Alternate: Wastewater Surveillance to Support Public Health Response: COVID-19 Case Studies

Introduction The Coronavirus Disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2), has exposed modern society's vulnerability to infectious diseases. Reliance on clinical testing of symptomatic individuals has proven challenging due to the inability to identify asymptomatic cases and time lags between disease onset and clinical reporting to public health agencies. Wastewater surveillance is a disease-tracking tool that supports early response, such as public health decision making and vaccination efforts. Public health agencies have partnered with local officials, wastewater utilities, research institutions, and consultants to implement practical wastewater surveillance programs. CDM Smith has focused on building these partnerships to facilitate SARS-CoV-2 wastewater testing programs around the globe. Our work aims to support the use of wastewater data to inform specific public health interventions. This presentation highlights wastewater surveillance case studies at facility, neighborhood, and city scales to illustrate best practices for developing wastewater surveillance programs. Wastewater Surveillance Program Development A successful wastewater surveillance program requires collaboration between community leaders, wastewater utilities, epidemiologists, public health officials, engineers, doctors, and other scientists. Our approach to building programs relies on early engagement of these stakeholders. The team defines program objectives, devises a cost-efficient approach to wastewater sampling and analysis, develops communication plans, establishes data presentation techniques, and informs on potential public health interventions. The collaborative approach improves consensus building. Program execution focuses on gathering and presenting reliable wastewater data in a timely and effective manner. Wastewater Surveillance Case Studies CDM Smith has helped develop wastewater surveillance programs at the facility-, neighborhood-, and city-scales in the United States and Middle East with varying goals and objectives. The United States Department of Veterans Affairs developed a program to monitor eight conjugate living centers (CLCs) throughout the U.S (CA, NC, PA(2), TN, TX, WA (2)). The goal of the program was to provide an early warning system to prevent outbreaks in CLCs. From January to June 2021, CDM Smith assisted in grab sample coordination, collection, and delivery to the VA analytical laboratories in Temple Texas. The VA project showed that initial planning of sampling and shipping logistics was critical to rapid turnaround of wastewater surveillance data. The VA labs indicated the SARS-CoV-2 wastewater data was used to target testing resources and mitigate outbreaks in CLCs. In collaboration with CDM Smith, the Massachusetts Department of Health implemented facility and neighborhood programs with the objectives of identifying COVID-19 cases sooner than clinical testing and confirming absence of disease. 24-hour composite wastewater samples were collected three days per week and analyzed for SARS-CoV-2 and other sewage markers. Results are communicated via email to state and city officials, and COVID-19 case data are evaluated for correlation with wastewater virus concentrations. Local-level surveillance provided public health officials an early-warning of an outbreak in a community in eastern Massachusetts. Public health measures included mask distribution, deployment of mobile testing units, and education campaigns. A city-scale surveillance program was established in April 2020 in Detroit, Michigan, and is still ongoing. The program objective is to develop a model to predict spatial and temporal variation in COVID-19 cases based on wastewater concentrations, demographic data, and sewer conditions. Grab samples are collected weekly at 12 locations, including at the wastewater treatment plant, and analyzed for SARS-CoV-2 and other sewage markers. Results are discussed weekly with public health officials, and data are analyzed using principal components analysis. Collaborating with the United States Agency for International Development (USAID), CDM Smith helped develop city-scale surveillance programs in Amman, Jordan and Cairo, Egypt. These program building projects focused on analyzing existing research infrastructure to support sampling campaigns and analytical testing, implementing wastewater monitoring and action plans, training seminars, and data visualization dashboards. Insights from U.S. case studies were used to establish recommendations that allow international partners to manage their wastewater surveillance programs. Conclusions and Recommendations Wastewater surveillance is an effective tool to measure aggregated community-level biomarker data. The approach is being used effectively at many scales during the COVID-19 pandemic. CDM Smith's wastewater surveillance work revealed several important findings including: A successful program starts with collaboration between public health agencies, local officials, research agencies, and their partners. SARS-Cov-2 wastewater concentrations are strongly correlated with COVID-19 cases. Normalizing viral concentration data to other wastewater data is helpful to mitigate competing influences in the sewer system. Wastewater surveillance data was used to inform specific public health actions such as awareness campaigns. Development of wastewater surveillance programs can provide a proactive tool to respond to disease outbreaks, understand drug use, and measure other indicators of community health and wellbeing. Future applications of the approach include early identification and understanding of disease outbreaks, understanding antibiotic resistance, and addressing health disparities Widespread development of programs could provide public health officials a proactive tool to respond to disease outbreaks. The Centers for Disease Control and Prevention (CDC) established the National Wastewater Surveillance System (NWSS) to improve acceptance of the approach. Wastewater surveillance is being funded through a combination of federal, state, and local support.