Ensuring Equity as Wastewater Testing Matures in the United States

[APARNA KESHAVIAH]

I think it’s kind of figuring out are these data representative, are they being studied in the right communities and diverse communities across the country, and then are the data being reported in a way that people who don’t have specialized knowledge of virology and viral concentrations, can they make sense of this data to quickly act on it and to guide pandemic response.

[J.B. WOGAN]

I’m J.B. Wogan from Mathematica and welcome back to On the Evidence, a show that examines what we know about today’s most urgent challenges and how we can make progress in addressing them. On this episode, we’re talking about the use of wastewater testing for monitoring the spread of the novel coronavirus known as SARS-CoV-2, which causes COVID-19, plus its viral variants like delta and omicron. And what we’ll be exploring in this episode specifically is whether this valuable public health tool, which has expanded in use during the pandemic, can also advance equity.

A little background is in order. About 80 percent of U.S. households are connected to a sewer system. People infected with SARS-CoV-2 and its variants shed the virus when they go to the bathroom, and that includes asymptomatic people who may not even know that they are infected. Before the pandemic, staff at almost 15,000 wastewater treatment plants around the country were already collecting samples to detect pollutants in sewage and sewer runoff. With the arrival of COVID-19, many municipalities turned to this existing infrastructure to conduct rapid repeated communitywide viral testing. In some places, wastewater testing has functioned as an early warning system, alerting local public health officials about new infections in the community.

Wastewater testing for infectious disease, sometimes described as wastewater epidemiology, is not new. In the past, it has helped detect outbreaks of pathogens like poliovirus and typhoid. But public health officials are still learning how to make the most of the data when dealing with a pandemic. To that end, the Rockefeller Foundation’s Pandemic Prevention Institute has established a Wastewater Action Group. As the name suggests, the group’s mission is to translate wastewater data into public health action through collaboration. The group includes leading researchers and public health officials in tribal nations as well as four U.S. cities, Atlanta, Houston, Louisville, and Tulsa.

One of the broad questions the Wastewater Action Group is grappling with is, how do we use wastewater testing in an equitable way? To the extent that this can be a valuable tool for preventing disease spread, how do we make sure that all communities benefit? And for communities whose residents have been at higher risk of infection, severe illness, and death during the pandemic, but who also have good reason to be skeptical about any new surveillance or collection of their data, how can we ensure wastewater testing helps rather than harms those communities? My guests for this episode are wrestling with those exact questions.

Otakuye Conroy-Ben is an assistant professor of Environmental Engineering at Arizona State University, and Na’Taki Osborne Jelks is an assistant professor in Environmental Health Sciences at Spelman College. Otakuye and Na’Taki are two of the researchers involved in the Wastewater Action Group and they are part of wastewater testing initiatives in the American Southwest, the Northern Great Plains, and the Atlanta metro area. My third guest, Aparna Keshaviah, is a principal researcher at Mathematica who has led wastewater-based research in Montana and North Carolina, and is currently providing technical assistance to the Rockefeller Foundation and its Wastewater Action Group. I began the interview by asking Otakuye to explain how the tribal nations she’s working with are using wastewater testing to inform public health decisions.

[OTAKUYE CONROY-BEN]

So, I work in tribal communities, primarily in the Western United States. And we have been collecting wastewater probably since the mid-2000s, a few months after the pandemic started. And in our particular project, we’re looking at the trends ongoing when it comes to COVID concentration levels. So, we would actually be looking to see if the levels increase or decrease. And, in that way, we can inform the utilities as well as the department health administrators, you know, maybe what to expect when it comes to clinical cases.

[J.B. WOGAN]

Na’Taki, what about you, where are you working, which communities do you serve, and how are you using the COVID-19 wastewater data to serve them?

[NA’TAKI OSBORNE JELKS]

I am working in the City of Atlanta. I am a professor and researcher at Spelman College, which is on the west side of Atlanta, but working with a team out of Emory University and the Global Center for Safe Water. The group at Emory has been engaged in this wastewater surveillance work for several months now, and they are looking really at different parts of the city, working in collaboration with the City of Atlanta’s Department of Watershed Management. And we’ve been engaged in conversations with our local health departments, the Fulton County Health Department, as well as the local school system, the Atlanta Public School System.

