1. Warschau Nov. 20081 Dr. K. Luden Legionella type bacteria in domestic distribution systems (house installations) Dr. Katrin Luden

2. Legionella type bacteria Dr. K. Luden Legionella  are fresh water bacteria (~ 50 species, all of them potentially pathogenic to humans)  grow best in warm water e.g. in warm drinking water supply, pools (filter), air condition-systems or cooling towers  hardly grow 60°C  infections are transmitted by inhalation of aerosols rarely by aspiration (90 % of infections caused by L. pneumophila)  cause Pontiac-fever and legionaires disease

3. Infections caused by Legionella Dr. K. Luden Pontiac-fever acute self-limiting influenza-like infection without pneumonia Incubation time: 2-3 days Cases ~800.000 – 1.5 billion / year (estimate of RKI) Legionaires disease Pneumonia (fever, chills, cough) sometimes fatal Incubation time: 2-10 days Cases:~ 6.000 - 20.000 / year (estimate of RKI) Fatal cases: ~ 1.000 - 3.000 / year (estimate of RKI)

4. Drinking water directive 98/83/EC Dr. K. Luden Legionella not mentioned but General obligations (Article 4): Water shall be clean if it: is free from micro-organisms which in numbers or concentrations, constitute a potential danger to human health Article 5 (3) Quality standards “A Member State shall set values for additional parameters not included in Annex I where the protection of human health within its national territory or part of it so requires. The values set should, as a minimum, satisfy the requirements of Article 4(1)(a).”

5. German Drinking water directive (DWD) Dr. K. Luden § 18 Monitoring by public health authorities (1) Public health authorities supervise the water supply... from domestic distribution systems from which water is made available for the public, in particular in schools, kindergartens, hospitals, restaurants and other communal facilities, regarding the compliance to the requirements of the regulation by appropriate examinations.

6. German Drinking water directive (DWD) Dr. K. Luden Legionella mentioned twice: §20 order of the public health authorities public health authorities can order analysis of additional parameters considering the circumstances of the individiual case... e.g. Legionella... And Audit monitoring (Annex) Audit monitoring includes the investigation on Legionella in central drinking water warming systems as part of domestic distribution systems that supply water to the public.

7. Rationale Dr. K. Luden Due to the considerable potential danger to human health connected to Legionella in warm water domestic distribution systems water from those systems has to be monitored for Legionella in facilities supplying water to the public. BUT

8. Questions Dr. K. Luden  What is the aim of the monitoring? Detection of systemic contamination or acute risk assessment?  What parametric values are to be used for assessment of results?  Sampling: where, how many samples, how, when?

9. Aim of monitoring Dr. K. Luden Recommendations by NLGA (2006) and FEA (2007): detection of systemic contamination The purpose in Lower Saxony is to gather information on systemic contamination with comparable results due to harmonized sampling techniques and sample identification using a coding system. The laboratory method for detection of Legionella was covered as well because ISO 11731 was not translated into a DIN.

10. Technical Standards Dr. K. Luden DIN 1988 (1988): technical standard for drinking water installations VDI*-Guide 6023 (2006): hygiene-conscious planning, construction, operation and maintenance of drinking water heating systems DVGW** W 551 (2004): Drinking water heating and distribution system, technical measures for limiting growth of legionella; planning, establishment, operation and redevelopment of drinking water installations DVGW** W 553 (1998): Dimensioning of central warm water circulation systems * VDI: Society of German Engineers **DVGW: German Technical and Scientific Association for Gas and Water

11. Recommendation of the Federal Environmental Agency (FEA) Dr. K. Luden Categories of facilities that have to be monitored 1)Hospitals and nursing facilities (geriatric homes, nursing homes, baby-nursery) 2)Facilities for ambulant surgery, dialysis, rehabilitation... 3)Schools, Kindergarten 4)Hotels, youth hostels 5)Other training facilities, homes, holiday camps etc. 6)Sports facilities 7)Community accommodations

12. Recommendation of the Federal Environmental Agency (FEA) Dr. K. Luden In addition to W551:  In Facilities of category 1 and 2 (Hospitals, nursing facilities) no orientating investigation but always extensive investigation  Additional sampling in units with high risk (e.g. intensive care units)  Facilities with many division ranks (Teilstränge) sampling has to be conducted in units were showers are used

13. Parametric values Dr. K. Luden No recommendation by authorities because:  Little or no data on the correlation between Legionella concentration in water and infection rates  Legionella are not normally distributed in water (biofilms, amoeba) ? Should a domestic warm water distribution system that is up to date not be free of Legionella? Detecting 500 CFU/100 ml one day can result in 5.000 or 500.000 the other day.

