CDC: Ionization not 'best strategy' for preventing Legionnaires'
By Adam Smeltz
Published: Thursday, Nov. 29, 2012, 12:01 a.m.
A popular ionization technology meant to prevent Legionnaires' disease in the VA Pittsburgh Healthcare System and other major hospitals has no recommendation from the Centers for Disease Control and Prevention, the federal agency said.
CDC officials in Atlanta endorse no system to prevent Legionnaires' but for several years have suggested chlorinated products — not ionization — as “the best strategy” for keeping Legionella bacteria out of hospital water supplies, spokeswoman Alison Patti said.
“Other hospitals with (ionization) systems should carefully review their continued usage of this system,” she wrote in an email.
The VA University Drive Campus in Oakland, which confirmed five Legionnaires' cases this month, in 1993 was one of the first in the country to adopt the copper-silver ionization method to safeguard its water from the bacteria. Now a dominant disinfection system across the United States, copper-silver puts charged molecules into piped water before it reaches hospital taps.
A CDC review of the Oakland outbreak is unfinished. Four patients who developed pneumonia from Legionella were successfully treated. VA spokesman Dave Cowgill would not release the status of the fifth patient, citing federal privacy rules.
Sen. Bob Casey Jr. on Wednesday asked the VA to outline protocols that safeguard water supplies and to prevent repeat episodes.
He said the outbreak “could have been prevented had the VA been appropriately monitoring its water-purification system,” according to a letter Casey, D-Scranton, wrote to VA Secretary Eric K. Shinseki.
Other VA facilities and West Penn Allegheny Health System use copper-silver, health officials said. UPMC, the region's largest hospital system, did not comment.
“The successful marketing of the product, I think, had to do with how it was pitched,” said Tim Keane, a water-systems consultant with 26 years in the field.
Sales forces pitching copper-silver to hospitals benefitted from research papers by Dr. Victor Yu, an epidemiologist, and microbiology researcher Janet E. Stout, two former Pittsburgh VA workers who found the method effective and advocated it in the Oakland hospital.
Yu and Stout led groundbreaking research at the Pittsburgh VA in the early 1980s to identify water systems as a key transmission source for Legionnaires', which got its name from a deadly outbreak at the 1976 American Legion convention in Philadelphia. Earlier research focused on cooling towers and air-conditioning systems.
That the Pittsburgh VA now has a Legionnaires' outbreak “is a paradox of paradoxes,” said Dr. Dennis G. Maki, a professor of medicine at the University of Wisconsin who studies hospital-acquired infections.
Yu said 16 early adopters of copper-silver agreed it works well and recorded just one Legionnaires' case among them in seven years. All had reported cases before installing copper-silver systems, and five switched from chlorination to ionization, he said.
Chlorine can corrode plumbing and yield compounds linked to cancer, Yu said.
Legionnaires' cases originating at the University of Wisconsin Hospital in Madison dropped to zero, from one or two a year, after it installed a copper-silver system about 20 years ago, Maki said. He was “sort of shocked” by the CDC position on Legionnaires' prevention, citing what he believes to be scant data on the long-term effectiveness of chlorination methods.
“There's quite a bit of long-term data on copper-silver,” said Maki, a professor of medicine who studies hospital-acquired infections.
Legionella counts increased in the Madison hospital when electrodes in the copper-silver system burned out, Maki said, underscoring the need to monitor the technology. Maki said some reports suggest growing Legionella resistance to copper-silver treatments, “but we've not seen it.”
“It's unquestionable that copper-silver is the most widely used disinfection modality in the world,” said Yu, a University of Pittsburgh professor of medicine.
His work with Pitt researcher Stout, the director of the Special Pathogens Laboratory in Uptown, found copper-silver failures typically stem from incomplete system maintenance or monitoring practices.
Yu and Stout left the VA about five years ago in a disagreement with department leadership. They believe the Oakland VA Legionnaires' outbreak was preventable.
“All it would have required was a commitment by the institution to staff it, monitor it and maintain the system just like any other hospital equipment,” Stout said. “Rather than blame the technology, what we'd like to see the VA do is investigate the root cause for that failure so that it can be prevented in the future.”
Cowgill would not respond to their assessment. Earlier, the VA conceded its ionization system in Oakland “may not be as effective as previously thought, as is the case in other health systems using this method.
“Consequently, we are shifting to a chlorination system to ensure better control,” the VA said in an emailed statement.
Cowgill did not respond to questions about the prices paid for the chlorination and ionization systems.
The national VA does not endorse the use of any particular system, said spokesman Mark Ballesteros.
The agency “does not have any information about other Legionella disease cases connected or potentially connected to improper maintenance of copper-silver ionization systems,” he said.
An anonymous complaint filed with the Department of Labor expressed concern about whether VA employees in Oakland could face Legionella exposure, too, AFGE Local 2028 President Kathi Dahl said. She learned of the complaint on Monday.
The VA detailed short-term fixes, including secondary water sources and shower-head filters, in a response to the complaint, she said.
“I think they're taking every effort — maybe going above and beyond — to maintain safety, both for the patients and the employees,” Dahl said of VA leaders.
Patti, the CDC spokeswoman, said the centers recommended hyperchlorinating and superheating to kill any lingering Legionella bacteria at the hospital. The government has “thorough, conclusive data” showing chlorine inhibits Legionella in complex plumbing systems, she said.
“But the studies we've seen that review the use of copper-silver to inhibit Legionella growth are not robust enough to make any public health recommendations,” she said. “And we regularly receive calls from health care facilities who are unable to control Legionella using copper-silver.”
Chlorinated approaches are the least expensive and probably the most effective, said Keane, who owns Legionella Risk Management in Bucks County.
Keane, who once worked for a chlorine-dioxide company, called copper-silver systems “essentially just a waste of money” in large plumbing networks.
They can cost $30,000 to $50,000 up front, then $10,000 to $25,000 per year to operate, Keane estimated. He said chlorine system may cost $6,000 to start, with fewer than $1,000 in annual operating expenses. Chlorine dioxide may run about $30,000 to start and perhaps $10,000 to $15,000 for annual operations.
Adam Smeltz is a staff writer for Trib Total Media. He can be reached at 412-380-5676 or firstname.lastname@example.org.
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