Genetic Epidemiology, Infectious Disease, and Public Health Ethics
Abstract and Keywords
This chapter outlines the ethical issues raised by the use of genomics in the study of infectious disease, in research and development of preventive and therapeutic measures, and to inform public health interventions and policies. More than two decades of ethical, legal, and social implications (ELSI) research on the application of genomics to complex diseases have produced many insights that are also relevant to infectious diseases; however, a number of factors unique to infectious diseases underscore the importance of identifying novel ELSI issues that might emerge from the application of genomics in this context, including issues surrounding personalized medicine and public health. While the science of genomics in the context of infectious disease is still in its infancy, and it is too early to identify all of the potential ELSI issues that may emerge from it, policy recommendations for public health strategies to prevent and control infectious disease must attend to such concerns.
(p. 678) The Danger of Infectious Disease and the Opportunity of Genomics
Genomic information offers the opportunity for greater “personalized” prevention and treatment (Pashayan et al., 2013) of infectious diseases, as well as new tools for addressing epidemics and newly emerging pathogens (Malik, 2013). Scientific advances in genomics can elucidate infectious disease pathology, immunology, and vaccinology; augment research and development of preventive and therapeutic measures; and enhance the efficiency of public health interventions and policies (Eisen and MacCullum, 2009; Telenti, 2004; Trautmann and Sekaly, 2011; Omenn, 2000; Pang, 2002; Yan, 2010, 203–220; Yang et al., 2008; Brusic and August, 2004). Such developments would mitigate the burden of infectious diseases, which contribute to significant morbidity and mortality worldwide (WHO, 2012). Infectious agents can cause illnesses that are acute (e.g., influenza), chronic (e.g., hepatitis B), have significant sequelae (e.g., meningococcal), or generate new epidemics (e.g., Ebola, Zika). While the disease burden is highest in low-income countries, new emerging and antibiotic-resistant infectious diseases threaten public health globally (Roca et al., 2015). Even for infectious diseases that have vaccines or treatments, preventive and therapeutic measures can be highly burdensome, variably effective, prohibitively expensive, or difficult to access for large portions of the population globally. Each infectious disease brings ethical dilemmas, ranging from (p. 679) resource allocation and contact tracing, to preventive and therapeutic care provision, to clinical trials—all of which could benefit from vector, pathogen, and host genomic scientific knowledge and application.
To control the spread of vector-borne diseases like malaria and dengue, genome editing tools are being used for the precise deletion of functional genes or insertion of toxic genes in vector mosquitoes (Reegan et al., 2017). Genomics also has been critical in pathogen identification (e.g., SARS) (Yeh et al., 2004). Rapid and large-scale sequencing provides stronger and more accurate evidence than was previously possible for source and contact tracing and is widely applied for surveillance and outbreak management (Gilmour et al., 2013), as was done in the 2014–2015 measles outbreak in Disneyland and the 2014–2016 Ebola epidemic in West Africa (Gire et al., 2014; Vogel, 2014). Additionally, pathogen genomics has focused on improved precision for the diagnosis of microbial infection, identifying transmission, understanding emerging drug resistance, and identifying targets for new therapeutics and vaccines.
