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.
© Special Pathogens Laboratory
Janet E. Stout, PhD
President & Director
LEGIONELLA AND
LEGIONNAIRES’
DISEASE
Emerging Cont...
© Special Pathogens Laboratory
My Affiliations
• President & Director
Special Pathogens Laboratory,
Pittsburgh, Pa.
• Rese...
© Special Pathogens Laboratory
MARK TWAIN
© Special Pathogens Laboratory
MARK TWAIN
It Ain’t What You Don’t Know
That Gets You into Trouble,
It’s What You Know For ...
© Special Pathogens Laboratory
Today’s Topics
• The Challenge of Legionnaires' disease
• Understanding Legionella In The B...
© Special Pathogens Laboratory
MY HISTORY WITH LEGIONELLA
IN BUILDING WATER SYSTEMS
© Special Pathogens Laboratory
© Special Pathogens Laboratory
Research Pioneers Starting in 1982
• Over 100 nosocomial
cases identified in 5
years in one...
© Special Pathogens Laboratory
• NOT a common
source for
sporadic and
hospital-acquired
cases
• More commonly
associated
w...
© Special Pathogens Laboratory
THE CHALLENGE OF
LEGIONNAIRES’ DISEASE
© Special Pathogens Laboratory
What Is Legionellosis?
• Legionnaires’ disease is a
multi-system illness, with pneumonia,
c...
© Special Pathogens Laboratory
Legionnaires’ Disease
Is Bacterial Pneumonia
© Special Pathogens Laboratory
The Bacteria:
Legionella
Hijacks
Human
Macrophage
© Special Pathogens Laboratory
Legionella
replicates within
pulmonary
macrophages
© Special Pathogens Laboratory
Treatment for Legionnaires’ Disease
• Ineffective
 Penicillins
• Amoxacillin
 Cephalospor...
© Special Pathogens Laboratory
Statistics: Centers for Disease
Control& Prevention
• 77% >50 years
• 62% male
• Hospitaliz...
© Special Pathogens Laboratory
Legionella
in water
(reservoir)
+
Transmission
to the host
(exposure)
+
Susceptible
Host
Ri...
© Special Pathogens Laboratory
Susceptible Hosts
• Elderly
• Smokers
• Immunocompromised
 Transplant patients
 High-dose...
© Special Pathogens Laboratory
Modes of Transmission
for Legionnaires’ disease
• Aerosolization
• Aspiration
• Direct inst...
© Special Pathogens Laboratory
Summary: Legionnaires’ Disease
• 2 – 5% of all community-acquired
pneumonia
• Most cases in...
© Special Pathogens Laboratory
Preventing Legionnaires’ Disease
How
are we
doing?
© Special Pathogens Laboratory
Legionella Is Winning
• Legionnaires’
disease is
increasing
• Legionella control
poses new
...
© Special Pathogens Laboratory
Legionnaires’ Disease Increasing?
Clinical Infectious Diseases 2008 vol. 47
© Special Pathogens Laboratory
2008 Conclusion
• Legionellosis cases have increased
substantially, particularly in the eas...
© Special Pathogens Laboratory
217% Increase in Cases (2011)
© Special Pathogens Laboratory
© Special Pathogens Laboratory
“Legionella …
is the single most common etiologic
agent asso...
© Special Pathogens Laboratory
Why Increase in Reported Cases?
Better reporting?
• Increase in diagnostic testing
 It’s n...
© Special Pathogens Laboratory
Wet Weather
and Legionnaires’ Disease?
© Special Pathogens Laboratory
What We Know Now
Potable water especially in hospitals
(and other buildings)
with complex h...
© Special Pathogens Laboratory
How does Legionella
get into our water?
© Special Pathogens Laboratory
Legionella in Source Water
• “Public water supplies may contaminate
the plumbing systems of...
© Special Pathogens Laboratory
Survey of Ground, Surface, and
Potable Waters for Legionella
• “Results of this study confi...
© Special Pathogens Laboratory
© Special Pathogens Laboratory
Origins of Legionella in Building Water
Systems Water?
