Legionella The History of Legionella & Legionnaires Disease - PowerPoint Presentation

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Legionella

The History of Legionella & Legionnaires Disease

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POINTS TO BE COVERED:

D

History

of Legionellosis

Case Studies

Route of Infection – Causative Chain

Introduction

A

B

C

Legionellosis – Hot & Cold Water Services

Conclusion

L

egislation

& Guidance

E

F

G

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Introduction to Legionellosis

Including Legionnaires Disease

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Legionnaires’ Disease

First identified after an outbreak of PNEUMONIA amongst American Service veterans attending a convention in Philadelphia in 1976.

The causative organism was subsequently called

LEGIONELLA PNEUMOPHILA

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A.

Legionnaires’ Disease

United Kingdom

Between 250 & 400 cases reported annually

Accounts for 2% of primary Pneumonia cases

United States

Between 10,000 & 11,000 cases annually requiring hospital treatment as a minimum

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Legionellosis – The Causative Chain

Water System

HABITAT

Legionella are commonly found in both Natural and Man-Made water systems

At least 56 Species of Legionella

At least 70 Serogroups of Legionella Pneumophila

3 Subgroups of Serogroup 1

L. Pneumophila, serogroup 1, subgroup

pontiac

has been associated with over 90% of outbreaks of Legionnaires’ disease

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A.

The Presence of Legionella in Buildings

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Legionellosis – The Causative Chain

Water System

Environment for Multiplication

Temperature of 37°C. The bacteria survive up to 60ºC, but prefer 20 - 45ºC

pH of 6.9 (5.5 - 8.1)

Trace of iron

Bacterial slime, algae, scale

Multiplication

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A.

Legionella Pneumophila

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A.

Legionella Pneumophila

Nutrient Sources

Other bacteria

Amoeba, protozoa, pseudomonas

Slime formation

Algae

Other organisms

Birds, Bats, Mice….etc

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Legionellosis – The Causative Chain

Water System

Aerosol Generation

Cooling or Condensing towers

Humidifiers

Taps and Showers

Spas

Multiplication

Aerosols

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Legionellosis – The Causative Chain

Water System

Route to Infection

Multiplication

Aerosols

Inhalation

Aspiration

Intubation

Inhalation

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Legionellosis – The Causative Chain

Water System

Most at Risk Categories

Males (3:1 ratio)

Smokers

Alcoholics

Immunosuppressed patients

Age group of 45+

Multiplication

Aerosols

Inhalation

Susceptible

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Case Studies

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A.

Case Studies

Three High Profile Case Studies

American Legion convention on Philadelphia

Stafford General Hospital

Barrow in Furness

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American Legion Convention in Philadelphia

The Bellevue-Stratford hosted the 58th state convention of the American Legion Department of Pennsylvania July 21-24, 1976.

In the days that followed the convention, the mystery disease killed 29 participants and gave rise to 180 cases, all of whom had spent time at the hotel.

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A.

Stafford District General Hospital

A large outbreak of Legionnaires' disease was associated with Stafford District General Hospital

A total of 68 confirmed cases was treated in hospital and 22 of these patients died. A further 35 patients, 14 of whom were treated at home, were suspected cases of Legionnaires' disease

All these patients had visited the hospital during April 1985

.

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Barrow-in-Furness

172 people were left seriously ill and are to believed to have been infected by the Legionella bacteria, which were discharged from a air conditioning cooling system in water droplets above a busy alleyway.

The source of the infection was an air conditioning system at the Forum 28 arts

centre

in the town

centre

, which sprayed infected water droplets into the atmosphere breathed in by passers-by.

The police charged a local government official with manslaughter over Britain's worst outbreak of Legionnaires' disease in a decade in Barrow-in-Furness during July and August 2002.

Cumbria police officials said that Gillian

Beckingham

, 45, a manager in charge of maintenance at Barrow Borough Council in northwestern England, was charged with seven manslaughter charges, one for each person who died in the August 2002 outbreak.