There is growing evidence that host genetic factors, and the interaction between host, vector, and pathogen, influence variability in infection rates, immune responses (Eisen and MacCullum, 2009; Poland et al., 2013), susceptibility (Withrock et al., 2015), disease progression and severity (Keynan, Malik, and Fowke, 2013; Srivastava et al., 2009), and response to preventive and therapeutic interventions (Petrizzo et al., 2012; Kaslow, McNicholl, and Hill, 2008; Mentzer et al., 2015; Pittman et al., 2016; Liang et al., 2014; Al-Qahtani et al., 2013; Zeng, 2014; Jiang et al., 2013; Zhang et al., 2010; Liu et al., 2011; Kirk et al., 2005; Mbarek et al., 2011; Sonneveld et al., 2012; Ovsyannikova, Jacobson, and Poland, 2004; Buonaguro et al., 2011; Nohynek et al., 2012; Mentzer et al., 2015; Pan et al., 2014; Jilg and Chung, 2013; Png et al., 2011; Hennig et al., 2008). Genome-wide association studies have identified several favorable host variants: the IL28B genotype, which predisposes individuals to spontaneously clear the hepatitis C virus (HCV); and the CCR5Δ32 genotype, which is protective against human immunodeficiency virus (HIV) infection (Dean et al., 1996; Livingstone, 1964; Mann et al., 1992; Mira et al., 2004; Ge et al., 2009; Thomas et al., 2009). Moreover, genetic information about the pathogen can influence its impact on the host. For example, differences in HIV subtype have been shown to have marked differences in disease progression in Kenya and Uganda (Baeten et al., 2007; Kiwanuka et al., 2008; Kiwanuka et al., 2010). In the United States, HIV-1 subtype B–infected hemophiliacs, those with lower viral replication capacity, had a survival advantage relative to those with higher replication capacity (Barbour et al., 2004). Differences in the specificity of a virus for a particular host tissue (called viral tropism) are associated with speed of disease progression, although it is unclear if it is the cause or consequence (Hunt et al., 2006; Briz et al., 2008). Genomic research is making important contributions to our understanding of infectious disease pathogenesis and immune response, and to future vaccine development and treatment strategies (Trautmann and Sekaly, 2011; Yang et al., 2008; Mentzer et al., 2015; Ovsyannikova, Jacobson, and Poland, 2004; Dandekar and Dandekar, 2010; Hill, 2001; Ozdemir, Faraj, and Knoppers, 2011; Ozdemir et al., 2011; Poland et al., 2007; Chapman and Hill, 2012).
(p. 680) This chapter explores the ethical, legal, and social implications (ELSI) of applying advances in genomics to public health prevention and control of infectious diseases. It starts with a brief description of the historical connection between infectious disease control and the prevention of genetic diseases. It then describes insights gleaned from ELSI research on the application of genomics to complex diseases and their relevance to infectious disease, drawing on three examples that highlight different ethical issues: inequities in HIV, personalized vaccines, and triage during epidemics. Throughout, the chapter incorporates considerations for future research and policy.
Historical Connections between Infectious and Genetic Disease Control
Ethical and policy questions stemming from the progressive fusing of genetic and epidemiological measures have long, rich traditions. Historically, case reporting, isolation and quarantine, contact tracing, and behavioral regulation and oversight developed as the cornerstones of infectious disease control (Fairchild, Bayer, and Colgrove, 2007; Mooney, 2015) and faced the bioethical conflict of autonomy versus the greater public health benefits. With advances in medical genetics, a generation of physicians began to apply genetics to public health methods of disease control, starting with preventing the birth of individuals with hereditary diseases (Comfort, 2012; also see, “Eugenics and Public Health: Historical Connections and Ethical Implications,” this volume) and shifting to the recognition that “complex diseases” result from the interaction between multiple genes and the environment. Although infectious disease surveillance might appear to be the epitome of one-size-fits-all medicine, it is now recognized that there is individual variability in susceptibility, transmission, and disease severity. The concept of “precision medicine” (White House, 2017; Jameson and Longo, 2015; Collins and Varmus, 2015) is evolving to broader considerations of “precision public health” (Hood and Flores, 2012; Khoury et al., 2012), which will have applications to infectious diseases. In short, in the genomic era, infectious disease surveillance may enhance research capabilities and target individuals for prevention and treatment to optimize infection control, and to prevent either horizontal or vertical transmission. This complex, integrative, and multidisciplinary approach to public health will require informed bioethical considerations that mediate between numerous pairs (or poles) of social and medical values, including autonomy versus public health surveillance; liberty versus disease control measures; privacy versus the duty not to harm others; and the responsibilities of patients to themselves, to their families, and to society.
(p. 681) ELSI Considerations for Genomics, Infectious Disease, and Public Health
Many insights relevant to infectious disease can be discerned from the more than twenty years of ELSI research on genomics applications in complex diseases (McEwen et al., 2014). Pertinent issues include the reliability, validity, confidentiality, and disclosure of genetic information. Clinical next-generation sequencing and the increasing number of large biobanks raise issues of the interpretation of data, data storage, data sharing, informed consent, incidental findings and return of results, and identifiability and privacy (Pinxten and Howard, 2014; Ross, Rothstein, and Clayton, 2013; Tabor et al., 2011; Kaye, 2012; McGuire et al., 2011; Wolf, 2013; Wolf et al., 2008, 2012; Meltzer, 2006; McGuire and Beskow, 2010; Bunnik et al., 2013).
