WATER HYGIENE & SAFETY


NTM – How do we mitigate against it and control it?


Karina Jones of Eta Projects, an IHEEM-registered Authorising Engineer (Water), takes a look at some of the health risks from growth and proliferation of Nontuberculous Mycobacteria – which she explains are ‘ubiquitous in the environment’ – and some of the key steps to lower them, and thus reduce the chances of infection.


I have been aware of Nontuberculous Mycobacteria (NTM) for some time, but three years ago I still knew relatively little of the bacteria’s key characteristics, since the majority of our attention in healthcare water system environments is focused on Legionella and Pseudomonas aeruginosa bacteria. However, when I was informed about the NTM outbreak of Mycobacterium abscessus at the Royal Papworth Hospital in 2019,1


and the fact that the investigation


confirmed water supply as the source, this further awakened my interest, and I felt that I needed to understand how this bacterium can affect our heath and how (if at all) we can control it.


Ubiquitous in the environment Nontuberculous mycobacteria, shortened to NTM, are ubiquitous in the environment, and are bacteria found in soil, dust, and water, including natural water sources (such as lakes, rivers, and streams) and municipal water sources (such as water that people drink or shower in).2


As with


the majority of bacteria, there can be many different strains; in fact there are approximately 180 strains of NTM bacteria and more than 170 different species. The history of this bacterium dates to the 19th century, when ‘tuberculosis’ in chickens was first described, in 1868.3


In


1890, this organism was recognised in the laboratory to be distinct, or different from, M. tuberculosis, the cause of tuberculosis. The organism which caused disease in chickens was later identified as M. avium. Because this organism did not cause characteristic disease when injected into guinea pigs, it was recognised as distinct from M. tuberculosis, and was not believed to cause disease in humans until the 1930s. In 1943 a man with underlying silicosis (a


form of lung disease) was the first cases of lung disease due to M. avium complex, and by the 1950s, pulmonary disease due to NTM became more commonly recognized. It is worth mentioning that under the


microscope, nontuberculous mycobacteria and tuberculosis appear very similar. Most


30 Health Estate Journal October 2023


We know that NTM bacteria can enter people’s lungs and other organs naturally through exposure in the environment, and are particularly likely to affect patients and / or people who are immunocompromised.


laboratories are capable of distinguishing between tuberculosis and nontuberculous mycobacteria, but fewer are equipped to determine exactly which NTM organism it might be, and its susceptibility to antibiotics, and of course it is important to be able to determine the difference to offer the optimal treatment for NTM. The importance of precisely identifying


the organism present can be illustrated with Mycobacterium gordonae and Mycobacterium scrofulaceum. While the two are very similar, and react the same way in many lab tests, they react in different ways in the human body; one organism causes disease; the other does not. Bacteria are more prevalent when human immunodeficiency is heightened, for instance when somebody is exposed to virus and various forms of illnesses. In the case of virus (such as HIV), the patient’s infection is distributed throughout the body, affecting skin, soft tissues, and bones/joints. We should thus always approach bacteria that can cause illness with the upmost care, striving to understand its characteristics, so that we are better able to control it, and – where possible – to eliminate the bacteria from the route of exposure. We know that NTM bacteria can enter people’s lungs and other organs naturally through exposure


in the environment, and are particularly likely to affect patients and/or people who are immunocompromised. While the microorganism is not usually harmful to the general population, it can cause lung infections in some individuals who already have specific underlying respiratory conditions. Knowing the path that the bacteria can take to enter our bodies is beneficial, in that makes us more aware of the high-risk areas (hospitals, clinics, augmented care and other high-risk (such as ICU and ITU) settings), and of the degree of risk that patients are exposed to.


Specific risk assessments These areas should undergo a specific risk assessment (especially if NTM has been found to be present) with a view to ensuring that sound hygiene practices and effective water system management are in place, enabling us to concentrate our efforts to address the contamination. Why – you may ask – is all of this is so important? When a person is affected by NTM bacteria, treatment is not always needed, but when it is, it can be via a combination of antibiotics, administered intravenously (through a vein) and orally (swallowed), and unfortunately this treatment may need to be prescribed for a prolonged period due to the difficulty


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