And what our hope is is to use this data to inform ultimately community members, community organizations, including communities of faith who are – you know, it seems like have been on pins and needles trying to figure out the right approach to things like reentry. You know, they’re trying to get a grasp of what COVID positivity rates look like in our community, you know, what’s the level of community spread. And while we know that we can look to tools like diagnostic testing, we also, you know, recognize that this more passive surveillance can also give us some key information about what’s happening in our community.

We’re also working with, in addition to local government, you know, working with local school systems and really trying to share that data. There’s a lot of interest, you know, in this data as schools are being faced with the decisions that they need to make or maintain to keep kids safe in school. So, for us, it’s really all about being able to understand what’s happening, share that information with the community, and co-create with these various entities in the community, ways that they want to be able to utilize this information to inform their decision-making.

[J.B. WOGAN]

Okay. Great. And you mentioned communities of faith. I’m just curious, are there special considerations, anything specific to communities of faith in terms of their, first of all, heightened concerns around COVID-19 but also why they might be more eager to return to normal?

[NA’TAKI OSBORNE JELKS]

This – you know, in my experience, as someone who belongs to a community of faith, you know, in the Atlanta area, even throughout Georgia, you know, there are some key concerns really only go back to the very early days of the pandemic. In South Georgia, we actually had some hot spots in Albany, Georgia, for instance, that were tied to a couple of funerals that had happened on one day, where, you know, folks who attended those funerals, you know, many of them contracted COVID, and some people ended up, you know, dying from that infection. So, for churches and other communities of faith, this has been a real issue, you know, how do you pull people together.

And kind of part of the foundation of these faith communities is the ability to be in fellowship with one another, to be in person, and to be connected. So, a lot of communities of faith have had to take their worship services, prayer meetings, et cetera, online, which is sort of – it kind of goes against the grain in terms of being a part of a community of faith, and it’s something that these faith communities have had to do, but it’s been challenging. You know, when the weather is nice, you see a lot of faith communities having some services and activities outdoors, but when we’re in the winter or when we’re having inclement weather, it’s not as feasible to do those things. So, churches and other communities of faith are really – I think there is this heightened awareness, heightened sensitivity because they would like to get back to business as usual.

And some churches and faith communities have – you know, they have returned, but they, in most cases, have protocols in place and they are asking themselves what more can they do to make sure that their congregations are safe, that their parishioners are safe. And in some cases, when we’ve seen some of the surges happen, you may have had some faith communities or individual churches or mosques or synagogues that had planned to reopen but, because of surges with the delta variant and then later with the omicron variant, they had to dial back some of those plans because they were not as confident, given the level of community spread, that it was safe to get people back together, even using public health measures and protocols. So, this community has been hit really hard, you know, kind of like schools were hit really hard. And now we’ve gotten our kids back in school, but, you know, the churches and faith communities are not all back just yet.

[J.B. WOGAN]

Okay. That’s really helpful. Aparna, you’ve been involved in piloting wastewater testing for COVID-19 in your home state of North Carolina. How are the counties in your area using information for wastewater testing and how does it supplement other kinds of information public health officials in your state are monitoring?

[APARNA KESHAVIAH]

Yeah. So, I live in the mountains in Western North Carolina. And since the summer of 2020, we have been working with officials in Jackson County, who I’m proud to say were actually one of the first – were the first in the region and one of the first across the state to leverage wastewater testing for pandemic management. It’s been really an incredibly successful collaboration, in part because partnerships that are needed between the public health department, the utility, and local government officials came really easy here. You know, this is a rural region with relatively small communities, and community is really valued in the Appalachian Mountains. So, that was kind of an easy thing to launch here.

On a weekly basis, we are sending the Jackson County Department of Public Health memos that describe trends in wastewater viral concentrations. And we’ve heard that they’ve tailored communications to the public based on the fact that wastewater data have provided an early warning to them of new outbreaks, of entry of the delta variant, and really their use of wastewater data aligns with results from a national wastewater survey that we recently administered. So, we launched the survey to assess the role of wastewater surveillance and pandemic management and surveyed about 200 public health agencies across the country. And what we heard is that public health agencies most commonly have been using wastewater data to tailor communications to the public. And then secondarily, they’ve also used the data to inform how to adapt testing and mobile vaccination to communities that need it most.

