Rapid, Large-Scale Wastewater Surveillance and Automated Reporting System Enable Early Detection of Nearly 85% of COVID-19 Cases on a University Campus.

Wastewater-based surveillance has gained prominence and come to the forefront as a leading indicator of forecasting COVID-19 (coronavirus disease 2019) infection dynamics owing to its cost-effectiveness and its ability to inform early public health interventions. A university campus could especially benefit from wastewater surveillance, as universities are characterized by largely asymptomatic populations and are potential hot spots for transmission that necessitate frequent diagnostic testing. In this study, we employed a large-scale GIS (geographic information systems)-enabled building-level wastewater monitoring system associated with the on-campus residences of 7,614 individuals. Sixty-eight automated wastewater samplers were deployed to monitor 239 campus buildings with a focus on residential buildings. Time-weighted composite samples were collected on a daily basis and analyzed on the same day. Sample processing was streamlined significantly through automation, reducing the turnaround time by 20-fold and exceeding the scale of similar surveillance programs by 10- to 100-fold, thereby overcoming one of the biggest bottlenecks in wastewater surveillance. An automated wastewater notification system was developed to alert residents to a positive wastewater sample associated with their residence and to encourage uptake of campus-provided asymptomatic testing at no charge. This system, integrated with the rest of the "Return to Learn" program at the University of California (UC) San Diego-led to the early diagnosis of nearly 85% of all COVID-19 cases on campus. COVID-19 testing rates increased by 1.9 to 13× following wastewater notifications. Our study shows the potential for a robust, efficient wastewater surveillance system to greatly reduce infection risk as college campuses and other high-risk environments reopen. IMPORTANCE Wastewater-based epidemiology can be particularly valuable at university campuses where high-resolution spatial sampling in a well-controlled context could not only provide insight into what affects campus community as well as how those inferences can be extended to a broader city/county context. In the present study, a large-scale wastewater surveillance was successfully implemented on a large university campus enabling early detection of 85% of COVID-19 cases thereby averting potential outbreaks. The highly automated sample processing to reporting system enabled dramatic reduction in the turnaround time to 5 h (sample to result time) for 96 samples. Furthermore, miniaturization of the sample processing pipeline brought down the processing cost significantly ($13/sample). Taken together, these results show that such a system could greatly ameliorate long-term surveillance on such communities as they look to reopen.

Two-year results: transantral balloon dilation of the ethmoid infundibulum.

BACKGROUND: Multiple prospective and retrospective studies have reported results from balloon-only procedures and hybrid balloon sinus surgeries through intermediate follow-up periods of up to 1 year. Long-term durability results beyond 2 years are limited. METHODS: One-year results from the original study of standalone transantral balloon dilation in patients with computed tomography (CT) evidence of chronic inflammation in the maxillary sinuses alone or maxillary and anterior ethmoid sinuses combined were previously reported. Revision rate, symptom improvement, and productivity improvement were prospectively evaluated after a minimum follow-up of 2 years. RESULTS: Fifty-nine patients (107 maxillary ostia) underwent balloon dilation of the maxillary sinus outflow tract and completed postprocedure follow-up assessment at 27.0 ± 3.6 months. Patient 20-item Sino-Nasal Outcome Test (SNOT-20) score improved from 2.65 ± 0.97 at baseline to 0.79 ± 0.71 at long-term follow-up (p < 0.0001). Improvement in work productivity and activity due to sinus-related health issues for all patients was statistically significant across all survey instrument characteristics (p range, <0.0001 to 0.02). An analysis of the outcomes in a subgroup of patients with maxillary and anterior ethmoid disease (20; 34%) showed similar significant improvement in symptoms (SNOT-20 decrease = -2.1; p < 0.0001). Approximately 92% of all patients reported satisfaction with the balloon procedure. Four (6.8%) patients underwent revision sinus surgery at 11.1 ± 7.3 months after treatment. CONCLUSION: Patients with chronic rhinosinusitis and radiographic evidence of isolated maxillary disease with or without anterior ethmoid disease have reported clinically meaningful and statistically significant improvement in symptoms, productivity, and activity through a minimum of 2 years following standalone balloon dilation.

First clinic experience: patient selection and outcomes for ostial dilation for chronic rhinosinusitis.

