Legionella: New Science, Insights, and Standards

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1 Legionella: New Science, Insights, and Standards Developed by: The Michigan Public Health Training Center & The Genesee County Health Department Great Lakes PHTC Members: University of Illinois at Chicago Indiana University at IUPUI University of Michigan University of Minnesota The Ohio State University University of Wisconsin

2 LEGIONELLA New Science, Insights and Standards Janet E. Stout, PhD Director, Special Pathogens Laboratory Research Associate Professor University of Pittsburgh

3 MARK TWAIN

4 It Ain t What You Don t Know That Gets You into Trouble, It s What You Know For Sure That Just Ain t So MARK TWAIN

5 Today s Topics The Challenge of Legionnaires' disease Understanding Legionella In The Built Environment or Why Is Legionella In My Water Systems? Role of Legionella Testing In Disease Prevention Approaches To Prevention- new regulations and standards

6 MY HISTORY WITH LEGIONELLA IN BUILDING WATER SYSTEMS

8 Research Starting in 1982 Over 100 nosocomial cases identified in 5 years in one hospital Janet E. Stout and Victor L. Yu An epidemic redefined - endemic disease and the source was the hospital water system not a cooling tower!

9 Paradigm Shift: Not Cooling Towers NOT a common source for sporadic and hospital-acquired cases More commonly associated with large community outbreaks

10 Legionella is the single most common etiologic agent associated with outbreaks involving drinking water National Academy of Sciences Report Report by the U.S. Environmental Protection Agency (EPA) and the Committee on Public Water Supply Distribution Systems

11 THE CHALLENGE OF LEGIONNAIRES DISEASE

12 What Is Legionellosis? Legionnaires disease is a multi-system illness, with pneumonia, caused by bacteria in the family Legionellaceae. The genus Legionella is a pathogenic group of Gram-negative bacteria that includes the species L. pneumophila

13 Legionnaires Disease Is Bacterial Pneumonia

14 Risk of Acquiring Disease Exposure Alone Doesn t = Disease Acquisition Legionella in water (reservoir) + Transmission to the host (exposure) + Susceptible Host

15 Modes of Transmission for Legionnaires disease Aerosolization Aspiration Direct instillation into the patient (tap water rinsing of nasogastric tubes, respiratory tubing, etc)

16 Centers for Disease Control and Prevention Statistics 77% >50 years 62% male Hospitalizations occurred in 98% ICU admission in 39% Death in 10% -30%

17 Susceptible Hosts Elderly Smokers Immunocompromised Transplant patients High-dose steroids for lung disease Diabetes Cancer Approx. 25% cases no known risk factors

18 The Bacteria: Legionella Hijacks Human Macrophage

19 Legionella replicates within pulmonary macrophages

20 Treatment for Legionnaires Disease Ineffective Penicillins Amoxacillin Cephalosporins Effective Macrolides Erythromycin Azithromycin Quinolones Ciprofloxacin Levofloxacin

21 Legionnaires Disease In the U.S. approximately 600,000 adults are diagnosed with communityacquired pneumonia requiring hospitalization 2 5% are caused by Legionella, as many as 30,000 cases/year

22 Summary: Legionnaires Disease Most cases in people with health conditions that increase risk Early treatment with effective antibiotics reduces mortality Mortality as high as 30% for healthcare acquired cases

23 Legionnaires Disease in Hospitals 35% of reported cases met the case definition for hospital-acquired infection (range 45% - 25%) Case fatality rate was 28% (range 46%-14%) From Benin A.L., Benson R.F., Besser R.E. Clin Infect Dis 2002; 35: Data reported to the CDC from

24 Cases and Outbreaks Majority of cases are sporadic and not outbreak-associated = no investigation Outbreak is defined as two or more cases related in time & location = investigation

25 Historical Approaches to Prevention: Healthcare REACTIVE After 1 transplant patient or 2+ cases within 6 months Combined epidemiologic and environmental investigation Legionella source identified = decontaminate PROACTIVE Before cases, perform environmental surveillance Also perform clinical surveillance to identify unrecognized cases Legionella source identified = decontaminate

27 Preventing Legionnaires Disease How are we doing?

28 Legionnaires disease is increasing Legionella Is Winning Legionella control poses new challenges

29 Public Health Alert Report available:

30 Legionnaires Disease Increasing? Clinical Infectious Diseases 2008 vol. 47 Report available:

31 2008 Conclusions Legionellosis cases have increased substantially, particularly in the eastern U.S. and among middle-aged adults Public health professionals should focus on prevention of this important and increasing public health problem

32 217% Increase in Cases (2011)

33 Why Increase in Reported Cases? Better reporting? Increase in diagnostic testing It s not an outbreak, it s an outbreak of diagnosis Environmental factors?

