WATER HYGIENE & SAFETY
Loebinger conducted by April Cashin- Garbutt, MA (Cantab), showed an increase in the number of NTM isolates from 137 in 2000 to 759 in the 2013.7
The increase in
NTM bacteria may be due to the increase in elderly population, a rise in the number of people with chronic lung disease and underlying diseases, and the fact that we are getting better at killing other bugs, and so NTM have less competition. It is widely acknowledged that NTM
In the NTM outbreak of Mycobacterium abscessus at the Royal Papworth Hospital in 2019, the subsequent investigation confirmed water supply as the source.
in removing build-up of phlegm trapped in the lungs.4
Chest physiotherapy and
regular exercise can help NTM infections go away without treatment, but it can take a long time to kill all the NTM bacteria, so infected patients may need to treated for a year or two. If one takes all one’s medication correctly, and as prescribed, the infection should resolve. However, it is possible to re-contract an NTM infection, especially if the medication prescribed is not taken regularly. The bacteria can also become resistant to the antibiotics being taken, making the infection much harder to treat. Adding to the difficulties, the bacteria can still exist even after samples come back negative. NTM infections are not thought to be transmissible between individuals except in very specific circumstances (for example, M. abscessus infection can pass between people with cystic fibrosis). To reduce the risk of cross-infection, it is sensible to adopt good hygiene precautions, such as coughing into a tissue and disposing of it in a covered bin.5 When commencing treatment of an individual, often you will be trying to get rid of the microbe. In some patients, either due to a lack of tolerance of particular drugs, the drugs’ lack of effectiveness, or the fact that the disease is too severe, the aim may rather be to keep the patient stable in the knowledge that while you may not actually eliminate the bacteria, you may prevent further lung damage. Water safety in UK healthcare is
Karina Jones
Karina Jones MIHEEM, MIET, MWMSoc, MWES, of Eta Projects, is an IHEEM-registered Authorising Engineer (Water), and a member of the Institute’s Water Technical Platform. She has extensive water management experience. She provides independent advice to clients across a range of industries, but specialises in healthcare. She is also a member of the Water Management Society, the Institution of Engineering and Technology, and the Women’s Engineering Society (MWES). She has considerable experience providing advice on
water hygiene management, advising clients on the legal drivers for statutory obligations and ACoP L8 compliance, and providing comprehensive guidance on microbiological waterborne contamination to NHS Trusts across the country.
regulated by the Health and Safety Executive, with the consent of the Secretary of State for Health, who has approved the Code of Practice ACoP L8,6
which gives
clear guidance on how to comply with the law. Health Technical Memorandum (HTM) 04-01, issued by the Department of Health & Social Care, also sets clear guidelines on good water quality management. However, none of the aforementioned guidance covers the management or control of NTM bacteria in healthcare. The Health and Safety Executive (HSE) provides a list in the Approved List of biological agents – Advisory Committee on Dangerous Pathogens (Third edition 2013) of a range of pathogens that fall under the high-risk category.6
This list
includes a wide range of Mycobacteria, including one mentioned earlier – Mycobacterium scrofulaceum (pathogen hazard group 3. Vaccine available). Mycobacterium scrofulaceum is a slow- growing, Nontuberculous Mycobacterium that belongs to the Mycobacterium avium complex.
Preventing the bacterium taking hold With the information that is available to us, how can we prevent or control this bacterium from taking hold in our domestic water systems within healthcare; can we prevent the bacteria entering our water distribution system? The latest study reported via the News Medical Life Science interview with Dr Michael
bacteria in patients are proving to be difficult to treat, and with this in mind and referring to the outbreak of Mycobacterium abscessus at the Royal Papworth Hospital in 2019 mentioned earlier, once we know that the bacteria are present in the water system, we should prevent the contamination reaching our patients wherever possible. This is normally achieved by implementing the correct point-of-use filtration at our water outlets (taps, showers). It is very important to ensure the filtration product used is of a type that will remove the NTM bacterium, as not all POU filters developed take this bacterium into consideration. Water filters must be specifically
tested on their retention of NTMs, rather than simply based on the theory that if Legionella / Pseudomonas aeruginosa bacteria are removed, then NTM bacteria should be too. Therefore, only filters on the market that have been tested against NTMs and provide 100% absolute retention guarantee, including a validation guide, should be considered.
References 1 Mycobacterium abscessus, Royal Papworth Hospital NHS Foundation Trust.
https://royalpapworth.nhs.uk/ mycobacterium-abscessus
2 Nontuberculous Mycobacteria. Aksamit T, Carreon M, Daley CL, Griffith DE, Levinger A, Estrada-Y-Martin RM. CHEST Foundation, 22 April 2021. https://tinyurl. com/4v3twua6
3 Mycobacterial skin infections National Jewish Health. Reviewed by Shannon H. Kasperbauer, MD. 1 July 2017) https://
tinyurl.com/uc8skuc9
4 Patient Information. For patients with Nontuberculous Mycobacterium infections (NTM). Worcestershire Acute Hospitals NHS Trust. https://tinyurl. com/48s6uh53
5 Non-tuberculous mycobacterial infection (NTM). Asthma + Lung UK. https://
tinyurl.com/22bh5crd
6 The Approved List of biological agents. Advisory Committee on Dangerous pathogens. Health & Safety Executive 2000.
https://www.hse.gov.uk/pubns/ misc208.pdf
7 NTM lung infections. Cashin-Garbutt A.
News-Medical.net. 23 November 2016.
https://www.news-medical.net/ news/20161123/
NTM-lung-infections.aspx
October 2023 Health Estate Journal 31
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