Risk factors for Cryptosporidium contamination in Minnesota public supply wells.

In a recent monitoring study of Minnesota's public supply wells, Cryptosporidium was commonly detected with 40% of the wells having at least one detection. Risk factors for Cryptosporidium occurrence in drinking water supply wells, beyond surface water influence, remain poorly understood. To address this gap, physical and chemical factors were assessed as potential predictors of Cryptosporidium occurrence in 135 public supply wells in Minnesota. Univariable analysis, regression techniques, and classification trees were used to analyze the data. Many variables were identified as significant risk factors in univariable analysis and several remained significant throughout the succeeding analysis techniques. These factors fell into general categories of well use and construction, aquifer characteristics, and connectedness to the land surface, well capture zones, and land use therein, existence of potential contaminant sources within 200-feet of the well, and variability in the chemical and isotopic parameters measured during the study. These risk categories, and the specific variables and threshold values we have identified, can help guide future research on factors influencing Cryptosporidium contamination of wells and can be used by environmental health programs to develop risk-based sampling plans and design interventions that reduce associated health risks.

Microbial pathogens and contaminants of emerging concern in groundwater at an urban subsurface stormwater infiltration site.

Urban stormwater may contain a variety of pollutants, including viruses and other pathogens, and contaminants of emerging concern (pharmaceuticals, artificial sweeteners, and personal care products). In vulnerable geologic settings, the potential exists for these contaminants to reach underlying aquifers and contaminate drinking water wells. Viruses and other pathogens, as well as other contaminants of emerging concern, were measured in stormwater and groundwater at an urban site containing a stormwater cistern and related subsurface infiltration gallery, three shallow lysimeter wells, and a monitoring well. Five of 12 microbial targets were detected more than once across the eight rounds of sampling and at multiple sampling points, with human-specific Bacteroides detected most frequently. The microbial and chemical contaminants present in urban stormwater were much lower in the water table monitoring well than the vadose zone lysimeters. There may be numerous causes for these reductions, but they are most likely related to transit across fine-grained sediments that separate the water table from the vadose zone at this location. Precipitation amount prior to sample collection was significantly associated with microbial load. A significant relation between microbial load and chloride-bromide ratio was also observed. The reduction in number and concentrations of contaminants found in the monitoring well indicates that although geologically sensitive aquifers receiving urban stormwater effluent in the subsurface may be prone to contamination, those with a protective cap of fine-grained sediments are less vulnerable. These results can inform stormwater infiltration guidance relative to drinking water wells, with an emphasis on restricting infiltration near water supply wells finished in geologically sensitive aquifers to reduce public health risks.

Readiness and Willingness to Provide Immunization Services after Pilot Vaccination Training: A Survey among Community Pharmacists Trained and Not Trained in Immunization during the COVID-19 Pandemic in Poland.

BACKGROUND: Immunization rates among the adult population in Poland are below desired targets, urging the need to expand this service in the community. During the COVID-19 pandemic, the ultimate goals for limiting the spread of the infection are vaccines against SARS-CoV-2. Pharmaceutical companies are in a race for the fastest possible way to deliver vaccines. Community pharmacists in Poland are recognised as an accessible yet underutilised group of medical professionals. Therefore, involving pharmacists in vaccinations may have beneficial results for the healthcare system. OBJECTIVES: The objectives of this study were to assess the readiness and willingness of community pharmacists following the Pharmacist Without Borders project who had either been trained or not in providing immunization services, and to identify the factors that may support the implementation of such services in Poland. METHODS: This study was conducted among pharmacists between February and August 2020 in Poland. A survey was developed to determine their readiness to provide vaccination services in their pharmacies, to recognise any barriers to vaccinations, as well as the factors necessary to implement vaccination services in Polish pharmacies. RESULTS: A total of 1777 pharmacists participated in the study, comprising 127 (7.1%) pharmacists trained in vaccinations during the Pharmacists Without Borders project and 1650 (92.9%) pharmacists not participating in the workshops. Pharmacists participating in the workshops more often indicated that providing vaccinations in community pharmacies would improve the overall vaccination rate (p = 0.0001), and that pharmacists could play an important role in advertising and promoting vaccinations (p = 0.0001). For the pharmacists not participating in the workshops, they indicated to a much greater extent possible barriers affecting the readiness to provide vaccinations in pharmacies. They most often pointed out that vaccination services would result in a significant workload increase (p = 0.0001), that pharmacies were not adapted to immunization, and that there were not enough training courses for pharmacists (p = 0.0001). CONCLUSION: The pharmacists working in community pharmacies indicated many advantages of vaccinations in pharmacies. This study identified barriers to the introduction of vaccinations and factors necessary to implement these services in pharmacies. The pharmacists trained during the immunization programme of the Pharmacists Without Borders project showed a greater readiness to provide immunization services.

Viral, bacterial, and protozoan pathogens and fecal markers in wells supplying groundwater to public water systems in Minnesota, USA.

