Navigating Ethical Issues in Wastewater Surveillance for Infectious Diseases

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ERIN LAIRD:
And thank you for joining us today, for today's conversation on ethical considerations related to wastewater surveillance.I'm Erin Laird, and I'm the director of emerging infections here at ASTHO, and I will be moderating today's session, which will be recorded and distributed to participants in the coming weeks.Today's session is a part of ASTHO's INSPIRE: Readiness. Webinar series.

So for those of you who may not be familiar INSPIRE: Readiness is a platform for public health professionals to share insights and solutions, enhancing response to communicable disease, outbreaks and disasters and advancing public health preparedness. INSPIRE: Readiness is a public platform available to anyone on ASTHO.org, and we invite you to access our library of stories and resources to enhance your agency's ability to tackle public health challenges with innovative approaches.So a link to the platform will be provided in the chat in a moment might already be there. It's hard for me to see, but as mentioned, today's webinar is focused on wastewater surveillance.

Wastewater surveillance is a valuable public health tool for detecting and monitoring infectious diseases and wastewater surveillance data can serve as an early warning system and help health departments, target prevention efforts, a critical strategy to maximize limited resources and public health impact in 2020 the centers for disease control and prevention established the national wastewater surveillance system to monitor Sars-cov-two trends in wastewater across the country.

The application of wastewater surveillance to COVID-19 response allowed us to scale up this powerful public health tool. And as we scale up, it's critical that we proactively identify and address ethical considerations such as privacy, stigma and data stewardship.and that we continue to center surveillance efforts around public health action.So to this end, ASTHO in collaboration with public health experts and folks implementing wastewater surveillance developed a framework for addressing ethical considerations in infectious disease.

Public health, wastewater surveillance which has just been added to the chat as well, and in addition to reviewing relevant literature, the framework was informed by engagement with epidemiologists, infectious disease, experts, academics, utilities and folks from local, state and federal levels of public health leadership.Drawing from these sources the framework outlines ethical considerations, and provides tools for ethical analysis to support decision-making in wastewater surveillance.All 3 of our panelists today engaged with ASTHO in this process.

So I'm really excited to have them on the line to talk about this topic, since they have been actively engaged in this work, both in their jurisdiction and beyond sharing their experience to inform conversations and resources beyond their jurisdictions.So today we'll explore those ethical considerations related to wastewater surveillance. We'll highlight key partners for community outreach and engagement, and we'll share strategies to help maximize the benefits of wastewater surveillance while safeguarding things like individual and group privacy.Our discussion is all about equipping you, our public health colleagues with real world strategies to meet growing challenges, head on.

So thank you to all of you on the line for the essential work that you do in your communities every day, and for being here on the line with us today.we're looking forward to a thoughtful discussion and to hearing your questions. So with that, let's get started. And before I dive into our questions for panelists. I will pass it over to our speakers to briefly introduce themselves. So, Dr. Chilek, I'll pass it to you first, st and then to Alison, and then to Dr. Mangla.

KATA CHILLAG:
Thank you. It's a real pleasure to be here. This has been a really exciting project in large part because of some of the things that Erin highlighted about the fact that we really and we continue to gather the perspectives of those working on the ground and policy around wastewater surveillance to inform how the methods and sort of the ethical issues that we are highlighting.

I'll just mention something briefly about my own biography. Now, I am an academic now, but for most of my career I was in a variety of different roles in governmental public health, and I always had some interest in ethics in different ways, but it was really crystallized, and I moved my career to the extent possible to really focus on applied public health ethics.because, firstly, it really came home to me that the nature of our work, some of the conditions that we may talk a little bit about, that we work under resource constraints working with vulnerable populations, etc, really make our daily work infused with ethical issues.

The other part that's so exciting about this project is that that we really need a model of ethics. Preparedness I felt like. And my colleagues and I've worked with all kinds of different different people in public health didn't always have the tools they needed to address ethics, as well as carrying some perceptions and experiences that that presented barriers to a sort of full picture of what ethics can do.not as a crisis response, which is often the experience we have, but as something that we build into the design and implementation of our projects to strengthen them and to, you know, advance public health effectiveness. So this project has been great, and I look forward to talking with my colleagues here, and hearing your questions about.

ALLISON WHEELER:
Hi all, I'm Allison Wheeler. I oversee our wastewater surveillance program in Colorado and have the pleasure of co-directing our wastewater center of excellence.and I don't know about all of you that are on the line that had experience in setting up a program. But you know we were instructed to get this set up as soon as possible as quickly as possible. So ethics was not on our mind at the time at the time. It was, you know, get as many wastewater utilities enrolled as possible, get the wastewater samples tested, and post the data, share the data.

And that's what we did. And when we started sharing the data. We didn't know what it meant. And so that was just kind of the 1st concern, you know. And then we discovered other ethical concerns. As we started to evaluate our program I was very intimidated by the word ethical, the ethics of wastewater surveillance, and I have to thank all of my colleagues on this call Kata and Anil and Erin and Alyssa for helping me understand that it's not as scary as it sounds to evaluate your program for ethical concerns. And so I'm excited to have this conversation today, and as always, learn more from my colleagues and share what we've done in Colorado to evaluate our program.

