Making waves: The benefits and challenges of responsibly implementing wastewater-based surveillance for rural communities

The sampling and analysis of sewage for pathogens and other biomarkers offers a powerful tool for monitoring and understanding community health trends and potentially predicting disease outbreaks. Since the early months of the COVID-19 pandemic, the use of wastewater-based testing for public health surveillance has increased markedly. However, these efforts have focused on urban and peri‑urban areas. In most rural regions of the world, healthcare service access is more limited than in urban areas, and rural public health agencies typically have less disease outcome surveillance data than their urban counterparts. The potential public health benefits of wastewater-based surveillance for rural communities are therefore substantial - though so too are the methodological and ethical challenges. For many rural communities, population dynamics and insufficient, aging, and inadequately maintained wastewater collection and treatment infrastructure present obstacles to the reliable and responsible implementation of wastewater-based surveillance. Practitioner observations and research findings indicate that for many rural systems, typical implementation approaches for wastewater-based surveillance will not yield sufficiently reliable or actionable results. We discuss key challenges and potential strategies to address them. However, to support and expand the implementation of responsible, reliable, and ethical wastewater-based surveillance for rural communities, best practice guidelines and standards are needed.

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.

Research integrity and the regulatory-industrial complex

Integrity in research is essential so that research can do what it is supposed to do: help us discover - or get closer to - the truth about the world and how it works. Research integrity means conducting oneself in ways that are worthy of the trust that the public invests in science. Efforts over the past five decades to ensure that researchers conduct themselves with integrity have focused on regulating researcher behavior. The suite of regulatory requirements - over 100 of them - is typically managed by an office of research compliance at universities and research institutions. The regulations, and the accompanying rules and policies, have created a regulatory-industrial complex that, while necessary, should give us pause. With the proliferation of regulations, professional organizations and certifications blossom, providing much-needed training and vouching for expertise in particular regulations. This credibility is crucial, but it also gives a false impression that we can regulate our way to ethical science. Creating a regulatory-industrial complex will not achieve our goal of an ethical research enterprise. We need to build ethical institutional cultures, engage the commitment of the entire research enterprise, and do the hard work of holding accountable the entire research ecosystem.

Timing and monitoring of financial disclosures in publications: A cross-institutional assessment of financial conflict of interest reports

A consistent mitigation strategy used in sponsored research to manage a financial conflict of interest (FCOI) is disclosure in publications. While federal funding regulations require mitigation strategies to be monitored through the end of the project's term, manuscripts are often published after the project term has ended. We examined whether it would be valuable to extend monitoring of publications for compliance with requirements for disclosure beyond the end date of a project's term and, if so, for how long after the term has ended. Using publicly available databases, we identified FCOI reports from public universities and analyzed disclosure completion in the years before and after the end of the project's term. We found that 80.2% of FCOI reports in our sample had a publication in which a conflicted Investigator served as an author, yet less than half (43.6%) of these publications contained disclosure statements acknowledging the known FCOI. We also found that publication most commonly occurred one year after the end of the project's term. These findings indicate that an effective way to support accountability and accuracy of the scientific record would be to extend monitoring of disclosure in publications through one year following the end of the project's term.

How Should Clinicians Own Their Roles as Past and Present Exacerbators of Health Inequity and as Present and Future Contributors to Health Equity?

To improve health outcomes, the science and practice of medicine must move quickly in response to new information. Yet, in other important ways, health professionals must operate slowly and in a mode of intentional stillness to center empathy and light a path from empathy to solidarity. Solidarity, or standing with, prompts efforts to create circumstances in which disadvantaged communities can achieve health equity. This article argues for intentional stillness and solidarity to inspire ethical conduct and structural change. In the case presented, inaction and delay, which are neither virtuous nor antiracist forms of stillness in this context, would leave intact the status quo of disparity and inequity in cardiac medicine.

