Optimizing Disease Detection and Containment Through a Waste-Before-Case Approach

by Megan Diamond – Manager, Health Initiative, The Rockefeller Foundation & Aparna Keshaviah – Senior Statistician, Mathematica

When a new public health threat emerges – like the highly infectious Omicron variant of the SARS-CoV-2 virus – detecting the first case before there has been widespread community transmission can be like searching for the proverbial needle in a haystack.

Yet wastewater testing is a tool optimized to do just that. People infected with SARS-CoV-2 shed the virus when they go to the bathroom – including asymptomatic people who may not even know they are infected. The sewers then act like large magnets, aggregating the virus particles found in feces into centralized locations where researchers and public health officials can take samples and detect the virus, sometimes before a clinical case emerges. In fact, over the past week, multiple cities in the United States were able to detect Omicron in the wastewater before a clinical case was identified.

As vaccinations plateau and testing declines, public health officials are looking for alternative means to passively collect data that provides real-time insights for decision-making. Wastewater testing does exactly that, at the fraction of the cost of clinical testing.

Wastewater-based epidemiology (WBE) is not a new field. Decades of evidence have shown that WBE is an effective tool for detecting outbreaks of pathogens like poliovirus and typhoid, with the potential for much more. And although it has been used in several countries, including in the United States, to monitor for SARS-CoV-2, ongoing questions remain on how to best interpret and use data derived from wastewater for pandemic response.

For example, wastewater data is inherently messy, and more work is needed to reliably distinguish signal from noise in viral concentrations collected from wastewater to detect a rising threat. It’s also unclear how wastewater data should be synthesized with other local public health data—such as clinical case counts and reports of Covid-like symptoms—to provide officials with a more holistic measure of Covid-19 risk in their community. The potential of sequencing viral RNA in wastewater remains underexplored, too.

The creation of the Wastewater Action Group (WAG) – which includes leading researchers and public health officials in Atlanta (Emory University), Houston, Louisville, Tribal Nations (Arizona State University) and Tulsa  – is one of the ways that The Rockefeller Foundation and PPI are supporting cities across the US to translate wastewater data into action.  Together, this network of partners is refining wastewater sampling, testing, and sequencing protocols; developing metrics and strategies for wastewater-based risk communication; and expanding wastewater testing to underserved populations that are not connected to centralized wastewater treatment plants.

The impact of these efforts are being seen in real time:

  • In Houston, Texas, partners at the Houston Health Department and Rice University detected Omicron in the wastewater before a confirmed clinical case and subsequently sequenced positive samples from school children residing in the service areas of the wastewater treatment plan.
  • In Louisville, Kentucky, partners at the University of Louisville and Louisville Metro Dept. Public Health & Wellness detected Omicron in the wastewater before a confirmed case in Jefferson County. Through close collaboration with the State of Kentucky, they can now do targeted sequencing within the community.
  • In Tulsa, Oklahoma, partners at the Tulsa Health Department and University of Oklahoma saw an increase in influenza A virus concentration was detected in the wastewater, enabling quick communication to the public.

PPI recently met the growing need for rapid peer-to-peer learning by hosting an urgent meeting focused on wastewater sequencing in light of the emergence of Omicron. More than 30 wastewater testing leaders attended and since then, more than half have either reached out to someone they met on the call or adapted their response plans based on information shared during the session.

PPI is also dedicated to hearing from end users of public health data. Through a collaboration with Mathematica, The Rockefeller Foundation is fielding a nationwide survey among public health leaders.

The results of the survey could inform the development of decision-making tools for public health departments and help policymakers determine how they can best support wastewater surveillance across the country.

At present, no single data source provides a full picture of COVID-19. The most widely reported data—clinical case counts—overlook large swaths of the population that lack access to quality health care. As a result, the first signs of an outbreak are often detected weeks, if not months, after the emergence of a new threat. Wastewater testing is a way to fill this critical data gap.

The world can no longer wait for fragmented, delayed, and biased data. By supporting the development and scaling of wastewater-based epidemiologic tools and knowledge, PPI seeks to boost the capacity of public health officials to detect infectious disease outbreaks and prevent the next pandemic.

A Treasure Lost – Surgeon, David Wulkan, M.D.

I lost a colleague this week to acute leukemia. He was diagnosed and treated at a world class Center of Excellence but succumbed to the complications of treatment so rapidly that those of us who worked with him daily had little knowledge that he was ill or gone until it was all over.  This 56 year old General and Vascular surgeon shared a February 17th birthday with me, came from a working class urban background and trained in the General Surgery program at the rigorous and demanding University of Miami Jackson Memorial Hospital Program. He completed his residency training several years after I completed my general medical training and then moved up to Boca Raton, Florida to join one of the premier surgical groups in the area.

