens with Low Concentrations of Fentanyl and/or Norfentanyl.

BACKGROUND: Many fentanyl immunoassays are limited in their ability to detect norfentanyl. Urine specimens collected from individuals who have been exposed to fentanyl frequently have detectable concentrations of norfentanyl (≥2 ng/mL) but low concentrations of fentanyl (<2 ng/mL) by LC-MS/MS. The Lin-Zhi Fentanyl II Immunoassay (Lin-Zhi) claims 100% cross-reactivity with norfentanyl and therefore may detect exposure missed by other assays. METHODS: In addition to verifying the manufacturer's analytical sensitivity claims, we selected 92 urine specimens with low-positive Lin-Zhi results (1-99 absorbance units, lowest 10%) for analysis by the Immunalysis Health Equity Impact Assessment and ARK II fentanyl methods. The accuracy of the 3 immunoassays was compared to LC-MS/MS as the reference method. RESULTS: Spiking studies using purified fentanyl and norfentanyl and a set of 100 consecutive specimens confirmed the manufacturer's claims of limit of detection for fentanyl (3.8 ng/mL) and norfentanyl (5.0 ng/mL). However, the 92 low-positive patient specimens demonstrated concentrations of norfentanyl and fentanyl below 2.0 ng/mL by LC-MS/MS, with 47 (51%) having only norfentanyl detected. When comparing Lin-Zhi to the Immunalysis and ARK II immunoassays, only 27 (29%) of the 92 specimens were concordant. Fifty-two (57%) of the specimens were positive by LC-MS/MS and Lin-Zhi but false negative by one or both other immunoassays. Seven specimens (8%) were positive by Lin-Zhi but negative by the other immunoassays and had undetectable concentrations (<2 ng/mL) of fentanyl and norfentanyl by LC-MS/MS. CONCLUSIONS: The clinical sensitivity of the Lin-Zhi exceeds the manufacturer's claims, providing results comparable to LC-MS/MS methods.

The environmental health impacts of Russia's war on Ukraine.

BACKGROUND: Russia's invasion of Ukraine in February 2022 ignited the largest armed conflict in Europe since World War II. Ukrainian government agencies, civil society organizations, and international agencies have gathered an unprecedented amount of data about the impact of war on the environment, which is often the silent victim of war. We review these data and highlight the limitations of international governance for protection of the environment during time of war. METHODS: We performed an integrative review of academic, institutional, and media information resources using the search terms "Ukraine", "Russia", "war", "environment", "health", "human rights", "international humanitarian law", "international human rights law", "ecocide", and "war crimes". MAIN TEXT: Nearly 500,000 military personnel have been killed or wounded during the war, and more than 30,000 civilians have been killed or injured. Indirect health effects of the war have likely accounted for an even greater amount of civilian morbidity and mortality. The war has displaced more than 11 million people. Russia's military forces have caused extensive damage to civilian infrastructure. The war has devastated Ukraine's economy and reduced food and energy security in many countries. The war has caused more than $56.4 billion in damage to the environment. There has been widespread chemical contamination of air, water, and soil, and 30% of Ukraine has been contaminated with landmines and unexploded ordnance. Landscape destruction, shelling, wildfires, deforestation, and pollution have adversely affected 30% of Ukraine's protected areas. Russia's seizure of the Zaporizhzhia Nuclear Power Plant and destruction of the Nova Kakhovka Dam have posed risks of long-term environmental catastrophe. Most of these environmental impacts threaten human health. CONCLUSION: In addition to enormous human costs, Russia's war on Ukraine has had devastating impacts on the natural environment and the built environment. International law mandates that methods of warfare must be implemented with due regard to the protection and preservation of the natural environment. A just and lasting peace necessitates, among other requirements, rebuilding and restoration of Ukraine's natural environment and built environment. The environmental consequences of all wars need to be investigated and more effective measures need to be implemented to protect the environment during war.

Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management.

Beta-blocker and calcium-channel blocker overdoses are associated with severe morbidity and mortality; therefore, it is important to recognize and appropriately treat individuals with toxicity. The most common clinical findings in toxicity are bradycardia and hypotension. In addition to supportive care and cardiac monitoring, specific treatment includes administration of calcium salts, vasopressors, and high-dose insulin euglycaemia treatment. Other advanced treatments (e.g. ECMO) may be indicated depending on the severity of toxicity and specific agents involved.

