Legionella, Pseudomonas and general pathogen control in water systems

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1 Legionella, Pseudomonas and general pathogen control in water systems Dr Tom Makin Makin & Makin Consultancy Ltd Formerly, Directorate Manager Department of Medical Microbiology Royal Liverpool University Hospitals

2 Roman public latrine at Ostia

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4 Waterborne pathogens Viruses Protozoa Fungi Bacteria

5 Viruses Hepatitis A Enteroviruses (polio) Rotavirus Norovirus Rotavirus Magn. x 200,000

6 Laboratory reports of norovirus in England and Wales 2000 to 2008(week 3) Weekly data Data from HPA

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11 Each bather introduces 600,000 microorganisms!!

12 Mycobacteria M. avium complex, M. ulcerans

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14 WHO publication

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16 Cryptosporidium oocyst Resists 50ppm chlorine

17 Salmonella bacterium Bacteria Salmonella Vibrio cholera Campylobacter E. coli Pseudomonads Mycobacteria Legionella

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19 Burkholderia cepacia, Acinetobacter spp Stenotrophomonas maltophilia

20 Aeromonas hydrophila, found in fresh and brackish water - rare cause of necrotising fasciitis

21 Necrotising fasciitis

22 27 th September 2012 Serratia marcescens ubiquitous. - commonly found in soil, water, plants and animals. It is widely present in non potable water. Produces red colonies Grows on bread and communion wafers possible explanation for transubstantiation miracles. Pathogenicity established in late 1950 s following US Government Operation Sea Spray re. transmission of biological weapons off coast of San Francisco increase in UTI and pneumonia cases October 2012

23 Pseudomonas aeruginosa

24 Legionella pneumophila

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28 An Edinburgh distillery, one of the possible sources of the Legionnaires disease outbreak

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30 Adiabatic cooler Hybrid cooler

31 Biofilm

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33 There are strong selection pressures in the natural aquatic environment for the expression of virulence genes in L. pneumophila sgp 1

34 L. pneumophila serogroup 1, Mab 3/1 +ve (Pontiac) - causes 92% of all culture +ve cases of LD, but represents just 8% of environmental legionella Knowing which strain of legionella is in a water system is as important as the quantity of legionella present

35 L. pneumophila and >50 other Legionella sp. L. pneumophila causes 90% of legionellosis 16 serogroups of L. pneumophila L. pneumophila serogroup 1 cause 84% of legionellosis (Mab x9, SBT, RFLP, PFGE)

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38 Environmenal pre-requisites for Legionella infection Temperature between 20 O C and 45 O C + Water stasis + Nutrients organic matter/biofilm/iron/amoebae Increased No s of Legionella bacteria & virulence + Aerosol generation + Susceptible host Legionnaires disease Pontiac fever

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40 Legionnaires disease Pontiac Fever - High attack rate - 95%, inc kids Legionnaires disease - Low attack rate (1%) Stafford Hospital outbreak attack rate 5%

41 Legionnaires disease Rare infection 8 cases per million capita per annum in UK Approx 400 cases reported per annum in UK 2-3% of all community acquired pneumonias (CAP s) 14-37% of severe CAPs (mortality 5 to 30%)

42 Legionnaires disease Route of infection Inhalation of aerosols most likely (also aspiration) No evidence of person to person spread Legionella survive 2hrs in aerosols at relative humidity of 65% Aerosols created by water impacting surfaces Aerosols <5µ can enter alveoli

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44 Admission Day 4

45 +1 year +7 years

46 HPA data Legionnaires disease in the UK Incidence Mortality Travel 48% 11% (43% abroad, 5% UK) Community 46% 12% Nosocomial 6% * 32% *Exemplary water management in healthcare premises, or poor diagnosis of nosocomial cases?