ANIL MANGLA:
So. Good morning, everybody. My name is Anil Mangla. I am the director for disease, surveillance, and control for the Southern Nevada Health district. Prior to this I served as a State epidemiologist for Washington, DC. And I bring that up because that's where the work of wastewater surveillance started. I implemented that program, just, you know, as Covid started. So I have that experience. But again we set it up. We got many sites, school sites, you know, different facilities. We looked at the community. And it was just data, right? We were doing monitoring. This was almost like a additional tool that we could use to monitor that could give us proactive information on what next steps to do when we looked at Disease Control.Nobody talked of ethics. No, you know that was not a concern.

But now, if you look at, you know, 4 years later, this has now become an issue where you're looking at data governance, you're looking at privacy. You're looking at equity. So so this team, we have worked so hard for the past 2 years in really identifying and developing these ethical frameworks. So I'm really looking forward to working with Aaron, you know, as our moderator in in making sure that your questions are answered, and we can provide you a depth of information on wastewater, its ethics, its use what the next steps are, and you know, if there is kind of pros and cons with it right? So we're really looking forward for this discussion. And we're really glad that you are participating in this national webinar, where, you know, there's going to be a lot of information that's going to be shared for different public health departments, be it state, be it local. But it's going to be a great discussion.

ERIN LAIRD:
Great. Thank you all so much, and thanks for sharing a little bit about yourselves with us and with all our folks on the line. So I'm going to go ahead and dive in. And I'm going to take facilitators prerogative here to ask a few questions to get us started. But we also really want to know what questions you all on the line have.

So please use the Q&A box throughout to submit any questions you may have, and we'll do our best to address them.And if your question is for a specific speaker, please, if you think of it, note that in your question so that I can direct it properly, but otherwise we'll just kind of open it up for all of our speakers on the line. So with that, Allison, can you kick us off? I mean, wastewater surveillance is fairly new compared to other forms of public health surveillance. And so I'm wondering if you can give us a little background. What is wastewater surveillance, and how has it been used in public health, as it relates to infectious diseases?

ALLISON WHEELER:
Sure I would be happy to. I think the cool thing about wastewater surveillance is, it takes a pooled community sample.And with that pooled community sample. We can assess disease trends. We always recommend, of course, assessing our wastewater data with complementary surveillance data. You know, other measures of disease burden. But this approach is non-invasive.

It's cost effective, and generally, when conducted at the sewer shed level. It is an anonymous method to surveillance, and so, when we see increasing levels of a pathogen in wastewater. We can allocate public health resources to affected areas, whether that be the deployment of vaccines or appropriate staffing in healthcare facilities before a surge of respiratory viruses or messaging to providers in the community, messaging to providers about an illness in their area, messaging to the community about what's circulating in their area and how they might be able to protect themselves in some cases wastewater surveillance data can really fill a surveillance gap when we don't have that strong clinical or syndromic data, and by sequencing wastewater samples we can determine which strain of a virus is circulating, and this can help in the development of vaccines and also help aid in the development of diagnostic tests.

We know that in Colorado our citizens use this data to monitor it for personal disease risk if they or a close family member is immunocompromised. And so they've shared that information with us which is really valuable. It helps kind of prove the worth of our work.

ERIN LAIRD:
Thanks so much, and I think you teed it up really nicely for what I was going to ask you, Dr. Mangla. I think Allison sort of started to talk about some of the ways that wastewater surveillance data can fill surveillance gaps. So I think this is one example. But is there anything else you would add about the value of wastewater surveillance as a public health tool.

ANIL MANGLA:
Yeah, thank you for that, Aaron. And I want to kind of reiterate. You know what Alison has brought up. So when you look at wastewater. Right? So wastewater surveillance has emerged as a powerful public health tool that complements our traditional surveillance systems. For example, essence. And then you're looking at active passive surveillance. Right second point is that the wastewater surveillance is valuable because it actually helps detect diseases in the community much earlier and often before people are diagnosed, or even cases are reported.

So this again, you know, when it when you look at outbreaks, right? You've been proactive because you're looking at a signal almost 5 to 10 days in advance. So again, that's so important when you're looking at preparedness.The other important thing is, the agencies can monitor these pathogens right across large populations, with, you know, being anonymous number one. But allowing that real time of emerging threats.the other important part of wastewater surveillance is it's particularly valuable for identifying asymptomatic and underreported infection. So again, when you look at rural communities, right? I think this is really good because it's given public health an idea? Are we seeing something unusual? What are we seeing? What are the actions? And then, you know, really important, especially like places like Vegas? Right? It strengthens our preparedness efforts.Good example is we have mass gatherings right? The nation is starting to prepare for the World Cup. Right? Wastewater surveillance is going to be the fundamental tool that we're going to be using. So over here in Southern Nevada, we already use that because we have so many mass events, and we've been using this continuously. So it's nothing new to us.And so in essence, when you look at this broad picture, your wastewater offers this non-invasive right cost effective. And you can scale up this method to detect and monitor different types of public health risks.In addition, it is a great tool in a toolbox right for epidemiologists in the prevention and control efforts that is already going about within that jurisdiction or within within that state.

