Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Legionnaires' Disease: A Preventable Disease

67 views

Published on

First of two presentations delivered by Dr. Janet Stout at Buffalo Industrial Chemical conference on April 28, 2017.

Published in: Environment
  • Be the first to comment

  • Be the first to like this

Legionnaires' Disease: A Preventable Disease

  1. 1. © Special Pathogens Laboratory Janet E. Stout, PhD President & Director LEGIONNAIRES’ DISEASE A Preventable Disease
  2. 2. © Special Pathogens Laboratory My Affiliations • President & Director Special Pathogens Laboratory, Pittsburgh, Pa. • SPL is “More Than a Lab” • Research Associate Professor, University of Pittsburgh Swanson School of Engineering Department of Civil & Environmental Engineering • Research on Legionella control strategies
  3. 3. © Special Pathogens Laboratory Today’s Topics • Understanding Legionella In The Built Environment • Role of Legionella Testing In Disease Prevention • NY Regs & ASHRAE Standard 188 • Approaches To Prevention
  4. 4. © Special Pathogens Laboratory Celebrating More Than 40 Years of Making Headlines
  5. 5. © Special Pathogens Laboratory Things That Happened in 1976 in Philadelphia 40 years is a long time!
  6. 6. © Special Pathogens Laboratory American Legion Convention at the Bellevue-Stratford Hotel
  7. 7. © Special Pathogens Laboratory 1976 Philadelphia • 58th convention of the American Legion held July 21-24 • Mysterious illness effects 221 and kills 34 • Causative agent of pneumonia would not be identified until 1977
  8. 8. © Special Pathogens Laboratory 1980: Research Begins in Pittsburgh • More than 30 years studying Legionnaires’ disease  I’m a Legionellologist
  9. 9. © Special Pathogens Laboratory Research Pioneers Starting in 1982 • Over 100 nosocomial cases identified in 5 years in one hospital • An epidemic redefined - endemic disease • The source was the hospital water system – not a cooling tower! Janet E. Stout and Victor L. Yu
  10. 10. © Special Pathogens Laboratory
  11. 11. © Special Pathogens Laboratory • NOT a common source for sporadic and hospital-acquired cases • More commonly associated with large community outbreaks Paradigm Shift: Not Cooling Towers
  12. 12. © Special Pathogens Laboratory What We Know Now Potable water especially in hospitals (and other buildings) with complex hot water systems, is the most important source of Legionella transmission.
  13. 13. © Special Pathogens Laboratory A HIGHLY SUCCESSFUL MICROBE Legionella
  14. 14. © Special Pathogens Laboratory Measures of Success • Numbers up? • In the news? • Famous people talking about you? • Getting too famous – industry and government agencies after you?
  15. 15. © Special Pathogens Laboratory Successful Microbe: Disease Incidence Increasing?
  16. 16. © Special Pathogens Laboratory Consider This… • Legionellosis cases have increased substantially – over 200% in last 10 years
  17. 17. © Special Pathogens Laboratory Who’s At Risk • Elderly • Smokers • Immunocompromised  Transplant patients  High-dose steroids for lung disease  Diabetes  Cancer • Approx. 25% cases no known risk factors
  18. 18. © Special Pathogens Laboratory Centers for Disease Control and Prevention Statistics • 77% >50 years • 62% male • Hospitalizations occurred in 98%  ICU admission in 39%  Death in 10%–30%
  19. 19. © Special Pathogens Laboratory Legionnaires’ Disease in Hospitals • 35% of reported cases met the case definition for hospital-acquired infection (range 45%–25%) • Case fatality rate was 28% (range 46%–14%) From Benin A.L., Benson R.F., Besser R.E. Clin Infect Dis 2002; 35:1039-46. Data reported to the CDC from 1980-1998.
