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The Flint Water Crisis-due to changes of water source and treatment procedures-has revealed many unsolved social, environmental, and public health problems for US drinking water, including opportunistic premise plumbing pathogens (OPPP). The true health impact of OPPP, especially in vulnerable populations such as the elderly, is largely unknown. We explored 10 8 claims in the largest US national uniformly collected data repository to determine rates and costs of OPPP-related hospitalizations. In 1991-2006, 617,291 cases of three selected OPPP infections resulted in the elderly alone of $0.6 billion USD per year of payments. Antibiotic resistance significantly increased OPPP illness costs that are likely to be underreported. More precise estimates for OPPP burdens could be obtained if better clinical, microbiological, administrative, and environmental monitoring data were cross-linked. An urgent dialog across governmental and disciplinary divides, and studies on preventing OPPP through drinking water exposure, are warranted.

Problem/condition: Since 1971, CDC, the U.S. Environmental Protection Agency (EPA), and the Council of State and Territorial Epidemiologists have maintained a collaborative Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data related to occurrences and causes of waterborne-disease outbreaks (WBDOs) and cases of waterborne disease. This surveillance system is the primary source of data concerning the scope and effects of waterborne disease in the United States., Reporting Period: Data presented summarize 28 WBDOs that occurred during January 2005--December 2006 and four previously unreported WBDOs that occurred during 1979--2002., Description of System: The surveillance system includes data on WBDOs associated with recreational water, drinking water, water not intended for drinking (WNID) (excluding recreational water), and water use of unknown intent. Public health departments in the states, territories, localities, and Freely Associated States (FAS) (i.e., the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau, formerly parts of the U.S.-administered Trust Territory of the Pacific Islands) are primarily responsible for detecting and investigating WBDOs and voluntarily reporting them to CDC by a standard form. Only cases and outbreaks associated with drinking water, WNID (excluding recreational water), and water of unknown intent (WUI) are summarized in this report. Cases and outbreaks associated with recreational water are reported in a separate Surveillance Summary., Results: Fourteen states reported 28 WBDOs that occurred during 2005--2006: a total of 20 were associated with drinking water, six were associated with WNID, and two were associated with WUI. The 20 drinking water-associated WBDOs caused illness among an estimated 612 persons and were linked to four deaths. Etiologic agents were identified in 18 (90.0%) of the drinking water-associated WBDOs. Among the 18 WBDOs with identified pathogens, 12 (66.7%) were associated with bacteria, three (16.7%) with viruses, two (11.1%) with parasites, and one (5.6%) mixed WBDO with both bacteria and viruses. In both WBDOs where the etiology was not determined, norovirus was the suspected etiology. Of the 20 drinking water WBDOs, 10 (50) were outbreaks of acute respiratory illness (ARI), nine (45%) were outbreaks of acute gastrointestinal illness (AGI), and one (5.0%) was an outbreak of hepatitis. All WBDOs of ARI were caused by Legionella, and this is the first reporting period in which the proportion of ARI WBDOs has surpassed that of AGI WBDOs since the reporting of Legionella WBDOs was initiated in 2001. A total of 23 deficiencies were cited in the 20 WBDOs associated with drinking water: 12 (52.2%) deficiencies fell under the classification NWU/POU (deficiencies occurred at points not under the jurisdiction of a water utility or at the point-of-use), 10 (43.5%) deficiencies fell under the classification SWTDs (contamination at or in the source water, treatment facility, or distribution system), and for one (4.3%) deficiency, classification was unknown. Among the 12 NWU/POU deficiencies, 10 (83.3%) involved Legionella spp. in the drinking water system. The most frequently cited SWTD deficiencies were associated with a treatment deficiency (n = four [40.0%]) and untreated ground water (n = four [40.0%]). Three of the four WBDOs with treatment deficiencies used ground water sources., Interpretation: Approximately half (52.2%) of the drinking water deficiencies occurred outside the jurisdiction of a water utility. The majority of these WBDOs were associated with Legionella spp, which suggests that increased attention should be targeted towards reducing illness risks associated with Legionella spp. Nearly all of WBDOs associated with SWTD deficiencies occurred in systems using ground water. EPA's new Ground Water Rule might prevent similar outbreaks in the future in public water systems., Public Health Actions: CDC and EPA use surveillance data to identify the types of water systems, deficiencies, and etiologic agents associated with WBDOs and to evaluate the adequacy of current technologies and practices for providing safe drinking water. Surveillance data also are used to establish research priorities, which can lead to improved water-quality regulation development. The majority of drinking water deficiencies are now associated with contamination at points outside the jurisdiction of public water systems (e.g., regrowth of Legionella spp. in hot water systems) and water contamination that might not be regulated by EPA (e.g., contamination of tap water at the POU). Improved education of consumers and plumbers might help address these risk factors.

