From the WebMD Archives

April 28, 2020 -- Given the shortage of COVID-19 testing, it’s hard for any community to gauge how widespread the disease truly is. Now, researchers in places as far-flung as Montana, Paris, and the Netherlands are using a proxy: measuring levels of the coronavirus in untreated sewage to see how much the infection is circulating among people.

“This is a really effective way to do surveillance,” says Blake Wiedenheft, PhD, an associate professor of microbiology and immunology at Montana State University in Bozeman. The virus has been found in the feces of patients who have tested positive.

Coronavirus in Context: COVID-19: Disparities, Reopening and Best InformationWebMD's Chief Medical Officer, Dr. John Whyte, speaks with Dr. Richard Besser, President of the Robert Wood Johnson Foundation about disparities, reopening the economy, and the CDC.793

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JOHN WHYTE: You're watching

Coronavirus in Context.

I'm Dr. John Whyte, Chief

Medical Officer and WebMD.

I'm delighted to be joined today

by Dr. Richard Besser.

He is the CEO and president

of the Robert Wood Johnson

Foundation.

Dr. Besser, thanks for joining

me.



RICHARD BESSER: Thanks, John.

It's great to be here.



JOHN WHYTE: I want to start off

with the issue of disparities.

Your foundation has always been

interested in addressing

disparities.

And in some cities

of the country, we're seeing

six times the death rate

in minority populations.

What are we doing,

and what should we be doing,

to combat this racial disparity

in COVID-19 cases and deaths?



RICHARD BESSER: Yeah, I-- you

know, I--

I think

that's-- that's a critically

important question.

Uh, if-- if you think about how

society was, uh, several months

ago before this crisis hit,

uh, for many in America,

uh, they were living on--

on the edge.

Millions of people in poverty,

uh, millions of people who live

paycheck to paycheck, uh,

major health disparities.



Uh, you know, I live

in Princeton, New Jersey,

where-- where a child born here

has a life expectancy of 87

years.



JOHN WHYTE: Wow.



RICHARD BESSER: 15 miles down

the road in Trenton, New Jersey,

same--

same county.

It's our-- it's our state

capital.

Uh, a child born there has

a life expectancy of-- of 73

years.



JOHN WHYTE: Mmm.



RICHARD BESSER: So you have

major disparities to begin with.

Um--



JOHN WHYTE: Pre-COVID-19.



RICHARD BESSER: Yeah,

before COVID-19.



JOHN WHYTE: Yeah.



RICHARD BESSER: And then

COVID-19 comes.

And you have-- you know,

there's a lot of reasons going

in here, but a lot more work has

to be done.

You have very high proportion

of-- of black and Latino, uh,

uh, people in this country who

work in what are considered

essential occupations.

Uh, and with that, they are

putting themselves at risk.

They're putting themselves

at risk to make sure we have

food on our tables,

that our streets are

safe and clean.

Uh, many working in-- in homes

as-- as, uh, home health care

workers, in hospitals.



And so if you're on the front

in these jobs and you don't have

personal protective equipment,

you're at increased risk.

Um, millions of people

in this country without health

insurance.

And so when they get sick,

um, might be slower to be

tested, slower to be treated.

So lots of factors here.

Lots of things that can be done

right now

and need to be done right now.

Uh, but a lot also comes down

to-- to structural racism

and-- and where we were

as a society when this started.



JOHN WHYTE: Will more testing

help address this issue?

Because if we don't know someone

has coronavirus, we can't help

treat them.

Or is not-- not as important,

right [INAUDIBLE]



RICHARD BESSER: Well, I--

yeah, I-- I think testing is

really important.

But it's also important who

is getting tested.

We're not seeing statistics

on testing by population,

testing by race and ethnicity.

Um, as we move forward

with testing--

and testing is going to be

critically important when we

move from a strategy of everyone

stays at home and-- and hunkers

down to one

where you try and identify cases

quickly and-- and provide

isolation, uh, contact tracing,

and-- and quarantine.

Um, as you move to that kind

of system, we want to make sure

that testing is

available for everybody.

Um, otherwise you're going

to-- you're going to further

amplify the disparities that we

see--

we see at present.



Uh, and most-- most locales are

not reporting data by-- by race

and ethnicity for cases

and-- and deaths.

And I haven't seen any data, uh,

broken out that way for testing.



JOHN WHYTE: And lately we've

been shifting our focus

onto antibody testing.

And there's been a concern

that many of these tests,

especially point of care

testing, are not as accurate

as we need to be.

