May 28, 2014
BIRMINGHAM, AL (WBRC) -Two out of eight patients who tested positive for the legionella bacteria have died at UAB, hospital officials confirm.
Legionella is a bacteria that can cause a form of pneumonia called legionellosis, or Legionaire's disease, according to Dr. Loring Rue, UAB's Chief Patient Safety and Clinical Effectiveness Officer.
After eight patients in the hematology/oncology unit tested positive for legionellosis, UAB Hospital implemented water restrictions in a section of the hospital on Saturday.
The bacteria was discovered in one unit that shares plumbing with two floors. So far, they have not found any new infections outside of that one unit.
The hospital installed filters on shower and faucet heads, flushed the water system and shocked it with extreme temperatures in an effort to make sure the water was safe, Rue said. They also asked patients to wear masks when flushing the toilet.
May 15, 2014
ASHRAE Standard 188P, Legionellosis: Risk Management for Building Water Systems, could be available for public review this summer.
According to an ASHRAE news release on May 15, Tom Watson, chair of the Standard 188P committee says he is “…optimistic that a fourth public review draft…will be approved and made available during the summer.”
Watson notes this new draft includes some major changes. These include removing Hazard Analysis and Critical Control Points (HACCP) terminology—what once was the cornerstone of the third draft. While the language may be removed some principles of the HACCP process could still be included.
The other notable change includes the addition of “environmental Legionella testing consideration.”
While building industry and other stakeholders have been eagerly awaiting the passage of the standard, Watson cautions against implementing the proposed standard due to more changes that could occur before the official standard is passed.
May 13, 2014
UPMC Presby, a Pittsburgh-based hospital, recently made headlines by announcing three Legionnaires' disease cases (including one death) in 2013 were a result of exposure to Legionella in ice machines. The staff tracked down the source after learning that the only exposure to water for one of the patients was ice chips, who had aspirated (choked on an ice chip).
Legionella is among several bacteria that have been isolated from ice machine water dispensers and ice. While the presence of these bacteria in ice is generally not a significant risk for disease transmission, those who are severely ill, immunocompromised and bedridden are the most vulnerable. They are at a greater risk for aspiration-fluids entering the upper airway to the lung by way of choking or by micro-aspiration. Legionnaires' disease has been shown to occur following documented episodes of aspiration.
Research confirms ice machines as a potential source of exposure for some cases of Legionnaires' disease. Our 1985 study, showed that while ice dispensers are supplied with cold water, the condenser/compressor can heat the piping inside the machine and warm the cold water enough to support bacterial growth. The charcoal filter on the cold water line removes chlorine and can become colonized. That water is ultimately dispensed or made into ice. Most bacteria do not multiply in ice, but they can survive at these low temperatures.
While there is concern about any source of Legionella within healthcare facilities, the warm water distribution system remains the most significant source of exposure to Legionella. This should be the primary focus for infection control and Legionnaires' disease prevention.
Two circumstances would warrant testing of ice machines: 1) as part of a case investigation or 2) following cleaning/disinfection of the ice machine to demonstrate effectiveness of the preventive maintenance.
Sampling Instructions for Ice Machines
- Use SPL sample bottles to scoop up ice. Two or three sample bottles of ice are needed so that the melted volume is at least 120 mL. (Ice is processed in the lab after allowing it to melt and is concentrated by filtration.)
- If a water dispenser is part of the machine, collect the water as you would from any faucet: turn on the faucet and immediately fill the sample bottle
- A swab of the faucet opening can also be collected and is recommended if assessing the outlet as a source of infection during a case investigation.
- Shipping instructions see Legionella testing
- Victor L. Yu, MD; Janet E. Stout, PhD. Legionella in an Ice Machine May Be a Sentinel for Drinking Water Contamination. Infect Control Hosp Epidemiol 2010; 31:317
- Stout J, Yu VL, Muraca P. Isolation of Legionella pneumophila from the cold water of hospital ice machines: implications for origin and transmission of the organism. Infect Control 1985; 6:141-146
- Graman P, Quinlan G., Rank J. Nosocomial Legionellosis Traced to a Contaminated Ice Machine. Infection Control and Hospital Epidemiology, Vol. 18, No. 9 (Sep., 1997), pp. 637-640Published
- Bencini, M A. et al. A Case of Legionnaires' Disease Caused by Aspiration of Ice Water. Archives of Environmental and Occupational Health. (2005) Vol 6 No. 6. p. 303-306.
May 03, 2014
Just a 10-minute walk separates UPMC Presbyterian from the Veterans Affairs Pittsburgh Healthcare System in Oakland, the hubs of two clusters of Legionnaires' disease during the past three years.
