Sewage is trying to tell us something about the future of COVID, polio, monkeypox and the next epidemic to come

“The danger of polio is present in New York today.”

The statement appears to be ripped from the headlines of the 1916 New York polio epidemic, which killed 6,000 – mostly children – and paralyzed 27,000 in just four months.

But it was made last week by the New York State Health Commissioner, Dr. Mary Bassett, following the identification of poliovirus in both Rockland and Orange counties in June and July. New York City health officials announced Friday the presence of the virus in sewage there as well.

Health officials were recently notified of an unvaccinated Rockland County resident diagnosed in July with the potentially debilitating and even fatal virus that famously paralyzed President Franklin D. Roosevelt from the waist down. Most people with the virus do not show symptoms. A handful present with flu-like ailments, but only one in about 100 develop serious side effects such as paralysis.

Public health officials likely wouldn’t be aware of a wider spread so quickly if it weren’t for sewage monitoring, which some say is a bit of a crystal ball when it comes to identifying epidemics and pandemics to come. The technology came to prominence during the onset of the COVID-19 pandemic, and public health officials are now turning to it to try to gauge the true spread of monkeypox, with its sometimes atypical symptoms and spread. We also wouldn’t know that polio spread if it weren’t for it.

“In some respects, wastewater is a public health dream scenario,” said Dr. Mark Siedner, an infectious disease physician at Massachusetts General Hospital and associate professor at Harvard Medical School. Assets.

“Everybody fucks, and most fucks every day. It provides real-time data on infection rates. In that regard, it’s an extremely powerful tool, especially good for detecting early warning signs.”

“Before people get sick, we might get a signal.”

When toilets are revealing

Consider sewage: a repulsive reality of human existence with the blessed potential to alert public health officials to unexpected pathogens in the community—perhaps before cases present in doctors’ offices and emergency rooms.

Global health emergencies like COVID-19 and monkeypox may seem like a new phenomenon, but they are not. Such plagues typically occur at least once every quarter or half century — and they are bound to become more frequent as climate change forces animals and humans into more frequent contact, experts say. And wastewater pathogen monitoring also has a long history, going back almost 100 years. It was used to monitor for polio in the 1940s and hepatitis A in the 1980s, but in limited circumstances and capacity. It began to gain traction after the turn of the century, when it was used to monitor levels of prescription and illegal drugs, track influenza, and again in efforts to detect and contain “silent” polio outbreaks.

But COVID-19 was its moment to shine.

Early in the pandemic, researchers discovered that SARS-CoV-2, the virus that causes COVID-19, is shed in fecal matter. Researchers increasingly began to rely on it as testing failed to meet demand. Soon it was picked up by high schools in an effort to curb large outbreaks, then cities and states.

Less than a year into the pandemic, it had gained enough recognition that the United States launched the National Wastewater Surveillance System, which works with local health departments to track COVID levels across the nation.

Nearly three years into the pandemic, rates of traditional PCR and antigenic COVID testing are abysmally low, and at-home test results are rarely reported to public health departments. This has put the United States and other countries with similar testing trends in a situation that many experts have likened to “flying blind” — at a time, no less, when the most transmissible, immune-evasive COVID variant to date, BA.5, is sweeping through . the world.

Waste water has become the eyes of researchers. Thanks to that, we know that COVID was recently at or near record highs in many places in the United States, including California’s Bay Area and Coeur d’Alene, Idaho.

“The levels we’re seeing in wastewater at a number of facilities we monitor — and other facilities around the country we don’t — are as high or nearly as high as they were during the first wave in January,” Alexandria Boehm, professor of environmental and civil engineering at Stanford University, said Assets in July.

Stanford and Emory University have partnered with Alphabet-owned Verily, a precision health company formerly known as Google Life Sciences, to offer wastewater reporting of pathogens like COVID-19 for free to interested wastewater treatment plants in the United States

The partnership started with reporting levels of COVID-19, influenza, respiratory syncytial virus (RSV) and human metapneumovirus, another upper respiratory virus, in participating communities, which now number about 40.

It recently added the ability to screen for monkeypox, given the global outbreak, and will soon have the ability to report which of two widely circulating monkeypox variants are most prevalent in a community, just as it reports on COVID-19 subvariants .

“As a scientist, I’m trained to be skeptical and to test the null hypothesis that things don’t work—and sewage time and time again proves to be a really great resource for investigating infectious diseases in the community,” Boehm noted.

Boehm said she is surprised by how well levels of infectious diseases in wastewater correlate with those traditionally diagnosed in communities — even respiratory diseases like influenza and RSV that one might not expect to find traces of in wastewater.