34 Wet Weather & Legionnaires Disease?

35 Many Cases Still Missed Diagnostic tests for Legionella not routine often not done Many studies have demonstrated under reporting/missed diagnosis

36 Under Reporting Due to Missed Diagnosis

37 Results for 37 Cases 41% of Legionella cases were missed following current IDSA-ATS recommendations for Legionella testing

38 Update on Diagnostic Methods Urine antigen tests were used to confirm 97% of U.S. resident cases reported during Only 5% of cases were confirmed by culture during this period <1% were confirmed by either serologic or direct fluorescent antigen testing MMWR 2011 Vol 60 (32)

39 Dangers of Dependency on Urine Antigen Testing for Diagnosis Urine antigen specific for L. pneumophila, serogroup 1 only If used to screen for healthcareacquired LD, better know what s in your water! If other than Lp-1, disease will be missed MMWR 2011 Vol 60 (32)

40 How does Legionella get into our water?

41 Legionella in Source Water (1987) Public water supplies may contaminate the plumbing systems of hospitals and other large buildings. From: States, SJ, Conley LF, Kuchta JM, et al. Survival and multiplication of L. pneumophila in municipal drinking water systems. Appl. Environ. Microbiol. 1987; 53:

42 Ground, Surface, and Potable Waters and Legionella (1997) Results of this study confirm the ubiquity of Legionella in aquatic environments, even ground water. Lye, D, Fout S, Crout S. et al. Survey of ground, surface, and potable waters for the presence of Legionella species by PCR, culture, and immunofluorescent staining. Water Res. 1997; 31:

Morbidity Mortality Weekly Report (MMWR). August 14, 2015/64 (31); 842-848.

43 Morbidity Mortality Weekly Report (MMWR). August 14, 2015/64 (31); Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water United States,

44 Legionella in Water: 2015 Centers for Disease Control and Prevention (CDC) reported: Legionella accounted for 66% of reported drinking water associated outbreaks 431 cases of illness, 102 hospitalizations, and 14 deaths. Legionella in building plumbing systems was among the most commonly identified deficiencies [factors] leading to drinking water associated outbreaks.

45 Origins of Legionella in Building Water Systems?

46 Historically Community (Municipal) Water Systems Not a Focus for Outbreaks or Disinfection Efforts

47 New Study Suggests Community Water Systems Could Be a Significant Source for Legionella

48 Community Water System Outbreak Epidemiology & Infection 2015

49 The Problem New Jersey Health Department reports cases of Legionnaires disease in senior high rise, geriatric center and single family housing

50 The Investigation The population in the area was 9000 and consistent with the area of influence of a 1 million gallon water tower.

52 Results 56 samples taken from 12 sites located within the targeted flushing zone L. pneumophila serogroup 1 was found in 25% of the sample sites from pre-flushing samples ( c.f.u.) 50% of the sample sites from flushing samples

53 Conclusion Investigation implicates poorly maintained water storage tank and surrounding distribution system

54 Probable Causes 1. Low flow conditions 2. Low or no chlorine 3. Little mixing of water storage tank 4. No regular flushing of water mains

55 Recommendations 1. Include community water systems as possible sources for Legionella transmission. 2. Community water systems supplied by surface water, especially where summer temperatures and available nutrients can amplify Legionella.

56 Be Proactive Public health action in the absence of disease is recommended

57 Another Community Water System Outbreak: Senior Apartment Complex Legionnaires disease case-finding algorithm, attack rates, and risk factors during a residential outbreak among older adults: an environmental and cohort study Benjamin J Silk, Jennifer L Foltz, Kompan Ngamsnga, Ellen Brown et al BMC Infectious Diseases 2013, 13:291

58 Senior Apartment Complex Baltimore Between August and December cases: 8 residents and 2 visitors 4 hospitalized with LD; 1 death 86% of the sample sites from the case building outlets positive fo L. pneumophila serogroup 1 (matched patient strain) 33% (2/6) fire hydrant samples positive for Legionella species

59 Probable Causes 1. Elderly population with comorbidity 2. Water heaters had low temperatures at the bottom of tanks (range: F/ C) 3. Low or no chlorine 4. Interruptions in water service

60 Interruption In Water Service 1. Three-quarters (75%) of residents who were interviewed noted at least one interruption in water service since August 1 st. 2. More than half of residents (56%) reported changes in the taste, odor, or color of their water during the same period.

