Project Development and Process
Early in the pandemic, the City of Santa Barbara’s wastewater team began gathering samples from El Estero Water Resource Center to track the COVID-19 outbreaks in the community, investing staff time and funding for third-party analysis to create a baseline and an alternative way for decision makers and health systems actors to track the epidemic locally. Thanks to their vision and tenacity, we have data stretching back nearly to the beginning of the pandemic that we can compare with case counts derived from testing results. This data has proven to be an invaluable tool to health system leaders to validate and test case count data, particularly when we have had significant spikes in cases that saturated our testing capacity or more recently as at home tests have taken an ever increasing role, leaving public health authorities increasingly in the dark about actual case counts in the community.
Over the past two years, the City of Santa Barbara team has made their data freely available to those who have sought it out, but it has not been broadly available. The Santa Barbara Community Health Wastewater Collaborative was launched in late 2021 to expand upon the City’s efforts and to make the available data more readily available. This website is the first iteration of that effort, and is intended to be expanded upon over time.
Background
WWS includes the field sampling, sample analysis, and associated data analysis and interpretation of the makeup of wastewater—aka sewage—to determine what diseases are circulating in the community. Human waste in sewers, wastewater treatment plants (WWTPs) and in septic systems, contains gut microbes—including pathogens—of all people contributing to the system. Analyzing the wastewater for pathogens can show public health managers what is there, and in what amount, and even where, since sewers upstream in communities can also be sampled. This approach enables equitable sampling, since no one needs to be able to pay for testing, while also ensuring privacy is maintained since sample results cannot be associated with individuals. Wastewater also contains chemicals such as prescribed and illicit drugs and tobacco use indicators that reflect the health of the community and point the way to programs and services to address those needs. Until COVID-19, WWS was largely a research arena. It was not widely used to learn how healthy or sick a community is and inform public health decisions such as campaigns to increase vaccination or mask wearing in areas facing outbreaks. The exception was in Israel, where public health officials routinely monitor for poliovirus in wastewater and adjust their vaccination efforts accordingly.
Globally, and across the US, wastewater surveillance (WWS) is now a proven tool for monitoring and early warning of community-wide COVID-19 outbreaks. Yet in Santa Barbara County, the use of WWS is limited to only one or two utilities that outsource SARS-CoV-2 analyses to expensive private sector labs, with only the City of Santa Barbara doing so on an ongoing basis. The Santa Barbara Community Health Wastewater Surveillance Collaborative aims to change that for Santa Barbara County as a whole, making high quality WWS accessible, equitable, and affordable, for all.
Santa Barbara County is a large (ca. 4,000 sq. miles: ocean, mountains, farmlands; 450,000 people) socioeconomically diverse, agriculturally rich, and environmentally important region in California. There are wastewater treatment plants (WWTPs), operated by cities in North County (Santa Maria and Lompoc) and South County (Goleta, Santa Barbara and Carpinteria) as well as sanitary districts that operate sewer systems (Goleta West, Summerland, Montecito, Solvang, Buellton, and the Santa Ynez Community Services District).
However, only the City of Santa Barbara has been using WWS—using private sector services at considerable expense—to monitor SARS-CoV-2 at its WWTP. Yet, there is widespread interest across the County to have access to WWS for its value in tracking diseases, and disease indicators plus related health factors, in the region’s communities. There are also approximately 9000 septic systems in the County, and tracking disease pockets similarly by sampling those systems and analyzing septage would be an important part of the public health toolkit needed in the County.
A Regional Lab
To ensure widespread accessibility of WWS as a public health decision-making tool for Santa Barbara County, we need a local lab to undertake analyses in a timely and cost efficient manner. The lab will extract DNA and RNA from wastewater and analyze it for SARS-CoV-2 or for other pathogens of interest. The lab team will guide where and when to sample, whether at wastewater treatment facilities or upstream in the sewer system to find disease hot spots in the community or downstream where treated effluent flows into the ocean or freshwater receiving streams. The lab team and wastewater utility employees will collaborate to pull samples.
