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

2. 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 -

3. 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”

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 2016 = 5,268
2015 = 6,079
2014 = 5,166
2013 = 4,954
2000 = 931

12. 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

13. ASHRAE Standard
ASHRAE Standard 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.

14. ASHRAE Standard
ASHRAE Standard 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.

15. 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

16. 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

17. 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 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.

18. 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.

19. 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”

20. 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

21. 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.

22. Forensic Analytical Consulting Services, Inc.
Thank You
Forensic Analytical Consulting Services, Inc.
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