developing a water management program to reduce legionella growth & spread in buildings ›...
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Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings
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George W. Young, CHC, CIECVice President of Operations
Environmental Safety Technologies
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Hospital-acquired LD (HA-LD) -or-Healthcare-associated LD
Hospital
aerosols
Many different Legionella species and serogroups
City water (Legionella possible in low numbers)
drinking/aspiration from URT
biofilm
or
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Legionella are a Family of EnvironmentalBacteria that Live in Water
Family of different species • > 50 different species in genus Legionella• L. pneumophila – 90% of disease• Some species no disease
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Building water – requirements to be met for Legionnaires disease• warm (not too cold, not too hot)• high levels of Legionella• mechanism for airborne (aerosol) dissemination or drinking• susceptible host (hospitalized, older, normal people)
Legionella Live in Building Water
biofilm
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Cooling towers Potable water (hot water)
Whirlpool spas Decorative fountains / Water wallsHydrotherapy pools
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Cooling Tower Outbreaks
Travel distances with the wind
Aerosol
Legionella
Legionella increase to high numbers in the water
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Potable Water Outbreaks
Legionella
Legionella
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Potable Water Outbreaks
Legionella
Estimates that 70% of all cases of Legionnaires’ disease are from potable water
Immuno-compromised patients
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Potable Water Outbreaks
Legionella colonize building potable water systems (especially hot loop)
Water containing Legionella gets into the air (aerosolization)
Faucets/showerheads
Legionella
reservoir
Inhale sufficient Legionella into lungs
Growth in lungs
Legionnaires’ Disease pneumonia
Not all of the patients used the showers!
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Legionnaires’ Disease
How can this be prevented?
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• Complying with ASHRAE Standard 188• Preventing Legionnaires’ Disease
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Part III• Complying with ASHRAE Standard 188
• Preventing Legionnaires’ diseaseASHRAE Standard 188 Committee
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Legionnaires Disease Guidelines
2008
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Legionnaires Disease Guidelines
2008Why is there still a problem? (i.e. why haven’t they worked?)Lack of consensus on some issues,
No mandate to do anything in most locales
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Centers for Disease Control and Prevention2017
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CDC Vital Signs Report
Legionnaires' disease is a severe pneumonia typically acquired through inhalation of aerosolized water containing Legionella bacteria. Legionella can grow in the complex water systems that supply many buildings, including health care facilities, when those systems are not well managed. Thus, effective water management programs could prevent the growth of Legionella in these building water systems.
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CDC Vital Signs Report
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Legionnaires' disease in hospitals is widespread, deadly and preventable," said CDC Acting Director Anne Schuchat, M.D., in a June 6 news release.(www.cdc.gov) "These data are especially important for health care facility leaders, doctors and facility managers because it reminds them to think about the risks of Legionella in their facility and to take action.
"Controlling these bacteria in water systems can be challenging, but it is essential to protect patients."
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CDC Vital Signs Report
Legionella Poses Risk for Patients in Health Care Facilities
June 15, 2017 05:00 pm News Staff – The CDC released a Morbidity and Mortality Weekly Report (MMWR)(www.cdc.gov) and an accompanying Vital Signs report on June 6 that analyzed the prevalence of Legionnaires' disease in the U.S. health care system and found that 76 percent of facilities studied reported health care-associated cases of the disease.
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CDC Vital Signs Report
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Seventy-two health care facilities in 16 of the 21 U.S. jurisdictions the CDC studied reported definite health care-related cases of Legionnaires' disease, which is known to kill one-quarter of patients who are infected.
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CMS Memorandum Summary
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Legionella Infections:
The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least 50 years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.
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CMS Memorandum Summary
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Facility Requirements to Prevent Legionella Infections:
Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water.