BACKGROUND: To report outcomes for subjects undergoing balloon dilation in either the operating room (OR) or the clinic and define criteria to identify suitable candidates for local anesthesia procedures. METHODS: Subjects with medically refractory chronic rhinosinusitis (CRS) underwent de novo surgery via transantral balloon dilation of the maxillary sinus ostium and ethmoid infundibulum. Concomitant nasal or endoscopic sinus surgeries were contraindicated. Technical success, surgical parameters, and long-term outcomes were evaluated through 12-month follow-up. RESULTS: Seventy-one subjects underwent balloon dilation and 94% completed follow-up through 12 months. A total of 132 maxillary ostia were targeted for treatment and 129 were successfully dilated (98%). Almost one-half (33) of the procedures were performed in the OR under local anesthesia with intravenous sedation. Average balloon procedure times for unilateral and bilateral treatment were 28.3 ± 21.1 and 40.2 ± 17.7 minutes, respectively. Thirty-three ostial dilations in 19 subjects were attempted in the clinic. Each ostium was successfully accessed and ballooned under local anesthesia. Patient tolerance was very good with an average self-reported pain level of 2.7 (2 = hurts a little bit) out of 10. Each subject was discharged within 2 hours of the procedure and there was no postoperative bleeding. Symptomatic improvement of the clinic subgroup at 3, 6, and 12 months postprocedure was statistically significant (p ≤ 0.0012) and clinically meaningful and similar in magnitude to improvement seen across all subjects regardless of site of service. CONCLUSION: Transantral balloon dilation can be performed safely in the clinic and operative settings with symptom improvement sustained through 1 year.

Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum.

BACKGROUND: Although multiple clinical trials have demonstrated that balloon dilation of sinus ostia in patients diagnosed with chronic rhinosinusitis (CRS) results in sustained symptomatic improvement, less data are available to measure the effects of sinusitis on worker productivity. The objective of our research was to analyze work and activity impairment before and after transantral, endoscopically-guided balloon dilation of the maxillary sinus ostia and ethmoid infundibulum. METHODS: Subjects diagnosed with CRS and computed tomography (CT) evidence of disease in the maxillary sinuses alone, or maxillary and anterior ethmoid sinuses, completed the Work Productivity and Activity Impairment (WPAI) questionnaire and the Work Limitation Questionnaire (WLQ) before treatment and at 3, 6, and 12 months postprocedure. RESULTS: A total of 56 subjects were enrolled and 53 completed the 1-year follow-up. The lost productivity composite score computed from the WLQ improved by 73% (9.0 to 2.4; p < 0.0001) at 1-year follow-up whereas lost productivity at work as measured by the WPAI improved by approximately 76% (38.3 to 9.2; p < 0.0001) 12 months after treatment. CONCLUSION: These results indicate that sinus-related health problems impose a substantial burden on work productivity and physical/mental activity levels. Treatment of CRS by dilating the maxillary sinus ostium and ethmoid infundibulum can significantly improve quality of life (QOL) and work productivity.

High costs of influenza: Direct medical costs of influenza disease in young children.

This study determined direct medical costs for influenza-associated hospitalizations and emergency department (ED) visits. For 3 influenza seasons, children <5 years of age with laboratory-confirmed influenza were identified through population-based surveillance. The mean direct cost per hospitalized child was $5402, with annual cost burden estimated at $44 to $163 million. Factors associated with high-cost hospitalizations included intensive care unit (ICU) admission and having an underlying high-risk condition. The mean medical cost per ED visit was $512, with annual ED cost burden estimated at $62 to $279 million. Implementation of the current vaccination policies will likely reduce the cost burden.

A case study of successful patient flow methods: St. John's Hospital.

Participating in the Institute for Healthcare Improvement (IHI) IMPACT collaborative has given St. John's Hospital the opportunity to improve patient flow and the delivery of patient care. This partnership has allowed us to experience a wealth of information shared by a collaborative network of hospitals. IHI has introduced rapid-cycle improvement methodologies, variability-reduction strategies, and strategies to aid in planning for the expected as methods that have enhanced our already established performance-improvement program. St John's has achieved breakthrough improvement with patient flow.

The impact of IMPACT on St. John's Regional Health Center.