1
2
3...
© Special Pathogens Laboratory
1 Drop of
Water Can
Contain
Thousands of
Legionella
© Special Pathogens Laboratory
Legionella Is Not Alone
• Legionella bacteria are part of a
community of microorganisms—a
c...
© Special Pathogens Laboratory
Many Other Microbes in
Water Help Legionella Grow
Amoebae
Bacteria Provide Nutrients
© Special Pathogens Laboratory
The
Bacteria:
Legionella
Hijacks
Human
Macrophage
© Special Pathogens Laboratory
In Nature
Legionella Hijacks Amoebae
© Special Pathogens Laboratory
Regulatory Approach to Legionella
• Opportunistic Bacteria - Legionella
 No level specifie...
© Special Pathogens Laboratory
Historically
Community Water
Systems Not a Focus
for Outbreaks or
Disinfection Efforts
© Special Pathogens Laboratory
New Study Suggests
Community Water
Systems Could Be a
Significant Source
for Legionella
© Special Pathogens Laboratory
Community Water System Outbreak
Epidemiology & Infection 2015
© Special Pathogens Laboratory
The Problem
New Jersey Health Department reports
cases of Legionnaires’ disease in
senior h...
© Special Pathogens Laboratory
The Investigation
• The population in the area was
∼9000 consistent with the area of
influe...
© Special Pathogens Laboratory
© Special Pathogens Laboratory
Results
• 56 samples taken from 12 sites located
within the targeted flushing zone
• L. pne...
© Special Pathogens Laboratory
Probable Causes
1. Low flow conditions
2. Low or no chlorine
3. Little mixing of water stor...
© Special Pathogens Laboratory
Recommendations
1. Include
community water
systems as
possible sources
for Legionella
trans...
© Special Pathogens Laboratory
Be Proactive
“Public health action
in the absence of
disease is
recommended”
© Special Pathogens Laboratory
Cases Linked to Water Systems
• Warm water distribution
in:
 Hospitals
 Nursing homes
 R...
© Special Pathogens Laboratory
Myth: Legionella Is Everywhere
• Published
studies find:
 20–70% of
buildings and
 30-50%...
© Special Pathogens Laboratory
Legionella Is Not Everywhere
• Legionella colonization or increases
associated with:
 Hot ...
© Special Pathogens Laboratory
PREVENTING
LEGIONNAIRES’ DISEASE
Is It Worth The Effort?
© Special Pathogens Laboratory
Legionnaires’ Disease
• In the U.S. approximately 600,000 adults
are diagnosed with
communi...
© Special Pathogens Laboratory
U.S. Healthcare Costs Associated
with Legionnaires’ Disease
Total hospitalization costs
$10...
© Special Pathogens Laboratory
Legionellosis in the U.S.
Outbreaks
continue to occur
(building warm
water systems,
cooling...
© Special Pathogens Laboratory
Legionnaires' Cases in
Quebec City
TOTAL=180
© Special Pathogens Laboratory
Outbreak
• Canada’s biggest and deadliest in
25 years
• 89 cooling towers disinfected
• Sou...
© Special Pathogens Laboratory
Outbreak in Germany
• Warstein, Germany
 165 cases, 12 ICU, 2 deaths caused by
Legionella ...
© Special Pathogens Laboratory
Public Safety Announcement
• “Whether or not the Warsteiner brewery is
found to be the bree...
© Special Pathogens Laboratory
South Bronx Outbreak
• 130 cases, 16
deaths
• Declared over
August 20,
2015
© Special Pathogens Laboratory
Outbreak Linked to Hotel
Cooling Tower
© Special Pathogens Laboratory
NEW YORK STATE
EMERGENCY REGULATIONS
© Special Pathogens Laboratory
© Special Pathogens Laboratory
Emergency Regulations
• Cooling towers must
be registered
• Sample collection
• Inspection
...
© Special Pathogens Laboratory
We Can Do Better!
Public health professionals should
focus on prevention of this important
...
