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Legionnella: New Science, Insights and Standards

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Presentation delivered by Dr. Janet Stout to APIC Atlanta. April 2016

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Legionnella: New Science, Insights and Standards

  1. 1. © Special Pathogens Laboratory Janet E. Stout, PhD Director, Special Pathogens Laboratory Research Associate Professor University of Pittsburgh LEGIONELLA New Science, Insights and Standards
  2. 2. © Special Pathogens Laboratory Microbiologist • Over 30 years studying Legionnaires’ disease in hospitals and other buildings  I’m a Legionellologist • I hope what I’ve learned can help you
  3. 3. © Special Pathogens Laboratory Microbiologist with a Minor in Plumbing!
  4. 4. © Special Pathogens Laboratory MARK TWAIN
  5. 5. © Special Pathogens Laboratory MARK TWAIN It Ain’t What You Don’t Know That Gets You into Trouble, It’s What You Know For Sure That Just Ain’t So
  6. 6. © Special Pathogens Laboratory Today’s Topics • The Challenge of Legionnaires' disease  Disease, epidemiology, diagnosis, treatment • Role of Infection Prevention • Approaches To Prevention- new regulations and standards
  7. 7. © Special Pathogens Laboratory MY HISTORY WITH LEGIONELLA IN BUILDING WATER SYSTEMS
  8. 8. © Special Pathogens Laboratory Research Starting in 1982 • Over 100 nosocomial cases identified in 5 years in one hospital • An epidemic redefined - endemic disease and the source was the hospital water system – not a cooling tower! Janet E. Stout and Victor L. Yu
  9. 9. © Special Pathogens Laboratory
  10. 10. © 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
  11. 11. © Special Pathogens Laboratory © Special Pathogens Laboratory “Legionella … is the single most common etiologic agent associated with outbreaks involving drinking water.” 2006. National Academy of Sciences Report Report by the U.S. Environmental Protection Agency (EPA) and the Committee on Public Water Supply Distribution Systems
  12. 12. © Special Pathogens Laboratory LEGIONELLA: AN OPPORTUNISTIC PATHOGEN? The Disease
  13. 13. © Special Pathogens Laboratory THE CHALLENGE OF LEGIONNAIRES’ DISEASE
  14. 14. © Special Pathogens Laboratory What Is Legionellosis? • Legionnaires’ disease is a multi-system illness, with pneumonia, caused by bacteria in the family Legionellaceae. • The genus Legionella is a pathogenic group of Gram-negative bacteria that includes the species L. pneumophila
  15. 15. © Special Pathogens Laboratory Legionnaires’ Disease Is Bacterial Pneumonia
  16. 16. © Special Pathogens Laboratory Legionella in water (reservoir) + Transmission to the host (exposure) + Susceptible Host Risk of Acquiring Disease Exposure Alone Doesn’t = Disease Acquisition
  17. 17. © Special Pathogens Laboratory Modes of Transmission for Legionnaires’ disease • Aerosolization • Aspiration • Direct instillation into the patient (tap water rinsing of nasogastric tubes, respiratory tubing, etc)
  18. 18. © Special Pathogens Laboratory IS LEGIONNAIRES’ DISEASE CONTAGIOUS?
  19. 19. © Special Pathogens Laboratory Cooling Tower 300km Away • Outbreak cluster Portugal • Patient 1 was a 48yo male worked at cooling tower complex where outbreak occurred • Travels home 300km where 74 yo mother provides care and also becomes ill • Same sequence type
  20. 20. © Special Pathogens Laboratory No Person-to-Person Transmission
  21. 21. © Special Pathogens Laboratory Transmission By CPAP?
