Household Water, Sanitation, and Hygiene Practices Impact Pathogen Exposure in Remote, Rural, Unpiped Communities

Household water, sanitation and hygiene (WASH) practices in remote, rural, and unpiped communities are likely to impact exposure to pathogens beyond the fecal-oral transmission routes that are typically prioritized in WASH interventions. We studied 43 homes in two remote, rural, unpiped communities in Alaska to evaluate seasonal water haul, water sources, water quality, and water reuse, as well as greywater and human waste disposal over 1 year. Hauled quantities of water reportedly ranged from 3.0 to 5.4 gallons per capita per day (gpcd) depending on the community and season. Natural, untreated water sources contributed 0.5-1.1 gpcd to household water availability. Reported quantities of water hauled were significantly correlated with total water storage capacity in the home. Total coliforms were detected in 30-60% of stored household water samples from treated and untreated sources, and total coliform counts were significantly higher in specific sources and during specific seasons. Exposure to pathogens during periods of low water access, from untreated water reuse, from greywater disposal and from human waste disposal are important pathways of disease transmission in these remote, rural, unpiped communities. We discuss intermediate steps that can be taken at the household and community levels to interrupt exposure pathways before piped infrastructure is installed. This model of examining specific household practices to determine transmission routes can be applied to other remote communities or unique conditions to aid in the recommendation of targeted WASH interventions.

Rainwater catchments in rural Alaska have the potential to produce high-quality water and high quantities of water for household use

Rainwater collection is a common source of household water in developed and developing communities where treated on-site water is not available. Although rainwater catchment has been practiced for generations in rural Alaska communities, there are little data available on the quality and quantity of rainwater resources. Forty-eight rainwater samples were collected from nine communities in Alaska over 2 years. Samples were tested for physical water quality parameters, metals, and bacteria. Characteristics of household catchments were recorded. Rainwater quantity in two communities was evaluated. Overall, high-quality water was observed in rain catchments, with average total organic carbon (TOC) and turbidity being lower than or equal to those values in other published rainwater studies. pH was consistently low. Over 80% of samples were below the United States limits for metals and met international microbiological water quality standards. However, variation was observed between households, communities, indoor/outdoor bacteria samples, covered/uncovered storage containers, and over time. The quantity of rainwater available for catchment could supply 17-40% of annual household water and is projected to increase in future decades according to Alaska climate models. Best practices are recommended for rural Alaska communities to maintain the naturally high quality of rainwater and take advantage of large quantities of rainwater available on-site.

Facelift Performed Safely With Local Anesthesia and Oral Sedation: Analysis of 174 Patients

BACKGROUND

Anesthesia for elective ambulatory procedures must provide appropriate pain control while minimizing perioperative risk. Local anesthesia in combination with oral sedation provides a safe office-based method of anesthesia for rhytidectomy.

OBJECTIVES

The purpose of this analysis was to identify the incidence of traditional outcome parameters in ambulatory rhytidectomy performed with local anesthesia and oral sedation.

METHODS

A retrospective chart review was performed on all patients who underwent office-based rhytidectomy under local anesthesia with oral sedation from February 2011 to May 2017. A total of 174 patients were included. The data collected included patient medical and surgical history, medications, body mass index, tobacco use history, operative time, technique, and concurrent procedures. All intraoperative and postoperative complications were recorded.

RESULTS

One hundred and sixty-five patients were female (94.8%) and 9 were male (5.2%) a mean age of 57.6 years (SD ± 7.90). There were 46 complications, including 23 hematomas (13.2%), 6 seromas, 6 episodes of emesis, 5 infections, 4 scar deformities, and 2 ear deformities. Of the 23 hematomas, only 2 required operative evacuation with local anesthesia in the office procedure room. Twenty-one hematomas were small and managed with percutaneous needle aspiration, followed by surveillance. The 5 infections resolved after oral antibiotics only. There were no thromboembolic events or hospitalizations.

CONCLUSIONS

The use of only local anesthesia in combination with oral sedation safely permits the performance of rhytidectomy with similar incidence of rhytidectomy-related complications without the risk related to general anesthesia.

LEVEL OF EVIDENCE: 4

Squamous cell carcinoma of the bladder: poor response to neoadjuvant chemotherapy

BACKGROUND

Squamous cell carcinoma (SCC) of the bladder is a rare, aggressive malignancy. Unlike urothelial cell carcinoma, SCC is resistant to chemotherapy and guidelines recommend radical cystectomy (RC) without neoadjuvant chemotherapy (NAC). We aimed to evaluate the current management and survival of patients with invasive SCC treated with or without NAC.

METHODS

671 patients with invasive SCC bladder cancer from 2004 to 2015 in the National Cancer Data Base were identified. Patients were stratified by treatment with RC alone or NAC prior to RC (NAC + RC). Survival analysis was performed with Kaplan-Meier and Cox regression. Secondary outcomes included length of stay and readmission.