ERIN LAIRD:
Great. Thank you so much, and I think that example with mass gatherings is such a good example for an application of wastewater surveillance, and particularly relevant for an area like yours, Dr. Wangla, Dr. The other panelists have made, I think, a good case for wastewater surveillance.probably preaching to the choir with our audience on the line here about why, this is a valuable public health tool, but shifting a little bit to dive into some of those ethical considerations. What potential ethical issues are raised by wastewater surveillance? And why is it important for implementers of wastewater surveillance programs to be thinking about ethics?

KATA CHILLAG:
Sure, I think I'll flip it and talk a little bit about the second part of your question first, st and then touch on some domains of ethical issues that we encounter in wastewater surveillance that emerge out of this process. But I think the 1st thing is that you know, we've already heard. As all of the panelists and Erin have mentioned, that wastewater surveillance has real potential for public health impact. So one of the things that we we often, maybe the preconceived notions we have about ethics work. If you want to call that or sort of our, you know, our experiences with doing it is that we're really focused on harms. And those are really important. But we're also need to do ethics work that fosters benefit. And we have a lot of questions, and we engage with questions about, you know, doing or not doing wastewater surveillance. But it's about maximizing benefit as well as avoiding harm.

And so, you know we're at this really interesting moment. That's been described and challenging moment in some ways with regard to wastewater surveillance. So it it rose quickly. You know, it had been rarely used in public health before the pandemic, and we had to build and implement programs in the context of a public health emergency. Public health emergencies are often times when you may not say you're dealing with ethical issues, but they're being foist upon you in various ways and intense ways. You may not name them as ethics.

So now we're moving to this post emergency phase. We're moving to a post emergency phase where we consider difficult questions about how to leverage the benefits of the infrastructure. We have how to make decisions in conditions of uncertainty, how to protect communities and to build trust. And we're we continue to face, and perhaps even heightened resource.Resource freshers in public health, so engaging with ethics is important to maintaining these benefits and to building trust and demonstrating trustworthiness to the communities that we serve. Now, one thing I'll say before I talk a bit more about this, and then I'll just open up by talking, elucidating some of the domains that we really focused on in terms of of ethical issues. As part of this process is to say that of course, this audience knows that that's important to build trust.

Of course, we all want to to build relationships with communities and serve those communities. But we have to have the tools to do that. It's not easy. And we have to have conversations about these pressures that we're facing So as part of the process we had in the 1st 2 years. Essentially of this project we identified 3 interrelated domains of specific focus with regard to ethical issues, and these called. These were privacy, stigma and data stewardship. And I'm sure we'll talk more about the sort of broad notion of stewardship and how that relates to data, and how these 3 are interrelated. We began with an overarching set of considerations about public health, purpose, and public health value.

So we really underscored that wastewater surveillance as the 1st sort of premise of ethical wastewater surveillance must be aligned with a legitimate public health purpose. Again, this is not to say that those considerations aren't always. They aren't always straightforward. They can involve an array of things. But that was the 1st part of it. The second part is, we consider other impacts, such as stigma and and privacy and data stewardship in relation to that, to make informed decisions that we can justify about what sort of activities to undertake through wastewater surveillance.

ERIN LAIRD:
And Dr. Till you've you've teed it up once again. I feel like you've teed it up beautifully for the next question, and I'm gonna kind of open this up to all speakers. Actually, because someone submitted a question in the Q&A box asking about the scale of surveillance right? How small is too small. When should we be worried about stigma and privacy? And I think you've just touched on this a little bit in your previous response. But I'd love to hear, perhaps starting with Dr. Munglen working the way around for anyone else who has thoughts. But how can we balance the benefits of wastewater surveillance as a public health tool with these risks or issues. And if you like to speak to that more specific audience question as a part of that that would be great.

ANIL MANGLA:
Yeah, thank you for that, Aaron. So you know, as we have in this discussion, right? That ethics remains the central challenge in public health right? So, balancing these benefits of wastewater surveillance with the potential ethical risks.calls for a very careful but also a principled approach noted in public health ethics. So as Carter brought up this, the when we guided by the ethical framework that's already been written, we can break this up into 5 different values, and I think got a, you know.alluded to at least 2 of them. So again, when you look at privacy, right? So let me kind of share from, you know, a community level to a granular level. So wastewater surveillance is fundamentally population based. And it's anonymous at large scales. But the risk of privacy increases with the smaller scale and upstream sampling.