Treating Workers as Essential Too: An Ethical Framework for Public Health Interventions to Prevent and Control COVID-19 Infections among Meat-processing Facility Workers and Their Communities in the United States

Meat is a multi-billion-dollar industry that relies on people performing risky physical work inside meat-processing facilities over long shifts in close proximity. These workers are socially disempowered, and many are members of groups beset by historic and ongoing structural discrimination. The combination of working conditions and worker characteristics facilitate the spread of SARS-CoV-2, the virus that causes COVID-19. Workers have been expected to put their health and lives at risk during the pandemic because of government and industry pressures to keep this "essential industry" producing. Numerous interventions can significantly reduce the risks to workers and their communities; however, the industry's implementation has been sporadic and inconsistent. With a focus on the U.S. context, this paper offers an ethical framework for infection prevention and control recommendations grounded in public health values of health and safety, interdependence and solidarity, and health equity and justice, with particular attention to considerations of reciprocity, equitable burden sharing, harm reduction, and health promotion. Meat-processing workers are owed an approach that protects their health relative to the risks of harms to them, their families, and their communities. Sacrifices from businesses benefitting financially from essential industry status are ethically warranted and should acknowledge the risks assumed by workers in the context of existing structural inequities.

Creating a Research Ethics Consultation Service: Issues to Consider

This article provides pragmatic advice for organizations interested in creating a research ethics consultation service (RECS). A robust RECS has the potential to build capacity among investigators to identify and consider the ethical issues they encounter while conducting their research. Determining whether to establish an RECS should begin with an institutional-needs assessment that includes three key questions: What are the current resources available to research teams to navigate ethical concerns that arise from their research? Is there a demand or perceived need for more resources? Is there institutional support (financial and otherwise) to establish and maintain an RECS? If this results in the decision to establish the consultation service, relevant institutional stakeholders must be identified and consulted, and personnel with the requisite skills recruited. The next step is to establish an RECS and build the infrastructure to process and respond to requests. The RECS's long-term sustainability will depend on a stable source of funding and a mechanism to receive constructive feedback to ensure that the service is meeting the institutional needs it set out to address.

Author Correction: A model for the fragmentation kinetics of crumpled thin sheets

A Correction to this paper has been published: https://doi.org/10.1038/s41467-021-22791-z

A model for the fragmentation kinetics of crumpled thin sheets

As a confined thin sheet crumples, it spontaneously segments into flat facets delimited by a network of ridges. Despite the apparent disorder of this process, statistical properties of crumpled sheets exhibit striking reproducibility. Experiments have shown that the total crease length accrues logarithmically when repeatedly compacting and unfolding a sheet of paper. Here, we offer insight to this unexpected result by exploring the correspondence between crumpling and fragmentation processes. We identify a physical model for the evolution of facet area and ridge length distributions of crumpled sheets, and propose a mechanism for re-fragmentation driven by geometric frustration. This mechanism establishes a feedback loop in which the facet size distribution informs the subsequent rate of fragmentation under repeated confinement, thereby producing a new size distribution. We then demonstrate the capacity of this model to reproduce the characteristic logarithmic scaling of total crease length, thereby supplying a missing physical basis for the observed phenomenon.

Synergistic Disparities and Public Health Mitigation of COVID-19 in the Rural United States

Public health emergencies expose social injustice and health disparities, resulting in calls to address their structural causes once the acute crisis has passed. The COVID-19 pandemic is highlighting and exacerbating global, national, and regional disparities in relation to the benefits and burdens of undertaking critical basic public health mitigation measures such as physical distancing. In the United States, attempts to address the COVID-19 pandemic are complicated by striking racial, economic, and geographic inequities. These synergistic inequities exist in both urban and rural areas but take on a particular character and impact in areas of rural poverty. Rural areas face a diverse set of structural challenges, including inadequate public health, clinical, and other infrastructure and economic precarity, hampering the ability of communities and individuals to implement mitigation measures. Public health ethics demands that personnel address both the tactical, real-time adjustment of typical mitigation tools to improve their effectiveness among the rural poor as well as the strategic, longer-term structural causes of health and social injustice that continue to disadvantage this population.

