Wastewater monitoring as ‘public health dream’ raises big ethical questions

Scientists have spent a lot of time during the COVID pandemic sifting through sewage — an attempt to consult with the so-called “toilet wonder” about what the virus is all about. next.

Their goal: to track COVID levels in human waste to gauge its spread in individual cities and states. Scientists can even trace them further downstream, tracing specific variations to neighborhoods, and even buildings like offices.

But is it ethical?

Wastewater monitoring is an epidemiological approach that dates back decades. It emerged during the early days of the COVID-19 pandemic, when it allowed universities to effectively track outbreaks in dormitories and isolate accordingly. With COVID testing less and less frequent, it’s become public health officials’ best information on community spread of the disease.

But a science that has the potential to do so much good — some say it could help prevent the next pandemic — can also be abused. Deterministic operating systems can track a particularly curious strain to an area, then a neighborhood, then a specific location like a house. And all this without your consent or even knowing.

“Looking at it, it’s not unethical,” said Dr David Larson, an environmental epidemiologist at Syracuse University in New York who studies wastewater. But “moral issues are prominent” as the search becomes more targeted, he said, like tracing a specific virus variant found in a city’s sewers to a finite location. “Personally, I worry about that,” he said.

Signal in the sewer

A recent article in Nature highlights a search by university scientists in Wisconsin for the origin of a disturbing, heavily mutated COVID variant. They theorized that it came from a person with a long-term COVID infection that was able to travel from the lungs to the intestines, where immune cells were less active.

They traced the curious variation — originally found in the wastewater of more than 100,000 state residents and countless animals — from the main plant to county lines, to city manholes. , to the village manholes, to the base lines, to the toilets, Nature reported.

So they narrowed their search to a small office of 30 people. Follow Nature, but there seems to be no variation mentioned. The researchers are now awaiting approval for a study that will examine fecal samples from well-wishers and, in the meantime, they’re scouring nearby sewers, hoping to track variation in one other position.

While wastewater monitoring has emerged early in the COVID-19 pandemic, the technology is hardly new. Dr. John Snow, father of epidemiology, was the first to document an outbreak of waterborne disease — a cholera epidemic in London in 1854. Using germ theory, he was able to convince city officials that the plague was tied to water. contamination from a pump on Broad Street. After the pump handle was removed, ending the community’s access to water from that source, the epidemic was contained.

So began the interest of domestic scientists in divination.

Wastewater monitoring, although much less sophisticated than it is, played a large role in the eradication of polio in the 20th century, in the United States and third world countries. It was used to track the spread of Hepatitis A in the United States in the 1980s and has been used by law enforcement to track the flow of drugs in communities for decades.

As COVID testing hits all-time lows in the US and abroad, public health officials increasingly rely on wastewater as the only accurate measure of the disease’s spread.

Dr Mark Siedner, an infectious disease physician at Massachusetts General Hospital and an associate professor at Harvard Medical School, has gone so far as to call wastewater “a public health dream scenario.”

“Everybody poop, and most people poop every day. It provides real-time data on infection rates,” he said. “In that respect, it’s an extremely powerful tool, particularly good at detecting early warning signs.”

A prisoner of public health?

At the community level, the public health benefits of wastewater monitoring are undeniable. This technology allows scientists and public health officials to identify outbreaks and intervene accordingly. And it gives its test-takers an accurate, unbiased view of disease spreading in the community — even in low-income areas where access to health care is limited. health and tests are often poor.

The wastewater monitoring debate becomes more heated about what to do after a person with a particularly interesting or dangerous disease is identified using this technology. Larson, a Syracuse University epidemiologist, says the scenario is a Pandora’s box.

He points to the case of an Arizona man with super-drug-resistant tuberculosis. After visiting a Phoenix convenience store without a mask in 2006, he was held in a hospital prison for nearly a year and treated like an inmate.

County health officials declared the man, Robert Daniels, posed a serious health risk to the community due to his illness and behavior. But Daniels, a Russian of Russian descent with dual citizenship, said CBS News that he did not understand the severity of his condition and that doctors in Russia did not wear masks around him.

