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While the world awaits effective treatments or a vaccine for SARS-CoV-2 (the novel coronavirus commonly known as COVID-19), the most important information that can be gathered is who is infected, who is infectious and where clusters of sick people are located.

Testing in the United States has made the news for a host of reasons and, after a slow start, has been fairly effective at identifying people with COVID-19 since the pandemic began here in mid-March. Epidemiologists rely on testing and monitoring followed by contact tracing to determine how the illness has or could spread and to stop transmission.

Another tool used to determine the spread of illness is wastewater-based epidemiology (WBE), also known as sewage surveillance. WBE can be a leading indicator of the presence of COVID-19 in a community.

How does wastewater-based epidemiology work?

WBE is relatively self-explanatory, said Kunal Rambhia, Ph.D., a biotechnologist at The MITRE Corporation, who recently moderated a webinar on the topic in partnership with ORAU’s University Partnerships Office.

“With wastewater-based epidemiology, an infected individual may be shedding the virus in their stool or in their urine or in their saliva prior to the development of symptoms,” Rambhia said. “And as they flush that down the toilet, it gets aggregated into our wastewater streams, and we can detect a signal [the presence of the virus] using this approach.”

Wastewater-based epidemiology is not new. Rather, the process has been used for decades as a means of surveillance of diseases and perhaps most recently for the pervasiveness of opioid use in a community.

To conduct wastewater testing, an individual or a device captures a sample from a university’s wastewater stream. That liquid or solid sample is then processed by a laboratory. The sample is processed, and the genetic signature of the virus, found in the ribonucleic acid or RNA, is extracted.

“When that RNA is extracted, the test that they run is actually very similar, nearly identical, to the assay that's brought into diagnostic testing for clinical purposes. It's a PCR-based (polymerase chain reaction or antigen-detecting) assay,” Rambhia said.

How is wastewater testing beneficial?

Rambhia said it can help guide elected officials and other leaders in making decisions about steps they might take to slow the spread of the virus.

“They are trying to make these really tough decisions that are often intrusive to people's lives. For example, wearing a face covering. It's not necessarily comfortable for everyone, but we know that it can be effective in controlling the virus,” he said. If jurisdictions can have some additional information that they're facing a surge in their COVID-19 cases based on what we see in the wastewater, they could make much more targeted decisions on who needs to wear a face mask, where to deploy limited-testing resources, or what subset of the population they might need to focus on in terms of their interventions.”

Rambhia moderated an ORAU/MITRE webinar (see below) for members of ORAU’s University Consortium. The webinar featured experts from Yale University, Rice University and Arizona State University, who shared what they’ve done and what they’ve learned in the process of ramping up their wastewater testing programs.

  • Rolf Halden, Ph.D., director of the Center for Environmental Health Engineering at the Biodesign Institute at Arizona State University, shared that Tempe, Ariz., population 185,000, has been a leader in wastewater monitoring since 2015. The city began monitoring for opioid hotspots around the city and has been monitoring for the coronavirus since March of this year. Halden noted that one area of the city where consistently high levels of virus can be found is Guadalupe, a town of 5,500 mostly Native American and Latino people who are essential workers such as day laborers and food service employees. Tempe offers a publicly available information dashboard explaining what is found in the city’s wastewater.
  • Lauren Stadler, Ph.D., assistant professor in the Department of Civil and Environmental Engineering at Rice University and leader of the Stadler Research Group, which focuses on advancing recovery from wastewater, shared that her team’s work is a collaboration with Houston’s Department of Public Health, Department of Public Works, and other entities. Stadler’s team collects samples twice a week from Houston’s 39 wastewater treatment facilities, which helps determine trends in the area around the individual facilities as well as spatial trends across all of Houston. This trend data can assist the health department with determining where to deploy resources in the city, like testing stations, contact tracing, etc.
  • Jordan Peccia, Ph.D., professor of environmental engineering and associate professor of chemical engineering at Yale University, said his team has been sampling primary sludge, or the solids that settle out of wastewater, in New Haven, Conn., since March 19, 2020. The New Haven Water Pollution Control Authority treats about 40 million gallons a day from 200,000 people in New Haven, East Haven, Hampton and Woodbridge. Peccia said analyzing sludge can predict the spread of COVID-19 up to six days early and hospitalizations in New Haven about four days early. He added that the program is being expanded to include all wastewater treatment facilities in Connecticut.

The purpose of the webinar was to help academic leaders who may be considering wastewater testing get a better understanding of how the process might be helpful, what challenges exist, and how they can work together.

Academic institutions are great prospects for wastewater surveillance because they often are contained communities with the capability to complete the entire surveillance process in house. They often have their own wastewater treatment facilities, laboratories and staff or students who can conduct the data analysis to help university leaders make critical decisions about bringing students on campus, mandating face coverings, deploying testing resources, etc.

Can wastewater surveillance replace individual testing?

The short answer is no, said Monique Mansoura, Ph.D.