[J.B. WOGAN]

Otakuye, Aparna mentioned that Jackson County embraced wastewater testing for this purpose, and I’m curious, with the communities that you’re working with, what is the reception like, what is the perception of wastewater testing? How do people feel about using this way of monitoring sort of the crests and falls of COVID-19?

[OTAKUYE CONROY-BEN]

I would say with the tribal communities that I’m working with, there has been mixed reception, but more often the case is the tribes are welcoming of this, the type of methodology to collect wastewater and inform community health levels. When we started to reach out to tribal communities, we have to go through a process, obviously, of approvals and coordinating with the utility and the health department, but for tribal communities it’s a bit more involved because of the hesitancy to conduct research and surveillance. And so, we do have to go through IRB or their tribal council to get this type of approval.

We actually started wastewater surveillance with a particular tribe in 2017 and they enthusiastically welcomed this type of monitoring because it was not invasive and it was not – we were not requesting biospecimens, which tribal communities are hesitant about, just testing urine, blood, and so forth. And so, they thought that this was a way to get to that health information, that health data stream for looking at drugs and abuse, other infectious diseases, and pollutant exposure.

Where I’ve had tribes kind of shy away from this is really more related to staffing. There are not enough wastewater personnel to assist with sampling. One tribe didn’t think that this data would really help them through the pandemic, that they were monitoring trends with their own clinical testing. And for other tribes, you know, they welcomed this type of research, but perhaps they don’t have research protocols in place, and so we really can’t assist them without having those legalities between the tribe and an academic institution detailed before we start sampling. But I would say, overall, tribes, they recognize that this is innovative and, wherever they can, they do try to implement this.

[J.B. WOGAN]

Okay. And I was reading about your work on wastewater epidemiology in an article on the University of Notre Dame’s website, where you earned a Bachelor’s Degree in Chemistry I also learned, and you make the point in the article that there can be some mistrust between tribes and researchers because of historical examples of researchers misusing tribal members’ data. And because of that history, you say that researchers today need to take time to rebuild that trust and make sure that the data is ultimately handed back to the tribes. Is that a feature of your wastewater work here? Do the tribal nations get to decide what happens with the data and how they are used?

[OTAKUYE CONROY-BEN]

Exactly. In general, tribes have the right to – they have their own data sovereignty policies for data sharing, data ownership. And if any data is collected within their reservation boundary, and some even with tribal members, like if you interview a tribal member, that information is owned by the tribe. And as a researcher, I recognize that. Federal agencies do as well. ASU does. And so, you know, we generate this data, we share the data back with them. In the IRB, they may specify how that data can or cannot be shared, and that’s the reason why I don’t mention the tribes I’m working with, nor have we shared publicly the data. There is a case, a paper will be coming out soon on a wastewater study where the tribe is anonymized, the data is available, but the hard data, original data is with the tribe.

[J.B. WOGAN]

Okay. And I believe I read in one of the news releases or one of the articles, there was a story of the surrounding communities having a decline in COVID-19 but it turning out that in one of the tribal communities, that the decline wasn’t happening and it allowed for a response in certain focused resources for that community?

[OTAKUYE CONROY-BEN]

Yes. So, in this particular tribal community, you know, it’s a community of three or four towns, very small towns, and they lumped all of the data from that region into a single line. And the clinical cases showed that, you know, there’s not really an issue for this particular tribe. But when we sampled the wastewater, a specific sewer line from one of the towns, from one of the housing subdivisions basically, showed very elevated levels compared to the other communities we were collecting from. So, we were able to discuss with the utility and health director what was going on.

[J.B. WOGAN]

Interesting. All right. Na’Taki, sorry, I went deep with Otakuye, but I’m curious, are there parallels in Atlanta in terms of the considerations when you begin wastewater testing in the community, and how has the community perceived and received the use of wastewater testing?

[NA’TAKI OSBORNE JELKS]

Well, in Atlanta, I would largely say that there is some curiosity around wastewater surveillance. Some people see it as something that seems innovative, pretty interesting, but I’ll be honest in saying that, you know, our work is still very early in terms of the community engagement stages around it. So, the wastewater surveillance work has started, you know, in part with some partnerships with local government, you know, happening kind of, you know, using water from the influent lines coming into wastewater treatment plants, for instance. But as we talk about some of the monitoring or surveillance that’s happening or starting to happen, you know, within communities, kind of near schools, getting samples from manholes, et cetera, you know, this is the time that this conversation has begun with these other entities, just to understand how receptive they would be.