61 Interruption In Water Service = Brown Water Event

62 Legionella Is Not Alone Legionella bacteria are part of a community of microorganisms a consortium of bacteria and protozoa. They live synergistically one benefiting the other for mutual survival.

64 Many Other Microbes in Water Help Legionella Grow Amoebae Bacteria Provide Nutrients

65 Origins of Legionella Incoming potable water (undetectable or very low conc.) Systems with warm water, such as water distributions systems and air cooling systems (provide growth factors) Biofilms within these systems provide growth-promoting conditions

66 Legionellosis in the U.S. Outbreaks continue to occur (building warm water systems, cooling towers, fountains)

67 Legionnaires' Cases in Quebec City TOTAL=180

68 Outbreak Canada s biggest and deadliest in 25 years 89 cooling towers disinfected Source=Cooling Tower

69 Outbreaks in Nursing Homes & Assisted Living Facilities

70 OHIO HOSPITAL OUTBREAK LINKED TO NEW CONSTRUCTION

71 Outbreak in Germany Warstein, Germany 165 cases, 12 ICU, 2 deaths caused by Legionella pneumophila, serogroup 1 Outbreak strain found in 2 cooling towers + other sources including wastewater from a brewery! Public safety alerts

72 Public Safety Announcement Whether or not the Warsteiner brewery is found to be the breeding ground for the Legionella bacteria, officials have been making it clear that the beer is completely safe to drink.

73 DRINKING WATER What Ben Franklin had to say about drinking water

74 With wine comes wisdom, with beer comes freedom, with water comes bacteria Legionella.

75 2015: Summer of Legionella

76 South Bronx Outbreak 130 cases, 12 deaths Declared over August 20, 2015

78 Outbreak Linked to Hotel Cooling Tower

79 NEW YORK STATE EMERGENCY REGULATIONS

80 Emergency Regulations Cooling towers must be registered Sample collection Inspection Reports to DOH Certification Maintenance program ooling-towers-new-chapter-8-title-24- rules-city-new-york-establish-rulesmaintenance#sthash.atdkztb2.dpuf

81 Unprecedented Response Our new emergency regulations will make sure that building owners live up to their responsibilities and provide health officials with critical information to counter the spread of Legionella bacteria. - Governor Cuomo

82 I Love New York!

83 Why Do Outbreaks Continue?

84 Legionella-Related Anxiety

85 Five Stages Of Coping with Legionella 1. Denial 2. Bargaining 3. Depression 4. Acceptance 5. Medication

86 1. Denial

87 Denial Most wait to address the problem until after a case of Legionnaires disease is diagnosed.

88 Approaches to Disease Prevention REACTIVE After 1 transplant patient or 2+ cases within 6 months Combined epidemiologic and environmental investigation Legionella source identified = decontaminate PROACTIVE Perform environmental surveillance before cases Perform clinical surveillance to identify unrecognized cases Legionella source identified = decontaminate

89 Proactive Approach Reduced Legionnaires Disease Am. J. Infection Control 2005; 33(6):

90 Our Study Results - 48 Hospitals Proportion of hospitals performing environmental surveillance = 65% Proportion of cases hospital-acquired: Pre-guideline = 33% Post-guideline = 9% Proportion that started water treatment (disinfection) = 44%

91 2. Bargaining

92 Bargaining Legionella is everywhere There s hardly any cases It is too costly to control/monitor If I don t know, I m not responsible

93 Myth: Legionella Is Everywhere Published studies find: 20 70% of buildings and 30-50% of cooling towers colonized with Legionella Legionella is not ubiquitous (everywhere)!

94 Legionnaires Disease In the U.S. approximately 600,000 adults are diagnosed with community-acquired pneumonia requiring hospitalization A minimum of 2-5% are caused by Legionella, as many as 30,000 cases/year

95 Is It Worth the Effort (Money)? PREVENTING LEGIONNAIRES DISEASE

96 U.S. Healthcare Costs Associated with Legionnaires Disease Total hospitalization costs $101 - $321 million per year Collier s.a., L. J. Stockman, l.a. Hicks, l. E. Garrison, f. J. Zhou and m. J. Beach. Epidemiol. Infect. (2012), 140,

97 Legionella Outbreaks Are Costly

98 Legionella in the water systems of buildings is a serious health risk Costly Outbreaks Even a single case can dramatically affect an organization $700,000

99 Outbreak Response: Pittsburgh VA Hospital $ 10 Million

100 3. Depression

101 4. Acceptance

102 The Times They Are a-changin New Paradigm for Prevention

103 ASHRAE Proposes a Standard to Prevent Legionnaires Disease American Society of Heating, Refrigerating and Air-conditioning Engineers

104 ASHRAE 188: The Long & Winding Road Committee was authorized as a standard committee in June 2005 Five Public Review Documents

105 First Legionella standard in the United States. Approved June 26, 2015

106 Purpose of ASHRAE Standard 188 Establish minimum Legionellosis risk management requirements for building water systems.

