Clean Water Works
CLEVELAND, OHIO: From the Northeast Ohio Regional Sewer District, an in-depth and fun conversation led by Donna Friedman and Mike Uva on any and all topics related to clean water, wastewater treatment, stormwater management, and the people, projects, and programs serving Lake Erie and our local waterways and communities.
Clean Water Works
Wastewater Surveillance and Community Health
A recent innovation, the National Wastewater Surveillance System (NWSS) has transformed from an emergency response to COVID-19 into a comprehensive early warning system for disease outbreaks.
The NWSS monitors approximately 45% of the US population through over 1,400 sampling sites. Public health laboratories can analyze genetic material from the waste stream to detect the presence of pathogens even before clinical symptoms appear in communities.
Despite the inherent complexity of wastewater samples, the process has demonstrated surprising accuracy in predicting disease trends.
Visit cdc.gov/nwss to explore the NWSS dashboard.
I'm excited always to talk about the program. Talk about wastewater which you don't hear often, it's all we do here. Actually, I'm really happy.
Speaker 2:Well, this is very exciting for us here at Clean Water Works Today. We have some pretty high-profile organizations represented on our program.
Speaker 3:We have Dr Zuzanna Borer, program Manager for the Ohio Wastewater Monitoring Network at the Ohio Department of Health. Welcome, thank you for being with us.
Speaker 2:Thank you for having me, and we have Dr Rachel West, senior Scientist from the Centers for Disease Control, joining us by phone from Atlanta.
Speaker 4:Thanks so much for having me.
Speaker 2:And we're having this conversation today to talk about the National Wastewater Surveillance System. This is a topic that piqued our interest a few years ago in a conversation with our Superintendent of Environmental Services, scott Broski. Scott was telling us about wastewater monitoring and the ability to collect and analyze water samples from the waste stream that could give us a more accurate picture of the spread of COVID cases. So that's what we're going to talk about today the National Wastewater Surveillance System. And I didn't know it existed. Did you know before?
Speaker 3:I didn't know. No, I really. I guess I found out about it, probably like most people, during the COVID pandemic. Zuzana, has it always been around? Is this?
Speaker 1:new, so the national system is completely new. In some other states in the world there were wastewater surveillance systems, but most of them were really more on the research side than really application. So this really was pivoted by the pandemic as a practical tool for public health.
Speaker 2:Rachel talk a little bit about the NWSS and what it does and why it is important.
Speaker 4:So NWSS, and we also call it NEWS for short, just sometimes for ease of conversation. It began during the 2020 pandemic.
Speaker 4:And it grew out of a need that we were seeing to sort of coordinate and collaborate with states and local health departments that were exploring wastewater surveillance for COVID-19 and monitoring for the virus that causes that disease, SARS-CoV-2. And so in 2020, we started with a few early implementers, one of whom was Ohio. So we have worked with them for quite a while and really appreciate their innovation and work, and while we started with SARS-CoV-2, we also have expanded to different pathogens now, like influenza A, influenza B and other diseases as needed by sort of the public health priorities. So it grew from, I think, eight early implementers and now we're supporting wastewater surveillance in 50 states and we're really excited that we have over 1,400 sampling sites now. That represents about 45% of the US population, and that was only possible because of our incredible partners at health departments and at utilities that have made all of this possible.
Speaker 3:That is quite a statistic 45% of the population. That's really impressive. Can you talk a little bit about your relationship with the sewer district and how that started, and are you then the ones that are coordinating that sampling with us?
Speaker 1:So at the health department, really in the pandemic, we worked very closely with Ohio EPA. Ohio EPA is the regulating agency for the wastewater treatment plants, the sewer districts, what we are doing and why we want to be doing it. Because they did not really know why we would be collecting untreated wastewater and looking for diseases. So we started onboarding utilities and asking them if they are willing to participate in the cities, if they want to participate in the program. So we worked with a lot of academic partners as well. So it really took everyone to kind of start these networks.
Speaker 3:Yeah, so just since the pandemic you've really expanded this program quite dramatically.
Speaker 4:Yes, it's been really exciting to see the different applications, and we know, too, that our jurisdictions that we work with are sometimes doing different wastewater surveillance for different pathogens that is more tailored to their community needs, and we really enjoy learning from them as well and sort of learning from their innovation and creativity.
