hanrahan waterborne diseases updated12 -...

© SHEA 2018SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM

Waterborne DiseasesJennifer Hanrahan, DO, MA

Chair, Infectious Disease Control CommitteeAssociate Professor, School of Medicine

Case Western Reserve University


Financial Disclosures Jennifer Hanrahan, DO, MA Received consulting fees from Gilead Sciences, Inc. Advisory boards: Gilead Sciences, Inc., Cempra, and Astellas


Learning ObjectivesUpon completion, participants should be able to: Describe waterborne diseases Discuss when to suspect healthcare-acquired Legionella Explain methods to control Legionella spp in healthcare settings


Outline Background on waterborne pathogens Case study Control and prevention methods for Legionella


Background on Waterborne Pathogens


Global Impact Waterborne pathogens are among the most common causes of

disease worldwide with most diseases due to unsafe drinking water, poor sanitation, sewage and fecal contamination

More than 2 million deaths annually are caused by waterborne disease, most in children under age 5

Natural disasters such as floods, earthquakes, and hurricanes can cause disruption of drinking water and contamination with sewage

Even in the absence of natural disasters, more than 2.5 billion people do not have access to basic sanitation and are at risk of acquiring waterborne diseases

Ramirez-Castillo FY, et al. Pathogens. 2015;4:307-34; Watson JT, et al. Emerg Infect Dis. 2007;13:1-5.


Waterborne Pathogens Cryptosporidium Giardia Hepatitis A and E Legionella Naegleria fowleri Norovirus Salmonella/E. coli/Campylobact/Shigella Vibrio

Ramirez-Castillo FY, et al. Pathogens. 2015;4:307-34.


Waterborne Illnesses Infection occurs after ingestion or inhalation of water mists OR

following exposure of non-intact skin to water contaminated with enteric pathogens

Water sources include drinking water, water parks, swimming pools, fountains, hot tubs, lakes, rivers, and flood waters after natural disasters

Contamination usually occurs when sewage containing enteric pathogens comes into contact with water sources

Food can also become contaminated by enteric pathogens via irrigation methods

Most waterborne pathogens are generally not healthcare acquired Ramirez-Castillo FY, et al. Pathogens. 2015;4:307-34; CDC. Waterborne Illnesses. www.cdc.gov;

CDC. Recreational water Illness. www.cdc.gov; CDC. Water Contamination. www.cdc.gov.


Symptoms of Waterborne Illnesses Diarrhea Conjunctivitis/ear infections Skin infections Hot tub lung

Ramirez-Castillo FY, et al. Pathogens. 2015;4:307-34;. CDC. Ear infections. www.cdc.gov;Elko L, et al. Curr Infect Dis Rep. 2003;5:398-406; ATS. Interstitial Lung Disease in a Hot Tub User. www.thoracic.org.


Why Do Outbreaks Occur? Some pathogens are chlorine resistant Chlorine levels may be inadequate Not all water sources are chlorinated Water runoff after heavy rain can increase bacterial contamination

CDC. Effect of Chlorination on Inactivating Selected Pathogen. www.cdc.gov;Sinclair RG, et al. J Appl Microbiol. 2009;107:176-80; Kleinheinz GT, et al. Int J Microbiol. 2009;2009:876050.


Challenges in Monitoring Waterborne Pathogens No one system of monitoring currently exists Methods that rely on indicator organisms such as E. coli may miss

other species Some organisms are difficult to culture Methods used have to be sensitive, specific, easy to perform, and

inexpensive

Ramirez-Castillo FY, et al. Pathogens. 2015;4:307-34.


Milwaukee, WI: Cryptosporidium Outbreak In 1993, Milwaukee experienced the largest outbreak of drinking-water–related

Cryptosporidium in the US because of ineffective filtration at 1of 2 municipal water treatment plants More than 400,000 individuals (25% of Milwaukee’s population) became ill Costs exceded $96 million

First clues of the outbreak were pharmacies selling out of anti-diarrhea medications and increased ED visits for GI illness

69 people died; 93% had underlying HIV infection People were sick an average of 9 days with 12 stools per day; 1% were

hospitalized

Corso PS, et al. Emerg Infect Dis. 2003;9:426-31; Mac Kenzie WR, et al. N Engl J Med. 1994;331:161-7.


