Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation.

Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.

Burden of disease from contaminated drinking water in countries with high access to safely managed water: A systematic review.

The vast majority of residents of high-income countries (≥90%) reportedly have high access to safely managed drinking water. Owing perhaps to the widely held perception of near universal access to high-quality water services in these countries, the burden of waterborne disease in these contexts is understudied. This systematic review aimed to: identify population-scale estimates of waterborne disease in countries with high access to safely managed drinking water, compare methods to quantify disease burden, and identify gaps in available burden estimates. We conducted a systematic review of population-scale disease burden estimates attributed to drinking water in countries where ≥90% of the population has access to safely managed drinking water per official United Nations monitoring. We identified 24 studies reporting estimates for disease burden attributable to microbial contaminants. Across these studies, the median burden of gastrointestinal illness risks attributed to drinking water was ∼2,720 annual cases per 100,000 population. Beyond exposure to infectious agents, we identified 10 studies reporting disease burden-predominantly, cancer risks-associated with chemical contaminants. Across these studies, the median excess cancer cases attributable to drinking water was 1.2 annual cancer cases per 100,000 population. These median estimates slightly exceed WHO-recommended normative targets for disease burden attributable to drinking water and these results highlight that there remains important preventable disease burden in these contexts, particularly among marginalized populations. However, the available literature was scant and limited in geographic scope, disease outcomes, range of microbial and chemical contaminants, and inclusion of subpopulations (rural, low-income communities; Indigenous or Aboriginal peoples; and populations marginalized due to discrimination by race, ethnicity, or socioeconomic status) that could most benefit from water infrastructure investments. Studies quantifying drinking water-associated disease burden in countries with reportedly high access to safe drinking water, focusing on specific subpopulations lacking access to safe water supplies and promoting environmental justice, are needed.

A systematic review and meta-analysis of pathogen reduction in onsite sanitation systems.

The safe management of fecal sludge from the 3.4 billion people worldwide that use onsite sanitation systems can greatly reduce the global infectious disease burden. However, there is limited knowledge about the role of design, operational, and environmental factors on pathogen survival in pit latrines, urine diverting desiccation toilets, and other types of onsite toilets. We conducted a systematic literature review and meta-analysis to characterize pathogen reduction rates in fecal sludge, feces, and human excreta with respect to pH, temperature, moisture content, and the use of additives for desiccation, alkalinization, or disinfection. A meta-analysis of 1,382 data points extracted from 243 experiments described in 26 articles revealed significant differences between the decay rates and T99 values of pathogens and indicators from different microbial groups. The overall median T99 values were 4.8 days, 29 days, >341 days, and 429 days for bacteria, viruses, protozoan (oo)cysts, and Ascaris eggs, respectively. As expected, higher pH values, higher temperatures, and the application of lime all significantly predicted greater pathogen reduction rates but the use of lime by itself was more effective for bacteria and viruses than for Ascaris eggs, unless urea was also added. In multiple lab-scale experiments, the application of urea with enough lime or ash to reach a pH of 10 - 12 and a sustained concentration of 2,000 - 6,000 mg/L of non-protonated NH3-N reduced Ascaris eggs more rapidly than without urea. In general, the storage of fecal sludge for 6 months adequately controls hazards from viruses and bacteria, but much longer storage times or alkaline treatment with urea and low moisture or heat is needed to control hazards from protozoa and helminths. More research is needed to demonstrate the efficacy of lime, ash, and urea in the field. More studies of protozoan pathogens are also needed, as very few qualifying experiments were found for this group.

Study design and methods of the Wells and Enteric disease Transmission (WET) Trial: a randomised controlled trial.

