Smooth Transitions: Enhancing Interprofessional Collaboration when Planned Community Births Transfer to Hospital Care.

In Washington state, planned community births are attended by direct entry licensed midwives (LMs) and certified nurse-midwives (CNMs). The most recently published vital statistics data from 2018 reported that 3.6% of the 84,648 births in Washington occurred at home or in freestanding birthing centers. Approximately 16.2% of planned home birth and birth center clients experience intrapartum or early postpartum transfer to the hospital, while 1.8% of their newborns do. The safety of and satisfaction with these types of referrals depends on multisystem processes performed by a variety of health care professionals. Smooth Transitions is a quality improvement (QI) initiative in Washington state that was developed to enhance interprofessional collaboration between community-based midwives, emergency medical services (EMS), and hospital personnel to improve the quality of hospital transfers from planned community settings. Key interventions to date have included (1) information sharing to dispel misconceptions and provide context regarding community births and midwives; (2) co-creation of transfer guidelines; (3) regularly held interprofessional meetings to review transfers and build relationships; and (4) ongoing review of qualitative feedback that captures the perspectives of all involved. Responses on questionnaires and audits indicate that Smooth Transitions has had a positive impact on provider, staff, and patient experiences with hospital transfers. Future endeavors will include strengthening quantitative data collection processes to measure safety indicators, expanding relationships with EMS, and building a case review process that is legally protected. By engaging representatives of all stakeholder groups and addressing community-to-hospital transfers as a multisystems issue, replication of the Smooth Transitions QI Program nationally could promote increased community midwifery integration by enhancing the referral experience for both patients and caregivers.

Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State.

OBJECTIVE: To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings. METHODS: We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders. RESULTS: The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses. CONCLUSION: Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

Cryptosporidium and Giardia in Wastewater and Surface Water Environments.

and spp. are significant contributors to the global waterborne disease burden. Waterways used as sources of drinking water and for recreational activity can become contaminated through the introduction of fecal materials derived from humans and animals. Multiple studies have reported the occurence or concentrations of these pathogens in the environment. However, this information has not been comprehensively reviewed. Quantitative microbial risk assessment (QMRA) for and can be beneficial, but it often relies on the concentrations in environmental sources reported from the literature. A thorough literature review was conducted to develop an inventory of reported and concentrations in wastewater and surface water available in the literature. This information can be used to develop QMRA inputs. and (oo)cyst concentrations in untreated wastewater were up to 60,000 oocysts L and 100,000 cysts L, respectively. The maximum reported concentrations for and in surface water were 8400 oocysts L and 1000 cysts L, respectively. A summary of the factors for interpretation of concentration information including common quantification methods, survival and persistence, biofilm interactions, genotyping, and treatment removal is provided in this review. This information can help in identifying assumptions implicit in various QMRA parameters, thus providing the context and rationale to guide model formulation and application. Additionally, it can provide valuable information for water quality practitioners striving to meet the recreational water quality or treatment criteria. The goal is for the information provided in the current review to aid in developing source water protection and monitoring strategies that will minimize public health risks.

Forensic analysis of tertiary-butyl alcohol (TBA) detections in a hydrocarbon-rich groundwater basin.

Tertiary-butyl alcohol (TBA), a high-production volume (HPV) chemical, was sporadically detected in groundwater and coalbed methane (CBM) wells in southeastern Colorado's hydrocarbon-rich Raton Basin. TBA concentrations in shallow water wells averaged 75.1 µg/L, while detections in deeper CBM wells averaged 14.4 µg/L. The detection of TBA prompted a forensic investigation to try to identify potential sources. Historic and recent data were reviewed to determine if there was a discernable pattern of TBA occurrence. Supplemental samples from domestic water wells, monitor wells, CBM wells, surface waters, and hydraulic fracturing (HF) fluids were analyzed for TBA in conjunction with methyl tertiary-butyl ether (MTBE) and ethyl tertiary-butyl ether (ETBE), proxies for evidence of contamination from reformulated gasoline or associated oxygenates. Exploratory microbiological sampling was conducted to determine if methanotrophic organisms co-occurred with TBA in individual wells. Meaningful comparisons of historic TBA data were limited due to widely varying reporting limits. Mapping of TBA occurrence did not reveal any spatial patterns or physical associations with CBM operations or contamination plumes. Additionally, TBA was not detected in HF fluids or surface water samples. Given the widespread use of TBA in industrial and consumer products, including water well completion materials, it is likely that multiple diffuse sources exist. Exploratory data on stable isotopes, dissolved gases, and microbial profiling provide preliminary evidence that methanotrophic activity may be producing TBA from naturally occurring isobutane. Reported TBA concentrations were significantly below a conservative risk-based drinking water screening level of 8000 µg/L derived from animal toxicity data.

