The Madison County Department of Health is located in Wampsville, New York. It is predominately rural with a population of 70,941, and a population density of 108 persons per land square mile, compared to 239 people per square land mile in New York State. About 45% of the land in the county is farmland, as compared to the state (24%). Madison County consists of fifteen (15) townships and the City of Oneida. The towns are rural, especially in the southern half of the county, with more suburban areas located in the northern third portion of the county. Madison County’s current economy is based primarily on agriculture. Approximately 14% of children and 8% of older adults currently live below the poverty level in Madison County. In terms of educational attainment, 37.2% of residents have completed high school or GED equivalent and 27.5% have a bachelor’s degree. The percentage of uninsured children and adults, 3% and 7% respectively, has decreased slightly. The majority of residents (96%) speak English only, while nearly 2% speak an Indo-European language and another 1% speak Spanish at home. There are 26 healthcare facilities in Madison County, including diagnostic and treatment centers, residential health, school-based clinics, and hospitals.

Madison County is home to two private colleges, Cazenovia College and Colgate University, and one public higher education institution, the State University of New York – Morrisville.

Madison County Health Department (MCDOH) teamed up with the SARS-CoV2 Early Warning Surveillance Platform (SARS2-EWSP), in a collaborative effort between Syracuse University, SUNY College of Environmental Science and Forestry, and SUNY Upstate Medical University; Quadrant Biosciences; and local wastewater treatment operators to study wastewater in Madison County for early warning signs of COVID-19. Two colleges and one municipality collected samples to monitor for potential increases in COVID-19 transmission in these congregate settings and communities.

The goal of the project was early detection of COVID-19 transmission in both the community and higher education settings. Objectives included the piloting of wastewater surveillance in a rural community, and identification of potential "hotspots" for transmission, particularly in congregate settings.

As a result of the wastewater surveillance sampling and testing, the health department identified a detectable increase in SARS COV2 RNA in samples from the community of Cazenovia New York in early October. These were communicated to the public through a press release and the health department coordinated a targeted PCR testing site, which registered the most people to get tested to that date.

The partnership with both the local and neighboring higher education institutions were a key part of the success of the project, particularly as they were able to contribute in-kind resources and expertise beyond what exists within the local health department.

This effort advances the evidence-base for wastewater surveillance and its potential utility for disease surveillance and early intervention to reduce transmission in both rural communities and closed congregate settings, such as colleges and universities.

During the first wave of the COVID-19 pandemic, Madison County, like many rural counties, had limited access to, or resources for, testing for COVID-19. Wastewater surveillance offered an additional tool in identifying potential community transmission.

Madison County reported its first positive COVID-19 case on March 21, 2020. From that date through the end of 2020, a total of 80,662 tests were performed, with 2,417 positive results. Of that number, there were 68 fatalities to date over the course of the pandemic, with 39 of these occurring in a nursing home setting. Early barriers to testing included lack of supplies, lack of lab capacity, and available state resources focused on areas with higher incidence and population density. Between March 11, 2020, and May 15, 2020, the date Madison County entered Phase 1 of New York’s reopening plan, a total of 2694 tests were conducted, representing just 3% of the total testing conducted to date. One outcome of this early lack of available testing for COVID was that fewer people in the county sought out testing. Lack of testing also challenged accurate detection of disease and understanding of the extent and locations of transmission. Additionally, as the state sought to expand testing resources in rural communities, the health department lacked the available staff to conduct testing, due to the need to focus limited staff resources on contact tracing and case investigation. Given these limits on individual testing, Madison County sought to identify other surveillance tools. Outbreaks in congregate settings, including long-term care facilities, and migrant worker housing, highlighted the need for early detection of transmission in these settings.

Another significant challenge posed by COVID-19 was the negative impact on the local economy as a result of the community mitigation measures implemented by New York State between March and June of 2020. In March, Madison County’s unemployment rate was 5.3%. In May 2020, prior to New York’s phased reopening of businesses, the unemployment rate had reached 11.5%. The implementation of wastewater testing and surveillance for COVID-19 was seen and ultimately used, as an early indicator of increased transmission, allowing both the county and colleges to target limited testing resources to areas of higher risk of community transmission. Identifying potential “hotspots” for transmission allowed for increased public education and targeted testing to reduce community spread and ultimately work to sustain the reopening of much-needed businesses.