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Barrow-in-Furness

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Barrow-in-Furness

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Legislation & Guidance

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Legislation & Guidance

Legislative & Guidance Documents Include:

Health & Safety Executive - Approved Code of Practice L8

- Legionnaires’ Disease, The Control of legionella bacteria in water systems

Health & Safety Guidance – HSG 274 parts 1, 2 & 3

- Legionnaires’ Disease, Technical guidance

NHS Estates - Health Technical Memorandum 04-01

- The Control of Legionella in Healthcare Premises - A Code of Practice

Control of Substances Hazardous to Health (COSHH)

Chartered Institution of Building Services Engineers Technical Memoranda TM13

- Minimising The Risk of Legionnaires Disease

British Association for Chemical Specialities Code of Practice

- The Control of Legionella By The Safe And Effective Operation of Cooling Systems

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The definitive standard for planned maintenance and essential tool to stay compliant with Legislation .

Water Treatment

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Introductory Procedures - Water Treatment

Water Treatment

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Ion Exchange Plant - Base Exchange Softening - Commercial

Water Treatment

65-03

Ion Exchange Plant - Base Exchange Softening - Domestic (capacity usually below 50 litres)

Water Treatment

65-04

Special Water Treatment Systems

Water Treatment

65-05

Filtration, Conditioning and pH Correction - Central Plant

Water Treatment

65-06

Filtration and Conditioning - Point of Use

Water Treatment

65-07

Reverse Osmosis

Water Treatment

65-08

Ultraviolet Disinfection Unit

Water Treatment

65-09

Ozonation Plant

Water Treatment65-10

Chemical Dosing

Water Treatment65-13

Introductory Procedures - Chlorine Dioxide Dosing for Domestic Low Level InjectionWater Treatment

65-14

Chlorine Dioxide Low Dosing Domestic Water SystemsWater Treatment

65-15Duplex Water Strainers

Water Treatment65-16

Water Purification and Demineralisation EquipmentWater Treatment

65-17Carbon Dioxide Dosing SystemWater Treatment

65-18

Chlorine Analyser/Controller SystemWater Treatment

65-19

Concentrate Filling Station (Haemodialysis)

Whirlpools - Hydrotherapy

66-01

Whirlpool/Spa Baths

Whirlpools - Hydrotherapy

66-02

Hydrotherapy Pools

Whirlpools - Hydrotherapy

66-03

Steam Rooms and Humidifiers

Heat Rejection Systems

30-01

Introductory Procedures - Heat Rejection Systems

Heat Rejection Systems

30-02

Cooling Towers - Precautions against Legionnaires Disease (Legionella Pneumophila)

Hot & Cold Water Services

31-01

Introductory Procedures - Hot and Cold Water Services

Hot & Cold Water Services

31-02

Legionella Training

Health Technical Memorandum

Water Services HTM 04

HTM 04-01

Hot and Cold Water Temperature Monitoring

Water Services HTM 04

HTM 04-02

Outlet Flushing (infrequently used outlets)

Water Services HTM 04

HTM 04-03

Hot and Cold Water Systems Maintenance

Water Services HTM 04

HTM 04-04

Thermostatic Mixing Valves (TMV)

Water Services HTM 04

HTM 04-05

Water Hygiene Awareness Training Course

Water Services HTM 04

HTM 04-06

Deluge/Emergency Showers

Water Services HTM 04

HTM 04-07

Ice Making Machines

Water Services HTM 04

HTM 04-08

Ion Exchange Plant - Base Exchange Softening - Commercial

Water Services HTM 04

HTM 04-09

Ion Exchange Plant - Base Exchange Softening - Domestic (capacity usually below 50 litres)

Water Services HTM 04

HTM 04-10

Dialysis Water Storage Tank

Water Services HTM 04

HTM 04-11

Endoscope Water Purification System

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Requirements of L8

Identification and assessment of risk

Management of the risk, management responsibilities, training and competence

Preventing or controlling the risk

Record Keeping

Responsibilities of manufacturers, importers, suppliers and installers.

