Wastewater Epidemiology: Tracking COVID-19 and beyond

Published: Feb 27, 2022 Duration: 00:30:16 Category: Education

Trending searches: wastewater covid activity map
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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