In 2008, prosecutors filed felony charges — two counts of illegally introducing an epidemic or parasite into a person. At the time, Daniels had undergone lung surgery and was deemed non-contagious. He fled to his native Russia the following month.

Situations like ‘Typhoid Mary’

Ethical conundrums may also recall the story of “Typhoid Mary”—a cook and an asymptomatic carrier of typhoid that infected more than 50 people and killed at least three when she She switched careers on the East Coast in the late 1800s and early 1900s.

The woman, Mary Mallon, was well aware of the accusations, reportedly with a knife chasing scientists who came to demand stool and urine samples from her. But she never admitted to being a carrier and probably never understood how an asymptomatic person could be one, based on National Geography.

Eventually, scientists and five police officers escorted her to a New York City hospital, where she tested positive and was quarantined in a small house on the hospital campus. In 1909, she sued the New York City Department of Health. The case went to the US Supreme Court, with her attorney arguing that she was jailed and denied due process. Mallon lost, with the court siding with public health officials and their desire to protect the public.

A sympathetic New York City health commissioner released Mallon in 1910, after she promised to stop cooking for others, according to National Geography. But she kept going, eventually sparking an outbreak at a New York hospital, where she was working under a pseudonym.

Mallon was taken and returned to the campus of the hospital in which she was first detained, where she would live until her death from a stroke in 1938.

Neither the Daniels case nor Mallon’s wastewater are related. But both are examples of the extent to which authorities can stave off a public health threat — at the expense of individual rights.

Public health officials “are often driven by a pragmatic ethic” that seeks “what’s best for the masses,” Larson said. But such an approach must be countered by concerns about individual liberties, he noted.

“As we have seen with COVID, individual rights will often be curtailed to reduce transmission of infectious disease,” he said. “It’s a place of tension, a place of balance.”

Data will free you

How can scientists and public health officials strike such a balance?

Peter Grevatt, CEO of the Water Research Foundation, a nonprofit that seeks to advance water science and improve quality of life, says it’s a question to think about – especially with Wastewater science is developing rapidly.

“Taking a biological sample from a group of individuals does not necessarily give you consent to do so, to collect information about their health status — it is not quite at the level of individual infectious disease information,” he said. human, but it’s almost the same thing.”

He added: “One has to ask, ‘What is the proper way to process this information?’ It’s a really important part of the discussion when one is designing a study. “

Currently, wastewater-based epidemiology has little oversight, mainly because it does not involve direct sample collection from individuals and, therefore, does not require informed consent. One Pandemic era guide published by the US Centers for Disease Control and Prevention on wastewater monitoring deals only with logistics and does not delve into ethical concerns and best practices.

However, courts can interpret the small-scale collection of wastewater data as a violation of the Fourth Amendment, which protects U.S. citizens from unreasonable search and seizure, under a. Article June 2020 inside Journal of Law and Biological Sciences. The U.S. Supreme Court has “recognized that the collection and analysis of biological samples may violate reasonable expectations of privacy,” and thus constitute a search warrant. change, according to the article.

Grevatt pointed to a set of ethical guidelines for wastewater monitoring from the European Center for Drugs and Addiction that could inform the actions of US researchers.

Some recommended best practices anonymous data was included — possibly by mixing samples from multiple locations, such as suburbs, so as not to stigmatize or single out a particular community.

Researchers should also consider how the results might be interpreted by the media, highlighting the error of community members, state guide. It also recommends that scientists using wastewater-based epidemiology seek approval from a research ethics committee, even if such approval is not required.

“Wastewater has a story to tell about the health of a community,” argues Grevatt. But those involved in research related to it must put public health — and that goal alone — first.

He cites a project in which his organization has partnered with law enforcement to monitor the flow of drugs in wastewater in multiple cities. At one location, a weekend spike in the presence of cocaine was noted, signaling parties with illicit drug use. But there is a conscious effort by the organization and the police to ensure the information obtained is used to advance public health goals, Grevatt said.

Larson argues that wastewater monitoring – when used properly – can really enhance individual rights. That’s the goal, anyway.

“When done well, wastewater monitoring should increase freedoms rather than restrict them,” he said. “By preventing disease transmission, we are actually maximizing the freedoms constrained by infectious diseases.”


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