So, you know, a lot of the institutions, like the school system, for instance, is very interested in the data, wanting to have data close to the schools to understand what might be happening in the schools. But still, on the community side of things, we’re just early on in this process. So, part of our work here in Atlanta is to engage community champions, to really talk through these issues with them, to understand what their concerns are with respect to how close this testing gets to various communities of concern. And so, we want to be very open-minded about hearing those concerns.

I believe that, based on my experience working at the grassroots community level, doing a lot of community-based participatory research and just community-engaged research in general, what I believe we’ll see is probably a mixed reception as well. Some folks who will, again, be very curious about it, think it’s very innovative, but there may also be some concerns just about the oversurveillance of our communities. Many of the communities that I work in in the Atlanta area, when you talk about communities of color, we talk about low-income communities, many communities feel very overstudied yet underserved at the same time.

So, there will be, I’m sure, questions around, once we have this data, what will it change, how can it be used to direct resources or to inform decision-making in a way that will improve the health of the community. So, those are the types of things that I anticipate people will be very concerned about. And I think that as the word gets out a little bit more and community organizations and community residents are engaged fully, that there will be both that curiosity and interest, as well as some concerns about how we can really use this data in a meaningful way, and how we can also make sure that communities aren’t harmed, that they aren’t stigmatized, that they are not further marginalized in any ways as a result of what might come from our read of the data.

[J.B. WOGAN]

I think one other piece of context that might be helpful for listeners is to know that while we’re talking about COVID, we’re talking about wastewater testing in the context of monitoring the rise and fall of COVID-19 and its variants, that the same tools can be used for other purposes, including the presence of illicit substances or drugs like opioids, and that there might be different feelings about sort of being lifted up as a community or a neighborhood that has a spike in drug use, that there might be sort of additional stigmas or different stigmas and a desirability there about being identified in a public way with that kind of data.

[APARNA KESHAVIAH]

Yeah, I mean, that registers with our experience at Mathematica. We actually began wastewater surveillance during the opioid epidemic because we heard that communities were lacking good data on drug use in communities. And in the U.S. as a whole in I think it was the late 1990s, early 2000s, the Office of National Drug Control Policy did a pilot test of wastewater surveillance for capturing community drug use. And they found that it was incredibly valuable because it provides information on amounts and types of drugs used, kind of the mix in a community and how that changes, but there was a real concern when you don’t have broad surveillance in place and you kind of have this spotlight surveillance, that communities can be stigmatized by the results. So, I think there’s still a real need to develop ethical frameworks in this field. Maybe it’s been less relevant for COVID because it is so widespread, but you’re right that with drug use and other kind of stigmatized behaviors it’s a greater, more salient concern.

[J.B. WOGAN]

Gotcha. Okay. Thank you, Aparna. So, getting back to the use for COVID, there are other ways of monitoring the prevalence of COVID in communities. I’m wondering how is wastewater testing helpful in areas where there is limited or inequitable access to other kinds of – to say individualized diagnostic tests for COVID? Maybe – I don’t think we’ve – maybe we go back to Otakuye because I think we just heard from Na’Taki and Aparna.

[OTAKUYE CONROY-BEN]

Right. So, this is particularly useful in tribal communities in remote areas where there is wastewater infrastructure but perhaps people are apprehensive about just going in to get testing. The COVID pandemic itself really highlighted the failures in just basic infrastructure in tribal communities when it comes to water and wastewater. And so, as a researcher, we first had to address that. You know, where could we implement this type of study and then, you know, how can that either complement clinical data or how can it be used in the absence of clinical data. So, quite a bit of background research had to be developed before we actually started working with tribal communities.

 

[J.B. WOGAN]

Okay. And, Aparna, I remember way back at the beginning of the pandemic, when we were first – I was working with you on putting something on our website about the use of wastewater epidemiology and surveillance for the pandemic, and you were excited about the potential advantages or ways that this could complement the data that we were getting from individual tests. What were – if you could expand upon that, like, what did you see as the opportunity in terms of offering something different compared to the kind of individual swabs that, unfortunately, we’ve become too accustomed to in the past couple years?