Or they're not quantitating

the type of antibodies that

might be important in conferring

immunity and protection.

Wh-- what are you hearing

about antibody testing

and where we might need to be

going?



RICHARD BESSER: Well, yeah,

antibody testing is going to be

very useful, very important.

Uh, but for it to be used

for public health purposes

or for clinical decision making,

it has to be tested.

It has to be validated.

And FDA has made the decision

to let a lot of tests

go forward without external--

without, uh, scientific

validation apart from what

a company does.



And so until

there's-- there's further

testing on this, um, and we

don't know at this point, uh,

whether a positive test truly

means someone has had a COVID

infection before or whether it

might, uh, be reacting to some

other type of virus that

a person had-- had

in their life.

We don't know what levels

of-- of antibodies

or protective factors

might suggest that a person is

truly protected.

Uh, we don't know

that if someone has protective,

uh, levels that they--

whether or not they could get

infected again

or spread the disease to someone

else.

So--



JOHN WHYTE: So why are we doing

them?

[LAUGHS] Why-- [INAUDIBLE]



RICHARD BESSER: Well, you know,

it-- they're impor--

it's-- it's important

to-- to get tests that are

validated.

But it's definitely too soon

to be making any decisions based

on these.

Uh, it's-- it's way, way early.



But you know, I--

I worry that so frequently what

we hear in the media are these

magic bullets without, uh,

taking the time to explain

the science that has to be done

to make sure they're--

they're used properly

and we understand what

the results mean.



JOHN WHYTE: You're

on this multi-state regional

council to reopen the economy.

And everyone's talking

about, uh, whether or not it's

too early, or is it OK to do.

What do we need to know,

and how do we decide?

And-- and what are you thinking

about as you're part

of this council to-- to reopen

the economy, reopen the state,

however we want to phrase it.



RICHARD BESSER: Yeah.

Well, you know, I think we want

to do this carefully, slowly,

and-- and based on the best

available public health science.

And there-- there are a number

of things that have to be

in place to be able to-- to meet

those criteria of doing it

safely.



Uh, the first is you have

to make sure there's

enough capacity in your health

care system.

Because when you start to loosen

up some of these,

uh-- these requirements, uh,

and let people come

out a little bit more,

we are going to see more cases

of COVID.

It's-- it's inevitable.

So you want to make sure there's

enough beds to take care

of-- of people.

There's enough health care

providers.

There's

enough protective equipment

for those people who are-- are

providing that care.



You want to make sure there's

enough care

in your-- uh, enough room

in your health care system

to take care of all

of the other medical problems.

You know, they didn't go away

during COVID.

There's still people who need

surgery for cancer.

There are people who need

treatment of their heart

disease,

of their kidney disease,

of their diabetes.

So there has to be room

in the health care system,

or-- or as soon as you start

to-- to loosen things up

and open up,

you'll-- you'll have

an overwhelmed system again.



Then you want to make

sure there's sufficient testing.

Because right now, most states,

most-- most hospitals

are only testing people who are

severely ill.

And we know that there's

a wide range of illness

with COVID.

There's people who have

no symptoms.

But you at least want to be

able to test people who have

mild symptoms.



JOHN WHYTE: Mm-hmm.



RICHARD BESSER: Because while it

may be mild for them,

they could be the person who

spreads it to someone else who's

at high risk.

So if you can identify everyone

who-- who is sick--



JOHN WHYTE: Mm-hmm.



RICHARD BESSER: --then-- then do

basic public health.

Identify all the people

those people have had contact

with--



JOHN WHYTE: Right.



RICHARD BESSER: --and tell them

to spend two weeks away

from everybody else,

uh, so that they don't spread it

if they get sick.



JOHN WHYTE: What's

the [INAUDIBLE]



RICHARD BESSER: In addition

to that--



JOHN WHYTE: Mm-hmm.



RICHARD BESSER: You need to make

sure that everyone in America

can do those things.

And that means thinking

about creative ways

to provide safe places

for people

to-- to isolate or quarantine.

Hotels, dormitory rooms.

There's all kinds of ways you

can approach it.

But just sending people

home means that you're saying

to those people who live

with someone who's

elderly or live

in a-- a small apartment

with many people

that you don't really care

whether they spread it

to their families.



JOHN WHYTE: You mentioned

contact tracing.

And that's what I was going

to ask you.

Some people have said there's

no way we have

enough public health officials

to do that,

even if we hire 100,000 more

people.