Flint, MI: Legionella and Shigella Outbreaks On 4/25/2014, Flint’s water source was changed from Lake Huron to Flint

River, resulting in the corrosion of pipes and increased lead and other contaminants in the water

Increased lead levels were found in children younger than 6 years Residents were advised to not drink the water on 10/15/15 Water contamination may have contributed to Legionella outbreak that

resulted in multiple deaths Outbreak of Shigella occurred because individuals were avoiding bathing in

the contaminated water Increase in skin rashes, but no clear cause found

Kennedy C, et al. MMWR Morb Mortal Wkly Rep. 2016;65:650-4; CDC. Flint Rash Investigation. www.atsdr.cdc.gov.


Multiple States: Waterborne Pathogen Outbreaks Following Hurricane Katrina Skin lesions/rashes and MRSA outbreaks reported in shelters Outbreaks of Vibrio vulnificus and Vibrio parahaemolyticus 18 wound-associated cases, likely due to abrasions and contamination

with floodwater 4 non-wound associated cases of Vibro infection

More than1,000 cases of diarrhea reported in adults and children, some due to norovirus, salmonella, and Vibrio; all within 3 weeks after evacuation

CDC. MMWR Morb Mortal Wkly Rep. 2005;54:928-31;CDC. MMWR Morb Mortal Wkly Rep. 2005;54:961-4.


Case Study


Case Study You are the director of infection prevention at a hospital located in

an area with recent flooding after a hurricane; the hospital experienced some flooding in non-patient-care areas, and construction is underway

It’s 4:55 pm on Friday afternoon, and you receive a call from a critical care physician concerned about a patient who was readmitted to the hospital with confusion, hyponatremia, and a right lower lobe infiltrate; the patient was discharged the week before after being admitted for an acute COPD exacerbation


Case Study On Monday morning, you look up the lab results on the patient The patient’s urine test is positive for the Legionella antigen What’s your next step?


Legionella At least 60 species of Legionella, half of which have been associated with human

disease Majority of cases caused by L. pneumophila

Bacteria survive as intracellular parasites of amoebae, protozoa, or slime molds and can enter a non-replication state in low-nutrient environments, making them more resistant to biocides

Water conditions that promote bacterial growth include: Heat (68-122 F) Water stagnation Biofilm Sediment

OSHA. Legionairre’s Disease. www.osha.gov; CDC. Legionella (Legionnaires’ Disease and Pontiac Fever). www.cdc.gov;Lin YE, et al. Infect Control Hosp Epidemiol. 2011;32:166-73; Newton HJ, et al. Clin Microbiol Rev. 2010;23:274-98.


Legionella Transmission Legionella spp have been found in a wide range of aquatic habitats,

including lakes, streams, air conditioning cooling towers, potable water, fountains, and spa baths Colonization in hot-water-distribution systems in hospitals is common

Transmission occurs usually by the organism being inhaled from mist or aspirated

Exposure to contaminated soil has also been linked to infection One incident of person-to-person transmission reported

Newton HJ, et al. Clin Microbiol Rev. 2010;23:274-98;Lin YE, et al. Infect Control Hosp Epidemiol. 2011;32:166-73;

OSHA. Legionairre’s Disease. www.osha.gov.


2004

Legionella Epidemiology Reported Legionella cases have been on

the rise since 2000 More illnesses in the summer and early fall) Increased rainfall is associated with

increased risk True incidence may be higher due to

Legionella being underdiagnosed

Most outbreaks are community rather than healthcare-associated (nosocomial)

Cause of atypical CAP in some areasCDC. Legionella (Legionnaires’ Disease and Pontiac Fever). www.cdc.gov;

Garcia-Vidal C, et al. PLoS One. 2013;8:e61036;Soda EA, et al. MMWR Morb Mortal Wkly Rep. 2017;66:584-9;

CDC. Atypical Pneumonia. www.cdc.gov.

2011

2015

2014

2013

2002

2001

2000

2008

2012

2009

2.01.8

1.0

0.6

0

Legionnaires’ Disease Is on the Rise2000-2015*

Year*National Notifiable Diseases Surveilance System

Inci

den

ce

(Cas

es/1

00,0

00 P

op

ula

tio

n)

1.61.4

0.40.2

1.2

0.8

2003

2007

2010

2005

2006


Nosocomial Legionella Nosocomial cases of

Legionella are underrecognized and even one case may signal an outbreak

Argawal S, et al. Infect Dis Clin North Am. 2017;31:155-65; Soda EA, et al. MMWR Morb Mortal Wkly Rep. 2017:66;584-9.