Meeting these needs within Santa Barbara County will require specialized laboratory equipment and a team with the necessary technical expertise necessary to manage the process. A dedicated lab with the proper equipment allows for a high degree of automation so samples from throughout Santa Barbara County can be processed in a timely fashion on a cost effective basis. Such equipment does not yet exist in Santa Barbara County, but the University of California, Santa Barbara (UCSB) has stepped up to offer space and a team with the requisite expertise to both house and operate the lab. We are lucky to have UCSB as a partner bringing their deep experience with WWS and the establishment and operation of lab facilities like this one.
The lab will serve long term needs in state-of-the-art public health assessment in ways that can extend beyond routine monitoring of wastewater that some communities may institute. The lab can flexibly respond to long term, changing community needs including new diseases and their pathogens and chemicals including pharmaceuticals and illicit drugs that provide community health indicators. Based on the characteristics of specific outbreaks or needs, the program can shift where sampling is undertaken at any given time within the system, whether in sewers, wastewater treatment plants, outfalls, outfall plume up to the surf zone in coastal areas, septic systems, groundwater in the vicinity of leaking sewers and septic system leach fields, and freshwater receiving streams like rivers or creeks. The lab will also be able to adapt its approaches as needed to meet these needs and to adopt new methods and approaches as the field evolves.
The Steering Committee
The Collaborative will provide community guidance and oversight to ensure that the lab serves the needs of communities countywide. To do so, the Collaborative is instituting a multi sector governing body to ensure that monitoring efforts are prioritized by the community leaders and that resources are deployed equitably. The governing body will guide the development of the monitoring program in a manner that engages and supports communities throughout the county, support the development of a financial model through public-private partnership that makes the program affordable and accessible to all communities, and guide research priorities to innovate and adapt to emerging challenges and needs.
Future Expansion Beyond COVID-19
Dr. Lynn N. Fitzgibbons, MD Infectious Disease, Cottage Health, identified the following high concern pathogens worthy of community level surveillance over the next 5-10 years:
Respiratory viruses of high concern, including coronaviruses, as well as influenza viruses and other human and animal-host respiratory viruses capable of pandemic potential (It is important to note that respiratory viruses generally cause illness of the upper and lower respiratory tract (nose, throat, ears, bronchi, lungs) but are secreted in the gastrointestinal tract, making WWS the most important leading indicator for a community’s burden of respiratory viral illness. It is also the most effective way to more simply assess if a pathogen is “present or not present” in a binary manner, as would be the most immediate need for the next global pandemic. It is also important to note the sophistication of genomic level surveillance which has matured in concert with WWS over the past 2 years, allowing detection of specific variants or versions of these viruses in wastewater. This will also be an immediate need for the next virus of epidemic (or pandemic) concern.)
Norovirus and other gastrointestinal viruses, which can move quickly through communities and long term care facilities and be difficult to contain
Hepatitis viruses, including hepatitis A, a cause of recent outbreaks in vulnerable homeless populations in Southern California
Poliovirus, the cause of devastating childhood neurologic disease (the era of the iron lung) (Poliovirus was formally eliminated in the United States in 1979 following a very successful public health vaccination campaign, but it is now, sadly increasing in prevalence in areas such as Eastern Europe. The ongoing conflict in Ukraine is causing significant concern amongst infectious disease physicians regarding the potential for a resurgence of Poliovirus, which in the context of increasing vaccine hesitancy in the U.S. is raising concern for rising vulnerability for Poliovirus to return to the US.)
Clostridium difficile, leading cause of severe healthcare associated diarrhea, often following antibiotic use, which can cause life-threatening infections (The epidemiology of this infection is very closely followed by the federal government through the Centers for Medicare and Medicaid Services, due to the association with overuse of antibiotics and an estimated cost to the U. S. healthcare system of $6.3 billion.)
Multiple high grade multi-drug resistant organisms (MDROs) including bacteria and fungi, which have the potential to cause serious illness with few or no treatment options
In addition to infectious diseases, there are many other opportunities within both the clinical medicine and population health realms within which wastewater surveillance can create significant value. These include surveillance of chronic disease-associated biometrics (therapeutic drug metabolites, certain biomarkers of diabetes or heart disease) as well as substance use disorder applications (with opiates and fentanyl, and methamphetamines as high priorities over recent years).
Wastewater surveillance offers myriad benefits to the public immediately for COVID-19 and in the future for an array of diseases and pathogens as well as population health concerns. Wastewater surveillance is a proactive public health management tool that can help our communities build resilience in the face of a growing number of threats and challenges.