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Risk of Hospital-Acquired Legionnaires' Disease in Cities Using Monochloramine Versus Other Water Disinfectants

  • James D. Heffelfinger (a1), Jacob L. Kool (a1), Scott Fridkin (a2), Victoria J. Fraser (a3), Jeffrey Hageman (a2), Joseph Carpenter (a2) and Cynthia G. Whitney (a1)...

To measure the association between the disinfection of municipal drinking water with monochloramine and the occurrence of hospital-acquired legionnaires' disease (LD).


One hundred sixty-six U.S. hospitals.


Survey of 459 members of the Society for Healthcare Epidemiology of America (SHEA) for hospital features; endemic- and outbreak-related, hospital-acquired LD; the source of the hospital water supply; and the methods of disinfection used by the hospitals and municipal water treatment plants.


SHEA members representing 166 (36%) of 459 hospitals responded; 33 (20%) reported one or more episodes of hospital-acquired LD during the period from 1994 to 1998 and 23 (14%) reported an outbreak of hospital-acquired LD during the period from 1989 to 1998. Hospitals with an occurrence of hospital-acquired LD had a higher census (median, 319 vs 221; P = .03), more acute care beds (median, 500 vs 376; P = .04), and more intensive care unit beds (median, 42 vs 24; P = .009) than did other hospitals. They were also more likely to have a transplant service (74% vs 42%; P = .001) and to perform surveillance for hospital-acquired disease (92% vs 61%; P = .001). After adjustment for the presence of a transplant program and surveillance for legionnaires' disease, hospitals supplied with drinking water disinfected with monochloramine by municipal plants were less likely to have sporadic cases or outbreaks of hospital-acquired LD (odds ratio, 0.20; 95% confidence interval, 0.07 to 0.56) than were other hospitals.


Water disinfection with monochloramine by municipal water treatment plants significantly reduces the risk of hospital-acquired LD.

Corresponding author
Centers for Disease Control and Prevention, 1600 Clifton Road, MS C-02, Atlanta, GA 30333
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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