Labor trafficking in marijuana production: a hidden epidemic in the shadows of the cannabis industry.

Labor trafficking in marijuana production remains a concealed epidemic within the expanding cannabis industry. This abstract brings attention to the systemic exploitation of vulnerable individuals engaged in cultivating, harvesting, and processing cannabis. It explores the factors contributing to labor trafficking, including demand for cheap labor, inadequate regulation, and the vulnerability of the workforce. By compiling published cases, both in peer-reviewed literature and the media, this perspective piece investigates the extent of health issues experienced by labor-trafficked victims. These include chronic pain from repetitive tasks, respiratory problems due to exposure to pesticides and other toxic substances, musculoskeletal injuries, malnutrition, and mental health disorders stemming from trauma and extreme stress. Additionally, this perspective article examines the factors contributing to poor health outcomes of labor-trafficked victims, including hazardous working conditions, lack of access to healthcare, and physical and psychological abuse. Addressing the health challenges faced by labor-trafficked victims in the cannabis industry requires multidimensional solutions: awareness among healthcare providers, comprehensive medical services, and mental health support. Furthermore, collaborative efforts among government agencies, healthcare providers, labor organizations, and the cannabis industry are essential in preventing trafficking and addressing the health disparities faced by labor-trafficked victims.

Surveying mental health stressors of emergency management professionals: Factors in recruiting and retaining emergency managers in an era of disasters and pandemics.

Emergency managers are responsible for managing crises and disasters, and while their work is essential, it can be stressful and impact their mental health, particularly during the COVID-19 pandemic. This study aimed to examine the mental health of professional emergency managers and factors associated with their intent to leave the field before and during the COVID-19 pandemic. A total of 903 respondents completed an online survey assessing their secondary traumatic stress, emergency reaction strategies, organizational culture, age, length of time in primary position, the highest level of education as well as other metrics. The Secondary Traumatic Stress Scale (STSS) was used to determine scores of secondary traumatic stress symptoms, and the Emergency Reaction Questionnaire (ERQ) index was used to evaluate levels of predominant personality types and its tendency towards "fight or flight" reactions in emergency situations. Results revealed significant differences among respondents who reported considering leaving the field before or during the COVID-19 pandemic in terms of secondary traumatic stress scores, ERQ levels, perceived organizational culture (OC), age category, length of time in primary position, and the highest level of education (p < 0.05). Logistic regression analysis indicated that respondents with higher secondary traumatic stress scores, poorer organizational culture, younger age, less experience, and a bachelor's degree had nearly three times the odds of reporting considering leaving the field (p < 0.05). Additionally, respondents with a graduate degree had nearly four times the odds of reporting leaving the field (p < 0.05), while those who had directly managed between three and five disasters had nearly two times the odds of reporting and considering leaving the field (p < 0.05). These findings underscore the importance of addressing secondary traumatic stress, promoting positive organizational culture, and providing support for emergency managers now and in the future. By addressing the factors identified in this study, such as secondary traumatic stress symptoms, promoting positive organizational culture, and providing adequate support, emergency management organizations can improve the mental health and well-being of their personnel, reduce attrition rates, and ensure that they are better equipped to respond to future crises.

Cannabis positivity rates in 17 emergency departments across the United States with varying degrees of marijuana legalization.

