N/A Hello, my name is
Dr. Andrew Sanderson, and I earned my Master of
Public Health and Health Policy and Management with
a class of 2016. I'm also a current member of the
Harvard T.H. Chan School Alumni Association and the chief
medical officer for the Water Environment Federation,
which is located in Alexandria, Virginia. West is a not for profit
technological and educational association, which has a primary
focus of protecting the health and safety of water
treatment professionals both in the United
States and globally. That's why I'm so excited
about today's program, which will showcase the work of
Harvard Chan alumna, Nour Sharara, MPH class of 2015. And her role as public health
scientist at Biobots analytics, as well as the crucial
role wastewater epidemiology plays to track
disease, infection trends, such as COVID-19. The office for alumni
affairs at the Chan School is always looking to
support programming that highlights the important
work of our alumni and faculty. So we're happy to help bring
this program to you today. Nour will give her
presentation, and then we'll have some time for
audience questions. So please use the Q&A box
to submit your questions. Nour? Thank you. Thank you for having me today. Thank you, Andrew,
for the introduction. I'm really happy to be back at
the School of Public Health. I wish this was in
person, but hopefully this will be for a later time. So before delving into
wastewater epidemiology and how it's been used since
the start of the pandemic on COVID-19 and
beyond, I thought I said I take a
step back and think about what did I think about
sewage when I was getting my public health training. Next, please. So when I was getting my
MPH, I remembered sewage as a vector of transmission. We knew that ingesting
or bathing in untreated, or contaminated, or stagnating
waters would lead to diseases. And you're all very familiar
with the Broad Street pump map when John Snow, father
of modern day epidemiology, investigated the source
of a cholera epidemic. And his investigation
led to the conclusion that contaminated water
from the Broad Street pump was the source of the
disease and that the removal of the handle would
end the epidemic. And so this is what I
thought about sewage when I was getting my MPH. Next, please. And then the pandemic happened. And then when the
pandemic started, I launched a wastewater
analytics company called Biobots analytics. And Biobots was
launched in 2017. It's a spin out of MIT where
both of our co-founders, Doctor Mariana Matus and Newsha
Ghaeli met during their studies and work. And at the time, they
were investigating-- they were addressing
the opioid epidemic, which was a public health
crisis at the time. And so in 2017,
what they were doing is that they were
collecting samples from men whole level, so
at the neighborhood level when we walk on the street
and analyzing in there how much opioid was being consumed. And that allowed to do some
heat mapping within a city to try and see areas of high
consumption and exposure to opioids versus lower
consumption of opioids. And this data set was extremely
helpful for city officials and public health professionals
working on substance use disorder programs. Next, please. And then in 2020 when
the pandemic started, Biobots very quickly pivoted
from opioids to SARS-CoV-2 and working with scientists at
the Harvard T.H. Chan School of Public Health and MIT
developed very quickly and assay to detect SARS-CoV-2
in wastewater in the greater Boston area and measure it. Next, please. And so why do we look for
SARS-CoV-2 in wastewater? So the SARS-CoV-2 virus
is shed in the stool of infected patients
and that includes all infected patients--
asymptomatic, pre-symptomatic, symptomatic. And what was neat is that
as the pandemic unfolded, vaccination status did
not alter that ability. Vaccinated individuals who had
breakthrough infections would still show up in a
wastewater analysis result. And so because the virus
is shed in the stool of infected patients,
flushed down the toilet, goes into the sewage all the
way to the wastewater treatment plants. When we receive the sample that
was taken at the wastewater treatment plant, we're able
to measure the virus RNA that is found and give out a result
in genomic copies per liter of sewage. Next, please. And so why sample from
wastewater treatment plants? Since the start of
the pandemic, we have been working with
wastewater treatment plants across the country,
but not just us. I mean, wastewater
epidemiology has taken off in the US and everywhere else
in the world pretty much. And be it state labs,
or University labs, or other groups that are
part of our ecosystem work with samples from
wastewater treatment plants. And so data that is
generated from sewage is a complete look of infections
in a given geographical area. So wastewater treatment
plant will receive water from a given geographical
area, and the data that we are able to extract
from our analysis of that sample really gives a
readout of everyone that is in that community
and using the toilet. And so nothing short of
individually testing everyone in the area, we deal the
same amount of information. And so that data set can be
used to independently evaluate COVID-19 burden and
trends in a community, so across time and
space, but also as you can see on the
map, rank areas of high versus low
transmission and based on the amount of
SARS-CoV-2 that is found. And so just like that
with one sample analyzed, we're able to get
a community risk indicator in time and space. Next, please. And so what are the key
advantages of this data set? So now that we're two years
in almost of analyzing sewage from locations
across the country, the first advantage
of this data set is that it's very comprehensive. Everyone that is infected that