[APARNA KESHAVIAH]

Yeah, I think the rural communities, there’s two key advantages, and this aligns with what Otakuye was saying as well. So, in poorer rural communities that aren’t well-connected to healthcare systems, a lack of means, a lack of transportation or lack of time can make it really difficult to get a clinical test. So, because wastewater surveillance doesn’t require people to present for testing for their infection to be registered, it’s an incredibly valuable complementary data source, and it’s one that also captures asymptomatic infections, which clinical testing doesn’t.

Secondarily, the fact that wastewater surveillance taps into existing infrastructure, not just kind of the sewer system, the pipes, but also sampling that’s done daily at wastewater treatment plants across the country to assess water quality has helped it thrive in rural regions. That’s, in part, because rural communities need to be more self-sufficient. So, they’re less visible, right, than their urban counterparts. They’re not featured on the nightly news, you know, in the same way that New York City might be. You know, if you look at kind of New York City versus rural communities in the early days of the pandemic, New York received tremendous assistance. So, there were military medical teams deployed to area hospitals, doctors and nurses flew across the country to support pandemic response there.

And, you know, a lot of rural communities didn’t receive that same level of support when SARS-CoV-2 first entered their region. And not only that but people emptied out of the cities and came to Western North Carolina, they came to rural regions because it’s easier to social distance, because it’s beautiful here. So, that increased the risk for COVID transmission and the potential strain on systems here. So, not only are they not getting the same level of support, you know, they’re also being kind of overly strained because of that mass exodus from the cities into rural communities.

[J.B. WOGAN]

Na’Taki, what about in Atlanta, have you seen – I know you said that it’s more nascent, the effort is earlier on in terms of wastewater testing there, but at least in terms of what the potential could be, do you see there being opportunities to help where there is limited or inequitable access to individual tests?

[NA’TAKI OSBORNE JELKS]

I definitely think there’s a lot of potential in using this wastewater surveillance data in a place like Atlanta. You know, we’ve seen an ebb and flow in terms of availability of diagnostic testing sites. When we’re in these surges, there tend to be multiple opportunities, maybe a testing site on any given corner within the city or definitely in certain parts of the community. But as those case numbers go down just a little bit, you see some of the accessibility waning just a bit.

If I think back really to the beginning stages of the pandemic, you know, the communities who really most needed diagnostic testing just didn’t have access to it. While that has changed over time, there’s still that potential that this sort of data can stand in the gap when those testing resources are not as readily available. We know it costs money to keep these testing facilities going. People aren’t charged for the testing. So, over time, there is a considerable cost associated with things. So, when you do that cost-benefit analysis, that might mean that some sites close up and don’t reopen. So, there is that potential to be able to use this data to help better understand what’s happening in terms of positivity rates in our local community.

[J.B. WOGAN]

Okay. Excellent. Na’Taki, I want to stick with you for a second and I’m going to ask you to do a little definitional work here as well. I want to talk a little bit about environmental justice communities and what wastewater testing would mean for them and, you know, both how it might empower environmental justice communities but also how it could potentially threaten or marginalize them. And, first, if you could just give listeners who aren’t familiar with that term, what do we mean or what should they have in mind when they’re thinking about an environmental justice community?

[NA’TAKI OSBORNE JELKS]

When I speak of environmental justice communities, and other people call them sometimes environmentally-overburdened communities, I’m thinking about those communities that are disproportionately impacted by exposure to environmental toxicants, hazards and stressors. I think that it’s also important to recognize, as we talk about COVID-19 prevalence across the country, COVID-19 hospitalizations and deaths, you know, many of these same communities who we call are considered to be environmental justice communities have been hardest hit in terms of COVID cases, hospitalizations, and even deaths.

So, I also would maybe lift up this idea, sometimes in public health we talk about the social determinants of health, you know, the conditions that people are born into, that they grow up in and live in that also impact health status. So, we’re talking – we’re moving beyond biological factors, but things related to income level, geography, place, you know, where one might live and what they might be exposed to in that community or even in a work environment. So, when we talk about environmental justice communities, we’re talking about these communities who have been made to be vulnerable because of a wide variety of factors. And these are the communities who I think can benefit from use of this wastewater surveillance data.