BACKGROUND: Many states in the United States have progressed towards legalization of marijuana including decriminalization, medicinal and/or recreational use. We studied the impact of legalization on cannabis-related emergency department visits in states with varying degrees of legalization. METHODS: Seventeen healthcare institutions in fifteen states (California, Colorado, Connecticut, Florida, Iowa, Kentucky, Maryland, Massachusetts, Missouri, New Hampshire, Oregon, South Carolina, Tennessee, Texas, Washington) participated. Cannabinoid immunoassay results and cannabis-related International Classification of Diseases (ninth and tenth versions) codes were obtained for emergency department visits over a 3- to 8-year period during various stages of legalization: no state laws, decriminalized, medical approval before dispensaries, medical dispensaries available, recreational approval before dispensaries and recreational dispensaries available. Trends and monthly rates of cannabinoid immunoassay and cannabis-related International Classification of Diseases code positivity were determined during these legalization periods. RESULTS: For most states, there was a significant increase in both cannabinoid immunoassay and International Classification of Diseases code positivity as legalization progressed; however, positivity rates differed. The availability of dispensaries may impact positivity in states with medical and/or recreational approval. In most states with no laws, there was a significant but smaller increase in cannabinoid immunoassay positivity rates. CONCLUSIONS: States may experience an increase in cannabis-related emergency department visits with progression toward marijuana legalization. The differences between states, including those in which no impact was seen, are likely multifactorial and include cultural norms, attitudes of local law enforcement, differing patient populations, legalization in surrounding states, availability of dispensaries, various ordering protocols in the emergency department, and the prevalence of non-regulated cannabis products.

Evaluation of Chemical, Biological, Radiological, Nuclear, Explosives (CBRNE) Knowledge Change and Skills Confidence Among Frontline-Line Providers During the Russia-Ukraine War.

OBJECTIVE: The aim of this study was to evaluate the change in knowledge and skill confidence after implementation of a chemical, biological, radiological, nuclear, and explosive (CBRNE) training course during the Russia-Ukraine War. METHODS: Pre/post-test study in the Ukrainian cities of Kyiv, Dnipro, Zaporizhzhia, and Odesa. Fifteen CBRNE courses were conducted over a 3-mo period, August to October 2022. Change in knowledge and skills confidence were evaluated with pre/post-course written exams and practical skill assessments that were observed during the training exercises. Changes were analyzed based on nonparametric Wilcoxon matched-pairs signed-rank testing. Pre/post self-efficacy surveys were analyzed with McNemar's test for paired data. Course evaluations were conducted with standardized questions which assessed instruction quality, teaching relevance, knowledge gained, and post-course skills confidence. RESULTS: A total of 523 participants registered and completed 1 of the 15 courses. Overall mean pre-course test score: 57.8% (SD 20.7%); mean post-course test score: 81.4% (SD 11.3%); participants with increasing test scores: 90.7%; mean difference in score (95% confidence interval) 23.6% (21.2%-25.9%), P < 0.0001. Pre/post self-efficacy surveys (4-point Likert scale) noted participants recognized signs and symptoms of a CBRNE incident, and necessary skills to manage CBRNE exposures, P < 0.0001. CONCLUSIONS: The implementation of this CBRNE course for front-line providers in Ukraine was successful. To our knowledge, it was the first implementation of a field course during the current Russian-Ukraine war. Future research should evaluate knowledge retention and impact of our innovative Train-the-Trainer model. Further iterations should emphasize expanding the quantity of training equipment and practical skill sessions.

Emergency Medicine Provider Impressions of Novel SMS-Based Toxicology Module.

The diagnosis and treatment of common toxicologic disorders is an area of core content that emergency medicine (EM) resident physicians and physician assistants (PA) are required to demonstrate competence in order to become proficient practicing clinicians. Even when EM programs have a required toxicology elective, learners do not encounter all core toxicologic presentations. To supplement these knowledge gaps, many toxicology curriculums rely on internet learning modules which have variable uptake in practice. With remote learning and education becoming more common, we aim to perform a need-based assessment of EM resident and PA toxicology education and use the results to develop and deploy a text message-based, interactive toxicology supplemental program for EM residents and PAs and measure its acceptability and preliminary effectiveness to teach core toxicology principles.

Health and Safety Threats to Ukraine From Nonconventional Weapons: A Clear and Present Danger.

This Viewpoint discusses the potential for use of nonconventional warfare threats (chemical, biological, radiological, nuclear, and explosives) in the conflict in Ukraine and how health care professionals need to recognize and respond to these threats.

Nationwide Trends in COVID-19 Cases and SARS-CoV-2 RNA Wastewater Concentrations in the United States.