  22. 22. © 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%
  23. 23. © Special Pathogens Laboratory Susceptible Hosts • Elderly • Smokers • Immunocompromised  Transplant patients  High-dose steroids for lung disease  Diabetes  Cancer • Approx. 25% cases no known risk factors
  24. 24. © Special Pathogens Laboratory SEEK AND YE SHALL FIND Diagnosis
  25. 25. © Special Pathogens Laboratory Many Cases Still Missed • Diagnostic tests for Legionella not routine – often not done • Many studies have demonstrated under reporting/missed diagnosis
  26. 26. © Special Pathogens Laboratory Under Reporting Due to Missed Diagnosis
  27. 27. © Special Pathogens Laboratory Results for 37 Cases 41% of Legionella cases were missed following current IDSA-ATS recommendations for Legionella testing
  28. 28. © Special Pathogens Laboratory Update on Diagnostic Methods • Urine antigen tests were used to confirm 97% of U.S. resident cases reported during 2005–2009 • Only 5% of cases were confirmed by culture during this period • <1% were confirmed by either serologic or direct fluorescent antigen testing MMWR 2011 Vol 60 (32)
  29. 29. © 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, better know what’s in your water!  If Lp-6 in the water, diagnosis will be missed MMWR 2011 Vol 60 (32)
  30. 30. © Special Pathogens Laboratory LEGIONELLA: AN INTRACELLULAR PATHOGEN Therapy
  31. 31. © Special Pathogens Laboratory The Bacteria: Legionella Hijacks Human Macrophage
  32. 32. © Special Pathogens Laboratory Legionella replicates within pulmonary macrophages
  33. 33. © Special Pathogens Laboratory Treatment for Legionnaires’ Disease • Ineffective  Penicillins • Amoxacillin  Cephalosporins • Effective  Macrolides • Erythromycin • Azithromycin  Quinolones • Ciprofloxacin • Levofloxacin
  34. 34. © Special Pathogens Laboratory Solithromycin: A Fluoroketolide Antimicrob. Agents Chemother. 2014, 58(2):909
  35. 35. © Special Pathogens Laboratory Solithromycin vs. Azithromycin Solithromycin demonstrated the highest in vitro and intracellular potency against all Lp1 isolates compared to Azithromycin
  36. 36. © Special Pathogens Laboratory TRANSMISSION AND HEALTHCARE-ACQUIRED CASES Epidemiology and Infection Prevention
  37. 37. © Special Pathogens Laboratory Legionnaires’ Disease • Most cases in people with health conditions that increase risk  Early treatment with effective antibiotics reduces mortality  Mortality as high as 30% for healthcare acquired cases
  38. 38. © 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.
  39. 39. © Special Pathogens Laboratory Cases and Outbreaks • Majority of cases are sporadic and not outbreak-associated = no investigation • Outbreak is defined as two or more cases related in time & location = investigation
  40. 40. © Special Pathogens Laboratory HALD Case Definitions • Incubation period for Legionnaires’ disease is typically 2-10 days, but can be longer • Definite Case: a patient admitted for at least 10 days prior to onset of illness. • Probable Case: admitted for a portion of the incubation period prior to onset, including patients discharged and re- admitted within the incubation period.
  41. 41. © Special Pathogens Laboratory Problem • The average length of stay for pneumonia in the U.S. was 5.4 days.* • Very few cases will fulfill the definition for “Definite” healthcare-acquired Legionnaires’ disease *According to the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality
  42. 42. © Special Pathogens Laboratory Alert • Two or more “probable/possible” cases of healthcare-acquired Legionnaires’ disease should be investigated as unusual occurrence • Initiate clinical and environmental investigation
  43. 43. © Special Pathogens Laboratory © Special Pathogens Laboratory
  44. 44. © Special Pathogens Laboratory Historical Approaches to Prevention: Healthcare • 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
  45. 45. © Special Pathogens Laboratory Preventing Legionnaires’ Disease How are we doing?
  46. 46. © Special Pathogens Laboratory 217% Increase in Cases (2011)
  47. 47. © Special Pathogens Laboratory Increasing Cases 1998 - 2014
  48. 48. © Special Pathogens Laboratory Why Increase in Reported Cases? Better reporting? • Increase in diagnostic testing. • Environmental factors?
  49. 49. © Special Pathogens Laboratory Wet Weather & Legionnaires’ Disease?
  50. 50. © Special Pathogens Laboratory Cases Linked to Water Systems • Warm water distribution in:  Hospitals  Nursing homes  Rehabilitation centers  Office buildings  Apartment buildings  Hotels  Residential homes • Other water systems:  Spas and hot tubs  Decorative fountains  Humidifiers  Cooling towers
  51. 51. © Special Pathogens Laboratory How does Legionella get into our water?
