POINTS TO BE COVERED D History of Legionellosis Case Studies Route of Infection Causative Chain Introduction A B C Legionellosis Hot amp Cold Water Services Conclusion L egislation ID: 929622
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Slide1
Legionella
The History of Legionella & Legionnaires Disease
Slide2POINTS 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
Slide3Introduction to Legionellosis
Including Legionnaires Disease
Slide4Legionnaires’ 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
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
Slide6Legionellosis – 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
Slide7A.
The Presence of Legionella in Buildings
Slide8Legionellosis – 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
Slide9A.
Legionella Pneumophila
Slide10A.
Legionella Pneumophila
Nutrient Sources
Other bacteria
Amoeba, protozoa, pseudomonas
Slime formation
Algae
Other organisms
Birds, Bats, Mice….etc
Slide11Legionellosis – The Causative Chain
Water System
Aerosol Generation
Cooling or Condensing towers
Humidifiers
Taps and Showers
Spas
Multiplication
Aerosols
Slide12Legionellosis – The Causative Chain
Water System
Route to Infection
Multiplication
Aerosols
Inhalation
Aspiration
Intubation
Inhalation
Slide13Legionellosis – 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
Slide14Case Studies
Slide15A.
Case Studies
Three High Profile Case Studies
American Legion convention on Philadelphia
Stafford General Hospital
Barrow in Furness
Slide16American 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.
Slide17A.
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
.
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.
Slide19Barrow-in-Furness
Slide20Barrow-in-Furness
Slide21Legislation & Guidance
Slide22Legislation & 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
The definitive standard for planned maintenance and essential tool to stay compliant with Legislation .
Water Treatment
65-01
Introductory Procedures - Water Treatment
Water Treatment
65-02
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
Slide24Requirements 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.
Slide25Practical 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
Slide26Supplier 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
Slide27The 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.
Slide28Legionella – Hot and Cold Water Services
Slide29Engineering Implications
Hot & Cold Water Services
Water Storage Tanks
Calorifiers
Pipework
Filters
Fittings
Showers & Taps
Slide30Hot & Cold Water Services
Hot Water Storage
Cold Water Storage Cistern
Bath
Basins
Showers
Vent
Cold Feed
Slide31Unsatisfactory 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
Slide32HSG274 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
Slide33HSG274 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)
Slide34Before & After
Slide35Showerhead Conditions
Slide36E
mergency
Showers
Slide37Satisfactory 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
Slide38Low Risk Hot Water Systems
Equipment Classified as Lower Risk
Horizontal Calorifiers
Direct Fired Units
Plate Heat Exchangers
Instantaneous Heaters / Electric Showers
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
Slide40Conclusion..
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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