Functional microbial diversity explains groundwater chemistry in a pristine aquifer.

BACKGROUND: The diverse microbial populations that inhabit pristine aquifers are known to catalyze critical in situ biogeochemical reactions, yet little is known about how the structure and diversity of this subsurface community correlates with and impacts upon groundwater chemistry. Herein we examine 8,786 bacterial and 8,166 archaeal 16S rRNA gene sequences from an array of monitoring wells in the Mahomet aquifer of east-central Illinois. Using multivariate statistical analyses we provide a comparative analysis of the relationship between groundwater chemistry and the microbial communities attached to aquifer sediment along with those suspended in groundwater. RESULTS: Statistical analyses of 16S rRNA gene sequences showed a clear distinction between attached and suspended communities; with iron-reducing bacteria far more abundant in attached samples than suspended, while archaeal clones related to groups associated with anaerobic methane oxidation and deep subsurface gold mines (ANME-2D and SAGMEG-1, respectively) distinguished the suspended community from the attached. Within the attached bacterial community, cloned sequences most closely related to the sulfate-reducing Desulfobacter and Desulfobulbus genera represented 20% of the bacterial community in wells where the concentration of sulfate in groundwater was high (> 0.2 mM), compared to only 3% in wells with less sulfate. Sequences related to the genus Geobacter, a genus containing ferric-iron reducers, were of nearly equal abundance (15%) to the sulfate reducers under high sulfate conditions, however their relative abundance increased to 34% when sulfate concentrations were < 0.03 mM. Also, in areas where sulfate concentrations were <0.03 mM, archaeal 16S rRNA gene sequences similar to those found in methanogens such as Methanosarcina and Methanosaeta comprised 73-80% of the community, and dissolved CH4 ranged between 220 and 1240 µM in these groundwaters. In contrast, methanogens (and their product, CH4) were nearly absent in samples collected from groundwater samples with > 0.2 mM sulfate. In the suspended fraction of wells where the concentration of sulfate was between 0.03 and 0.2 mM, the archaeal community was dominated by sequences most closely related to the ANME-2D, a group of archaea known for anaerobically oxidizing methane. Based on available energy (∆GA) estimations, results varied little for both sulfate reduction and methanogenesis throughout all wells studied, but could favor anaerobic oxidation of methane (AOM) in wells containing minimal sulfate and dihydrogen, suggesting AOM coupled with H2-oxidizing organisms such as sulfate or iron reducers could be an important pathway occurring in the Mahomet aquifer. CONCLUSIONS: Overall, the results show several distinct factors control the composition of microbial communities in the Mahomet aquifer. Bacteria that respire insoluble substrates such as iron oxides, i.e. Geobacter, comprise a greater abundance of the attached community than the suspended regardless of groundwater chemistry. Differences in community structure driven by the concentration of sulfate point to a clear link between the availability of substrate and the abundance of certain functional groups, particularly iron reducers, sulfate reducers, methanogens, and methanotrophs. Integrating both geochemical and microbiological observations suggest that the relationships between these functional groups could be driven in part by mutualism, especially between ferric-iron and sulfate reducers.

Batch tests on mineral deposit formation due to co-mingling of leachates derived from municipal solid wastes and waste-to-energy combustion residues.