My wife had the privilege of teaching one of his children at the pre-school level and knew his wife and children. We never broke bread together or visited each other in our respective homes. We didn’t go out socially together either. Despite this, I considered him a friend as I saw him on a daily basis while I made morning and evening rounds at the Boca Raton Community Hospital as we both strove to prevent disease and help others. He was warm, understanding, even-tempered, showed great judgment clinically and great understanding of his patients’ needs and concerns.

Surgeons are often branded as arrogant, cold, and volatile. Dave was like a teddy bear, just a very bright talented competent one.  We shared patients and they all thanked me for finding them such a special physician in their time of need. He educated me when I needed to be educated and he did it in a manner that conveyed the message in a professional and respectful way without making me feel like I should have known that.

I know the kind of hours he put in and the sacrifices his wife and children made with regard to time so that he could care for other persons’ loved ones. That is time one never recaptures.

My community has lost a treasure of a doctor and a wonderful human being. We will miss his kind and affable manner, wisdom and skill. My thoughts and prayers will be with him and his family and with the families of all those other caregivers who make it easier for their loved one to care for and help someone else’s loved one routinely.

I was proud to be Dr. Wulkan’s colleague and will miss him greatly.

Medicare, if you only knew…

The following guest post was written by Aimee Seidman, M.D., FACP.  Dr. Seidman is an award winning internal medicine physician in Rockville, MD, a suburb of Washington, D.C.

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If I could have a penny for every dollar I saved Medicare, I’d be rich. As a concierge physician, my patients can expect advocacy that stretches from the office to the home, hospital, rehab facility, long term care setting, and to the hospice. When I work with a patient, they can expect me to intervene between the various subspecialty physicians or hospitalists involved in their care, spread out my arms in front of them as if ready to take a bullet for them, and defiantly yell “get your paws off my patient until we hear what the plan is”.

How often are x-rays, ultrasounds, MRI’s, cardiac caths, and yada, yada, yada done in patients with a shortened life expectancy, poor quality of life, or clear living will instructions? How often is patient autonomy ignored in the rush to ‘complete work-ups’? Why do we have to work everything up? We need to stop what we’re doing (and stop the cowboys who are shooting from the hip) and think about the patient’s status and whether or not the proposed intervention is appropriate.

The last time I asked one of my 80-101 year olds how aggressively they wanted their medical treatment to be, they said “no way…leave me the hell alone! When my time comes, it comes. Just make a nice party!“  I shudder to think of the feeding tubes inserted and other interventions done in clear violation of a living will, even if that living will is right there with the patient or family members present.

I believe we scare the daylights out of people by telling them all the horrible things that will happen if they don’t consent to treatment plans. But it’s all defensive medicine. “I’ve got to be able to document that I warned them about this horrible death so I don’t get sued”. I suspect non-intervention, comfort measures, and hospice care are rarely offered to families in a way they can hear it. ER doctors and hospital physicians are just doing their jobs-they want to ‘save lives’ (or at least keep them alive until the next shift) and the primary care doctor is never consulted.

What do people think we do, order mammograms all day? Those of us in concierge medicine who have close relationships with our patients know them and their families well enough to expedite decision-making in a way that is medically and ethically appropriate. The whole point of my concierge practice is to first, do no harm (remember that?), allow my late stage Alzheimers disease patient to have a dignified death, and not spend millions of dollars on unnecessary procedures.

Not only that (I’m almost done), if all primary care physicians and the health care community made a conscious effort to inquire about living wills, explain the subtleties, and respect the choices made, fewer people would use ambulances, go to the ER, stay in the hospital, etc.

The other piece to this is the education of families regarding end of life issues, preparation, ethics, and closure. As it is, families deal with guilt, sadness, confusion, and anger when called upon to make these tough decisions or to respect an established living will. Most of us have seen families reluctant to honor a living will because they can’t bear the thought of letting grandpa starve to death.

If consulted about these decisions ahead of time, much of the combat will not occur. So how much have I saved Medicare by avoiding all this unnecessary stuff? Tens of thousands of patients, times a fortune of money, equals a boatload of bucks.

So, do you want to know ways to fix health care?

1.      Tort reform so docs aren’t so paranoid and aren’t playing “cover-your-butt medicine”;

2.      Docs, shut up and listen to your patients;

3.      Stop insulting the community of doctors who want to practice medicine in a particular model labeling them elitist and focus on things that will work (and by the way, most of us have scholarship patients, indigent patients and perform community service);

4.      A national campaign to educate consumers about the importance of living wills and have discussions over details, including family members in the discussion;

5.      Make it clear to the medical community that honoring a patient’s autonomy in the form of an advance directive is their obligation under the law

6.      Do no harm.

Just listen to me and give me a penny for every dollar I save Medicare, then I’ll really be rich.

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Please note, the opinions expressed in this guest blog post are those of Dr. Aimee Seidman, founder of Rockville Concierge Doctors.