Wastewater-based epidemiology has emerged as a promising technology for population-level surveillance of COVID-19. In this study, we present results of a large nationwide SARS-CoV-2 wastewater monitoring system in the United States. We profile 55 locations with at least six months of sampling from April 2020 to May 2021. These locations represent more than 12 million individuals across 19 states. Samples were collected approximately weekly by wastewater treatment utilities as part of a regular wastewater surveillance service and analyzed for SARS-CoV-2 RNA concentrations. SARS-CoV-2 RNA concentrations were normalized to pepper mild mottle virus, an indicator of fecal matter in wastewater. We show that wastewater data reflect temporal and geographic trends in clinical COVID-19 cases and investigate the impact of normalization on correlations with case data within and across locations. We also provide key lessons learned from our broad-scale implementation of wastewater-based epidemiology, which can be used to inform wastewater-based epidemiology approaches for future emerging diseases. This work demonstrates that wastewater surveillance is a feasible approach for nationwide population-level monitoring of COVID-19 disease. With an evolving epidemic and effective vaccines against SARS-CoV-2, wastewater-based epidemiology can serve as a passive surveillance approach for detecting changing dynamics or resurgences of the virus.

Human trafficking and the growing malady of disinformation.

Disinformation has endangered the most vulnerable communities within our world. The anti-trafficking movement in particular has been adversely impacted by disinformation tactics advanced through the QAnon campaign. QAnon's extremist messaging exacerbates gendered, racist, and xenophobic manifestations of trafficking victimization as well as problematic responses to trafficking that underpin historic structural inequities built into the United States' response to trafficking. We describe an overview of mechanisms used by the QAnon campaign to spread disinformation and illustrate how these mechanisms adversely affect the anti-trafficking movement. Given the critical role of healthcare providers in both the identification and connection to care for trafficked persons, as well as their susceptibility to disinformation, we provide several recommendations for the health sector to leverage their educational and advocacy power to combat trafficking disinformation while addressing the root causes of human trafficking.

Chemical, biological, radiological, nuclear, and explosives (CBRNEs) preparedness for sporting event mass gatherings: A systematic review of the literature.

OBJECTIVE: Sporting events often constitute mass gatherings (MGs) featuring large crowds of spectators and participants. Our objective is to understand the current state of emergency preparedness for sporting events by examining past MG sporting events to evaluate mitigation, preparedness, response, and recovery against chemical, biological, radiological, nuclear, and explosive (CBRNE) events. METHODS: In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was carried out among 10 literature databases. The quality and risk of bias in each reviewed publication was assessed using the Mixed Methods Appraisal Tool. RESULTS: A total of 5,597 publications were identified. Of these, 81 papers were selected for full text reads and 25 publications were accepted. The included articles documented sporting events worldwide, ranging from incidents occurring from 1972 to 2020. Cross-cutting themes found in best practices and recommendations were strategic communication, surveillance, planning and preparedness, and training and response. CONCLUSION: More evidence-based guidelines are needed to ensure best practices in response and recovery for CBRNE incidents at sporting events. Public health risks as well as implementation barriers and opportunities to prepare for potential CBRNE threats at sporting event MGs require further investigation.

Evaluation of change in emergency care knowledge and skills among front-line healthcare providers in Ukraine with the Basic Emergency Care course: a pretest/post-test study.

OBJECTIVE: Evaluate the change in participant emergency care knowledge and skill confidence after implementation of the WHO-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) course. DESIGN: Pretest/post-test quasi-experimental study. SETTING: Mechnikov Hospital in Dnipro, Ukraine. PARTICIPANTS: Seventy-nine participants engaged in the course, of whom 50 (63.3%) completed all assessment tools. The course was open to healthcare providers of any level who assess and treat emergency conditions as part of their practice. The most common participant profession was resident physician (24%), followed by health educator (18%) and prehospital provider (14%). INTERVENTIONS: The 5-day WHO-ICRC BEC course. PRIMARY AND SECONDARY OUTCOME MEASURES: Change in pre-course and post-course knowledge and skill confidence assessments. Open-ended written feedback was collected upon course completion and analysed for common themes. RESULTS: Participant knowledge assessment scores improved from 19 (IQR 15-20) to 22 (IQR 19-23) on a 25-point scale (p<0.001). Participant skill confidence self-assessment scores improved from 2.5 (IQR 2.1-2.8) to 2.9 (IQR 2.5-3.3) on a 4-point scale (p<0.001). The most common positive feedback themes were high-quality teaching and useful skill sessions. The most common constructive feedback themes were translation challenges and request for additional skill session time. CONCLUSIONS: This first implementation of the WHO-ICRC BEC course for front-line healthcare providers in Ukraine was successful and well received by participants. This is also the first report of a BEC implementation outside of Africa and suggests that the course is also effective in the European context, particularly in humanitarian crisis and conflict settings. Future research should evaluate long-term knowledge retention and the impact on patient outcomes. Further iterations should emphasise local language translation and consider expanding clinical skills sessions.