When you talk about this data helping to be that early warning sign of what’s happening in communities, especially in the absence of having a significant amount of diagnostic testing data, I think it’s really up to those communities with their sense of self-determination to determine or to decide how this data is used and how they can use it to push for the types of changes that they need to see happen, whether we’re talking about more resources that are focused on things like diagnostic testing or whatever the communities deem as being most important in terms of how this pandemic is impacting them. So, I think that potential is there, but the communities really have to be at the table themselves. They have to be brought in and it has to be a process of kind of co-discovery and perhaps cocreation of the strategies that can be most protective of communities. So, having researchers in universities, academics, whoever is engaged in this wastewater surveillance, you know, really needs to partner in a very authentic way with those communities.

[J.B. WOGAN]

It doesn’t sound too different in principle from what Otakuye was saying about the needs to be building authentic and strong relationships with the community. She was talking about it in terms of tribal communities, but it sounds like the same principles would apply here, and also in terms of making sure the data is being used in a way that the original sort of generators or owners of that data would feel comfortable.

[NA’TAKI OSBORNE JELKS]

Yeah, I think there definitely are a lot of similarities. So, you know, communities want to be at the center of this process. And while a lot of our environmental justice communities, if they are not tribal communities, may not have their own policies around data sovereignty, more and more, I am seeing the development of these kind of community IRBs, if you will, where communities are beginning to be very savvy about the research that is conducted within their borders, and very intentional about from the outset, you know, talking about ownership of the data, how that data is used, and they’re looking for outcomes beyond publishing academic papers. But it’s all about how can we change policy, how can we change practice in a way that improves health outcomes.

[J.B. WOGAN]

Okay. Thank you, Na’Taki. Aparna, I want to turn back to you now. We’ve talked a bit about the expansion of wastewater testing and the potential of wastewater testing, but we haven’t figured everything out yet. What are the challenges with reporting and analyzing wastewater today, and what can be done to address those challenges?

[APARNA KESHAVIAH]

Yeah, so wastewater surveillance for COVID has been underway for, you know, one to two years now, but there’s still this huge need to translate the data into simple metrics that can inform public health action. Data streams are improving, and so public health officials now have several indicators they can routinely review, but each of these indicators has its own bias, has its own limitation. So, what that means is that they don’t always align to tell the same story. So, the challenge is how do you unite these different data sources to give officials a more comprehensive and holistic picture of risk and how that risk is changing over time.

So, Mathematica and some of the Rockefeller grantees are developing a multi-indicator risk score that synthesizes wastewater data with other public health data sources. You know, we’re in the process of defining these new metrics and validating them on large datasets to determine if they’re really robust across different types of communities and communities that range in demographics, size, and the methods that they’re using for wastewater sampling and testing. So, really, kind of that focus on reporting, there’s been a lot of work around validation of lab methods, but less attention paid to how do you use that data once you have it in hand.

[J.B. WOGAN]

Okay. That’s interesting. I remember in a paper that you published last year, one of the points you made was that – that you and your coauthors made was it’s been great that there are so many communities across the country that are now doing wastewater testing for COVID-19 but that it’s almost as if there are hundreds of pilots, that they’re not all kind of using the same practices, that if we want to get to sort of a national system that can work going forward, they’ve got to get more on the same page.

[APARNA KESHAVIAH]

That’s right, yeah. I mean, there’s still more to be done to figure out how do you scale this up in a way that there’s equal access, there’s equal opportunity. A lot of the early success stories came out of places that had a university researcher that was a specialist nearby, right, that happened to specialize in virology or environmental engineering and was doing wastewater surveillance already. And that kind of put those communities at an unfair advantage, which was maybe okay early on, but as CDC and HHS kind of scale this up and develop a national wastewater surveillance system, it’s important to make sure that communities that might not have that specialized knowledge nearby also are included in kind of the wastewater surveillance systems that get developed.

So, yeah, I think it’s kind of figuring out are these data kind of representative, are they being studied in the right communities and diverse communities across the country, and then are the data being reported in a way that people who don’t have specialized knowledge of virology and viral concentrations, can they make sense of this data to quickly act on it and to guide pandemic response.

[J.B. WOGAN]

The last question I wanted to ask, and this question is really to the group, as wastewater testing becomes a more prominent public health tool for monitoring and managing infectious disease prevalence in the United States, and that goes beyond the current pandemic, what needs to change to make sure it benefits everybody? Otakuye, do you want to start us off?