  52. 52. © Special Pathogens Laboratory Legionella in Source Water (1987) • “Public water supplies may contaminate the plumbing systems of hospitals and other large buildings.” From: States, SJ, Conley LF, Kuchta JM, et al. Survival and multiplication of L. pneumophila in municipal drinking water systems. Appl. Environ. Microbiol. 1987; 53: 979-986.
  53. 53. © Special Pathogens Laboratory Ground, Surface, and Potable Waters and Legionella (1997) • “Results of this study confirm the ubiquity of Legionella in aquatic environments, even ground water.” from: Lye, D, Fout S, Crout S. et al. Survey of ground, surface, and potable waters for the presence of Legionella species by PCR, culture, and immunofluorescent staining. Water Res. 1997; 31: 287-293.
  54. 54. © Special Pathogens Laboratory Morbidity Mortality Weekly Report (MMWR). August 14, 2015/64 (31); 842-848. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water — United States, 2011–2012 Cases Linked to Drinking Water
  55. 55. © Special Pathogens Laboratory Legionella in Water: 2015 Centers for Disease Control and Prevention (CDC) reported: • Legionella accounted for 66% of reported drinking water–associated outbreaks • Legionella in building plumbing systems lead to drinking water–associated outbreaks.
  56. 56. © Special Pathogens Laboratory Origins of Legionella • Incoming potable water (undetectable or very low conc.) • Systems with warm water, such as water distributions systems and air cooling systems (provide growth factors) • Biofilms within these systems provide growth-promoting conditions
  57. 57. © Special Pathogens Laboratory Water Quality & LD
  58. 58. © Special Pathogens Laboratory Flint Legionnaires’ Disease Outbreak
  59. 59. © Special Pathogens Laboratory Legionellosis in the U.S. Outbreaks continue to occur (building warm water systems, cooling towers, fountains)
  60. 60. © Special Pathogens Laboratory Legionnaires' Cases in Quebec City TOTAL=180
  61. 61. © Special Pathogens Laboratory Outbreak • Canada’s biggest and deadliest in 25 years • 89 cooling towers disinfected • Source=Cooling Tower
  62. 62. © Special Pathogens Laboratory Outbreaks in Nursing Homes & Assisted Living Facilities
  63. 63. © Special Pathogens Laboratory OHIO HOSPITAL OUTBREAK LINKED TO NEW CONSTRUCTION
  64. 64. © Special Pathogens Laboratory Outbreak in 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 safety alerts
  65. 65. © Special Pathogens Laboratory Report available: https://han.pa.gov Public Health Alert
  66. 66. © 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.”
  67. 67. © Special Pathogens Laboratory DRINKING WATER What Ben Franklin had to say about drinking water
  68. 68. © Special Pathogens Laboratory 2015: Summer of Legionella
  69. 69. © Special Pathogens Laboratory South Bronx Outbreak • 130 cases, 12 deaths • Declared over August 20, 2015
  70. 70. © Special Pathogens Laboratory
  71. 71. © Special Pathogens Laboratory Outbreak Linked to Hotel Cooling Tower
  72. 72. © Special Pathogens Laboratory NEW YORK STATE EMERGENCY REGULATIONS
  73. 73. © Special Pathogens Laboratory Emergency Regulations • Cooling towers must be registered • Sample collection • Inspection • Reports to DOH • Certification • Maintenance program http://rules.cityofnewyork.us/content/c ooling-towers-new-chapter-8-title-24- rules-city-new-york-establish-rules- maintenance#sthash.aTDKzTB2.dpuf
  74. 74. © Special Pathogens Laboratory Unprecedented Response “Our new emergency regulations will make sure that building owners live up to their responsibilities and provide health officials with critical information to counter the spread of Legionella bacteria.” - Governor Cuomo
  75. 75. © Special Pathogens Laboratory Why Do Outbreaks Continue?
  76. 76. © Special Pathogens Laboratory Legionella-Related Anxiety
  77. 77. © Special Pathogens Laboratory Five Stages Of Coping with Legionella 1. Denial 2. Bargaining 3. Depression 4. Acceptance 5. Medication
  78. 78. © Special Pathogens Laboratory 1. Denial
  79. 79. © Special Pathogens Laboratory Denial Most wait to address the problem until after a case of Legionnaires’ disease is diagnosed.