Addressing Ethical Challenges in US-Based HIV Phylogenetic Research

In recent years, phylogenetic analysis of HIV sequence data has been used in research studies to investigate transmission patterns between individuals and groups, including analysis of data from HIV prevention clinical trials, in molecular epidemiology, and in public health surveillance programs. Phylogenetic analysis can provide valuable information to inform HIV prevention efforts, but it also has risks, including stigma and marginalization of groups, or potential identification of HIV transmission between individuals. In response to these concerns, an interdisciplinary working group was assembled to address ethical challenges in US-based HIV phylogenetic research. The working group developed recommendations regarding (1) study design; (2) data security, access, and sharing; (3) legal issues; (4) community engagement; and (5) communication and dissemination. The working group also identified areas for future research and scholarship to promote ethical conduct of HIV phylogenetic research.

Reconstruction of an idiopathic hemipalatal hypoplasia: report of a case

Idiopathic hemipalatal hypoplasia is rare and leads to speech problems and the regurgitation of fluids, and the reconstruction of asymmetrical velopharyngeal incompetence is a challenge to the cleft surgeon. We present a case in a 5-year-old boy, and introduce the one-stage surgical technique that we used to resolve it.

Equitable Health Care and Low-Density Living in the United States

In 1818, John Sinclair's advice for health and longevity included temporary retirement to the country. Two centuries later, life in rural America means higher death rates throughout the lifespan. Health care delivery in rural areas is limited by a number of hardships associated with low-density living, including a shortage of providers, limited cultural diversity, and geography. There are both profound challenges and deep rewards associated with providing health care services in rural areas. Barring a major change in the health care financing and delivery systems, solutions for bringing a full range of quality health care and preventive services to rural residents include incentivizing a full range of providers to practice in rural areas; exploiting the delivery infrastructure that has developed in response to the explosive growth in e-commerce; taking advantage of cellular, digital, and satellite technologies; and learning about what motivates providers to choose rural practice settings.

Geometric frustration induces the transition between rotation and counterrotation in swirled granular media

Granular material in a swirled container exhibits a curious transition as the number of particles is increased: At low densities, the particle cluster rotates in the same direction as the swirling motion of the container, while at high densities it rotates in the opposite direction. We investigate this phenomenon experimentally and numerically using a corotating reference frame in which the system reaches a statistical steady state. In this steady state, the particles form a cluster whose translational degrees of freedom are stationary, while the individual particles constantly circulate around the cluster's center of mass, similar to a ball rolling along the wall within a rotating drum. We show that the transition to counterrotation is friction dependent. At high particle densities, frictional effects result in geometric frustration, which prevents particles from cooperatively rolling and spinning. Consequently, the particle cluster rolls like a rigid body with no-slip conditions on the container wall, which necessarily counterrotates around its own axis. Numerical simulations verify that both wall-disk friction and disk-disk friction are critical for inducing counterrotation.

Public Health Data Collection and Implementation of the Revised Common Rule

For the first time, the revised Common Rule specifies that public health surveillance activities are not research. This article reviews the historical development of the public health surveillance exclusion and implications for other foundational public health practices.

A Sequence of Developmental Events Occurs Underneath Growing Bacillus subtilis Pellicles

Biofilms are structured communities of bacteria that exhibit complex spatio-temporal dynamics. In liquid media, Bacillus subtilis produces an opaque floating biofilm, or a pellicle. Biofilms are generally associated with an interface, but the ability of Bacillus subtilis to swim means the bacteria are additionally able to reside within the liquid phase. However, due to imaging complications associated with the opacity of pellicles, the extent to which bacteria coexist within the liquid bulk as well as their behavior in the liquid is not well studied. We therefore develop a high-throughput imaging system to image underneath developing pellicles. Here we report a well-defined sequence of developmental events that occurs underneath a growing pellicle. Comparison with bacteria deficient in swimming and chemotaxis suggest that these properties enable collective bacterial swimming within the liquid phase which facilitate faster surface colonization. Furthermore, comparison to bacteria deficient in exopolymeric substances (EPS) suggest that the lack of a surface pellicle prevents further developmental steps from occurring within the liquid phase. Our results reveal a sequence of developmental events during pellicle growth, encompassing adhesion, conversion, growth, maturity, and detachment on the interface, which are synchronized with the bacteria in the liquid bulk increasing in density until the formation of a mature surface pellicle, after which the density of bacteria in the liquid drops.