14. W551 Dr. K. Luden Legionella CFU/100ml Level of contamination measures Further investigation Follow up > 10.000 extremely highDirect clearance measures (disinfection, prohibition of use) remediation necessary Instantaneous1 week after disinfection or remediation > 1.000HighRemediation depends on outcome of further investigation Immediately  100 MiddleNoneWithin 4 weeks < 100Low/noNone After 1 year Assessment of the results of a routine monitoring (orientating 1x a year)

15. Lower Saxony Dr. K. Luden Sampling point Water body to be checked during monitoring Verteiler Zulauf 1 2 i 2) LS1-LSi Steigstrang 1) L1 Austritt Trinkwassererwärmer 3) L3 Rücklauf Zirkulationsleitung 1 2 i Technical survey and inspection of the distribution system always first (checklist provided with the recommendation) Negative results of Legionella samples are no proof of a technically correct system

16. Sampling Dr. K. Luden Specifications: L1sampling at maximum temperature, document sampling temperature LSrun off exactly 1 liter of water, take sample, document sampling temperature, flush to maximum temperature, document temperature L3flush shortly to sample circulating water, document temperature Follow instructions of ISO 19458 purpose b.

17. Sampling - ISO 19458 Dr. K. Luden PurposeQuality Remove attached devices and inserts Disinfectflush aIn the mainYes b As it reaches the tap Yes No a (miminal) c As consumed No a flush shortly only to overcome influence of disinfection of the tap Detection of systemic contamination: purpose b

18. Sampling - ISO 19458 Dr. K. Luden PurposeQuality Remove attached devices and inserts Disinfectflush aIn the mainYes b As it reaches the tap Yes No a (miminal) c As consumed No a flush shortly only to overcome influence of disinfection of the tap Risk assessment or case related investigation: purpose C

19. Dr. K. Luden Water sample Direct platingMembrane filtration 0.5 ml GVPC 20 ml GVPC 100 ml GVPC Incubation at 36 ± 2°C for 7-10 days Subculture confirmation Detection method - ISO 11731 optional

20. Dr. K. Luden Detection method - ISO 11731 Range of measurement: 1)Plating of 2x 0.5 ml → < 100 to 40.000 CFU/100 ml with a maximum of 200 colonies per plate in accordance with ISO 8199 2)Membrane filtration of 20 ml → < 5 to 500 CFU/100 ml with a maximum of 100 CFU/filter Total of < 5 to 40.000 CFU/100 ml

21. Dr. K. Luden Results 2005 Legionella [n] Samples [n] Assessment by W551 total2637 < 51873No / low contamination  5 764 Low contamination > 10 644 Low contamination > 100409Middle mid term remediation > 1.000149High cont. short term remediation > 10.00042Extremely high cont. imediate action > 100.0001Extremely high cont. imediate action

22. Dr. K. Luden Consequences  Facilities with samples that show extremely high contamination with Legionella might be asked to take action immediately.  Operators of house installations with medium contamination are asked to provide a mid term remediation plan.  Advice is offered and sometimes facilities are closed e.g. showers at a public swimming pool as a safety measure to public health.  NO concrete action is ordered by the public health services. The responsibility for providing safe water lies with the operator of the house installation.

23. Concluding remarks Dr. K. Luden  Sampling and evaluation of Legionella detection in house installations has been harmonized in Lower Saxony.  Consulting of Public health services and operators of house installations contaminated by Legionella has become easier.  Sampling techniques fit the purpose of the monitoring.  If the recommended protocol is used and all temperatures are documented a first step towards finding the cause of the problem often is taken.  Although technical standards have been existing for more than 20 years facilities prevail that are not at the state of the art.