Speaker 2:So how does wastewater monitoring work, what's the process for gathering data and how does it eventually end up on the National Wastewater Surveillance System webpage.
Speaker 1:So in Ohio it looks slightly different in different states. I first want to say but I will just talk about Ohio so we really rely on the utilities to collect samples for us and they do it often for their own operations. Sometimes they do specially for us someday when they don't collect, but most of the time we try to leverage their process. But they do it without any compensation. We provide all the supplies. They give us sample which is untreated wastewater, so wastewater coming into the treatment plant and we have it delivered currently to the public health laboratory which is in central Ohio. They concentrate it and they extract the genetic material and then they are able to quantify specific targets we call it or pathogens we are looking for.
Speaker 1:So all this process collecting and quantification is about two to three days and then the Ohio Department of Health received the data from the laboratory. We also collect data from the wastewater treatment plant, from the utility, about their flow and some of the other conditions and then, based on those two data streams, we kind of analyze it and see if we see something unusual and we put it in a format and push it to CDC. We also do our processes. So if we see something unusual we actually send notification to the local health district and to the utility that. Oh, we see increases in influenza in your community. So we put our data to CDC, usually about the same two to three days. It's very like few hours at the processing by us.
Speaker 3:So just to jump in for a little bit of clarification when you say you're sampling for genetic material for the pathogens, what you're saying is that all the pathogens, like us, are living, they have a genetic genome, they have a code, right, and so are you isolating specific sequences that only that specific pathogen has, and then that's what you're looking for.
Speaker 1:Yes. So we kind of determine unique kind of genetic code of specific pathogens and we only evaluate those like quantify how much of that is in the wastewater and then we know how much wastewater we process. So then we can recalculate how much there is kind of in that community. But we don't really look at how much there is in a community. We more look at what the trend looks like, like is it increasing or is it steady, as we are used to, or is it going down?
Speaker 1:Right now on the statewide level we are looking for still SARS-CoV-2, so the COVID-19 virus, then influenza viruses, both A and B it has two kind of strains very distinct and then RSV, which is respiratory syncytial virus, which is another respiratory virus, usually affecting children, causing pneumonia in children. We're also starting to look at norovirus now, which is a foodborne pathogen which causes diarrhea and vomiting in people. And then we do a few kind of emergency monitoring. We subtype influenza A to C if there is avian influenza. We subtype influenza A to C if there is avian influenza. And then we also in very few communities, do MPOX monitoring for the new clade which is in Africa, which kind of there is some concern that it could spread worldwide, same as the MPOX two years ago. So that's the one we currently do in Ohio.
Speaker 3:We also do, actually, whole genome sequencing of SARS-CoV-2 to see what exact variant there is. So when we had like that really bad spike in the flu earlier this year, were you seeing that in the data?
Speaker 1:Yeah, there is very strong correlation with wastewater data and clinical indicator data like cases, hospitalizations data and clinical indicator data like cases, hospitalizations.
Speaker 4:So the CDC process is very similar to what Susana described at the state level, in that really what happens at the state level depends on their capacity and their needs and what works best for them.
Speaker 4:So the utility or a trained staff member will take that untreated wastewater sample and then that sample is usually sent to a public health lab or another lab and that lab will then test it for those pieces of the pathogen usually the genetic material and then, once we get that data, then we can quality check and visualize those data in a platform that we call OneCDP.
Speaker 4:It's a secure data platform where all of the data can be stored so that they can really quickly look at different metrics. And one of the things that Zahra mentioned was, for some of our pathogens, we want to understand how those levels that we're measuring of the pathogen are changing over time. For other pathogens, we use metrics that are really more about presence or absence, so understanding if there is a positive detection and then is that persisting over time? Is this a consistent detection or is this intermittent? Is this a consistent detection or is this intermittent? But all of that really depends on timely, consistent, high-quality data, and that again goes back to our utility partners, who are sampling this and doing so in a really consistent way so that we can have metrics that we can rely on.
Speaker 2:Once this program really ramped up during COVID, did you find a lot of cooperation with partner agencies like utilities?
Speaker 4:When it first started up it was a pretty new surveillance system to a lot of people and understandably there were some questions about what benefits it would have. We also had some partners like the Water Environment Federation and the Association for Public Health Labs so APHL like the Water Environment Federation and the Association for Public Health Labs so APHL and they really helped us connect with those communities, particularly utilities. No-transcript. The infrastructure of wastewater surveillance and its innovation was really important to us and our partners at WES really helped enable that. They helped connect us to those utilities and also helped us understand what, and sometimes we've used that to improve the system and make changes and that's been really helpful along the way.
