Copyright ISHEM Limited 1

Size: px

Start display at page:

Download "Copyright ISHEM Limited 1"

Cordelia Rosalind Sparks
5 years ago
Views:

1 Controlling Legionella and Legionnaires Disease: Outbreak Case Studies FM IRELAND 8 MARCH ISHEM Ltd The information in this document is the property of ISHEM Ltd and may not be copied or communicated to a third party, or used for any purpose other than that for which it is supplied without the express written consent of ISHEM Ltd This information is given in good faith based upon the latest information available to ISHEM Ltd, no warranty or representation is given concerning such information, which must not be taken as establishing any contractual or other commitment binding upon ISHEM Ltd or any of its subsidiary or associated companies. Clive Hanna Ireland Consultant ISHEM Limited Agenda Legionellosis: The Facts Legionella Risk Controls Legionnaires Disease Outbreak Case Studies LD Outbreaks Overview LD Outbreaks Barrow, Edinburgh and Ireland Summary: Lessons Learned Codes of Practice, Standards and Guidelines ISHEM Profile and Services Copyright ISHEM Limited 1

Legionellosis: The Facts Legionellosis = Term used for 3 illnesses: Legionnaires Disease, Pontiac Fever & Lochgoilhead Fever Caused by Legionella bacteria over 50 different species Legionnaires

2 Legionellosis: The Facts Legionellosis = Term used for 3 illnesses: Legionnaires Disease, Pontiac Fever & Lochgoilhead Fever Caused by Legionella bacteria over 50 different species Legionnaires Disease A form of pneumonia (lung infection) Contracted by inhaling infected droplets of water (aerosol) Has an incubation period of typically 2-10 days Fatality rate typically 10-20%, increasing to 30-40% for hospital acquired cases Legionella: Growth Conditions Temperature Below 20 o C - Does not multiply significantly 20 to 45 o C - Increase in proliferation, more virulent at higher temperatures 37 o C - Breeds fastest Above 50 o C - Does not multiply Above 60 o C - Does not survive Nutrients Algae, amoebae, bacteria, organic matter, corrosion Environment Sludge, sediment, scale, biofilm, still or stagnant water Growth Conditions Copyright ISHEM Limited 2

Aerosol Formation Water droplets in range

enter deep in lungs, sources include: Showers

Factors Affecting Risk Source of bacteria

3 Aerosol Formation Water droplets in range 2-5microns can bypass natural defences and enter deep in lungs, sources include: Showers and spray taps Cooling Towers Humidifiers Running taps Spa baths, water features Vehicle wash systems Sources of Aerosol Factors Affecting Risk Source of bacteria Growth Aerosol Formation Exposure of host Copyright ISHEM Limited 3

4 Legionella Control Why do we need to Control? Protect the health of our employees, customers, visitors and neighbours. More specifically to prevent cases of Legionellosis Legionnaires disease fatal form of pneumonia Pontiac Fever flu-like illness Compliance with Health and Safety Legislation Duty of Care Legionella Control What do we need to Control? Exposure to Legionella bacteria in the form of an aerosol Preventing conditions promoting the growth and multiplication of Legionella bacteria, that is: Temperatures between 20 and 45 o C Nutrients for bacteriological growth Sediment, corrosion and biofouling providing hide-outs for Legionella bacteria. Generation and release of aerosols Legionella Control Howdowecontrol? Identify and Assess Risks Assign and record acceptance of responsibilities/duties Prevent and Control Risks by: maintaining system cleanliness avoiding water temperatures/conditions which favour growth avoiding water stagnation and use of materials which harbour bacteria and release nutrients for growth controlling generation/release of water sprays and aerosols using water treatment where required safe operation and maintenance of water systems Monitor and document compliance Copyright ISHEM Limited 4

5 Legionella Control Consequences of Poor or Inadequate Control? Presence of Legionella bacteria Legionella exceeding guidelines levels Prosecution for operating an unsafe water system Cases and Outbreaks of Legionnaires Disease Manslaughter charges for persons deemed to responsible Fines, imprisonment Civil claims Adverse publicity, loss of confidence by stakeholders and general public Legionella Sources of Risk Legionnaires Disease Outbreaks Philadelphia USA, 1976: 221 cases, 34 deaths Stafford 1985, 101 cases, 28 deaths BBC London 1988, 22 cases, 2 deaths Glastonbury 1998, 12 cases, 3 deaths Netherlands 1999, 244 cases, 28 deaths Lens, France 2004, 85 cases, 13 deaths Stavanger, Norway, 2007, 54 cases, 7 deaths Edinburgh, 2012, 150 cases 4 deaths Portugal, 2015, 336 cases 11 deaths New York, 2015, 120 cases 12 deaths Copyright ISHEM Limited 5

Barrow Legionnaires Disease Outbreak In August 2002 there were over 180 LD cases and 7 deaths The source of the outbreak was a cooling tower serving an air conditioning unit at Forum 28, an arts and