She hopes the levels of monkeypox in wastewater will prove just as useful — but the jury is still out, as researchers can’t be sure whether wastewater levels are predictable until they have a good handle on the presence of the disease in a community out from traditional tests.

“What we can say is that we know if we get a positive [in a community], at least one person is infected and excreting,” she said, adding that those with monkeypox shed virus via respiratory secretions, urine, feces and open wounds. “We can also look at trends and see if the concentration is increasing or decreasing.”

‘Fantastic for broad brush strokes’

The practicality of wastewater is that it is almost impervious to changes in human behavior or barriers to obtaining health care.

Regardless of whether someone knows they need to be tested for a disease—whether they want to be tested, are able to get a test, or report the results of a home test—their infection will be recorded because, as people do, they bathes, showers, brushes teeth and uses the toilet.

“People don’t have to choose to have their secretions go down the drain the way they had to when they take a PCR test,” Boehm said. “They don’t have to make an appointment, drive there, wait in line, get that thing stuck up their nose.”

“If you are connected to the system, your information will be recorded in the sewage.”

However, it is not perfect. Some pathogens, such as group A streptococci, which causes strep throat — cannot be detected in wastewater, Siedner said. In fact, many bacteria cannot be.

And while a positive result from sewage alerts public health officials to the presence of disease, it doesn’t alert them to who is sick and where, so they can take action.

“It’s great for broad brush strokes and early warning signs, but not great if more detailed data is needed,” he said.

Lack of consistency in testing nationwide also hampers the potential utility of wastewater. Some areas don’t test, and not all areas test for the same pathogens, experts say.

Further, “you have to know what you’re testing for in wastewater” to find it, meaning it’s not a tool that can be used to detect new pathogens with pandemic potential, Dr. Howard Forman, professor of radiology, biomedical imaging and public health at the Yale School of Medicine.

“In hospitals, patients are only checked for what their symptoms are. Sewage, I still think it’s very different from place to place what people test for. I think it would be great to have a wider screening.

“It would be great if we had the type of assays that would allow us to screen for all kinds of viruses.”

Divining waste water

However, the knowledge provided by wastewater enables health professionals to “move in quickly” and promote prevention.

“People tend to be more receptive to immunizations when they see the threat versus when they think it’s for some public health purpose.”

Dr. Morgan Katz, an infectious disease specialist at Johns Hopkins Bayview Medical Center in Baltimore and an assistant professor at the Johns Hopkins School of Medicine, said Assets that wastewater alone is insufficient for community disease surveillance because it does not provide the exact number and location of those with the disease. But it augments traditional methods like PCR and antigen testing, she said.

“It’s complementary to our existing surveillance systems and a great way for us to get a marker of a brewing outbreak before we start seeing a lot of people with symptoms,” she said. It can be “particularly useful in dormitories, nursing homes, or other community centers where identifying a developing outbreak early is particularly important.”

While wastewater provides an incomplete view of the spread of disease in society, it offers invaluable insight.

A recent takeaway: Monkeypox could easily end up in “virtually every major metro in the United States,” Bradley White, a senior researcher at Verily, told me recently Assets.

A look at the partnership’s monkeypox heat map, which shows data for its nearly 40 U.S. testing sites so far, shows levels rising in California’s Bay Area, as well as the presence of monkeypox in Parker, Colo.; Roswell and College Park, Ga.; Coeur d’Alene, Idaho; Ann Arbor; and Garland and Sunnyvale, Texas.

“There’s definitely a spread across the entire United States,” White said. “It looks like eventually it will probably get everywhere — something we had hoped would remain isolated doesn’t look like it will.”

One of the most important things about the COVID-19 pandemic has been that it has highlighted the utility of wastewater monitoring and the ability to detect and potentially stop breeding outbreaks early.

Using the same setup and even samples it used to test for COVID-19 and subvariants, RSV and influenza, Verily was able to quickly pivot and add testing for monkeypox. It will soon add a test that determines which strains of monkeypox appear in local sewage systems and may add an assay for polio if staff at local public health agencies request it, Boehm said.

“It’s the future, and a resource we haven’t yet fully tapped into.”

The pandemic certainly did its part to make wastewater testing “fashionable,” Siedner said. “It was not something that was routinely done before. It is a very creative tool. Hopefully, as we think about the lessons we’ve learned from COVID-19 and how we can strengthen our public health systems, one thing that will be elevated will be wastewater detection.

“It could be the way of the future.”

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