© Special Pathogens Laboratory
INDICATION FOR
DISINFECTION
Environmental Monitoring for
Legionella: Key to Prevention
© Special Pathogens Laboratory
Legionella Up Close
Colonies of
Legionella
pneumophila have a
typical ground-glass,
opalesc...
© Special Pathogens Laboratory
Risk Criteria Based on
Environmental Monitoring Results
Concentration-based
thresholds that...
© Special Pathogens Laboratory
Risk – Potable Water
Risk of Legionnaires’ disease was better
predicted by the
proportion
o...
© Special Pathogens Laboratory
Other
species
10%
L. p. other
serogroups
10%
L. pneumophila; 90%
L. pneumophila,
serogroup ...
© Special Pathogens Laboratory
Legionella Species
• Gram negative bacterium – rod shaped
• >50 named species, over 60 sero...
© Special Pathogens Laboratory
All Legionella Are Not Dangerous
© Special Pathogens Laboratory
Legionella Species Are Not Equal
When it Comes to Causing Disease
• 58 named species to dat...
© Special Pathogens Laboratory
Legionella Species That
Fluoresce Under UV Light
• Some fluoresce
red and some
fluoresce bl...
© Special Pathogens Laboratory
Legionella Species Table
www.specialpathogenslab.com
© Special Pathogens Laboratory
© Special Pathogens Laboratory
Methods for Legionella
Testing & Identification:
Did You Know That Labs
Differ in Their Met...
© Special Pathogens Laboratory
“Apples To Apples”
or
“Apples To Oranges”?
Laboratory Testing
© Special Pathogens Laboratory
Culture Method
• Processing Methods
 Pretreatment (heat and/or acid)
 Filtration (yes/no ...
© Special Pathogens Laboratory
Selecting a Laboratory
• Environmental culturing should be
performed by a laboratory that i...
© Special Pathogens Laboratory
Culture Method
• Industry standard/best practice
 Standards based
• ISO 11731 (1&2)
• ASTM...
© Special Pathogens Laboratory
Culture Is Gold Standard
• Culture is more
reliable than “rapid
tests”
 DFA
 ICT
 PCR
 ...
© Special Pathogens Laboratory
Quick But Inaccurate?
© Special Pathogens Laboratory
Molecular Methods For
Legionella Testing:
Are We There Yet?
© Special Pathogens Laboratory
Molecular Methods: U.S. Centers
For Disease Prevention (CDC)
• CDC does not currently recom...
© Special Pathogens Laboratory
Is the Sky Falling if I
Find Some Legionella?
© Special Pathogens Laboratory
INTERPRETING RESULTS
What is the
acceptable
amount of
Legionella?
© Special Pathogens Laboratory
000000000000000000000000000000000000000000000000000000000000000000000
000000000000000000000...
© Special Pathogens Laboratory
Preventing Legionnaires’ Disease
Through Legionella Control
Zero Cases Is The Goal,
Not
Zer...
© Special Pathogens Laboratory
Approaches to Prevention
© Special Pathogens Laboratory
The Times They Are a-Changin’
New
Paradigm
for
Prevention
© Special Pathogens Laboratory
ASHRAE Proposes a Standard to
Prevent Legionnaires’ Disease
American Society of Heating, Re...
© Special Pathogens Laboratory
SPC 188: The Long & Winding Road
Committee was
authorized as a
standard
committee in
June 2...
© Special Pathogens Laboratory
• First Legionella
standard in the
United States.
• Approved
June 26, 2015
© Special Pathogens Laboratory
What Is ASHRAE Standard 188?
The purpose is to
establish minimum
Legionellosis risk
managem...
© Special Pathogens Laboratory
ASHRAE 188
Water Safety
and
Management
Plans
© Special Pathogens Laboratory
Step One
The building shall be surveyed annually
to determine whether it has one or
more of...
© Special Pathogens Laboratory
Elements of Water Management
Program
Program Team – Persons responsible for Program develop...
