GTS Legionella Water Testing Lab

Maryland sets guidelines on disease Water tests urged for Legionnaires' Disease

Putting Maryland at the forefront nationwide in dealing with Legionnaire's disease, state health officials are calling on hospitals to step up their monitoring and prevention efforts.

A task force report released yesterday recommends that hospitals routinely test their water systems for the legionella bacteria, that doctors have quick access to diagnostic tests, and that hospitals set up Legionnaire's teams.

The state health secretary, Dr. Georges Benjamin, appointed the task force last summer, after a series of Baltimore-area cases. The group's report has been awaited by public health officials around the country because of conflicting opinions about how hospitals should handle the issue.

For years, the U.S. Centers for Disease Control and Prevention has recommended against routine water testing; instead, CDC officials call for testing after a case is discovered. But some public health advocates say that is too late.

In the absence of a consensus, two areas, New York and Pittsburgh, have created guidelines. California and Texas are working on their versions. But experts say many places, including European countries, have been waiting for Maryland's study because it is considered the most comprehensive review.

During the past year, the task force considered all the scientific evidence, brought in top experts and held heated debates. Their unanimous conclusion: Hospitals need to be more aggressive.

"You're better off attempting to prevent disease than reacting to disease once it occurs," said Dr. Glenn Morris Jr., who headed the task force and is chair of the department of epidemiology and preventive medicine at the University of Maryland School of Medicine.

The CDC's expert was unavailable yesterday, but spokesman Tom Skinner said the agency's guidelines were based on the most current scientific information available.

The agency's guidelines, last updated in 1997, note that hospitals' water systems are often colonized by the bacteria, and that it is unclear what level is dangerous. CDC officials have also expressed the fear that negative test results would give physicians a false sense of security.

Dr. Victor Yu, a professor of medicine at the University of Pittsburgh and one of the top Legionnaire's experts in the country, said tests have shown that the higher the levels of bacteria, the higher the risk. A longtime advocate of routine testing, he hailed Maryland's effort. "The entire country is watching Maryland on this," Yu said. "The guidelines are highly sophisticated. I think right now, they're the best guidelines."

Legionella bacteria can cause mild respiratory illness or, in people with serious health problems, a deadly pneumonia known as Legionnaire's disease. Spread when people breathe in the mist from showers and air conditioners, the bacteria can live in virtually any setting where people are exposed to water and water systems.

The task force focused on hospitals, because the illness is most likely to occur among people with compromised immune systems, such as transplant patients.

From 1990 to 1999, 366 Legionnaire's cases were reported to the state, including four deaths in Harford County last summer. Nationwide, 10,000 to 20,000 Americans get Legionnaire's disease each year, according to CDC estimates. Up to 40 percent of these patients die, but physicians say they could be saved. "The mortality is close to zero if you pick it up right away," said Yu.

Because most hospitals don't routinely test their water supply, the cases can be missed.

According to a survey of Maryland hospitals conducted by the task force, only 23 percent of 47 hospitals had in-house testing available for the bacteria. Thirty-four percent performed routine legionella testing on hot water systems, and 62 percent regularly tested the cooling towers.

According to the report, though, more than half of the hospitals doing routine water testing initiated it after the well-publicized cases at Harford Memorial Hospital last summer.

Also, until recently, Johns Hopkins Hospital and the University of Maryland Medical Center, which care for some of the most vulnerable patients, had to send out legionella lab tests and wait for results, Morris said. The delay could affect treatment - and make a difference in whether an outbreak is detected, he said.

Both hospitals have since instituted in-house testing and are in compliance with the report's key recommendations, said Morris. The task force calls for each hospital to judge how often it should test its water based on its own risk -whether it has transplant patients, how old its physical plant is, and other factors. At Harford Memorial Hospital, where three of the deaths occurred last summer, officials also started routine testing and treating of the water.

The report also called for labs to report Legionnaire's cases directly to local health departments, and hot water temperature limits to be raised from 110 to 122.

The Maryland Hospital Association's working group on infection control has reviewed the report, said spokeswoman Nancy Fiedler, and its preliminary reaction was positive.

In coming months, Benjamin will be working with the association to implement the guidelines. It is unclear whether laws will have to be changed.