It’s been two weeks since the public learned the parasite cryptosporidium was found in Baltimore-area drinking water, putting immunocompromised people on notice to boil their water.

While we know that two subsequent water samples tested crypto-free, questions remain about Baltimore City officials’ response to the threat and what they’ll do differently if it happens again.

At a hearing on Wednesday, Baltimore City Council members grilled officials about their response to the contamination. Officials blamed any missteps on a lack of experience with testing for the parasite — which they started doing monthly in July following an EPA mandate — and a lack of state regulations on how to respond in the event contamination is detected.

They said their actions were based on guidance from the Maryland Department of the Environment and the state Department of Health indicating a more robust response was not required due to low detected levels of the parasite, and any information given to the public had to first be approved by these same state agencies.

These are among the questions that remain less than fully answered.

What are the city’s emergency plans for water contamination?

City officials have said they have an emergency response plan “to deal with water contamination” but have not answered The Baltimore Banner’s questions about the contents of that plan.

In an email to The Banner, Yianni Varonis, communications director for the Baltimore City Health Department, said waterborne disease outbreaks and intentional contamination of food or water are addressed in the department’s infectious disease response plan, but noted that Public Works leads “water-related responses” while the health department assumes a support role.

At Wednesday’s hearing, Kimberly Eshleman, director of the city health department’s Office of Public Health Preparedness and Response, did not address emergency plans for water contamination specifically, but said her office routinely does “training and exercising of some of our plans for public health emergencies” internally and with agency partners.

She said in April her office did a “tabletop exercise” with the Department of Public Works in which they “talked through” a hypothetical scenario and how to respond. She said DPW officials attended a meeting between her agency and hospital administrators in May to discuss emergency response plans.

Richard Luna, interim director of DPW, said testing is “a relatively new process for us,” and for the state. But after contamination was discovered, DPW “immediately” began collaborating with city and state agencies and the federal Environmental Protection Agency to plan next steps, he said, and it continues to do so.

How will Baltimore alert residents the next time something like this happens?

At Wednesday’s hearing, Councilwoman Danielle McCray said the city needs better ways to disseminate information “without relying on a press release” or expecting people to watch the news or check social media. She and Councilwoman Odette Ramos said their constituents felt like they were left in the dark, and were panicked about water quality due to E. coli contamination that occurred last year.

Joe Henderson, acting director of the Office of Emergency Management, said the agency is in the process of transitioning to a new alert system, and should have an idea of when it will be operational in the next month. But the alert system, he said, would not have been used for notification of water contamination, anyway, as it’s reserved for “threat to life” or property damage or a serious incident “that’s cascading.”

Luna said DPW has a “very robust network” of community-based organizations and neighborhood associations that it keeps in the loop with important information.

Ramos started to ask if the city has a tiered response system, coded in an easy-to-understand way — such as by color — then abruptly changed course: “I know the answer to that. We don’t.”

City administrative officer Faith Leach said the city must “do everything in partnership with our state regulators,” and such a system would need to be approved by them.

Varonis said cryptosporidium contamination “was not a public health emergency,” but when one does occur and widespread message dissemination is needed, health department plans include “standing up a Joint Information Center” to coordinate communication.

Will Baltimore switch to a water-testing laboratory that offers faster results?

Cryptosporidium can be detected by laboratory tests in as little as 24 hours, but city officials have said they were at the mercy of their contracted lab’s processing time.

Paul Warden, vice president and director of operations at the contracted lab, Vermont-based Analytical Services, Inc., declined to answer The Banner’s questions about whether it offered 24-hour testing for crypto. He also would not comment on whether other public utilities typically request faster testing when crypto contamination has been detected or if it’s the lab’s responsibility to offer it.

Luna said Wednesday that DPW has asked the state to advise on which lab they should use and is waiting on a response. In the meantime, he said, the agency is working with Analytical Services to make sure it gets results back quickly as possible. DPW received results for its second follow-up sample, taken on Oct. 3, just two days later on Oct. 5

How many people became ill because of the contamination?

City officials said there were no cases of cryptosporidiosis reported during the two months prior to when the contamination was found. Leach said that data helped determine the city’s response.

But Dr. David Gatz, assistant medical director of the emergency department at the University of Maryland Medical Center, said it’s unlikely that patients would be tested for the parasite before the contamination was reported.

For a “run-of-the-mill, healthy individual,” with acute diarrhea — the primary symptom of crypto infection — testing for the parasite would not be part of a standard assessment in the emergency department, which is typically “fairly limited” for people with symptoms lasting a few days. In the case of diarrhea lasting two weeks or longer, Gatz said he’d probably order additional testing to determine “exact cause.”

The threshold to order a crypto test for an immunocompromised person — with HIV, undergoing cancer treatment, or with a transplanted organ — is lower than for healthy people, Gatz said, and that’s especially true now, in the context of known crypto contamination in the water supply.

But, “I’m not testing people just to find out whether or not it [crypto] is there,” he said.

And the testing itself can be complicated. According to the CDC, multiple stool samples often must be tested over several days to reliably detect crypto. Although the University of Maryland, as an academic medical center, has access to more sensitive testing, Gatz said he’s not sure to what extent the same test is used by other health systems.

Still, a crypto infection is “self-resolving” in most healthy people, Gatz said, and would typically not produce symptoms severe enough to drive someone to seek medical help. This means that even in an outbreak, the majority of cases would likely go undetected, he said, especially in the absence of known contamination.

In an email to The Banner, Leach said Baltimore “is fortunate to have some of the best medical facilities and practitioners in the country, [and] we are confident that individual doctors and hospitals are handling patient tests appropriately,” adding that no positive tests have been reported in the two weeks since the public was notified of crypto contamination.

sarah.true@thebaltimorebanner.com