INTRODUCTION: The burden of disease attributed to drinking water from private wells is not well characterised. The Wells and Enteric disease Transmission trial is the first randomised controlled trial to estimate the burden of disease that can be attributed to the consumption of untreated private well water. To estimate the attributable incidence of gastrointestinal illness (GI) associated with private well water, we will test if the household treatment of well water by ultraviolet light (active UV device) versus sham (inactive UV device) decreases the incidence of GI in children under 5 years of age. METHODS AND ANALYSIS: The trial will enrol (on a rolling basis) 908 families in Pennsylvania, USA, that rely on private wells and have a child 3 years old or younger. Participating families are randomised to either an active whole-house UV device or a sham device. During follow-up, families will respond to weekly text messages to report the presence of signs and symptoms of gastrointestinal or respiratory illness and will be directed to an illness questionnaire when signs/symptoms are present. These data will be used to compare the incidence of waterborne illness between the two study groups. A randomly selected subcohort submits untreated well water samples and biological specimens (stool and saliva) from the participating child in both the presence and absence of signs/symptoms. Samples are analysed for the presence of common waterborne pathogens (stool and water) or immunoconversion to these pathogens (saliva). ETHICS: Approval has been obtained from Temple University's Institutional Review Board (Protocol 25665). The results of the trial will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04826991.

The effects of racism, social exclusion, and discrimination on achieving universal safe water and sanitation in high-income countries.

Drinking water and sanitation services in high-income countries typically bring widespread health and other benefits to their populations. Yet gaps in this essential public health infrastructure persist, driven by structural inequalities, racism, poverty, housing instability, migration, climate change, insufficient continued investment, and poor planning. Although the burden of disease attributable to these gaps is mostly uncharacterised in high-income settings, case studies from marginalised communities and data from targeted studies of microbial and chemical contaminants underscore the need for continued investment to realise the human rights to water and sanitation. Delivering on these rights requires: applying a systems approach to the problems; accessible, disaggregated data; new approaches to service provision that centre communities and groups without consistent access; and actionable policies that recognise safe water and sanitation provision as an obligation of government, regardless of factors such as race, ethnicity, gender, ability to pay, citizenship status, disability, land tenure, or property rights.

Cognitive decline and quality of life after resective epilepsy surgery.

OBJECTIVES: The objectives of this study were to examine the association between cognitive decline and quality of life (QoL) change in a large sample of individuals with drug-resistant epilepsy who underwent resective surgery and to examine whether the association between cognitive decline and QoL is differentially affected by seizure classification outcome (Engel Class 1 vs. 2-4) or side of surgery (left vs. right hemisphere). MATERIALS AND METHODS: The sample comprised 224 adults (ages ≥ 18) with drug-resistant focal epilepsy treated with resective surgery who underwent comprehensive pre-operative and post-operative evaluations including neuropsychological testing and the Quality of Life in Epilepsy Inventory - 31 between 1991 and 2020. Linear mixed-effects models were fit to examine subject-specific trajectories and assess the effects of time (pre- to post-operative), cognitive decline (number of measures that meaningfully declined), and the interaction between time and cognitive decline on pre- to post-operative change in QoL. RESULTS: Increases in QoL following resection were observed (B = -10.72 [SE = 1.22], p < .001; mean difference between time point 1 and time point 2 QoL rating = 8.11). There was also a main effect of cognitive decline on QoL (B = -.85 [SE = .27], p = .002). Follow-up analyses showed that the number of cognitive measures that declined was significantly associated with post-surgical QoL, (r = -.20 p = .003), but not pre-surgical QoL, (r = -.04 p = .594), and with pre-to post-surgery raw change in QoL score, (r = -.18 p = .009). A cognitive decline by time point interaction was observed, such that those who had greater cognitive decline had less improvement in overall QoL following resection (B = .72 [SE = .27], p = .009). Similar results were observed within the Engel Class 1 outcome subgroup. However, within the Engel Class 2-4 outcome subgroup, QoL improved following resection, but there was no main effect of cognitive decline or interaction between cognitive decline and time point on QoL change. There was no main effect of resection hemisphere on overall QoL, nor were there interactions with hemisphere by time, hemisphere by cognitive decline, or hemisphere by time by cognitive decline. CONCLUSIONS: Quality of life improves following epilepsy surgery. Participants who had cognitive decline across a greater number of measures experienced less improvement in QoL post-operatively overall, but there was no clear pattern of domain-specific cognitive decline associated with change in QoL. Our results indicate that cognitive decline in a diffuse set of cognitive domains negatively influences post-operative QoL, particularly for those who experience good seizure outcomes (i.e., seizure freedom), regardless of the site or side of resection.

