There is an increasing need for reliable methods to measure the reduction of microorganisms during the domestic laundering process. An enhanced throughput (ETP) methodology, an adaptation of the European standard BS EN 17658:2022, was developed as a screening tool for evaluating experimental laundry formulations with improved capacity and efficiency. The modifications include the replacement of a lab-scale tumbling device with a more compact and affordable instrument along with additional procedural modifications to simplify the test procedure without compromising the critical parameters such as mechanical action, bioburden, liquor ratio and soil. The ETP method was utilized to replicate the rinse cycle test from an international ring trial, where the participating laboratories assessed the efficacy of 0.04% Dodecyl dimethylammonium chloride (DDAC) as a benchmark standard. In addition, an experimental formulation was evaluated according to ETP and the full EN standard against the five required microorganisms including Pseudomonas aeruginosa, Escherichia coli, Staphylococcus aureus, Enterococcus hirae and Candida albicans. Overall, the average log reduction values obtained with both the benchmark and experimental formulation did not differ between the two methods. Furthermore, based on the benchmark data, the ETP method consistently showed lower variability within a lab than the EN method, as evaluated in the ring trial. The advantages and weaknesses of ETP as a research screening tool are also discussed in this work.

Across the United States, rural residents rely on unregulated and generally unmonitored private wells for drinking water, which may pose serious health risks due to unrecognized contaminants. We assessed the nature, degree, and spatial distribution of cumulative health risks from inorganic contaminants in groundwater. Our analysis included nearly 84,000 data points from 6,500+ wells, across 51 of Montana’s 98 watersheds, using a public groundwater database. We compared a drinking water screening level cumulative risk assessment (CRA) for inorganics based on the U.S. Environmental Protection Agency (EPA) protective health thresholds (Maximum Contaminant Level Goals, Health Advisories [MCLG-HAs]) to a CRA based on EPA public supply enforceable Maximum Contaminant Levels (MCLs). Based on median concentrations of 19 inorganics (antimony, arsenic, barium, beryllium, boron, cadmium, chromium, copper, fluoride, manganese, molybdenum, nickel, nitrate, lead, selenium, strontium, thallium, uranium, zinc), 75% of watersheds had MCLG-HA-based cumulative risk values > 1.0; arsenic and uranium contributed the most risk, followed by strontium, fluoride, manganese and boron. Hence, this screening level (Tier I) CRA indicated widespread potential for unrecognized human health risk to private well users from inorganic contaminants considering both carcinogenic and non-carcinogenic risks. Sensitivity analysis showed that benchmarks applied (MCLG-HAs versus MCLs) exerted the largest control on results. Our findings identify priority regions for Tier 2 risk assessments to elucidate local sources and distributions of geogenic versus anthropomorphic contaminants. Our study is the first statewide assessment of cumulative health risk from groundwater that we are aware of, and results support increased statewide drinking water education and testing to reduce human health risks from contaminated private well water.

Common adhesives for nonstructural applications are manufactured using petrochemicals and synthetic solvents. These adhesives are associated with environmental and health concerns because of their release of volatile organic compounds (VOCs). Biopolymer adhesives are an attractive alternative because of lower VOC emissions, but their strength is often insufficient. Existing mineral fillers can improve the strength of biopolymer adhesives but require the use of crosslinkers that lower process sustainability. This work introduces a novel approach to strengthen biopolymer adhesives through calcium carbonate biomineralization, which avoids the need for crosslinkers. Biomineral fillers produced by either microbially or enzymatically induced calcium carbonate precipitation (MICP and EICP, respectively) were precipitated within guar gum and soy protein biopolymers. Both, MICP and EICP, increased the strength of the biopolymer adhesives. The strength was further improved by optimizing the concentrations of bacteria, urease enzyme, and calcium. The highest strengths achieved were on par with current commercially available nonstructural adhesives. This study demonstrates the feasibility of using calcium carbonate biomineralization to improve the properties of biopolymer adhesives, which increases their potential viability as more sustainable adhesives.