So balancing this benefit means setting clear limits on data granularity and also ensuring that no individual or individual groups is targeted without strong public health. Justification number 2 is stigma right? So how to avoid stigma. So we want to be very clear and transparent with the messaging about public health purpose of the surveillance, which means that what the data do and do not mean. So you know, we don't want to have a little spike and say, Okay, this meant, there's a, you know, increase in something. It's got to be complementary to other type of surveillance systems.Another big concern we have when you're doing balance is data stewardship. And we find this all the time.

So agencies because we're going to have this collaboration, it's not just a health department working with it. It'd be health Department universities, utilities. So agencies must establish this clear governance of data collection data use data sharing and the retention of data.If that is not the case, or if that is not in a governance, then we're going to run into ethics issues.and then the other one is justice and equity. Right wastewater surveillance should be used to address health, disparity, and not impair them.

The surveillance also should benefit all communities equally, and you know, this is including underserved and historical marginal kind of communities. And finally, when we're looking at community engagement, this is again building trust. So when we're building trust.These decisions need to be made should be very clear in explaining the purpose of wastewater surveillance and providing open channels for feedback and concerns. And this is going to both trust in the community as well as other partners of how to implement and what to really do with wastewater. So when you embed all these ethical principles in the program and the design of the program, the public health leaders can maximize the benefit of wastewater surveillance while maintaining that minimum harm that could occur, and then maximizing strength maximizing the trust. And that's why that's where that balance actually comes in with wastewater surveillance.

ALLISON WHEELER:
Hmm.Add on a little bit to address the question in the the Q. And a.And and this is what we've done in Colorado. This is not appropriate for for everywhere, but it fits our population generally. And so we have decided that when Dr. Maglaw was talking about setting a threshold for population. We decided that a thousand people for us is our threshold.

So anything below any population below a thousand we will not display on our public dashboard. We only display on our public dashboard. We've also added, or actually are, in the process of formalizing our new data release policy. And we've added a clause that addresses wastewater surveillance data to our data release policy.So that if we are to get you know, a a formal data request, we won't have to release this data.

However, I think there are always extenuating circumstances, right and exceptions to our rule. And so, if it was a community, you know, perhaps a marginalized community or I don't know. There was something unique about this community that could identify just individuals in the community. We would not post that data. And so I think it's important with wastewater surveillance, and especially when you apply these ethical principles that you have to be flexible and understand that there are always exceptions to the rule.

KATA CHILLAG:
And I'll just add a couple of things. But just to say what Allison described to us was clearly the the product of a systematic process of thinking about these issues, and what sort of weighing different sorts of values in doing so. And we may talk in a moment about some of the methods that we have as part of the framework to do. Analysis of these issues.

Questions of scale come up quite a bit, and they raise all of the different domains with which we are engaging. I've talked about here.One thing I'll underscore, which was implicit and explicit in both of what anil. And Allison said, is that we really emphasize the importance of meaningful community engagement as part of understanding ethical issues. Community engagement isn't just about communication, though communication can be. It's about building relations over time and investing the time and resources for this, acknowledging that can be quite. quite challenging in certain environments.

I think the other important thing that emerged out of both of what you heard from Anil and Allison is that we begin with certain principles or certain values. But knowing your context. Often a dynamic context, and that there are always exceptions, but that you have a method to assess whether or not to implement something different in ways that are consistent with the, with the values of public health, with governance, scientific and public health ethics, values.and that build trust in your communities. But you have to have this deep relationship to your context. So there's no one. Size fits all. There's no checklist here sometimes that can be challenging with people with ethics. It is not something that you you make a policy.

And then you're like, that's how I'm going to implement it for the rest of the time. But you have to have things so that you can look at the planning. You've done the prepared, and then examine dimensions of context to make good decisions.

ERIN LAIRD:
Thanks so much for that for all of our speakers, and Kata for ending on that. And I do want to ask you about ethical analysis in a moment before I do. You know, Dr. Mongol, you touched on the importance of data stewardship, and Alison, you talked about your data release policy. And so I do want to acknowledge an audience question and just see if there's anything that y'all would like to add. So how do you ensure ethical treatment of data. And how do you give constituents? A voice in data, stewardship.

ANIL MANGLA:
Thank you for that, Aaron. So why don't I get started with that? So I mean the voice again, when we're looking at data stewardship. I think you know.when you look at the partners involved. Number one, right? There needs to be some sort of clear right governance where you know their data sharing is going to be part of it.They also need to be almost like a dashboard right? And the dashboard is where the public gets involved looking at what you've seen looking at what is provided and have public input, of, you know questions and answers. If there is certain spikes going on, you know, have the public comment, and then provide them very transparent answers of you know what is wastewater capable of doing, and what is it capable of not doing right. And I think those step of being that transparent with the public is going to be crucial, because that's what's going to build that trust.

KATA CHILLAG:
So one of the ways that we thought about about this in addressing data stewardship is to really draw upon existing resources around data, stewardship and data equity to consider the entire data lifecycle and to use some of the frameworks that we're advancing in methods to have institutions doing wastewater surveillance.think through the entire data, what they know and what they don't know about the entire data lifecycle from collection of data to to sort of whatever the endpoint or disposition of the data or storage of samples and other things, and consider what issues might emerge in those.