However, a number of factors unique to infectious disease underscore the importance of identifying novel ELSI issues that might emerge from the application of genomics in this context (Geller et al., 2014). Importantly, the nature of disease transmission and susceptibility differs, with implications for who is at increased risk. Infectious diseases are most often transmitted horizontally (not directly through family members), based on exposure (air, sexual, vector) to related or unrelated individuals. Horizontal transmission is ethically problematic because those exposed are often unaware of their risk. In addition, potential benefits or harms of disease interventions (i.e., vaccine policy) accrue to the entire population, in keeping with the goals of public health. But there are well-described ethical tensions between the goals and implementation of personalized medicine and those of public health. Existing literature on the ethical, legal, and policy issues in infectious disease describes the potential for stigmatization of individuals or subpopulations, the challenge of balancing individual interests (e.g., privacy, autonomy, freedom of movement) against risks of harms to others and to public health, and obligations on the part of employers or health professionals (Gostin, Bayer, and Fairchild, 2003; Battin et al., 2009).
There has been some discussion of the ELSI issues involved in using pathogen genomic sequencing for source and contact tracing (Rump and Woonink, 2012; Rump et al., 2013; Bubela and Yanow, 2012; Luheshi et al., 2015). Human genetic markers could lead to identification of people at a higher risk for contracting or spreading a disease. People can be “super-spreaders” (infected hosts who infect disproportionately more secondary contacts) due to a biological predisposition to shed high levels of infectious particles, not limiting their risk behaviors, or continued shedding post-recovery. The ability of pathogen sequencing to identify a human source of infection creates potential questions of blame and legal liability, stigmatization, and risks to privacy (Rump and Woonink, 2012; Rump et al., 2013).
(p. 682) The significance of genomic information, and its application, may generate specific ELSI concerns, including imbalance in health-related risks and potential benefits to individuals and populations; protection of privacy and confidentiality of personal information; challenges to autonomy, choice, and limitations on liberty; social and behavioral impacts of genomic information on individuals, family members, and others; and equitable distribution of scarce resources. Although these issues are in no way unique to infectious diseases, they need to be considered as part of development in practice and policy as scientific understanding of the role of genomics in infectious disease management advances (Geller et al., 2014). Genotypic information may exacerbate the inherent tension between the goals of personalized medicine (to tailor prevention and treatment to individuals) and those of public health (to maximize wellness for entire populations), giving rise to inequitable distribution of benefits and harms among specific subgroups of the population and adding an additional layer to the perennial tension between individual and population interests in public health.
Ethical challenges often arise when there is a gap in the time between the identification of a problem and the capacity to mitigate it. That is the case with genomic discoveries and infectious diseases; those at either increased risk of contracting or transmitting infection or those who are more or less likely to respond to interventions might be identified before there are safe and effective interventions to offer, or before risk-mitigation policies can be adopted. Another significant ethical challenge results from the variability in predictive value of genotypic information and how variable risk can complicate risk management policy, cost-benefit analyses, allocation of scarce resources, and considerations of privacy and autonomy.
Cost-benefit analysis and overall predicted impact on morbidity and mortality might influence the ethical justifiability of preventive interventions targeted at individuals and populations (Pittman et al., 2016). Investing in the research to identify genetic variants, and to ensure individuals are screened, raises questions about cost, efficient use of limited resources, and moral duties. Vaccines are used for many infectious diseases, but the scientific knowledge about individual variation of efficacy/immunogenicity and safety/reactogenicity of these vaccines is limited. Vaccines or other public health measures that work for the majority of the community and result in positive public health, such as reduction of morbidity and mortality, have been accepted. However, the ability to identify a genetic predisposition for adverse events or immunogenomic markers that predict immunogenicity following vaccination might provide an opportunity for immunization programs to screen and thus limit adverse outcomes or immune failures in a subset of individuals. However, if the genetic markers are not absolutely predictive, or if the adverse event was not severe, this may cause undue concern, decrease vaccination rates, and in the end not be cost-effective. In light of the large public investment in and strong support for vaccines from state and (p. 683) federal authorities, it is not clear how immunization programs ought to consider the moral and policy arguments related to screening for genetic risk factors.