Mansoura is the executive director for global health security and biotechnology at MITRE. Shehas a leadership role in the 1,000-plus-member COVID-19 Healthcare Coalition, which brings together private sector entities to share and learn from each other about work they are doing to control COVID-19.

“It seems infeasible for us to imagine that all of us would need to be tested every day individually, and so [wastewater surveillance] really is an opportunity to create a more feasible approach to identify those individuals or congregate settings or cities and communities at risk,” Mansoura said. “And then it has to be paired with the decisions that get made once you have that initial indicator that there might be a positive signal of the virus in wastewater. You want to make sure you've got the resources to follow on now that you've identified an enhanced risk, and that you can proceed then with the individual testing.”

There is a very real sense of urgency in the United States to gather all of the information possible as very large, high-consequence decisions are being made about K-12 schools, universities—all sectors of education, Mansoura said.

“We all hope that someday we will have the virus more under control where we can keep up with individual testing,” she said. “That is certainly not the case right now in the United States, where we have widespread transmission, and where we have more than 5,000,000 cases and over 163,000 deaths.” (Editor’s note: this conversation occurred in early August 2020.)

COVID-19 Healthcare Coalition

The sense of urgency to bring COVID-19 under control drives the COVID-19 Healthcare Coalition, of which both ORAU and MITRE are members.

The coalition was established in mid-March. MITRE had been approached by leaders from the Mayo Clinic and the Massachusetts Institute of Technology to coordinate the COVID-19-related activity taking place among private sector healthcare organizations, technology companies, academic institutions and startup companies to preserve the healthcare system and protect U.S. populations.

The work of the coalition is focused in three areas:

  • Social Policies, including data-driven decisions to “reopen” businesses and communities, set up testing sites and contact tracing programs, and track exposures through the use of technology.
  • Clinical Decision-Making, including the investigation of potential vaccines and therapeutics, like the use of convalescent blood plasma from people who have experienced and recovered from COVID-19.
  • Supporting the Supply Chain to ensure that communities and healthcare systems that need them have access to the necessary personal protective equipment, ventilators, testing supplies, etc.

“This has been a coalition of the willing,” Mansoura said. “The rules of engagement or coming together to join the Coalition are pretty simple. We are all solely focused on the goals of saving lives and preserving our healthcare system. We operate without any exchange of funds, with minimal paperwork, and really a commitment to share information, share learning, in as near real-time as possible, with the goal and intent that by learning together we'll all learn faster and better.”

After all, time is of the essence.

“We all understand these are urgent, real-time issues, and bringing solutions with speed and at scale is really what we're aiming to do,” Mansoura said.

What’s next for the ORAU/MITRE partnership?

ORAU and MITRE signed a memorandum of understanding to work together in November 2019. The strategic partnership was formed to advance the U.S. science, technology, and management agenda. MITRE and ORAU will work together to achieve their common vision, which includes multiple higher education, research, engineering and related activities that may complement each organization’s workforce, work programs and strategic goals. Through this partnership, MITRE will be able to leverage the ORAU network of universities to tap the expertise needed to benefit MITRE’s federal sponsors.

The wastewater surveillance webinar and working together on the COVID-19 Healthcare Coalition are the first projects the companies have worked on together. But it’s definitely not the last.

Ken Tobin, vice president for University Partnerships at ORAU said Sara Alert™ is the next project ORAU and MITRE will tackle together.

Sara Alert™ is an open-source, publicly available software system that organizations use to monitor people who have been tested for COVID-19. It will keep tabs on people through quarantine, and if they become symptomatic, it is used to monitor them through their illness and provide information to municipal and state health agencies as an integral part of the whole contact tracing system. Sara Alert™ can be used by municipalities, universities, K-12 schools, companies and other organizations.

MITRE has been working with the Department of Health & Human Services and the Centers for Disease Control and Prevention on the Sara Alert™ system, and ORAU and MITRE will work together to adapt the Sara Alert™ system to the university environment and ORAU will host the software, providing everything needed to monitor and protect students, faculty, and staff as schools begin the fall semester.

“We are hoping very quickly to be able to stand up a number of pilots to get the software out there, to cover the universities in terms of the needs that they have for monitoring the students that are coming back to their universities,” Tobin said.

“I would imagine after we have a successful pilot that we can offer this capability to a broader group of universities, perhaps in the future even outside of ORAU's member universities, and so that's a very exciting next step for both of us,” he added.

To hear more about wastewater surveillance from the experts quoted in this story, listen to Further Together, the ORAU Podcast.

Webinar: Surveillance for SARS-CoV-2 Using Wastewater

Early research indicates that SARS-CoV-2 can be detected in the feces of infected individuals. The fact that the SARS-CoV-2 virus can be detected in wastewater prior to an individual developing symptoms and presenting to the healthcare system for a diagnostic test, gives it the potential to serve as a leading-edge indicator of virus transmission in a community. There is a need to define and develop the end-to-end process for implementation of sewage surveillance for relevant and priority use cases.

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