© Special Pathogens Laboratory
WMP Team
Determines Approach to Testing
• The Program Team shall determine
the testing appr...
© Special Pathogens Laboratory
© Special Pathogens Laboratory
Legionella Testing
If you don’t look for it,
you won’t find ...
© Special Pathogens Laboratory
ASHRAE 188: Mind the Gaps
© Special Pathogens Laboratory
Compliance Not Legionella Control
The ASHRAE 188
Legionella Standard
tells building owners
...
© Special Pathogens Laboratory
A Few Gaps
• Legionella testing
isn’t required to
validate that the risk
management
program...
© Special Pathogens Laboratory
ASHRAE 188:
Your Decisions Fill The Gaps
© Special Pathogens Laboratory
ASHRAE Compliance
Compliance
doesn’t guarantee
Legionella control
and
cases could occur.
© Special Pathogens Laboratory
CONTROL STRATEGIES FOR
PREVENTION
© Special Pathogens Laboratory
Secondary Disinfection Methods
• Thermal shock
treatment
(heat & flush)
• Shock chlorinatio...
© Special Pathogens Laboratory
Disinfection Methods Review: Infection
Control and Hospital Epidemiology
© Special Pathogens Laboratory
Journal Am Water Works Assoc 2014; 106(10): 24-32
Latest Review: Journal of the American
Wa...
© Special Pathogens Laboratory
EPA: Safe Drinking Water Act
http://water.epa.gov/lawsregs/rulesregs/sdwa/index.cfm
© Special Pathogens Laboratory
Building Disinfection Options
Municipal Water Treatment Building Water Treatment
Chlorine C...
© Special Pathogens Laboratory
MONOCHLORAMINE
Newest Approach for Legionella
Control in Building Water Systems
© Special Pathogens Laboratory
Performed First Study
in United States
OBJECTIVE
Determine the efficacy of this new
system ...
© Special Pathogens Laboratory
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline
(4/11 -
9/19/2011)
Week 1
(10/6/2011)
...
© Special Pathogens Laboratory
Conclusions
• On-site monochloramine (1.5 – 3.0 mg/L)
injection into the hot water signific...
© Special Pathogens Laboratory
Published Results
© Special Pathogens Laboratory
© Special Pathogens Laboratory
© Special Pathogens Laboratory
What Should I Do?
© Special Pathogens Laboratory
Approaches to Disease Prevention
• REACTIVE
 After 1 transplant
patient or 2+ cases
within...
© Special Pathogens Laboratory
Proactive Approach Reduced
Legionnaires’ Disease
Am. J. Infection Control 2005; 33(6):360-3...
© Special Pathogens Laboratory
Mission: End Legionnaires’ Disease
• No one should die
from a preventable
disease caused by...
© Special Pathogens Laboratory
WWW.SPECIALPATHOGENSLAB.COM
THANK YOU
Dr. Janet E. Stout
Director, Microbiologist
info@spec...
