Reporting on patients living with HIV "disengaging from care". Who is actually "lost to follow-up"?

Retention in care remains an important concern for health care providers. However, accurately identifying who is or is not retained in care can be problematic. Not all patients believed to be engaged in care are actually in care, and not all patients believed to be disengaged are truly disengaged. Identifying the status of individuals within populations is important for clinical, administrative and surveillance concerns. As part of the Linkage and Retention in Care Project at St Michael's Hospital in Toronto, Canada, we investigated the status of patients diagnosed with HIV. Detailed investigation determined who was actually Lost-to-Follow-Up (i.e., disengaged from care >12 months) and who had disengaged for known reasons. This approach determined more precisely who was currently followed in care and who was not, and to target efforts to contact and reengage patients more effectively. This study illustrates the importance of accurately monitoring populations enhancing disease management.

Achieving robust mainstream nitrite shunt at pilot-scale with integrated sidestream sludge treatment and step-feed.

As a promising energy- and carbon efficient process for nitrogen removal from wastewater, mainstream nitrite shunt has been extensively researched. However, beyond the laboratory it is challenging to maintain stable performance by suppressing nitrite-oxidising bacteria (NOB). In this study, a pilot-scale reactor system receiving real sewage was operated in two stages for >850 days to evaluate two novel NOB suppression strategies for achieving nitrite shunt: i) sidestream sludge treatment based on alternating free nitrous acid (FNA) and free ammonia (FA) and ii) sidestream FNA/FA sludge treatment integrated with in-situ NOB suppression via step-feed. The results showed that, with sidestream sludge treatment alone, NOB developed resistance relatively quickly to the treatment, leading to unstable nitrite shunt. In contrast, robust nitrite shunt was achieved and stably maintained for more than a year when sidestream sludge treatment was integrated with a step-feed strategy. Kinetic analyses suggested that sludge treatment and step-feed worked in synergy, leading to stable NOB suppression. The integrated strategy demonstrated in this study removes a key barrier to the implementation of stable mainstream nitrite shunt.

Full-scale investigation of ferrous dosing in sewers and a wastewater treatment plant for multiple benefits.

This study demonstrates the full scale application of iron dosing in a metropolitan wastewater treatment plant (WWTP) and the upstream sewer system for multiple benefits. Two different dosing locations, i.e., the WWTP inlet works (Trial-1) and upstream sewer network (Trial-2) were tested in this study. Both dosing trials achieved multiple benefits such as sulfide control, phosphate removal and improved sludge dewaterability. During Trial-1, a sulfide reduction of >90% was achieved at high dosing rates (>19 kgFe ML-1) of ferrous chloride in the inlet works and in Trial-2 the in-sewer ferrous dosing had significant gas phase hydrogen sulfide (H2S) concentration reduction in the sewer network. The ferrous dosing enhanced the phosphate removal in the bioreactor up to 76% and 53 ± 2% during Trial-1 & 2, respectively. The iron ending up in the anaerobic sludge digester reduced the biogas H2S concentration by up to 36% and 45%, respectively. The dewaterability of the digested sludge was improved, with relative increases of 9.7% and 9.8%, respectively. The presence of primary clarifier showed limited impact on the downstream availability of iron for achieving the afore-mentioned multiple benefits. The iron dosing enhanced the total chemical oxygen demand removal in the primary clarifier reaching up to 49% at the high dose rates during Trial-1 and 42 ± 1% during Trial-2. This study demonstrated that multiple benefits could be achieved independent of the iron dosing location (i.e., at the WWTP inlet or in the network). Further, iron dosing at both locations enhances primary settling, beneficial for bioenergy recovery from wastewater.

Opportunities for reducing coagulants usage in urban water management: The Oxley Creek Sewage Collection and Treatment System as an example.

Iron and aluminium based coagulants are used in enormous amounts and play an essential role in urban water management globally. They are dosed at drinking water production facilities for the removal of natural organic matter. Iron salts are also dosed to sewers for corrosion and odour control, and at wastewater treatment plants (WWTPs) for phosphate removal from wastewater and hydrogen sulfide removal from biogas. A recent laboratory study revealed that iron dosed to sewers is available for phosphate and hydrogen sulfide removal in the downstream WWTP. This study demonstrates for the first time under real-life conditions the practical feasibility and effectiveness of the strategy through a year-long full-scale investigation. Over a period of 5 months, alum dosing at ∼190 kg Al/day to the bioreactor in a full-scale WWTP was stopped, while FeCl2 dosing at ∼160 kg Fe/day in the upstream network was commenced. Extensive sampling campaigns were conducted over the baseline, trial and recovery periods to investigate sulfide control in sewers and its flow-on effects on phosphate in WWTP effluent, H2S in biogas, as well as on the WWTP effluent hypochlorite disinfection process. A plant-wide mass balance analysis showed that the Fe2+ dosed upstream was effectively used for P removal in the activated sludge tanks, with an effluent phosphate concentration comparable to that in the baseline period (i.e. with alum dosing to the bioreactor). Simultaneously, hydrogen sulfide concentration in biogas decreased ∼43%, from 495 ±â€¯10 to 283 ±â€¯4 ppm. No effects on biological nitrogen removal and disinfection processes were observed. Both effluent phosphate and H2S in biogas increased in the recovery period, when in-sewer dosing of FeCl2 was stopped. X-ray diffraction failed to reveal the presence of vivianite in the digested sludge, providing strong evidence that thermal hydrolysis prevented the formation of vivianite during anaerobic digestion. The latter limits the potential for selective recovery of Fe and P through magnetic separation. Overall, our study clearly demonstrates the multiple beneficial reuse of iron in a real urban wastewater system and urges water utilities to adopt an integrated approach to coagulant use in urban water management.