  20. 20. © Special Pathogens Laboratory Cases Linked to Water Systems • Warm water distribution in:  Hospitals  Nursing homes  Rehabilitation centers  Office buildings  Apartment buildings  Hotels • Other water systems:  Spas and hot tubs  Decorative fountains  Humidifiers  Cooling towers
  21. 21. © Special Pathogens Laboratory HEALTHCARE-ACQUIRED CASES Epidemiology and Infection Prevention
  22. 22. © Special Pathogens Laboratory Many Cases Still Missed • Diagnostic tests for Legionella not routine – often not done • Many studies have demonstrated under reporting/missed diagnosis
  23. 23. © Special Pathogens Laboratory Under Reporting Due to Missed Diagnosis
  24. 24. © Special Pathogens Laboratory Results for 37 Cases 41% of Legionella cases were missed following current IDSA-ATS recommendations for Legionella testing
  25. 25. © Special Pathogens Laboratory Urinary Antigen: the Primary Diagnostic Method • Urine antigen primary method of diagnosis in 97% of cases • Culture of Legionella from respiratory secretions (sputum) in only 5% of cases • Early diagnosis and treatment = better outcome MMWR 2011 Vol 60 (32)
  26. 26. © Special Pathogens Laboratory Dangers of Dependency on Urine Antigen Testing for Diagnosis • Urine antigen specific for L. pneumophila, serogroup 1 only • If used to screen for healthcare- acquired LD, you’d better know what’s in your water!  If Lp-6 in the water, diagnosis will be missed MMWR 2011 Vol 60 (32)
  27. 27. © Special Pathogens Laboratory Transmission by CPAP?
  28. 28. © Special Pathogens Laboratory PREVENTING LEGIONNAIRES’ DISEASE Is It Worth The Effort?
  29. 29. © Special Pathogens Laboratory Legionnaires’ Disease • In the U.S. approximately 600,000 adults are diagnosed with community-acquired pneumonia requiring hospitalization • 2-5% are caused by Legionella, as many as 30,000 cases/year
  30. 30. © Special Pathogens Laboratory Annual Healthcare Costs From Legionnaires’ Disease • Total hospitalization costs $101 - $321 million dollars per year • Assumption 10 day stay and $34,000 per patient COLLIER S.A., L. J. STOCKMAN, L.A. HICKS, L. E. GARRISON, F. J. ZHOU AND M. J. BEACH. Epidemiol. Infect. (2012), 140, 2003–2013.
  31. 31. © Special Pathogens Laboratory Legionellosis in the U.S. Outbreaks continue to occur (building warm water systems, cooling towers, fountains)
  32. 32. © Special Pathogens Laboratory Outbreaks 2000 to 2014
  33. 33. © Special Pathogens Laboratory Hospitals at Significant Risk According to Recent CDC Report Legionella in hospitals – accounted for 57% of all cases and 85% of deaths
  34. 34. © Special Pathogens Laboratory Measures of Success Increasing ratings? In the news? • Famous people talking about you? • Getting too famous – industry and government agencies after you?
  35. 35. © Special Pathogens Laboratory Outbreaks in Nursing Homes & Assisted Living Facilities
  36. 36. © Special Pathogens Laboratory HOSPITAL OUTBREAK LINKED TO NEW CONSTRUCTION
  37. 37. © Special Pathogens Laboratory South Bronx Outbreak • 130 cases, 12 deaths • Declared over August 20, 2015
  38. 38. © Special Pathogens Laboratory Outbreak Linked to Hotel Cooling Tower
  39. 39. © Special Pathogens Laboratory NEW YORK STATE EMERGENCY REGULATIONS
  40. 40. © Special Pathogens Laboratory Emergency Regulation • Cooling towers must be registered • Legionella testing every 90 days • Inspection • Certification • Maintenance program
  41. 41. © Special Pathogens Laboratory I Love New York!
  42. 42. © Special Pathogens Laboratory Outbreaks Worldwide
  43. 43. © Special Pathogens Laboratory Outbreak • Catalonia, Spain  113 cases, caused by Legionella pneumophila, serogroup 1  13 cooling towers tested  DNA subtype of isolates from one tower matched the subtype of 10 patient isolates implicating it as the outbreak source
  44. 44. © Special Pathogens Laboratory More Outbreaks: Germany • Warstein, Germany  165 cases, 12 ICU, 2 deaths caused by Legionella pneumophila, serogroup 1  Outbreak strain found in 2 cooling towers + other sources – including wastewater from a brewery!  Public health communication
  45. 45. © Special Pathogens Laboratory Public Safety Announcement “Whether or not the Warsteiner brewery is found to be the breeding ground for the Legionella bacteria, officials have been making it clear that … the beer is completely safe to drink.”
