July 01, 2015
Nine years in the making, the United States has its first standard to manage risk for Legionella. The ANSI/ASHRAE Standard 188-2015, Legionellosis: Risk Management for Building Water Systems, approved June 26, 2105, establishes minimum legionellosis risk management requirements for building water systems
The standard applies to owners and managers of human-occupied buildings d those responsible for design, construction, installation, commissioning, operation, maintenance and service of centralized building water systems and components.
According to the news release from ASHRAE, “The industry interest and input into developing this standard has been tremendous,” said Tom Watson, chair of the committee. “With 8,000 to 10,000 cases of Legionnaires’ disease reported each year in the United States, and with more than 10 percent of those cases fatal, it is vital that we set requirements to manage risk of this bacteria.”
Specific requirements include:
• Minimum Legionellosis risk management requirements for buildings and potable and non-potable water systems.
• Establishing a program team and water management program
• Specific and detailed requirements what control strategies must accomplish and documented
While the standard provides information on what to do, there are no specific directions for implementing risk managment strategies.
To assist you in controlling Legionella, Special Pathogens Laboratory will be offering education and services that include compliance with the ASHRAE 188 standard. For more information, please contact us.
Legionella Engineer for Special Pathogens Laboratory Receives Consulting-Specifying Engineer 40 under 40 Award
May 15, 2015
Legionella engineer and Special Pathogens Laboratory Vice President of Consulting Services Frank P. Sidari III, PE, BCEE, is the recipient of Consulting-Specifying Engineer’s 40 under 40 award for combining engineering expertise with a specialization in water quality and Legionella, the waterborne bacteria that causes Legionnaires’ disease.
Given to 40 building industry professionals age 40 and younger, CSE’s award recognizes those who stand out in all aspects of their lives, particularly in the nonresidential building community.
Sidari stood out for creating a unique niche by combining his engineering expertise with a specialization in water quality and Legionella control. This novel approach promotes building water safety and prevents disease caused by waterborne pathogens.
Early in his career, Sidari conducted the first field evaluation of chlorine dioxide disinfection of a hospital campus water system to control Legionella. At that time, chlorine dioxide was a new technology that was a potential alternative to chlorine. His work was published in the Journal of the American Water Works Association (JAWWA) in 2004. Since then, chlorine dioxide has become an industry standard and is used worldwide to control Legionella. Subsequently, Sidari’s most recent publication (JAWWA, Oct. 2014) confirmed the findings of the original study.
“Recognition for Frank’s accomplishments is well deserved,” says Dr. Janet E Stout, president of Special Pathogens Laboratory. “Disease caused by waterborne pathogens, especially Legionella, in the built environment is a growing public health issue. Frank’s rare skill set and ability to apply his expert knowledge of water systems to Legionella control is critical to disease prevention and advancing knowledge.”
In addition to his seminal work in engineering and water quality and Legionella, Sidari was also recognized for his commitment to mentoring young girls in science, technology, engineering and math (STEM). For more than 10 years, he has volunteered and assisted classes at The Ellis School, an all-girl institution in Pittsburgh. Under his engineering mentorship of the school’s Future City team, three teams made it to the competition's national finals held during National Engineers Week in Washington, DC.
“These diverse young professionals are dedicated to the building profession,” said Amara Rozgus, Editor-in-Chief of Consulting-Specifying Engineer. “Now in its eighth year, the program has increased in the number of nominees, and each winner truly stands out both professionally and personally.”
Candidates for CSE’s 40 under 40 award were nominated by a professional colleague or mentor and judged on nine areas including: their commitment to excellence in their academic, professional, personal, and community involvement. Winners will receive their awards at the presentation ceremony held in Chicago on Tuesday, Sept. 29.
May 06, 2015
Chlorine treatments meant to stop dangerous bacteria that can lead to Legionnaires' disease are eating away metal pipes across the Veterans Affairs Pittsburgh Healthcare's plumbing system, threatening long-term damage that could cost millions to correct, an independent evaluation shows.