uses a toilet that is connected to a sewage system will show
up in a wastewater sample analysis. And so that includes
asymptomatic cases, which would not be captured
by clinical case data. It also addresses a
huge problem of barriers to testing as we know,
and barriers to testing comes in different flavors. First of all, there's limited
availability of testing. We have seen this at the
start of the pandemic and we saw it again
during the Omicron surge where there was just-- it was very hard to get a test. It was even harder to
get results very quickly. Sometimes, it would
take five to a week-- five to seven days before
people would get resolved. Then there's geographical
areas that are just not near testing centers. So think about medical deserts. Then there's individuals
who don't have access to the health care system have
very limited access to testing. Then there is people who
are hesitant to get tested. There's fear of stigma. There's also fear of
getting a positive result and not being able to
work and potentially put one's livelihood at risk. And then most recently, now that
at home and rapid antigen tests have become much more
widely available in the US, there's also all those
tests that people take that are not captured
in official statistics. And so for all these reasons,
wastewater data really acts as a great complementary
because it addresses all the limitations that
come with relying only on clinical case data. Another key advantage
of this data set is that it's inclusive. We always say that everyone
has a voice in the sewer, including people who don't
have access to the health care system. Wastewater sampling is simple. One wastewater sample
will give information on a whole community. It's very fast. We are able to give back
results within 24 hours. And even when we were at
the peak of the Delta curve and the peak of
the Omicron curve, we did not face the issues
that clinical testing face in terms of much
slower turnaround time to send back results. And last but not
least, wastewater has proven more than
once in this pandemic to be a leading indicator. And that's for two main reasons. The first one is
a biological one. Infected individuals spread
the virus in their stool very early on in
their infection cycle. So before even they potentially
become symptomatic, and then go get a test, and
then wait for a result, and then aggregated
clinical data results are reported at
the County or state level. So all this time frame,
wastewater doesn't-- is completely independent
of all these variables and very quickly can
give out information. And so the mix of the health
system limitations of access and turnaround time and the
biological fact that there is a shedding period at the
beginning of the infection course have rendered
wastewater data to be a leading indicator
by four to six days, but really, we saw
10 days at some point when the testing
infrastructure was really suboptimal in at some point. And so taking all this into
account two years into this, we can really say that
wastewater data may be the best way to
measure COVID-19 disease activity in real time. So taking this aggregate
bird's eye view of what's happening
in a given community, it has proven to be very
reliable by both public health officials, decision
makers across the board. Next, please. So some of you in
the Boston area may be familiar with the
data set and this trend line that the media has picked
up both in the Boston area, but really across the country. We've had a
wonderful partnership since the start of
the pandemic, working with MWRA, the Massachusetts
Water Resource Authority, and we've been able to
have historical data as you can see from
these trend lines. And it's really come to be
the go to source to see trends and where is the
pandemic heading. And that's really
when wastewater data becomes very important to
detect inflection points. And for instance, if
we look at last year, so beginning January
2021, vaccination was just getting started,
the British variant was just starting to
infect more people, it was more transmissible and we
clearly detected this increase. And you can see that the steep
of the line in that trend was much steeper
than even what we had back in the spring of
2020 when we were getting started with the pandemic. You can also see it of
course, much more clearly when the Omicron surge
started after Thanksgiving and how steep that was. What you can also see
is the leading indicator that I was just referring to. The dark green is
wastewater data, the light green
is clinical data. And if you look, it's very
clear during the Omicron surge that the wastewater incline
precedes the clinical case inclined by a few weeks. But more than just
situational awareness, which is what meets
the eye when you look at this, what
this data set has proven to be very useful for. So yes, detection in
trends and inflection points in the pandemic. For instance, when
Omicron peaked, we could breathe
a sigh of relief that we can see the
wastewater starting to dip. And in the Boston area,
many newspapers saying, looks like we see the light
at the end of the tunnel. But more than just
that, this data set has been very useful to plan, to
plan for testing, for instance. As soon as an increase
in wastewater shows up, we know that means that there's
higher community transmission. And we know the reproductive
number of this virus, we know that it's
exponential spread. So there's a lot
of things that we can put in motion once we see
a trend change in wastewater. There is planning. We've also worked with
hospital systems that look very carefully at this data
to think about nursing staff, think about beds, think also
about monoclonal antibodies that may not work for one
variant versus another one and that was definitely the
case during the Omicron surge. When the wastewater started