Responding to stakeholder needs to engage rehabilitation professionals in the delivery of evidence-based health programming for adults with osteoarthritis.

Although there are many evidence-based programs that promote healthy lifestyles and symptom modification for people with osteoarthritis, their delivery in rehabilitation clinical settings in the United States is limited. These programs can be a primary component of treatment or a discharge option to facilitate long-term mobility and pain management. The purpose of this perspective article is to describe a delivery model that brings one arthritis-appropriate, evidence-based intervention, the Arthritis Foundation's Walk With Ease program, to older adults seeking physical therapy related to their osteoarthritis. We embedded program delivery into a Doctor of Physical Therapy curriculum using a student health coaching approach and partnering with physical therapy clinics and other community agencies for participant referrals. This model of delivery is cost-effective, sustainable, and provides outcomes that meet goals of the national agenda for osteoarthritis. The model provides benefits for students in health professions education programs, community organizations and rehabilitation clinics, and adults living with osteoarthritis.

Passive sampling, a practical method for wastewater-based surveillance of SARS-CoV-2.

In search of practical and affordable tools for wastewater-based surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), three independent field experiments were conducted using three passive sampler sorbents (electronegative membrane, cotton bud, and gauze) in Guelph, Ontario, Canada. Total daily cases during this study ranged from 2 to 17/100,000 people and 43/54 traditionally collected wastewater samples were positive for SARS-CoV-2 with mean detectable concentrations ranging from 8.4 to 1780 copies/ml. Viral levels on the passive samplers were assessed after 4, 8, 24, 48, 72, and 96 hrs of deployment in the wastewater and 43/54 membrane, 42/54 gauze, and 27/54 cotton bud samples were positive. A linear accumulation rate of SARS-CoV-2 on the membranes was observed up to 48 hours, suggesting the passive sampler could adequately reflect wastewater levels for up to two days of deployment. Due the variability in accumulation observed for the cotton buds and gauzes, and the pre-processing steps required for the gauzes, we recommend membrane filters as a simple cost-effective option for wastewater-based surveillance of SARS-CoV-2.

Minimizing errors in RT-PCR detection and quantification of SARS-CoV-2 RNA for wastewater surveillance.

Wastewater surveillance for pathogens using reverse transcription-polymerase chain reaction (RT-PCR) is an effective and resource-efficient tool for gathering community-level public health information, including the incidence of coronavirus disease-19 (COVID-19). Surveillance of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) in wastewater can potentially provide an early warning signal of COVID-19 infections in a community. The capacity of the world's environmental microbiology and virology laboratories for SARS-CoV-2 RNA characterization in wastewater is increasing rapidly. However, there are no standardized protocols or harmonized quality assurance and quality control (QA/QC) procedures for SARS-CoV-2 wastewater surveillance. This paper is a technical review of factors that can cause false-positive and false-negative errors in the surveillance of SARS-CoV-2 RNA in wastewater, culminating in recommended strategies that can be implemented to identify and mitigate some of these errors. Recommendations include stringent QA/QC measures, representative sampling approaches, effective virus concentration and efficient RNA extraction, PCR inhibition assessment, inclusion of sample processing controls, and considerations for RT-PCR assay selection and data interpretation. Clear data interpretation guidelines (e.g., determination of positive and negative samples) are critical, particularly when the incidence of SARS-CoV-2 in wastewater is low. Corrective and confirmatory actions must be in place for inconclusive results or results diverging from current trends (e.g., initial onset or reemergence of COVID-19 in a community). It is also prudent to perform interlaboratory comparisons to ensure results' reliability and interpretability for prospective and retrospective analyses. The strategies that are recommended in this review aim to improve SARS-CoV-2 characterization and detection for wastewater surveillance applications. A silver lining of the COVID-19 pandemic is that the efficacy of wastewater surveillance continues to be demonstrated during this global crisis. In the future, wastewater should also play an important role in the surveillance of a range of other communicable diseases.