107 Compliance The building shall be surveyed to determine whether it has one or more of the listed water systems and/or the factors described that relate to risk for Legionellosis.

108 New Responsibilities BUILDING OWNERS & FACILITY MANAGERS Responsible for implementing ASHRAE 188 requirements and safeguards to protect against Legionella.

109 Water Systems Covered By 188 Potable and non-potable water systems, in the building or on the site Includes building water distribution systems (including centralized potable water heater systems) Cooling towers, evaporative condensers Whirlpools or spas Ornamental fountains, misters, atomizers, air washes, humidifiers or other non-potable water systems or devices that release water aerosols in the building or on the site

110 Section 5.2: Building Characteristics Multiple housing units > 10 stories high (including below grade) Patient stays exceed 24 hours One or more areas for purpose of housing or treating occupants receiving treatment for burns, chemotherapy, organ transplantation or bone marrow transplantation

111 Section 5.2: Building Characteristics One or more areas for the purpose of housing or treating occupants that are immuno-compromised, at-risk, taking drugs that weaken immune system, have renal disease, have diabetes, or chronic lung disease Housing occupants over the age of 65.

112 Elements of Water Management Program Program Team Persons responsible for Program development and implementation. Water Systems/Flow Diagrams Describe potable and non-potable water systems and develop water system-schematics. Water System Analysis/Control Measures Evaluate where hazardous conditions may occur and decide where control measures should be applied. Monitoring/Corrective Actions Establish procedure for monitoring whether control measures are within operating limits and, if not, take corrective actions. Confirmation Establish procedure to confirm Program is being implemented as designed (verification) and the Program effectively controls the hazardous conditions (validation). Documentation Establish documentation and communication procedures for all activities of the Program.

113 Knowledge The Program Team shall have knowledge of the building water system design and water management as it relates to Legionellosis

114

Common Assumptions: True or False? Legionella is ubiquitous (everywhere). If chlorine levels at or above 0.5 mg/l in the supply water, Legionella is controlled.

115 Common Assumptions: True or False? Legionella is ubiquitous (everywhere). If chlorine levels at or above 0.5 mg/l in the supply water, Legionella is controlled. Only old buildings have Legionella problems. If total bacteria are controlled, Legionella is controlled. Water and energy conservation approaches minimize Legionella risk.

116 ASHRAE 188: Mind the Gaps

117 A Few Gaps Legionella testing isn t required to validate that the risk management program is working. BUT testing is the only way to validate efficacy of your control measures and assess threat from Legionella. The standard requires reducing hazardous conditions to an acceptable level through monitoring and maintenance BUT doesn t define acceptable level.

118 If you don t look for it, you won t find it. If you don t find it, you don t think you have a problem. If you don t think you have a problem, you don t do anything about it. Legionella Testing Dr. Bruce Dixon, Director Allegheny County Health Department

119 Elements of Water Management Program Confirmation Establish procedure to confirm Program is being implemented as designed (verification) and the Program effectively controls the hazardous conditions (validation). Validation Evidence that confirms the effectiveness of the plan How do you know Legionella is being controlled? Establish validation measures? Quarterly culture for Legionella?

120 Not All Legionella Are Dangerous

121 Keeping Risk in Perspective Legionella pneumophila, serogroup 1 is the primary disease-causing species Non-pneumophila species cause illness on very rare occasions

122 Legionella Species Not Equal in Causing Disease 58 named species to date Only half implicated in human disease Some species very common in the environment, but rarely cause illness, and almost exclusively in the immunocompromised

123 Legionella Up Close Colonies of Legionella pneumophila have a typical ground-glass, opalescent morphology

124 Legionella Species That Fluoresce Under UV Light Some fluoresce red and some fluoresce blue-white Blue-white species L. anisa L. dumoffii L. gormanii L. bozemanii Legionella rubrilucens