its incline very rapidly and we knew that
some drugs were not as effective against Omicron
than Delta for instance, then it's a lot of clinical
decisions that need to be made and all these preparation
that hospitals need to do as we know that this
is a leading indicator and that after cases,
hospitalizations, and more. And so it's very
much this double use. There's the people like
individual citizens like me who can look at
this to guess what my community risk right now? If I go out, is there a lot? Is there less? Are we-- And then there's
decision makers who use this data to
take the decisions for hospitals, for instance
or for their constituents. There was the chief
medical officer of the Boston
Children's Hospital who was interviewed
in the New York Times and said that once Omicron
peaked in wastewater and really started
its descent, that was a way for them to start
thinking about rescheduling elective surgeries that had
been canceled due to the Omicron surge. So there's various ways in which
this data set of course, used in conjunction
with the other data sets that we monitor like case
data, and hospitalization, and death can be
very informative as we respond in real
time to an evolving and very dynamic pandemic. Next, please. And so I've spoken a fair
bit about the Boston area. But as I said, we
work across the US. And in fact, in
last summer in 2021, we partnered with the US
Department of Health and Human Services and the CDC to
launch a nationwide wastewater monitoring program. So the CDC, about six
months into the pandemic, launched the National
Wastewater Surveillance System. And as part of this wastewater
surveillance system, they partnered
with us last summer to enroll wastewater treatment
plants from across the US, all 50 states, tribal
territories and we had a coverage of over
90 million Americans through this partnership. And more than just measuring
how much SARS-CoV-2 was in wastewater,
what we also did in partnership with
Concentric by Ginkgo was doing genomic sequencing
on wastewater samples. And that's something
that has really emerged, as well as a key strength
of wastewater epidemiology is the way it can complement
genomic sequencing done on clinical samples. Next, please. And so what we saw
during the summer and if you remember before
the Omicron variant, there was the Delta variant. And we really saw this Delta
variant sweep through the US last summer. So on the top is
wastewater data, on the bottom is clinical cases. And you can really see how
as the summer progressed and the Delta variant took
over, cases increased. Next, please. And that's a data specific
tool to genomic sequencing. You can really see that in
July how Delta completely took over the alpha
variant to come to be over 90% of variant
found in wastewater sample. Next, please. And so on this point
of genomic sequencing, one other thing I
wanted to add is that in the latest
Omicron surge, in fact, genomic sequencing
done on wastewater samples found the presence of
Omicron in a community before clinical specimen
had been sequenced and reported Omicron as well. And so that is
definitely something a key strength of
wastewater epidemiology that has to continue as
we enter this new wave and new phase of the pandemic. And it can be to
detect a new variant, it can be to detect
resurgence of disease, but it's definitely
something that has to be part of our
arsenal as we think about how do we live and continue
to do public health surveillance in this next
phase of the pandemic. Next, please. And I had promised Andrew
that I wouldn't only speak about COVID-19 because
wastewater epidemiology can be useful for all kinds
of other pathogens. We really feel like we
just started and we're just scratching the surface here. We at Biobots started
already doing pilots to monitor influenza
in wastewater and other groups in the
US are also doing that. There is a lot of
interest in tracking antibiotic resistant
bacteria in wastewater. There's also a
biomarkers of disease-- sorry, of diet and nutrition
to be able to get a bird's eye view again, of how
are people eating t a population health level. There's also other infectious
diseases of interest. There's polio viruses
are very known example where wastewater epidemiology
has been very, very helpful in 2013. So Israel has been implementing
wastewater epidemiology for polio virus monitoring
for a long time now. And in 2013, they saw a
detection in wastewater, quickly rolled out a vaccination
campaign in the area, and they were able to
avert a larger outbreak. Thanks to this detection, but
also very swift action that was taken based on the data. Another interesting
biomarker is hepatitis C, similarly to SARS-CoV-2 that
has this asymptomatic phase. And people are
carriers, but don't know because of
asymptomatic studies, yet this is something that
can be seen in wastewater. And then there's
pharmaceuticals and drugs. As I said, Biobots started
with the opioids and it's-- unfortunately, that
this epidemic has not decreased in if anything it
has intensified unfortunately and has really become
a shadow epidemic to the current pandemic. And so this is something
that we have already started piloting
in many communities and should be launching
very soon large scale across the country to really
work with public health departments and helping them
with this new data set looking at consumption of opioids. Because right now, all the
data is overdose death. The death is the tip of the
iceberg or emergency room visits. Again, it only tells you
when things are that bad, but there's everything else
beneath that we don't know. And so this data set
can help us understand better how to do what
public health does best, prevent opioid related
death, prevent visits to the emergency room. And so that we think that
