Public acceptability, bioethics, and legal governance of wastewater and environmental surveillance for measles in South Africa

Objectives: This study investigates public opinion regarding the use of wastewater and environmental surveillance for measles in South African urban centres across ethical, legal, and public health policy themes, and maps these opinions onto existing bioethical and legal precedents. Design: In-person field survey. Setting: Three metropolitan catchment areas in Gauteng Province, South Africa (City of Tshwane, City of Ekurhuleni, and City of Johannesburg). Participants: A sample of 100 adult community members residing or working within the selected sewer catchment areas. Primary outcome measures: Baseline wastewater and environmental surveillance awareness, target-specific acceptability, spatial monitoring preferences, data-sharing comfort, and legal/privacy perceptions. Results: Baseline awareness of WES was low (19%). Support was high for monitoring a range of biological and chemical targets using wastewater and environmental surveillance. However, acceptability was dependent on spatial scale: 83% supported macro-level city-wide monitoring, whereas support fell to 28% for localized sampling (individual homes and schools). Institutional trust in data handling was high among scientific and public health bodies. Conclusions: Public acceptability of WES for communicable diseases, particularly measles, in urban South Africa is high but conditional upon macro-level data aggregation (anonymity by aggregation) and governance by dedicated scientific entities. Given strong community support for measles surveillance and its alignment with the country bioethical and legal frameworks, the bioethical and legal requirements for this surveillance approach can be satisfied, paving the way for routine implementation of wastewater and environmental surveillance for communicable diseases.