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CMS Memorandum Summary
In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least 50 years old, smokers, and those with underlying medical conditions such as chronic lung disease or immunosuppression. Legionella can grow in parts of building water systems that are continually wet, and certain devices can spread contaminated water droplets via aerosolization. Examples of these system components and devices include:
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CMS Memorandum Summary-Examples of these system components and devices include:
Hot and cold water storage tanks Water heaters Water-hammer arrestors Pipes, valves, and fittings Expansion tanks Water filters Electronic and manual faucets Aerators Faucet flow restrictors Showerheads & hosesEyewash stations Ice machines
Centrally-installed misters, atomizers, air washers, and humidifiers Nonsteam aerosol-generating humidifiers Hot tubs/saunas Decorative fountains Cooling towers Medical devices (such as CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)
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Surveyors will review policies, procedures, and reports documenting water management implementation results to
verify that facilities:
Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
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Surveyors will review policies, procedures, and reports documenting water management implementation results to
verify that facilities:
Implement a water management programthat considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
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Surveyors will review policies, procedures, and reports documenting water management implementation results to
verify that facilities:
Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
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In 2015, a total of 6,079 cases of legionellosis were reported to NNDSS, although the CDC noted that this estimate may be low due to underdiagnosis.
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Does the Standard apply to all buildings?
Who needs to comply with the Standard?
NO!
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Scope
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Assembled by the owner/CEO/top management
Size of the committee depends on the complexity of the buiding risks
Administration / Management
Operations / Engineering
Water Treatment Company (under contract)Legionella Microbiologist
Infection Prevention
Risk Management / Safety
Infectious Diseases Physician
Hospital – multiple risks (potable water, cooling towers, etc)
Appoint Program/Designated Team
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Assembled by the owner/CEO/top management
Most BuildingsHealthcare Facilities
(Accredited with Infection Preventionists)
Comply with Normative Appendix A
Step 1
Appoint the Program Team Appoint the Designated Team
Comply with the main body of Standard 188
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Compliance
Potable water system?
Perform a risk characterization survey for Legionnaires’ disease based on building characteristics, its water systems, and its
occupants
Appoint a person or committee
Standard only applies for buildings if: Inpatient healthcare facility Persons taking immunosuppressive drugs, chemotherapy
Building owners, CEO, Facility Management
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Compliance
Potable water system?
Perform a risk characterization survey for Legionnaires’ disease based on building characteristics, its water systems, and its
occupants
Appoint a person or committee
Standard only applies for buildings if: Inpatient healthcare facility Persons taking immunosuppressive drugs, chemotherapy Persons over 65 years old (i.e. nursing homes)
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Compliance
Potable water system?
Perform a risk characterization survey for Legionnaires’ disease based on building characteristics, its water systems, and its
occupants
Appoint a person or committee
Standard only applies for buildings if: Inpatient healthcare facility Persons taking immunosuppressive drugs, chemotherapy Persons over 65 years old (i.e. nursing homes) Multiple housing units with centralized hot water heaters
(hotels, condos, prisons, etc) Building more than 10 stories
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Building owners, CEO, Facility Management
Cooling tower?
Perform a risk characterization for Legionnaires’ disease based on building characteristics, its
water systems, and its occupants
Appoint a person or committee
Compliance
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Building owners, CEO, Facility Management
Appoint a person or committee
Cooling tower?
Whirlpool spa?
Decorative fountain?
Other aerosol-generating device?