Allocation of Scarce Resources
Disparities in access to treatments and prevention can be a result of financial, educational, sociocultural, geographical, or environmental barriers. When circumstances, such as a pandemic, create demands for resources that exceed supply, decision-making about the distribution and allocation of resources may be influenced by genetic information. Tailored drugs or vaccines might be developed and produced for at-risk genetic (“orphan”) subgroups or, contrary to social justice, for those who can pay. It remains to be seen what the implications would be for health insurance coverage and public financing of interventions if they vary by genotype. The extent to which infectious disease genomics will be translated into benefits for public health will likely be largely influenced by the allocation of resources for research and development efforts. Research that is likely to have the greatest global benefits might not be given funding priority by those countries with the greatest resources. Differences in regional investments in genomic science and technology will have important implications for equitable distribution of benefits and public health impact (OECD, 2013, 7–9).
Privacy, Autonomy, and Choice
In the context of infectious disease management, individual rights and liberties such as autonomous decision—making, freedom of choice and action, privacy, and the right to personal information can conflict with public health priorities. Whereas public health programs may target people or subgroups with particular risk factors, the possibility to ascertain (or to require reporting of) otherwise unobservable genetic risk factors may complicate issues of protection of personal information, privacy, and autonomy.
Considerations of privacy and autonomy are being challenged by genetic sequencing technologies that will likely contribute to our understanding of host genomics in the context of infectious disease. The growing literature on the ethical implications of sequencing has focused on privacy, data sharing, return of results and the management of incidental findings, and best practices for obtaining informed consent (Pinxten and Howard, 2014; Ross, Rothstein, and Clayton, 2013; Tabor et al., 2011; Kaye, 2012; McGuire et al., 2011; Wolf, 2013; Wolf et al., 2008, 2012; Meltzer, 2006; McGuire and Beskow, 2010; Bunnik et al., 2013). Informed consent policies and practices for sequencing information will need to consider (1) whether the information that people have in the context of infectious disease is different in morally relevant ways from chronic disease, and (2) whether the processes for disclosing information about host genomics should vary in different parts of the world.
(p. 684) It is important to consider ways in which individual genotyping could be used or mandated, and how this genetic information could affect personal liberties. Individual genomic data might be consulted when decisions about prevention and control are considered, such as determining which subpopulations should be screened and which vaccine formulation is appropriate. Genomic data about individuals and groups might be consulted during disease outbreaks, in planning for public health programs, or in developing new or assessing existing public health policies: Where are the genomic clusters or hotspots for infection; where should vaccines be deployed most urgently; which therapies should be offered to which genomic populations; and where should treatment programs, isolation policies, mandatory vaccination, or public health control programs be implemented to halt the spread of infections? Genetic markers of infectivity or likelihood of being a “super-spreader” could be used to justify quarantine and isolation policies, with the concomitant implications for individual liberty. The value placed on individual autonomy varies in different cultures, so the primacy that it receives in the context of public health planning and decision-making, and the role of informed consent, might be different in different countries (Geller et al., 2014; Knoppers, Zawati, and Kirby, 2012; Rotimi and Marshall, 2010).
In the United States, the legal and policy paradigm in genomics places a high value on privacy, which can conflict with the public health framework in which individual rights can be overridden for the benefit of others (Gerard, Hayes, and Rothstein, 2002). Federal and state genetic privacy legislation protects patients from discrimination based on their genetic profile. But it is unlikely that the potential benefit of the utilization of genomic information in the diagnosis, treatment and/or prevention of infectious disease was considered when these laws were enacted. Specific individuals may be better suited to work in high-risk job placements during an infectious disease outbreak because they are more likely to have a protective response to a vaccine, or because their genotype makes them less likely to develop severe infection (Geller et al., 2014). Alternatively, others might have a variant associated with increased risk of severe infection. In both situations, the provisions of the Genetic Information Nondiscrimination Act of 2008 (GINA, a US law addressing aspects of genetic discrimination in employment and insurance contexts) may limit the ability to use genetic information to determine which employees would be best suited to high-risk job placements in case of an infectious disease outbreak. Furthermore, this may increase liability for injuries from vaccines in individuals whose genotype is associated with greater susceptibility to adverse reactions following vaccination. Additionally, those who are found to be at increased risk for adverse events might be exempted from mandatory vaccine laws, potentially affecting herd immunity.
More recent advances in genetic sequencing technologies present even greater challenges for law and policy development because of the rapidity with which the science is changing. As knowledge of the role of pathogen and host genomic factors in the treatment and control of infectious disease expands, evaluating the current legal framework to determine which current genetic privacy laws—both state and federal—may hinder or facilitate the ability to use genetic information to protect the health of both individuals (p. 685) and the general public is critical. The next sections explore some of these ELSI issues in the context of three specific examples.