Machine learning in a data-limited regime: Augmenting experiments with synthetic data uncovers order in crumpled sheets

Machine learning has gained widespread attention as a powerful tool to identify structure in complex, high-dimensional data. However, these techniques are ostensibly inapplicable for experimental systems where data are scarce or expensive to obtain. Here, we introduce a strategy to resolve this impasse by augmenting the experimental dataset with synthetically generated data of a much simpler sister system. Specifically, we study spontaneously emerging local order in crease networks of crumpled thin sheets, a paradigmatic example of spatial complexity, and show that machine learning techniques can be effective even in a data-limited regime. This is achieved by augmenting the scarce experimental dataset with inexhaustible amounts of simulated data of rigid flat-folded sheets, which are simple to simulate and share common statistical properties. This considerably improves the predictive power in a test problem of pattern completion and demonstrates the usefulness of machine learning in bench-top experiments where data are good but scarce.

National Bioethics Commissions as Educators

As has become tradition, executive directors of United States' presidential bioethics committees offer reflections about their experience shortly after the orderly shutdown of the commission staff. After the records are filed according to government records regulations; after all the staff members, who are hired into temporary positions that must be renewed every two years, have secured permanent employment; after preparations are made to ensure that the next commission staff (should there be one) has a budget and standard operating procedures in order to begin its work in a timely manner; after the lights are turned out for the last time, the executive director makes the final climb up the stairs into the sunlight and reflects on the whirlwind. There is much about my work with the Presidential Commission for the Study of Bioethical Issues that deserves comment, but one aspect of the commission that has been especially valuable to me is its work to educate the nation on bioethical issues. This is, moreover, a contribution in which the commission staff was central, and it is one that, as an ethics educator myself, I will cherish deeply.

Abstract P3-12-13: Breast atypical hyperplasia and guideline compliance

Background: Atypical hyperplasia of the breast is a high-risk benign lesion that is found in approximately 10% of benign breast biopsies[1]and confers a risk for future breast cancer[2]. The American Society of Clinical Oncology guideline states that pharmacologic risk reduction with the use of a selective estrogen receptor modulator or an aromatase inhibitor should be discussed with women with a 5-year projected absolute risk of breast cancer of 1.7% or higher[3]. The NCCN guideline for risk reduction recommends consideration of risk-reduction interventions, including the use of pharmacologic agents in women with a 5-year risk of 1.7% or higher and a life expectancy of 10 years or longer [4] .The majority of women with atypical hyperplasia meet this risk criterion with their cumulative risk of approximately 1% per year.

Method: We retrospectively reviewed excisional biopsy pathology reports between January 2016 and June 2016 with the diagnosis of atypical ductal or lobular hyperplasia to identify patients with pure atypical hyperplasia. Medical records of these patients were then reviewed to identify the percentage of patients referred to a medical oncologist for chemoprevention discussion and the percentage of patients who received chemoprevention following excisional biopsy.

Results: Two hundred seventy six patients with the diagnosis of atypical ductal or lobular hyperplasia were identified. Two hundred and sixteen patients were excluded from the analysis due to the presence of other histologies such as carcinoma in situ and invasive carcinoma. Medical records of the remaining sixty patients with pure atypical hyperplasia were reviewed. Eighteen patients' charts were unavailable for review. All of the remaining forty two patients had a 5-year breast cancer risk of 1.7% or higher. Five of these patients (8.3%) were referred to a medical oncologist for chemoprevention discussion. Two of these five patients (2.3%) received chemoprevention with tamoxifen. For patients who were not referred to medical oncologist, there was one documented discussion of chemoprevention with patient by her surgical oncologist. One patient underwent prophylactic bilateral mastectomies, and therefore, chemoprevention was not recommended.