Perform a risk characterization for Legionnaires’ disease based on building characteristics, its
water systems, and its occupants
Compliance
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Building owners, CEO, Facility Management
No
StopFile a document with this finding and repeat yearly
Appoint a person or committee
Perform a risk characterization for Legionnaires’ disease based on building characteristics, its
water systems, and its occupants
Compliance
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Building owners, CEO, Facility Management
Yes
Required to comply with certain measures in the Standard intended to reduce or eliminate the risk of
Legionnaires’ disease in those building water systems
Appoint a person or committee
Perform a risk characterization for Legionnaires’ disease based on building characteristics, its
water systems, and its occupants
Compliance
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Comply with the main body of Standard 188
Compliance
Most Buildings Healthcare Facilities (Accredited with Infection
Preventionists)
Comply with Normative Appendix A
or
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Compliance
HospitalsMost Buildings
Main Path for compliance Healthcare Path for compliance
7 Easy Steps to Compliance
1
2
3
4
5
6
7
Written into a document Risk Management Plan
Written into a document Water Management Program
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Cooling towers
Whirlpool spas Decorative fountainsDevelop flow diagrams/end points of use
Water Management Program
Program/Designated Team
Step 2
Potable water (hot water)
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Cooling towers
Whirlpool spas Decorative fountains
Program/Designated Team
Water Management Program
Steps 3-5
Biocides
Halogen Monitor
Control Measures
Potable water (hot water)
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Cooling towers
Whirlpool spas Decorative fountains
Program/Designated Team
Water Management Program
Step 6
Verification
Validation
Legionella
Potable water (hot water)
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Cooling towers Potable water (hot water)
Whirlpool spas Decorative fountains
Water Management Program
Validation?
Program/Designated Team
Step 6NYC
Quarterly testing for Legionella Legionella
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Cooling towers Potable water (hot water)
Whirlpool spas Decorative fountains
Program/Designated Team
Water Management Program
Let’s look at an example
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Hospital A
Risk Characterization
Multiple building campus needs only one Legionella Risk Management Plan as long as management is handled by the same group
Program/Designated Team
Healthcare facility – potable waterCooling towers – fourHeated therapy poolWater wall
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Hospital A
Control MeasuresPotable Water
Flow diagrams
Designated Team
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Control Measures
Cl2 from city >0.5 ppm
Not reliable
Helpful- not 100%Hot water must exceed 124°F in order to prevent growth of Legionella
Water temperature
140° F storage>130° F discharge>124° F return(VA Directive 2014)
Mixing valve to reduce the water temperature to 110°F at each distribution point immediately before the faucet or showerhead. Plus anti-scald devices.
Cold water must <67°F to the greatest extent practical in order to prevent growth of Legionella
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Control Points
Cl2 from city >0.5 ppm
Point-of-use filters
Bottled water for patient drinking
Not reliable
Helpful- not 100%
100% effective
100% effective
Hospitals140° F storage130° F discharge>124° F return(VA Directive 2014)
Water temperature
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Hospital A
Control MeasuresPotable Water
Temperature (140/130/124 F)• Monitoring the Control? Continuous temp records
Designated Team
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Hospital A
Critical Control Points (CCP)Potable Water
Samples throughout the distribution system (typically at least 10)
Temperature (140/130/124 F)• Validation - Has the hazard been controlled?
Temperature (140/130/124 F)• Validation - Legionella testing of water
- cases of Legionnaires’ disease
Designated Team
Many healthcare facilities do both, as the best possible risk management of Legionnaires’ disease
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Hospital A
Corrective Action
Designated Team
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Hospital A
Corrective ActionEmergency Potable Water Disinfection
• heat/flush (flush all distal sites for 30 min with 160-170 F water)
• hyperchlorination ( flush all distal sites for at least 2 hr with 5 ppm Cl2)
Post-disinfection re-test for LegionellaNot reliable for permanent eradicationDesignated Team
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Hospitals
Corrective ActionLong-term Potable Water Disinfection
• Secondary disinfection system
Designated Team
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Hospitals
Corrective ActionLong-term Potable Water Disinfection
• Cu/Ag Ionization - good biofilm penetration- extensively validated in
>300 hospitals worldwide- monitor Cu/Ag
New Control Measure
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Hospitals
Corrective ActionLong-term Potable Water Disinfection
• Cu/Ag Ionization - good biofilm penetration- extensively validated in
>300 hospitals worldwide- rigorous maintenance
plans to monitor Cu/AgNew Control Measure
Cu 0.2-0.8 mgLAg 0.01-0.08 mg/L
Program/Designated Team
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Hospitals
Corrective ActionLong-term Potable Water Disinfection
• Chlorine dioxide - good biofilm penetration- hospital validation but
slower than Cu/Ag- lower concentrations
obtained in hot water vs cold water
ClO2 0.5-0.7 mg/L
Program/Designated Team
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Hospitals
Corrective ActionLong-term Potable Water Disinfection
• Monochloramine - good biofilm penetration- hospital validation
Program/Designated Team
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Hospital Campus
Critical Control Points (CCP)Cooling Towers
Flow diagrams
Program/Designated Team
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Cooling Tower #1
Flow Diagram
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Cooling Towers – Control Measures
aerosols
Microbiological Control
Control Measure
Legionnaires’ Disease
Control Legionella (hazard) in the cooling tower water
Which biocides to choose?