BACKGROUND:High hand hygiene (HH) workload is a commonly cited barrier to optimal HH performance. The objective of this study was to assess trends of HH workload as defined by HH opportunities (HHO) and performance rates over different timescales using automated HH monitoring system data. METHODS:This multiyear retrospective observational study was conducted in 58 inpatient units located in 10 North American hospitals. HHO and HH rates were analyzed by time series mixed effects general additive model. RESULTS:Median HH rates peaked at 50.0 between 6 and 7 AM with a trough of 38.2 at 5 PM. HHO over hours in a day were the highest at 184 per hospital unit per hour at 10 AM with a trough of 49.0 between 2 and 3 AM. Median rates for day and night shifts were 40.8 and 45.5, respectively (P = .078). Weekend day shift had the lowest median rate (39.4) compared with any other 12-hour shift (P < .1018). The median rates and HHO varied little across days in a week and months. CONCLUSIONS:HH workload and performance rates were negatively correlated and changed drastically over hours in a day. Hospitals should consider HH workload in the development and timely delivery of improvement interventions.

In this study, the impacts to soil thermal properties during and after biocementation via microbially induced calcite precipitation (MICP) method on silty silica sand specimens with varying fines content (0%, 5%, and 15%) were investigated. Firstly, calcium conversion was measured after each pulse; then, the MICP-treated specimens were tested for cementation uniformity. The evolution of thermal conductivity of silty soils with the MICP treatment was assessed using a thermocouple probe. The results show that thermal conductivity of silty saturated sands increased by 17% for specimens treated to 9.7% CaCO3. The improvement in thermal conductivity was attributed to the formation of calcium carbonate bridges binding the soil grains together. The results suggested that the thermal conductivity of silty soil depends on water content, the number of treatment pulses, and the treatment uniformity through the soil specimen. Presence of fines content in the soil was found to play an important role in the distribution and uniformity of biocementation through the soil specimen. However, no statistically significant difference in the thermal conductivity values of MICP-treated specimens with different fines content was observed (p>0.05). The average calcium carbonate content ranged between 10.7% and 7.2% for the soils with 0% and 15% fines content, respectively. The findings of this research could be used to improve the efficiency of geothermal boreholes and other energy geostructures using MICP by improving thermal conductivity of dry and partially saturated soil.

The CDC Biofilm Reactor method is the standard biofilm growth protocol for the validation of US Environmental Protection Agency biofilm label claims. However, no studies have determined the effect of coupon orientation within the reactor on biofilm growth. If positional effects have a statistically significant impact on biofilm density, they should be accounted for in the experimental design. Here, we isolate and quantify biofilms from each possible coupon surface in the reactor to quantitatively determine the positional effects in the CDC Biofilm Reactor. The results showed no statistically significant differences in viable cell density across different orientations and vertical positions in the reactor. Pseudomonas aeruginosa log densities were statistically equivalent among all coupon heights and orientations. While the Staphylococcus aureus cell growth showed no statistically significant differences, the densities were not statistically equivalent among all coupon heights and orientations due to the variability in the data. Structural differences were observed between biofilms on the high-shear baffle side of the reactor compared to the lower shear glass side of the reactor. Further studies are required to determine whether biofilm susceptibility to antimicrobials differs based on structural differences attributed to orientation.

Biofilm has been implicated in multi-drug resistant organism outbreaks following endoscopic procedures. Automated Endoscope Reprocessors (AER) are devices validated to clean and disinfect endoscopes per applicable standards. The ISO 15883 part 4 standard guides performance testing validation of AERs, including cleaning performance using a biofilm test soil. The standard recommends assessment of biofilm reduction using protein or carbohydrate quantification methods. The aim of this study was to assess the suitability of various quantification methods using the ISO biofilm model.The ISO 15883 part 5 biofilm test soil method was used to grow biofilm within lumens representative of endoscopes channels. The biofilm was then quantified using five methods: Crystal Violet (CV), Colony Forming Units (CFU), Total Organic Carbon (TOC), protein assay with Orthophtalaldehyde (OPA), and protein assay by micro bicinchoninic acid (μBCA). The five methods were statistically analyzed for their ability to assess biofilm reduction on samples accurately and precisely. In addition, the quantification methods were compared to demonstrate statistical equivalency, and thus their suitability for assessing biofilm cleaning performance testing of AERs.