Strategies to Counter Disinformation for Healthcare Practitioners and Policymakers.

Medical disinformation has interfered with healthcare workers' ability to communicate with the general population in a wide variety of public health contexts globally. This has limited the effectiveness of evidence-based medicine and healthcare capacity. Disinformation campaigns often try to integrate or co-opt healthcare workers in their practices which hinders effective health communication. We describe a critical overview of issues health practitioners and communicators have experienced when dealing with medical disinformation online and offline as well as best practices to overcome these issues when disseminating health information. This article lists disinformation techniques that have yet to be used against the medical community but need to be considered in future communication planning as they may be highly effective. We also present broad policy recommendations and considerations designed to mitigate the effectiveness of medical disinformation campaigns.

La desinformación médica ha interferido con la capacidad de los trabajadores de la salud para comunicarse con la población en general en una amplia variedad de contextos de salud pública a nivel mundial. Esto ha limitado la eficacia de la medicina basada en la evidencia y la capacidad sanitaria. Las campañas de desinformación a menudo intentan integrar o cooptar a los trabajadores de la salud en sus prácticas, lo que dificulta la comunicación efectiva de la salud. Describimos una descripción general crítica de los problemas que los profesionales de la salud y los comunicadores han experimentado al lidiar con la desinformación médica en línea y fuera de línea, así como las mejores prácticas para superar estos problemas al difundir información de salud. Este artículo enumera las técnicas de desinformación que aún no se han utilizado contra la comunidad médica, pero que deben tenerse en cuenta en la planificación de comunicaciones futuras, ya que pueden ser muy efectivas. También presentamos amplias recomendaciones y consideraciones de políticas diseñadas para mitigar la efectividad de las campañas de desinformación médica.

Avian Toxins and Poisoning Mechanisms.

All around the world, there are species of birds that have developed the ability to acquire toxic chemicals in their bodies making them less palatable or even lethal when consumed or contacted. Exposure to poisonous bird species is rare among humans, yet their poisons can produce serious clinical outcomes. In this study, we conducted a literature search focusing on seven avian species: the pitohuis (Pitohui spp.), blue-capped ifrita (Ifrita kowaldi), European quail (Cortunix corturnix coturnix), spur or spoor-winged goose (Plectropterus gambensis), North American ruffed grouse (Bonasa umbellus), Brush bronzewings (Phaps elegans), and European hoopoes and woodhoopoes (Upupa epops and Phoeniculus purpureus, respectively). We present the geographic distribution of each poisonous bird, toxin physiology and origin, clinical signs and symptoms of poisoning, cases of human toxicity if available and discuss the birds' ability to prevent self-intoxication. Our results suggest that most cases of contact with toxic birds produce mild symptoms as most of these birds apart from the European quail (C. c. corturnix) and North American ruffed grouse (B. umbellus) are not commonly consumed by humans. Furthermore, we discuss several methods of toxin acquisition in these bird species, which are mostly diet acquired apart from the hoopoes and woodhoopoes (Upupa and Phoeniculus spp.) who have a symbiotic relationship with chemical-producing bacteria in their uropygial glands. In summary, our study provides a comprehensive review of the toxic physiology, clinical manifestations, and evolutionary insight to avian toxins.

Pesticide Poisoning Among Children in India: The Need for an Urgent Solution.