But confirmation this week of Legionnaires' cases at Presby should not raise red flags over the neighborhood water supply, a leading microbiologist said. Tainted ice machines blamed in the Presby cases are a rare source for the disease, caused when immune-compromised people inhale common Legionella bacteria from contaminated water or mist, said Janet E. Stout, director at the Uptown-based Special Pathogens Laboratory.
The Tribune-Review reported Thursday on the Presby incident, in which one patient died and two fell ill last year after chewing on the hospital's ice chips. UPMC officials are sterilizing about 500 ice machines throughout its 20-hospital network, including 90 at Presby.
Six veterans died and 16 were sickened from February 2011 to November 2012 in the VA outbreak, which federal reviewers linked to bacteria-contaminated tap water and poor management of internal water systems. “The concept of eliminating Legionella from every nook and cranny — it's not really something that can be achieved,” Stout said. She said ice machines are a much lower risk than hospitals' hot-water systems, where Legionella can multiply on a larger scale and reach more patients.
Stout wrote in 1985 about the presence of Legionella in hospital ice machines [Stout J, Yu VL, Muraca P. Isolation of Legionella pneumophila from the cold water of hospital ice machines: implications for origin and transmission of the organism. Infect Control 1985;6:141-146]. Since then, federal guidelines and hospital policies for Legionella control have focused on safeguarding hot-water systems from Legionella through specialized ionization systems and chemical treatments.
May 02, 2014
After one patient died and two were sickened by Legionnaires' disease in November and December at UPMC Presbyterian, where they contracted the disease, UPMC has a message for hospitals nationwide.
"Hospitals in the U.S.: If you have not been looking in ice machines for Legionella, please look," Tami Minnier, UPMC's chief quality control officer, said Friday. "That's the message."
The three hospital-acquired Legionnaires' cases were the first to occur in more than two years at UPMC Presbyterian, she said, and led to a thorough cleaning and disinfection of all of the hospital system's 500 ice machines in 20 hospitals -- including 80 machines in Presbyterian.
Although the cases occurred about five months ago, Ms. Minnier said that UPMC began talking publicly about it this week because it had a difficult time finding existing hospital protocols on Legionnaires' disease and ice machines and little discussion about the issue around the country.
The second goal of going public, she conceded, was to make sure the public did not put UPMC in the same boat as the Veterans Affairs Pittsburgh Healthcare System. The VA was lambasted with criticism over the past 1½ years for how it dealt with an Legionnaires' outbreak here that infected at least 22 veterans, six of whom died over a 16-month period in 2011 and 2012.
February 27, 2014
Legionella doesn't grow (multiply) substantially in cold water. The articles listed below were published many years ago and demonstrated that higher temperatures are required for Legionella to grow and multiply.
- Wadowsky, R. M., R. Wolford, A. M. McNamara, and R. B. Yee. 1986. Effect of temperature, pH, and oxygen level on the multiplication of naturally occurring Legionella pneumophila in potable water. Appl. Environ. Microbiol. 49:1197-1205.
- Rogers, J., A. B. Dowsett, P. J. Dennis, J. V. Lee, and C. W. Keevil. 1994. Influence of temperature and plumbing material selection on biofilm formation and growth of Legionella pneumophila in a model potable water system containing complex microbial flora. Appl. Environ. Microbiol. 60:1585–1592.
- Mauchline WS, James BW, Fitzgeorge RB, Dennis PJ, Keevil CW. Growth temperature reversibly modulates the virulence of Legionella pneumophila. Infect Immun. 1994 Jul;62(7):2995-7.
The article by Wadowsky et al demonstrated that growth of Legionella did not occur at 77°F (25°C). Growth was only observed at 89.6°F (32°C) and 107.6° (42°C). Similarly, The article by Rogers et al showed that Legionella did not multiply significantly at temperatures below 77°F (25°C). Increased growth only occurred as temperatures rose above 100° F (40° C).
Should we worry about Legionella in cold water?
The article by Mauchline suggests that Legionella is like many other bacteria and the disease-causing ability (virulence) is regulated by temperature. Virulence is significantly decreased at lower temperatures.It is well accepted that Legionella enters our buildings via the cold source water—usually in numbers too low to detect. We want to address significant risk where the risk has been scientifically demonstrated and corrective action is evidence-based. We do not want to set into motion expensive treatment of cold water if that treatment will not substantially mitigate the risk for Legionnaires’ disease. Chemicals in our water bring with them exposure to disinfection by-products. This is true for chlorine as well as for other disinfectants.
The regulatory requirement in most states is to have a measurable residual oxidant level in the cold water that arrives at your building usually around 0.2 mg/L. Because Legionella are relatively resistant to chlorine and survive the water treatment process, it is widely accepted that Legionella exist in municipal water supply at levels too low to detect. Furthermore, if Legionella are in amoebae cysts they can survive exposure up to 50 ppm of chlorine. In the presence of warmer temperatures in the hot water system, chlorine essentially disappears due to the kinetics of chlorine decay. Even if when residual chlorine is higher than 0.5 mg/L in the cold water, the residual in the hot water will approach zero.