Abstract Background There is emerging evidence that implementation of an automated hand hygiene monitoring system (AHHMS) must be part of a multimodal hand hygiene (HH) program that includes complementary strategies. There are few published studies describing in detail the intervention strategies used with an AHHMS. Methods An AHHMS that provides group HH performance rates (100 x HH product dispenses divided by the number of room entries plus exits) was implemented on two Acute Care (AC) units and six long-term care (LTC) units at a Veterans Affairs Medical Center from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included many components, such as weekly huddles, unit nurse manager engagement, vendor provided clinician-based training and feedback, leadership support, unit recognition, signage and development of a new slogan to remind colleagues to perform HH. Statistical analysis was performed with a Poisson general additive mixed model. Results During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI: [16.5, 21.0]) for all 8 units. During the intervention period, the median HH rate increased to 21.6 [19.1, 24.4], and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 [22.2, 28.4], (p < 0.0001) [Figure 1]. The median HH rate increased from 17.5 to 20.0 (p < 0.0001) in LTC units and from 22.9 to 27.2 (p < 0.0001) in AC units. The intervention increased the use of hand sanitizer from 57.5% during baseline to 65.1% (p < 0.0001). The increase in HH rates was due to HH events increasing from 88,758 dispenses during the baseline to 123,722 dispenses during the last 4 weeks of the intervention. Direct observation results during the same periods showed HH compliance ranging from 61-86%. Figure 1- Monthly Hand Hygiene Performance Rates for all Units The green curve shows the change in the median HH rate during the intervention period compared to the baseline and washout periods, with vertical bars showing 95% confidence intervals for the monthly HH rate. Conclusion The intervention increased hand sanitizer usage and HH performance rates for all units. AC units were consistently better than LTC units, which have more visitors and more mobile veterans. Further HH improvement will rely on continued implementation of complementary strategies and long-term monitoring. Disclosures James W. Arbogast, PhD, GOJO Industries, Inc.: employee Pamela Wagner, RN MSN CPPS, GOJO Industries, Inc: Employee of GOJO Gregory A. Robbins, BS, GOJO Industries, Inc.: Current employee of GOJO Industries, Inc. Albert E. Parker, PhD, GOJO Industries: Advisor/Consultant John M. Boyce, MD, Diversey: Advisor/Consultant|Diversey: Expert Testimony|Diversey: Travel support|GOJO Industries: Advisor/Consultant|GOJO Industries: Expert Testimony|GOJO Industries: Travel support|Sodexo Healthcare: Advisor/Consultant.

Hand hygiene product usage characteristics by food employees when hand sanitizers are made available are not well understood. To investigate hand hygiene product usage in casual dining and quick-service restaurants, we placed automated monitoring soap and sanitizer dispensers side-by-side at handwash sinks used by food employees in seven restaurants. Dispenses were monitored, and multiple dispenses that occurred within 60 s of each other were considered a single hand hygiene event. This resulted in 186,998 events during the study (149,779 soap only, 21 985 sanitizer only, and 15,234 regimen [defined as soap followed by sanitizer at the same sink within 60 s]) over 15,447 days of use. Soap was the most frequently used hand hygiene method by food employees in both restaurant types. Regimen use, despite being the preferred hand hygiene method by both restaurant chains, was the least used hand hygiene method. When pooled over restaurant types, the median daily usage for soap was statistically significantly highest of all methods at 23.5 dispenses per sink per day (p < 0.0001), the sanitizer median daily usage was 4.27 dispenses per sink per day, and regimen use was statistically significantly lowest of all methods at 4.02 dispenses per sink per day (p < 0.0001). When hand hygiene event types were pooled, casual dining restaurants had similar median hand hygiene event rates (11.4 dispenses per sink per day) compared to quick-service restaurants (11.9 dispenses per sink per day; p = 0.890). The number of events by sink location varied, with sinks located at a warewash station having the highest number of events (19.3 dispenses per sink per day; p < 0.0001), while sinks located by a ready-to-eat food preparation area had the lowest number of events (6.8 dispenses per sink per day; p < 0.0001). These data provide robust baseline benchmarks for future hand hygiene intervention studies in these settings.