And also consider. And this is across the ethical issues. It's really important to understand. You know, what is optimal data stewardship for your institution, but recognize that as part of that. You may not have everything you need. So one of the purposes of the ethics framework that we're advancing is to give this space through a series of questions and answers for institutions to examine what they have and what they don't have, who is responsible for what and to think about it all the way through.

I mean, the fact is that there are many different aspects of ethical analysis, but one of them is as a preparedness. Matter is to give people the space to sit down and think through things that they do not routinely have the ability to do so, and also to acknowledge as part of that, is that you.you think through what you can acknowledge, the uncertainties that are always present. In some of these, you know, there are different uncertainties that we examine to some degree. What do you do when you know we're in a with data and data storage and other things, we're in a period where things are really actively changing. And they're very. It's not, you know. You don't always have the expertise to understand all of the implications of that thinking about things like how the data might be used.

There are protections you can put in place, but the 1st part of this is understanding what you have and don't have for that. And that's also anticipating and revisiting this in ways because things will be changing. The question also emerged about sort of community engagement relationship.

So how do you? It's really important, that which has been asserted that we understand how our our communities understand what we are doing with data throughout the data life cycle. This may or may not reflect what is actually being done. This may come from other sources, so we need to attend to our own practices, but also understand there's an entire information environment, an entire historical context in which some of the populations we want to reach the most might have the most mistrust of of things around data. And so these are all important dimensions of of trying to address these issues.

ALLISON WHEELER:
I can talk a little bit about the data stewardship and community or stakeholder engagement, you know, as far as as data stewardship. And and this is directly tied into stakeholder engagement. As Kata mentioned, we have memorandum of understanding agreements with our wastewater utilities that define each of our roles, and who owns the data, and so that has really helped us understand each other's roles.

We have monthly meetings with our wastewater utility partners and our local public health partners, and we have a wastewater surveillance coordinator who really functions as a utility relations specialist, and so is going out to the utilities, visiting them on a regular basis.calling them, emailing them to help again, understand roles, answer questions, be transparent about what we're doing. And then we have really focused in Colorado on our community engagement community.

So with our public stakeholders, and what we've been doing there is, we've provided a public feedback form on our website so that they can give us feedback about the data, ask questions about our program, ask questions about how to interpret our data, why, we're doing surveillance for these targets. That kind of thing. We've also been hosting community engagement meetings formerly known as Town halls, and this we invite any member of the public to, or any of our stakeholders.

We held our 1st one as a hybrid option, so part in person, part virtual, and realized that we needed to do it virtually, so that everyone was kind of on the same playing field and could ask questions. You know, online, we had a little technical Snafu during our second meeting, and we had only planned to have the Q&A up and running, and it wasn't working, and so we allowed all public stakeholders to come off mute and talk to us, and it was awesome. It was really great. They asked some very tough questions, but it was really nice for us to be able to talk to each other directly. And so those are some of the things that we're doing, you know, to address that that stakeholder engagement piece.

ERIN LAIRD:
Thanks so much for that, Allison, I mean, of course. No, no virtual convening is complete without a technical snafu. But I'm glad that one worked to your advantage and thank you all for those audience questions. Do keep them coming, please, as a reminder. Do submit them in the Q&A box, not the chat. I don't have enough eyeballs to monitor all of the places, so if you're in the chat, I'm more likely to miss your questions, so do submit to the Q&A. We do have more audience questions. But before I get to those Dr. As Alison mentioned in her Intro ethics and ethical analysis can sound really academic or intimidating? Can you explain what is ethical analysis in the context of wastewater surveillance? And how can wastewater surveillance programs integrate ethical analysis into their program planning and decision making.

KATA CHILLAG:
Yeah. So I'll begin by talking a little about the work we've done together for the last couple of years to really develop a framework as a substantial starting point for ethical analysis in wastewater surveillance. So we really focused on something we'll call values based ethical analysis. So as part of our process. We thought a lot about what were the values that were most pertinent for us in public health generally, and in wastewater surveillance specifically, and I won't highlight them all, but they included things in in different domains and public health, ethics and governance.and in science, evidentiary standards, things like common good trust and trustworthiness.

I've always already mentioned things like, of course, justice, equity, and fairness, reciprocity and resource, stewardship in different ways. and in this we we talked about sort of ethics. Analysis generally is meant to give people a systematic and structured structured, and in this case, and we hope generally practical method of working through these issues together. And so specifically in the framework, we formed it in terms of questions that people can ask about their own programs and outbound in these specific domains like privacy to explore the ethical issues they're encountering. And, for example, again, as I mentioned before, a lot of times, we don't have the space and focus.

To do this, really thinking about what the public health goals of the program are, or the application of different pathogens. For example, talking, going through the potential benefits and potential harms of it and the public health implications and and examining whether communities have had meaningful opportunities to provide. Input so I can talk more about the structured method around privacy, data, stewardship, etc. But the other thing that we really did was go through a number of applications and exercises with this, and the framework itself contains case studies, because one of the most important things around demystifying as we've talked about before, ethical analysis is to practice it and do it.and I'll underscore here just for a second.