Conclusion: Multidisciplinary strategies need to be implemented to bridge the gap between guidelines and clinical practices which may lead to improved patient outcomes.

References:

1. 1. Simpson JF. Update on atypical epithelial hyperplasia and ductal carcinoma in situ. Pathology 2009;41:36-39.

2. 2. Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med 2005;353:229-237.

3. Visvanathan K, Hurley P, Bantug E, et al. Use of pharmacologic interventions for breast cancer risk reduction: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013;31:2942-2962. J Clin Oncol 2013;31:4383.

Citation Format: Lee LM, Klein P, Velazy R. Breast atypical hyperplasia and guideline compliance [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-13.

A Bridge Back to the Future: Public Health Ethics, Bioethics, and Environmental Ethics

Contemporary biomedical ethics and environmental ethics share a common ancestry in Aldo Leopold's and Van Rensselaer Potter's initial broad visions of a connected biosphere. Over the past five decades, the two fields have become strangers. Public health ethics, a new subfield of bioethics, emerged from the belly of contemporary biomedical ethics and has evolved over the past 25 years. It has moved from its traditional concern with the tension between individual autonomy and community health to a wider focus on social justice and solidarity. Public health has a broad focus that includes individual, community, and environmental health. Public health ethics attends to these broad commitments reflected in the increasing concern with the connectedness of health of individuals to the health of populations, to the health of animals, to the health of the environment; it is well situated to reconnect all three "fields" of ethics to promote a healthier planet.

Ethics and subsequent use of electronic health record data

The digital health landscape in the United States is evolving and electronic health record data hold great promise for improving health and health equity. Like many scientific and technological advances in health and medicine, there exists an exciting narrative about what we can do with the new technology, as well as reflection about what we should do with it based on what we value. Ethical reflections about the use of EHR data for research and quality improvement have considered the important issues of privacy and informed consent for subsequent use of data. Additional ethical aspects are important in the conversation, including data validity, patient obligation to participate in the learning health system, and ethics integration into training for all personnel who interact with personal health data. Attention to these ethical issues is paramount to our realizing the benefits of electronic health data.

Defining the Boundaries of a Right to Adequate Protection: A New Lens on Pediatric Research Ethics

We argue that the current ethical and regulatory framework for permissible risk levels in pediatric research can be helpfully understood in terms of children's moral right to adequate protection from harm. Our analysis provides a rationale for what we propose as the highest level of permissible risk in pediatric research without the prospect of direct benefit: what we call "relatively minor" risk. We clarify the justification behind the usual standards of "minimal risk" and "a minor increase over minimal risk" and explain why it is permissible to impose any risks at all on child participants who do not stand to benefit directly from enrollment in research. Finally, we illuminate some aspects of the concept of "best interests."

Comparison of Anyplex II RV16 assay with conventional methods for detection of respiratory viruses

Early detection of viral etiologies of acute respiratory tract infections of patients affects management and disease control in pediatric patients. In this study, the performance of Anyplex II RV16 assay (Seegene, Seoul, Korea) was evaluated by comparing with viral culture and direct immunofluorescence staining of clinical specimens for detection of respiratory viruses in patients. A total of 168 respiratory specimens were collected from 122 patients from November 2012 to May 2013 at the time of admission to the University of Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia. The Anyplex II RV16 assay, viral culture, and direct immunofluorescence staining were positive in 74.4%, 18.5% and 14.9% of the specimens, respectively. HRV was the predominant virus detected by the Anyplex II RV16 assay. In 47 cases, two or more respiratory viruses were detected by the Anyplex II RV16 assay, which were missed by conventional methods. The performance of the Anyplex II RV16 assay was better than viral culture and direct immunofluorescence staining of clinical specimens for the detection of respiratory viruses. The implementation of the Anyplex II RV16 assay in hospital laboratories will provide rapid diagnosis of major viral infections of the respiratory tract.