wastewater epidemiology really has a key role to play in
bringing a very new data set to substance use
mitigation programs. Next, please. And those are four
key components in-- to control for in
high risk substance programs, or fentanyl,
of course, meth, cocaine, and nicotine. Next, please. And based on our experience
on SARS-CoV-2, and opioids, and high risk
substance more largely and all the R&D that
we have in the pipeline for other infectious agents, and
bacteria, and other respiratory viruses, the goal is
really to make wastewater surveillance as a permanent
pillar of public health infrastructure. Public health
surveillance has existed for a very long time, has very
traditional methods of doing-- collecting data and
investigating sources of disease, and
then addressing them with programs and
initiatives, but we really think that this creating a
new public health data set will be able to make public
health more proactive and data driven. So thank you for your
time today and I'm happy to take any questions. Nour, thank you so much
for that presentation. You gave us a wealth
of information and it's really hard to pack
it into such a short period of time. Unfortunately, that
means that we're only going to be able to get
to a few of the questions. The first question from the chat
comes from Michael Chung who asks, what level
of fidelity can you get between residential versus
commercial zones, schools, et cetera? How much can you differentiate
between residents and visitors? Thank you. That's a good question. So the point of fidelity,
the limit of detection is actually quite good. We can detect one
infected person in a 6,500 people or less. So this is-- we work and
I haven't mentioned this, but we work with building
levels customers. So think about congregate
living settings like nursing homes for instance
or rehabilitation center. So they're also really
care about this data to be able to use it for to
implement other mitigation strategies. And so be it at the municipal
level, at the building level, or at the wastewater
treatment level, all three levels of sampling
provide high fidelity of results. Now, to the question
about visitors, that's an interesting question
because the data you get is of everyone who has used
the toilet in this setting, be it a building or
a community, and you don't know if that person
lives there or works there or is just visiting
for the weekend because there is a Halloween
party, or Christmas, or so. The short answer
is that you can't know because it's
completely anonymous, it's an aggregate data
set that you have. But by-- and this is where
the power of trends comes in and that's why frequently
testing, you're able to see was this an outlier
or does this really represent the
amount of community transmission and viral spread
there is in the community? So the next question
is by Vanessa Palmer. And Vanessa asks, do you
have a sense of coverage both over time and space? That is for how many
municipalities in the US these data are available
and going back, how far? So I can speak about what
the work we do at Biobots. We've been working with
communities since March 2020. So we are coming up to almost
two years very, very soon. Last summer, I'd say, we
covered about all 50 states, but we were receiving
data from over 320 wastewater treatment
plants or communities and representing over
90 million Americans. But different other
states have also wastewater
epidemiology programs, some university
groups also have some, some make the data public. I think there's
quite a few efforts going on around the country. I mean, there's even data
to show from other countries where they've actually detected
SARS-CoV-2 in their wastewater because they were testing
for other pathogens, viruses, and bacteria in
November of 2019. The last question from the
chat will be able to get into-- forgive me if I
mispronounce your name, is from Gautham Thakur. Could you talk about the assay
used for SARS-CoV-2 detection and wastewater? Is it target specific like PCR? What are some
challenges when trying to detect viral RNA,
which can easily degrade amidst all
the background, quote unquote, junk
you'd find in sewage? That's a good question. And the good news is
that SARS-CoV-2 viral RNA is quite stable, and
so no fear of degradation for that virus. And yes, absolutely, we do
a PCR test the same way. When we receive the
wastewater samples in the lab, we do a PCR test, looking
at primers the same way that we do a PCR
test on a nasal swab. Well, I think that that's going
to be all the time that we have for questions. Nour, I just want to thank
you so much for providing us a look into this topic. Obviously, it's extremely
relevant right now and we believe it will continue
to be so moving forward. On behalf of the Office of
Alumni Affairs at the Harvard T.H. Chan School, we'd like to
thank you for taking your time to be with us. We will be sharing a survey
linked now in the Q&A box and in a follow up email
for you to provide feedback about today's
session and to help us plan for future programming. The Office of Alumni
Affairs is continuously looking for alumni
stories to showcase. And so please share
yours in the survey to help plan and shape
future programming. Definitely, this
type of session will have to make an hour,
instead of in half an hour. I'd also like to put in
a shameless plug for web. Obviously, we believe that this
is an extremely important topic as well. So much so that we're planning
the first public health and water conference and
wastewater disease surveillance summit, which is next
month in Cincinnati, Ohio. So if you have the
time and the interest, you can register and join us. Thank you all for your
attention and have a great rest of your day.
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