Advancing Wastewater Surveillance for Public Health Impact

Public health agencies routinely encounter ethical issues and may face challenges addressing them. To enhance the effectiveness of WWS initiatives and build public trust, it is essential that public health staff understand potential ethical issues and have the tools to support decision-making.

Challenges addressing ethical issues may be due to several factors, including:

• Responsibility of ethical analysis: “Ethics work” can be intimidating and ineffective if perceived as individuals’ responsibility, rather than a systemic approach with infrastructures to support its implementation.
• Resources: Public health staff could benefit from increased time, support, and resources to effectively carry out ethical analysis and address complex issues.
• Reactive focus: Ethics are often seen as punitive, only a response to scandals or related to legal or regulatory issues, instead of being a proactive, essential part of effective public health.
• Trust: Building and fostering trust among communities that have significant mistrust in public health is no easy feat.
  
  

Key areas of ethical concern in WWS:

• Individual and group privacy concerns: WWS programs must carefully consider the scale necessary for surveillance, as small-scale wastewater sampling can increase the risk of privacy-related issues (e.g., individuals or groups being identified).
• Stigma: Surveillance findings can cause stigma if a disease or outcome is associated with an individual or group. To reduce stigma-related harm, WWS programs should ensure the protection and careful communication of information/data.
• Data stewardship: Without clear policies or guidelines, it can be unclear who owns the data or how it is shared. WWS programs can advance data stewardship by monitoring potential uses and misuses of data.
  
  

In 2025, ASTHO developed the "Framework for Addressing Ethical Considerations in Infectious Disease Public Health Wastewater Surveillance" to support public health departments and WWS partners in addressing ethical issues related to infectious disease WWS. Relevant literature, technical reports, and public health ethics frameworks/guidance inform this framework. The resource provides tools for ethical analysis to support public health practitioners’ decision-making, focusing on three areas of ethical concern in WWS: privacy, stigma, and data stewardship.

This section highlights a successful and innovative solution that your peers implemented to address ethical considerations for WWS of infectious diseases. This story presents the factors that catalyzed the innovation, the existing policies or funding mechanisms that facilitated action, the potential barriers the organization faced, the collaborations and partnerships the organization leveraged, and tips for implementing and/or scaling the solution.

Colorado’s "Ethical Considerations for Wastewater Surveillance Systems" Training

Since 2022, the Colorado National Wastewater Surveillance System Center of Excellence (CO NWSS CoE) has served as a dedicated resource for WWS and communicable disease prevention. The CO NWSS CoE, a collaboration between the Colorado Department of Public Health and Environment (CDPHE) and the University of Denver, provides support and education to local and state public health agencies, wastewater utility partners, and public health laboratories within the U.S. Department of Health and Human Services regions 7 and 8.

Building off of ASTHO’s framework, the CO NWSS CoE developed and launched a course, Ethical Considerations for Wastewater Surveillance Systems. This helps public health and wastewater professionals improve their knowledge and understanding of ethical considerations related to WWS, and apply recommendations outlined in ASTHO’s framework while also providing practical insights and local examples for users.

Policies and Funding

CO NWSS CoE developed this course with funding from the CDC’s Epidemiology and Laboratory Capacity (ELC) program, specifically NWSS 2. The course took approximately 4.5 months to develop, from initial conversations to publication.

Challenges and Barriers

• The partnership between CDPHE and the University of Denver, along with engagement with external subject matter experts (SMEs), allowed the CoE to tap into a robust network of expertise; however, it also introduced challenges inherent to collaboration, such as developing a shared vision and priorities.
• The CO NWSS CoE team also experienced challenges related to communicating complex information in plain language, without losing or changing the message. They actively engaged team members who had not previously participated in ethics-related discussions, valuing their fresh perspective to help review materials and flag potential areas of confusion.
  
  

Collaboration and Partnerships

Several key partners collaborated on this important training course. In addition to the CO NWSS CoE staff, other key contributors and collaborators include a graduate student from the University of Denver College of Professional Studies in the Instructional Design and Technology program, the University of Denver video production team, and CDPHE wastewater surveillance staff. The course also features feedback from external SMEs who were key in developing ASTHO’s framework, and members of the CO NWSS CoE Advisory Board – consisting of infectious disease physicians, wastewater utility partners, academic partners, and local public health staff – also reviewed the course.

Tips for Implementation and Scaling from the CO NWSS CoE Staff

• Community needs: Conduct surveys or focus groups to determine training needs and gaps, and establish a clear channel of communication with communities where surveillance is conducted to understand their perspectives.
• Audience: Discuss the target audience for the training, identify promising practices or strategies that resonate with that audience, and routinely engage members of your target audience throughout the development process.
• Goals and objectives: Set clear, well-defined goals and objectives to minimize scope creep.
• Collaborators: Work with a variety of SMEs, relevant partners, and community organizations to ensure training is relevant for users and community needs are met.
• Ongoing feedback: Establish regular opportunities to gather feedback and suggestions during the planning, implementation, and evaluation phases of the training.
• Tailor content: Develop examples or case studies specific to your state/region to contextualize the content and make it most relevant to your audience.