So what's the role of tech?

Google and Apple have been

talking about, hey,

we can use technology--

Bluetooth, location services,

whatever-- to play a role there.

Does that really have a role?

Or is there just

the cultural issues here

in the United States

that we're not going to give up

that amount of privacy

to advance public health?



RICHARD BESSER: You know, I--

I think that technology can be

a tool that's-- that's part

of this.

Uh, but you're not going to be

able to replace the-- the need

for public health workers.

You know, one-- there-- there

are a lot of people who are out

of work.

And so there are people who can

be trained to do this kind

of work.



And-- and one thing--

you know, a-- as you move

towards a strategy

where you're going to try

and identify cases and do

contact tracing,

the public has to believe

that this is in their best

interests.

Contact tracing involves asking

all kinds of very personal

questions

about where you've been,

who you've been in contact with.

And so recruiting people from

diverse communities so that

people are doing contact tracing

in the communities in which they

live would-- would allow people

to--

to, uh, feel more

comfortable with providing

this information,

uh, with-- with participating

in this.



And then, yeah, there are tools

that could be used

to-- to ensure that you're--

you're collecting

this information and sharing it.

One thing that-- that, uh, uh,

you know, this regional group

will-- will be talking about

is, how do you share this kind

of information across states?

Someone in New York City, uh,

isn't limiting their contacts

to people in New York City

or New York state.

You want to make sure that you

can share information

with Connecticut, and New

Jersey, and-- and other places.

And technology, I-- I would

think, would have a role to play

there.



I-- I worry greatly

about the-- the thinking

that technology-- uh, using it

as location trackers would--

would allow you to say where

a person's been and who they've

been in-- in contact

with with devices.

I think it's, uh--

it's a slippery slope in terms

of personal privacy.

And-- and, uh, I think very

few people would trust big tech

with that kind of information.



JOHN WHYTE: You were

the acting director of the CDC

during a different pandemic.

And you were out there every day

talking to the country

about what we needed to do, what

we knew, what we didn't know.

Why do you think we're not

seeing the CDC front and center

during this epidemic?



RICHARD BESSER: You know, I--

I wish I knew the answer

to that, John.

Because I-- I think that--

that transparent, open

communication, uh, was

critically important.

It was a critical success factor

for us in 2009.

And we're missing that right

now.



It's very hard to know what

things we're being told

for public health reasons

and what things we're being told

for--

for policy reasons,

and what things we're being told

for-- for political reasons.

And-- and I found it very

valuable when I was in that role

to have the media asking me

really hard questions.

It improved our work.

It-- it forced us to go back

and say, well, why aren't we

thinking about that?

Why-- why haven't we--

we answered that question?

What can we do to find out

that information?



And-- and CDC isn't getting

that interaction right now.

And the public isn't getting

to hear from the world's best

public health scientists.



JOHN WHYTE: And the media world

has changed since then, even

over the last few years

with the proliferation

of social media.

Everyone who has a blog

seems to be an expert

in-- in public health

and epidemiology.

So what guidance do you give

folks in-- in terms of where

they should go

for that information?

The CDC is a great site.

But let's be honest,

in this day and age,

a lot of folks don't end up

there as-- as well as they

should.

But how should we decide how we

trust the information we hear,

we read, we find online?



RICHARD BESSER: Yeah,

it's-- it's a much bigger

challenge now than it was

in 2009.

It was challenging then

with all kinds

of misinformation--



JOHN WHYTE: [? Sure, ?]

[? yes. ?]



RICHARD BESSER: --and, uh, fake

cures out there on the internet.

But now we have such

a hyper-polarized society

and people getting

their information from, uh--

from very different voices.

Uh, it-- it makes it

challenging.



I-- I tend to recommend

government sources

as a good place to start.

So the CDC website, NIH, uh,

FDA.

FEMA has a rumor control site

that-- that I like.

Johns Hopkins has

a terrific resource center for--

for COVID.

Uh, preventing epidemics, which

is Tom [? Friedan's, ?] uh, uh,

organization out of, uh, New

York has--

has terrific materials.



Uh, and then once you find

a site that is really good, uh,

many of these sites

also have links to other sites--



JOHN WHYTE: [INAUDIBLE]



RICHARD BESSER: --that--

with-- with high quality

information.



JOHN WHYTE: Mm-hmm.



RICHARD BESSER: But-- but just

clicking on whatever someone

shared with you--



JOHN WHYTE: [? No. ?]