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aerosols
Microbiological Control
Critical Control Point
X
Legionnaires’ Disease
Control Legionella (hazard) in the cooling tower water
Document biocide addition or achieved concentration
Verification Is the control being implemented as planned?
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Cooling Towers – Control Measures
aerosols
Microbiological Control
Control Measure
X
Legionnaires’ Disease
Control Legionella (hazard) in the cooling tower water
Validate via Legionella testing
Validation Is the hazard (Legionella)under control?
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Critical Control Points (CCP)Cooling Towers
Biocides• Validating effectiveness? Legionella testing
Frequency? Monthly, Quarterly or Annually?
Hospital A
Program/Designated Team
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Critical Control Points (CCP)Cooling Towers
Biocides• Validating effectiveness? Legionella testing
Frequency? Monthly, Quarterly or Annually?
Hospital A
Interpretation of Legionella results?Program/Designated Team
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Critical Control Points (CCP)Cooling Towers
Biocides• Validating effectiveness? Legionella testing
Frequency? Monthly vs quarterly?
Hospital A
What to do with a positive test result?Program/Designated Team
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Corrective ActionOnline disinfection - 20-50 ppm chlorine
- 2 hr with bleed offRe-test following disinfection (24 hr)Verify that biocides were being addedChange to different biocides?More frequent validation in future
cooling tower
Hospital A
Program/Designated Team
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Control MeasuresWhirlpool spa
Same process
Halogen control in spas
Hospital A
Program/Designated Team
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Control MeasuresWater wall
Same process
Hospital A
Program/Designated Team
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The New Face of Legionnaires Disease Prevention• ASHRAE Standard 188 is a voluntary consensus standard and ASHRAE has no enforcement or regulatory authority
Final Thoughts
ASHRAE
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The New Face of Legionnaires Disease Prevention• The Standard language is normative (mandatory) and “code ready”. ASHRAE/ANSI standards are often incorporated into regulatory codes such as building codes, and into local, state or federal regulations
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The New Face of Legionnaires Disease Prevention• The Standard language is normative (mandatory) and “code ready”. ASHRAE/ANSI standards are often incorporated into regulatory codes such as building codes, and into local, state or federal regulations
Hospitals
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The New Face of Legionnaires Disease Prevention• The Standard language is normative (mandatory) and “code ready”. ASHRAE/ANSI standards are often incorporated into regulatory codes such as building codes, and into local, state or federal regulations
No reimbursement for hospital-acquired infections
Hospitals
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The New Face of Legionnaires Disease Prevention• Standard 188 is a voluntary consensus standard and ASHRAE has no enforcement or regulatory authority
• The Standard language is normative (mandatory) and “code ready”. Many ASHRAE/ANSI standards are often incorporated into regulatory codes such as building codes, and into local, state or federal regulations
• ASHRAE/ANSI standards invariably become an important consideration in litigation proceedings.
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Litigation Illness and Death from Legionnaires’ Disease
Dec
reas
e
Dec
reas
e
Start your facilities movement toward Legionella control
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The End
79
Questions?