16 of 21 Jurisdictions Reported Definite Cases of Healthcare-Associated Legionnaires’ Disease (LD) in 2015

*Alaska had no cases to report

Reported definite cases of healthcare-associated LDDid not report a definite case of healthcare-associated LDNot included in the analysis: jurisdictions reporting less than90% of Legionella infections to SLDSS, which contains information such as healthcare facility exposures

AZ

CO

TN

WY

WA

OR

CA

NVUT

NM

TX

OK

KS

SD

NDMT

ID

AK*

HI

LA

AR

MO

IA

MN

WI

IL IN

MI

OH

MEVT

PA

NY

VAWV

KY

ALMS

SC

NC

GA

FL

MA

DEMD NJ

DC

NYCNE

NH

RICT


People at Increased Risk of Legionella People 50 years or older Current or former smokers People with a chronic lung disease People with underlying illnesses like diabetes, kidney failure, or liver

failure People with weak immune systems or those on

immunosuppressants People with cancer

CDC. Legionella (Legionairre’s Disease and Pontiac Fever): Causes, How It Spreads, and People At Increased Risk. www.cdc.gov.


Factors That Can Lead to Legionella Growth Changes in water pressure due to construction or water main

breaks Can disrupt biofilm and free Legionella

Changes in municipal water quality Use of electronic-eye faucets More likely to be contaminated with Legionella than manual faucets

Failure to replace water system filters Allows for build-up of sediment and biofilm

Water stagnation in rarely used faucets, tubs, or showersCDC. Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. www.cdc.gov;

Snydor ER, et al. Infect Control Hosp Epidemiol. 2012;33:235-40; Borella P, et al. Ann Ig. 2016;28:98-108.


Clinical Signs and Symptoms of Legionella Symptoms include cough, fever, anorexia, headache, myalgia, nausea,

vomiting, diarrhea, mental status changes, seizures, and delirium Cough is purulent in 50% of patients, sputum is usually thin with few

WBCs Extra-pulmonary infection can occur but is rare

Pontiac Fever has symptoms of primarily fever and muscle aches and is a milder infection than Legionnaire’s disease

Cunha BA, et al. Lancet. 2016;387:376-85;CDC. Legionella (Legionnaires’ Disease and Pontiac Fever): Signs and Symptoms. www.cdc.gov.


Diagnosing Legionnaire’s Disease Laboratory test findings may be nonspecific and shared with CAPs

that mimic Legionnaire’s disease Nonspecific laboratory abnormalities associated with Legionnaire’s

disease include: Hyponatremia Decreased serum phosphorus Elevated CPK

CXR shows all types of lung infiltrates

Cunha BA, et al. Lancet. 2016;387:376-85;CDC. Legionella (Legionnaires’ Disease and Pontiac Fever): Signs and Symptoms. www.cdc.gov.


Diagnostic Testing Culture of lower respiratory tract secretions,

and lung tissue or pleural fluid is definitive, but usually not available in most hospitals

Direct comparison between clinical and environmental isolates

Positive culture can be determined within 48-72 hours, and the test can stay positive for several weeks or months

Negative test doesn’t rule out legionella

Sensitivity lower for nosocomial legionella, as those infections are more likely from strains other than L. pneumophila serogroup I

Paired serology can be used

Direct fluorescent antibody may be helpfulCDC. Legionella (Legionnaires’ Disease and Pontiac Fever): Diagnosis, Treatment and Prevention. www.cdc.gov;

Yamakuchi H, et al. Intern Med. 2017;56:487-91.

Test Sensitivity (%) Specificity (%)

Culture 20-80 100

Urinary antigen for L. pneumophilaserogroup 1

70-100 95-100

Paired serology 80-90 > 99

Direct fluorescent antibody stain

25-75 ≥ 99

Polymerase chain reaction

unknown unknown


Who Should Be Tested for Legionella? Anyone who has failed outpatient antibiotic therapy for pneumonia

Anyone admitted to the ICU with pneumonia or severe CAP

Immunocompromised patients

Patients with a travel history or an overnight stay in a healthcare facility within 14 days before the illness (10% of cases associated with travel)

Patients with pneumonia in the setting of an outbreak

Anyone with pneumonia ≥ 48 hours after admission to healthcare facility

Mandell LA, et al. Clin Infect Dis. 2007;44:S27-72;CDC. Legionella (Legionnaires’ Disease and Pontiac Fever): Diagnosis, Treatment and Prevention. www.cdc.gov.