AbstractObjective:Although needleless connectors (NCs) are widely used in clinical practice, they carry significant risk of bloodstream infection (BSI). In this study, we quantified differences in bacterial transfer and biofilm formation between various NCs.Design:Prospective, clinically simulated in vitro experimental study.Methods:We tested 20 NCs in a 5-day clinical simulation of Staphylococcus aureus inoculations onto NC septum surfaces, which were then flushed with saline and cultured for bacterial transfer. Biofilm formation was measured through destructive sampling of the connector-catheter system. Moreover, 8 NC design factors were evaluated for their influence on bacterial transfer and biofilm formation. This study was designed without a disinfection protocol to ascertain the intrinsic risk of each NC.Results:Clave Neutron and MicroClave had the lowest overall mean log density of bacteria in the flush compared to other NCs (P < .05), except there were no statistically significant differences between Clave Neutron, Microclave, SafeTouch, and SafeAccess (P ≥ .05). The amount of biofilm in the NC was positively associated with bacteria in the flush (P < .0005). Among 8 design factors, flow path was most important, with the internal cannula associated with a statistically significant 1 log reduction (LR) in bacteria in the flush (R2 = 49%) and 0.5–2 LR in the connector (R2 = 34%). All factors together best explained bacteria in the flush (R2 = 65%) and biofilm in the connector (R2 = 48%).Conclusions:Bacterial transfer and biofilm formation in the connector-catheter system varied statistically significantly between the 20 NCs, suggesting that NC choice can lower the risk of developing catheter-related BSIs.

Sample size formulas are provided to determine how many events and how many patient care units are needed to estimate the sensitivity of a monitoring system. The monitoring systems we consider generate time series binary data that are autocorrelated and clustered by patient care units. Our application of interest is an automated hand hygiene monitoring system that assesses whether healthcare workers perform hand hygiene when they should. We apply an autoregressive order 1 mixed effects logistic regression model to determine sample sizes that allow the sensitivity of the monitoring system to be estimated at a specified confidence level and margin of error. This model overcomes a major limitation of simpler approaches that fail to provide confidence intervals with the specified levels of confidence when the sensitivity of the monitoring system is above 90%.

Aims: Microbial samples are often serially diluted to estimate the number of microbes in a sample, whether as colony-forming units of bacteria or algae, plaque forming units of viruses, or cells under a microscope. There are at least three possible definitions for the limit of detection (LOD) for dilution series counts in microbiology. The statistical definition that we explore is that the LOD is the number of microbes in a sample that can be detected with high probability (commonly 0.95).Methods and results: Our approach extends results from the field of chemistry using the negative binomial distribution that overcomes the simplistic assumption that counts are Poisson. The LOD is a function of statistical power (one minus the rate of false negatives), the amount of overdispersion compared to Poisson counts, the lowest countable dilution, the volume plated, and the number of independent samples. We illustrate our methods using a data set from Pseudomonas aeruginosa biofilms. Conclusions: The techniques presented here can be applied to determine the LOD for any counting process in any field of science whenever only zero counts are observed. Significance and impact of study: We define the LOD when counting microbes from dilution experiments. The practical and accessible calculation of the LOD will allow for a more confident accounting of how many microbes can be detected in a sample.