Upcoming SlideShare
Loading in …5
×

Legionella and Legionnaires' Disease: Emerging Contaminant and Preventable Disease

133 views

Published on

Presentation delivered to SE PA AWWA on October 22, 2015 by Dr. Janet Stout.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Legionella and Legionnaires' Disease: Emerging Contaminant and Preventable Disease

  1. 1. © Special Pathogens Laboratory Janet E. Stout, PhD President & Director LEGIONELLA AND LEGIONNAIRES’ DISEASE Emerging Contaminant & Preventable Disease
  2. 2. © Special Pathogens Laboratory My Affiliations • President & Director Special Pathogens Laboratory, Pittsburgh, Pa. • Research Associate Professor, University of Pittsburgh Swanson School of Engineering Department of Civil & Environmental Engineering
  3. 3. © Special Pathogens Laboratory MARK TWAIN
  4. 4. © 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
  5. 5. © Special Pathogens Laboratory Today’s Topics • The Challenge of Legionnaires' disease • Understanding Legionella In The Built Environment or • Why Is Legionella In My Water Systems? • Role of Legionella Testing In Disease Prevention • Approaches To Prevention
  6. 6. © Special Pathogens Laboratory MY HISTORY WITH LEGIONELLA IN BUILDING WATER SYSTEMS
  7. 7. © Special Pathogens Laboratory
  8. 8. © Special Pathogens Laboratory Research Pioneers 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 • NOT a common source for sporadic and hospital-acquired cases • More commonly associated with large community outbreaks Paradigm Shift: Not Cooling Towers
  10. 10. © Special Pathogens Laboratory THE CHALLENGE OF LEGIONNAIRES’ DISEASE
  11. 11. © Special Pathogens Laboratory What Is Legionellosis? • Legionnaires’ disease is a multi-system illness, with pneumonia, caused by Legionella species. • Admission to ICU is common
  12. 12. © Special Pathogens Laboratory Legionnaires’ Disease Is Bacterial Pneumonia
  13. 13. © Special Pathogens Laboratory The Bacteria: Legionella Hijacks Human Macrophage
  14. 14. © Special Pathogens Laboratory Legionella replicates within pulmonary macrophages
  15. 15. © Special Pathogens Laboratory Treatment for Legionnaires’ Disease • Ineffective  Penicillins • Amoxacillin  Cephalosporins • Effective  Macrolides • Erythromycin • Azithromycin  Quinolones • Ciprofloxacin • Levofloxacin
  16. 16. © Special Pathogens Laboratory Statistics: Centers for Disease Control& Prevention • 77% >50 years • 62% male • Hospitalizations occurred in 98%  ICU admission in 39%  Death in 10% -30%
  17. 17. © Special Pathogens Laboratory Legionella in water (reservoir) + Transmission to the host (exposure) + Susceptible Host Risk of Acquiring Disease Exposure Alone Does Not = Disease Aquisition
  18. 18. © 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
  19. 19. © 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)
  20. 20. © Special Pathogens Laboratory Summary: Legionnaires’ Disease • 2 – 5% of all community-acquired pneumonia • 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
  21. 21. © Special Pathogens Laboratory Preventing Legionnaires’ Disease How are we doing?
  22. 22. © Special Pathogens Laboratory Legionella Is Winning • Legionnaires’ disease is increasing • Legionella control poses new challenges
  23. 23. © Special Pathogens Laboratory Legionnaires’ Disease Increasing? Clinical Infectious Diseases 2008 vol. 47
  24. 24. © Special Pathogens Laboratory 2008 Conclusion • Legionellosis cases have increased substantially, particularly in the eastern U.S. and among middle-aged adults • Public health professionals should focus on of this important and increasing public health problem
  25. 25. © Special Pathogens Laboratory 217% Increase in Cases (2011)
  26. 26. © 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
  27. 27. © Special Pathogens Laboratory Why Increase in Reported Cases? Better reporting? • Increase in diagnostic testing  It’s not an outbreak, it’s an “outbreak of diagnosis” • Environmental factors?
  28. 28. © Special Pathogens Laboratory Wet Weather and Legionnaires’ Disease?
  29. 29. © 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.
  30. 30. © Special Pathogens Laboratory How does Legionella get into our water?
  31. 31. © Special Pathogens Laboratory Legionella in Source Water • “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.
  32. 32. © Special Pathogens Laboratory Survey of Ground, Surface, and Potable Waters for Legionella • “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.
  33. 33. © Special Pathogens Laboratory © Special Pathogens Laboratory Origins of Legionella in Building Water Systems Water? 1 2 3 4
  34. 34. © Special Pathogens Laboratory 1 Drop of Water Can Contain Thousands of Legionella
  35. 35. © Special Pathogens Laboratory Legionella Is Not Alone • Legionella bacteria are part of a community of microorganisms—a consortium of bacteria and protozoa. • They live synergistically—one benefiting the other for mutual survival.