Deposit formation in leachate collection systems can be problematic for landfill operations. Deposits from municipal solid waste (MSW) derived leachates are impacted by microbial activity and biofilm development, whereas leachates generated from co-disposal of MSW with combustion residues (CR) from waste-to-energy (WTE) facilities and other mineral-rich waste materials are more prone to forming dense mineral deposits dominated by calcium carbonate. In this study, leachates from laboratory lysimeters containing either WTE-CR or shredded MSW were mixed at different volumetric ratios. The mixed leachates were incubated for 5 weeks in batch tests to evaluate the potential for formation of precipitates. Although mineral precipitates have been reported to form in landfills with no co-disposal practices, in this study mineral precipitates did not form in either the WTE-CR derived leachate or the MSW derived leachate, but formed in all leachate mixtures. Mineral precipitates consisted of calcium carbonate particles, with the highest yield from a 1:1 combination of the WTE-CR derived leachate mixed with the MSW derived leachate. The introduction of gaseous carbon dioxide or air into WTE-CR derived leachate resulted in the production of particles of similar chemical composition but different morphology. Operation of landfills to prevent co-mingling of mineral-rich leachates with microbially active leachates and/or to control leachate exposure to sources of carbon dioxide may help to prevent this type of precipitate formation in leachate collection systems.

Pathogen and indicator organism reduction through secondary effluent filtration: implications for reclaimed water production.

The reduction of pathogens and indicator organisms through secondary effluent filtration was investigated at six full-scale treatment facilities, ranging in capacity from 0.04 to 1 m3/s (1 to 25 mgd). Grab samples were assayed for pathogens (cultivable enteric viruses, Giardia, and Cryptosporidium) and indicator organisms (coliforms, enterococci, Clostridium perfringens, and coliphages) quarterly under peak flow conditions from each facility over the course of 1 calendar year. Log10 removals resulting from filtration averaged 0.3 to 0.8 log10 for cultivable enteric viruses, 0.4 to 1.5 log10 for protozoan parasites, 0.01 to 3.7 log10 for indicator bacteria, and 0.3 to 1.1 log10 for coliphages. In addition to filter design (cloth, monomedium shallow- or deep-bed, or dual-media filters), differences in reduction of pathogens and indicators could be attributed to the combined effects of hydraulic loading rates, chemical addition practices, backwashing and postbackwashing operating strategies, and the effectiveness of upstream biological treatment and sedimentation.

Batch test assessment of waste-to-energy combustion residues impacts on precipitate formation in landfill leachate collection systems.

Disposal practices for bottom ash and fly ash from waste-to-energy (WTE) facilities include emplacement in ash monofills or co-disposal with municipal solid waste (MSW) and residues from water and wastewater treatment facilities. In some cases, WTE residues are used as daily cover in landfills that receive MSW. A recurring problem in many landfills is the development of calcium-based precipitates in leachate collection systems. Although MSW contains varying levels of calcium, WTE residues and treatment plant sludges have the potential to contribute concentrated sources of leachable minerals into landfill leachates. This study was conducted to evaluate the leachability of calcium and other minerals from residues generated by WTE combustion using residues obtained from three WTE facilities in Florida (two mass-burn and one refuse-derived fuel). Leaching potential was quantified as a function of contact time and liquid-to-solid ratios with batch tests and longer-term leaching tests using laboratory lysimeters to simulate an ash monofill containing fly ash and bottom ash. The leachate generated as a result of these tests had total dissolved solid (TDS) levels ranging from 5 to 320 mg TDS/g ash. Calcium was a major contributor to the TDS values, contributing from 20 to 105 g calcium/kg ash. Fly ash was a major contributor of leachable calcium. Precipitate formation in leachates from WTE combustion residues could be induced by adding mineral acids or through gas dissolution (carbon dioxide or air). Stabilization of residual calcium in fly ashes that are landfilled and/or the use of less leachable neutralization reagents during processing of acidic gases from WTE facilities could help to decrease the calcium levels in leachates and help to prevent precipitate formation in leachate collection systems.

Evaluation of the persistence of micropollutants through pure-oxygen activated sludge nitrification and denitrification.