  46. 46. © Special Pathogens Laboratory HEALTHCARE-ACQUIRED LD Approaches To Prevention
  47. 47. © Special Pathogens Laboratory Denial Most wait to address the problem until after a case of Legionnaires’ disease is diagnosed.
  48. 48. © Special Pathogens Laboratory Legionella Testing If you don’t look for it, you won’t find it. If you don’t find it, you don’t think you have a problem. If you don’t think you have a problem, you don’t do anything about it. −Bruce Dixon, M.D. Director, Pittsburgh ACHD
  49. 49. © Special Pathogens Laboratory CDC Changes Position on Testing “We are not against testing water for the presence of Legionella… We think it has its place, particularly in healthcare facilities.” Cynthia Whitney, MD, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC. June 8, 2016 Pittsburgh Post Gazette
  50. 50. © Special Pathogens Laboratory Approaches to Prevention • REACTIVE  After 1 transplant patient or 2+ cases within 6 months • Combined epidemiologic and environmental investigation • Legionella source identified = decontaminate • PROACTIVE  Before cases, perform environmental surveillance  Also perform clinical surveillance to identify unrecognized cases • Legionella source identified = decontaminate
  51. 51. © Special Pathogens Laboratory Proactive Approach Reduced Legionnaires’ Disease Am. J. Infection Control 2005; 33(6):360-367
  52. 52. © Special Pathogens Laboratory Pittsburgh Proactive Approach Culture hot water systems. Was Legionella found? Prior cases of legionellosis observed? Colonization of distal sites >30%? Prospective clinical surveillance detected legionellosis? Consider Secondary Disinfection Continue Environmental Surveillance YES NO YES NO YES NO YES NO Reference: Approaches to Prevention and Control of Legionella Infection in Allegheny County Health Care Facilities. 1997.
  53. 53. © Special Pathogens Laboratory Study Findings • Reviewed 487 reported cases from 1991-2001 (Pre- and-post guideline) • Proportion of cases hospital-acquired:  Pre-guideline = 33%  Post-guideline = 9% • Significant decrease in the post guideline period (p<0.0001)
  54. 54. © Special Pathogens Laboratory Our Study Results of 48 Hospitals • Proportion of hospitals performing environmental surveillance = 65% • Proportion that started water treatment (disinfection) = 44%
  55. 55. © Special Pathogens Laboratory I Love New York! New York Is being Proactive! State-wide regulation requires testing and water management plans for cooling towers AND potable water systems of healthcare facilities
  56. 56. © Special Pathogens Laboratory Table at www.specialpathogenslab.com
  57. 57. © Special Pathogens Laboratory Legionella Prevention In New York: Cooling Towers AND Healthcare • First Regulation in the U.S.  Addition of Part 4 to Title 10 of the Official Compilation of Codes, Rules and Regulations of the State of New York (Protection Against Legionella) • This Subpart addresses Legionella exposure in general hospitals and residential health care facilities (collectively, “covered facilities”).
  58. 58. © Special Pathogens Laboratory New NY State Regulation For Legionella Prevention • Requires that all covered healthcare facilities adopt and implement:  a sampling and management plan for their potable water systems by December 1, 2016, and  new covered facilities must adopt such plan prior to providing services.
  59. 59. © Special Pathogens Laboratory Percentage of Positive Legionella test Sites Response <30% Maintain environmental assessment and Legionella monitoring in accordance with the sampling and management plan >30% Institute short-term control measures and notify the department. • Re-sample no sooner than 7 days and no later than 4 weeks after disinfection • If retest is ≥ 30% positive, repeat short-term control measures. • If results < 30% positive, resume monitoring in accordance with the sampling and management plan. Interpretation of Routine Legionella Culture Results from Covered Facilities
  60. 60. © Special Pathogens Laboratory Where Did The 30% Target Come From?
  61. 61. © Special Pathogens Laboratory Evidence-based Origins of 30% Distal Site Positivity As Risk Indicator
  62. 62. © Special Pathogens Laboratory Correlation Between Disease and Distal Site Positivity • Whenever monthly site positivity exceeded 30%, cases of Legionnaires’ disease appeared in those months. • Similarly, when positivity fell to 20% or less, no case of disease were observed.
