Maintaining a social license to operate for wastewater-based monitoring: The case of managing infectious disease and the COVID-19 pandemic

Towards the outbreak tail, what is the public opinion about wastewater surveillance in the United States?

National opinions on a wide variety of public health topics can change over time and have highly contextual nuances. This study is a follow-up to prior inquiries into the knowledge of wastewater-based epidemiology, privacy concerns surrounding sample collection, and the use of data acquired, along with privacy awareness from an online survey conducted in the metropolitan United States during the winter of 2023. Mentions of wastewater-surveillance-related terms in the media remained common. Towards the outbreak tail in 2023, public support for surveillance of toxins (91%), diseases (91%), terrorist threats (87%), illicit drugs (70%), prescription medications (69%), and gun residue (60%) remained high. There was less support for surveillance of alcohol consumption (49%), mental illness (46%), healthy eating (37%), and lifestyle behaviors (35%). In terms of geographic scale, most respondents supported citywide surveillance (85%) with markedly lower levels of support for smaller (less anonymous) geographic scales covered by specific locations. Wastewater surveillance does not receive the public pushback that other COVID-19-related health system actors have witnessed. Instead, the public supports the expansion of wastewater surveillance as a standard to complement public health tools in other areas of health protection.

Wastewater surveillance for viral pathogens: A tool for public health

A focus on water quality has intensified globally, considering its critical role in sustaining life and ecosystems. Wastewater, reflecting societal development, profoundly impacts public health. Wastewater-based epidemiology (WBE) has emerged as a surveillance tool for detecting outbreaks early, monitoring infectious disease trends, and providing real-time insights, particularly in vulnerable communities. WBE aids in tracking pathogens, including viruses, in sewage, offering a comprehensive understanding of community health and lifestyle habits. With the rise in global COVID-19 cases, WBE has gained prominence, aiding in monitoring SARS-CoV-2 levels worldwide. Despite advancements in water treatment, poorly treated wastewater discharge remains a threat, amplifying the spread of water-, sanitation-, and hygiene (WaSH)-related diseases. WBE, serving as complementary surveillance, is pivotal for monitoring community-level viral infections. However, there is untapped potential for WBE to expand its role in public health surveillance. This review emphasizes the importance of WBE in understanding the link between viral surveillance in wastewater and public health, highlighting the need for its further integration into public health management.

Balancing public health and group privacy: Ethics, rights, and obligations for wastewater surveillance systems

As the threat of COVID-19 recedes, wastewater surveillance - unlike other pandemic-era public health surveillance methods - seems here to stay. Concerns have been raised, however, about the potential risks that wastewater surveillance might pose towards group privacy. Existing scholarship has focused upon using ethics- or human rights-based frameworks as a means of balancing the public health objectives of wastewater surveillance and the potential risks it might pose to group privacy. However, such frameworks greatly lack enforceability. In order to further the strong foundation laid by such frameworks - while addressing their lack of enforceability - this paper proposes the idea of the 'obligation' as an alternative way to regulate wastewater surveillance systems. The legal codification of said obligations provides a method of ensuring that wastewater surveillance systems can be deployed effectively and equitably. Our paper proposes that legal obligations for wastewater surveillance can be created and enforced through transparent and purposeful legislation (which would include limits on power and grant institutions substantial oversight) as well as paying heed to non-legislative legal means of enforcement, such as through courts or contracts. Introducing legal obligations for wastewater surveillance could therefore be highly useful to researchers, policymakers, corporate technologists, and government agencies working in this field.

Structured Ethical Review for Wastewater-Based Testing in Support of Public Health

Wastewater-based testing (WBT) for SARS-CoV-2 has rapidly expanded over the past three years due to its ability to provide a comprehensive measurement of disease prevalence independent of clinical testing. The development and simultaneous application of WBT measured biomarkers for research activities and for the pursuit of public health goals, both areas with well-established ethical frameworks. Currently, WBT practitioners do not employ a standardized ethical review process, introducing the potential for adverse outcomes for WBT professionals and community members. To address this deficiency, an interdisciplinary workshop developed a framework for a structured ethical review of WBT. The workshop employed a consensus approach to create this framework as a set of 11 questions derived from primarily public health guidance. This study retrospectively applied these questions to SARS-CoV-2 monitoring programs covering the emergent phase of the pandemic (3/2020-2/2022 (n = 53)). Of note, 43% of answers highlight a lack of reported information to assess. Therefore, a systematic framework would at a minimum structure the communication of ethical considerations for applications of WBT. Consistent application of an ethical review will also assist in developing a practice of updating approaches and techniques to reflect the concerns held by both those practicing and those being monitored by WBT supported programs.

Structured Ethical Review for Wastewater-Based Testing

Wastewater-based testing (WBT) for SARS-CoV-2 has rapidly expanded over the past three years due to its ability to provide a comprehensive measurement of disease prevalence independent of clinical testing. The development and simultaneous application of the field blurred the boundary between measuring biomarkers for research activities and for pursuit of public health goals, both areas with well-established ethical frameworks. Currently, WBT practitioners do not employ a standardized ethical review process (or associated data management safeguards), introducing the potential for adverse outcomes for WBT professionals and community members. To address this deficiency, an interdisciplinary group developed a framework for a structured ethical review of WBT. The workshop employed a consensus approach to create this framework as a set of 11-questions derived from primarily public health guidance because of the common exemption of wastewater samples to human subject research considerations. This study retrospectively applied the set of questions to peer- reviewed published reports on SARS-CoV-2 monitoring campaigns covering the emergent phase of the pandemic from March 2020 to February 2022 (n=53). Overall, 43% of the responses to the questions were unable to be assessed because of lack of reported information. It is therefore hypothesized that a systematic framework would at a minimum improve the communication of key ethical considerations for the application of WBT. Consistent application of a standardized ethical review will also assist in developing an engaged practice of critically applying and updating approaches and techniques to reflect the concerns held by both those practicing and being monitored by WBT supported campaigns.

Abstract Figure

Synopsis

Development of a structured ethical review facilitates retrospective analysis of published studies and drafted scenarios in the context of wastewater-based testing.

Au-Fe3O4 nanozyme coupled with CRISPR-Cas12a for sensitive and visual antibiotic resistance diagnosing

The accumulation and spread of antibiotic resistance bacteria (ARB) in the environment may accelerate the formation of superbugs and seriously threaten the health of all living beings. The timeliness and accurate diagnosing of antibiotic resistance is essential to controlling the propagation of superbugs in the environment and formulating effective public health management programs. Herein, we developed a speedy, sensitive, accurate, and user-friendly colorimetric assay for antibiotic resistance, via a synergistic combination of the peroxidase-like property of the Au-Fe₃O₄ nanozyme and the specific gene identification capability of the CRISPR-Cas12a. Once the CRISPR-Cas12a system recognizes a target resistance gene, it activates its trans-cleavage activity and subsequently releases the Au-Fe₃O₄ nanozymes, which oxidizes the 3,3,5,5-tetramethylbenzidine (TMB) with color change from transparent to blue. The diagnosing signals could be captured and analyzed by a smartphone. This method detected kanamycin-resistance genes, ampicillin-resistance genes, and chloramphenicol-resistance genes by simple operation steps with high sensitivity (<0.1 CFU μL^-1) and speediness (<1 h). This approach may prove easy for the accurate and sensitive diagnosis of the ARGs or ARB in the field, thus surveilling and controlling the microbial water quality flexibly and efficiently.