Legionnaires Disease Prevention: Presented by: David Krause, Ph.D., MSPH, CIH March 1, 2017 - North Texas AIHA Section

Acknowledgements American Industrial Hygiene Association IEQ Committee: Past Chair Ben Kollmeyer & Current Chair Dr. Cherie Marcham Bill Kerbel, CIH Environmental Health Investigations, Inc. Jack Springston, CIH, CSP, FAIHA TRC Environmental Corporation in NYC Brian Shelton, MPH PathCon Laboratories Mold -

Legionella pneumophila – history Aquatic bacteria responsible for a major outbreak of pneumonia with 34 deaths at a convention of the American Legion in a hotel in Philadelphia in 1976 The previously unknown microbe was first isolated and identified by the CDC in 1977 The pneumonia was popularly called “Legionnaires’ disease and the bacteria was “Subsequently named “Legionella”

Basic Biology of Legionella Kingdom: Bacteria Phylum: Proteobacteria Class: Gammaproteobacteria Order: Legionellales Family: Legionellaceae Genus: Legionella Species: L. pneumophila Pathogenic gram negative bacteria Ubiquitous in soil and aquatic systems – However it can thrive in man-made water systems More than 34 species & 70 serogroups identified May contaminate up to 70% of all plumbing systems Warm water & Chlorine tolerant

Biology & Ecology of Legionella Legionella pneumophila is a bacteria that is commonly found in practically all surface waters. Legionella pneumophila is spread via inhalation (MIST), it can not cause illness from skin contact or if consumed orally. Legionella pneumophila requires specific conditions for it to become virulent and aerosolized.

Ecology of Legionella Water Temp: 68 to 126 Degrees F Contaminated source water Foreign material in water/system Stagnation/dead heads Biofilm vs. Planktonic Sediments in system Protozoa and amoeba Shut down & recharging of the water system

Where Does Legionella Exposure Occur? Washing - Aerator on sink Brushing Teeth – Aerator on sink Showering – Shower head Hot Tub/Spa – Water Vapors Decorative Fountains – Mists Drinking From Fountains – Inhalation of Potable water At Work – Cooling towers, Cutting Fluids, Showers, Fountains, Pressure Washers, Garden Hoses, etc. Medical Devices – Therapy pools, Nebulizers, Cardiac Heater-Cooler Units, Dental Spray Units

Legionella Aerosols Cooling Tower mists Shower Heads & Sink Aerators Do not have a building air intake within 100 feet of a cooling tower Do not locate a break area within 100 feet of a cooling tower Shower Heads & Sink Aerators Remove and disinfect (70 – 100 ppm Chlorine)or replace annually Check inside the shower head or spout for biofilm. Disinfect if present

Legionella Aerosols Misters/ Humidification Hot Water All misters and humidifiers must be disinfected on a regular basis and checked for bacteria growth, they create the perfect conditions for growth Hot Water Domestic water should be disinfected if hot water mean temperature is below 130°F Disinfect with Chlorine Dioxide, Chlorine or raising water temperature above165°F

Legionnaires’ Disease is on the rise and no change in sight CSTE (CDC)– Outbreak Oriented Passive Surveillance System ~95% of reported cases are NOT associated with an outbreak Public health officials typically perform investigations of LD outbreaks Reactionary responses don’t effectively prevent occurrence of environmental disease

2016 = 5,268 2015 = 6,079 2014 = 5,166 2013 = 4,954 2000 = 931

Using an Industrial Hygiene Approach Industrial Hygienists perform the oversight of remediation efforts and perform long term testing Recommendations before 2015 were to perform environmental assessments for Legionella AFTER an outbreak Assessing sources of Legionella and the effectiveness of Legionella control measures provides valuable information Performing a hazard assessment for potential sources of Legionella can prevent exposure

ASHRAE Standard 188-2015 ASHRAE Standard 188-2015 Legionellosis: Risk Management for Building Water Systems. Management system based on HACCP. Establishes minimum risk mgmt. requirements for building water systems. Develop water-system schematics of potable and non-potable water systems. Determine where control measures are applied and monitored.

ASHRAE Standard 12-2000 ASHRAE Standard 12-2000 Minimizing the Risk of Legionellosis Associated with Building Water Systems. Provides guidance on how to minimize Legionella in building water systems. Potable and emergency water systems; heated spas; architectural fountains and waterfalls; cooling towers and evaporative coolers. Culturing for Legionella may be appropriate if carried out for a specific purpose.

Intro to AIHA Guideline Recognition, Evaluation, and Control of Legionella in Building Water Systems Background on its development In many ways it “picks up” where ASHRAE 188 leaves off. Incorporates industrial hygiene perspective Focuses on proactive effort Recommends disease prevention through source identification risk assessment and control

Summary of AIHA Guideline This guidance updates and expands upon information previously used to conduct environmental source assessments for Legionella during outbreak investigations Provides a framework for competent professionals to establish a proactive assessment strategy of hazard assessment and longitudinal monitoring of building water systems Provides a framework for routine and investigative assessments of Legionella sources

AIHA Guidleine It provides a framework for the “Program Team”, described in ASHRAE 188, to validate control efforts, or “confirm the program” The AIHA Guideline provides a framework and interpretative criteria for competent professionals to establish the testing procedures to validate the program’s effectiveness (See Section 6.2.8 of 188) Mycometer test is based on the detection and quantification of a specific enzyme present in both mycelium and spores of fungi. The activity is measured using a fluorogenic enzyme substrate, which upon cleavage, releases a fluorophore that fluoresces under UV light. The fluorescence is measured using a fluorometer.

Summary of AIHA Guideline The intent of the AIHA guidance document is for Competent Professionals to develop evaluation and assessment strategies for Legionella and to shift to a proactive approach that may reduce the public health threat of this disease.

The AIHA Guideline does NOT… Provide a prescribed or pre-established formula for testing – no “recipe” Provide health-based interpretive values   Provide all of the knowledge for an individual to become a “Competent Professional”

The AIHA Guideline does…  Advance the practice of Legionella source recognition, evaluation and control beyond current reactionary practices  Establish an industry standard of practice for assessing sources of water for Legionella amplification, before or after human disease has occurred  Add to the tools for public health officials and industrial hygienists in efforts to prevent and resolve Legionellosis outbreaks

US EPA Technologies for Legionella Control Summarizes peer-reviewed scientific literature, and reports. Characterizes the effectiveness of different technologies that may be used to control Legionella growth in premise plumbing systems of large buildings (e.g., hospitals, hotels, schools). Six technologies used for Legionella control (chlorine, monochloramine, chlorine dioxide, copper-silver ionization (CSI), ultraviolet (UV) disinfection and ozone). Discusses risk management approaches for addressing microbial, physical and chemical risks in premise plumbing system.

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