Some things we've already been saying is that you are already ethics experts, even if you don't call it that. I mean, there are certain forms of expertise that are relevant to ethical analysis, and that's why we had this interdisciplinary approach. But you are dealing with the ethical issues. What you have to be given is the tools to do so.

And also, you know, it doesn't have to be esoteric, as sometimes it's perceived to be or abstract. It can be quite focused on what you're doing on the ground. But we really think, in addition to having a framework as a starting point. It has to be surrounded by other forms of ethics. Infrastructure if you will. And we're really thinking about how to do that.

So that includes things like talking to people about ethical issues and wastewater surveillance. But some of the things that, like Alison, has been involved with which is developing accessible, educational. and, you know, focused on state and local health departments around ethics as well as developing additional case studies, exploring things like peer-to-peer ethics networks. So there's a variety of different ways that can be employed.

ERIN LAIRD:
Great thanks so much.Alison, I think you've already touched on this, but I want to make sure that there's nothing to add here we did have a question about community engagement and the practices that your Health Department has identified for involving local communities in the decision-making process. And again. I think you maybe already responded to this in previous questions, but I just wanted to make sure that I opened it up in case there was anything you would add to that.

ALLISON WHEELER:
I don't think I have anything to add other than you know. We do have a public dashboard that we really encourage all of our stakeholders to use. And I will say, though, that we do not post data to our public dashboard during the pilot period of you know, when we bring on a new target.

So, for example, with measles, right now, we're trying to understand what these detections mean. And so we're having a lot of trace detections which is technically below our limit of detection. And so we're not exactly sure how to communicate that to our public stakeholders and even our local public health stakeholders. And so we've made it an internal policy that we do not publicly share the data until we've had a pilot season so that we can understand the data and accurately relay what it means to the best of our knowledge, of course, so that it is kind of fit for more public consumption.

So we do. Yes, filter our stakeholders to our public dashboard and actively ask for feedback about how to improve our visualizations, and the the interpretation guide that we have in our Faqs on our on our website.

ERIN LAIRD:
Great thanks for that. And another question for you, Allison. In what ways can effective communication minimize misinformation related to surveillance of wastewater.

ALLISON WHEELER:
Yeah, that's a great question. And I think it goes back to the point that a couple of the panelists have already brought up, and and being transparent, being as transparent as possible. And so we have really learned that we need to be proactive in sharing information about our programs activities with our stakeholders.That has helped quell opportunities for misinformation.

And so we we share information through multiple channels. You know whether that be emails or phone calls or webpage announcements and and meetings with our our stakeholders, including the public. We really, also, too, take advantage of media inquiries and social media opportunities. I know that media inquiries can be.or at least for me. When I 1st started in wastewater they were a little bit scary. I wanted to make sure that I didn't misstep and say something that I shouldn't. But I've realized that it is an opportunity for us to share our information about our programs activities widely.

So we try to respond to media inquiries in a timely manner, to share what we're doing, and again, to be as transparent as possible, as transparent as our organization will allow, and we know that this has been really appreciated by our Colorado communities with social media.I've seen some really great examples of wastewater surveillance, social media campaigns by other states like New York, where they post videos of educating the public and other stakeholders about wastewater surveillance. And so what is wastewater surveillance? Which pathogens are they monitoring? What do the results mean? Why are we doing surveillance for specific pathogens in certain areas? And so I think that's been really successful for New York, and we look forward in the future to doing something like that.

ERIN LAIRD:
That's fantastic. And I think that New York example that you just ended on again. You all just keep like teeing me up for all the questions here, but it's a great example of what I wanted to ask Dr. Mangela next, which is what strategies can public health professionals use to communicate about wastewater surveillance to the public in a way that promotes transparency and builds trust. And I think that example of New York is a great one.

ANIL MANGLA:
Yeah, you know, this is a great question, right? And so, you know, we've we've kind of talked about transparency. We talked about being consistent. We've talked about communication strategies. So when you think of this, and you put it in a broader picture, you know, I think of 5 key components. Here is number one is, be clear about the purpose and the benefits of wastewater.

So what do I mean by that right? Explain what wastewater surveillance is in simple terms. This means emphasizing that it is going to be monitoring. Community health trends. Right? So it's not. This is what we've seen. It's more trends. It's going to detect outbreaks early, and it's going to inform different types of prevention. Efforts even make it clear that the wastewater surveillance is a tool for public health good. And it's not. Again I repeat this right? It's not for surveillance of individuals, and I think that is so important. It's a bigger picture than just individuals.Number 2 is address. The privacy and data use concerns upfront.

So when we talk of that, it's, you know, openly discuss how the data is collected, how it's managed, how it's protected and then clarify what wastewater surveillance does not identify individuals. Right? It's again looking at the community. Level 3rd is. And we've talked about this already is engage communities early and often. And I think what Alison is doing is fantastic, right? Having these town halls having these stakeholders on hand, having, you know.by monthly or monthly meetings, and I think that way you standardizing the process, and everybody is on board, and then I think the last and most important thing that I feel is is to be honest and talk about the limitations and the uncertainty of wastewater surveillance. What do I mean by that.