Integrating Public Health and Deliberative Public Bioethics: Lessons from the Human Genome Project Ethical, Legal, and Social Implications Program

Public health policy works best when grounded in firm public health standards of evidence and widely shared social values. In this article, we argue for incorporating a specific method of ethical deliberation--deliberative public bioethics--into public health. We describe how deliberative public bioethics is a method of engagement that can be helpful in public health. Although medical, research, and public health ethics can be considered some of what bioethics addresses, deliberative public bioethics offers both a how and where. Using the Human Genome Project Ethical, Legal, and Social Implications program as an example of effective incorporation of deliberative processes to integrate ethics into public health policy, we examine how deliberative public bioethics can integrate both public health and bioethics perspectives into three areas of public health practice: research, education, and health policy. We then offer recommendations for future collaborations that integrate deliberative methods into public health policy and practice.

Adding justice to the clinical and public health ethics arguments for mandatory seasonal influenza immunisation for healthcare workers

Ethical considerations from both the clinical and public health perspectives have been used to examine whether it is ethically permissible to mandate the seasonal influenza vaccine for healthcare workers (HCWs). Both frameworks have resulted in arguments for and against the requirement. Neither perspective resolves the question fully. By adding components of justice to the argument, I seek to provide a more fulsome ethical defence for requiring seasonal influenza immunisation for HCWs. Two critical components of a just society support requiring vaccination: fairness of opportunity and the obligation to follow democratically formulated rules. The fairness of opportunity is informed by Rawls' two principles of justice. The obligation to follow democratically formulated rules allows us to focus simultaneously on freedom, plurality and solidarity. Justice requires equitable participation in and benefit from cooperative schemes to gain or profit socially as individuals and as a community. And to be just, HCW immunisation exemptions should be limited to medical contraindications only. In addition to the HCWs fiduciary duty to do what is best for the patient and the public health duty to protect the community with effective and minimally intrusive interventions, HCWs are members of a just society in which all members have an obligation to participate equitably in order to partake in the benefits of membership.

Foundational values for public health

The development of an agreed-upon set of foundational ethical values for the field of public health is ongoing. In this paper we outline key elements of recent convergence on some basic moral precepts that drive public health. We suggest that three elements are particularly useful for anchoring public health practitioners' reflections on public health ethics: 1) the notions of "common" and "professional" morality, 2) an understanding of the practice and content of modern public health and especially its practical, solution-focused orientation, and 3) an appreciation of the history of public health as integrally linked to evolving and contested views of the relationship between citizens, science, and the state. There is broad agreement that governments are stewards of their populations and are responsible for providing conditions that allow for its members to be healthy and productive. Given the role of policy and government in public health, the role of political philosophy likely has a substantial place as we seek a coherent system of ethical justification in our work. The aim here is not to align with one theoretical approach or another, rather, to consider the foundational values of public health practice order to identify the common moral governance of our work. Our profession's morality-the set of norms shared by all public health professionals-is determined by what public health is and what we think it should be. As our aspirations for public health evolve, it is incumbent upon us to engage in reflective discourse to reach a new equilibrium about our moral foundation.

Teaching bioethics

From accessible and affordable health care to old or new reproductive technologies, human or animal research, and beyond, the justice and well-being of our society depends on the ability of key groups-such as scientists and health care providers-along with members of the public to identify the key issues, articulate their values and concerns, deliberate openly and respectfully, and together find the most defensible ways forward. The Presidential Commission for the Study of Bioethical Issues and The Hastings Center are committed to improving the ethical literacy of the American public in the domain of bioethics. But what are the best educational practices to spur and support these sorts of societal conversations? And where are the greatest gaps in our collective knowledge of how best to inspire and increase moral understanding, analytical thinking in the moral domain, and professional integrity?