Treating cold water to control Legionella doesn’t address the primary breeding ground for Legionella—hot water systems. Moreover, adding chemical biocides like chlorine to the cold drinking water may require monitoring for their by-products. This monitoring checks for by-products which are known carcinogens such as haloacetic acid (HAA) and trihalomethane (THM) of chlorine.
Before you worry about Legionella in cold water here are some facts you should know that will save you time and money:
- Chlorine is not the "magic bullet." Although at a high enough concentration chlorine can kill Legionella, this high level comes with a cost. The Wadsworth VA in Los Angeles was one of the first hospitals to have an outbreak of Legionnaires' disease and use continuous hyper chlorination for Legionella control. A few years later the chlorination systems were removed after spending millions of dollars replacing pipes due to extensive corrosion.
- Avoid expensive engineering fixes. One such engineering solution that has been suggested is to keep cold water cold by installing a dedicated chilled water system. If the region of the country has higher source water temperatures, the disinfectant in the source water may be low. Address this issue during the risk assessment at each facility and determine through Legionella testing whether supplemental disinfection is needed. Don’t broadly apply such “fixes” or implement disinfection requirements that in most instances would not be needed to reduce Legionella risk but would be very expensive.
February 10, 2014
Do you know who is at risk for Legionnaires' disease in your facility? Can you identify key personnell respsonsible for water safety in your building? Do you know what parts of a water system could lead to Legionella exposure? Discover the answers to these questions and more by attending Fundamentals of Legionella Water Safety, on Thursday, March 6 at 10 a.m. in Rm 318 (Session Number: R2.18 Track:Maintenance and Operations).
In this session, VP of SPL Consulting Services Frank Sidari will explore the benefits of taking a proactive approach to minimize the risk of Legionella in utility and building water distribution systems. He will share simple, fundamental principles to assist you in reducing facility liability associated with Legionella and demonstrate excellence in building operation. These include: 1) Understanding risk in your building, 2) Applying effective water treatment when needed, and 3) Completing validation of effectiveness by periodic monitoring of your system and Legionella.
A registered professional engineer, board certified environmental engineer and certified construction document technologist, Frank provides engineering consultation on water systems impacted by Legionella. He has significant experience in all phases of water engineering projects from development through operation. His project work has focused on distribution systems, pumping, storage, treatment, and disinfection. Early in his career, Frank evaluated the efficacy of chlorine dioxide and published the first field evaluation of chlorine dioxide disinfection of a hospital campus water system to control Legionella in the Journal of the American Water Works Association.
Visit Special Pathogens Laboratory at booth 2546, to talk with Frank and Dr. Janet Stout to learn more about preventing Legionella in building water systems.
February 03, 2014
Routine monitoring of disinfectant residuals in water samples collected from both on-line (circulating) cooling tower cells and off-line (non-circulating) cells is essential to confirm correct biocide dosing.
It is important to monitor off-line cells as well as on-line cells because many automated building management systems may bring these non-circulating cells into rotation at a moment's notice. If the water contained in off-line cooling tower cells is not properly treated during periods when it is not in use, it can impact overall water quality and provide the potential for biological contamination in the rest of the system.
Monitoring also includes Legionella testing by culture. The use of rapid field tests for Legionella hasn't been shown to provide an accurate indicator of Legionella presence or concentration. Rapid tests, such as ATP, may help determine if changes in the microbiological community are occurring, but they cannot be relied upon for accurate determination of Legionella positivity.
Laboratory culture for Legionella provides "gold-standard" validation of your water treatment program to demonstrate efficacy. Legionella risk assessments, use of biocides effective against Legionella and periodic cultures comprise a program likely to reduce Legionella positivity that could reduce potential liability associated with operation of cooling towers.
November 19, 2013
One person was sickened by Legionella found in the water of a senior high rise building in Sharpsburg. The building is home to 106 people ages 62 and older. Officials say one woman who lived in the building was sickened, but is in the hospital and doing fine.
November 11, 2013
The copper-silver ion system is expected to disinfect the water at the senior high rise.
“The ions come off the bars and through the water that comes through the flow cells,” said Janet Stout of Special Pathogens Laboratory.
Stout said it will be in place for at least a month, and the more Sharpsburg Towers residents run their hot water, the faster the system will kill the bacteria.
According to Stout, even though someone recently got sick from Legionella at the building, it could have been there for years and not hurt anyone.
“I know they did the right thing,” said Peg Panza about the new system.
Panza has lived in the building for 30 years.