Contamination of water systems can not only entail high risks to human health but can also result in economic losses due to closure of beaches and shellfish harvesting areas. Understanding the origin of fecal pollution at locations where shellfish are grown is essential in assessing associated health risks—as well as the determining actions necessary to remedy the problem. The aim of this work is to identify the species-specific source(s) of fecal contamination impacting waters overlying the shellfisheries in the Blackwater Estuary, East Anglia, UK. Over a twelve-month period, water samples were taken from above the oysters and from a variety of upstream points considered to be likely sources of fecal microorganism, together with oyster samples, and the number of fecal streptococci and E. coli were determined. Transition from low to high tide significantly decreased the concentration of fecal streptococci in waters overlying the oyster beds, indicative of a freshwater input of fecal pollution in oyster bed waters. In 12 months, the number of E. coli remained constant throughout, while fecal streptococci numbers were generally higher in the winter months. Analyses of upstream samples identified a sewage outfall to be the main source of E. coli to the oyster beds, with additional fecal streptococci from agricultural sources. The findings may assist in developing approaches for assessing the risks to shellfishery industries of various fecal inputs into an estuary, which could then help local governmental authorities address the problem.

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model was adapted to the Italian context. The analysis compared nivolumab with observation (wait and watch approach) from the health-care payer perspective, over a 60-year time horizon. An indirect treatment comparison based on patient-level data from CheckMate 238 and CA184-029 trials informed the efficacy of nivolumab and observation on recurrence free survival (RFS). Overall survival (OS) was modelled using an RFS/ OS correlation equation supported by published literature. Local data informed subsequent therapy distributions in the two arms. Drug acquisition, administration, monitoring, subsequent therapy, adverse events and end-of life costs were sourced from published prices, DRG Italian tariffs and literature. Utility values based on Italian EQ-5D tariffs were obtained from CheckMate 238 collected data. Three percent annual discount rates were applied for costs and benefits. Results: Nivolumab was associated with higher utility versus observation (11.35 QALY vs 7.66 QALY) and incremental costs (V143,324 for nivolumab vs V94,433 for observation), resulting in an ICUR of V13,273/QALY compared to observation. This suggests that nivolumab is a cost-effective treatment at current published prices. Conclusions: Nivolumab is a cost-effective strategy for the adjuvant treatment of melanoma in Italy.

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