Investigation of Cases Case definition

If ≥1 definite healthcare-acquired (patient spent the entire prior 10 days in healthcare facility) or ≥ 2 possible healthcare-associated cases (patients spent part of prior 10 days in same facility before symptoms began) occurs, conduct an investigation

Exposure/epidemiologic history Environmental sampling

CDC. Guidelines for Preventing Health-Care–Associated Pneumonia. www.cdc.gov.


Control and Prevention Methods for Legionella


Facility Requirements to Prevent Legionella Infections On June 2, 2017, the Centers for Medicare and Medicaid Services

at the Department of Health and Human Services issued a memo stating that:

Facilities (hospitals, CAHs, and LTC) must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water

CMS. www.cms.gov.


Immediate Control Methods Superheat and flush Hyperchlorination Point-of-use filtration

Lin YE, et al. Infect Control Hosp Epidemiol. 2011;32:166-73.


Long-Term Control Methods Copper-silver ionization (CSI)

Legionellae can develop tolerance to silver ions, and higher concentrations may be needed over time; copper can precipitate at alkaline pH, leading to decrease in efficacy

Monochloramine Chlorine dioxide

Useful over a broader range of pH (6.0-8.5)

Lin YE, et al. Infect Control Hosp Epidemiol. 2011;32:166-73;Dziewulski DM, et al. Am J Infect Control. 2015;43:971-6.


CSI Copper and silver ions are both bactericidal against Legionella and other waterborne

pathogens Copper ion concentration should be tested weekly with a field colorimeter kit Silver ion concentration testing is more complex and should be done every 2

months

For a typical 250-bed hospital’s hot water recirculating line, the cost of an ionization system is ~$40,000 to $50,000 Relatively easy to install and maintain Elevated pH and low ion concentration may compromise efficacy Failures of the ionization system to prevent L. pneumophila in hospitals have

occurred due to resistant organisms and inadequate ion levels Lin YE, et al. Infect Control Hosp Epidemiol. 2011;32:166-73.


Chlorine Dioxide Method used in Europe since the 1940s

Advantages of chlorine dioxide disinfection include: Superior penetration into biofilms compared with chlorine Biocidal action maintained over a wider pH range compared with chlorine and

CSI

Disadvantages include: Prolonged time before significant reductions in Legionella positivity rate Reactions with organic material and corrosion scale in piping can produce chlorite

and chlorate, which may pose health risks Challenging to maintain effective residual concentration

Cost varies depending on whether the equipment is purchased or leased



Monachloramine This water treatment has not been evaluated as extensively as

chlorine dioxide or CSI Monochloramine provides a steady residual that penetrates biofilm

and has a wider working pH range than chlorine or CSI Disadvantages include that it may cause drinking water to take on

an ammonia odor, and it may cause an increase in other microorganisms (Mycobacterium species)



CDC. Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. www.cdc.gov.


Conclusions Outbreaks of a number of different waterborne diseases can occur

after natural disasters Disruption of water and fluctuations in water pressure can have

specific implications for healthcare facilities and can increase the risk of Legionella

Even one case of healthcare-acquired Legionella is concerning and warrants further investigation

A water-management policy is an important component of infection prevention


Additional References Rebmann T. Assessing Hospital Emergency Management Plans: A Guide for Infection

Preventionists. www.ncbi.nlm.nih.gov/pubmed/19699558

Crises and Emergency Risk Communication (CERC). Centers for Disease Control and Prevention. emergency.cdc.gov/cerc/index.asp

Emergency Preparedness and Response Preparation and Planning. Centers for Disease Control and Prevention. emergency.cdc.gov/planning/

Hospital All-Hazards Self-Assessment. Centers for Disease Control and Prevention. www.cdc.gov/phpr/healthcare/documents/hah_508_compliant_final.pdf

Hospital Emergency Management Program Checklist. California Hospital Association. www.calhospitalprepare.org/sites/main/files/file-attachments/emp_checklist_v080311.doc

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