Modelling rotavirus concentrations in rivers: Assessing Uganda's present and future microbial water quality.

Faecal pathogens can be introduced into surface water through open defecation, illegal disposal and inadequate treatment of faecal sludge and wastewater. Despite sanitation improvements, poor countries are progressing slowly towards the United Nation's Sustainable Development Goal 6 by 2030. Sanitation-associated pathogenic contamination of surface waters impacted by future population growth, urbanization and climate change receive limited attention. Therefore, a model simulating human rotavirus river inputs and concentrations was developed combining population density, sanitation coverage, rotavirus incidence, wastewater treatment and environmental survival data, and applied to Uganda. Complementary surface runoff and river discharge data were used to produce spatially explicit rotavirus outputs for the year 2015 and for two scenarios in 2050. Urban open defecation contributed 87%, sewers 9% and illegal faecal sludge disposal 3% to the annual 15.6 log10 rotavirus river inputs in 2015. Monthly concentrations fell between -3.7 (Q5) and 2.6 (Q95) log10 particles per litre, with 1.0 and 2.0 median and mean log10 particles per litre, respectively. Spatially explicit outputs on 0.0833 × 0.0833° grids revealed hotspots as densely populated urban areas. Future population growth, urbanization and poor sanitation were stronger drivers of rotavirus concentrations in rivers than climate change. The model and scenario analysis can be applied to other locations.

Microbial water quality improvement associated with transitioning from intermittent to continuous water supply in Nagpur, India.

Nearly half a billion people living in Indian cities receive their drinking water from an intermittent water supply (IWS), which can be associated with degraded water quality and risk of waterborne disease. The municipal water supply in Nagpur, India is transitioning from intermittent to continuous supply in phases. We conducted cross-sectional sampling to compare microbial water quality under IWS and continuous water supply (CWS) in Nagpur. In 2015 and 2017, we collected 146 grab samples and 90 large-volume dead-end ultrafiltration (DEUF) samples (total volume: 6,925 liters). In addition to measuring traditional water quality parameters, we also assayed DEUF samples by droplet digital PCR (ddPCR) for waterborne pathogen gene targets. At household taps served by IWS, we detected targets from enterotoxigenic E. coli, Shigella spp./enteroinvasive E. coli, norovirus GI and GII, adenovirus A-F, Cryptosporidium spp., and Giardia duodenalis. We observed a significant increase in the proportion of grab samples positive for culturable E. coli (p = 0.0007) and DEUF concentrates positive for waterborne pathogen gene targets (p = 0.0098) at household taps served by IWS compared to those served by CWS. IWS continues to be associated with fecal contamination, and, in this study, with increased prevalence of molecular evidence of waterborne pathogens. These findings add mounting evidence that, despite the presence of piped on premise infrastructure, IWS is less likely to meet the requirements for safely-managed drinking water as defined by the Sustainable Development Goals. Importantly, these findings demonstrate the transition from IWS to CWS in Nagpur is yielding meaningful improvements in microbial water quality.

On How Psychophysical Thresholds are Altered by Unilateral Brain Injury Due to Stroke.