  63. 63. © Special Pathogens Laboratory
  64. 64. © Special Pathogens Laboratory Proportion Not Concentration Risk of Legionnaires’ disease was better predicted by the proportion of water system sites testing positive for Legionella than by the concentration of Legionella bacteria. Kool J L, et al. Infect. Control Hosp. Epid. 1999 20:797-805
  65. 65. Validated in a Multi-Center Study Infect Control Hosp Epid 2007; 28 (7)
  66. 66. 0% 20% 40% 60% 80% 100% 120% DistalSitePositvity Date High (>30%) Legionella Distal Site Positivity And Cases Prior to Treatment Distal Site Positivity No Cases after Treatment (NH2Cl) Cases
  67. 67. © Special Pathogens Laboratory Where You Can Find Legionella • Building (warm) water systems  Faucets, showers  Hot water tanks  Decorative fountains  Pools, spas  Cooling towers  Ice Machines
  68. 68. © Special Pathogens Laboratory You Can’t Tell by Looking >3000 CFU/mL Legionella pneumophila serogroup 1 Automated dosing of chemical biocides and clean
  69. 69. © Special Pathogens Laboratory Microbiological Testing: HPC (Total) Bacteria Does An HPC Test Predict A Problem With Legionella?
  70. 70. © Special Pathogens Laboratory Heterotrophic Plate Count (HPC) Bacteria Testing • Bacteriological indicator … estimates microbial content in the circulating water of a cooling tower system, such as heterotrophic plate count (HPC) as measured in a water sample or by a dip slide.
  71. 71. © Special Pathogens Laboratory
  72. 72. © Special Pathogens Laboratory Heterotrophic Plate Count (HPC) Bacteria Testing What do you learn? • HPC method does not detect Legionella • HPC cannot be used to predict presence or absence of Legionella • HPC counts can be low when Legionella is high
  73. 73. © Special Pathogens Laboratory 2015 Publication
  74. 74. © Special Pathogens Laboratory Heterotrophic Plate Count (HPC) Bacteria Testing HPC or ATP Test Can: • Be used as a biocide performance indicator for general microbiological fouling • Be an inexpensive early warning of a process or biocide application upset
  75. 75. © Special Pathogens Laboratory NYC HPC Test NYS HPC Test Weekly bacteriological sampling and analysis using dip slides or heterotrophic plate counts (HPC). Monthly bacteriological sampling and analysis using dip slides or heterotrophic plate counts (HPC). Result & Response Result & Response CFU/mL < 10,000 maintain program >10,000 and <100,000; Initiate immediate disinfection (See Table 8-2 for details) Not Specified
  76. 76. © Special Pathogens Laboratory Legionella Test Result (CFU/mL) Response Not Detected (<20 CFU/mL) Maintain treatment program and Legionella monitoring in accordance with the maintenance program and management plan For levels at ≥ 20 CFU/mL but < 1000 CFU/mL perform the following: Review treatment program. • Institute immediate online disinfection Retest the water in 3 – 7 days until one sample result is < 20 CFU/mL. If retest is ≥ 20 CFU/mL but < 100 CFU/mL, repeat online disinfection and retest until < 20 CFU/mL attained. • If retest is ≥100 CFU/mL but < 1000 CFU/mL, further investigate and immediately perform online disinfection. Retest until < 20 CFU/mL attained. • If retest is ≥ 1000 CFU/mL, undertake control strategy and notifications Guidance for Cooling Towers In NYS
  77. 77. © Special Pathogens Laboratory Risk Assessment and Environmental Monitoring Results • Concentration- based thresholds that establish target values in CFU per liter or milliliter  OK for cooling towers as a performance- based target (not health-based) • Colonization rate or proportion of distal sites in the water system that are positive for Legionella  Best for hospitals and building water systems
  78. 78. © Special Pathogens Laboratory Meaning for You Sampling the water system of a building can give you a meaningful “snapshot” of the colonization status.
  79. 79. © Special Pathogens Laboratory Legionella Testing • Legionella testing can verify the performance of water treatment & water safety plans
  80. 80. © Special Pathogens Laboratory Did You Know CDC Has a New Position On Testing? “We are not against testing” water for the presence of Legionella…We think it has its place, particularly in healthcare facilities.” Cynthia Whitney, MD Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC. June 8, 2016 Pittsburgh Post Gazette
  81. 81. © Special Pathogens Laboratory Is the Sky Falling? If I Find Some Legionella?