6 Barrow Legionnaires Disease Outbreak In August 2002 there were over 180 LD cases and 7 deaths The source of the outbreak was a cooling tower serving an air conditioning unit at Forum 28, an arts and leisure centre owned by Barrow Borough Council There were prosecutions for manslaughter against Barrow Borough Council and one of its employees for failing in a duty of care towards the public Both parties found guilty under HSWA with fines in excess of 150K Mr Justice Burnton concluded that the failings, which contributed to the outbreak, stretched from the lowest levels to the top of the Council in terms of its serving officers. Barrow Legionnaires Disease Outbreak Barrow Failures and Lessons Learned Poor Lines of communication and unclear lines of responsibility lack of leadership and direction; no appointed Responsible Person; no clear definition of the responsibilities Failure to act on advice and concerns raised failed to act on Information from HSE; ignored concerns on lack of water treatment and risk assessment from service providers Failure to carry out risk assessment Council had failed to properly assess the risks from legionella; backlog due to lack of resources; no suitable control scheme Poor Management of contractors and contract documents No formal contract documentation exchanged between Council and contractor; no checks if work completed; Council needs to manage contractors to discharge its legal duties Copyright ISHEM Limited 6

Barrow Failures and Lessons Learned Inadequate training and resources Health & safety management was lacking and under resourced; actions were reactive with no time for preventive checks;

7 Barrow Failures and Lessons Learned Inadequate training and resources Health & safety management was lacking and under resourced; actions were reactive with no time for preventive checks; insufficient training to cover absences or shortages Individual failings Failures made by different officers over a period of time; contract procurement fell far short of the expected standards; more should have been done when concerns were expressed regarding shortcomings in water treatment The public meetings highlighted a catalogue of errors and series of oversights that led to the legionella outbreak. The number of fateful coincidences involved was scarcely credible. Such basic failings should not have occurred and, sadly, these failures could have been easily prevented. Edinburgh Outbreak Edinburgh Failures and Lessons Learned Neither Health and Safety Executive nor Incident Management Team (IMT) at NHS Lothian were able to identify the source. The IMT concluded outbreak was caused by aerosol release of Legionella pneumophila Sg1 Knoxville ST191 and the most likely source was an industrial complex containing wet cooling towers. Several organisations were prosecuted for failures including: inadequate risk assessments lacking in documentation of roles, responsibilities and lines of communication. inadequate training and system understanding inadequate cooling tower cleaning and disinfection and cleanliness assessments shortcomings in the performance of cooling tower water treatment and monitoring programmes Copyright ISHEM Limited 7

8 LD Outbreaks and Incidents in Ireland South Eastern Health Board reported a patient with LD at St Luke's General Hospital in Kilkenny 3 cases of LD at Wexford hotel (Easter 2011) Woman died after contracting LD at Waterford Regional Hospital Man contracted community acquired LD in Cork, not travel linked but regular hot tub user Woman mid-30s working at St Vincent s Hospital Mountmellick contracted LD Various LD cases linked to hotels and leisure facilities but no genetic linkage with potential sources Ireland Failures and Lessons Learned No formal appointment of the Duty Holder, Responsible Persons or Deputies Incomplete risk assessment, e.g. not including all water assets or risk control and monitoring requirements Lack of a robust management process for closing of actions and non-conformances No records of independent audits of performance of risk control measures. Risk assessments not reviewed on an annual basis Lack of specific training in the implementation of risk control and monitoring programme and the interpretation of results Summary: Lessons Learned Read, digest and implement the recommendations of HPSC National Guidelines and UK HSC ACoP L8 Appoint a Responsible Person Undertake effective risk assessment by people with the requisite levels of skill, training and competence Ensure all parties involved have clearly defined responsibilities Ensure there are effective lines of communication with all parties and management Implement controls Ensure all involved are aware of the control measures and what they mean and know what to do when non-conformances arise Keep records and review regularly Ensure that all, including external parties, are trained to undertake the tasks assigned to them Listen to and act upon guidance given by specialist Copyright ISHEM Limited 8

9 Codes of Practice, Standards and Guidelines HPSC National Guidelines for the Control of Legionellosis in Ireland, 2009 HSE Estates Directorate Guidelines for preventing and controlling the growth of Legionella bacteria in healthcare water systems, 2011 UK Health and Safety Executive (HSE) has Approved Code of Practice and guidance on regulations L8 (Fourth edition) Published 2013 BS8580 Risk Assessment Standard UK Health Technical Memorandum HTM Addendum to Health Technical Memorandum HTM ISHEM Experience Team has over 50 years experience in field Dr Bill Thomas internationally recognised expert in field, consulted by Government Departments, consulted on BSI, ASHRAE, LCA, WMSoc technical committees, including committee producing BS 8580 Legionella risk assessment code of practice; LCA Chairman 2004 to 2008 ISHEM is LCA Category 1 member since 2002 ISHEM accredited to ISO9001 ISHEM accredited UK HSE Management system Services Provided Water Hygiene and Legionella Control Legionella Risk Assessment Written Control Schemes & Record Systems Manager and Operator Training Compliance Auditing Independent Water Quality Monitoring Engineering Design Reviews Policy and Management Reviews Expert Witness & Emergency Planning Troubleshooting and Incident Investigation Copyright ISHEM Limited 9

10 Clients Food Production & Retail (UK & Ireland) Petrochemical Exploration, Refining & Retail Chemicals and Pharmaceuticals (UK & Europe) Aerospace (Global) Hospitals and Healthcare (UK & Ireland) Banking and Financial Services (UK) IT, Manufacturing & Services ( UK, USA & Ireland) County, District and Borough Councils (UK and Ireland) Copyright ISHEM Limited 10

Legionella. A detailed insight from our specialists. Overview Lifecycle How it manifests Strains and species Facts and statistics

Legionella. A detailed insight from our specialists Overview Lifecycle How it manifests Strains and species Facts and statistics Laboratory process Sampling and analysis Illness and symptoms Interpreting