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Practical Steps to Control the Risk

Appoint a ‘responsible manager’

Identify and assess the risk

Prepare a written scheme of precautions

Monitor the effective implementation of procedures

Keep records of any actions

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Supplier Responsibilities

Designers / Manufactures / Importers

Ensure that risk is avoided

Provide adequate information on safe operation

Service Providers

Provide adequate information

Ensure staff are adequately trained

Clearly define limitations

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The Role of the Responsible Person

A clear line of communication must be agreed and persons involved must sign an agreed declaration of their duties of responsibility.

THE DUTY HOLDER -

The person with ultimate responsibility. They should appoint a person or persons in writing to take managerial responsibility and prove supervision for the implementation of precautions. Statutory Duty normally falls on the business owner, managing director or the person in control of premises or systems concerned

.

THE RESPONSIBLE PERSON

–

“Appointed Competent Person” is someone who is in a suitable and sufficient position of authority to oversee various people and tasks, as well as having the budget control and the authority to act. They should also ensure the competence of any contractors carrying out work.

THE DEPUTY RESPONSIBLE PERSON

-

Responsible for the supervision of staff engaged in relevant operational duties. Should ensure that correct procedures are followed and that deadlines are met. When a Responsible Person is not available, an authorized Deputy should be appointed to maintain cover.

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Legionella – Hot and Cold Water Services

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Engineering Implications

Hot & Cold Water Services

Water Storage Tanks

Calorifiers

Pipework

Filters

Fittings

Showers & Taps

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Hot & Cold Water Services

Hot Water Storage

Cold Water Storage Cistern

Bath

Basins

Showers

Vent

Cold Feed

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Unsatisfactory Cold Water Distribution

No lid, air vent, filter or insulation

Water sitting at 26°c

Cold feed & discharge on the same side allowing possible stagnation

Water draw-off 26°c after 2 minutes

Distribution and storage temperatures high

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HSG274 Guide on Typical Domestic Systems

Clean tank but slight corrosion on bolts

Light debris but corrosion to restraining bars

Moderate fouling, suggest clean within 12 months

Slight surface scum indicating poor turnover and large debris count – must be cleaned

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HSG274 Guide on Typical Domestic Systems

Heavy debris and corrosion internal parts that will require remedial works

Severe stagnation indicating that the tank is unlikely to be required

Unusually heavy scale formation requiring more than a regular clean and disinfection

.

Gel coat failure resulting in local biological fouling (dark spots)

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Before & After

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Showerhead Conditions

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E

mergency

Showers

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Satisfactory Cold Water Distribution

Storage Cistern <20°c

Cold water draw off<20°c within 2 minutes

Insulated distribution pipes

Lid fitted to prevent fouling

Insulated pipework

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Low Risk Hot Water Systems

Equipment Classified as Lower Risk

Horizontal Calorifiers

Direct Fired Units

Plate Heat Exchangers

Instantaneous Heaters / Electric Showers

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S

calding

v Legionellosis

It is a

requirement

for the control of Legionellosis in domestic hot water systems, that hot water is stored at a minimum temperature of 60°C.

However

hot water temperatures in excess of 50°C are considered to increase the risk of scalding to the outlet user.

The Solution

Thermostatically controlled Mixing Valves (TMV) are recommended to reduce the risk of scalding.

`

Installation Locations:

All hot water outlets within the occupied and

“open” areas of the building

Baths, showers and wash hand basins in toilets or bathrooms

Staff-room sinks

Food preparation kitchens maybe exempt however “Caution Hot Water” signs must be fitted

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Conclusion..

Legionella bacteria is probably present in most water systems, the task must be to prevent

:

-Multiplication

-Aerosol Production

-Inhalation of Water Droplets

Particular care is needed in buildings which house, or where systems are located near a high risk population, for example:

-Hospital

-Residential Elderly Care Homes or similar

When the guidelines presented are fully implemented, then the risk of infection will be minimised

Keep cold water cold and moving, keep hot water hot and moving.

vdv

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THANK YOU