  82. 82. © Special Pathogens Laboratory What is an acceptable amount of Legionella?
  83. 83. © Special Pathogens Laboratory 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000000000 IS ZERO NECESSARY?
  84. 84. © Special Pathogens Laboratory Zero Legionella is virtually impossible to achieve in complex water systems Don’t Chase Zero
  85. 85. © Special Pathogens Laboratory Preventing Legionnaires’ Disease • Controlling Legionella is about preventing disease not about reaching zero Legionella in water. • Zero Cases Is the Goal
  86. 86. © Special Pathogens Laboratory AN INSIDE LOOK AT LEGIONELLA
  87. 87. © Special Pathogens Laboratory Legionella Colony Morphology Colonies of Legionella pneumophila have a typical ground-glass, opalescent morphology
  88. 88. © Special Pathogens Laboratory Not All Legionella Are Dangerous
  89. 89. © Special Pathogens Laboratory Auto fluorescing Legionella Species: Uncommon Disease-causing Agent Some species show blue-white extracellular fluorescence Under long wave ultra-violet light
  90. 90. © Special Pathogens Laboratory Legionella Culture Isolation • These species include L. anisa, L. bozemannii L. dumoffii, L. gormanii, L. erythra and L rubrilucens
  91. 91. © Special Pathogens Laboratory Labs Vary in Culture Methods for Legionella Testing & Identification Apples to apples or apples to oranges?
  92. 92. Did you know that labs differ in their methods for Legionella testing & identification? ELITE Certified Laboratories
  93. 93. © Special Pathogens Laboratory • Methods for Legionella detection and quantitation  Standard culture – validated/gold standard  Non-culture based molecular methods • Quantitative Polymerase Chain Reaction (qPCR) • Molecular/Sequencing (NGS, WGS) Detection of Legionella
  94. 94. © Special Pathogens Laboratory Culture Method • Industry standard/best practice  Standards based • ISO 11731 (1&2) • ASTM D 5952 • CDC • International – HSE L8 ACP 2013  Laboratory Proficiency Programs • NY ELAP • ELITE is not a traditional proficiency program
  95. 95. © Special Pathogens Laboratory Labs Use Different Culture Methods • Labs use all or only some of these processing methods  Pretreatment (heat and/or acid)  Filtration (yes/no or how much)  Special culture media (types and how many) • Labs provide limited identification (ID)  Only presumptive agglutination test?  Definitive ID with DFA or sequencing for unusual species?
  96. 96. © Special Pathogens Laboratory Legionella Identification • Suspected Legionella isolates are confirmed by either slide agglutination or by direct fluorescent antibody staining • Latex agglutination for L. pneumophila serogroups 1, 2-14 and Legionella species. Oxoid Latex agglutination
  97. 97. © Special Pathogens Laboratory • Used for definitive identification of Legionella after isolation by culture Fluorescent Antibody Stain
  98. 98. © Special Pathogens Laboratory Patient isolates compared to environmental isolates using PFGE (Pulsed-field Gel Electrophoresis). Cultured Legionella “Fingerprinted” by DNA Typing
  99. 99. © Special Pathogens Laboratory NYC Specifies Culture Method • Labs testing samples from NY must use International Organization for Standardization (ISO) Legionella culture methods:  Enumeration of Legionella (ISO 11731) or International Standard Method 11731- 2 Water quality detection and enumeration of Legionella
  100. 100. © Special Pathogens Laboratory NY State Specifies Culture Method • All Legionella culture analyses must be performed by a laboratory that is approved to perform such analysis by the New York State Environmental Laboratory Approval Program (ELAP).
  101. 101. © Special Pathogens Laboratory Confirm Lab Meets Requirements • Labs performing testing should be  Accredited for microbiology testing, quality (ISO 17025) and for Legionella testing as a specific field of testing  Not just CDC ELITE certified
  102. 102. © Special Pathogens Laboratory SPL - Most accurate results are obtained when all steps are performed
  103. 103. © Special Pathogens Laboratory Accreditation & Certification
  104. 104. © Special Pathogens Laboratory Measures of Success Increasing ratings? In the news? • Famous people talking about you? • Getting too famous – industry and government agencies after you?