  80. 80. © Special Pathogens Laboratory Approaches to Disease Prevention • REACTIVE  After 1 transplant patient or 2+ cases within 6 months • Combined epidemiologic and environmental investigation • Legionella source identified = decontaminate • PROACTIVE  Perform environmental surveillance before cases  Perform clinical surveillance to identify unrecognized cases • Legionella source identified = decontaminate
  81. 81. © Special Pathogens Laboratory 2 . Bargaining
  82. 82. © Special Pathogens Laboratory Bargaining • Legionella is everywhere • There’s hardly any cases • It is too costly to control/monitor • If I don’t know, I’m not responsible • Prevention isn’t required
  83. 83. © Special Pathogens Laboratory Myth: Legionella Is Everywhere • Published studies find:  20–70% of buildings and  30-50% of cooling towers colonized with Legionella • Legionella is not ubiquitous (everywhere)!
  84. 84. © Special Pathogens Laboratory Legionnaires’ Disease • In the U.S. approximately 600,000 adults are diagnosed with community-acquired pneumonia requiring hospitalization • A minimum of 2-5% are caused by Legionella, as many as 30,000 cases/year
  85. 85. © Special Pathogens Laboratory PREVENTING LEGIONNAIRES’ DISEASE Is It Worth the Effort (Money)?
  86. 86. © Special Pathogens Laboratory U.S. Healthcare Costs Associated with Legionnaires’ Disease Total hospitalization costs $101 - $321 million per year 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.
  87. 87. © Special Pathogens Laboratory Legionella Outbreaks Are Costly
  88. 88. © Special Pathogens Laboratory Costly Outbreaks • Even a single case can dramatically affect an organization $700,000
  89. 89. © Special Pathogens Laboratory $ 10 Million Outbreak Response: Pittsburgh VA Hospital
  90. 90. © Special Pathogens Laboratory 3. Depression
  91. 91. © Special Pathogens Laboratory 4. Acceptance
  92. 92. © Special Pathogens Laboratory The Times They Are a-Changin’ New Paradigm for Prevention
  93. 93. © Special Pathogens Laboratory ASHRAE Proposes a Standard to Prevent Legionnaires’ Disease American Society of Heating, Refrigerating and Air-conditioning Engineers
  94. 94. © Special Pathogens Laboratory ASHRAE 188: The Long & Winding Road • Committee was authorized as a standard committee in June 2005 • Five Public Review Documents
  95. 95. © Special Pathogens Laboratory • First Legionella standard in the United States. • Approved June 26, 2015
  96. 96. © Special Pathogens Laboratory Purpose of ASHRAE Standard 188 Establish minimum Legionellosis risk management requirements for building water systems.
  97. 97. © Special Pathogens Laboratory Impact on Legionella Litigation Property & Probate, Jan/Feb 2012
  98. 98. © Special Pathogens Laboratory Building Operating Management (Facilitiesnet.com) ASHRAE 188
  99. 99. © Special Pathogens Laboratory A Safe Harbor • ASHRAE Standard 188 is now industry “best practice” for prevention of Legionnaires’ disease • Compliance is a good defense against claims of negligence
  100. 100. © Special Pathogens Laboratory New Responsibilities BUILDING OWNERS & FACILITY MANAGERS Responsible for implementing ASHRAE 188 requirements and safeguards to protect against Legionella.
  101. 101. © Special Pathogens Laboratory Compliance The building shall be surveyed to determine whether it has one or more of the listed water systems and/or the factors described that relate to risk for Legionellosis.
  102. 102. © Special Pathogens Laboratory Water Systems Covered By 188 • Potable and non-potable water systems, in the building or on the site  Includes building water distribution systems (including centralized potable water heater systems)  Cooling towers, evaporative condensers  Whirlpools or spas  Ornamental fountains, misters, atomizers, air washes, humidifiers or other non-potable water systems or devices that release water aerosols in the building or on the site
  103. 103. © Special Pathogens Laboratory Section 5.2: Building Characteristics • Multiple housing units • > 10 stories high (including below grade) • Patient stays exceed 24 hours • One or more areas for purpose of housing or treating occupants receiving treatment for burns, chemotherapy, organ transplantation or bone marrow transplantation
  104. 104. © Special Pathogens Laboratory Section 5.2: Building Characteristics • One or more areas for the purpose of housing or treating occupants that are immuno-compromised, at-risk, taking drugs that weaken immune system, have renal disease, have diabetes, or chronic lung disease • Housing occupants over the age of 65.