OBJECTIVE: This study examined whether and how the absolute thresholds and the just noticeable difference thresholds for eleven, sensory/perceptual continua are altered by unilateral left and right hemisphere lesions due to stroke relative to healthy subjects. METHODS: The three subject groups were those with unilateral right hemisphere lesions (n=21), with unilateral left hemisphere lesions (n=13), and age-matched control subjects (n=76). Absolute thresholds of sensory detection and just noticeable difference thresholds were assessed for perceptual continua spanning the visual, tactile, proprioceptive, thermal, and gustatory sensory modalities. For stroke subjects, brain lesions were analyzed using subtraction techniques and volume analysis with the MRIcro and MRIcroN software programs. Stroke subjects also complete tests for spatial neglect, stroke severity and functional independence. RESULTS: There was no significant difference among subject groups regarding gender, race, hand dominance, age, or educational composition. There was no significant difference between subjects with right and left hemisphere lesions on measures of function, stroke severity, or lesion volume except for those with spatial neglect. The RHL group had a higher percentage of impaired perceptual continua (16%) than both normal controls (4%) and the LHL group (9%). If a stoke subject had an impaired threshold on one side of the body, they were ~5 times more likely to have an impaired threshold on the other side of the body. This result was more consistent and even exaggerated (~8 times more likely) in the small percentage of normal control subjects who demonstrated "impaired" sensory thresholds. Lesion volume was positively correlated with stroke severity and sensory threshold impairment, and it was negatively correlated with functional independence. CONCLUSIONS: When subjects, have difficulty detecting and discriminating sensory experiences, they tend to do so on both sides of the body. Unilateral right hemisphere stroke appeared to increase the relative frequency of altered thresholds occurring on the contralesional side of the body even though they made errors on both sides.

The Impact of Pipe Material on the Diversity of Microbial Communities in Drinking Water Distribution Systems.

As many cities around the world face the prospect of replacing aging drinking water distribution systems (DWDS), water utilities must make careful decisions on new pipe material (e.g., cement-lined or PVC) for these systems. These decisions are informed by cost, physical integrity, and impact on microbiological and physicochemical water quality. Indeed, pipe material can impact the development of biofilm in DWDS that can harbor pathogens and impact drinking water quality. Annular reactors (ARs) with cast iron and cement coupons fed with chloraminated water from a municipal DWDS were used to investigate the impact of pipe material on biofilm development and composition over 16 months. The ARs were plumbed as closely as possible to the water main in the basement of an academic building to simulate distribution system conditions. Biofilm communities on coupons were characterized using 16S rRNA sequencing. In the cast iron reactors, ß-proteobacteria, Actinobacteria, and α-proteobacteria were similarly relatively abundant (24.1, 22.5, and 22.4%, respectively) while in the cement reactors, α-proteobacteria and Actinobacteria were more relatively abundant (36.3 and 35.2%, respectively) compared to ß-proteobacteria (12.8%). Mean alpha diversity (estimated with Shannon H and Faith's Phylogenetic Difference indices) was greater in cast iron reactors (Shannon: 5.00 ± 0.41; Faith's PD: 15.40 ± 2.88) than in cement reactors (Shannon: 4.16 ± 0.78; Faith's PD: 13.00 ± 2.01). PCoA of Bray-Curtis dissimilarities indicated that communities in cast iron ARs, cement ARs, bulk distribution system water, and distribution system pipe biofilm were distinct. The mean relative abundance of Mycobacterium spp. was greater in the cement reactors (34.8 ± 18.6%) than in the cast iron reactors (21.7 ± 11.9%). In contrast, the mean relative abundance of Legionella spp. trended higher in biofilm from cast iron reactors (0.5 ± 0.7%) than biofilm in cement reactors (0.01 ± 0.01%). These results suggest that pipe material is associated with differences in the diversity, bacterial composition, and opportunistic pathogen prevalence in biofilm of DWDS.

Why pathogens matter for meeting the united nations' sustainable development goal 6 on safely managed water and sanitation.