Premature corrosion at VA campuses in Oakland and O'Hara eventually could force exorbitant bills for plumbing repairs and slash the pipes' lifespan by years, according to disinfection and engineering experts briefed on the matter. A 57-page analysis obtained by the Tribune-Review blames high chlorination for pitted pipes and outright failures found in the water distribution system, where workers report occasional dark discharge from faucets.
“This is a hospital, and we are afraid to drink the water,” said Colleen Evans, a registered nurse and executive vice president for the American Federation of Government Employees Local 2028. The union represents about 2,500 VA Pittsburgh workers.
VA officials said chlorination, adopted in 2013, has proven effective in containing Legionella bacteria that led to the deaths of at least six VA Pittsburgh patients and sickened at least 16 others in 2011 and 2012.
“Our real goal is patient safety. A trade-off of a little more maintenance and repair is worth it if we're saving lives,” said Dr. Brooke Decker, infection prevention director for the VA Pittsburgh, who acknowledged some darkened tap water might be related to the chlorine treatments.
The analysis released last May by Cyrus Rice Water Consultants in Coraopolis showed chlorine levels up to five parts per million, or 20 percent higher than limits for drinking water set by the federal Environmental Protection Agency.
VA officials said the levels have since eased up, complying with drinking water standards and maintaining chlorine low enough that it poses no health risks.
Decker said the last Legionnaires' case linked to the VA Pittsburgh was in 2012, before the health system replaced its less corrosive copper-silver ionization technology with chlorination to stave off the waterborne bacteria.
Workers block off affected spigots and pass out bottled water if chlorine levels exceed standard ranges, Decker said.
The VA did not specify the cost of chlorine-related plumbing damage but reported spending $11.7 million in 2013 on anti-Legionella upgrades, including chlorination equipment in Oakland and O'Hara. Water filters, chemicals, routine testing and related Legionella-prevention expenses — excluding pipe repairs — totaled about $632,000 in 2014, according to the VA.
The agency did not quantify the volume of chlorine-related plumbing problems, although a facilities manager said the issues are concentrated around 19 injection points for the chlorine.
It's very clear in multiple publications that these negative consequences are associated with ongoing use of chlorine,” said Janet Stout, a former VA Pittsburgh worker, a microbiologist and president of the Special Pathogens Lab,Uptown.
March 02, 2015
It's quite common to find Legionella species other than Legionella pneumophila in cooling towers and water distribution systems. To date, fifty-eight Legionella species have been described in published articles. Of these approximately 25 are linked to disease.
Legionella pneumophila serogroup 1 is the most virulent strain causing the majority of infections. The remaining non-pneumophila species (found in water and soil) are considered nonpathogenic until shown to cause disease. Of the CDC reported cases less than 5% are attributed to these species. Since risk for infection is rare, adjusting your response to an adequate threat level is appropriate.
For example, there are Legionella species whose colonies exhibit blue-white fluorescence under long-wave UV light and some exhibit red fluorescence. These "blue-white" Legionella species include: L. anisa, L. dumoffii, L. gormanii, L. cherri, L. parisiensis and L. bozemanii. The red fluoresceing species include: L. erythra and L. rubrilucens. Such non-pneumophila species are commonly found in the environment, but rarely cause infection and when they do it is almost exclusively in very immunocompromised individuals.
In SPL's study, Role of Environmental Surveillance in Determining the Risk of Hospital-Acquired Legionellosis: A National Surveillance Study With Clinical Correlations (ICHE July 2007, Vol 28 No. 7. P 818 - 824) investigators found no infection from species like L. anisa even though it was present in the water systems.
Take the analogy of bacteria on skin. We know our skin is covered with many bacteria including Staphylococcus aureus, but we only get infections under extreme conditions. Most staph on our skin is inherently not pathogenic but if a patient is immuno-compromised or has a procedure that helps staph gain entry into the body, infection can occur. This is sometimes referred to as an "opportunistic infection." Like staph other Legionella species are common in the environment but won't cause illness under normal circumstances.