First Report of a Novel Begomovirus Associated with Yellow Vein Disease of Browne's Blechum (Blechum pyramidatum)

Browne's Blechum (Blechum pyramidatum) is a common weed found in fields and waste grounds in the Philippines. A disease was observed causing begomovirus-like yellow/chlorotic leaf veins and shortened internodes of Browne's Blechum plants on the island of Luzon, Philippines; disease incidence ranged from 10 to 50% in fields in 2012. Samples were collected from two plants with symptoms from each of Laguna and Quezon provinces and one plant without symptoms from Laguna Province. All four samples from plants with symptoms tested positive for begomovirus by PCR using primer pair PAL1v1978B/PAR1c715H (2), but the symptomless plant sample did not. However, no virus DNA-B component was detected in any of the samples using either general detection primer pair DNABLC1/DNABLV2 or DNABLC2/DNABLV2 (1). Using abutting primers AFPH12W1-R2F (TCTGGATCCATTGTTGAACGAGT) and AFPH12W1-R2R (CCGGGATCCCACATTGTTAAACA), a complete DNA-A component sequence was obtained for a Laguna isolate (GenBank Accession No. KF446659) and for a Quezon isolate (KF446660). The Laguna and Quezon isolate sequences were 2,764 and 2,756 nucleotides, respectively, and shared 90.6% nucleotide sequence identity. Both had six open reading frames (ORFs)-two in the virus sense (V1 and V2) and four in the complementary sense (C1 to C4)-and the geminivirus conserved sequence (TAATATTAC). Based on BLASTn searching of GenBank and sequence analysis using MEGALIGN (DNASTAR), both isolates should be considered as a new begomovirus (tentatively named Blechum yellow vein virus, BlYVV) since their DNA-A sequences share less than 89% nucleotide identity with any other begomovirus. Both DNA sequences had the highest nucleotide identity (84.8 to 87.6%) with Papaya leaf curl Guangdong virus isolates (AJ558122, AY650283, FJ495184, FJ869907, and JN703795). To our knowledge, this is the first report of a previously unidentified begomovirus associated with yellow vein disease of this species. References: (1) S. K. Green et al. Plant Dis. 85:1286, 2001. (2) W. S. Tsai et al. Plant Pathol. 60:787, 2011.

Expected ethical competencies of public health professionals and graduate curricula in accredited schools of public health in North America

OBJECTIVES

We assessed expected ethics competencies of public health professionals in codes and competencies, reviewed ethics instruction at schools of public health, and recommended ways to bridge the gap between them.

METHODS

We reviewed the code of ethics and 3 sets of competencies, separating ethics-related competencies into 3 domains: professional, research, and public health. We reviewed ethics course requirements in 2010-2011 on the Internet sites of 46 graduate schools of public health and categorized courses as required, not required, or undetermined.

RESULTS

Half of schools (n = 23) required an ethics course for graduation (master's or doctoral level), 21 did not, and 2 had no information. Sixteen of 23 required courses were 3-credit courses. Course content varied from 1 ethics topic to many topics addressing multiple ethics domains.

CONCLUSIONS

Consistent ethics education and competency evaluation can be accomplished through a combination of a required course addressing the 3 domains, integration of ethics topics in other courses, and "booster" trainings. Enhancing ethics competence of public health professionals is important to address the ethical questions that arise in public health research, surveillance, practice, and policy.

First Report of Bhendi yellow vein mosaic virus Associated with Yellow Vein Mosaic of Okra (Abelmoschus esculentus) in Thailand