Background and Objectives: Hospital-acquired legionnaires' disease can be prevented by disinfection of hospital water systems. This study assessed the long-term efficacy of copper-silver ionization as a disinfection method in controlling Legionella in hospital water systems and reducing the incidence of hospital-acquired legionnaires' disease. A standardized, evidence-based approach to assist hospitals with decision making concerning the possible purchase of a disinfection system is presented., Design: The first 16 hospitals to install copper-silver ionization systems for Legionella disinfection were surveyed. Surveys conducted in 1995 and 2000 documented the experiences of the hospitals with maintenance of the system, contamination of water with Legionella, and occurrence of hospital-acquired legionnaires' disease. All were acute care hospitals with a mean of 435 beds., Results: All 16 hospitals reported cases of hospital-acquired legionnaires' disease prior to installing the copper-silver ionization system. Seventy-five percent had previously attempted other disinfection methods including superheat and flush, ultraviolet light, and hyperchlorination. By 2000, the ionization systems had been operational from 5 to 11 years. Prior to installation, 47% of the hospitals reported that more than 30% of distal water sites yielded Legionella. In 1995, after installation, 50% of the hospitals reported 0% positivity, and 43% still reported 0% in 2000. Moreover, no cases of hospital-acquired legionnaires' disease have occurred in any hospital since 1995., Conclusions: This study represents the final step in a proposed 4-step evaluation process of disinfection systems that includes (1) demonstrated efficacy of Legionella eradication in vitro using laboratory assays, (2) anecdotal experiences in preventing legionnaires' disease in individual hospitals, (3) controlled studies in individual hospitals, and (4) validation in confirmatory reports from multiple hospitals during a prolonged time (5 to 11 years in this study). Copper-silver ionization is now the only disinfection modality to have fulfilled all four evaluation criteria.

Objectives: To determine whether a newly-constructed long-term care facility would become colonized with Legionella and whether Legionnaires' disease would occur in residents of this new facility., Design: Prospective environmental surveillance of the hospital's water distribution system for the presence of Legionella pneumophila during construction. Utilization of diagnostic tests for Legionnaires' disease in cases of nosocomial pneumonia., Setting: The Pittsburgh VA Health Care System, Aspinwall Division, a two-building 400-bed complex., Participants: Six patients who acquired Legionnaires' disease while in the facility., Intervention: Installation of copper-silver ionization systems., Measurements: Isolation of L. pneumophila from potable water and the occurrence of Legionnaires' disease., Results: L. pneumophila serogroup 1 was recovered from the water distribution system within 1 month of operation; 74% (61/82) of distal sites were positive during construction. In the first 2 years of occupancy, six cases of legionellosis were diagnosed. Both clinical isolates of L. pneumophila were identical to environmental isolates by pulsed field gel electrophoresis (PFGE). Copper-silver ionization systems were installed to control Legionella in the water system., Conclusions: We conclude that long-term care residents are at risk for acquiring nosocomial Legionnaires' disease in the presence of a colonized water system, even in a newly constructed building.

At present, 11 different species of Legionella have been implicated in human disease. It has become apparent that disease caused by Legionella is acquired from a variety of environmental sources and that water is the factor that links many of them. Patients who are immunosuppressed, such as individuals receiving cancer chemotherapy or therapy designed to prevent organ rejection, are particularly susceptible to such environmental sources. It appears that intact cell-mediated immunity is more important in host defense than are adequate numbers of granulocytes or immunoglobulin concentrations. Diagnostic steps should be undertaken in all patients developing nosocomial pneumonia who present with a picture suspicious for this disorder. In the meantime, appropriate antimicrobial therapy with erythromycin and rifampin should be begun. If clusters of cases are detected in a hospital, immediate steps should be taken to attempt to isolate the organism from any aqueous environmental sources, and if found appropriate, steps taken. Awareness of the threat of legionnaires' disease must be maintained among clinicians and hospital epidemiologists because it is unlikely that the problem of nosocomial legionnaires' disease will disappear.

Tremendous progress has been made recently in characterization of Legionella pneumophila and infections caused by it. Certain areas that are particularly germane to immunosuppressed patients, who are affected more frequently than other patients, and areas that are controversial and merit particular consideration are considered herein. These include pathogenesis and correlation of experimental and clinical evidence, nosocomial outbreaks and almost ubiquitous distribution of L. pneumophila in water despite only a limited number of studies linking the two by aerosols, prevalence and possible reasons for the apparent spotty distribution, protean clinical manifestations, difficulties in diagnosis, certain aspects of therapy, and control by environmental changes.

Serial surveys on the etiology of nosocomial bacteremia have been conducted over a period of years at Boston City Hospital (Boston) and Grady Memorial Hospital (Atlanta). A comparison of the information from these surveys with that from single-period surveys at 10 other hospitals in the United States illustrates changes in the etiology of nosocomial bloodstream infection over the past five decades. Prominent trends include an increased frequency of episodes of polymicrobial bacteremia, an increased frequency of sequential episodes of bacteremia in the same patient, a resurgence of infection due to Staphylococcus aureus, the recognition of Staphylococcus epidermidis and other components of the endogenous flora as pathogens, and an increased prominence of enterococci, gram-negative aerobic bacilli, anaerobes, and fungi as agents of nosocomial bloodstream infection. Changes in the etiology of nosocomial infection that are not illustrated by the data on bacteremia include an increased appreciation of the importance of viruses, a diminished role for Mycobacterium tuberculosis, and the description of new and unusual pathogens, usually in patients with compromised host defenses. This last trend can be expected to continue.

The medicolegal medical toxicologist is described: What they do, what toxicology is, how the toxicologist moves in a world of regulations, chemicals, differential diagnosis, and treatment of poisoning; his or her knowledge as an expert witness in evaluation of serious adverse drug reactions, medical malpractice, and poisoning cases; and the toxicologist's awareness of the role of alcohol, the problem of causation of death, and the limitations of the laboratory are discussed.