Drinking water supply wells can be contaminated by a broad range of waterborne pathogens. However, groundwater assessments frequently measure microbial indicators or a single pathogen type, which provides a limited characterization of potential health risk. This study assessed contamination of wells by testing for viral, bacterial, and protozoan pathogens and fecal markers. Wells supplying groundwater to community and noncommunity public water systems in Minnesota, USA (n = 145) were sampled every other month over one or two years and tested using 23 qPCR assays. Eighteen genetic targets were detected at least once, and microbiological contamination was widespread (96% of 145 wells, 58% of 964 samples). The sewage-associated microbial indicators HF183 and pepper mild mottle virus were detected frequently. Human or zoonotic pathogens were detected in 70% of wells and 21% of samples by qPCR, with Salmonella and Cryptosporidium detected more often than viruses. Samples positive by qPCR for adenovirus (HAdV), enterovirus, or Salmonella were analyzed by culture and for genotype or serotype. qPCR-positive Giardia and Cryptosporidium samples were analyzed by immunofluorescent assay (IFA), and IFA and qPCR concentrations were correlated. Comparisons of indicator and pathogen occurrence at the time of sampling showed that total coliforms, HF183, and Bacteroidales-like HumM2 had high specificity and negative predictive values but generally low sensitivity and positive predictive values. Pathogen-HF183 ratios in sewage have been used to estimate health risks from HF183 concentrations in surface water, but in our groundwater samples Cryptosporidium oocyst:HF183 and HAdV:HF183 ratios were approximately 10,000 times higher than ratios reported for sewage. qPCR measurements provided a robust characterization of microbiological water quality, but interpretation of qPCR data in a regulatory context is challenging because few studies link qPCR measurements to health risk.

Cryptosporidium Incidence and Surface Water Influence of Groundwater Supplying Public Water Systems in Minnesota, USA.

Regulations for public water systems (PWS) in the U.S. consider Cryptosporidium a microbial contaminant of surface water supplies. Groundwater is assumed free of Cryptosporidium unless surface water is entering supply wells. We determined the incidence of Cryptosporidium in PWS wells varying in surface water influence. Community and noncommunity PWS wells ( n = 145) were sampled ( n = 964) and analyzed for Cryptosporidium by qPCR and immunofluorescence assay (IFA). Surface water influence was assessed by stable isotopes and the expert judgment of hydrogeologists using site-specific data. Fifty-eight wells (40%) and 107 samples (11%) were Cryptosporidium-positive by qPCR, and of these samples 67 were positive by IFA. Cryptosporidium concentrations measured by qPCR and IFA were significantly correlated ( p < 0.001). Cryptosporidium incidence was not associated with surface water influence as assessed by stable isotopes or expert judgment. We successfully sequenced 45 of the 107 positive samples to identify species, including C. parvum (41), C. andersoni (2), and C. hominis (2), and the predominant subtype was C. parvum IIa A17G2R1. Assuming USA regulations for surface water-supplied PWS were applicable to the study wells, wells positive for Cryptosporidium by IFA would likely be required to add treatment. Cryptosporidium is not uncommon in groundwater, even when surface water influence is absent.

A qualitative process evaluation of a diabetes navigation program embedded in an endocrine specialty center in rural Appalachian Ohio.

BACKGROUND: Diabetes in the United States has reached epidemic proportions and the people of Appalachia have been disproportionately affected by this disease. Strategies that complement standard diabetes care are critically important to mitigate the risk of complications, reduce health expenditures, and improve the quality of life of patients living in rural Appalachia. The purpose of this study was to conduct a qualitative process evaluation of a patient navigation program for diabetes after its first year of implementation. METHODS: The process evaluation assessed how the Diabetes Navigation Program was delivered as well as how it was experienced by the navigators, providers, health administrators, and office staff at an endocrine specialty center in rural Appalachian Ohio. We employed total population sampling to conduct in-depth, face-to-face interviews with all providers, health administrators, staff, and navigators at a Diabetes Endocrine Center. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 11 software. RESULTS: Seventeen individuals (providers n = 5, health administrators n = 4, office staff members n = 3, and navigators n = 5) participated in in-depth, face-to-face interviews (age = 44.7 ± 11.6 years, 82.4% female, 94.1% white, 13.3 ± 9.6 years work experience). Fidelity of implementation: The navigation team carried out most of the activities denoted in the Work Plan, therefore the program was implemented somewhat successfully. Qualitative analysis revealed three themes: 1) The navigator addresses sources of health disparities: All participants described the role of the diabetes navigator as someone who is knowledgeable about diabetes and able to identify and address health disparities. 2) The navigators are the eyes in the community and the patients' homes: Navigators offered providers and clinic staff a rare glimpse into the personal lives of patients, which led to the identification of unrecognized barriers. 3) Difficulties with cross-system integration of services: Differences in the organizational culture and vision of the specialty center and navigation office contributed to systemic barriers. CONCLUSIONS: Overall, this process evaluation highlights the importance of coordinating providers, health administrators, medical office staff, and navigators to address barriers to diabetes care. Forthcoming research is needed to document the clinical effectiveness and sustainability of the Diabetes Navigation Program in rural Appalachia.