Water and wastewater utilities, water and sanitation hygiene (WASH) practitioners, and regulating bodies, particularly in developing nations, rely heavily on indicator microorganisms, as opposed to pathogens, for much of their regulatory decisions. This commentary illustrates the importance of considering pathogens and not relying only on indicator organisms when making decisions regarding water and sanitation, especially with respect to meeting the current targets of the Sustainable Development Goal (SDG) 6. We use quantitative microbial risk assessment (QMRA) to present three common scenarios that WASH and public health practitioners encounter to illustrate our point. These include 1) chlorination of surface water for drinking, 2) land application of latrine waste as a fertilizer, and 3) recreation/domestic use of surface waters impacted by wastewater discharge. We show that the calculated probabilities of risk of infection are statistically significantly higher when using treatment/survival information for pathogens versus using indicator species data. Thus, demonstrating that relying solely on indicators for sanitation decision making is inadequate if we truly want to achieve the SDG6 targets of safely managed water and sanitation services.

Septic Systems and Rainfall Influence Human Fecal Marker and Indicator Organism Occurrence in Private Wells in Southeastern Pennsylvania.

In the United States, approximately 48 million people are served by private wells. Unlike public water systems, private well water quality is not monitored, and there are few studies on the extent and sources of contamination of private wells. We extensively investigated five private wells to understand the variability in microbial contamination, the role of septic systems as sources of contamination, and the effect of rainfall on well water quality. From 2016 to 2017, weekly or biweekly samples (n = 105) were collected from five private wells in rural Pennsylvania. Samples were tested for general water quality parameters, conventional and sewage-associated microbial indicators, and human pathogens. Total coliforms, human Bacteroides (HF183), and pepper mild mottle virus were detected at least once in all wells. Regression revealed significant relationships between HF183 and rainfall 8-14 days prior to sampling and between total coliforms and rainfall 8-14 or 0-14 days prior to sampling. Dye tracer studies at three wells confirmed the impact of household septic systems on well contamination. Microbiological measurements, chemical water quality data, and dye tracer tests provide evidence of human fecal contamination in the private wells studied, suggesting that household septic systems are the source of this contamination.

Preparing Nurses for Palliative Care in the NICU.

BACKGROUND: Neonatal intensive care unit (NICU) nurses require knowledge and skill to meet the unique needs of infants and families. Increasingly, principles of palliative care are being integrated into the NICU setting to improve the quality of care. PURPOSE: The purpose of this article is to describe the efforts of the End-of-Life Nursing Education Consortium (ELNEC) project and its Pediatric Curriculum, which began in 2003 to provide this education, and to also describe efforts by nurses to implement the training into their practice settings. METHODS: The ELNEC Pediatric Palliative Care (ELNEC-PPC) project is a train-the-trainer educational program and evidence-based curriculum. FINDINGS/RESULTS: Participants attend a course or receive online training and then apply the education to implement improved practices in areas such as symptom management, care at the time of death, and bereavement support for families. IMPLICATIONS FOR RESEARCH: Experiences with ELNEC-PPC have demonstrated that nurses can implement the curriculum to improve care. IMPLICATIONS FOR PRACTICE: Continued attention to palliative care in this setting is needed, and future research is needed to evaluate the outcomes of this education and practice change.

Private Wells and Rural Health: Groundwater Contaminants of Emerging Concern.

PURPOSE OF REVIEW: Approximately 12% of the population in the US and Canada rely on federally unregulated private wells, which are common in rural areas and may be susceptible to microbiological and chemical contamination. This review identifies and summarizes recent findings on contaminants of emerging concern in well water across the US and Canada. RECENT FINDINGS: Private well water quality modeling is complicated by the substantial variability in contamination sources, well construction, well depth, and the hydrogeology of the environment surrounding the well. Temporal variation in contaminant levels in wells suggests the need for monitoring efforts with greater spatial and temporal coverage. More extensive private well monitoring will help identify wells at greater risk of contamination, and in turn, public health efforts can focus on education and outreach to improve monitoring, maintaining, and treating private wells in these communities. Community interventions need to be coupled with stricter regulations and financing mechanisms that can support and protect private well owners.

School-based, blacklight handwashing program can improve handwashing quality and knowledge among pre-school aged children.