RICHARD BESSER:

--on-- on Facebook,

that can lead

to some-- some big problems.



JOHN WHYTE: [INAUDIBLE]

Well, Dr. Besser,

I want to thank you for taking

the time today to share

your insights.



RICHARD BESSER: Thanks so much

for having me, John.

It's a-- it's a real pleasure.



JOHN WHYTE: And thank you

for watching Coronavirus

in Context.

I'm Dr. John Whyte.



[MUSIC PLAYING]

John Whyte, MD, MPH. Chief Medical Officer, WebMD Richard E. Besser, MD President and CEO of the Robert Wood Johnson Foundation/delivery/aws/1d/4f/1d4fe7e6-1b55-3c22-81b7-410960e4db63/Besser_042320_,4500k,2500k,1000k,750k,400k,.mp404/24/2020 10:01:0018001200Richard Besser/webmd/consumer_assets/site_images/article_thumbnails/video/covid19-images/Besser_042320_1800x1200.jpg091e9c5e81ed20e4

Montana reported its first case of COVID-19 on March 12. Gov. Steve Bullock ordered the state’s residents to stay home beginning on March 28.

Aware that the coronavirus (also called SARS-CoV-2) is shed in feces, Wiedenheft and his fellow researchers decided to collect wastewater samples from the Bozeman municipal wastewater treatment plant, which serves the city’s roughly 48,000 residents. They drew the samples from March 23 to April 8.

Then the researchers used the same type of test done in people to detect SARS-CoV-2 levels in the wastewater, with the assumption that the higher the levels, the greater the number of infections in the community.

From March 30 to April 1, they found a significant increase in viral levels.

Then about a week after the governor’s mandate, the levels dropped gradually from April 3 to 6, suggesting the virus was becoming less widespread in the community.

“I think it’s pretty encouraging that the numbers in Bozeman have dipped,” Wiedenheft says. To him, it was a sign that the stay-at-home order was working to curtail the spread of the illness.

The researchers’ study has not yet been peer-reviewed.

Similar efforts to analyze sewage for SARS-CoV-2 are happening around the globe. For example, researchers in Paris sampled wastewater for more than a month and found that a rise and fall in virus concentrations corresponded to an increase in cases, followed by a reduction after the city shut down.

According to a recent article in Nature, more than a dozen research groups in various countries have begun analyzing wastewater to detect levels of SARS-CoV-2. Monitoring wastewater has the potential to provide better estimates of actual viral load in a community because it detects virus from untested people and those with infections who have mild or symptoms or no symptoms at all. But it shouldn’t take away resources from testing individuals, the article says.

While wastewater monitoring provides a general picture, including trends, it can’t yet accurately estimate how many people are infected, Wiedenheft says. Being able to figure that out is complicated because it includes a number of factors, such as how long the virus lives in wastewater and how much virus is being released by a specific person.

“At this point, we can’t make that leap.”

That’s one of the big challenges that researchers hope to tackle, he says. “To be able to do that would be extremely powerful.”

But Wiedenheft and his team were able to trace the “viral ancestry” of the samples. “Our limited sequencing suggests that there’s a single prevalent strain that’s circulating in this community,” he says. Most strains in Bozeman had originated from France, with some from Iceland. Whether a Bozeman resident went to France or a French citizen visited Bozeman is unknown, Wiedenheft says, or more likely, the strain could have already been circulating within the U.S.

Wastewater analysis can also give policymakers information as they decide when to lift shelter orders, according to Wiedenheft. “The concern happening around the country and the globe is this tension about when it’s the right time to lift the shelter-in-place order and when will we know that it’s appropriate to reinstate that order,” he says. “I really think the wastewater testing is a data-based information point, a way to inform those decisions.”

Detecting rising levels of the virus in wastewater could also serve as a noninvasive, relatively inexpensive early warning tool for new or second-wave outbreaks. “If we see [the coronavirus] come back,” Wiedenheft says, “that’s going to be really important information to provide to the policymakers -- to ask if it’s time to reinstate the shelter-in-place order that seems to have been so effective.”

WebMD Health News

Sources

Blake Wiedenheft, PhD, researcher, Montana State University.

Nature: “How Sewage Could Reveal True Nature of Coronavirus Outbreak.”

medRxiv: “Temporal detection and phylogenetic assessment of SARS-CoV-2 in municipal

Wastewater.”

medRxiv: “Time course quantitative detection of SARS-CoV-2 in Parisian wastewaters correlates with COVID-19 confirmed cases.”

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