  105. 105. © Special Pathogens Laboratory FAMOUS PEOPLE TALKING ABOUT YOU Successful Legionella
  106. 106. © Special Pathogens Laboratory Erin Brockovich & Legionella? • Draws attention to the release of a report that said Legionnaires’ disease cases are on the rise in New York because of poor enforcement of clean water regulations.
  107. 107. © Special Pathogens Laboratory Hollywood Walk of Fame for Legionella?
  108. 108. © Special Pathogens Laboratory Measures of Success Increasing ratings? In the news? Famous people talking about you? Getting too famous – industry and government agencies after you?
  109. 109. © Special Pathogens Laboratory Legionella Has Their Attention • ASHRAE • CDC • EPA • NSF • WRF • Industry Organizations AWT and CTI
  110. 110. © Special Pathogens Laboratory • First Legionella standard in the United States. • Approved June 26, 2015
  111. 111. © Special Pathogens Laboratory Risk Management Process
  112. 112. © Special Pathogens Laboratory Purpose of ASHRAE Standard 188 Establish minimum Legionellosis risk management requirements for building water systems.
  113. 113. © Special Pathogens Laboratory The Real Purpose of ASHRAE Standard 188 To help engineers and infection preventionists communicate more effectively
  114. 114. © Special Pathogens Laboratory Elements of Water Management Program Program Team – Persons responsible for Program development and implementation. Water Systems/Flow Diagrams – Describe potable and non-potable water systems and develop water system-schematics. Water System Analysis/Control Measures – Evaluate where hazardous conditions may occur and decide where control measures should be applied. Monitoring/Corrective Actions – Establish procedure for monitoring whether control measures are within operating limits and, if not, take corrective actions. Confirmation – Establish procedure to confirm Program is being implemented as designed (verification) and the Program effectively controls the hazardous conditions (validation). Documentation – Establish documentation and communication procedures for all activities of the Program.
  115. 115. © Special Pathogens Laboratory The Team • Titles  Administrator  Facilities manager  Infection control  Water treatment professional  Risk manager/adjuster  Legionella consultant • Abilities  Power to make decisions  Understanding of facility  Knowledge of water systems  Ability assess facility risk tolerance  Expertise in Legionella
  116. 116. © Special Pathogens Laboratory SPL’s 5 Steps to a Legionella Water Safety Plan 1. Pre-Assessment information 2. Pre-assessment water safety team meeting/call 3. Onsite assessment 4. Baseline data assessment report 5. Water safety plan
  117. 117. © Special Pathogens Laboratory Fundamentals for Legionella Water Safety • Know who is at risk for Legionnaires’ disease in your facility  Highest risk: smokers, elderly and immune suppressed  But, can affect those with no risk factors • Identify key players who are responsible for water safety  Facility managers, maintenance, occupants, regulators, engineers, water treatment providers, Legionella experts, etc.
  118. 118. © Special Pathogens Laboratory Legionella Water Safety • Know what part of a water system could lead to Legionella exposure  Highest risk: Hot potable water systems  Not all buildings have Legionella  Risk is a function of • susceptibility of occupants • extent of colonization or exposure • pathogenicity of Legionella species
  119. 119. © Special Pathogens Laboratory ASHRAE 188: Mind the Gaps
  120. 120. ASHRAE Compliance • Compliance is just the first step to protect yourself and building occupants • Compliance doesn’t guarantee Legionella control and cases can occur.
  121. 121. © Special Pathogens Laboratory ASHRAE 188: Your Decisions Fill The Gaps
  122. 122. © Special Pathogens Laboratory ASHRAE 188 Compliance Good News, Bad News • Standard is not prescriptive –  Good News - You get to make lots of decisions  Bad News - You get to make lots of decisions
  123. 123. © Special Pathogens Laboratory Team Determines Approach to Testing And Disinfection • The Program Team shall determine the testing approach including:  Sampling frequency  Number of samples  Locations and sampling methods
  124. 124. © Special Pathogens Laboratory Knowledge The Program Team shall have knowledge of the building water system design and water management as it relates to Legionellosis
  125. 125. © Special Pathogens Laboratory
  126. 126. © Special Pathogens Laboratory Test Your Knowledge: True or False? • Legionella is ubiquitous (everywhere). • If chlorine levels at or above 0.5 mg/L in the supply water, Legionella is controlled. • Only old buildings have Legionella problems. • If total bacteria (HPC or ATP) are controlled, Legionella is controlled. • Water and energy conservation approaches minimize Legionella risk. • Legionella is not a concern during construction.