With 4600 college students poised to return to the county in the Fall, wastewater surveillance was a promising practice to prevent large-scale outbreaks on campuses and the surrounding communities.

In May of 2020, the New York State Association of Counties presented a webinar on The SARS2 Early Warning Wastewater Surveillance Platform is a collaboration between scientists from Syracuse University, SUNY ESF, and SUNY Upstate Medical. As a result of this effort, New York State chose to pilot Wastewater surveillance but focused their initial efforts in three urban locations in Upstate New York. Madison County proactively reached out to the partnership in Syracuse to pilot wastewater surveillance in a rural community. Madison County leveraged the expertise of its environmental health staff in working with public water supplies and wastewater entities to engage partners in the surveillance effort.

Environmental surveillance is a tried and trusted technology. First developed 20 years ago as a surveillance tool for Poliovirus. Polio paralysis only occurs in 1 in 200 cases, leading to silent outbreaks. Wastewater surveillance serves as a marker to identify transmission in the absence of symptomatic cases. In March of 2020, scientists from the Netherlands produced proof of the presence of SARS COV2 RNA in wastewater samples as a marker for community transmission. Subsequent wastewater surveillance efforts in other countries confirmed that wastewater could serve as an early indicator of increased community transmission of COVID-19. (The Ohio Water Resources Center at Ohio State University includes links to several publications supporting the use of Wastewater Surveillance. https://wrc.osu.edu/wastewater-sars-cov-2/inside-emerging-science-wastewater-surveillance)

Madison County Health Department (MCDOH) teamed up with the SARS-CoV2 Early Warning Surveillance Platform (SARS2-EWSP), in a collaborative effort between Syracuse University, SUNY College of Environmental Science and Forestry (SUNY-ESF), and SUNY Upstate Medical University (SUNY Upstate); Quadrant Biosciences; and local wastewater treatment operators to study wastewater in Madison County for early warning signs of COVID-19.

Syracuse University, SUNY ESF, SUNY Upstate, and Quadrant Biosciences provided the program model, technical expertise, and testing of samples. Wastewater influent samples were collected from the municipality of Cazenovia, SUNY Morrisville’s and Colgate University’s wastewater treatment plants. Samples were collected twice a week and SUNY Morrisville and Cazenovia samples were sent to Quadrant Biosciences for testing and analysis for detection of COVID-19. Colgate University conducted testing for their system. The Madison County Health Department monitored testing results for each college community, individually, along with aggregate data for all three communities. The results were part of metrics established for the colleges for monitoring and early identification of COVID positive individuals in the campus communities. The local data gathered determined a numeric value of “high risk.” Syracuse University developed a Tableau dashboard by treatment plant and will assist in monitoring upticks.

•          Low Risk: SARS-CoV-2 RNA undetected

•          Medium Risk: SARS-CoV-2 RNA detected

•          High Risk: TBD

The wastewater testing was also used as a marker to track the COVID-19 virus in the community as a potential indicator of the absence or presence of positive cases in county residents. The county-wide goal was to potentially identify hotspots earlier in the community to allow for focused public health interventions and community education to help reduce the spread of COVID-19.

As part of their ongoing environmental health services, the Madison County Health Department works with public water and wastewater operators to monitor the safe operation and maintenance of systems, providing guidance and support in maintaining compliance with state laws. Environmental Health staff:

·        Provide technical assistance to public and community water suppliers.

·        Monitor the quality of water to ensure compliance with state and federal drinking water regulations.

·        Inspect public water systems (PWS) for state and federal regulation compliance.

·        Review plans and specifications for new water systems and water system upgrades.

·        Investigate waterborne illness outbreaks.

·        Collect surveillance samples and submit samples for testing.

·        Work cooperatively with the New York State Department of Environmental Conservation reviewing municipal wastewater collection systems.

·        Coordinate operator certification programs and training.

·        Review security and emergency response plans.