  105. 105. © 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.
  106. 106. © Special Pathogens Laboratory Knowledge The Program Team shall have knowledge of the building water system design and water management as it relates to Legionellosis
  107. 107. © Special Pathogens Laboratory Common Assumptions: 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 are controlled, Legionella is controlled. • Water and energy conservation approaches minimize Legionella risk.
  108. 108. Important Information To Avoid Outbreaks • Outbreaks and New Construction  With renovation, installation of low flow/electronic sensor faucets  Commissioning process ineffective for Legionella removal  Long dormant periods (months) before occupying • CDC ELITE Labs  All are not equal in Legionella testing proficiency • Cooling Tower Biocides  All are not effective against Legionella
  109. 109. ELITE Certified Labs Did You Know That Labs Differ in Their Methods for Legionella Testing & Identification?
  110. 110. “Apples To Apples” or “Apples To Oranges”? Laboratory Testing
  111. 111. Culture Method • Processing Methods  Pretreatment (heat and/or acid)  Filtration (yes/no or how much)  Culture media (types and how many) • Identification (ID) Methods  Only presumptive agglutination test?  Definitive ID with DFA or sequencing for unusual species?
  112. 112. Testing Can Be Revealing Hospitals performing Legionella environmental testing are more likely to prevent cases of hospital-acquired Legionnaires’ disease Squier CL, Stout JE, Krystofiak S, McMahon J, Wagener MM, Dixon B. Yu VL. Am. J. Infect. Control 2005; 33(6): 360-367.
  113. 113. Questions to Ask • Was Legionella found in the water system? • Pathogenic species? • Extent of colonization?  Colonization Rate of >30% (Percent Positivity) = Increased Risk (Especially if L. pneumophila serogroup 1 present) • Colonization in sensitive areas?
  114. 114. TO TEST OR NOT TO TEST? Evaluating Risk of Exposure to Legionella
  115. 115. Proactive Approach Proactive: ACHD • Initiate environmental testing now! • if >30% sites positive for L. pneumophila, intensify clinical surveillance for cases • If cases identified, then consider disinfection
  116. 116. Allegheny County Approach to Prevention of Hospital-Acquired Legionnaires’ Disease
  117. 117. Approach to Environmental Sampling • Select a minimum of 10 distal sites (faucets or showers) that roughly represent the water distribution system, plus hot water tanks or recirc. line. • Include sites on multiple floors and wings, high risk areas like oncology, transplant units, medical surgical units.
  118. 118. Calculating Percent Positivity • Number of OUTLETS positive for Legionella of 10 distal sites (faucets or showers) that were tested • Estimating the probability of a patient “bumping into” Legionella (Percent Positive)
  119. 119. Risk – Potable Water 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
  120. 120. Risk Criteria Based on 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
  121. 121. © Special Pathogens Laboratory ASHRAE 188: Mind the Gaps
  122. 122. ASHRAE Compliance • Compliance is just the first step to protect yourself and building occupants • Compliance doesn’t guarantee Legionella control and cases can occur.
  123. 123. © Special Pathogens Laboratory ASHRAE 188: Your Decisions Fill The Gaps
  124. 124. © 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
  125. 125. © Special Pathogens Laboratory A Few Gaps • Legionella testing isn’t required to validate that the risk management program is working. • BUT testing is the only way to validate efficacy of your control measures and assess threat from Legionella. • The standard requires reducing hazardous conditions to an “acceptable level” through monitoring and maintenance • BUT doesn’t define “acceptable level.”
  126. 126. © Special Pathogens Laboratory Elements of Water Management Program • Validation  Evidence that confirms the effectiveness of the plan  How do you know Legionella is being controlled? • Establish validation measures – ? Quarterly culture for Legionella? Confirmation – Establish procedure to confirm Program is being implemented as designed (verification) and the Program effectively controls the hazardous conditions (validation).
  127. 127. © Special Pathogens Laboratory 5. Anxiety
  128. 128. © Special Pathogens Laboratory What is an acceptable amount of a contaminant?
  129. 129. © 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?