  127. 127. © Special Pathogens Laboratory CDC Focuses on Effective Water Management For Legionnaires’ Disease Prevention
  128. 128. © Special Pathogens Laboratory
  129. 129. © Special Pathogens Laboratory DISINFECTION APPROACHES I Have Legionella in My Building… Now What?
  130. 130. © Special Pathogens Laboratory DISINFECTION OPTIONS
  131. 131. © Special Pathogens Laboratory Secondary Disinfection Methods • Thermal shock treatment (heat & flush) • Shock chlorination (>10 mg/L residual), may require water tanks to be 20-50 mg/L • Continuous chlorination (2-4 mg/L) • Copper-silver ionization (continuous and short-course) • Chlorine Dioxide (ClO2) • Monochloramine • Point-of-use filtration
  132. 132. © Special Pathogens Laboratory Short-term Disinfection Is Whack-a-Mole
  133. 133. © Special Pathogens Laboratory PROTECTING TRANSPLANT, HIGH RISK PATIENTS, NEONATES We Filter the Air… But Let Them Drink Tap Water?
  134. 134. © Special Pathogens Laboratory Water is a Source of infection especially for high risk patients –including neonates
  135. 135. © Special Pathogens Laboratory Healthcare-acquired Pediatric LD • CDC study showed 72% pediatric cases had healthcare exposure • Mortality rate 22% Alexander NT, et al 2008 ICAAC
  136. 136. © Special Pathogens Laboratory Fatal Water Birth E, Sanyal K, Threadgill H, Cervantes D. Fatal legionellosis after water birth, Texas, USA, 2014. Emerg Infect Dis. 2015 Jan].
  137. 137. © Special Pathogens Laboratory
  138. 138. © Special Pathogens Laboratory Point-of-Use Filtration • High Risk Patients • Bone marrow and solid organ transplant units • Hematology/ oncology units • NICU
  139. 139. © Special Pathogens Laboratory Field Evaluation AJIC 2014; 42: 1193-1196
  140. 140. © Special Pathogens Laboratory Point-of-Use Filters: Conclusions • System-wide disinfection may not always be the best answer. • Next generation filters last longer – more than 60 days • High risk areas may require long-term use for maximum risk reduction • Extend protection to home for high risk patients?
  141. 141. © Special Pathogens Laboratory Journal Am Water Works Assoc 2014; 106(10): 24-32 Review of Methods
  142. 142. © Special Pathogens Laboratory EPA Issues Review of Legionella Control & Disinfection Methods
  143. 143. © Special Pathogens Laboratory Acinetobacter Pseudomonas aeruginosa S. maltophilia Amoeba Resistant Microorganisms (Mycobacteria ) Not Just Legionella in Our Faucets
  144. 144. © Special Pathogens Laboratory Culture Shows Pathogens Klebsiella oxytoca and Enterobacter cloacae Pseudomonas aeruginosa
  145. 145. © Special Pathogens Laboratory See You in Portland - APIC 2017 • 1401/1402 - Water and Healthcare-Associated Infections: The Importance of Developing and Implementing a Water Management Plan • Presenters: Janet E. Stout & Matthew Arduino • Wednesday, June 14, 2017 • 3:00 PM – 5:30 PM
  146. 146. © Special Pathogens Laboratory PREVENTING LEGIONNAIRES’ DISEASE How are we doing?
  147. 147. Progress Has Been Slow… Really Slow!
  148. 148. © Special Pathogens Laboratory Total Legionella Control An evidence-based, integrated platform of solutions: • Legionella & Pathogen Testing • Consulting & Education • ZEROutbreak Protection
  149. 149. © Special Pathogens Laboratory Our Mission: End Legionnaires’ Disease • No one should die from a preventable disease caused by a bacteria in water. • Legionnaires’ disease can and should be prevented.
  150. 150. © Special Pathogens Laboratory WWW.SPECIALPATHOGENSLAB.COM THANK YOU Dr. Janet E. Stout President, Microbiologist info@specialpathogenslab.com

×