The health department also regularly works with the higher education systems both through regulatory compliance activities and through its Community Health Assessment process and the development and implementation of the Community Health Improvement Plan (CHIP). In their current CHIP, local colleges are engaged in addressing the two top health priorities, Substance Abuse, and Lung Cancer, both identified as part of the county’s community health assessment. Colleges are working with the health department and other partners to implement an evidence-based intervention to address binge drinking on college campuses. Additionally, the county is engaged in conducting public health detailing visits to a variety of stakeholders, including the local colleges, to promote smoke and vape-free policies for multi-unit rentals, schools, public spaces, college campuses, and workplaces. These established relationships underpinned this project, which was part of the colleges’ and county’s plans to implement a safe return to campus for the fall 2020 semester. Additionally, the colleges were able to engage students, faculty, and staff in broadening the evidence-base regarding the utility of this public health surveillance tool.

In addition to working with the colleges within the county, the project allowed Madison County Health Department the opportunity to work with the innovative public-private partnership established through Syracuse University, SUNY College of Environmental Science and Forestry (SUNY-ESF), and SUNY Upstate Medical University (SUNY Upstate); Quadrant Biosciences. This has built new relationships with these institutions which may open up future opportunities for the local health department to partner and advance evidence-based research and interventions in the field of public health. Because the New York State-sponsored pilot projects on wastewater surveillance focused on more urban and suburban settings, Madison County’s willingness to proactively engage in this effort provided the opportunity to explore the utility and practicality of wastewater surveillance in rural settings.

In general, testing wastewater is equitable, in that anyone who on the public wastewater system contributes to the sample.  Unfortunately, due to resource restraints, the health department was limited to the initial participating partners, and unable to do multiple test sites which would have enabled them to possibly target specific streets or neighborhoods; while this was a downside to the initial implementation of the practice, the influent samples did capture anyone on the system.

Due to limited funds, the MCDOH was only able to support one testing location for each site (SUNY Morrisville and Village of Cazenovia).  However, over time, both sites realized the value of this information and either expanded the number of sites (e.g., SUNY Morrisville) or found other sources of funds, or both.  For SUNY by expanding the testing sites they were able to target specific dorms for human covid-19 testing.  Cazenovia received support from both the village and the town to continue testing.  They also decided to move the testing site (which was originally at the influent to the wastewater treatment plant.  For instance, they set up a test site near the public school.  

The second area of improvement had to do with the use of the testing results.  Because most of those testing wastewaters, at least in NYS, were colleges and university settings, they were using this as research to better understand the data, especially how it related to predicting positive cases and using their campus as a research lab.  They also had the simultaneous testing of students and staff to compare the data for such an analysis.  However, Madison County was the only county DOH using the results for public health application.  The health department was collecting samples for a village and how the department wanted to use the data was different.  Because the health department did not have the robust data set that the college setting had, it was instead decided that if a positive test result was detected, the health department would notify the community and coordinate a testing event in that community. When a positive detection occurred, MCDOH created a public announcement and coordinated a PCR testing event for the community.  As a result, that particular test site registered the most people to get tested up to that date.

Testing wastewater is equitable, in that anyone who is on the public wastewater system contributes to the sample.  Unfortunately, MCDOH was unable to do multiple test sites which would have enabled us to possibly target specific streets or neighborhoods; however, the influent sample captured anyone on the system.

The county DOH funded the first 12 weeks of sampling at two of our three college sites (Colgate funded their own site, and also ran their own tests).  SUNY and Village of Cazenovia staff collected the samples and submitted them to the county DOH, which in turn took the samples to the lab.  Since the wastewater treatment plant already collects samples routinely, adding another sample to the mix was relatively easy.  There were some adjustments that needed to be made as the weather became colder and nearing freezing. Test results were shared with all

Based on the partnerships and model established, the health department has discussed with participants the potential for wastewater treatment plant sample testing for opioids.  This discussion is ongoing at this time.

The wastewater surveillance testing in Madison County was one of the first implemented in a rural county. Information from this testing will allow municipalities and colleges to estimate COVID-19 transmission in real-time, provide instant feedback on social distancing and reopening phases, help predict hospitalizations and provide confidence for locations with zero transmission to resume normal activity.