  36. 36. © Special Pathogens Laboratory Many Other Microbes in Water Help Legionella Grow Amoebae Bacteria Provide Nutrients
  37. 37. © Special Pathogens Laboratory The Bacteria: Legionella Hijacks Human Macrophage
  38. 38. © Special Pathogens Laboratory In Nature Legionella Hijacks Amoebae
  39. 39. © Special Pathogens Laboratory Regulatory Approach to Legionella • Opportunistic Bacteria - Legionella  No level specified by regulation or public health standard  U.S. Environmental Protection Agency (EPA) considers water acceptable if treatment plant uses techniques to control parasites
  40. 40. © Special Pathogens Laboratory Historically Community Water Systems Not a Focus for Outbreaks or Disinfection Efforts
  41. 41. © Special Pathogens Laboratory New Study Suggests Community Water Systems Could Be a Significant Source for Legionella
  42. 42. © Special Pathogens Laboratory Community Water System Outbreak Epidemiology & Infection 2015
  43. 43. © Special Pathogens Laboratory The Problem New Jersey Health Department reports cases of Legionnaires’ disease in senior high rise, geriatric center and single family housing
  44. 44. © Special Pathogens Laboratory The Investigation • The population in the area was ∼9000 consistent with the area of influence of a 1 million gallon water tower. • Investigation implicates poorly maintained water storage tank and surrounding distribution system
  45. 45. © Special Pathogens Laboratory
  46. 46. © Special Pathogens Laboratory Results • 56 samples taken from 12 sites located within the targeted flushing zone • L. pneumophila serogroup 1 was found in 25% of the sample sites from pre-flushing samples (1–2100 c.f.u.) • 50% of the sample sites from flushing samples
  47. 47. © Special Pathogens Laboratory Probable Causes 1. Low flow conditions 2. Low or no chlorine 3. Little mixing of water storage tank 4. No regular flushing of water mains
  48. 48. © Special Pathogens Laboratory Recommendations 1. Include community water systems as possible sources for Legionella transmission. 2. Community water systems supplied by surface water, especially where summer temperatures and available nutrients can amplify Legionella.
  49. 49. © Special Pathogens Laboratory Be Proactive “Public health action in the absence of disease is recommended”
  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 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)!
  52. 52. © Special Pathogens Laboratory Legionella Is Not Everywhere • Legionella colonization or increases associated with:  Hot water heater temp <122oF  Buildings taller than 10 stories  Buildings with centralized hot water systems  Interruptions in water service
  53. 53. © Special Pathogens Laboratory PREVENTING LEGIONNAIRES’ DISEASE Is It Worth The Effort?
  54. 54. © 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
  55. 55. © Special Pathogens Laboratory U.S. Healthcare Costs Associated with Legionnaires’ Disease Total hospitalization costs $101 - $321 million dollars 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.
  56. 56. © Special Pathogens Laboratory Legionellosis in the U.S. Outbreaks continue to occur (building warm water systems, cooling towers, fountains)
  57. 57. © Special Pathogens Laboratory Legionnaires' Cases in Quebec City TOTAL=180
  58. 58. © Special Pathogens Laboratory Outbreak • Canada’s biggest and deadliest in 25 years • 89 cooling towers disinfected • Source=Cooling Tower
  59. 59. © 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
  60. 60. © 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.”
