Health Departments

Overview

Delays in recognizing outbreaks of extrapulmonary NTM can occur because of:

• the long period of time between exposure and symptom onset
• the nonspecific symptomatology
• the act that patients often present to different healthcare facilities

This can results in delays in public health actions and further infections. Health departments should therefore consider adding extrapulmonary NTM infections to the list of reportable conditions in their jurisdiction.

Reporting of extrapulmonary NTM infections can lead to timely outbreak detection and implementation of public health interventions to decrease the risk of new infections. Jurisdictions that have added extrapulmonary NTM infections to the list of conditions which are required to be reported to the health department have been able to analyze surveillance data to identify and promptly respond to NTM outbreaks.

Outbreaks of extrapulmonary NTM infections have occurred in a number of settings, and are usually due to a water source.

Settings with increased risk of NTM infections include:

• Tattoo parlors
• Nail salons
• Hot tubs or spas
• Healthcare settings

NTM outbreaks have been reported in healthcare settings due to the ability of NTM to form biofilms in hospital plumbing and on medical devices. Healthcare-associated outbreaks often result from breaches in infection control practices that allow patients to be exposed to contaminated water during invasive procedures such as injections, infusions, or surgeries. Healthcare-associated NTM outbreaks can also result from contaminated medical equipment, such as bronchoscopes or heater-cooler devices used in cardiac surgery. NTM outbreaks can occur in many different clinical settings and result from a wide range of medical procedures and practices including:

• Surgery
  • Breast surgery
  • Heart surgery, including infections related to heater-cooler devices
  • Eye surgery with exposure to consumer-grade humidifiers
• Dental procedures
• Medical tourism
• Cosmetic surgery
• Medicine compounding and mixing
• Medication preparation
• Injection preparation and administration
• Central line placement and maintenance
• Manufacturing of medical products

Public health case definition for extrapulmonary NTM

In June of 2017 the Council of State and Territorial Epidemiologist approved a standardized case definition for extrapulmonary NTM infections [PDF – 13 pages]. The purpose of the definition is to assist state health departments in making extrapulmonary NTM infections reportable, ensure consistency across jurisdictions, and facilitate detection and reporting of extrapulmonary NTM outbreaks. The case definition focuses on extrapulmonary NTM infections as these infections are more likely to be associated with outbreaks compared to pulmonary NTM infections. The case definition is intended to be utilized for public health surveillance and not clinical diagnosis.

Health Departments Should:

• Consider making extrapulmonary NTM infections notifiable within their jurisdiction
  • Council of State and Territorial Epidemiologists Standardized Case Definition for Extrapulmonary Nontuberculous Mycobacteria Infections [PDF – 12 pages]
• CDC conducts surveillance for NTM infections
• Encourage healthcare facilities to establish a water management program
  • Reduce Risk From Water
  • Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings
  • CMS Memo S&C 17-30-Hospitals/CAHs/NHs [PDF – 4 pages]
• Serve as a resource for healthcare facilities on infection control practices related to water
• Investigate clusters of NTM infections within and across healthcare facilities to determine common exposures and potential sources of infections
• Emphasize good infection control and water management practices to prevent and stop NTM healthcare-associated outbreaks
• Evaluate laboratory capacity for NTM testing and species identification and consider developing capacity for species identification if it is not present
• Consult with CDC as needed for epidemiology and laboratory support, especially if there is concern for the potential of a multi-state outbreak (e.g., contaminated medical product, medical tourism)

Tools

• The CSTE position statement which established these standardized case definitions [PDF – 12 pages]
• The operational guidance developed by CSTE to assist states with implementing surveillance of extrapulmonary NTM infections [DOC – 5 pages]

Resources

• Oregon Health Authority NTM Investigative Guidelines [PDF – 5 pages]
• Morbidity and Mortality Weekly Report article describing the Oregon Health Authority’s experience with making extrapulmonary NTM reportable in Oregon
• Tennessee Department of Health website on reporting extrapulmonary NTM infections
• Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings
• Reduce Risks from Water
• CMS Memo S&C 17-30-Hospitals/CAHs/NHs [PDF – 4 pages]

Examples of select healthcare-associated NTM outbreaks

• Perkins KM, Reddy SC, Fagan R, Arduino MJ, Perz JF. Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017. Infect Control Hosp Epidemiol. 2019 Jun; 40(6):621-626.
• Baker AW, Lewis SS, Alexander BD, Chen LF, Wallace RJ Jr, et al. Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation. Clin Infect Dis. 2017; 64(7):902-911.
• Lyman MM, Grigg C, Kinsey CB, Keckler MS, Moulton-Meissner H, Cooper E, Soe MM, Noble-Wang J, Longenberger A, Walker SR, Miller JR, Perz JF, Perkins KM. Invasive Nontuberculous Mycobacterial Infections among Cardiothoracic Surgical Patients Exposed to Heater-Cooler Devices. Emerg Infect Dis. 2017 May;23(5):796-805.
• Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes from the Field. Mycobacterium abscessus Infections Among Patients of a Pediatric Dentistry Practice — Georgia, 2015. MMWR Morb Mortal Wkly Rep 2016;65:355–356.
• Brown-Elliott BA, Wallace RJ Jr, Tichindelean C, Sarria JC, McNulty S, Vasireddy R, Bridge L, Mayhall CG, Turenne C, Loeffelholz M. Five-year outbreak of community- and hospital-acquired Mycobacterium porcinum infections related to public water supplies. J Clin Microbiol. 2011;49(12):4231-8.
• Conger NG, O’Connell RJ, Laurel VL, Olivier KN, Graviss EA, Williams-Bouyer N, Zhang Y, Brown-Elliott BA, Wallace RJ Jr. Mycobacterium simae outbreak associated with a hospital water supply [PDF – 6 pages]. Infect Control Hosp Epidemiol. 2004;25(12):1050-5.
• Edens C, Liebich L, Halpin AL, Moulton-Meissner H, Eitniear S, Zgodzinski E, Vasko L, Grossman D, Perz JF, Mohr MC. Mycobacterium chelonae Eye Infections Associated with Humidifier Use in an Outpatient LASIK Clinic–Ohio, 2015. MMWR Morb Mortal Wkly Rep. 2015 Oct 23;64(41):1177. 
• Bryant JM, Grogono DM, Rodriguez-Rincon D, et al. Population-level genomics identifies the emergence and global spread of human transmissible multidrug-resistant nontuberculous mycobacterium. Science. 2016 Nov 11; 354 (6313): 751-757.