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Achieving safely managed sanitation and resource recovery in areas that are rural, geographically challenged, or experiencing rapidly increasing population density may not be feasible with centralized facilities due to space requirements, site-specific concerns, and high costs of sewer installation. Non-sewered sanitation (NSS) systems have the potential to provide safely managed sanitation and achieve strict wastewater treatment standards. One such NSS treatment (backend) technology is the NEWgeneratorTM, which includes an anaerobic membrane bioreactor (AnMBR), nutrient recovery via ion exchange, and electrochlorination. Although the system has been shown to achieve robust treatment of real waste streams for over 100 users, the technology’s relative life cycle sustainability across deployment locations remains unclear. This study characterizes the financial viability and life cycle environmental impacts of the NEWgeneratorTM and prioritizes opportunities to advance system sustainability through targeted improvements and deployment. The costs and greenhouse gas (GHG) emissions of the NEWgeneratorTM (general case) leveraging grid electricity were 0.139 [0.113 – 0.168] USD·cap-1·d-1 and 79.7 [55.0 – 112.3] kg CO2-eq·cap-1·yr-1, respectively. A transition to photovoltaic-generated electricity would increase costs to 0.145 [0.118 – 0.181] USD·cap-1·d-1 but decrease GHG emissions to 56.1 [33.8 – 86.2] kg CO2eq·cap-1·yr-1. The deployment location analysis demonstrated reduced median costs (relative to the general case) for deployment in China (-38%), India (-53%), Senegal (-31%), South Africa (-31%), and Uganda (-35%), but at comparable or increased GHG emissions (-2% to +16%). Examining targeted improvements revealed the relative change in median cost and GHG emissions to be -21% and -3% if loading is doubled (i.e., doubled users per unit), -30% and -12% with additional sludge drying, and +9% and -25% with the addition of a membrane contactor, respectively, with limited benefits (0-5% reductions) from an alternative photovoltaic battery, low-cost housing, or improved frontend operation. This research demonstrates the NEWgeneratorTM is a low-cost, low-emission NSS backend technology with the potential for resource recovery to increase access to safe sanitation.

Background A challenge the healthcare system faced during the COVID-19 pandemic was ensuring appropriate use of therapeutics. Hydroxychloroquine (HCQ), azithromycin, and ivermectin are FDA-approved for rheumatic, antibacterial, and antiparasitic conditions, respectively. During the pandemic, these drugs were used for COVID-19 treatment, despite unproven benefit and lack of clinical guideline support. Payer-based formulary edits of these agents during the COVID-19 pandemic were reviewed to determine effectiveness in supporting appropriate use. Methods After local discovery of COVID-19 the University of Rochester Medical Center and a local payor in the upstate New York area, Excellus BlueCross BlueShield, disseminated education about the unproven role of these agents in treatment or prevention of COVID-19. In March 2020, May 2020 and February 2021, respectively, Excellus BCBS placed a quantity limit (QL) on prescriptions for HCQ, azithromycin and ivermectin and prior authorization (PA) for ivermectin in October 2021 for all formularies except Medicare. The QL for HCQ and azithromycin were in effect until December 2020. An exception process was available for individuals who required a higher quantity. Data was gathered retrospectively for claims and total drug utilization amongst Excellus BCBS members through February 2022. Results Use of HCQ increased by 56.5% prior to QL implementation. After HCQ QL was implemented, HCQ use returned to near pre-pandemic baseline, and most (88%) claims were processed. For azithromycin, after the QL limit was implemented, while overall usage dropped, most claims (77%) were processed. Prior to QL and PA, ivermectin usage quadrupled. Following implementation of the ivermectin QL, usage was stable and a minority (41%) of ivermectin claims were processed. The month that PA was implemented, usage dropped by 81%, and 9% of claims were processed. Conclusion Formulary edits resulted in returning use of HCQ to pre-pandemic levels despite an initial rise in use. The edits may have curtailed azithromycin use as well. A QL was associated with stabilization in ivermectin use but ultimately usage did not decrease until PA was required. Formulary edits consistent with local messaging appeared to help control use of unproven therapeutics for COVID-19. Disclosures Alyssa Tutino, PharmD, BCGP, Excellus BlueCross BlueShield: Salary Justin Bender, BS, Excellus BlueCross BlueShield: Salary Michelle Sageer, Pharm D, BCACP, Excellus BlueCross BlueShield: Salary Mona Chitre, PharmD, Excellus BlueCross BlueShield: Salary.

Omni Processors (OPs) are community-scale systems for non-sewered fecal sludge treatment. These systems have demonstrated their capacity to treat excreta from tens of thousands of people using thermal treatment processes, but their relative sustainability is unclear. In this study, QSDsan (an open-source Python package) was used to characterize the financial viability and environmental implications of fecal sludge treatment via OP technology treating mixed and source-separated human excreta, and to elucidate the key drivers of system sustainability. Overall, the daily user cost for the treatment of mixed excreta (pit latrines) via the OP was estimated to be 0.05 [0.03 – 0.08] USD·cap-1·d-1, while the treatment of source-separated excreta (from urine-diverting dry toilets) was estimated to have a user cost of 0.09 [0.08 – 0.14] USD·cap-1·d-1. Operation and maintenance of the OP is a critical driver to total user cost; whereas the contribution from capital cost of the OP is much lower because it is distributed over a relatively large number of users (i.e., 12,000 people) for the system lifetime (i.e., 20 yr). The total emissions from the source-separated scenario were estimated to be 11 [8.3 – 23] kg CO2 eq·cap-1·yr-1, compared to 49 [28 – 77] kg CO2 eq·cap-1·yr-1 for mixed excreta. Both scenarios fall below the estimates of greenhouse gas (GHG) emissions for anaerobic treatment of fecal sludge collected from pit latrines. Source-separation also creates opportunities for resource recovery to offset costs through nutrient recovery and carbon sequestration with biochar production. For example, when carbon is valued at 150 USD·Mg-1 of CO2, the user cost of sanitation can be further reduced by 44% and 40% for the source-separated and mixed excreta scenarios, respectively. Overall, our results demonstrate that OP technology can provide low-cost, low-GHG fecal sludge treatment while reducing global sanitation gaps.

Omni Processors (OPs) are community-scale systems for non-sewered fecal sludge treatment. These systems have demonstrated their capacity to treat excreta from tens of thousands of people using thermal treatment processes (e.g., pyrolysis), but their relative sustainability is unclear. In this study, QSDsan (an open-source Python package) was used to characterize the financial viability and environmental implications of fecal sludge treatment via pyrolysis-based OP technology treating mixed and source-separated human excreta and to elucidate the key drivers of system sustainability. Overall, the daily per capita cost for the treatment of mixed excreta (pit latrines) via the OP was estimated to be 0.05 [0.03-0.08] USD·cap