Antibiotic-resistant (AR) bacterial infections are a growing threat causing approximately 35,000-48,000 U.S. deaths per year. The AR bacteria, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin- resistant Enterococci (VRE) are considered serious threats by CDC. Black and African American communities experience disproportionately higher infection rates from AR bacteria, including MRSA (aRR, 2.78; 95% CI, 2.30–3.37) compared to whites. Traditionally associated with healthcare settings, several recent studies have identified environmental sources of AR bacteria, such as wastewater. Due to aging sewer infrastructure and increasing frequency of extreme precipitation from climate change, wastewater sometimes overflows into homes and waterbodies untreated, called sanitary sewer overflow (SSOs). SSOs are a chronic, under-studied public health threat that disproportionately impact low-income and minority populations in many U.S. and international cities. AR bacterial infections have been linked to wastewater exposures, yet no studies have evaluated the risk of these infections from SSOs nor the resultant household basement backups (“backups”). Addressing the risk of AR bacterial infections from these events will have a major impact on preventing disease and promoting health, an NIH research priority, and improving minority health and reducing health disparities, a crosscutting theme in the NIH-wide 2021-2025 Strategic Plan. Our pilot study detected MRSA and E. coli on 30% and 20% of surfaces in Baltimore homes impacted by SSOs or backups, respectively. Yet, a major limitation to our pilot study was that our pre-planned sampling days did not align with recent SSOs or basement backups. We propose to create a community-driven Water Emergency Team (WET) to respond to SSOs and backups in Baltimore, MD homes as they occur. In Baltimore, 63% of residents are Black or African American and 18.9% live in poverty. We will use innovative mixed method approaches to: 1) Develop a rapid-response WET in collaboration with community organizations and local leaders to collect environmental samples from SSOs and backups; 2) Analyze water and surface swab samples for MRSA and VRE, comparing previous traditional techniques with new protocols; 3) Conduct surveys and interviews with Baltimore residents to examine the impact of backups on their physical and mental health, and perceptions of local government; 4) Translate research findings into innovative outreach materials to empower community members and inform local government officials. Rapid responses and reduced time between sample collection and results distribution will enable community members to mitigate contaminated areas and access emergency resources more quickly. New insights on public health risks achieved from this study can be applied widely, as ≥75,000 SSOs occur yearly across the U.S. Community-driven rapid-response exposure assessments combined with social science data can create an effective approach to reducing AR bacteria exposure in underserved communities facing disproportionately higher infection rates.

Project Narrative Antibiotic-resistant (AR) bacterial infections are a growing public health threat, and studies have identified environmental sources of AR bacteria, such as wastewater. Sanitary sewer overflows (SSOs) and basement backups – when wastewater overflows into homes and waterbodies untreated due to aging sewer infrastructure and frequent extreme precipitation events – are chronic, under-studied public health threats disproportionately impacting low-income and minority populations that may also place them at greater risk for AR bacterial infections. This proposal would create a community-driven Water Emergency Team (WET) to respond to basement backup and SSOs as they occur, employ surveys and interviews to evaluate health risks caused by these events, and inform a more effective approach to reducing AR bacteria exposure in underserved communities.