To say that all Legionella species have the "potential" to cause illness is mere speculation. More than 30 years of research shows few or no reported illnesses from more than half of the known Legionella species. So it's safe to assume the risk of disease is so low as to not to be actionable.
When assessing risk rely on science rather than speculating about unknowns. When other or new Legionella species are found to contribute significantly to the disease threat, then risk assessments could be adjusted. For now it's appropriate to adjust your response to an adequate threat level as seen is the recent VA Directive that non-pneumophila species only require disinfection in limited circumstances.
February 14, 2015
It's common to find other Legionella species in your water. As previously mentioned, the Legionella family is a big family with 58 species that exist in soil and water. When you find other Legionella species does that mean Legionella pneumophila serogroup 1 is also present?
An often cited 2006 French study attempts to make the case that after eradicating L. anisa by thermal shock treatment Legionella pneumophila serogroup 1 (LP1) appeared and that L. anisa had "masked" LP1. The authors assert that system-wide disinfection is required to reveal LP1 and that the presence of the non-pneumophila species was a predictor of the presence of the more dangerous Legionella pneumophila serogroup 1.
No other studies support their claim that finding one Legionella species predicts the presence or absence of LP1. While it's true that multiple serogroups and even species can colonize a water system, we aren't aware of any study that has statistically correlated the presence of a non-pneumophila species as predictive of the presence of LP1.
The ability of a laboratory to detect some non-pneumophila Legionella species is dependent upon the methods and culture media used by the laboratory. For example, some species won't grow in the presence of glycine--a common additive in Legionella selective media used to isolate Legionella from the environment.
Even so, based on this claim French researchers concluded that action should be taken to "eradicate all Legionella contamination."
In contrast, all studies show that LP1 is the primary cause for disease. While non-pneumophila species have caused illness on rare occasions, to conduct a system-wide disinfection when only non-pneumophila species, such as L. anisa, are isolated is a time-consuming and costly proposition backed by very little evidence to support such an action.
To better illustrate, take a recent example. During an investigation of a facility for a suspected case of Legionnaires' disease due to L. pneumophila serogroup 1, the testing of the facility only revealed the presence of Legionella feelei. No link could be made between the illness caused by L. pneumophila serogroup 1 and the facility. Despite this, the health department, citing CDC guidance, insisted on restricting admissions, restricting showering, use of bottled water and multiple shock chlorine treatments of the water system until all cultures were zero. The impact of these measures on the patients, staff and operation of this facility caused hardship and were extremely expensive.
In our opinion, all of these precautions were unnecessary and could have been lifted when environmental testing failed to show the presence of L. pneumophila serogroup 1.
January 28, 2015
Risk Assessment and Prediction for Healthcare-Associated Legionnaires’ Disease: Percent Distal Site Positivity as a Cut-Point
To date there is no definitive indicator for risk of disease regarding levels of Legionella. In 1983, SPL researchers offered a cut point based on the proportion of outlets (faucets and showers) positive for L. pneumophila. Clinical experience supported this approach. If 30% or greater of outlets was positive for Legionella, environmental and clinical surveillance must be done concurrently; and depending on the extent of colonization consider disinfection. The Allegheny County Health Department was the first to adopt the cut point that public agencies and hospitals now use worldwide.
However, an article published in American Journal of Infection Control (AJIC) challenged this approach. SPL’s editorial commentary, Risk Assessment and Prediction for Healthcare-Associated Legionnaires’ Disease: Percent Distal Site Positivity as a Cut-Point, examines the flaws of that study. That is, researchers applied the 30% criteria to studies not designed to assess this endpoint and therefore the data presented doesn’t prove or disprove the efficacy of the cutpoint.
Commentary Abstract: Legionella has been reported as the single most commonly reported pathogen associated with disease outbreaks from drinking water. Two strategies have been proposed for risk assessment. The first is the strategy advocated by the Centers for Disease Control and Prevention (CDC) to search assiduously for Legionnaires' disease in all cases of hospital-acquired pneumonia. However, the diagnosis is commonly missed, even if the Infectious Diseases Society of America and American Thoracic Society guidelines are followed.