  61. 61. © Special Pathogens Laboratory South Bronx Outbreak • 130 cases, 16 deaths • Declared over August 20, 2015
  62. 62. © Special Pathogens Laboratory Outbreak Linked to Hotel Cooling Tower
  63. 63. © Special Pathogens Laboratory NEW YORK STATE EMERGENCY REGULATIONS
  64. 64. © Special Pathogens Laboratory
  65. 65. © Special Pathogens Laboratory Emergency Regulations • Cooling towers must be registered • Sample collection • Inspection • Reports to DOH • Certification • Maintenance program
  66. 66. © Special Pathogens Laboratory We Can Do Better! Public health professionals should focus on prevention of this important and increasing public health problem
  67. 67. © Special Pathogens Laboratory INDICATION FOR DISINFECTION Environmental Monitoring for Legionella: Key to Prevention
  68. 68. © Special Pathogens Laboratory Legionella Up Close Colonies of Legionella pneumophila have a typical ground-glass, opalescent morphology
  69. 69. © Special Pathogens Laboratory 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
  70. 70. © Special Pathogens Laboratory 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
  71. 71. © Special Pathogens Laboratory Other species 10% L. p. other serogroups 10% L. pneumophila; 90% L. pneumophila, serogroup 1; 50-80% Causes of Legionnaires’ Disease Among more than 50 species
  72. 72. © Special Pathogens Laboratory Legionella Species • Gram negative bacterium – rod shaped • >50 named species, over 60 serogroups • Legionella pneumophila (sg’s 1-15) accounts for approx. 90% of cases reported to the CDC • L. pneumophila, serogroup 1 causes approx. 80% of cases (most virulent)
  73. 73. © Special Pathogens Laboratory All Legionella Are Not Dangerous
  74. 74. © Special Pathogens Laboratory Legionella Species Are Not Equal When it Comes to Causing Disease • 58 named species to date • Only half implicated in human disease • Some species very common in the environment, but rarely cause illness, and almost exclusively in the immunocompromised
  75. 75. © Special Pathogens Laboratory Legionella Species That Fluoresce Under UV Light • Some fluoresce red and some fluoresce blue- white • Blue-white species  L. anisa  L. dumoffii  L. gormanii  L. bozemanii Legionella rubrilucens
  76. 76. © Special Pathogens Laboratory Legionella Species Table www.specialpathogenslab.com
  77. 77. © Special Pathogens Laboratory
  78. 78. © Special Pathogens Laboratory Methods for Legionella Testing & Identification: Did You Know That Labs Differ in Their Methods?
  79. 79. © Special Pathogens Laboratory “Apples To Apples” or “Apples To Oranges”? Laboratory Testing
  80. 80. © Special Pathogens Laboratory 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?
  81. 81. © Special Pathogens Laboratory Selecting a Laboratory • Environmental culturing should be performed by a laboratory that is experienced in culturing Legionella spp. from environmental samples.
  82. 82. © Special Pathogens Laboratory Culture Method • Industry standard/best practice  Standards based • ISO 11731 (1&2) • ASTM D 5952 • International – HSE L8 ACP 2013  Proficiency Programs • ELITE is not a traditional proficiency program
  83. 83. © Special Pathogens Laboratory Culture Is Gold Standard • Culture is more reliable than “rapid tests”  DFA  ICT  PCR  Dip slide • Laboratory-based and validated culture method is the industry standard
  84. 84. © Special Pathogens Laboratory Quick But Inaccurate?
  85. 85. © Special Pathogens Laboratory Molecular Methods For Legionella Testing: Are We There Yet?
  86. 86. © Special Pathogens Laboratory Molecular Methods: U.S. Centers For Disease Prevention (CDC) • CDC does not currently recommend the routine use of genetic probes or PCR for detection of Legionella.  “Use of PCR for the identification of Legionella spp. is not recommended until more data regarding sensitivity and specificity of procedures are available”
  87. 87. © Special Pathogens Laboratory Is the Sky Falling if I Find Some Legionella?
  88. 88. © Special Pathogens Laboratory INTERPRETING RESULTS What is the acceptable amount of Legionella?
  89. 89. © 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?
  90. 90. © Special Pathogens Laboratory Preventing Legionnaires’ Disease Through Legionella Control Zero Cases Is The Goal, Not Zero Legionella (Not Necessary to Avoid Outbreaks)
  91. 91. © Special Pathogens Laboratory Approaches to Prevention
  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 SPC 188: The Long & Winding Road Committee was authorized as a standard committee in June 2005, formally renamed SPC188 Jan 2006.
