Wastewater-based surveillance is an effective tool for disease monitoring and can provide early warning of outbreaks. Although wastewater viral loads (WVL) correlate with disease burden, their utility for improving real-time forecasting remains under investigation. During the early phases of an epidemic, many indicators can effectively monitor disease spread, but their reliability may decline because of reporting fatigue and low prevalence. Hospital burden can vary substantially even during low-prevalence periods, making accurate forecasting of burden indicators essential for minimizing disease impacts. In this paper, we present principled approaches for processing wastewater data, characterizing its relationship with burden indicators, and generating real-time forecasts. We assess the predictability of WVL using entropy measures. We analyze the relationship between WVL and burden indicators using causality tests that capture temporal dynamics and the leading-indicator behavior of WVL. We incorporate these insights into a time-varying forecasting model that accounts for the evolving relationship between the signals. We also evaluate the effects of delays in WVL reporting through simulations. We test the utility of our methods by forecasting COVID-19 hospital admissions across Virginia and its health regions during periods of varying disease prevalence. Incorporating WVL improves forecast accuracy relative to baseline models, particularly during critical epidemic phases, and results in a 20 percentage point improvement in forecast coverage. Our results demonstrate that WVL signals can improve infectious disease forecasting even under conditions of low prevalence or delayed reporting.
Wastewater influenza surveillance can reveal community circulation before clinical reporting, but wastewater alone is not a fully identifiable proxy for human burden. Existing wastewater models assume a fixed evidence set, while generic evidence-acquisition methods treat official surveillance streams as interchangeable costly features. We cast wastewater-first influenza monitoring as a selective decision problem: starting from mandatory wastewater evidence, the system must decide whether wastewater is sufficient, which delayed official stream to query next, and when abstention is the only scientifically defensible action under source ambiguity. We propose Bayesian Selective Latent Inference (BSLI), a principled Bayesian method that maintains a posterior over latent burden and identifiability, certifies answerability through explicit scientific gates, and optimizes query-stop decisions with an exact cost-calibrated Bellman policy. We prove the key variational, answerability, Bellman-optimality, and one-dimensional cost-calibration properties. On a fixed public-data benchmark with 5,933 forecasting episodes and 3,102 source-ambiguity episodes, BSLI improves the matched-budget cost-performance frontier while preserving conservative abstention under source ambiguity.