The persistence of pharmaceuticals, hormones, and household and industrial chemicals through a pure-oxygen activated sludge, nitrification, denitrification wastewater treatment facility was evaluated. Of the 125 micropollutants that were tested in this study, 55 compounds were detected in the untreated wastewater, and 27 compounds were detected in the disinfected effluent. The persistent compounds included surfactants, fire-retardant chemicals, pesticides, fragrance compounds, hormones, and one pharmaceutical. Physical-chemical properties of micropollutants that affected partitioning onto wastewater solids included vapor pressure and octanol-water partition coefficients.

Lysimeter comparison of the role of waste characteristics in the formation of mineral deposits in leachate drainage systems.

A common operational problem in leachate collection systems is clogging due to the formation of deposits within pore spaces and collection pipes. The role of co-disposal of municipal solid waste (MSW) and combustion residues from waste-to-energy (WTE) facilities in clogging is evaluated in this paper. Five parallel lysimeters were operated in monofill or co-disposal mode using MSW, WTE combustion residues, and water/wastewater treatment byproducts. Leachate was applied to each lysimeter to simulate sequential flooding and draining and leachates were characterized over a 7-month period. Waste composition and the presence/absence of biological activity influenced the redox potential, pH, and alkalinity, which impacted the rate and extent of biological degradation and chemical solubility. Calcium carbonate was identified as the most abundant chemical precipitate. Leachates from ash monofills were highly alkaline (pH > 11) and had higher ionic strength due to relatively higher levels of calcium and other minerals, while carbonate levels were limited due to the lack of biological activity. The MSW monofill generated leachates with high levels of biological activity, lower concentrations of calcium, and a rich carbonate system. Co-disposal of MSW, combustion and treatment process residues generated leachates that were not limited in either calcium or carbonate, creating ideal conditions for formation of precipitates.

Validity of the indicator organism paradigm for pathogen reduction in reclaimed water and public health protection.

The validity of using indicator organisms (total and fecal coliforms, enterococci, Clostridium perfringens, and F-specific coliphages) to predict the presence or absence of pathogens (infectious enteric viruses, Cryptosporidium, and Giardia) was tested at six wastewater reclamation facilities. Multiple samplings conducted at each facility over a 1-year period. Larger sample volumes for indicators (0.2 to 0.4 liters) and pathogens (30 to 100 liters) resulted in more sensitive detection limits than are typical of routine monitoring. Microorganisms were detected in disinfected effluent samples at the following frequencies: total coliforms, 63%; fecal coliforms, 27%; enterococci, 27%; C. perfringens, 61%; F-specific coliphages, approximately 40%; and enteric viruses, 31%. Cryptosporidium oocysts and Giardia cysts were detected in 70% and 80%, respectively, of reclaimed water samples. Viable Cryptosporidium, based on cell culture infectivity assays, was detected in 20% of the reclaimed water samples. No strong correlation was found for any indicator-pathogen combination. When data for all indicators were tested using discriminant analysis, the presence/absence patterns for Giardia cysts, Cryptosporidium oocysts, infectious Cryptosporidium, and infectious enteric viruses were predicted for over 71% of disinfected effluents. The failure of measurements of single indicator organism to correlate with pathogens suggests that public health is not adequately protected by simple monitoring schemes based on detection of a single indicator, particularly at the detection limits routinely employed. Monitoring a suite of indicator organisms in reclaimed effluent is more likely to be predictive of the presence of certain pathogens, and a need for additional pathogen monitoring in reclaimed water in order to protect public health is suggested by this study.

Evaluation of biological hydrogen sulfide oxidation coupled with two-stage upflow filtration for groundwater treatment.

Hydrogen sulfide in groundwater can be oxidized by aerobic bacteria to form elemental sulfur and biomass. While this treatment approach is effective for conversion of hydrogen sulfide, it is important to have adequate control of the biomass exiting the biological treatment system to prevent release of elemental sulfur into the distribution system. Pilot scale tests were conducted on a Florida groundwater to evaluate the use of two-stage upflow filtration downstream of biological sulfur oxidation. The combined biological and filtration process was capable of excellent removal of hydrogen sulfide and associated turbidity. Additional benefits of this treatment approach include elimination of odor generation, reduction of chlorine demand, and improved stability of the finished water.