preventing legionellosis outbreaks - ashnha · respiratory infection caused by legionella bacteria...
TRANSCRIPT
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Preventing Legionellosis Outbreaks
Alaska Infection Control ConferenceAnchorage, AK
October 8, 2019Larry Lee, CIH, Pacific Industrial Hygiene LLC
Rob Hinton, University of Washington Medical Center
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PreventionA lot can be learned about prevention
by going through an outbreak
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Prevention
• Prevention = Risk minimization
• All the measures we will discuss will minimize risk and the chance that an outbreak can occur
• But they cannot guarantee that it will never happen
• “Life, uh, finds a way” –Jurassic Park
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Legionella bacteria• Legionellosis – typically a
respiratory infection caused by Legionella bacteria
• ~50 Legionella species• 19 human pathogenic species
• Legionella pneumophila• Gram negative, flagellated rod,
0.3 – 0.9 x 2 microns• ~90% of infections• Serotypes 1, 4 & 6 cause most
infections• 16 serotypes – surface antigens
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Ecology Legionella bacteria?
• Fresh water & soil, dependent on biofilm• Legionella Life Cycle
• Eaten by ameoba• Ameoba eaten by paramecium• Paramecium dies & releases Legionella
• Survive temperatures 41 to 145˚F• Thrive between 77 to 115˚F• Biofilm and bacteria can colonize building water systems
• Piping, cooling towers, faucets, ice machines, fountains, etc.
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Building ecology
• Hospital sources• Potable water systems, sinks, shower heads, spas and jet tubs, ice machines,
humidifiers, dialysis water, water features, cooling towers, emergency showers & water cooled-equipment
• Community sources• Domestic water systems, spas & whirlpools, sprinklers & water features
(hotels, flower shows, restaurants & cruise ships), vegetable misters, humidifiers, cooling towers & water cooled-equipment
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Building ecology• Conditions that promote Legionella & biofilm growth in plumbing
• Low chlorine/oxidant concentrations• Low flowing or stagnant water – chlorine/oxidant becomes
“consumed”• High sediment levels & scale
• Consumes chlorine/oxidant• Interferes with chlorine/oxidant efficacy
• Preferred temperature – 77⁰ F to 115⁰ F• High pH – chlorine less effective• Dead-legs
• Sections of the plumbing systems in which there is low flowing or stagnant water
• Physical dead-legs: capped off lengths of piping• Operational dead-legs: rooms, fixtures and equipment that is
seldom used
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Building ecologyOperational dead legs
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Patients most at risk
• Advanced age• Male• Smoking history• Alcohol abuse• Chronic pulmonary disease• Immune suppression
• Transplant• AIDS• Underlying pulmonary disorder
(children)
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Legionellosis• Onset
• 2 to 10 days from exposure• Pontiac fever
• Self-limiting (24 – 48 hours) flu-like illness without pneumonia• Legionellosis
• Cough & low grade fever progresses to:• Pneumonia • Stupor• Organ failure• Fever exceeds 40 C/104 F• Headache• Confusion• Pleuritic chest pain• GI symptoms
• < 10% mortality with quinolone therapy
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Actions
• Water Management Plan• Ownership & accountability
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Actions
• Know your water• Who provides your water• Where your water comes from and how it
is delivered• Straight to pipe or via reservoirs, etc.
• Characterize your water: Chlorine/oxidant, pH, temperature, sediment
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ActionsBe informed about delivery system
changes & work
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Actions
• Characterize your water at the entry point: Chlorine oxidant, pH, temperature, sediment, water pressure
• Determine how water moves through your building(s)
• Characterize your water at the distal outlets
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Actions
• Search for, and remove dead-legs
• Identify operational dead-legs• Flushing plan
• Identify construction dead-legs• Flushing plan
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Actions
• Identify likely at-risk patients & locations• Transplant• Oncology• Respiratory therapy• Geriatrics• CCU/ICU• Birthing Center• Pediatrics – Neonatal ICU• Burns
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Actions
• Inventory your distal outlets & equipment• Prioritize primary water contacts for at-risk
patients• Sinks, showers & toilets• Ice machines• Hydrotherapy & birthing tubs• Scrub sinks• Bottle fillers• CPAP machines• Nebulizers• Cooling towers
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Actions• Inventory & assess performance of critical
plumbing equipment & systems• Hot water tanks
• Validate cleaning & maintenance• Temperature setting & actual
temperatures• Interties• Cross connections• Backflow
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Actions
• Cooling towers• Validate cleaning &
treatment• Validate maintenance
schedule
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Actions
• Remove/replace carbon filters• Removes chlorine from water
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Actions
• Conduct risk assessment• Water status• At-risk patients• Primary water contacts
• Prioritize risk of contamination
• High-risk for colonization outlets & equipment
• High exposure (consumption & aerosolization) scenarios & equipment
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Actions
• Legionella sampling
• Ultimate validation tool & commitment
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Actions
• Prepare for an outbreak• Water restrictions
• Bottled water, ice & vendor/supplies• Bathing & showering• Handwashing?
• Intervention• Hyperchlorination/oxidant, CuAg & filtration
• Pre-qualify vendor & contract documents• Heat treatment
• System capacity & system capability• POU filters
• Hardware requirements & availability• Communications
• Transparency• Sampling
• Pre-qualify lab & lab sampling support
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Actions
• Put your eyes on all that you are doing to validate your process and actions
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Conclusion
• To be in the best position you can
• Develop a great plan• Own the plan• Carry out the plan• Validate the plan