125 Legionella Species Table

126 5. Anxiety

127 Is the Sky Falling? If I Find Some Legionella?

128 What is an acceptable amount of a contaminant?

129 IS ZERO NECESSARY?

130 EPA Maximum Contaminant Regulatory Levels Maximum Contaminant Level Maximum Contaminant Level Goal

131 U.S. EPA Regulatory Approach to Legionella Opportunistic Bacteria - Legionella No level specified by regulation or public health standard; MCLG is zero. U.S. Environmental Protection Agency (EPA) considers Legionella controlled if treatment plant uses techniques to control parasites (Treatment Technique Rule) no Legionella testing required

132 Risk Potable Water Risk of Legionnaires disease was better predicted by the proportion of water system sites testing positive for Legionella than by the concentration of Legionella bacteria. Kool J L, et al. Infect. Control Hosp. Epid :

133 Risk Criteria Based on Environmental Monitoring Results Concentration-based thresholds that establish target values in CFU per liter or milliliter OK for cooling towers as a performancebased target (not health-based) Colonization rate or proportion of distal sites in the water system that are positive for Legionella Best for hospitals and building water systems

134 ASHRAE Compliance Compliance is just the first step to protect yourself and building occupants Compliance doesn t guarantee Legionella control and cases can occur.

135 ASHRAE 188 Compliance Good News, Bad News Standard is not prescriptive Good News - You get to make lots of decisions Bad News - You get to make lots of decisions

136 WHEN TO CONSIDER SUPPLEMENTAL DISINFECTION

137 Questions to Ask Was Legionella found in the water system? Pathogenic species? Extent of colonization? Colonization in sensitive areas?

138 DISINFECTION OPTIONS

139 Secondary Disinfection Methods Thermal shock treatment (heat & flush) Shock chlorination (>10 mg/l residual), may require water tanks to be mg/l Continuous supplemental chlorination (2-4 mg/l) Copper-silver ionization (continuous) Chlorine Dioxide (ClO2) Monochloramine Point-of-use filtration

EPA: Safe Drinking Water Act http://water.

140 EPA: Safe Drinking Water Act

141 Building Disinfection Options Municipal Water Treatment Chlorine Chlorine Dioxide Monochloramine UV Building Water Treatment Chlorine Chlorine Dioxide Monochloramine UV * Copper-Silver Ionization * Point of Use Filters

142 Disinfection Methods Review: Infection Control and Hospital Epidemiology

143 Latest Review: Journal of the American Water Works Association 2014 r Journal Am Water Works Assoc 2014; 106(10): 24-32

144 Field Evaluations

145 Field Evaluation of New Filter Extended Use (60 day) POU Filters

146 We Filter the Air But Let Them Drink Tap Water? PROTECTING TRANSPLANT, HIGH RISK PATIENTS, NEONATES

147 Epidemiology of Pediatric LD CDC study showed 72% pediatric cases had healthcare exposure Mortality rate 22% Alexander NT, et al 2008 ICAAC

148 Physical Barrier Against Exposure to Waterborne Pathogens American Journal of Infection Control 2005; 33:S20-25.

149 Results in Published in AJIC American Journal of Infection Control 2014: 42;

150 EPA Document: 815-D

151 New EPA Document Legionella in water systems of buildings can adversely impact public health. This draft document provides information on the use and effectiveness of Legionella control strategies.

152 New EPA Document EPA published the draft Legionella document on October 21, 2015 Held public meeting November 9, 2015 ( drinking-water-distribution-systems)

153 Legionella in Our Water New at-risk populations: longterm care facilities (nursing homes) and rehabilitation centers Increase number of younger patients with no typical risk factors Potable water is the source Aerosolization overemphasized, aspiration a mode of transmission Immunocompromised children at risk

154 is the XXXXXXXX ^

155 Legionella-Related Anxiety

156 6. Medication

157 Dr. Stout s Legionella Chill Pills For treatment of Legionella-related anxiety. Take 2 tablets 1 hour before Legionella testing or as needed.

158 Mission: End Legionnaires Disease No one should die from a preventable disease caused by a bacteria in water. Legionnaires disease can and should be prevented.

159 THANK YOU Dr. Janet E. Stout President, Microbiologist

ANSI/ASHRAE Standard Legionellosis: Risk Management for Building Water Systems

ANSI/ASHRAE Standard Legionellosis: Risk Management for Building Water Systems ANSI/ASHRAE Standard 188-2015 Legionellosis: Risk Management for Building Water Systems Published June 26, 2015 Patricia T. Graef, P.E. Member SSPC-188 January, 2018 PURPOSE: Establish minimum legionellosis