January 28, 2015
Can Total Bacteria Measurement Be Used To Predict Legionella Presence?
Microbiological growth in cooling water systems presents several challenges for water treatment providers. Culture methods such as heterotrophic plate count (HPC) and “dipslides” provide valuable information related to general microbiological water quality but require several days to produce results. Alternative methods using adenosine triphosphate (ATP) measurement provide faster results and have been applied when rapid water quality assessment is necessary. Our evaluation reviewed potential applications for ATP analysis in cooling water systems. We also assessed whether total bacteria measurement using culture methods or ATP analysis can predict the Legionella presence/absence using both experimental data and data collected from field observations.
Dr. Stout will present study results on Monday, February 9 at 11 a.m. at CTI in Nashville.
December 09, 2014
Legionella Testing: Dispelling Myths and Misinformation
11:00 am ET on Thursday, January 22, 2015
Join the Association for Water Technologies for a free webinar with Janet E. Stout, PhD, president and director of Special Pathogens Laboratory.
The glut of misinformation about Legionella detection continues to create unnecessary confusion. From sample collection to interpretation water treatment professionals are often asked to address well-worn myths, especially when there is a case. Some professionals may even dread testing for fear of finding a positive result. However, you can protect yourself and your clients by knowing the facts about Legionella.
1) New research in sample collection, transport and interpretation (including flush / no flush and sample volume);
2) How to use Legionella testing in water safety plans;
3) What testing does and doesn’t tell you about the efficacy of your water treatment program;
4) Legionella basics: separating myth from fact; and
5) What to tell clients when there is a positive result.
The webinar is open to AWT members and nonmembers.
Legionella Controlled with Monochloramine in Hospital Hot Water System, Says First US Study Published in ICHE
October 27, 2014
Legionella is effectively controlled with a new onsite monochloramine generation system in a hospital hot water system, says an SPL study in November’s Infection Control and Hospital Epidemiology available online.
Evaluation of A New Monochloramine Generation System for Controlling Legionella in Building Hot Water Systems is the first field trial and published study in the US to evaluate the efficacy of a monochloramine generation system to control Legionella in a hospital hot water distribution system. Prior to this technology, monochloramine had been only used at the municipal level in cold water.
According to Janet E. Stout, PhD, director of Special Pathogens Laboratory, who led the team of researchers that conducted the 29-month study, “This prospective collaboration provides important objective scientific evidence that demonstrates that onsite generation of monochloramine was effective and that treating only the hot water prevented further cases of Legionnaires’ disease. ”
Researchers installed the system (Sanikill, a product of Sanipur [Italy]) at a Pittsburgh 459-bed hospital. Early results, publically reported at the Association of Water Technologies annual conference in 2012, reported a rapid and significant reduction of Legionella within the first week of application. Throughout the study, Legionella was controlled. There was no significant increase in microbial population and none of the negative effects associated with monochloramine use in municipal cold water systems.
“Monochloramine is a promising new technology and viable alternative to historic disinfection methods, especially chlorine, ” says Dr. Stout.
October 17, 2014
In 2004, SPL published the first field trial of chlorine dioxide for control of Legionella pneumophila applied to a hospital's secondary water distribution system. (See Keeping Legionella out of Water Systems. Sidari, F.P., Stout, J.E., VanBriesen, J.M., Bowman, A.M., Grubb, D., Neuner, A., Wagener, M.M., Yu, V.L., Journal of the American Water Works Association, Vol. 96, No. 1, pp. 111-119, January 2004.) The results of that 18-month study, which appeared in the Journal AWWA, showed chlorine dioxide was effective in controlling Legionella.
Recently, SPL conducted a case study of that same hospital, which had been using chlorine dioxide since 2000, to validate the conclusions of the 2004 study and evaluate long-term use of this biocide. The article Maintaining Legionella Control in Building Water Systems by Frank P, Sidari III, Janet E Stout. et al., appears in the October issue Journal American Water Works Association.