RESULTS

Of 671 patients, 92.8% were treated with RC alone and 7.2% with NAC + RC. Cox regression for mortality was performed including age, Charlson score, clinical stage, and NAC. Increased risk of mortality was noted with increasing age (OR 1.01, p = 0.023) and Charlson score of 1-3 (HR 1.58-1.68, p < 0.05). NAC did not confer survival advantage (HR 1.17, p = 0.46). On Kaplan-Meier analysis, the overall survival was equivalent (log-rank p = 0.804). Hospital stay and readmission were similar between RC and NAC + RC groups.

CONCLUSIONS

Analysis of a national tumor registry suggests a lack of overall survival benefit for NAC with localized, muscle invasive SCC of the bladder. Further research directed at chemotherapy regimens for SCC is needed to optimize treatment and improve survival outcomes.

Applicability of energy-positive net-zero water management in Alaska: technology status and case study

Challenges of water and wastewater management in Alaska include the potential need for above-grade and freeze-protected piping, high unit energy costs and, in many rural areas, low population density and median annual income. However, recently developed net-zero water (NZW), i.e., nearly closed-loop, direct potable water reuse systems, can retain the thermal energy in municipal wastewater, producing warm treated potable water without the need for substantial water re-heating, heat pumping or transfer, or additional energy conversion. Consequently, these systems are projected to be capable of saving more energy than they use in water treatment and conveyance, in the temperate USA. In this paper, NZW technology is reviewed in terms of potential applicability in Alaska by performing a hypothetical case study for the city of Fairbanks, Alaska. Results of this paper study indicate that in municipalities of Alaska with local engineering and road access, the use of NZW systems may provide an energy-efficient water service option. In particular, case study modeling suggests hot water energy savings are equivalent to five times the energy used for treatment, much greater savings than in mid-latitudes, due largely to the substantially higher energy needed for heating water from a conventional treatment system and lack of need for freeze-protected piping. Further study of the applicability of NZW technology in cold regions, with expanded evaluation in terms of system-wide lifecycle cost, is recommended.

The search for an alternative to piped water and sewer systems in the Alaskan Arctic

Forty-two communities in rural Alaska are considered unserved or underserved with water and sewer infrastructure. Many challenges exist to provide centralized piped water and sewer infrastructure to the homes, and they are exacerbated by decreasing capital funding. Unserved communities in rural Alaska experience higher rates of disease, supporting the recommendation that sanitation infrastructure should be provided. Organizations are pursuing alternative solutions to conventional piped water and sewer in order to maximize water use and reuse for public health. This paper reviews initiatives led by the State of Alaska, the Alaska Native Tribal Health Consortium, and the Yukon Kuskokwim Health Corporation to identify and develop potential long-term solutions appropriate and acceptable to rural communities. Future developments will likely evolve based on the lessons learned from the initiatives. Recommendations include Alaska-specific research needs, increased end-user participation in the design process, and integrated monitoring, evaluation, and information dissemination in future efforts.

Benzotriazole Enrichment in Snowmelt Discharge Emanating from Engineered Snow Storage Facilities

Snowpacks in urban environments can retain a high load of anthropogenic contaminants that, upon melting, can deliver concentrated contaminant pulses into the aquatic environment. In climates with an extended period of snowfall accumulation, such as in Anchorage, Alaska, contaminant amplification within meltwater may affect aquatic ecosystem health. A spatiotemporal study of benzotriazoles on snow, meltwater and soils was performed in association with three urban snow disposal facilities. Benzotriazole elution from engineered snow disposal sites behaved similarly to inorganic salt and dissolved organic carbon (DOC) during the initial melt period, with maximum concentrations between 2.23-7.39 μg/L; similar enrichment was observed in creeks. Assays of disposal site soils revealed the presence of tolytriazole. Furthermore, using fluorescence spectroscopy and PARAFAC analysis, a modeled component representative of benzotriazoles was identified, a possible indicator of anthropogenic input rather than a unique indicator for benzotriazole compounds.

The effect of UV/H2O2 treatment on disinfection by-product formation potential under simulated distribution system conditions

Advanced oxidation with ultraviolet light and hydrogen peroxide (UV/H(2)O(2)) produces hydroxyl radicals that have the potential to degrade a wide-range of organic micro-pollutants in water. Yet, when this technology is used to reduce target contaminants, natural organic matter can be altered. This study evaluated disinfection by-product (DBP) precursor formation for UV/H(2)O(2) while reducing trace organic contaminants in natural water (>90% for target pharmaceuticals, pesticides and taste and odor producing compounds and 80% atrazine degradation). A year-long UV/H(2)O(2) pilot study was conducted to evaluate DBP precursor formation with varying water quality. The UV pilot reactors were operated to consistently achieve 80% atrazine degradation, allowing comparison of low pressure (LP) and medium pressure (MP) lamp technologies for DBP precursor formation. Two process waters of differing quality were used as pilot influent, i.e., before and after granular activated carbon adsorption. DBP precursors increased under most of the conditions studied. Regulated trihalomethane formation potential increased through the UV/H(2)O(2) reactors from 20 to 118%, depending on temperature and water quality. When Post-GAC water served as reactor influent, less DBPs were produced in comparison to conventionally treated water. Haloacetic acid (HAA5) increased when conventionally treated water served as UV/H(2)O(2) pilot influent, but only increased slightly (MP lamp) when GAC treated water served as pilot influent. No difference in 3-day simulated distribution system DBP concentration was observed between LP and MP UV reactors when 80% atrazine degradation was targeted.