So avoid right overstating the capability of wastewater surveillance. That's number one.number 2 is acknowledge the scientific uncertainty, uncertainties right? And then explain how wastewater surveillance complements other surveillance systems. So it's not just one surveillance. And we're going to make a decision. And we're going to have a press release. Go out.There is a lot of background information. There's a lot of meetings within stakeholders. The health department in identifying. Okay, we got a spike is this complementary with other tools of surveillance. And when you come to that, I think that makes it very strong in building this trust, when we lock in of wastewater, because these are key components that need to be addressed before even starting and building the program.

ERIN LAIRD:
Yeah, that's fantastic. And you you answered a question as it came in, Dr. Mangla, which is magic. We had a question come in about. Should we address the limitations? And then you said it? And someone's responded and said, got it already answered. So thanks for that.So what resources related to ethics and wastewater surveillance exist, or maybe in the work. And I think a related audience question very specifically, are there any ethical frameworks that you would use to support your approaches. So maybe, Dr. Truc, I'll start with you.

KATA CHILLAG:
Well, this is a you know. It feels a little awkward to say part of this effort was the production of an ethical framework of which we we are are proud. And we, we see, as I said.starting point, it isn't the whole answer to things, but it definitely gives a very tailored approach to addressing these things.

But there are others, too, and just to step back a second to say, You know, I've already talked a little bit as have my colleagues here about the fact that that you know many of the issues and the goals that we have ethically and public health are not unique to any particular surveillance program or application surveillance. It's much broader than that. So it's, you know, and this combines a number of different things at different points, like, you know, ethics and public health emergencies, ethics and surveillance generally.

So there's lots, or at least several resources. I think, in the chat earlier. There are there who has a really comprehensive document on ethical issues in surveillance more generally.which I think is incredibly useful. And and so I recommend that as well as as a starting point.I also would just underscore again the idea of practice. We really want to work further on. Informed by real fictionalized issues that occur. Case studies that case studies and using a structured method to go through case studies and finding the time in all of our busy schedules. To do that together is one of the most valuable things you can do, rather than simply reading through a framework that I do encourage you to do that, especially the ethical analysis and undertaking and practicing it. You know, we've talked a lot about how ethics can be really intimidating. It can feel like, we don't have what we need and trying out in collaboration with others who in your context is really important. We don't, you know, one of the real challenges around. Ethics, too, is, we often feel like, and sometimes we have experiences that reinforce, that we feel responsible individually to somehow figure out what to do but very little in public health is like that, and so the opportunity to practice it with colleagues.Those are some frameworks, and my colleagues, and I can talk more again. We've already talked a little bit about it, but some other activities and resources we might want to have, and that we're very interested as we move into additional phases of this work, to hear what resources would be most useful for you.

We have some general broad categories of things we have in mind. But even within those like education or peer networks or other things, we.we imagine there's a lot of creative innovation and input that we could get to to inform that. So I'm sure my colleagues can comment further.

ALLISON WHEELER:
Yeah, Kata, thank you for bringing up the the peer networks. You know. When I was thinking about this this panel.I remembered our discussion from the workshop about what's what's next. Or maybe it was a meeting after the workshop, and and we had a discussion about putting together a work group or a network that people from wastewater surveillance programs can come to or approach and say, Hey, I have this situation. I just wanted to run it past you what ethical concerns would be.

You know, do we have here? And I find that really beneficial with my team in Colorado, you know. We have. We have a decent sized team, and all have differing opinions, and we have great conversations. When we bring up a scenario right? We kind of just break it down together, and there are always suggestions that I never would have thought of without my my teammates.

And so I think it's really beneficial to have these discussions in a group. So whether it's your team or whether you reach out to one of us or Erin at ASTHO, I think it's a really good resource, and I'll say I don't have all the answers, but I so enjoy talking through, you know, possible solutions, and then can suggest my colleagues for follow up.

ANIL MANGLA:
Yeah, thank you for that. Alison. And so, you know, when we talk a resource, I think this is such a new science, right, and I know Allison and I, you know, sometimes meet at these different conferences, and we just go on a tangent with these conversations. And so How I look at it. Number one, when you're looking at resource is the framework right? Look at that framework.

Study the framework. It was so. It is so important because we had nothing like that. There was no guidance, there was nothing to guide us, and that's a really good document for guidance and to guide the Health Department into a direction of, you know, looking at ethics, looking at governance, looking at a lot of components.

The other resource is, Europe is far ahead of us, right when you're looking at wastewater. Look at some of the programs that Europe is doing. There's great information in what Sweden is doing. Look at. You know the wastewater site for Sweden and get ideas from there and then. 3rd thing I think we were talking of is discussion, and and then throwing out ideas because we don't know everything yet. Right? And I think having this expertise coming together.