Pesticides have been increasingly recognized as a significant source of morbidity and mortality, especially in the developing world. In particular, significant attention has been given to the use of pesticides to cause deliberate self-harm in India. Approximately half of suicides in India are due to intentional poisoning of which the majority are from pesticides. Young children are commonly poisoned by accidental ingestion, unintentional dermal or inhalational exposure, whereas adolescents are more severely poisoned if attempting self-harm through intentional ingestion. It is the purpose of this paper to highlight the problem of pesticide poisoning in the pediatric population of India, and to recommend policy options to address this global problem. Reducing access to pesticides and educating farmers and the public regarding the proper storage and use of pesticides and the establishment of more poison centers in India can be part of a broader strategy to address these life-threatening poisonings in children.

Maintaining health professional education during war: A scoping review.

PURPOSE: War negatively impacts health professional education when health care is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarise the research. METHODS: We conducted a scoping review between 20 June 2018 and 2 August 2018. The search was restricted to English publications including peer-reviewed publications without date ranges involving war and health professional education (medical school, residency training and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences. RESULTS: Screening identified 3271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 17 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified five categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era. CONCLUSIONS: There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.

The new humanitarian crisis in Ukraine: Coping with the public health impact of hybrid warfare, mass migration, and mental health trauma.

One of the largest mass movements of displaced people from their homelands in recent history must be recognized and assisted by the Free World. The unprovoked Russian attacks on Ukraine during February-March 2022 will leave long-lasting devastating effects on millions of innocent victims. Nations worldwide, especially NATO member countries, will need to intervene to ameliorate the situation. This letter describes major public health issues apart from the COVID-19 pandemic that are emerging concerns, such as shortages of healthcare professionals, chronic care treatments and health prevention services, disinformation communication campaigns affecting the healthcare infrastructure, and the generational impact of the conflict on people's mental health. A global response and public health support need immediate action including humanitarian assistance, food security, clean water supplies, adequate shelter, and safe transportation out of the active military zones.

Environmental and health risks posed to children by artisanal gold mining: A systematic review.

There are an estimated 5 million children working in artisanal and small-scale gold mines worldwide; however, the hazards are poorly characterized and often underreported. We systematically reviewed the literature on reports of hazards among children as a consequence of such activities through PubMed database using pre-defined search terms. We identified 113 articles published between 1984 and 2021 from 31 countries. Toxicological hazards were reported in 91 articles, including mercury, lead, and arsenic. Infectious hazards, noted in 18 articles, included malaria, cholera, and hepatitis. Six articles reported occupational hazards, including malnutrition, heat stroke, and reactive airway disease. Three articles reported traumatic hazards, including cave-ins, burns, animal attacks, falls, and weapon-inflected wounds. Those findings likely indicate a profound underreporting of the prevalence and consequences of such hazards among children. More work is needed both to characterize the burdens of those hazards and to address the underlying drivers of child labor in those settings.

Metrics to relate COVID-19 wastewater data to clinical testing dynamics.

Wastewater surveillance has emerged as a useful tool in the public health response to the COVID-19 pandemic. While wastewater surveillance has been applied at various scales to monitor population-level COVID-19 dynamics, there is a need for quantitative metrics to interpret wastewater data in the context of public health trends. 24-hour composite wastewater samples were collected from March 2020 through May 2021 from a Massachusetts wastewater treatment plant and SARS-CoV-2 RNA concentrations were measured using RT-qPCR. The relationship between wastewater copy numbers of SARS-CoV-2 gene fragments and COVID-19 clinical cases and deaths varies over time. We demonstrate the utility of three new metrics to monitor changes in COVID-19 epidemiology: (1) the ratio between wastewater copy numbers of SARS-CoV-2 gene fragments and clinical cases (WC ratio), (2) the time lag between wastewater and clinical reporting, and (3) a transfer function between the wastewater and clinical case curves. The WC ratio increases after key events, providing insight into the balance between disease spread and public health response. Time lag and transfer function analysis showed that wastewater data preceded clinically reported cases in the first wave of the pandemic but did not serve as a leading indicator in the second wave, likely due to increased testing capacity, which allows for more timely case detection and reporting. These three metrics could help further integrate wastewater surveillance into the public health response to the COVID-19 pandemic and future pandemics.