In the United States, lack of proper handwashing is associated with respiratory and gastrointestinal illnesses. Interventions to improve handwashing practices have led to an increase in handwashing knowledge and behavior, and decreases in gastrointestinal illnesses. Most studies have evaluated their interventions in the context of reported handwashing rates by observation, reduction of illnesses, as well as reduced absences, however none of these studies examined handwashing quality or knowledge as outcome measures. The objective of this paper is to present the results from a handwashing program with a special focus on the evaluation methods. A pre-post design was used to evaluate a handwashing program that took place in two pre-schools the northeast of the United States. The program utilized a black light technology to demonstrate to children the importance of good quality. The evaluation consisted of assessing knowledge and quality of handwashing using a linear puzzle and individual handwashing observation, respectively. Students from both schools improved on both knowledge and quality over time (p-values 0.071 and <0.001, respectively). The present study demonstrates that the use of black light technology as an educational tool may help to improve handwashing quality among pre-school aged children, even after only one instructional session.

Translating pathogen knowledge to practice for sanitation decision-making.

Sanitation planners make complex decisions in the delivery of sanitation services to achieve health outcomes. We present findings from a stakeholder engagement workshop held in Kampala, Uganda, to educate, interact with, and solicit feedback from participants on how the relevant scientific literature on pathogens can be made more accessible to practitioners to support decision-making. We targeted Water, Sanitation and Hygiene (WASH) practitioners involved in different levels of service delivery. Practitioners revealed that different sanitation planning tools are used to inform decision-making; however, most of these tools are not user-friendly or adapted to meet their needs. Most stakeholders (68%) expressed familiarity with pathogens, yet less than half (46%) understood that fecal coliforms were bacteria and used as indicators for fecal pollution. A number of stakeholders were unaware that fecal indicator bacteria do not behave and persist the same as helminths, protozoa, or viruses, making fecal indicator bacteria inadequate for assessing pathogen reductions for all pathogen groups. This suggests a need for awareness and capacity development around pathogens found in excreta. The findings underscore the importance to engage stakeholders in the development of support tools for sanitation planning and highlighted broader opportunities to bridge science with practice in the WASH sector.

Integrating environmental and neighborhood factors in MaxEnt modeling to predict species distributions: A case study of Aedes albopictus in southeastern Pennsylvania.

Aedes albopictus is a viable vector for several infectious diseases such as Zika, West Nile, Dengue viruses and others. Originating from Asia, this invasive species is rapidly expanding into North American temperate areas and urbanized places causing major concerns for public health. Previous analyses show that warm temperatures and high humidity during the mosquito season are ideal conditions for A. albopictus development, while its distribution is correlated with population density. To better understand A. albopictus expansion into urban places it is important to consider the role of both environmental and neighborhood factors. The present study aims to assess the relative importance of both environmental variables and neighborhood factors in the prediction of A. albopictus' presence in Southeast Pennsylvania using MaxEnt (version 3.4.1) machine-learning algorithm. Three models are developed that include: (1) exclusively environmental variables, (2) exclusively neighborhood factors, and (3) a combination of environmental variables and neighborhood factors. Outcomes from the three models are compared in terms of variable importance, accuracy, and the spatial distribution of predicted A. albopictus' presence. All three models predicted the presence of A. albopictus in urban centers, however, each to a different spatial extent. The combined model resulted in the highest accuracy (74.7%) compared to the model with only environmental variables (73.5%) and to the model with only neighborhood factors (72.1%) separately. Although the combined model does not essentially increase the accuracy in the prediction, the spatial patterns of mosquito distribution are different when compared to environmental or neighborhood factors alone. Environmental variables help to explain conditions associated with mosquitoes in suburban/rural areas, while neighborhood factors summarize the local conditions that can also impact mosquito habitats in predominantly urban places. Overall, the present study shows that MaxEnt is suitable for integrating neighborhood factors associated with mosquito presence that can complement and improve species distribution modeling.