During the growth of a polycrystalline ice lattice, microorganisms partition into veins, forming an ice vein network highly concentrated in salts and microbial cells. We used microfabricated electrochemical impedance spectroscopy (EIS) sensors to determine the effect of microorganisms on the electrochemical properties of ice. Solutions analyzed consisted of a 176 μ S cm −1 conductivity solution, fluorescent beads, and Escherichia coli HB101-GFP to model biotic organisms. Impedance spectroscopy data were collected at −10 °C, −20 °C, and −25 °C within either ice veins or ice grains (i.e., no veins) spanning the sensors. After freezing, the fluorescent beads and E. coli were partitioned into the ice veins. The corresponding impedance data were discernibly different in the presence of ice veins and microbial impurities. The presence of microbial cells in ice veins was evident by decreased electrical characteristics (electrode polarization between electrode and ice matrix) relative to solid ice grains. Further, this electrochemical behavior was reversed in all bead-doped solutions, indicating that microbial processes influence sensor response. Linear mixed-effects models empirically corroborated the differences in polarization associated with the presence and absence of microbial cells in ice. We show that EIS has the potential to detect microbes in ice and differentiate between veins and solid grains.

AbstractObjective:To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates.Design:Prospective, before-and-after, controlled observational study.Setting:The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals.Methods:HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1–2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives.Results:Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001).Conclusions:AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.

Biofilm methods consist of four distinct steps: growing the biofilm in a relevant model, treating the mature biofilm, harvesting the biofilm from the surface and disaggregating the clumps, and analyzing the sample. Of the four steps, harvesting and disaggregation are the least studied but nonetheless critical when considering the potential for test bias. This article demonstrates commonly used harvesting and disaggregation techniques for biofilm grown on three different surfaces. The three biofilm harvesting and disaggregation techniques, gleaned from an extensive literature review, include vortexing and sonication, scraping and homogenization, and scraping, vortexing and sonication. Two surface types are considered: hard non-porous (polycarbonate and borosilicate glass) and porous (silicone). Additionally, we provide recommendations for the minimum information that should be included when reporting the harvesting technique followed and an accompanying method to check for bias.

AIM:To assess removal versus kill efficacies of antimicrobial treatments against thick biofilms with statistical confidence.METHODS AND RESULTS:A photo-activated chlorine dioxide treatment (Photo ClO2 ) was tested in two independent experiments against thick (>100 μm) Pseudomonas aeruginosa biofilms. Kill efficacy was assessed by viable plate counts. Removal efficacy was assessed by 3D confocal scanning laser microscope imaging (CSLM). Biovolumes were calculated using an image analysis approach that models the penetration limitation of the laser into thick biofilms using Beer's Law. Error bars are provided that account for the spatial correlation of the biofilm's surface. The responsiveness of the biovolumes and plate counts to the increasing contact time of Photo ClO2 were quite different, with a massive 7 log reduction in viable cells (95% confidence interval [CI]: 6.2, 7.9) but a more moderate 73% reduction in biovolume (95% CI: [60%, 100%]). Results are leveraged to quantitatively assess candidate CSLM experimental designs of thick biofilms.CONCLUSIONS:Photo ClO2 kills biofilm bacteria but only partially removes the biofilm from the surface. To maximize statistical confidence in assessing removal, imaging experiments should use fewer pixels in each z-slice, and more importantly, at least two independent experiments even if there is only a single field of view in each experiment.SIGNIFICANCE AND IMPACT OF STUDY:There is limited penetration depth when collecting 3D confocal images of thick biofilms. Removal can be assessed by optimally fitting Beer's Law to all of the intensities in a 3D image and by accounting for the spatial correlation of the biofilm's surface. For thick biofilms, other image analysis approaches are biased or do not provide error bars. We generate unbiased estimates of removal and assess candidate CSLM experimental designs of thick biofilms with different pixilations, numbers of fields of view and number of experiments using the included design tool.

In this paper we investigate the convexity of the relevance-compression function for the Information Bottleneck and the Information Distortion problems. This curve is an analog of the rate-distortion curve, which is convex. In the problems we discuss in this paper, the distortion function is not a linear function of the quantizer, and the relevance-compression function is not necessarily convex (concave), but can change its convexity. We relate this phenomena with existence of first order phase transitions in the corresponding Lagrangian as a function of the annealing parameter.