  130. 130. © Special Pathogens Laboratory Preventing Legionnaires’ Disease • Controlling Legionella is about preventing disease not about reaching zero Legionella in water. • Zero Cases Is the Goal • Zero Legionella not necessary to Avoid Outbreaks
  131. 131. © Special Pathogens Laboratory DISINFECTION APPROACHES I Have Legionella… Now What?
  132. 132. © Special Pathogens Laboratory WHEN TO CONSIDER SUPPLEMENTAL DISINFECTION
  133. 133. © Special Pathogens Laboratory Questions to Ask • Was Legionella found in the water system?  Pathogenic species?  Extent of colonization?  Colonization in sensitive areas?
  134. 134. © Special Pathogens Laboratory DISINFECTION OPTIONS
  135. 135. © 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 supplemental chlorination (2-4 mg/L) • Copper-silver ionization (continuous) • Chlorine Dioxide (ClO2) • Monochloramine • Point-of-use filtration
  136. 136. © Special Pathogens Laboratory ASHRAE 188: Information on Secondary Disinfection Missing • Generation technology • Impact to water quality • Impact to system components • Manufacture's operating ranges • Ability to maintain effective residual • Evidence-based efficacy • Permitting and operation requirements
  137. 137. © Special Pathogens Laboratory Disinfection Methods Review: Infection Control and Hospital Epidemiology
  138. 138. © Special Pathogens Laboratory Choosing Disinfection Method Choice of method must include infection control in addition to engineering
  139. 139. © Special Pathogens Laboratory Journal Am Water Works Assoc 2014; 106(10): 24-32 Latest Review: Journal of the American Water Works Association 2014 r
  140. 140. © Special Pathogens Laboratory Field Evaluations
  141. 141. © Special Pathogens Laboratory PROTECTING TRANSPLANT, HIGH RISK PATIENTS, NEONATES We Filter the Air… But Let Them Drink Tap Water?
  142. 142. © Special Pathogens Laboratory Epidemiology of Pediatric LD • CDC study showed 72% pediatric cases had healthcare exposure • Mortality rate 22% Alexander NT, et al 2008 ICAAC
  143. 143. © Special Pathogens Laboratory Point Of Use Filters Now Extended Use (60 day) POU Filters
  144. 144. © Special Pathogens Laboratory Evaluation Published in AJIC American Journal of Infection Control 2014: 42; 1193-6.
  145. 145. © Special Pathogens Laboratory ^ is the XXXXXXXX
  146. 146. © Special Pathogens Laboratory Not Just Legionella In Our Water Faucets Acinetobacter P. aeruginosa S. maltophilia Amoeba Resistant Microorganisms ( NTM’s )
  147. 147. © Special Pathogens Laboratory Culture Shows Klebsiella oxytoca, Enterobacter cloacae, Pseudomonas aeruginosa Water From MICU faucet!
  148. 148. © Special Pathogens Laboratory Nontuberculous Mycobacteria Clinical Infectious Diseases® 2015;61(1):67–75
  149. 149. © Special Pathogens Laboratory Emerging Infectious Diseases June 2016;22
  150. 150. © Special Pathogens Laboratory Sorin 3T Heater Cooler Unit
  151. 151. © Special Pathogens Laboratory Positive Sorin Culture M. chimaera
  152. 152. Summary • Legionnaires’ disease is increasing • Potable Water systems, especially in hospitals (and other buildings) with complex hot water systems, are the most important source of Legionella transmission. • Proactive prevention = ASHRAE 188 Water Management Programs and Risk Assessments • Environmental testing for Legionella is a key indicator for disease risk
  153. 153. Start Your ASHRAE 188 Water Safety Program Establish a Plan to Respond Not React
  154. 154. Legionella Anxiety?
  155. 155. © Special Pathogens Laboratory Mission: End Legionnaires’ Disease • Legionnaires’ disease can and should be prevented.
  156. 156. © Special Pathogens Laboratory Total Legionella Control An evidence-based, integrated platform of solutions: • Legionella & Pathogen Testing • Consulting & Education • ZEROutbreak Protection
  157. 157. © Special Pathogens Laboratory Let’s End LD Together
  158. 158. © Special Pathogens Laboratory WWW.SPECIALPATHOGENSLAB.COM THANK YOU Dr. Janet E. Stout President, Microbiologist info@specialpathogenslab.com

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