  95. 95. © Special Pathogens Laboratory • First Legionella standard in the United States. • Approved June 26, 2015
  96. 96. © Special Pathogens Laboratory What Is ASHRAE Standard 188? The purpose is to establish minimum Legionellosis risk management requirements for building water systems
  97. 97. © Special Pathogens Laboratory ASHRAE 188 Water Safety and Management Plans
  98. 98. © Special Pathogens Laboratory Step One The building shall be surveyed annually to determine whether it has one or more of the listed water systems and/or the factors described that relate to risk for Legionellosis.
  99. 99. © 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.
  100. 100. © Special Pathogens Laboratory WMP Team Determines Approach to Testing • The Program Team shall determine the testing approach including:  Sampling frequency  Number of samples  Locations and sampling methods
  101. 101. © Special Pathogens Laboratory © 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.
  102. 102. © Special Pathogens Laboratory ASHRAE 188: Mind the Gaps
  103. 103. © Special Pathogens Laboratory Compliance Not Legionella Control The ASHRAE 188 Legionella Standard tells building owners what to do but not how to do it. • This creates gaps when it comes to Legionella control— gaps that could make building owners vulnerable and open to liability claims for failing to prevent disease.
  104. 104. © 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.”
  105. 105. © Special Pathogens Laboratory ASHRAE 188: Your Decisions Fill The Gaps
  106. 106. © Special Pathogens Laboratory ASHRAE Compliance Compliance doesn’t guarantee Legionella control and cases could occur.
  107. 107. © Special Pathogens Laboratory CONTROL STRATEGIES FOR PREVENTION
  108. 108. © 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
  109. 109. © Special Pathogens Laboratory Disinfection Methods Review: Infection Control and Hospital Epidemiology
  110. 110. © Special Pathogens Laboratory Journal Am Water Works Assoc 2014; 106(10): 24-32 Latest Review: Journal of the American Water Works Association 2014 r
  111. 111. © Special Pathogens Laboratory EPA: Safe Drinking Water Act http://water.epa.gov/lawsregs/rulesregs/sdwa/index.cfm
  112. 112. © Special Pathogens Laboratory Building Disinfection Options Municipal Water Treatment Building Water Treatment Chlorine Chlorine Chlorine Dioxide Chlorine Dioxide Monochloramine Monochloramine UV UV * Copper-Silver Ionization * Point of Use Filters
  113. 113. © Special Pathogens Laboratory MONOCHLORAMINE Newest Approach for Legionella Control in Building Water Systems
  114. 114. © Special Pathogens Laboratory Performed First Study in United States OBJECTIVE Determine the efficacy of this new system for on-site generation of monochloramine for controlling Legionella in a hospital water systems
  115. 115. © Special Pathogens Laboratory 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Baseline (4/11 - 9/19/2011) Week 1 (10/6/2011) Month 1 (10/24/2011) Month 2 (11/21/2011) Month 3 (12/19/2011) Month 4 (1/17/2012) Month 5 (2/21/2012) Month 6 (3/19/2012) Distal Site Positivity (%) Dramatic Reduction in Legionella after Treatment Sanipur Monochloramine Injection: 9/26/2011
  116. 116. © Special Pathogens Laboratory Conclusions • On-site monochloramine (1.5 – 3.0 mg/L) injection into the hot water significantly reduced Legionella positivity • No increase in other pathogens (Pseudomonas, Stenotrophomonas, etc) • Ongoing testing shows reduction in Mycobacteria
  117. 117. © Special Pathogens Laboratory Published Results
  118. 118. © Special Pathogens Laboratory © Special Pathogens Laboratory
  119. 119. © Special Pathogens Laboratory What Should I Do?
  120. 120. © 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  Before cases, perform environmental surveillance  Also perform clinical surveillance to identify unrecognized cases • Legionella source identified = decontaminate
  121. 121. © Special Pathogens Laboratory Proactive Approach Reduced Legionnaires’ Disease Am. J. Infection Control 2005; 33(6):360-367
  122. 122. © Special Pathogens Laboratory 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.
  123. 123. © Special Pathogens Laboratory WWW.SPECIALPATHOGENSLAB.COM THANK YOU Dr. Janet E. Stout Director, Microbiologist info@specialpathogenslab.com

×