The Big Hole River basin in southwestern Montana supports the only indigenous, self-sustaining fluvial population of Arctic Grayling Thymallus arcticus in the conterminous United States, but the basin is fragmented by numerous low-head irrigation diversion dams. Denil fishways at 63 diversion dams provide Arctic Grayling and other fishes opportunities for year-round access to critical habitats; however, their efficiency has not been evaluated. We quantified attraction, entrance, and passage for hatchery-reared Arctic Grayling, wild trout (Brook Trout Salvelinus fontinalis and Brown Trout Salmo trutta), and wild suckers (White Sucker Catostomus commersonii and Longnose Sucker C. catostomus) during 14 field trials conducted at six Denil fishways over a representative range of fishway slopes and hydraulic conditions using passive integrated transponder telemetry. Attraction (60.4-84.3%) and entrance (44.3-78.6%) efficiencies were variable across test conditions and reduced overall fishway efficiencies (19.1-55.8%). In contrast, upon entry, passage efficiencies were high (96.2-97.0%) for all taxa across all test conditions. Attraction of hatchery-reared Arctic Grayling increased with upstream depth (a surrogate for fishway discharge) and attraction flow, but attraction of wild fish was less affected by these conditions. Entrance of Arctic Grayling, Brook Trout, and Brown Trout decreased with upstream depth and fishway slope, especially when plunging entrance conditions associated with shallow downstream depths were present. However, entrance of Arctic Grayling and both trout species increased with downstream depth, and submerged fishway entrances demonstrated promise for increasing entrance efficiency at fishways with high discharges and steep slopes. We demonstrate that comprehensive evaluations of fishway efficiency components can identify specific solutions that improve fishway efficiency; application of these engineering solutions at individual fishways (as needed) could improve their efficiency and further enhance aquatic connectivity for fishes in the Big Hole River basin and elsewhere.

The development, validation, and use of new quantitative methodologies for testing the effectiveness of antimicrobial products are necessary to meet the regulatory challenges associated with an ever-changing marketplace, novel product claims, new infection control practices, and the emergence of new clinical pathogens. A series of four interlaboratory studies were conducted in a standardized manner on an interim quantitative method for testing liquid treatments against bacteria to assess its statistical performance. The Quantitative Method, a derivative of ASTM E2197, is designed to enumerate the number of viable microbes remaining on a test carrier following exposure to a liquid antimicrobial treatment; a log10 reduction (LR) in viable bacteria is calculated based on the difference between the mean log(10) density values of the untreated control and treated carriers. The Quantitative Method uses 1 cm diameter disks (carriers) of brushed stainless steel as the material to represent a hard, non-porous surface. The LR value is used as the measure of product effectiveness, where higher LR values are indicative of greater microbial kill. The test microbes were Staphylococcus aureus, Pseudomonas aeruginosa, and Mycobacterium terrae. The liquid antimicrobial treatments used in these studies were highly relevant to those in the marketplace and provided a wide range of mean LR outcomes. The focus of the statistical assessment was on the repeatability of the LRs across experiments within a lab (Sr) and the reproducibility of the LRs across labs (SR). Due to the additional sources of variability, the S-R is expected to be higher than the variability within a laboratory (Sr); this was observed in the studies reported here. Across the studies, the Sr values for LR were small (i.e., less than 0.84), most notably for treatments generating high mean LRs (5 or above) where the Sr was as small as 0.12. Overall, the S-R values ranged from 0.227 to 1.217. Only three of the twenty-four treatment combinations over the study period resulted in SR values above 1.0 - the associated LRs for the three treatments ranged from 2.22 to 3.26. Antimicrobial treatments with a LR of 4.5 or higher exhibited SR of 0.561 or less. The statistical attributes reported here for the draft Quantitative Method when used to test P. aeruginosa, S. aureus, and M. terrae provide information for decision makers when considering the method as a candidate regulatory procedure. The data and statistical analyses contained in this report are historical in nature and provide useful baseline information for individuals conducting additional technical review of the method. Based on the data, the Quantitative Method displays a statistical profile consistent with other standard methods approved by standard-setting organizations where method performance data are available.