Speaker 3:I know that at the district when COVID was really ramping up, folks were nervous about taking samples of wastewater. Did you run into that at all, Susanna?
Speaker 1:Yeah, in the beginning we had to kind of do a lot of research to make sure that there is not risk to the wastewater treatment workers. I think every new target is it's always concerning to the utility. So now we kind of try to make the research beforehand and see, you know what might be the risks of the utility workers and and to make sure that we can answer those questions. But also a lot of them know that the wastewater has pathogens. They are aware of that and definitely they know their procedures. So we just kind of emphasize that.
Speaker 3:Gloves, making sure you have your safety glasses on all of that. Gloves, making sure you have your safety glasses on? Yeah, all of that.
Speaker 2:So you have this resource, the National Wastewater Surveillance System, or NEWS as we'll call it, and it's a dashboard up at the CDC website, cdcgov. Can you give us some examples of how this data is used once it is up on the site?
Speaker 4:Sure so from the public and how they interact with the dashboard. For some people who may not have a ton of time or they just want a really high-level understanding, looking at the national or regional trends is most helpful. Just a quick at-a-glance oh in my region.
Speaker 4:How are flu levels right now, especially like if they're traveling or if they're visiting family members that may be at higher risk? Just sort of trying to understand that landscape. But there's also data available on the dashboard that is a little bit more granular so at the state level and also available in some cases for counties. That way if someone is potentially at higher risk or they're caring for someone who's at high risk, they're able to look at more granular data to understand those more hyper-local trends.
Speaker 4:On the internal side, for some different pathogens like H5, wastewater data are also used to support the other surveillance systems that we have and also the outbreak responses and when I say H5, I'm sorry, I'm referring to influenza A H5. So that avian influenza that was a pretty high concern last year and when there was that outbreak response, wastewater surveillance was providing a really helpful additional perspective on the presence of that in different communities. So from the public side, we hope that wastewater data can be used to inform individual actions to protect yourself and your loved ones, but also to care for others in your community and understanding what's happening at the community level. And then on the CDC side, we really value the timeliness of wastewater surveillance data and that it can capture people who might not be able to present to healthcare facilities, or maybe they can't access testing, or they're just not symptomatic and they don't know they're sick. We can still get that community-level health information and use that to support outbreak responses, allocate resources, things like that.
Speaker 2:Zuzana, how does the Ohio Department of Health use this data? Do you disseminate it down to the local agencies?
Speaker 1:So we work closely with CDC on a lot of aspects of the news. We have our own processing and dashboard of the data as well, which is more granular, which is on the go all the way to the basically treatment plant or area. When we see something unusual, as I said, we usually notify the local health authorities and also we let know the wastewater treatment plant. The treatment plants are often part of the municipal leadership, so they also talk with the municipal, with their leaders and then the local health authorities. We really let them make the decisions. We definitely encourage looking at other surveillance data, but they usually know the community the best. So they know like, did we have some big event? Or, you know, did the schools just open? So they know like, did we have some big event? Or, you know, did the schools just open? So they know the community the best.
Speaker 1:So they do some public health notifications. But they also let know their stakeholders like schools, hospitals. We're getting now more and more requests from hospitals to, for example, put them on the notification email, so so that's kind of the most common things we do with the monitoring data. We also do some like CDC, a lot of different analysis, looking statewide trends, looking at, you know hot spots, where the diseases appear first. Now, when we have multiple year data, it's becoming kind of we are looking how else we can use the data, looking at outbreaks and where they are. We are working with CDC on hopefully being able to predict hospitalization, because we treat these data as an early warning, because they are very timely and you can see the trends, often slightly before you see it in the other clinical indicators.
Speaker 2:So you give the hospitals a heads up that something's coming.
Speaker 1:Yes, that's our hope yeah. They can kind of optimize their operations.
Speaker 2:Rachel, you contributed to a paper that addressed ethical considerations in infectious diseases, concerns people might have about being part of studies, etc. Can you talk a little bit about those concerns?