So I do want to share what kind of the next plan is is, you know, we had, and and Alice and I and I sat on a Federal wastewater work group that I chaired, which you know was dissolved. And so we kind of thinking we have the key players there.And to bring those players back right and have this so-called expert network. That's a national network. And really start these new conversations. And so that would be really key in getting experts that are in the nation answering certain questions. And there's thousands of questions right? But that group would be these expertise subject matter. Experts.be it academic, be it public health.be it utilities. But it's components all put together. That would be a great resource. So Allison and I kind of thinking, or something like that. So again, this is all new. But you know it's an opportunity, and and it's a great opportunity to move forward.

ERIN LAIRD:
Thanks so much for that. I was gonna try and squeeze 2 more questions in, I think. Probably only have time for one. So I'm gonna start there. If we're if we get lucky, then I'll ask one more. But, you know, we are public health, I think, is always operating under a lot of different challenges. And so I would like to end on a more positive note if we might, if we may. So what are you most excited about when it comes to the future of wastewater surveillance, of infectious disease, and in particular, the ways that we are continuing to integrate ethics into our wastewater surveillance programs.And it's open floor. So whoever would like to respond first.st

ANIL MANGLA:
I can start. So what excites me the most of wastewater is the future of this wastewater is a potential to transform infectious disease, monitoring right to be proactive, to be equitable. It's a great tool for public health. The wastewater surveillance also allows us to detect emerging early threats. Right? And you know, as I had brought up earlier, this is even before you get clinical symptoms appearing. So in certain areas, certain jurisdictions where there's, you know, potential for an outbreak.High tourist attractions, high tourists coming in like we are in Vegas. To me this is such a great tool because it gives us advance notice. And so with that advance notice, we can alert public with, you know.health alerts and health notices. And this is what we kind of seen, you know.I mean.if we're looking at, say, Norovirus, we can provide guidance. So we don't get an outbreak. So this is really great, and it excites me even right now. So you know, I look at if we look at the next year or 2 or 3, I think there's going to be much more advancement so very exciting to be, you know, part of this public health and wastewater surveillance group.

ALLISON WHEELER:
I think, for me, you know. During a time when public health is under scrutiny, and and our funding is tight.Wastewater surveillance is as we've talked about. It's cost effective. It's non privacy invading at the sewer shed level. And it is a tool that helps us understand levels of disease in our communities so that we can determine an appropriate public health response.I think, by considering the the possible ethical concerns about our activities and by addressing them. We're really safeguarding the future of wastewater surveillance as a core, public health surveillance tool, regardless of the political climate. And so that is what is exciting to me.

KATA CHILLAG:
Yeah, I, in addition to all of the public health potential and contributions today on waste flower surveillance which I've learned about as part of this project.I continue, for the reasons I outlined in my introduction.and others, to be really excited for a variety of reasons about about really establishing and strengthening accessible ethics methods for people that are practicing in public health.And there are reasons I've already outlined about why that's important, because it does strengthen our decision making, particularly when we and as we should adopt an ethics preparedness model strengthened with the resources that we need to do that, but also because, especially at this moment, but always ethical issues are things that can contribute to burnout can make us question. You know what we do, or be less effective at times and having the tools to address this for positive impact is a matter of public health workforce stewardship. And I know all of us are very invested in that. And as part of this process, I will also say, the process of doing this together, including doing things like working through ethical issues together strengthened our relationships to others in ways that also are supportive in terms of workforce stewardship. Sometimes you adopt vulnerability with ethical issues, but but you know it can be fun. Actually, it can be relationship strengthening. And it is good for the workforce. And that's why I'm excited.

ALLISON WHEELER:
I realized I neglected to mention an important resource that we have developed during that section of the panel. And so I wanted to mention, and Alyssa put it in the chat. But our center of excellence created a wastewater ethics training that is based on the ethics framework. And so we look at this as a bite. Sized version of the framework.So really a summary using public health language with decision trees and case studies to help us at least to help me and my team better understand this this amazing ethics framework. So please check it out again. Alyssa put the the resource or the link in the chat, and thank you.

ERIN LAIRD:
Thanks for that, Allison. Glad you caught that, and thank you to all of our panelists and to all of you for joining us today and for submitting such thoughtful questions, we got a lot of fabulous questions. I wanted to try and squeeze a few more in, but obviously I'm at the top of the hour. I love. How many of you are excited to talk about ethics in wastewater surveillance? This is wonderful. It's a good problem to have.but I apologize if we didn't get to your question. I do hope this has been a valuable event for all of you, and we would love to hear from you on what we did well, and on any areas where we could improve. So I believe on the next slide, there's a QR code for the meeting evaluation. So please do share your feedback with us, so we can continue to build on those things that worked well and change or improve the things that maybe didn't meet your expectations. But with that, as mentioned, this recording will be available to you, and you can access ASTHO's framework and all the other fabulous resources in the chat, and we appreciate you all so much for joining, and look forward to seeing you all the next time.