Examining antecedents of caregivers' access to early childhood developmental screening: implications for campaigns promoting use of services in Appalachian Ohio.

Although developmental delays are common in the United States, only about one third of developmental delays are identified before a child enters school. As challenging as use of developmental screening is on a national basis, the Appalachian region faces extreme lack of screening, diagnosis, and treatment for developmental delay. Local health care providers attribute this lack to poor parent understanding and have called for communication interventions to educate caregivers. This investigation sought to understand the antecedents of Appalachian caregivers' intentions to access developmental screening and services for their children as formative research for a communication-based intervention. The investigation was grounded by the health belief model. Surveys completed by 366 caregivers were used to model antecedents to behavioral intention. Perceived severity, perceived benefits, and self-efficacy were found to be the strongest predictors of intention to access developmental screening. Implications for a communication-based intervention are provided.

Predictors of daily blood glucose monitoring in Appalachian Ohio.

OBJECTIVE: To determine factors contributing to successful diabetes self-management in Appalachia, as evidenced by daily blood glucose monitoring. METHODS: A telephone survey (N=3841) was conducted to assess health status and health care access. The current investigation is limited to the subset of this sample who report having diabetes (N=529). RESULTS: A multivariate logistic regression model established that having attended a diabetes education class (P<.01) was the most significant predictor of successful diabetes self-management. The inability to pay for care, demographic variables, and health risk indicators were not found to be significantly related to self-management. CONCLUSIONS: This study identifies the role of education in successful diabetes self-management for patients in the Appalachian region.

Recruiting and retaining mental health professionals to rural communities: an interdisciplinary course in Appalachia.

CONTEXT: Faculty from 5 disciplines (health administration, nursing, psychology, social work, and special education) collaborated to develop and teach a distance-learning course designed to encourage undergraduate and graduate students to seek mental health services employment in rural areas and to provide the skills, experience, and knowledge necessary for successful rural practice. METHODS: The primary objectives of the course, developed after thorough review of the rural retention and recruitment literature, were to (1) enhance interdisciplinary team skills, (2) employ technology as a tool for mental health practitioners, and (3) enhance student understanding of Appalachian culture and rural mental health. Didactic instruction emphasized Appalachian culture, rural mental health, teamwork and communication, professional ethics, and technology. Students were introduced to videoconferencing, asynchronous and synchronous communication, and Internet search tools. Working in teams of 3 or 4, students grappled with professional and cultural issues plus team process as they worked through a hypothetical case of a sexually abused youngster. The course required participants to engage in a nontraditional manner by immersing students in Web-based teams. FINDINGS: Student evaluations suggested that teaching facts or "content" about rural mental health and Appalachian culture was much easier than the "process" of using new technologies or working in teams. CONCLUSIONS: Given that the delivery of mental health care demands collaboration and teamwork and that rural practice relies increasingly more on the use of technology, our experience suggests that more team-based, technology-driven courses are needed to better prepare students for clinical practice.

Controlled-release paroxetine in the treatment of patients with social anxiety disorder.

BACKGROUND: This double-blind, placebo-controlled, flexible-dose study was conducted to investigate the efficacy and tolerability of the controlled-release (CR) formulation of paroxetine in adults with social anxiety disorder. METHOD: Outpatients with a primary diagnosis of social anxiety disorder according to DSM-IV criteria entered a 1-week, single-blind, placebo run-in period. Eligible patients were randomly assigned to receive paroxetine CR (flexible dose of 12.5-37.5 mg/day) or placebo for 12 weeks of treatment. The primary efficacy measures were the change from baseline in Liebowitz Social Anxiety Scale (LSAS) score and the proportion of responders based on Clinical Global Impressions (CGI)-Global Improvement scale score. Data were gathered from September 2001 to July 2002. RESULTS: The intent-to-treat population consisted of 186 patients randomly assigned to paroxetine CR and 184 patients randomly assigned to placebo. Statistically significant differences in favor of paroxetine CR compared with placebo were observed in the change from baseline to week 12 last-observation-carried-forward (LOCF) dataset in LSAS total score (difference = -13.33, 95% confidence interval [CI] = -18.25 to -8.41, p <.001). In the CGI-Global Improvement responder analysis, 57.0% of patients treated with paroxetine CR achieved response (very much improved or much improved), compared with 30.4% of patients treated with placebo at week 12 LOCF (odds ratio = 3.12, 95% CI = 2.01 to 4.83, p <.001). Dropout rates due to adverse events were low and comparable in both treatment groups. CONCLUSION: Paroxetine CR effectively treated the symptoms associated with social anxiety disorder and was well tolerated, with few patients stopping treatment due to adverse events. This favorable tolerability profile may enable more patients to experience the benefits of effective therapy.