47 Urinary antigen test has replaced antibody testing and culture for diagnosis and has contributed to a significantly reduced mortality rate for Legionnaires disease (Predominantly detects Pontiac strains of L. pneumophila sgp 1)

48 Data from European Centre for Disease Prevention and Control

49 Predominantly detects Pontiac strains of L. pneumophila sgp 1 Sensitivity for: travel 90%, non-travel 66%, nosocomial 46% (S. Jespersen et al. Scandinavian Journal of Infectious Diseases Vol 41, p )

50 Sources of waterborne infections Showers Taps Cooling towers Spa baths Ice machines Bottled water dispensers Humidifiers in neonatal units Ornamental fountains Flushing toilets Hydrotherapy pools and birthing pools Dental units

51 Sunderland Health Club cases of LD >120 cases of PF

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54 Spa/Hydrotherapy pools Biannual reviews of pool water management Pool manager Pool engineer Microbiologist Therapist Water treatment company

55 HSE Guidance - control of legionella EH ACoP + HS(G) HS(G)70 (revised) H&CWS (supplement) ACoP & Guidance (L8)?? Next version Better explanation required re. RP and DH duties Extent of reasonably practicable Accreditation, and quality of RA s Cooling tower packs

56 Supplementary guidance to HSE s L8 on HSE website Removal of cooling tower packs In-situ cleaning Additional measures - Side stream filtration Additional monitoring Endoscope analysis

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58 Sources of waterborne infections Showers Taps Cooling towers Spa baths Ice machines Bottled water dispensers Humidifiers in neonatal units Ornamental fountains Flushing toilets Hydrotherapy pools and birthing pools Dental units

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61 Sources of waterborne infections Showers Taps Cooling towers Spa baths Ice machines Bottled water dispensers Humidifiers in neonatal units Ornamental fountains Flushing toilets Hydrotherapy pools and birthing pools Dental units

62 Restaurant fountain Rapid City, South Dakota - 18 cases

63 Sources of waterborne infections Showers Taps Cooling towers Spa baths Ice machines Bottled water dispensers Humidifiers in neonatal units Ornamental fountains Flushing toilets Hydrotherapy pools and birthing pools Dental units

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65 Lancet : February 18 th 2012; Vol 379: p684

66 Water stagnation

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68 Intelligent hands-free systems Assist in preventing cross infection Auto flush facility Thermal disinfection

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76 Electronmicrographs of EPDM

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78 Sustainable development Solar heating system

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80 Heat gain due to close proximity of hot and cold water supplies

81 Radiant heat panels

82 The design of the Venturi splitter to prevent water stagnation? Shorter periods of flushing, better distribution of biocides where used

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84 Broadgreen Hospital, Liverpool Achieved control of Legionella and Pseudomonas aeruginosa St Mary s Hospital, Manchester

85 Hot and Cold Water Systems Controlling the risk of legionellosis High and low temperatures Chlorine Chlorine dioxide Copper and silver ions Silver and hydrogen peroxide Regular flushing of outlets Self-purging showers UV irradiation and filters Point of use filtration

86 Cardio-Thoracic Centre at Broadgreen Hospital, Liverpool, UK

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90 Hot and Cold Water Systems Controlling the risk of legionellosis High and low temperatures Chlorine Chlorine dioxide Copper and silver ions Silver and hydrogen peroxide Regular flushing of outlets Self-purging showers UV irradiation and filters Point of use filtration? Sustainable development

91 Hot and Cold Water Systems Controlling the risk of legionellosis Point of use filtration

92 WHO Legionella guidelines 2007 Elderly, smokers, alcoholics Target level <1000cfu/l L. pneumophila Alert level 1000 cfu/l L. pneumophila Max level 10,000 cfu/l L. pneumophila High risk patients Severe immunodepression, transplantation, corticotherapy = 0.5mg/kg per day prednisilone for 30 days or more, or 5mg/kg/day for 5 days or more Target level not detectable (?POU filters) Alert level 250 cfu/l Legionella spp *

93 Athletes Village London Olympics 2012

94 Olympic Games 2012

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96 Swan neck and downward displacement taps RADA Unatherm-3LL& 3HL

97 Downward displacement v Swan neck taps 8 month study Test rig under construction

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