Health Disparities, Inequities, and Vulnerabilities in Infectious Disease
There are significant racial and ethnic disparities in infectious disease morbidity and mortality (Callinan et al., 2013; Adekoya, 2007; Christensen et al., 2009). For example, in the United States, the burden of HIV/AIDS is highest among African American, Latino, and other racial/ethnic minorities (CDC, 2012), and case rates of tuberculosis are disproportionately high in African Americans and American Indian/Alaska Natives (Bloss et al., 2011; CDC, 2012). Racial and ethnic disparities were also evident during the 2009–2010 influenza A (H1N1) virus pandemic, when rates of H1N1-related hospitalizations, complications, and deaths disproportionally affected African Americans, people of Hispanic race/ethnicity, and American Indian/Alaska Natives (Callinan et al., 2013).
Although social determinants of health such as poverty and limited and/or delayed access to care are often the major factors contributing to these health disparities, host genotypic variation also plays a role. For example, known protective variants for HIV and HCV (CCR5∆32 and IL28B, respectively) have a lower allele frequency in those with African ancestry (Huang et al., 1996; Duggal et al., 2013). The relative absence of this protective effect in a subgroup of the population that is already stigmatized exacerbates the health disparities in disease prevalence in the United States.
Compounding the risk of stigma for these marginalized populations is ongoing research on pathogen genomics and phylogenetic sequencing that can compromise privacy by associating particular strains of the virus with particular individuals and social networks (Rump and Woonink, 2012; Rump et al., 2013; Bubela and Yanow, 2012). In addition, HIV phylogenetic analysis has been used to identify the direction of transmission from one person to another. Although this is useful for targeting interventions, it has also resulted in criminal liability cases. This is problematic in several African countries, where behaviors associated with HIV transmission are illegal. The Ethics Working Group of the Phylogenetics and Networks for Generalized HIV Epidemics in Africa consortium (PANGEA-HIV) is working to combat the adverse consequences of collecting large samples of viral sequence data among key populations of Africa (Coltart et al., 2018; Pillay et al., 2007; Pillay et al., 2015).
Increasingly, collections of biospecimens from patient populations, study cohorts, and research trials, are being stored for potential future use (see, “Public Health Genomics, Biobanking, and Ethics,” this volume). Among the areas of increasing research interest is information related to the impact of genetics on infections and the course of infectious diseases. Particular ethical challenges could arise when DNA or tissue samples from specific communities are collected and banked, particularly if those (p. 686) populations are already vulnerable. Research may also reveal health information about an entire group, risking discrimination and stigmatization of that group. Therefore, it is necessary to consider consequences for the group—not simply for the individual—when planning appropriate policies, best practices, and informed consent processes.
Public Health Impact of Personalizing Vaccines
Vaccine policies involve balancing considerations of individuals versus communities and will become more complex when applying genomics to infectious diseases. The nascent field of “vaccinomics”—the application of genomics to understanding individual or subpopulation variation in immunogenic responses to vaccines—could be used to apply a systems biology approach to vaccinology to assist in the elucidation of the genetic determinants and variability of immune responses to vaccines (Poland et al., 2007). The immunogenomic differences among individuals could inform policy and planning for public health vaccination programs and public health response to pandemics.
This enhanced understanding may include the assessment of the safety and effectiveness of vaccines, thereby potentially guiding future vaccine policy development (Poland, Ovsyannikova, and Jacobson, 2008). Vaccines could be targeted for those most likely to have a protective response induced by immunization, or those least likely to have adverse events. The ability to predict and quantify an individual’s response to vaccination based upon immunogenomics could enhance vaccine safety by facilitating causality assessments of adverse reactions after vaccination. For example, a recent discovery points to a gene variant associated with a significantly increased risk of febrile seizure following vaccination for measles, mumps, and rubella (Feenstra et al., 2014); however, febrile seizures are rare and usually benign, raising questions about the usefulness of screening. As another example, the AS03 adjuvanted pandemic 2009 influenza A/H1N1 vaccine was associated with an increased risk of narcolepsy among children, with differences in the risk estimates for associations between different countries due, in part, to differences in the prevalence of the HLA-subtype DQB1*602 (Partinen et al., 2014). The identification of this HLA-subtype assisted causality assessment and has potential implications for vaccine development, clinical practice, and vaccination programs. In addition, research has identified genetic predictors of the immune response to several infectious diseases (Pulendran, 2009; Poland et al., 2013; Mentzer et al., 2015).