Nitrosamine, dimethylnitramine, and chloropicrin formation during strong base anion-exchange treatment

Strong base anion-exchange resins represent an important option for water utilities and homeowners to address growing concerns with nitrate, arsenate, and perchlorate contamination of source waters. Most commercially available anion-exchange resins employ quaternary amine functional groups. Previous research has provided contradictory evidence regarding whether these resins serve as sources of nitrosamines, considered as highly carcinogenic nitrogenous disinfection byproducts (N-DBPs), even without disinfectants. For three common varieties of commercial anion-exchange resins, we evaluated the importance of releases of nitrosamines, and two other N-DBPs (dimethylnitramine and chloropicrin), when the resins were subjected to typical column flow conditions with and without free chlorine or chloramine application upstream or downstream of the columns. In the absence of disinfectants, fresh trimethylamine- and tributylamine-based type 1 and dimethylethanolamine-based type 2 anion-exchange resins usually released 2-10 ng/L nitrosamines, likely due to shedding of manufacturing impurities, with excursions of up to 20 ng/L following regeneration. However, the lack of significant nitrosamine release in a full-scale anion-exchange treatment system after multiple regeneration cycles indicates that releases may eventually subside. Resins also shed organic precursors that might contribute to nitrosamine formation within distribution systems when chloramines are applied downstream. With free chlorine or chloramine application upstream, nitrosamine concentrations were more significant, at 20-100 ng/L for the type 1 resins and approximately 400 ng/L for the type 2 resin. However, chloropicrin formation was lowest for the type 2 resin. Dimethylnitramine formation was significant with free chlorine application upstream but negligible with chloramines. Although no N-DBPs were detected in cation-exchange-based consumer point-of-use devices exposed to chlorinated or chloraminated waters, our results indicate that inclusion of anion-exchange resins in these devices, as in laboratory deionized water systems, would likely be problematic.

Nitrogen enriched dissolved organic matter (DOM) isolates and their affinity to form emerging disinfection by-products

Increased contributions from wastewater discharges and algal activity in drinking water supplies can lead to elevated levels of dissolved organic nitrogen (DON), which can increase the likelihood for the formation of emerging nitrogenous disinfection by-products (N-DBPs) of health concern. Dissolved organic matter (DOM) isolated from five waters, using a newly developed DOM isolation method specific to DON fractionation, produced thirty-four isolates of suitable mass. Each isolate was treated with free chlorine or chloramines under formation potential conditions. The DBP yields were determined for three halogenated DBPs (trichloromethane, dichloroacetonitrile, and trichloronitromethane) and one non-halogenated DBP (N-nitrosodimethylamine [NDMA]). Halogenated DBP yields were greater during the application of free chlorine, however chloramination produced significant levels of halogenated N-DBPs for some isolates. NDMA was only observed to form from selected nitrogen-enriched isolates (DOC/DON ratio < 20 mg/mg), especially those isolated from treated wastewater. Other results indicated that nitrogen-enriched DOM resulted in increased yields of the other N-DBPs studied.

Long-term administration of 13-cis retinoic acid in common variable immunodeficiency: circulating interleukin-6 levels, B-cell surface molecule display, and in vitro and in vivo B-cell antibody production

We have previously shown that retinoids can induce differentiation of B cells in vitro as well as in vivo in patients with common variable immunodeficiency (CVI). While changes were observed over 1 week when retinoic acid (RA) was added to CVI hybridoma cells in vitro, maturation of the patients' B-cell compartment in vivo occurred only after 4 months of drug administration. We have now performed a 64-week open trial of oral 13-cis RA in five patients to see if prolonged treatment would result in continued improvement in their humoral immune compartment. In this trial, drug was given for 32 weeks followed by a 32-week wash-out period. During the treatment, the patients showed changes in a variety of parameters indicating an alteration towards normal of their humoral immune systems. This change included a fall in the elevated circulating interleukin-6 (IL-6) levels, a more normal display of B-cell surface markers (L-selectin and CD20), a decrease in B-cell size, and improved in vitro and in vivo B-cell function. In order to determine if VH gene use was affected by the retinoid treatment, VH gene expression in the CVI patients was characterized. Results showed an unusual predominance of non-mutated VH gene sequences, representative of cells that are recent bone marrow emigrants. While no common pattern of change occurred in VH gene segment use in the patients while on retinoid therapy, large-scale (> 10-fold) changes in the expression of these genes were observed in each individual over time. Taken together, these results provide multiple lines of evidence that 13-cis RA promotes maturation of B cells in patients with CVI. However, the effect appears to be partial, such that stimuli in addition to 13-cis RA will be necessary to provide for further B-cell differentiation in order to achieve normalization of humoral immunity.