Table 1. Consolidated Framework for a Structured Ethical Review to Assess Potential Adverse Outcomes of WBT Efforts^a.

Category	0—Minimal Review Required	1—Review Suggested	2—Review Strongly Suggested
Legitimacy: Are surveillance data collected only for a legitimate public health purpose?†	Data support public health agents for public health measures	Data support nonpublic health agents for public health measures	Data support nonpublic health agents (or public health agents acting outside of public health) for nonpublic health purposes
Unfair Disadvantage: Is the information used in such a way as to cause unwarranted harm or disadvantage to its subject?*	WBT is implemented with clear scope, oversight, and decision-making procedures including procedures for response to wastewater data with policies for follow-up clinical testing applicable to full communities	Unintentionally subjecting specific areas to the possibility of a disruptive intervention (lockdowns, quarantines, isolations of entire areas without any process for identifying and isolating relevant individuals; mandatory testing of individuals in response to wastewater data) whereas excluding others from the same level of surveillance scrutiny and response	Intentionally subjecting specific areas to the possibility of a disruptive intervention (lockdowns, quarantines, isolations of entire areas without any process for identifying and isolating relevant individuals; mandatory testing of individuals in response to wastewater data) whereas excluding others from the same level of surveillance scrutiny and response
Data Stewardship and Protection: Is the data properly maintained to protect those monitored?*	Data managed per requirements of and for community monitored (codeveloped with the community and professional practice)	Data managed per requirements for community monitored (set by professional practice alone)	Data management plan absent
Creation of Unwanted Precedents: Is it likely to create precedents that will lead to its application in undesirable ways?*	Analysis for individual identification prohibited; explorations outside of agreed-upon community scope is explicitly prohibited	No positional statement regarding individual identification; No discussion of future research is discussed	Explicitly for identification of individuals or otherwise unethical applications
Awareness: Are individuals informed they are being monitored and why?*	Representative(s) of the monitoring campaign are in a cycle of continued community outreach and engagement during WBT and over the clearly defined reporting period providing contextualization of the scope and intent to minimize misrepresentation or misuse; those monitoring capture the questions from the community rather than the wastewater utility operators	Duration, scope, and intent is communicated and disseminated in a passive manner without contextualization or engagement OR communicated to a single representative of the community; the wastewater utility operators respond to increased inquiries but have access to those collecting the data to direct inquiries	No direct communication of the duration, scope, and intent to the monitored community members; the burden of communication falls solely on the third-party wastewater utility operators rather than the data collectors
External Data Sharing: Is the public health surveillance data shared with other public health agencies when addressing a public health need?†	Collected WBT-supported public health data is shared freely with/between public health agencies when a public health need presents or persists	Collected WBT-supported public health data only partially shared with/between public health agencies when a public health need presents or persists	No data is shared when a public health need presents or persists
Public Decision-Making: Was the decision to use WBT in surveillance arrived at through some public discussion and decision-making process?*	Surveillance program was designed in a public manner (e.g., review by elected officials and public through town halls for initial implementation and continued operation) with a good-faith effort to reach both those receptive or resistant to the objectives of public health	Program does not receive formal public authorization but is broadly supported by the public (as informed by representative public surveys)	Program does not receive formal public authorization and is not supported by the public (as informed by representative public surveys)
Right of Inspection: Are people aware of the findings of WBT supported surveillance and how they were created?*	Representative(s) of the monitoring campaign are in a cycle of continued community outreach and engagement during the sample collection and reporting period providing contextualization of the collected data to minimize misrepresentation or misuse (e.g., updating an annotated and agreed-upon Internet-accessible dashboard; timely and routine public town-halls or open seminars; direct mailing to surveyed individuals)	The collected data is communicated and disseminated in a passive manner without contextualization or engagement OR communicated to a single representative of the community	No direct communication of the collected data to the monitored community members
Equality-inequality: Is WBT broadly applied to all or only those able to resist?*	Entire community is monitored (e.g., treatment plant; jail sampling that monitors the effluent of the whole jail including staff and inmates)	Representative coverage is achieved (e.g., manhole sampling, but ensuring that demographics of surveilled communities are representative of the entire city; jail sampling that has sites for staff and inmates separately)	Only protected-class communities are monitored (e.g., manhole sampling that surveils only low-GDP per capita areas; jail sampling that only surveils inmates)
Community Values: Are the values and concerns of the communities taken into account in planning, implementing, and using data from surveillance?†	Representative of the monitoring campaign are in a cycle of continued community outreach and engagement during the planning and implementing period to address the concerns and support the values of the community	Representative of the monitoring campaign are engaged during the planning period only to address the concerns and support the values of the community	No direct involvement of the monitored community members
Consequence of Inaction: What are the consequences of taking no surveillance action?*	Mortality, morbidity, or other adverse effects is imposed on community by lack of surveillance	The surveillance data does not minimize adverse effects to the community	The community benefits by not being surveilled

^aSpecific categories originated from either Marx 1997³⁷ (*) or Hrudey et al., 2021³² [^†]. “Review” within the framework indicates that further critical discussion is suggested among stakeholders to explore this category in detail and codevelop best practices. The top 11 categories based on the internal voting are presented here, and the full framework is presented as Supporting Table 1, also available at DOI: 10.17632/2xkfkcsxx8.1.