A disease of okra (Abelmoschus esculentus) causing yellowing veins and mosaic on leaves and fruit has emerged in Thailand. Incidences of 50 to 100% diseased plants were observed in fields in Kanchanaburi and Nakhon Pathom provinces in 2009 and 2010, respectively. Leaf samples were collected from three and four diseased plants in Kanchanaburi and Nakhon Pathom, respectively. All seven samples tested positive for begomovirus by PCR using universal primer pair PAL1v1978B/PAR1c715H (3). One sample from Kanchanaburi also tested positive by ELISA using Okra mosaic virus (Genus Tymovirus) antiserum (DSMZ, Braunschweig, Germany). When the nucleotide sequences of the 1.5 kb begomovirus PCR products were compared they were found to share 99.1 to 99.5% identity with each other, and 97.5 to 97.7% identity to Bhendi yellow vein mosaic virus Okra isolate from India (GenBank Accession No. GU112057; BYVMV-[IN: Kai:OY: 06]). The complete DNA-A sequence for a Kanchanaburi isolate (JX678967) was obtained using abutting primers WTHOK6FL-V/-C (WTHOK6FL-V: 5'-GCGAAGCTTAGATAACGCTCCTT-3'; WTHOK6FL-C: 5'-TCCAAGCTTTGAGTCTGCAACGT-3'), while that of a Nakhon Pathom isolate (JX678966) was obtained with primers WTHOK6FLV/WTHOK2FL-C (WTHOK2FL-C: 5'-TCCAAGCTTTGAGTCTGCATCGT-3'). The DNA-A sequences of both isolates are 2,740 nucleotides in length and share 99.6% identity. Each has the geminivirus conserved sequence (TAATATTAC), two open reading frames (ORFs) in the virus sense (V1 and V2) and four in the complementary sense (C1 to C4). Based on BLASTn searching GenBank and sequence analysis using MegAlign (DNASTAR), both DNA-A sequences have greatest nucleotide identity (96.2 to 96.4%) with BYVMV-[IN: Kai:OY: 06] from India. Also, BYVMV-associated betasatellite DNA (1.4 kb) was detected in all begomovirus-positive samples, except one sample from Nakhon Pathom (1). However, no virus DNA-B was detected in any of the samples using either general detection primer pair DNABLC1/DNABLV2 or DNABLC2/DNABLV2 (2). Okra infected with BYVMV has been reported in South Asia in Bangladesh, India, and Pakistan. To the best of our knowledge, this is the first report of BYVMV associated with Okra Yellow Vein Mosaic Disease in Southeast Asia. Since fruits with symptoms are regarded as low quality and have little market value, even low incidence of the disease is likely to cause significant reductions in marketable yield. Strategies for managing BYVMV in okra in South and Southeast Asia should be sought, including the breeding and selecting of resistant varieties. References: (1) R. W. Briddon et al. Mol. Biotechnol. 20:315, 2002. (2) S. K. Green et al. Plant Dis. 85:1286, 2001. (3) W. S. Tsai et al. Plant Pathol. 60:787, 2011.

The variability of vision loss assessment in federally sponsored surveys: seeking conceptual clarity and comparability

PURPOSE

To review U.S. national population-based surveys to evaluate comparability and conceptual clarity of vision measures.

DESIGN

Perspective.

METHODS

The vision questions in 12 surveys were mapped to the World Health Organization's International Classification of Functioning, Disability and Health framework under the domains of condition, impairment, activity limitation, participation, and environment. Surveys examined include the National Health Interview Survey, the Behavioral Risk Factor Surveillance Survey, National Health and Nutrition Examination Survey, the Census, and the Visual Function Questionnaire.

RESULTS

Nearly 100 vision measures were identified in 12 surveys. These surveys provided no consistent measure of vision or vision impairment. Survey questions asked about differing characteristics of vision-related disease, function, and social roles. A question related to ability to read newspaper print was the most commonly asked question in surveys.

CONCLUSIONS

Limited comparability of data and lack of conceptual clarity in the population-based surveys resulted in an inability to consistently characterize the population of people experiencing vision impairment. Consequently, vision surveillance was limited.

Public health surveillance in the United States: evolution and challenges

In its landmark 1988 report, a committee of the Institute of Medicine highlighted assessment as one of the three core functions of public health along with policy development and assurance. The committee recommended that every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health of the community, including statistics on health status, community health needs, and epidemiologic and other studies of health problems. Public health surveillance, often called the cornerstone of public health practice, is an essential element of the assessment function.