Speaker 4:Sure. Oddly, ethics and wastewater surveillance is one of my favorite things to talk about. This framework was really meant to make public health ethics accessible and normal and familiar for everyone who's implementing wastewater surveillance. What we know from working with all of our partners is that ethics and ethical values are being incorporated every day into decisions. Some of those values that were really centered in the framework were things like trust and trustworthiness, equity and fairness and privacy, so trying to center those values and define what they mean for wastewater surveillance.
Speaker 4:And then, as this program has grown and we've expanded not only geographically but also to different pathogens, those ethical concerns have come up, and those are really focused on privacy, stigma and data stewardship. So the framework walks through those and that there are ways to address those concerns and mitigate them in ways that also strengthen the wastewater surveillance system. So for things like data stewardship, oftentimes there's a very good question of who owns the data, how is it shared, what safeguards can we build into the system to try to mitigate this? And some communities we know have different histories with public health surveillance and with the federal government, and so we want to be mindful of those two, because trust is one of those values that's really important in sustainability of wastewater surveillance.
Speaker 3:Is one of the concerns that you would collect the sample and then use it for something else.
Speaker 4:There's definitely that concern Future use or function creep or things like that. So there's not only the data but there are the physical samples that in some cases are stored and there is a possibility for those to be used in the future. And sometimes that's for things like developing new assays or understanding sort of a look back at when a disease may have started spreading in a community. But there's also the question of as new technologies emerge. Then we might have to consider, should these samples be used in this way, what risks might be associated. So there's definitely that concern about those physical samples.
Speaker 3:Did this come up for you as well, Dr Rohr?
Speaker 1:that concern about those physical samples. Did this come up for you as well, dr Rohr, we are always part of these debates as well and I was part of another kind of academic article on this topic. But generally in Ohio we only collect wastewater from these treatment plants, which is really kind of quite large population, even if it's a smaller town, and you never know who you are collecting from, because people also come visit and go to restaurants and we can kind of pinpoint individuals and we definitely don't even try to do that. But we also try to be very transparent about exactly what we monitor. If we add any target we talk with all our partners about it, we would never just start something.
Speaker 1:We show all our data on dashboard which is public, so we are open to kind of any concern and discussion on these topics.
Speaker 2:So privacy is a concern how the data is going to be used now or in the future. And the third one was stigma. Is that correct?
Speaker 4:Yes, stigma Stigma for public health surveillance and for wastewater surveillance is just the potential risk of are monitoring for the presence of a disease to have a negative connotation on that participating community. So the concern that there may be blame or negative impact on a participating community because of an association with an outbreak. Stigma has different levels. It can change depending on what pathogen you're thinking about, about where you're sampling. If you're sampling in a really small sewer shed or contributing community, there may be more concern if an emerging pathogen or a pathogen that maybe has some connotations that aren't so great, if it's a really small community and it's tied to that disease through wastewater surveillance, there can be a risk of stigmatization of that community.
Speaker 4:We do have to acknowledge that stigma is a potential issue and so one of the questions is how can you think about those potential stigma-related risks that might emerge? But then also trying to this is a hard one, but anticipating and addressing potential misinformation by just really regularly communicating with your partners so the community, the health department, the utilities, so that you're transparent about what you're testing for and why. So that way they know what that truth is, they know why you're doing this, so that if they hear something that sounds risky or stigmatizing. They have the right information to know exactly what the benefits are. So stigma can be a tricky one and can really vary by pathogen and even timing. We would want the focus and the purpose of the wastewater surveillance data to be just supporting whatever public health measures would be right for that community to try to reduce disease spread, and not necessarily tying it to a cause or putting any blame on anyone.
Speaker 2:So, with these wastewater surveillance efforts, have there been any real surprises for either of you?
Speaker 1:I don't think we expected how well it will correlate with all the other indicators because there is so many. This is an environmental sample. Wastewater is not only a human sample. Right we have washing machines, dishwashers, industries, restaurants and it's just incredible how well it really shows and predicts often what's going to happen in the community. In all the markers we've been doing so far and it's extremely sensitive. For example, for SARS-CoV-2, you can really see very few cases in a community very early or we can detect variants very early on.
Speaker 1:So I think nobody really expected it because these pathogens decay in the collection system and everything seems so imperfect. You can find so many uncertainties we have in all these processes and the lab analysis and in the end it works like amazingly. So there is a lot of data, consistent data we have now for a few years and most of course they are kind of supporting what the clinical data are telling us. Sometimes they are slightly surprising when we see some of the infectious diseases, for example, more in the affluent communities because of travel recently, because they travel much more, we see two waves of COVID which we did not know. There is summer and winter wave and other respiratory diseases have like influenza and RSV have one wave. So, and that's very confirmed with the wastewater and we even saw in 2024, the summer wave was as significant as the winter wave we had now.