However, vaccines and genomic research are highly polarized among the public and stakeholders, including the vaccine research community, and vaccinomic science carries the potential for both positive and negative consequences (Ozdemir, Faraj, and Knoppers, 2011). The history of compulsory vaccination provides an important example of resistance to coercive public health measures, based on a range of beliefs, including religious, ethical, and libertarian objections (Colgrove, 2006; Durbach, 2004; Greenough, 1995). With advances in vaccinomic research, mandatory vaccination policies (e.g., California SB277 ) may need to be reconsidered based on genetic factors (p. 687) that influence vaccination risk or efficacy. Identifying subpopulations at increased risk of adverse events may lead to policies not to immunize these subpopulations, thereby reducing community protection, assuming the vaccines would be effective in these subpopulations. Alternatively, identification of a genetic basis for an increased risk of adverse reaction to vaccination, even if the adverse reaction is extremely rare, may lead to increased vaccine refusals and could provide the anti-vaccination movement with scientific justification to promote resistance to immunization more generally. However, vaccines are only one means of preventing and controlling infectious diseases. Additional strategies are necessary, particularly during an epidemic of a highly virulent infectious disease.
Emerging Infectious Disease Epidemics
Highly virulent, infectious diseases continue to pose public health threats worldwide. The prevention and control of such diseases involve significant ELSI and policy challenges that may be influenced by genomic discoveries. For example, the 2014–2016 Ebola outbreak illustrates the enormous public health challenges surrounding a highly infectious, high-mortality disease outbreak for which there is currently no approved prevention or treatment other than supportive care. It is known that risk of transmission is high in the case of direct contact with bodily fluids of symptomatic individuals, and that in an epidemic situation, where access to adequate health care is poor, the case fatality rate among those with symptomatic infection is extremely high. People exposed to Ebola show phenotypic variability in susceptibility to infection and disease severity. Thus, it is likely that human genetic variation may contribute to individual immunity and infectivity. Additionally, it is not known who may remain infected with subclinical disease, but some early evidence suggests this may occur; therefore, the range of infectivity and virulence of Ebola is unknown (Leroy et al., 2000).
If scientists identify genetic variants that are associated with an increased likelihood of contracting Ebola, spreading it, having more severe disease, or responding to treatment, an ethical tension would arise between screening at-risk groups (patients or health care workers) for these variants and using the genomic information to influence a range of decisions. For example, in the absence of effective interventions and sufficient facilities to treat all infected patients, genetic information could be used to triage patients at greatest risk of severe disease to receive care first. Or perhaps health care workers could be screened in order to alter precautionary practices based on their genotype. These and other ethical challenges need to be considered when designing and conducting genomic research on host factors and host-pathogen interactions for acute, emerging infectious diseases.
In recognition that public health preparedness requires ethics preparedness, the Presidential Commission for the Study of Bioethical Issues created a set of policy recommendations to facilitate a proactive response to public health epidemics. The commission’s report, Ethics and Ebola (Presidential Commission for the Study of Bioethical Issues, 2015), articulates lessons from the US response to the epidemic in western Africa for ethics preparedness in future public health emergencies, and examines ethical dimensions of restrictive public health measures, the use of placebos for treatment and vaccine trials, and the collection and sharing of biospecimens for future research. Traditional public health response to these outbreaks, such as contact tracing, isolation, follow up, and/or quarantine, may not be contested, but how best to implement these measures is often far from clear. In addition to these traditional infection control measures, attention must be paid to the rapid development and testing of preventive and infectious disease control interventions, including the application of host and pathogen genomics, in the context of an outbreak. For example, in cases where affected individuals refuse to provide names of their contacts, pathogen genomics enables a more precise type of contact tracing, raising ethical concerns about privacy and discrimination.
While the science of genomics in the context of infectious disease is still in its infancy, and it is too early to identify all of the potential ELSI issues that may emerge from it, such considerations should factor into the development of policy recommendations for public health strategies to prevent and control infectious disease, both domestically and internationally (Geller et al., 2014; Pang, 2013). Attention to ELSI issues could also guide research questions and decisions about public investments in science. This would contribute to the ongoing systematic effort to provide an evidence base for the utility, priority, and ethical acceptability of genomic applications in infectious disease (Burke et al., 2010; Malogajski et al., 2013).
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