[OTAKUYE CONROY-BEN]

So, when we were analyzing which tribes can use this type of surveillance, we went through the EPA database and special wastewater permits, we found that only 100 out of 574 tribes have the infrastructure to do this type of work. But even with that, it will take additional work on the researcher’s part to navigate the tribe’s research policies, to figure out where is the best place to sample, how can we build up the staffing within tribal communities to do this type of work, if they’re interested, and also for the tribes that I’m working with, even just collecting samples is difficult. The distances are far. We have to fly places and they don’t really have autosamplers built into their infrastructure, which I think would definitely help elevate this type of work. So, it really is working with the tribe to leverage this work.

[J.B. WOGAN]

For folks who might not know exactly what autosamplers are, I mean, I have – I can kind of guess based on the name, but what is auto-sampling and why might that be a benefit to have?

[OTAKUYE CONROY-BEN]

Right. So, the standard is, for wastewater surveillance, is to use a type of robot that pulls from the wastewater sewer line or from the headworks of the treatment plant over 24 hours. So, that’s really the standard, but tribal wastewater infrastructure is different. Most facilities are lagoons and we cannot sample from a lagoon. So, we’re out in the field, upstream of the lagoon, popping manholes and installing these autosamplers in the sewer line. There are some tribes that have nicer, refrigerated, they’re located in sheds or structures, have autosamplers there. And I think just doing that would help a lot of tribes, particularly the ones that have embraced wastewater-based epidemiology.

[J.B. WOGAN]

Okay. Great. Aparna, how can we make sure that the future of wastewater testing benefits everybody?

[APARNA KESHAVIAH]

Yeah, building on what Otakuye mentioned about not all tribes being connected to a sewer system, no one’s really been looking at whether communities connected to a sewer system differ in important ways from those not connected. You know, what is the generalizability of this data? And so, we’re starting to explore that now in North Carolina, in collaboration with the North Carolina Department of Health and Human Services. We’re comparing the demographics of sewered and unsewered populations to see, are there still some population groups that remain overlooked because of a lack of a sewage infrastructure? Wastewater surveillance is better than clinical testing in the fact that it covers broad swaths of the country, but 25 percent of Americans are still not connected to a sewer system and they’re underrepresented in the state or not represented, and is it important – I mean, it is important, I think, to know who these 25 percent of Americans are. So, that’s one.

And then, secondly, I would say that as CDC funds states to build the capacity for wastewater testing, so not all labs have the methods in place to process wastewater samples, which present unique challenges compared to clinical samples, so as state labs build capacity, it’s important to make sure that rural communities have access to those types of labs and the specialist knowledge needed so that it’s not just the urban centers that happen to have, you know, that university researcher or state lab in the capital, but also communities on the outskirts, that they also have an equal chance to participate in these types of systems and surveillance.

[J.B. WOGAN]

What would you say, Na’Taki?

[NA’TAKI OSBORNE JELKS]

For this type of data to benefit everyone, you know, I think that those who have a potential to be most impacted just have to be at the table. While we look at wastewater surveillance as something that is passive, we’ve already discussed ways that, especially if we go beyond COVID-19, which is pretty prevalent throughout our society, when we began to look at other things, there is that potential for communities to be stigmatized and to be marginalized. So, making sure that those community voices are at the table, talking about how this data is collected, who owns the data, how it’s used is going to be critical.

You know, it seems for many it may be a novel or very innovative thing, but I don’t think that we quite know enough, I don’t think that we’ve delved enough into any sort of ethical framework around this sort of activity, and we need to ask some of those hard questions and delve into this from that perspective. But I think having those diverse voices at the table is part of the key to making sure that we cover and really explore the issues that need to be explored to ensure that this is something that can actually be beneficial for all and harmful for no one.

[J.B. WOGAN]

Thanks to my guests, Otakuye Conroy-Ben, Na’Taki Osborne Jelks, and Aparna Keshaviah. In the show notes, I’ll include additional resources you can read to learn more about the Wastewater Action Group as well as other efforts by the Rockefeller Foundation and Mathematica to address the COVID-19 pandemic.

As always, thank you for listening to On the Evidence. There are a few ways you can keep up with the show. Subscribe wherever you listen to podcasts. You can also learn about new episodes by following up on Twitter. I am @jbwogan. Mathematica is @mathematicanow.