St. John's Regional Health Center (SJRHC) is participating in the Institute for Healthcare Improvement's (IHI) IMPACT collaborative, a new IMProvement ACTion network of health care organizations that have joined together to improve patient care. By utilizing the network for sharing ideas, continuous quality improvement tools and support staff and physician involvement, we have achieved three important breakthrough improvements in patient flow in the hospital setting. The areas highlighted in this article are Perioperative Services, Emergency Department Admission, and Transfers to Cardiac Intensive Care Units.

Leaf Spot Disease of Spinach in California Caused by Stemphylium botryosum.

Beginning in 1997, a new disease of spinach was found in the Salinas Valley, Monterey County, CA. Initial symptoms were leaf spots that were 2 to 5 mm in diameter, circular, and gray-green in color. Spots later enlarged, turned tan in color, and became dry and papery in texture, resembling phytotoxicity due to agrichemicals. Although fungal signs were generally absent from the spots, Stemphylium botryosum was consistently isolated and caused identical symptoms when inoculated onto 20 spinach cultivars. Three isolates did not cause disease symptoms when inoculated onto other crop plants representing 16 different genera and a Chenopodium weed species. A fourth isolate showed similar results with the exception of small leaf spots occurring on inoculated fava bean. Isolates produced a Pleospora herbarum teleomorph after 7 months incubation at 5°C. Preliminary experiments with cell-free culture filtrates indicated that phytotoxins apparently were not produced by these isolates. This is the first report of a foliar spinach disease caused by S. botryosum.

Bacterial Blight of Leek: A New Disease in California Caused by Pseudomonas syringae.

During 1996 and 1997, a new and damaging disease of leek (Allium porrum) was observed on greenhouse-produced transplants and field-grown plants in California. Symptoms were water-soaked lesions at leaf tips, which eventually expanded down the length of the leaf and resulted in brown, elongated, stripe-like lesions with yellow margins. Diseased leaves eventually wilted. A blue fluorescent pseudomonad was consistently recovered from lesions, and biochemical and physiological tests indicated that it was Pseudomonas syringae. Pathogenicity tests established that representative strains of this P. syringae induced disease symptoms in leek that were similar to those observed on leek plants in the greenhouse and field, and that this bacterium caused similar symptoms in onion, chives, and garlic plants. Representative strains were further characterized by fatty acid analysis, repetitive bacterial sequence-polymerase chain reaction (rep-PCR), and rDNA sequencing. Fatty acid analysis confirmed that these isolates were P. syringae, but did not provide a clear pathovar designation. Rep-PCR analysis revealed that all the California leek P. syringae strains had identical DNA fingerprints and that these strains were indistinguishable from those of known strains of P. syringae pv. porri. In addition, the rDNA sequence of the spacer region between 16S and 23S rDNA genes was identical among the California leek P. syringae strains and P. syringae pv. porri. Together, these results established that the new leek disease in California is caused by P. syringae pv. porri. P. syringae pv. porri was recovered from a commercial leek seed lot imported into California, which suggests that the pathogen was introduced in association with seed. Commercial leek production in California is favorable for development of this disease because transplants are produced in greenhouses with high plant densities, overhead irrigation, and mowing of plants.

Bacterial Blight of Broccoli Raab: A New Disease Caused by a Pathovar of Pseudomonas syringae.

Bacterial blight is a new disease of broccoli raab or rappini (Brassica rapa subsp. rapa) that has developed on commercially grown crops in the Salinas Valley (Monterey County) in California. Symptoms consist of small, angular, water-soaked flecks on lower foliage that are visible from both adaxial and abaxial sides of the leaves. These flecks expand and become surrounded by bright yellow borders. With time, multiple leaf spots coalesce and result in large, irregular necrotic areas, extensive leaf yellowing, and eventual leaf death. If symptoms develop on the uppermost leaves attached to the inflorescence, the shoot loses market quality and will not be harvested. Pseudomonas syringae was consistently isolated from symptomatic plants, and selected strains caused similar symptoms when inoculated onto broccoli raab test plants. Broccoli raab strains caused leaf spot symptoms on nine other Cruciferous plants, as well as on three grass species (California brome, oat, and common timothy). Conversely, broccoli raab was not infected by P. syringae pathovars coronafaciens, maculicola, and tomato. Broccoli raab strains were positive for coronatine toxin production. Fatty acid analyses indicated that the P. syringae from broccoli raab was most closely related to P. syringae pvs. coronafaciens and maculicola, but its distinct host range suggests that it may be considered a separate pathovar.