Speaker 3:So when people get vaccinated, you're like you're getting a small dose of what it is, so your body can build up your immunities. But would that show in the wastewater data?
Speaker 1:So it depends on the vaccine. The COVID vaccine will not show up in wastewater but some of the live attenuated vaccines, like polio vaccine, which you take it orally, it can show up in wastewater. Oh, that's interesting so it really depends on the vaccine.
Speaker 4:It's been really incredible to see the flexibility of wastewater and even MPOX-CLAVE2. Those were really incredible to see how it supported our health departments in tailoring their actions and helping them early on and sort of get ready for potential cases. I managed to learn things about utilities and wastewater all the time with that avian influenza response. We never expected to have to think about truck stops but we learned that those were really important in washing down the trucks that may have had animals that maybe were shedding bits of the virus in their excrement. And then when you wash it down and it's in a truck stop and it enters the wastewater system that that can sometimes impact signals.
Speaker 4:And so just thinking about the complexity and landscape of what is contributing to the wastewater and how that can impact what you're measuring, but then how that can continue to support public health and one health sort of the connection between animal health and environmental health and human health. That's been a really nice surprise and sometimes challenging, but with our utility and lab and health department partners it's been a really rewarding activity. I always like to emphasize how incredible the utility community has been. Pretty much the majority of utility operators who are taking these samples two to three times a week for the past four to five years they've been doing that voluntarily just because of their commitment to their community and public health and that I always like to highlight because I think that's so valuable and important. And sometimes even you know friends and family don't quite know that. And then, of course, the health department and the labs just their commitment and time that they've invested in building trust around this system and innovating things constantly. I just think that's always really incredible.
Speaker 1:And I mean the community is really excited. Right, we have epidemiologists which are used to work with like a number of cases and number of hospitalization and this is very new to them because it brings that very strong environmental side and all these uncertainties coming with those samples and they really had to learn a lot of things. But they are really excited about the data and you know how they can use and really open to learning. We went today to visit one of the treatment plant right and we usually invite the local health district and they every time came. So I think that just is like testament also of the excitement of the public health professionals to kind of explore this completely new field.
Speaker 3:Dr Ward, can you tell us a little bit about your background? How did you end up working for ODH?
Speaker 1:So I actually studied soil science, agriculture, but then I started working on a research how to use treated wastewater to irrigate soil. Oh, sure. And that's how I kind of worked then for a long time in environmental engineering and wastewater and drinking water treatment, mainly connected with new technologies for killing pathogens, yeah, and I worked with so many different pathogens and I was thinking like I so wish I would know more of the you know health side of what I'm doing.
Speaker 1:So I decided to go back to study and I studied public health, master of Public Health, at Ohio State University and really fell in love with the public health side of things and that's how I ended up in the end managing the wastewater monitoring network. I kind of had the background in both you know and moved to Ohio Department of Health to manage that program.
Speaker 3:That's really cool. You were like the perfect candidate. Rachel, do you want to tell us a little bit about your background?
Speaker 4:So my background is actually more on the molecular biology side. I did my PhD in malaria developmental biology so looking at the parasite and understanding what molecular factors are influencing its development and I loved that. But I also did an internship and a postdoc with the Johns Hopkins Center for Health Security where I focused a little bit more on sort of global health security and synthetic biology, and I did a fellowship in 2021, the Presidential Management Fellowship and that's how I got to CDC and I started working with the news team and I've really loved the whole experience ever since then.
Speaker 3:That's great. You guys have really interesting backgrounds. I'm so glad that we were able to have you on the podcast today. I learned a lot.
Speaker 2:Dr Zuzana Boer is Program Manager for the Ohio Wastewater Monitoring Network at the Ohio Department of Health and Dr Rachel West is a Senior Scientist with the CDC's wastewater program. Again, you can look at the National Wastewater Surveillance System dashboard at cdcgov backslash nwss and you can access information on the Ohio Department of Health and its monitoring programs at odhohiogov.
Speaker 3:Thank you so much for having me. Thank you both for keeping us safe.
